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Analysis

Current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal benefit

BMJ 2023; 381 doi: https://doi.org/10.1136/bmj-2022-071082 (Published 17 May 2023) Cite this as: BMJ 2023;381:e071082

Linked Feature

Is the UK really ready to roll out prostate cancer screening?
  1. Andrew Vickers, attending research methodologist1,
  2. Frank O’Brien, consultant urologist2,
  3. Francesco Montorsi, professor of urology3,
  4. David Galvin, consultant urologist4,
  5. Ola Bratt, professor5,
  6. Sigrid Carlsson, assistant attending epidemiologist156,
  7. James WF Catto, NIHR research professor7,
  8. Agne Krilaviciute, researcher8,
  9. Michael Philbin, patient advocate9,
  10. Peter Albers, professor of urology810
  1. 1Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
  2. 2Department of Urology, Cork University Hospital, Ireland
  3. 3University Vita-Salute San Raffaele, Italy
  4. 4Department of Surgery, University College Dublin, Ireland
  5. 5Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
  6. 6Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
  7. 7Academic Urology Unit, Department of Oncology and Metabolism, University of Sheffield, UK
  8. 8Division of Personalized Early Detection of Prostate Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
  9. 9Patient and patient advocate, New York, USA
  10. 10Department of Urology, University Hospital, Medical Faculty, Heinrich-Heine-University Düsseldorf, Germany
  1. Correspondence to: A J Vickers vickersa{at}mskcc.org

Informed choice approaches lead to high rates of unsystematic PSA testing, especially among those least likely to benefit and most likely to be harmed, argue Andrew Vickers and colleagues

Screening for prostate cancer with prostate specific antigen (PSA) remains highly controversial because it is unclear whether the benefits of reduced prostate cancer mortality offset the harms of overdiagnosis and overtreatment. Given this uncertainty, most high income countries have chosen not to implement a national programme of prostate cancer screening, but allow men to obtain a PSA test after a conversation with their physician.

Countries that have adopted screening policies based on shared decision making have seen high rates of PSA testing, particularly among men 70 years or older, who are particularly prone to overdiagnosis1 but do not benefit from screening.2 This is one of the reasons why opportunistic screening results in only a small reduction in cancer specific mortality.3 Moreover, relying on shared decision making to guide PSA testing has led to an uneven distribution, with higher rates of PSA testing among those who are wealthier and more educated.

In 2022 the European Union recommended that organised screening programmes should be extended to prostate cancer.4 We argue that high income countries should either implement a comprehensive risk based approach to PSA testing, one that is designed to reduce overdiagnosis and overtreatment, or discourage PSA testing through a clear recommendation against screening, along with policies that make it hard to obtain a test without defined urological indications.

Informed choice approach drives high rates of testing

High income countries that have made PSA testing available to men who request it after shared decision making with their physician now have a high prevalence of PSA testing with an inappropriate age distribution (table 1). In the UK, men aged 80-89 are twice as likely to get a PSA …

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