Prostate Screening FAQ

If early prostate cancer is detected, what treatments are used?
Approximately two out of every three men who have a prostate biopsy will not have prostate cancer. The initial treatment options for men with early localised prostate cancer are:

Watchful waiting
This involves the conscious decision to avoid treatment unless symptoms develop. Those men who do develop symptoms of progressive disease are usually managed with hormonal therapy.

Active surveillance
With active surveillance the treatment of slow growing cancers is avoided by only treating those whose cancers show early signs of progression. Serial PSA measurements and prostate biopsies allow the cancer to be monitored and surgery or radiotherapy is offered in the event of disease progression. The disadvantage is that the cancer may grow to a more advanced stage. Some men find the uncertainty difficult to cope with.

This involves an operation to remove the prostate gland. The aim is to cure, although there are possible side effects. These include incontinence which is experienced by up to 2 in every 10 men. Up to 8 in every 10 men experience impotence following the surgery. Four or five men in every 1,000 who have major surgery for prostate cancer may die.

Radiotherapy external beam
This involves a course of radiotherapy treatment on the prostate gland at an outpatient clinic and usually follows a course of hormonal therapy. The aim is to cure, although there are possible side effects. Impotence may be experienced by up to 6 in every 10 men. Bowel problems are experienced by 3 in every 10 men and incontinence by 4 in every 100 men.

Radiotherapy brachytherapy
This involves placing radioactive seeds or wires directly into the prostate. Possible side effects include urinary problems and impotence in up to 2 in every 10 men.

What are the Prostate Cancer Risk Management Programme’s referral guidelines?
The Programme recommends that the following age related cut-off values are used for the PSA test:

Age PSA cut-off (ng/ml)
50-59 ≥ 3.0
60-69 ≥ 4.0
70 and over > 5.0
And the benefits of the PSA test?
It may provide reassurance if the test result is normal and may find cancer before symptoms develop. If prostate cancer is detected at an early stage, treatment could be beneficial. If treatment is successful, the consequences of more advanced cancer are avoided.

What are the limitations of the test?
The PSA test is not diagnostic. PSA is tissue specific but not tumour specific in the prostate. Therefore, other conditions such as benign enlargement of the prostate, prostatitis and lower urinary tract infections can also cause an elevated PSA. Approximately 2 out of 3 men with a raised PSA level will not have prostate cancer. The higher the level of PSA the more likely it is to be cancer. The PSA test cannot distinguish between slow growing cancers that may never cause any symptoms or shorten life, and fast growing cancers.

The PSA test can miss cancer, and provide false reassurance. It can lead to unnecessary anxiety and medical tests when no cancer is present.

What is the PSA test?
The PSA test is a blood test that measures the level of PSA in the blood. PSA (Prostate Specific Antigen) is a substance made by the prostate gland, which naturally leaks out into the blood stream. A raised PSA can be an early indication of prostate cancer. However, other conditions which are not cancer (e.g. enlargement of the prostate, prostatitis, and urinary infection) can also cause a rise in PSA.

The PSA test is currently the best method of identifying localised prostate cancer. There are two further recognised methods; digital rectal examination (DRE) and transrectal ultrasound (TRUS).

What are the symptoms of prostate cancer?
Men with early prostate cancer may not have any symptoms as these only occur when the cancer is large enough to put pressure on the urethra or disturb bladder function. But some symptoms may be the same as those for benign prostatic hypertrophy (BPH ), an enlargement of the prostate gland which is common in older men. These are:

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
More advanced prostate cancer may cause pain in the lower back, hips or pelvis, and less commonly, blood in the urine.

Some prostate cancers grow slowly and may not cause problems. Others grow quickly and need early treatment. If you are worried about any of the above symptoms, you should go and see your doctor.

Are some men more at risk of developing prostate cancer?
The biggest risk factor is age. However, other factors may also play a part. Risk is greater in those with a family history and is also known to be greater in black Carribean and black African men.

There is often increased anxiety amongst men with risk factors. It is important that these men receive the best available information and support to assist them in deciding whether or not to have a PSA test.

What do we know about prostate cancer?
Prostate cancer is the most common cancer in men in the UK. A quarter of all new cases of cancer diagnosed in men are prostate cancers. In 2008, 37,051 men in the UK were diagnosed with prostate cancer and around 10,000 men in the UK die from the disease each year

Is the Department of Health funding any research into prostate cancer?
Yes. These include:

The ProtectT Trial – evaluating the effectiveness of treatment for clinically localised prostate cancer. This is a large scale randomised controlled trial of treatments for localised prostate cancer detected by PSA-test screening.
The Department of Health and other National Cancer Research Institute (NCRI) members fund the NCRI Prostate Cancer Collaboratives.
A highly innovative study to create and test a new non-invasive treatment for prostate cancer. The technique uses magnetic resonance imaging (MRI) to locate the cancer and High Intensity Focused Ultrasound (HIFU) to destroy it inside the body.
MRI for radiotherapy treatment planning – a study to improve radiotherapy treatment for prostate cancer by using magnetic resonance imaging (MRI).
Will a national screening programme be introduced?
A national screening programme will only be introduced if and when screening and treatment techniques are sufficiently developed and the 10 principles of screening have been met.

Why isn’t there a national screening programme for prostate cancer in England?
Until there is clear evidence to show that a national screening programme brings more benefit than harm, we will not be offering prostate cancer screening for asymptomatic men.

When considering population screening programmes the benefits and harms should be assessed and the benefits should always outweigh the harms. In 1968, Wilson and Junger of the World Health Organisation developed 10 principles which a national screening programme should meet. To date, we are only able to identify the first principle for prostate cancer screening:

Important health problem
Natural history well understood
Recognisable at an early stage
Treatment better at an early stage
A suitable test exists
An acceptable test exists
Adequate facilities exist to cope with abnormalities detected
Screening at repeated intervals when insidious onset
Chance of harm is less than the chance of benefit
Cost balanced against benefit
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 over treatment. 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.

What about men who require further information?
Men requiring further information about PSA testing and prostate cancer can obtain it from from Cancer Research UK and The Prostate Cancer Charity.

Is this initiative UK wide?
The Prostate Cancer Risk Management Programme is an English initiative. However Wales, Scotland and Northern Ireland have also issued the information pack.

How will this impact on the GP’s work load?
The pack is designed to aid and relieve GPs’ workload by providing comprehensive information to share with patients. The packs provide consistent and standardised information for primary care clinicians across the country, thus cutting inequalities.

How was the information pack developed?
We wanted to ensure that the information contained in the pack responded to the needs of GPs and primary care staff and would assist them in providing men with information on the benefits and limitations of the PSA test for prostate cancer. A wide consultation exercise was undertaken.

The original packs were developed following consultation with over 100 GPs and practice nurses. In addition, an expert, multi-disciplinary group set up by the Department of Health advised on all aspects of the Prostate Cancer Risk Management Programme.

The materials were developed by a specially commissioned GP, Dr Graham Easton, before going out to consultation via the National electronic Library for Health (NeLH) website.

The Cancer Research UK Primary Care Education Research Group finalised the materials, taking into account this consultation, work with primary focus groups and the specially established Scientific Reference Group (including urologists, representatives of primary care, scientific staff and lay membership).

The Royal College of General Practitioners has endorsed the approach of the Prostate Cancer Risk Management Programme. The second edition of the information pack, launched in July 2009, follows a review of the materials to ensure that they reflect current evidence and knowledge. Again a wide consultation exercise was undertaken, including the views of GPs.

What does the information pack contain?
The GP packs consist of:

A summary sheet
A booklet entitled PSA testing in asymptomatic men : Information for primary care
The Cancer Research UK Prostate CancerStats sheets (2008)
A leaflet for men, entitled PSA Testing for Prostate Cancer
The leaflet for men takes the form of a tear-off pad at the back of the pack which GPs can give to men to take home following consultation. If a man wants a PSA test after the consultation and consideration of the leaflet, he will be tested.

What is the Prostate Cancer Risk Management Programme?
One of the main aims of the programme is to ensure that men who are concerned about prostate cancer and considering a PSA test are given clear and balanced information about the benefits, limitations and risks associated with the test. Evidence-based materials have therefore been produced by the NHS Cancer Screening Programmes and Cancer Research UK to help GPs provide patients with an informed choice about whether or not to have the test.

The PCRMP was initially announced by the Secretary of State for Health as part of the NHS Prostate Cancer Programme in September 2000 and a primary care information pack was published in 2002. This information pack has now been reviewed and updated to include the latest evidence and information.