Full disclosure about cancer screening

Dear Madam,

PROSTATE CANCER SCREENING & MISLEADING STATISTICS

The British Medical Journal is a respected publication whose editorials and articles are considered to be authoritative. In so far as prostate cancer (PCa) is concerned and with the BMJ’s power to influence opinion, its latest editorial “Full Disclosure About Cancer Screening” [1] and analysis entitled “Cancer Screening Has Never Been Shown To Save Lives” [2] are highly misleading due to outdated references used by the authors to support their case.

Prostate cancer is the commonest cancer in UK men and second commonest cause of cancer deaths with 43,000 new registrations and 11,000 deaths each year. Despite this there is no national screening programme and although screening using the Prostate Specific Antigen (PSA) blood test is available via the NHS, only 8% of UK men avail themselves of the test. The reasons for this low uptake are lack of awareness amongst men and a negative attitude from the medical establishment based on perceived inaccuracy of PSA and the concepts of “over-diagnosis” and “over-treatment” of non-aggressive cancer based largely on outdated clinical practice.

In countries where PSA screening is extensive, the percentage of men presenting with advanced, incurable, metastatic PCa had dropped from 60-80% in the pre-PSA era to 20% or less now. Since the biggest international PSA screening trials commenced in Europe, cancer specific mortality has fallen consistently by approximately 30% with best trial results reporting a 50% drop! [3]

Regarding “over-diagnosis” and “over-treatment”, UK specialists are fully familiar with these historical problems and are working successfully to eliminate them as judged by the consistent rise in the proportion of men with apparent non-aggressive PCa who go onto active surveillance programmes.

In the BMJ articles emphasis is given to the differences between cancer specific and overall mortality but it is unacceptable to use a reference that is 13 years old [4]. It is equally misleading to quote references comparing PCa mortality statistics from the pre-PSA era and present these as if the data was current [5].

Regarding death from either metastatic PCa or locally advanced PCa, this is almost always thoroughly unpleasant and to be avoided if at all possible; screening almost always achieves this.

The editorial suggests the facilitation of Informed Decision Making (IDM). In the UK early PCa was used as the model for the introduction of IDM almost 10 years ago and its practice is standard in UK urology cancer practice.

So far as PCa and PSA screening is concerned, these BMJ articles from foreign authors, who are not urologists, are outdated, unbalanced, do not reflect current UK practice, do not reflect the international consensus [6] that advocates PCa screening based on an individual assessment of risk and informed decision making and do nothing to help men at risk, particularly those with a family history and black African and African Caribbean men, from this serious and frequently fatal disease.

References:
1. Gigerenzer G, BMJ, 2016; 352, 8
2. Prasad V et al, BMJ, 2016; 352, 22-23
3. Bokhorst L P et al, European Urol, 2014; 65(2), 329-36
4. Black C W et al, J.Natnl Cancer Inst, 2002; 94(3), 167-73
5. Fang F et al, J.Natnl Cancer Inst, 2010, 102(5), 307-14
6. Murphy D G et al, BJU International, 2013, 113, 186-188

Yours faithfully,
Clinical Advisory Board Members, Tackle Prostate Cancer

Chris Booth, MBBS, FRCS,
Clinical Advisory Board, Tackle
Clinical Director, CHAPS Men’s Health Charity

Professor Frank Chinegwundoh MBE
Consultant Urological Surgeon
Barts Health NHS Trust

Professor Stephen Langley MS FRCS Urol.
Professor of Urology & Clinical Director
Royal Surrey County Hospital, Guildford

Professor Heather Payne
Professor of Prostate Oncology
University College Hospitals, London

Dr Jonathan Rees,
GP Backwell and Nailsea Medical Group
Chair of the Primary Care Urology Society

Keith Cass, Patient Representative,
and Trustee of Tackle Prostate Cancer