Intended for healthcare professionals


Screening without evidence of efficacy

BMJ 2004; 328 doi: (Published 05 February 2004) Cite this as: BMJ 2004;328:301

PSA Screening: Honest information is always better than patronising advice

The implied conclusion of Malcolm Law’s editorial is that PSA testing should be banned(1). Leaving aside the scientific arguments, the ‘genie is out of the bottle’ and the PSA (prostate specific antigen) screening of prostate cancer is here to stay.

The current MMR vaccine fiasco demonstrates that even when a policy is underpinned by good scientific evidence, public can remain skeptical of the public health authorities. Hence it is better to provide honest information and let the men decide rather be patronising and deny PSA testing to all.

I agree with most of the comments in the editorial but PSA screening of prostate cancer differs in one subtle but important aspect from screening of other cancers. Breast screening, for example, is done in completely asymptomatic women. But PSA screening takes place in men who have atleast mild urinary tract symptoms. The symptoms of prostate cancer are very similar to the symptoms of benign enlargement of prostate. Lower urinary symptoms due to benign prostatic hyperplasia (BPH) are quite common in elderly in whom the incidence of prostate cancer is the highest. With increasing awareness of prostate cancer, it is going to be quite difficult for a general practitioner to deny a PSA test to patients who request it.

Furthermore, effective treatment is available for prostate cancer(2). Its entirely a different matter that the cure of prostate cancer doesn’t lead to an increase in life expectancy. But it’s not for the clinicians to decide the trade off between side effects of potentially curative treatment and the risks of cancer progression related symptoms (3). Patients views matter most and it is definitely not useless to provide honest information.

1. Law M. Screening without evidence of efficacy. BMJ 2004;328:301- 302.

2. Holmberg L, Bill-Axelson A, Helgesen F, Salo JO, Folmerz P, Haggman M, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med. 2002;347(11):781- 789.

3. Steineck G, Helgesen F, Adolfsson J, Dickman PW, Johansson JE, Norlen BJ, et al. Quality of life after radical prostatectomy or watchful waiting. N Engl J Med. 2002;347(11):790-796.

Competing interests: I treat prostate cancer patients and have research interests in prostate cancer.

Competing interests: No competing interests

24 February 2004
Santhanam Sundar
Consultant Oncologist
Dept of Oncology, Nottinghma City Hospital, NG5 1PB