The pros and cons of a UK national screening programme for prostate cancer

So far the UK has no national screening programme for prostate cancer. Such screening for prostate cancer, which offers a PSA test to apparently healthy men without symptoms, is controversial, mainly because it is unproven that this strategy will lead to treatment that will improve death rates, and we do know that treatment for prostate cancer can cause serious harm. 

Survival seems to improve in populations of men where screening is more common. But survival statistics represent the length of time men know they have a condition. If more men are diagnosed earlier, their length of survival with cancer will appear to improve, simply because they have been aware of their diagnosis for longer. This is called 'lead time bias'.

Argues that we don't know that earlier diagnosis and treatment of prostate cancer lengthens life but we do know that treatments have side effects.

In the United States death rates from prostate cancer have decreased, but it is not known if the reduction in death rates is due to screening or some other factor, such as improvements in treatment. In the USA, regions with different rates of prostate cancer screening and treatment have similar death rates for prostate cancer. Prostate cancer death rates have also declined in countries where PSA screening is uncommon.

Some of the men we talked to showed they understood why screening for prostate cancer hasn't been introduced in the UK. If prostate cancer is diagnosed there can still be much uncertainty about treatment, not least because the side effects of treatment are unpleasant. 

Suggests that the UK doesn't have a national screening programme partly because if cancer is diagnosed men have to face difficult choices about treatment.

A few men, particularly those with a medical background (Interviews 01, 02, 41), were strongly against screening for the present. 

Argues that it is irresponsible to advocate PSA screening for prostate cancer until there is better evidence that screening reduces mortality.

No screening test is 100% accurate, and all screening can lead to anxiety. One of the reasons why PSA screening is so controversial is that the PSA test is inaccurate. About 2 out of 3 men with a raised PSA level will not have prostate cancer. And occasionally the PSA may read 'normal' when there really is cancer there. Many men said that screening for prostate cancer using the PSA test could lead to anxiety because of this. 

Suggests that the PSA test may be misleading and lead to great anxiety.

Thinks that screening for prostate cancer might cause unnecessary anxiety.

Suggests there is no UK screening programme because of false positive results, because some cancers are very slow growing, and because of cost.

The task of The National Screening Committee is to use research evidence that identifies screening programmes that do more good than harm. The committee has not recommended PSA screening in the UK at present, partly for the reasons given above, and also because there are different types of prostate cancer, some which kill and some which appear to remain dormant throughout a man's life. Probably more than a third of men in their 80's have 'latent' prostate cancer, yet it develops in only very few of them before they die. 

At the moment it is not possible to identify which prostate cancers are of this 'latent' variety. The biopsy may give some indication of whether or not the cancer is likely to be slow growing, but grading systems, such as the Gleason score, are not very accurate. If all men were screened for prostate cancer a proportion of men with the types of cancer that would not develop symptoms, would suffer serious harms from treatments for such cancers. Thus on present evidence screening all men over a certain age in the UK might do more harm than good. 

Screening may cause unnecessary anxiety, particularly since prostate cancer can be 'unproblematic' or 'dormant', over a considerable period.

A screening programme must minimise harm and maximise benefit. Thus the National Screening Committee also has to make policy recommendations that will do more good than harm at a reasonable cost, focusing on opportunity cost; that is the professional time involved as well as the financial cost. Many of the men we talked to realised that costs and benefits must be balanced, and some mentioned the shortage of urologists and lack of money in the National Health Service.

He finds it hard to be enthusiastic about screening when we don't have enough resources to treat patients already presenting with symptoms.

Says that it is important that the test is accurate before introducing a national screening programme partly because of the cost implication.

Another man with a medical background also thought that cost had to be considered.  

Thinks the benefits of detecting prostate cancer early are 'pretty slim' compared with the costs and difficulties of running a screening programme.

In spite of the cost and other concerns about screening for prostate cancer many of the other men we talked to were in favour of a national screening programme. Some felt their lives had been saved because they had had a PSA test, and others said that they felt less anxious because they had been tested and had had a 'normal' result. Some men couldn't understand why the UK has screening for other conditions but not for prostate cancer. 

He has regular screening for colon cancer because his father died of it and is in favour of screening for prostate cancer too.

A few men felt strongly that all men over 50 should be offered a PSA test. One complained about the 'nanny state' and said that all men should be screened and given the opportunity to make an informed choice about treatment options. 

Says that men over 50 should be screened for prostate cancer because the disease destroys families.

Another man said that he thought all men over 50 should at least be told about the PSA test because doctors don't make it clear whether or not urinary symptoms are due to prostate cancer or something else. He also pointed out that since cancer may be present without any symptoms screening may be beneficial.

Argues that GP's should tell men about the PSA test because men may have prostate cancer without having symptoms and symptoms are confusing.

Although some men told us that they would rather have slightly shorter lives than endure the side effects of treatment for prostate cancer, others thought that the side effects of treatment were worth risking in order to stay alive. 

Some men suggested that the PSA test should be part of routine health checks for men (over 50) similar to checks for blood pressure and cholesterol. One man recalled a time in the 1960's when he had nursed men with prostate cancer who had died a painful death, and he argued that just as blood pressure or cholesterol tests save lives, the PSA test might save lives too.

He remembers nursing men in the 1960's when they died a painful death from prostate cancer and argues that the PSA test is useful.

At the moment large randomised trials are underway in Europe and in the USA to assess the impact of screening and to compare three different treatment options - surgery, radiotherapy and 'active monitoring' for prostate cancer (detected at an early stage). These trials will help us to assess screening and different treatments and help us to decide whether or not they reduce death rates from prostate cancer (for more information on these trials and the initial results see Cancer Help UK).

Explains that men are taking part in a large controlled trial to compare three different options; surgery, radiotherapy and active monitoring.

There may be some benefits from PSA screening, but no study has yet convincingly demonstrated this. It is also not clear whether the available treatments for prostate cancer save lives. However, it is absolutely clear that the treatment of prostate cancer causes serious health problems. 

Until we have better evidence and know the results of these trials any man can request a PSA test, providing he has read information about the lack of good quality evidence on the risks and benefits of testing (see 'Finding information about the PSA test' and 'Deciding whether or not to have the PSA test'). 

Last reviewed October 2010.

Last updated October 2010.