There is no organised screening programme for prostate cancer but an informed choice programme, Prostate Cancer Risk Management, has been introduced.
Why isn’t there a national screening programme for prostate cancer?
All screening programmes cause some harm. This could include false alarms, inducing anxiety, and the treatment of early disease which would not otherwise have become a problem.
When considering population screening programmes the benefits and harms must be carefully assessed, and the benefits should always outweigh the harms.
Until there is clear evidence to show that a national screening programme will bring more benefit than harm, the NHS will not be inviting men who have no symptoms for prostate cancer screening.
In 1968, Wilson and Jungner of the World Health Organisation developed ten principles which should govern a national screening programme. These are:
- The condition is an important health problem
- Its natural history is well understood
- It is recognisable at an early stage
- Treatment is better at an early stage
- A suitable test exists
- An acceptable test exists
- Adequate facilities exist to cope with abnormalities detected
- Screening is done at repeated intervals when the onset is insidious
- The chance of harm is less than the chance of benefit
- The cost is balanced against benefit
To date, prostate cancer screening fulfils only the first condition. See the Health Technology Assessment Programme’s monograph Diagnosis, management and screening of early localised prostate cancer: a review for details.
Evidence from a prostate cancer screening trial in Europe, ERSPC, has shown that screening reduced mortality by 20 per cent. However, this was associated with a high level of overtreatment. To save one life, 48 additional cases of prostate cancer needed to be treated.
Following research evidence published in 1997 the UK National Screening Committee recommended that a prostate cancer screening programme should not be introduced in England. This policy was reviewed in Dec 2010 but no significant changes were made. It is due to be considered again in 2013/14, or earlier if significant new evidence emerges.
Although evidence does not yet support population screening for prostate cancer there is considerable demand for the PSA test amongst men worried about the disease. In response to this, the Prostate Cancer Risk Management programme was introduced in September 2002.
The PCRM provides high quality information to enable men to decide whether or not to have the PSA test based on the available evidence about risks and benefits. After consideration of this information and in discussion with their GPs, men over 50 who choose to have the test may do so free of charge, on the NHS.
Prostate Specific Antigen (PSA) Tests
Prostate-Specific Antigen (PSA) exists in different forms (isoforms). It can be joined to other proteins when it is often referred to as complex PSA, or it can exist on its own, known as free PSA.
The PSA tests commonly referred to and used in Prostate Cancer Risk Management are total PSA tests. This means that they detect both free and complexed PSA to give a measure of all PSA present in the blood sample.
Total PSA tests used in Prostate Cancer Risk Management to measure PSA levels in men with no symptoms of prostate disease have to meet certain quality criteria. The NHS Centre for Evidence-based Purchasing evaluated PSA tests against these and published their Evaluation Report – Total PSA Assays in 2008. The PSA tests are currently being re-evaluated.
PSA tests that measure only free or complex PSA do exist. The relative proportions of free and complexed PSA are thought to be different in men with prostate cancer when compared to men with other prostatic diseases where the total PSA level is also raised. Men with cancer are thought to have a smaller proportion of free PSA and more complexed PSA than men with other benign prostatic diseases such as benign prostatic hyperplasia (BPH) or prostatitis.
Free or complexed PSA tests are provided by some laboratories. They are often used as follow on tests following a raised total PSA test result. The results are reported as the percentage of free PSA compared with the total amount of PSA detected. Any results below a cut-off value are thought to be suggestive of prostate cancer. These free or complex PSA tests are designed to be used when the total PSA test result is marginally raised, and not in cases where the total PSA test result is very high and suggestive of advanced prostate cancer.
Key messages on the Prostate
What is the prostate?
- The prostate is only found in men. It is very important for a man’s sex life, producing some of the fluid in semen. It is found below the bladder and is about the size of a walnut. It surrounds the tube that carries urine from the bladder
- When something goes wrong with the prostate, it can affect a man’s sex life, his long term health and with prostate cancer can lead to death
What can go wrong with the prostate?
- Benign disease (Benign Prostatic Hyperplasia – BPH) – the prostate slowly gets bigger as men get older This can cause difficulty when passing urine as the growing prostate puts pressure on the tube that carries urine from the bladder. BPH is treatable and is rare in men under 50
- Prostatitis – an inflammation of the prostate gland that causes difficulty when passing urine. Prostatitis is treatable and can occur in men of any age
- Prostate cancer – a single cell in the prostate begins to multiply out of control and forms a tumour. Some cells may break away and travel to other parts of the body, starting new tumours. Prostate cancer is treatable and can be cured in many cases. It is rare in men under 50 but gets more common as men get older
The symptoms of prostate disease are similar:
- Needing to urinate often, especially at night
- Difficulty in starting to urinate
- Straining to urinate or taking a long time to finish
- Pain when urinating or ejaculating
Other less common symptoms:
- Pain in lower back, hips or pelvis
- Blood in the urine (this is unusual)
However, these symptoms are often not cancer. Some prostate cancers grow slowly and may not cause problems. Some grow quickly and need early treatment. If you are worried about any of these symptoms, you should go and see your doctor.
PSA testing in England and Wales
How much testing for prostate cancer is taking place in England and Wales?
There are no routinely collected data in the UK with which to monitor or study the extent to which men are being tested for prostate cancer. These data are important if we wish to know the amount of testing that is taking place, its impact on the workload of the NHS and future changes in incidence of and mortality from prostate cancer.
The Policy Research Programme of the Department of Health-funded an independent investigation of the rate of Prostate-Specific Antigen (PSA) measurement in general practice in England and Wales. The study was conducted by the Cancer Screening Evaluation Unit at The Institute of Cancer Research in association with 28 pathology laboratories and over 300 general practices. The aim of the study was to investigate the rate of PSA testing in asymptomatic men and to study factors associated with variation in the rate of testing within general practice. The overall annual rate of testing in men with no prior diagnosis of prostate cancer was estimated to be 6.0 per 100 men, of which the annual rates of asymptomatic testing, symptomatic testing and re-testing were 2.0, 2.8 and 1.2 per 100 men respectively after adjusting for missing values. The rate decreased with increasing social deprivation, and increasing proportions of black and Asian populations. The overall rate of PSA testing increased significantly from 1999 to 2002. If the recommendations of the NHS Prostate Cancer Risk Management Programme were applied, 14 per cent of asymptomatic tests and 23 per cent of symptomatic tests would have led to the referral. As the rate of PSA testing is rising and there are uncertainties about the benefit of screening, the workload and costs in general practice and hospitals should be monitored.