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Searching for answers: prostate screening in a stretched NHS

BMJ 2023; 381 doi: (Published 18 May 2023) Cite this as: BMJ 2023;381:p1118
  1. Juliet Dobson, managing editor
  1. The BMJ
  1. jdobson{at}
    Follow Juliet on Twitter @Juliet_hd

The UK National Screening Committee is due to review its advice on prostate cancer screening in the next year. At present a national screening programme is not recommended. Prostate specific antigen (PSA) testing can miss cancers while leading to high rates of overdiagnosis, creating treatment harms without benefits to many. But do the benefits of screening now outweigh the potential harms? Some researchers believe they do, thanks to technological advances, but the evidence is still unclear.

As Elisabeth Mahase reports this week, earlier this year a non-peer reviewed research abstract suggested that multiparametric magnetic resonance imaging and transperineal guided biopsies reduced the harms of screening (doi:10.1136/bmj.p1062).1 Use of these technologies meant fewer unnecessary biopsies, fewer men developing sepsis during diagnosis, and fewer overdiagnoses of “clinically insignificant cancer.”

However, there is still much disagreement among researchers. Although MRI reduces the chance of overdiagnosis, it is not clear by how much, and there isn’t yet the substantial evidence base needed to support population level screening. For Sam Merriel, a GP, we lack “clear, strong evidence that this new approach is worth rolling out nationally, inviting all men regularly.”

This view is echoed by Andrew Vickers and colleagues, who caution against the current approach of informed choice, whereby men can choose to have a PSA test if they wish after discussion with their doctor (doi:10.1136/bmj-2022-071082).2 They say this has “resulted in the worst possible practical outcome of high levels of PSA testing and medical harm, with minimal benefit and inequity.” Instead, they propose that countries either adopt a risk based approach to PSA testing that is designed to reduce overdiagnosis and overtreatment or limit PSA testing only to those with symptoms.

The impact of screening needs also to be considered in terms of ensuring equality of access and sufficient resourcing to deal with demand. In response to Prostate Cancer UK’s call for men to seek a prostate cancer check, the GP Margaret McCartney asks “what work they would like me to stop doing, which patients they would like to wait longer, so that I can do this work instead?” (doi:10.1136/bmj.p284).3

Rammya Matthew, also a GP, considers the wider harms to patients of overdiagnosis and overmedicalisation and the pressures placed on an already overstretched healthcare system (doi:10.1136/bmj.p1075).4 She calls on politicians to develop policies to help combat this growing problem but laments that “tackling overmedicalisation will never be a vote winner.”

But what approach to the NHS would win votes? John Appleby’s data briefing provides little comfort to politicians searching for answers (doi:10.1136/bmj.p1071).5 The public’s satisfaction with the NHS has dropped to an all time low, but opinions vary with political affiliation. Reducing waiting times—especially to see a GP—was found to be a priority for Conservative supporters, while Labour voters favoured boosting staff numbers. A recent report by NHS England and the Department of Health and Social Care looked at how access to GPs can be improved, but Helen Salisbury is unimpressed with the suggestion that new telephones will help GPs manage growing demand without more receptionists to answer them (doi:10.1136/bmj.p1101).6 “No amount of shiny new tech will compensate for all those years of failed workforce planning,” she says.

And where is the long promised workforce plan? Proposals from the plan have been leaked to the media, including the suggestion that medical training could be shortened and narrowed to tackle the shortage of doctors. David Oliver is not convinced: “The notion that we could condense the required undergraduate training into three years and produce equally rounded graduates seems bizarre” (doi:10.1136/bmj.p1100).7 It is yet another solution to the workforce crisis that is in search of a better answer.