Intended for healthcare professionals

CCBYNC Open access

Rapid response to:

Practice Rapid Recommendations

Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3581 (Published 05 September 2018) Cite this as: BMJ 2018;362:k3581

Population

Diagnostic pathway for prostate cancer Localised Stage I or II Stage III or IV Advanced Abnormal biopsy and staging No cancer diagnosis Normal biopsy Still possible to have a biopsy and be diagnosed, based on clinical suspicion No Biopsy Biopsy Normal PSA Elevated PSA or Choices considered in this comparison Prostate-specific antigen (PSA) screening No PSAscreening Width of lines proportional to approximate numbers of people Subsequent treatment Surgery Radiation Active surveillance With or withouthormonal therapy Can be followed byradical treatment Men without a previous diagnosis of prostate cancer considering screening

Comparison

or Screening No screening Screening No screening Using prostate-specific antigen testing

We suggest against systematic PSA-based screening for prostate cancer. Either option is reasonable. Shared decision making is needed for men considering screening. Moredetails Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.

Comparison of benefits and harms

All evidence

With screening With no screening Evidence quality Events per 1000 people Within 10 years No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

No important difference All cause mortality Moderate More 129 128

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns PSA screening probably has little or no effect on all cause mortality

No important difference Prostate cancer mortality Low More 3 3

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency Serious Publication bias No serious concerns PSA screening may have little or no effect on prostate cancer mortality

7 fewer Incidence of cancer (any stage) Low More 32 39

Risk of Bias Serious Imprecision Because of inconsistency Indirectness No serious concerns Inconsistency Serious Publication bias No serious concerns PSA screening may increase the detection of prostate cancer (any stage)

7 fewer Incidence of localized cancer Low More 19 26

Risk of Bias Serious Imprecision Because of inconsistency Indirectness No serious concerns Inconsistency Serious Publication bias No serious concerns PSA screening may increase the detection of localized cancer (stage I or II)

Incidence of advanced cancer Low More 13 11 No important difference

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency Serious Publication bias No serious concerns PSA screening may have little or no effect on the detection of advanced cancer (stage III or IV)
Within 1 month

Fewer Biopsy-related complications Low More

Among 1000 men with PSA screening, more presented with complications due to prostate biopsies: Blood in semen: 94 Pain: 45 Fever: 19 Hospitalized for sepsis: 1 Blood in urine: 67 Because of uncertainty due to estimating likelihood along the diagnostic pathway
At any time

Fewer Cancer treatment complications Low More

Among 1000 men with PSA screening, more presented with complications due to cancer treatment: Erection not firm enough for intercourse: 25 Urinary incontinence: 3 Because of uncertainty due to estimating likelihood along the diagnostic pathway
See patient decision aids
See all outcomes

Selected evidence at lower risk of bias This section includes only data from the ERSPC trial, conducted in 162 243 participants in 9 European countries

With screening With no screening Evidence quality Events per 1000 people Within 10 years No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

No important difference Moderate More 129 129 All cause mortality

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns PSA screening probably has little or no effect on all cause mortality

1 fewer Moderate More 3 2 Prostate cancer mortality

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns PSA screening probably leads to a small reduction in prostate cancer mortality

18 fewer Moderate More 32 50 Incidence of cancer (any stage)

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns PSA screening probably increases the detection of prostate cancer (any stage)

14 fewer Moderate More 19 33 Incidence of localized cancer

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns PSA screening probably increases the detection of localized cancer (stage I or II)

13 Moderate More 3 fewer 10 Incidence of advanced cancer

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns PSA screening probably slightly decreases the detection of advanced cancer (stage III or IV)
Within 1 month

Low More Biopsy-related complications Fewer

Among 1000 men with PSA screening, more presented with complications due to prostate biopsies: Blood in semen: 94 Pain: 45 Fever: 19 Hospitalized for sepsis: 1 Blood in urine: 67 Because of uncertainty due to estimating likelihood along the diagnostic pathway
At any time

Low More Cancer treatment complications Fewer

Among 1000 men with PSA screening, more presented with complications due to cancer treatment: Erection not firm enough for intercourse: 25 Urinary incontinence: 3 Because of uncertainty due to estimating likelihood along the diagnostic pathway
See patient decision aids
See all outcomes

Men with family history of prostate cancer Family history defined positive if man’s father or at least one brother had been diagnosed with prostate cancer

With screening With no screening Evidence quality Events per 1000 people Within 10 years No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

29 fewer Incidence of cancer (any stage) Moderate More 50 79

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns PSA screening probably increases the detection of prostate cancer (any stage)

19 fewer 25 Incidence of localized cancer Moderate More 44

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns PSA screening probably increases the detection of localized cancer (stage I or II)
See patient decision aids
See all outcomes

Men of African descent

With screening With no screening Evidence quality Events per 1000 people Within 10 years No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

Prostate cancer mortality Moderate More 7 1 fewer 6

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns PSA screening probably has little or no effect on prostate cancer mortality

29 fewer Incidence of cancer (any stage) Moderate More 51 80

Risk of Bias Serious Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns PSA screening probably increases the detection of prostate cancer (any stage)
See patient decision aids
See all outcomes
Men with these characteristics carry a higher incidence of prostate cancer, and could be at higher risk of dying of prostate cancer. It remains uncertain whether the impact of screening is similar in these higher risk men in comparison to men at lower risk. Men at higher risks There is considerable variability among men's values and preferences regarding prostate cancer screening. Men who place a high value in avoiding complications from biopsies and subsequent treatment are likely to decline screening. In contrast, men who place a higher value in even a small reduction of prostate cancer mortality may opt for screening. Higher risk patients may be more likely to seek screening because they may worry more about prostate cancer and want to rule out the diagnosis. Values and preferences LUTS symptoms like these are common complaints in adult men that can have a major impact on quality of life and substantial economic burden. The aetiology of LUTS is multifactorial, benign prostatic enlargement, due to hyperplasia, being the major cause. Evidence to date indicates that men with LUTS are at no higher risk of prostate cancer than men without LUTS. Lower Urinary Tract Symptoms (LUTS) Key practical issues PSA testing is done with a regular blood sample Usually taken through rectum guided by ultrasound Takes about 5-10 minutes Antibiotics given before procedure Local anaesthesia or sedation given before procedure May have to stop blood thinners before procedure Screening If biopsy is required Slow stream Sensation of incomplete emptying Increased urinary frequency Family history of prostate cancer African descent Poorer socio-economic groups

©BMJ Publishing Group Limited.

Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/

Find recommendations, evidence summaries and consultation decision aids for use in your practice

Rapid Response:

Prostate screening: worse than useless if multi-needle biopsy spreads cancer

The BMJ publishes a clear guideline based on an excellent systematic review confirming yet again a population screening strategy that does not ‘work’: asymptomatic men are harmed by routine PSA testing.(1) For every 1000 men screened vs not screened there is no reduction in all-cause deaths, and a great many men damaged by ‘life-changing’ labels, invasive investigations, treatments and complications. Yet many men are offered ‘routine’ PSA checks and think them a good idea,(2) few realize they are not.(3) Privately, morose doctors comment that no one’s more grateful than incontinent, impotent men who believe their lives ‘were saved by screening’. Even the test’s founder decries it.(4)

Meanwhile money spent on screening and its aftermath is diverted away from effective treatments for the sick. Maybe evidence has no impact because men aren’t shown the excellent available decision aids,(1,5) or they aren’t warned about the uncertain safety of multi-needle prostate biopsy which has the potential to cause needle track spread and local extension?(6,7) Failing to look for, and correctly stage, extra-capsular tumour preoperatively might partly explain the failure of screening strategies to improve survival. The general public deserves new, explanatory narratives. It’s possible to live healthily and long with small specks of dormant cancers. It’s not a good idea to search out and biopsy indolent lesions with multiple needles, just as it’s dangerous to poke sleeping dogs with sticks.

References
1. Tikkinen KAO, Dahm P, Lytvyn L, Heen AF, Vernooij RWM, Siemieniuk RAC, Wheeler R, Vaughan B, Fobuzi AC, Blanker MH, Junod N, Sommer J, Stirnemann J, Yoshimura M, Auer R, MacDonald H, Guyatt G, Vandvik PO, Agoritsas T. Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline. BMJ 2018;362:k3581 BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3581 (Published 05 September 2018)
2. Fry S. Stephen Fry announces he has prostate cancer. https://www.youtube.com/watch?v=9yDNAc8YS9c&feature=youtu.be (last accessed 27 Sept 2018)
3. Monbiot G. I have prostate cancer. But I am happy. https://www.theguardian.com/commentisfree/2018/mar/13/prostate-cancer-ha... (last accessed 27 Sept 2018)
4. Albin RJ. The Great Prostate Mistake. https://www.nytimes.com/2010/03/10/opinion/10Ablin.html?pa (last accessed 27 Sept 2018)
5. Harding Centre for Risk Literacy. Early detection of prostate cancer with PSA testing and a digital rectal exam. https://www.harding-center.mpg.de/en/fact-boxes/early-detection-of-cance... (last accessed 27 Sept 2018)
6. Stainsby GD. 10-Year Outcomes in Localised Prostate Cancer. Letter to Editor. N Engl J Med 2017; 376: 178-181. January 12: 2017. https://www.nejm.org/doi/full/10.1056/NEJMc1614342
7. Stainsby GD, Bewley S. Patients’ roles and rights in research https://www.bmj.com/content/362/bmj.k3193/rr-10
8. ProTecT study. Prostate testing for cancer and Treatment. HTA No 96/20/99. Principal investigators: FC Hamdy, JL Donovan, DE Neal. Coordinator: JA Lane. https://www.nejm.org/doi/full/10.1056/NEJMoa1606220

Competing interests: SB declares no interests (see www.whopaysthisdoctor/58), GDS participated in the ProTecT trial.(8) Unusually, post positive biopsy, he underwent ultrasound examination which showed unexpected extra-capsular tumour spread, confirmed and demonstrated in greater detail by MRI scan.

27 September 2018
Susan Bewley
Professor (emeritus) of Obstetrics and Women's Health
G. David Stainsby, FRCS, Retired Consultant Orthopaedic Surgeon
King's College London
Department of Women's and Children's Health, c/o 10th floor St Thomas' Hospital, Westminster Bridge Road, London SE1 7NH