Weighing up the risks and benefits of prostate cancer screening | Letters

It is understandable for patients suffering from a late diagnosis of prostate cancer, or families who have lost loved ones, to demand that something should be done (Letters, 5 December). I, however, respect the UK National Screening Committee’s recommendation not to screen most men using the prostate specific antigen (PSA) test.

The job of the committee was to weigh up the benefits and harms of any available test for routine screening. PSA testing, as a first step to diagnose cancer, results in false negatives and a significant number of false positives, meaning it has both low sensitivity and low specificity, making it a poor screening marker. PSA screening has been conducted in the US; there are varying estimates that, over three decades, it has resulted in more than 1 million patients receiving treatment (eg surgery or radiotherapy) they did not need.

Randomised trials are considered the gold standard in modern medicine. Approximations from the European Randomized Study of Screening for Prostate Cancer estimate that PSA-based screening prevents about 1.3 deaths from prostate cancer per 1,000 men screened over 13 years. This illustrates the problem of overdiagnosis of low-volume, low-risk cancers that would not cause patients harm. In addition to a huge psychological burden for patients, any treatment may be unnecessary and result in possible lifelong side-effects (such as incontinence and erectile dysfunction).

As difficult as it may seem, we should not settle for PSA tests for routine screening. We must redouble efforts to identify screening markers with high sensitivity and high specificity, and accelerate research into treatment for this terrible disease.
Aamir Ahmed
London

I deeply sympathise with your letter writer Pat Sharpe regarding the loss of her husband. However, as a retired consultant physician, I have always refused PSA testing. There is a naive belief that early detection and treatment improves outcomes. For most cancers this is true, but sadly not so for prostate cancer. The best study I know of (Hamdy et al, New England Journal of Medicine, 2023) clearly shows that outcomes in terms of mortality are essentially identical whether patients are assigned to radical surgery, radiotherapy or simple observation. Few patients die in any group, and active treatment doesn’t influence this.

However, radical treatment has frequent and horrible side-effects. Screening is only worthwhile if there is effective treatment. This isn’t so for prostate cancer.
Dr Graham Simpson
Melbourne, Australia

Pat Sharpe’s letter resonates forcefully with my wife and me. I had always understood PSA testing to be little more than worthless. However, a year ago, I had to undergo routine blood tests and decided to ask the nurse to include a PSA test because of an interview I had heard on the radio that morning. I was 62, with no symptoms or reason to test.

I am so glad that I asked. I had an elevated PSA (6.4) and was swiftly diagnosed with high-risk, high-volume prostate cancer; fortunately it was still contained.

I have had a prostatectomy, which brings its own consequences, but my wife and I can live with those. Had I continued in my ignorance, I wonder just how many more Christmases I would have enjoyed.
Adrian Bell
Gosport, Hampshire

I first showed a (slightly) elevated PSA level some 20 years ago in the course of an annual check-up. The consultant to whom I was referred explained that I could have a biopsy but that it carried a risk of erectile dysfunction and/or impotence. So, valuing my continence and sexual life, I declined. This set a pattern over the ensuing years of a gradually but consistently rising PSA. Eventually I had a multi-parametric MRI (mpMRI) and a number of other non-invasive tests, and I was advised that the likelihood of my having cancer was very low.

As I understand it, mpMRI is a far more accurate predictor than PSA. Why is it not used in routine screening? Men who, like me, do not want to undergo the painful and potentially damaging biopsy, might be much more likely to have the painless and safe mpMRI scan.
David Gollancz
London