The pros and cons of prostate specific antigen screening

Prostate cancer is the most common cancer in men and early detection is crucial, yet there is currently no screening programme using prostate specific antigen (PSA) tests currently.

Around 475,000 men are living with or after the disease in the UK, and every year more than 52,000 men are diagnosed on average according to Prostate Cancer UK. ¹ But while screening programmes are offered nationally to increase the rate of early detection of certain diseases or cancers, such as, breast cancer, the National Screening Committee has previously recommended against population screening for prostate cancer.

“This is because the evidence has shown that while testing more men will lead to earlier diagnoses and more lives saved, standard tests – such as the prostate specific antigen blood test and systematic trans rectal biopsies – have not been considered reliable enough,” says Sophie Smith, senior specialist nurse at Prostate Cancer UK.

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“There has also been concern that some men could experience harm from screening, due to the stress or side effects of unnecessary tests that are deemed invasive, or side effects from treatments for a cancer that would not have harmed them,” she says.

At a population level, Ms Smith says the large number of men experiencing a harm was deemed to outweigh the smaller number of men who have their lives saved. However, at an individual patient level they can only experience one lot of harm or benefit. “That’s why NHS guidance is clear that men should be supported to make an informed choice as to whether a prostate specific antigen test is the right thing for them,” she says.

Prostate specific antigen screening

In the absence of a screening programme, the NHS Prostate Cancer Risk Management Programme (PCRMP) exists to support asymptomatic men who are considering the SAP test. PCRMP gives GPs evidence-based information to help counsel men on the pros and cons of the PSA test so they can make an informed choice whether to have the test or not.

Prostate Cancer UK’s position is that “men should be able to make an informed choice whether they want a prostate specific antigen blood test or not based on their individual risk factors and the pros and cons of the PSA test”, says Ms Smith. “That’s why we have developed and tested an online risk checker to effectively support men to learn about the pros and cons of testing.” (See resources) It’s also important to refer to the correct guidelines when consulting men on the PSA test, she says.

 

 

To support the timely referral of suspected prostate cancer, Dr Richard Roope, Cancer Research UK Primary Care Adviser, says health professionals can act on clinical suspicion with consideration of risk factors such as family history and Black ethnicity.

Dr Roope says to conduct face to face appointments/testing with patients if there is suspicion, and to consider a Digital Rectal Examination (DRE) and a suspected cancer referral for patients with an abnormal DRE, advising that a normal DRE does not rule out prostate cancer. Practitioners could  consider a discussion with a urologist, and should be aware if multiparametric MRI (mpMRI) is available in their area, as it can detect more clinically significant prostate cancers than the PSA test says Dr Roope.

“Important every man knows his individual risk”

Prostate cancer can develop when cells in the prostate start to grow in an uncontrolled way, says Ms Smith. “If prostate cancer is caught early, there’s a good chance it can be cured. Unfortunately, too many men are still being diagnosed after their cancer has spread and become incurable,” says Ms Smith.

“Because early prostate cancer is asymptomatic, it’s important that every man knows his individual risk and talks to a health professional about the pros and cons of the PSA test,” she says.

She says there are three main risk factors for prostate cancer: getting older – prostate cancer mainly affects men aged 50 or over and risk increases with age – having a family history of prostate, breast, or ovarian cancer, and being Black. Prostate Cancer UK recommends Black men talk to their GP about a prostate specific antigen test from the age of 45.

Signs and symptoms of prostate cancer

Prostate cancer symptoms only happen when the cancer is large enough to press on the tube that carries the urine from the urethra. If the cancer is in the early stage it may not cause any symptoms, says Macmillan Cancer Support. ²

The prostate gland can also become enlarged due to benign prostatic hyperplasia (BPH), which is non-cancerous. ² The symptoms of benign (non-cancerous) prostate conditions and prostate cancer are similar. ²

They can include needing to urinate more often than usual, especially at night, difficulty urinating – for example, a weak flow, having to strain, or a feeling that the bladder has not completely emptied, an urgent need to urinate,  blood in the urine or semen, and, rarely, pain when urinating or ejaculating, says Macmillan Cancer Support. ²

Prostate cancer: the impact on men’s lives

Dr Unnati Desai, National GP lead at Nuffield Health, says some men diagnosed with prostate cancer may not require treatment immediately, and may be advised to have their prostate cancer monitored for progression before treatment is recommended. “This may result in anxiety, fear,  and frustration during the monitoring phase,” she says.

Dr Desai says many people who are diagnosed with any cancer will often feel “isolated, feel that their identity has changed, have a sense of loss, be in denial or angry, be upset, or apprehensive about their future.

“There may also be the physical and emotional impact of prostate cancer, or side-effects of treatment, which may include ongoing and worsening urinary symptoms, sexual function and intimacy concerns, as well as the wider impact that is often seen in the family unit,” she says.

Living with or after treatment for prostate cancer can also involve extra practical considerations for men, in areas such as work, finance, and travelling, says Ms Smith.

Every prostate cancer is different

Every prostate cancer is different, and as a result there are many different types of treatments. Patients may have a choice of treatments depending on the stage and grade of their cancer, says Ms Smith.

She says localised prostate cancer often grows slowly – or doesn’t grow at all – and might not need treatment. However this is not always the case – localised G9 cancer can grow and be fatal. “Men may be able to have their cancer monitored with regular check-ups instead,” she says.

The two ways of monitoring localised prostate cancer are active surveillance and watchful waiting. The main treatments for localised prostate cancer are surgery (radical prostatectomy), external beam radiotherapy, and brachytherapy. Patients might also be offered high-intensity focused ultrasound (HIFU) or cryotherapy, but they are less common, says Ms Smith.

Locally advanced prostate cancer is cancer that has started to break out of the prostate or has spread to the area just outside the prostate, she says. The treatment options for locally advanced prostate cancer are  external beam radiotherapy with hormone therapy (and sometimes with high dose-rate brachytherapy or permanent seed brachytherapy), hormone therapy alone (now very rare) surgery (radical prostatectomy), often followed by hormone therapy and radiotherapy, and watchful waiting, says Ms Smith. “A small number of men may be offered high dose-rate brachytherapy on its own, but this isn’t very common,” she says.

Advanced prostate cancer is cancer that has spread from the prostate to other parts of the body. “For men with advanced prostate cancer, treatment won’t cure the cancer, but it can help keep it under control and manage any symptoms,” says Ms Smith. The main treatments are  chemotherapy with hormone therapy, hormone therapy alone, clinical trials, and olaparib.

Supporting patients

Any cancer not only impacts on physical health but can also affect people mentally and emotionally. Practitioners can signpost patients and their loved ones to charities like Prostate Cancer UK and Macmillan Cancer Support, which provide help, advice, support, and information on prostate cancer. (See resources box.)

A key message for patients is that any new urinary symptom should be checked with the GP, says Dr Desai. She says men with a strong family history of prostate disease should also consider speaking to their GP about the relevant prostate checks.

And Ms Smith advises: “Until we have population screening for prostate cancer in the UK, men need to understand their risk of getting the disease and talk to their GP about the prostate specific antigen blood test, without waiting for symptoms to appear.”

 

 

 

References

1. Prostate Cancer UK  (2023) About prostate cancer. Available at: https://prostatecanceruk.org/prostate-information-and-support/risk-and-symptoms/about-prostate-cancer Accessed April 2023.
2. Macmillan Cancer Support Prostate Cancer. (2023) https://www.macmillan.org.uk/cancer-information-and-support/prostate-cancer Accessed April 2023.