Prostate Cancer ‘Test by Request’ Policies: Beneficial or Detrimental

Informed choice approaches in prostate cancer screening may lead to high rates of unsystematic prostate-specific antigen (PSA) testing, argue experts writing in journal The BMJ. These high rates of testing only provide minimal benefit and inequity. Prostate cancer is the most common cancer in men and the third leading cause of cancer death in men in Europe. But it’s still not clear whether the benefits of PSA screening, as currently practiced, outweigh the harms of overdiagnosis and overtreatment (1^✔ ✔Trusted Source
Prostate-Specific Antigen–Based Screening for Prostate Cancer Evidence Report and Systematic Review for the US Preventive Services Task Force

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In the UK, for example, it is estimated that about 10,000 men are overdiagnosed with prostate cancer every year, exposing them to potential side effects of treatment without receiving any benefit. Given this uncertainty, almost all high-income countries have opted for PSA testing based on shared decision-making.

Prostate-Specific Antigen (PSA) Test Approach: Risk-Based or Shared Decision?

But relying on shared decision-making to guide PSA testing has led to high rates of PSA testing, particularly in older men, who are most likely to be harmed by screening and least likely to benefit. The shared decision-making approach also reflects and reproduces health inequities.

In contrast, implementing a comprehensive, risk-based prostate cancer early detection program that carefully manages not just testing, but also biopsy and subsequent treatment, could substantially reduce the harms of overdiagnosis and overtreatment that have accompanied PSA-based screening.

Alternatively, experts suggest restricting PSA testing to men with symptoms, with possible exceptions for a small number of men at high risk, but they acknowledge that such policies are largely untested and would require further research.

Although we believe that early detection of prostate cancer should involve shared decision-making, the current approach of determining testing by shared decision-making has resulted in the worst possible practical outcome of high levels of PSA testing and medical harm, with minimal benefit and inequity (2^✔ ✔Trusted Source
Current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal benefit

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To make better use of PSA testing, policymakers should choose between a comprehensive, risk-adapted approach that is specifically designed to reduce overdiagnosis and overtreatment, or restricting PSA testing to people referred to urologists with symptoms.

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That choice will need to consider wider patient and public perspectives, as well as health and economic concerns.

References:

1. Prostate-Specific Antigen–Based Screening for Prostate Cancer Evidence Report and Systematic Review for the US Preventive Services Task Force - (https://jamanetwork.com/journals/jama/fullarticle/2680554)
2. Current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal benefit - (https://www.bmj.com/content/381/bmj-2022-071082)

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Source-Eurekalert