PC Screening

Hi excavator unfortunately the link asks for a trial subscription on my iPad, so not able to see it.  I think men should have a PSA test and recorded on their file routinely, then any subsequent change can be picked up.  I understand the negative impact of mass screening but changes in PSA to an individual are important indicators.

That's a shame, I didn't realise that as I have a subscription.

Here's a cut and paste, hope that works better.

Here, two leading figures from either side of the debate put forward their arguments.

Harms outweigh the benefits

Professor Sir Mike Richards, chair of the national screening committee

I would be very keen to recommend a screening programme for prostate cancer if I knew that it would save a significant number of lives without harming a considerably larger number of men. That is my position as chair of the UK national screening committee, which makes recommendations to ministers in the four UK countries. It is also my position as an individual who has had prostate cancer and undergone robot-assisted laparoscopic prostatectomy.

My colleagues on the committee and I have looked at the evidence on the benefits and harms of screening for prostate cancer in great detail. We have experts on screening, a geneticist, an ethicist, a health economist and a patient representative on the committee. We also consult widely with clinicians, academics, charities and patient groups. The evidence simply does not support a
population-wide screening programme at present.

Let me be clear about what the evidence actually shows. For every 1,000 men screened, two fewer are likely to die from prostate cancer, after 15 to 20 years. However, we need to be cautious about those two lives saved, as the data from the trials shows that overall survival is no different between those who were screened or not screened. Most people die of causes other than prostate cancer. This may be difficult to explain, but it is what the trials show.

Now consider the harms. For every 1,000 men screened there will be around 20 who will receive a cancer diagnosis, but whose cancer would never have caused a problem in their lifetime. They will, however, be subject to the anxiety of knowing they have a cancer. Around 12 of the 1,000 men will undergo treatment that can cause harm, without getting any benefit. The harms of prostatectomy or
radiotherapy include debilitating incontinence and erectile dysfunction, which can last for the rest of their lives. These harms can occur despite the best modern techniques, though research into new approaches is continuing.

To improve the balance between benefits and harms, it is important to separate out those men whose prostate cancers are likely to lead to death from those who would not experience any problem in their lifetime. Unfortunately, we cannot always do this reliably.

I understand why most men who have had prostate cancer diagnosed through screening believe that this has saved their lives. However, the evidence shows that for many men this is not the case. Individual stories, even in large numbers, do not provide the evidence we need to make rational decisions. The task of my committee is to make recommendations based on the best available evidence.

We have not recommended population-wide screening for prostate cancer because we believe the harms outweigh the benefits. Nor have we recommended screening for men with a family history of cancer or for black men, because we simply do not have sufficient evidence one way or the other for these groups.

We very much hope that ongoing research will provide the evidence we need. We have, however, recommended screening for a small group of men with a BRCA2 genetic abnormality and a family history of relevant cancers, as these men are at much higher risk and suffer more aggressive disease.

This is a start. The national screening committee is committed to going further as soon as the evidence permits. That is why we are keeping the topic open. We understand the public support for screening, but we must stick with the fundamental principle of screening programmes: that they must do more good than harm.

Technology has changed the game

Nick Jones, founder of Soho House Group and prostate cancer survivor

The decision of the UK national screening committee is a bitter disappointment for many men and their families. Despite prostate cancer being the most common cancer in men and killing more than 12,000 people every year, the committee has once again decided against screening for most of those at highest risk.

Black men remain excluded, despite facing around double the risk of developing prostate cancer and being more likely to die from the disease. Men with a strong family history remain excluded too, unless they also carry a BRCA2 gene variant. Even eligibility for men with BRCA variants has been narrowed since the draft recommendation published last year.

The question is why. The committee’s position has long rested on concerns about overdiagnosis and overtreatment and that screening will do more harm than good. Those concerns deserve to be taken seriously. No responsible campaigner is calling for a return to the crude screening approaches of the past.

But medicine has changed dramatically. Over the last decade we have seen major advances in MRI technology that allow doctors to identify clinically significant cancers far more accurately than before. Faster and cheaper MRI scans are increasingly being adopted. AI is now being trialled across the NHS to improve the interpretation of scans and help clinicians identify the men most likely to benefit from treatment.

The same is true for treatment itself. Robotic surgery has transformed outcomes for many patients. Radiotherapy has become more precise and less burdensome. Active surveillance has become a standard and increasingly sophisticated option for men with lower-risk disease, allowing many to avoid treatment altogether while remaining under careful monitoring.

Taken together, these advances fundamentally change the balance between benefits and harms.

Yet reading this recommendation, it is difficult to escape the feeling that the committee is looking backwards while medicine is moving forwards.

Many of the studies that underpin the decision were designed in a very different era. Since then, diagnosis has improved. Treatment has improved. Risk stratification has improved. Patients themselves are better informed and more empowered to make decisions about their care.

Public policy must therefore evolve too. That is why I believe the new health secretary, James Murray, should reject the committee’s recommendation.

He should ask whether the latest advances in diagnosis, imaging and treatment have been properly reflected. He should ask whether enough weight has been given to the realities facing men at highest risk. And he should ask whether Britain is comfortable continuing to tell black men that they face one of the highest prostate cancer risks in the world while offering them no screening programme at all.

James Murray has an opportunity to show leadership. He should send this recommendation back and ask for something better, especially for Britain’s black community and for families who know first-hand the devastating impact of prostate cancer.

If we know who is most at risk, continuing to look the other way is no longer a neutral choice. It is a decision in itself.

Thank you for that Derek, there was something very similar in the Telegraph yesterday and over 600 comments. To be honest after reading some of the comments - from educated people - I was left fuming . It's easy to comment on something that's not affected you - yet!

After reading about 150 comments, I fed the dog, took him for a walk and had a couple of pints to "cool down".

My simple thoughts:

* The PSA test is an indicator.

* The DRE (digital rectal examination is an indicator).

* It's a cancer that in the main affects men over 50.

So if you meet any of the 3 criteria above (never mind if you are black or BRACA2) and yes let's do the PSA test, (the DRE if your GP feels it's needed) let's get you on that MRI table. Let's get a testing plan going.

You can argue there are not enough MRI machines - we have a new Community Diagnostic Centre where I live with plenty of capacity, and don't forget if we invite every man who meets the criteria for a test - there won't be a 100% take up!

YES - my view is biased because IF testing was in place I don't think I would be typing this today - I would be doing something else in my dotage (go on, Google it ).

WHY - is Brest and Cervical cancer (and now the scope for Lung Cancer testing is being increased) offered to every woman of a certain age? (sorry ladies but I have to make that comment!).

Ask me why am I bothered - I already have Prostate Cancer and the testing debate wouldn't affect me. I am bothered because I have seen the devastation this cancer causes not only to the men with a diagnosis but to their family and friends. Mentally I am strong and have a supportive wife and family but not everyone has!

So there you have my thoughts - anyone else?  (and this is only about testing - not treatments!)

Best wishes - Brian.

Hi Brian

I can only say something about cervical cancer since that’s my area of personal experience, and you’ve mentioned it specifically in your post.

My point would be that cervical screening is NOT a test for cervical cancer.

It is a test for the presence of the hpv virus at the time the test is carried out. The virus can come and go-be dormant or active-and the screening only shows whether you have the virus at that particular time of testing. Almost everyone in the general population who has ever, even once, been sexually active, both men and women, will have come across the virus at some stage in their life, but most people can clear it through the action of their immune system.

Note I’ve said “clear” the virus, not cure, as there is no cure for hpv.

If the test is negative for hpv, you’re sent on your way- but that doesn’t mean you can’t get cervical cancer, and doesn’t quantify the risk of developing it at some stage. Not all cervical cancers (and there are several different types) are driven by hpv, so you could have a non hpv driven cervical cancer and cervical screening (smear test) could miss it. Like all tests, it is not failsafe. 

If the test is positive for hpv, the cells taken at the smear test are analysed further, and this could show pre cancerous cell changes, which is a very common result. These calls can then be removed in an outpatient procedure, and will hopefully not develop further. Another test will be carried out in 6 months to check things have gone back to normal and all the abnormal cells have been removed.

Apologies if you are already aware of all of this!

Sarah xx

Hello Sarah (SarahH21 ) 

Thank you so much for your post. I was aware of most but not all of what you said.

My apologies for using Cervical as an example BUT I wanted to show there was other testing out there - we have NONE!

Thanks again for your great post!

Kind regards - Brian xx

No worries about using cervical screening in your example, Brian! I actually found it really interesting to read the article Derek shared-understanding the differing views, and why there is no national screening for prostate cancer. I completely get where you’re coming from!

Both girls and boys are benefiting from the vaccine now given as youngsters against hpv, which is a very good thing. Too late for me, but great progress. 

Sarah xx

Thank you Derek, two balanced arguments.  I wonder if it is the choice of language that is making me not understand.  Perhaps screening is the wrong word.  Screening indicates going out actively searching for PCa and taking Sir Mike Richards argument perhaps on balance that will negatively impact too many people against the number of lives it saves.  That sounds like playing God and am happy to leave that to the experts.

My argument is slightly different.  In my case, despite having several blood tests without PSA, when my PSA was first taken and was discovered to be 74, I was incurable.  Had a rise been picked up months/years before, maybe my outcome would have been different.  I want to stop guys being diagnosed too late.  OK in statistical terms, I might not die of PCa, but it has had one hell of an impact on my life and if I don’t die from PCa then am I really a statistic in favour of not testing!

I would suggest that a PSA test is included in a normal blood tests, so that a baseline can be created and monitored for each individual.

Thank you for posting these two opposing opinions about routine screening for prostate cancer. I can see and understand both! My comments are as follows:

No routine screening programme is mandatory. If introduced, those who don’t want it can refuse it. Without it being introduced, those who want to be screened have no choice - they can’t access it!

My husband and I went through genetic counselling due to a high incidence of both breast and prostate cancer deaths in his family. We were told that, yes, the BRCA gene which can cause these cancers can be detected. But we were warned that they might not have yet discovered other genes associated with breast and prostate cancer so family members should continue to be screened. So, why limit to just those with the BRCA gene?

We are a country plagued with naturally occurring and socially caused health inequalities which the Governments in recent years have pledged to address. To remove the choice of regular screening from ethnic groups who are twice as likely to get prostate cancer seems to be a total disregard of health inequalities and the need to address them.

Yes, there are the risks of false negatives leading to lack of treatment and false positives leading to over treatment. But, think of the FIT test for bowel cancer screening. This is to test, I think, for faecal occult blood indicating bleeding in the bowel from a cancerous tumour. But, what ifthe tumour is not bleeding at the time of the test? What if there is bleeding from some other cause? A positive FIT test can, arguably, lead to unnecessary investigations and anxieties etc.

The cynic in me suspects that a greater motivation not to do routine PSA screening, especially excluding a wide group of men considered to be at risk, could be because urology and oncology services are currently so under-resourced that the NHS could not cope with the increased demand. I have been reading people’s experiences here and these, coupled with our own experiences, have demonstrated that, even now, diagnostics and treatment delays are a regular occurrence.

Just wanted to throw in my own thoughts