Prostate Cancer Screening: Balancing Risks and Rewards

This commentary builds on my recent article in last week's patient newsletter, Movember Matters: Shedding Light on Prostate Cancer Screening in the UK (and Beyond)—the second instalment in a Movember series dedicated to men's health. While there's some overlap with the original piece, it simply underscores the critical importance and widespread impact of this disease.

Prostate cancer is the most common cancer in men in the UK, with over 52,000 new cases diagnosed annually. It’s no wonder that screening for the disease seems like an obvious solution. After all, early detection could save lives, right? But as recent discussions in The Times highlight, prostate cancer screening—particularly through the use of the PSA (Prostate-Specific Antigen) blood test—is far from a straightforward decision.

Despite growing attention on prostate cancer during Movember, the UK is unlikely to introduce a national prostate cancer screening programme any time soon. The National Screening Committee (NSC) is expected to rule against it, citing concerns about the balance between the potential benefits and harms of PSA testing. This decision reflects the complexity of prostate cancer screening, which continues to divide experts, patients, and policymakers alike.

In this article, we’ll explore the benefits and pitfalls of PSA screening, why the evidence remains inconclusive, and what men should consider when deciding whether to request the test.

What Is PSA Screening?

PSA screening involves a simple blood test to measure levels of prostate-specific antigen, a protein produced by the prostate gland. Elevated PSA levels can indicate prostate cancer but are not definitive, as they may also result from non-cancerous conditions like an enlarged prostate or prostatitis (inflammation of the prostate). If PSA levels are high, further diagnostic tests, such as MRI scans or biopsies, are required to confirm the presence of cancer.

For men over 50, PSA testing is available on request through their GP in the UK, but it is not part of a national screening programme. High-risk groups, such as men with a family history of prostate cancer, Black men, and those with BRCA1 or BRCA2 gene mutations, may benefit from earlier testing starting at age 45.

Why Isn’t There a National Screening Programme?

Unlike national screening programmes for breast, cervical, and bowel cancer, the evidence for PSA-based prostate cancer screening does not yet meet the threshold for widespread implementation. Screening programmes must demonstrate that the benefits significantly outweigh the harms, and for prostate cancer, this balance remains unclear.

The Benefits of PSA Screening

1. Early Detection Saves Lives

PSA testing can detect prostate cancer at an early stage when it is easier to treat. For some men, this early detection may prevent a more aggressive, life-threatening cancer from developing.

2. Improved Diagnostic Techniques

Advances in imaging, such as MRI scans, and safer, more targeted biopsy techniques have reduced the risks associated with follow-up testing after a raised PSA result.

3. Focused Screening for High-Risk Groups

Targeted screening for men at higher risk of prostate cancer—based on age, family history, or ethnicity—could potentially save lives without subjecting the entire population to unnecessary testing.

The Pitfalls of PSA Screening

1. Overdiagnosis and Overtreatment

PSA tests often detect slow-growing cancers that may never cause symptoms or pose a serious threat during a man’s lifetime. However, once detected, these cancers are frequently treated with surgery, radiotherapy, or other interventions. Treatments for prostate cancer can have significant side effects, including urinary incontinence, erectile dysfunction, and bowel problems.

Research suggests that 10 to 40 men need to be treated for PSA-detected prostate cancer to save one life. For the other 9 to 39 men, the treatment may have been unnecessary, leading to reduced quality of life without extending survival.

2. False Positives and False Negatives

Elevated PSA levels don’t always mean cancer, and normal levels don’t always rule it out. False positives can lead to unnecessary anxiety and invasive procedures, while false negatives may delay diagnosis of aggressive cancers.

3. Weighing the Harms and Benefits

The NSC and other health authorities must consider the bigger picture. While PSA screening saves some lives, it also exposes many men to the harms of overdiagnosis and overtreatment. Lithuania remains the only country with a national PSA-based screening programme, but global evidence has yet to justify widespread adoption elsewhere.

What Should Men Do?

While there’s no national screening programme, men can still take proactive steps to protect their prostate health:

• Know Your Risk: Men over 50—or over 45 for high-risk groups—should discuss PSA testing with their GP.

• Understand the Pros and Cons: It’s important to weigh the potential benefits of early detection against the risks of overdiagnosis and overtreatment.

• Watch for Symptoms: Prostate cancer often develops without symptoms, but warning signs include difficulty urinating, blood in urine or semen, and pain in the back, hips, or pelvis.

Learning from Other Screening Programmes

The debate over PSA screening mirrors similar challenges faced by other screening programmes, such as breast cancer screening. Mammograms save lives by detecting breast cancer early, but they also result in overdiagnosis and unnecessary treatments. According to NICE, for every 180 women screened, one life is saved, but 1 in 100 women will be overdiagnosed.

The same principles apply to prostate cancer screening. For the men whose lives are saved, PSA testing is invaluable. But for those who undergo unnecessary treatment and experience life-altering side effects, the harms may outweigh the benefits.

A Note on Prostate Cancer in High-Risk Populations

While the jury is still out on population-wide screening, there is growing support for targeted screening of high-risk groups. For example:

• Black men are twice as likely to develop prostate cancer and are often diagnosed at a younger age.

• Men with a family history of prostate cancer—or related cancers like ovarian or breast cancer linked to BRCA gene mutations—are also at greater risk.

For these groups, PSA testing may offer a better balance between benefits and harms, making early discussion with a GP particularly important.

Final Thoughts: Screening Is Not a “No Brainer”

Prostate cancer is a complex disease, and screening for it is equally complex. As the NSC debates the future of PSA testing in the UK, it’s clear that a one-size-fits-all approach is not the answer. Instead of a national programme, the focus may shift toward individualised screening for high-risk men.

This Movember, let’s use the spotlight on men’s health to encourage informed choices. By understanding both the benefits and pitfalls of PSA screening, men can make decisions that are right for them. Early detection can save lives, but it’s just as important to avoid unnecessary harm.

Speak to your GP or healthcare provider, know your risk, and take charge of your health.

#Movember #ProstateCancerAwareness #MensHealth #PSATesting #EarlyDetection #InformedChoices #MensHealthMatters

Disclaimer: This newsletter is for informational purposes only and does not constitute medical advice. Always consult your healthcare provider for any medical concerns.

Source

Screening for prostate cancer is not a no brainer. Here's why

Article by Dr. Mark Porter

It doesn’t look as if the UK is going to have a screening programme for prostate cancer any time soon. The National Screening Committee (NSC) has yet to announce its final decision, but sources The Times has spoken to suggested it has already ruled out using prostate-specific antigen (PSA) blood testing to screen men for the disease.

Few subjects provoke more debate in medicine than PSA tests (see below). Opinion can be broadly divided into three groups: keen promoters such as Stephen Fry at one end of the spectrum, balanced by concerned sceptics at the other, with most people being twixt the two and somewhat confused as to what to do.

Introducing more screening for disease — so you catch it earlier, making it easier to treat — is widely seen as a step in the right direction, while any resistance from the NHS gets blamed on shortsighted cost-cutting. But it is a complex issue. Cost will always be a factor — screening needs to be affordable and to not divert vital resources from other areas — but the main determinant has to be that the benefits far outweigh any harms. And this isn’t always the case. All screening programmes cause some harm.

Take breast cancer. Nearly four decades after the introduction of the national screening programme, the National Institute for Health and Care Excellence (Nice) estimates that it prevents one woman dying of breast cancer for every 180 screened. However, mammograms also detect some less worrying cancers that would never otherwise come to light during the woman’s lifetime. According to Nice, about 1 in 100 women will be overdiagnosed with one of these between the ages of 50 and 70, and receive treatment, such as surgery and radiotherapy, that they probably did not need (although the latest research suggests overdiagnosis rates may be a bit lower than this).

Harm — anything from the anxiety and stress generated by being told you have cancer, to side-effects of treatment — has always been harder to quantify than benefits. Every woman I have met who has had breast cancer picked up by screening is in no doubt that the programme saved her life. So side-effects, such as radiation damage to your skin, are a small price to pay, right? Well, yes if you were one of the 1 in 180 who avoided a fatal breast cancer by accepting your invitation, but not if you were one of the 1 in 100 who ended up having unnecessary treatment.

I know what it is like. Eight years ago I was part of a now discontinued pilot scheme to assess the impact of a one-off bowel scope at 55. In my case it revealed a worryingly large benign polyp which, if left, could have turned into cancer. While convinced that the test saved my bacon, I will never know for sure, but that hasn’t stopped me joining the ardent supporters’ camp. At least for bowel cancer.

Overdiagnosis is a particular problem when screening for prostate cancer. Although assessment of men with raised PSA levels has improved considerably in recent years, thanks mainly to MRI scans and targeted safer biopsy techniques, we still struggle to work out which cancers pose a threat and which are nothing to worry about.

PSA screening will save some men’s lives, but at considerable cost to others because the test also picks up cancers that might never have posed a serious threat. Estimates vary, but research shows that we need to treat somewhere between 10 and 40 men with PSA-detected prostate cancer to save one of their lives. As with breast screening, great if you happen to be the one whose early death from more serious prostate cancer is prevented, but not so good for the 10-40 men who will have had treatments such as surgery (prostatectomy) and radiotherapy for less threatening tumours. Treatments that they probably never needed and which often have a significant impact on their quality of life due to side-effects such as incontinence and difficulties getting an erection.

Once again, as with breast screening, nearly every man I meet who has had treatment as a result of PSA testing is convinced that his life has been saved and, typically, they urge all their male friends and relatives to request the test too. After my bowel issue I understand their fervour, but the NSC has to look at the bigger picture and, while there is growing evidence that targeted screening aimed at high-risk men may work (see below), most research shows that, for the rest of us, the harms still outweigh the benefits. Which is why Lithuania is the only country in the world that has an established national PSA-based screening programme. The evidence just doesn’t stack up. Not yet anyway.

And for the record, while I will continue to take up every invitation I receive for all the current national screening programmes, I have never requested, or had, a PSA test. If this ever changes, and it might, you will be the first to know.

PSA testing

• PSA is a protein produced by the prostate gland, and raised levels in the blood suggest problems ranging from infection and age-related enlargement to cancer.

• There is no national PSA-based screening programme, but men over 50 can request a test from their GP.

• The following groups are at higher risk and may benefit from earlier testing (eg from 45): men who have had a father or brother with the disease; black men; those with a strong family history of ovarian or breast cancer (a shared gene variation — BRCA 1 and 2 — can predispose to all three).

• For more information visit prostatecanceruk.org.

Disclaimer: This newsletter is for informational purposes only and does not constitute medical advice. Always consult your healthcare provider for any medical concerns.