- Margaret McCartney, GP1
If reading about prostate specific antigen (PSA) screening in the British press, you could be forgiven for thinking that the NHS is actively withholding a test from men that could otherwise and straightforwardly “save their lives.” Several UK newspapers have pushed the narrative that screening is an obvious good and that the NHS failing to have a screening programme for prostate cancer is stupid, negligent, or irrational.
Currently, the UK does not have a national screening programme for prostate cancer. It has a workaround, in the form of a “test on request” system. However, men from the least deprived areas are more likely to ask for and receive tests.1 The NHS recommends GPs to not proactively discuss PSA screening with patients who are asymptomatic.2 Men who request testing are meant to make an informed choice by using information from the NHS Prostate Cancer Risk Management Programme.3 The UK National Screening Committee members, who regularly review the evidence on screening and make recommendations to UK politicians, currently recommend against prostate cancer screening and are due to report on their latest review of the evidence in the next few months.
Although a few articles have tried to inform readers that “it’s complicated,” most of the media narrative has been neither fair nor helpful. The coverage risks making men feel that they must “fight” to get a test—hardly creating the optimal environment for trusted discussions about risk in a healthcare setting. The media has sown mistrust in the NHS, depicting it as unfeeling and uninformed. PSA screening is not straightforward and its use can result in harm without benefit—overdiagnosis and overtreatment, which can lead to impotence and incontinence.4 This means it is crucial that men are well informed.
At least two newspapers are actively campaigning for a national prostate cancer screening programme. A recent Daily Mail headline featured men telling their stories of diagnosis stating: “We’re proof prostate cancer screening can save men’s lives,” even though there is no way an individual could know or prove this.5 One of the interviewees in the article, whose prostate cancer was detected at screening, was quoted as saying the test “could well have saved my life.” This quotation contrasts with the definitive implication of the headline, which adds drama but lacks nuance. Evidence informed comment would have explained the difficulty of interpreting the impact of a PSA test on an individual—including the potential for overdiagnosis and overtreatment. Instead, the article included a consultant surgeon complaining that while some GPs “stick religiously” to guidance not to offer PSA for screening, some practices offer tests. The consultant surgeon adds: “We are supposed to have a National Health Service so it should not be this variable,” and “It’s so unfair.” This could be considered in the opposite direction: it is unfair that many men are subjected to a test that the NHS does not recommend GPs proactively offer because it does net harm.25
In the Daily Telegraph, there is outrage that many men have to visit their GP at least three times before their cancer is detected—an appointment to discuss the test, another to have the test, and another to get the results of the test does not seem unreasonable (even though they say that 60.2% were diagnosed at one visit).6 They confidently assert that there is “proof that prostate screening benefits outweigh the risks” even though many men who are fully informed of the evidence would disagree.67
Back at the Daily Mail, another headline reads “Is UK National Screening Committee really going to deny prostate tests for sake of £18 a patient? Report estimates targeted screening would save thousands of men’s lives.”8 They go on to report that a “lifesaving” prostate screening programme would require “5 [magnetic resonance imaging] scanners and 75 extra staff, including 4 urologists.” This figure is based on modelling data used in a report, written by a healthcare consultancy firm, and published by a charity rather than through a peer reviewed journal process: the charity want screening for “high risk men aged 45-69.”9
The net result is that some of the media are badly informing men, raising the risk of decision making that is not aligned with higher quality evidence. Even the well intended “targeted national screening programme” pressed for by Prostate Cancer Research is not evidenced—we should not assume that higher risk groups will benefit from more frequent or earlier screening.10 Prostate Cancer UK’s current campaign, which has been rolled out online and by advertising in high streets, directs men to the charity’s risk checker.11 The online series of questions results in all men aged over 50 and all black men aged over 45 being told that they are at higher risk and prompts them to speak to their GP. Though it acknowledges that the pros and cons should be discussed with a GP, the tool asserts that the PSA test is “safe and effective” for working out “if you need more tests” but men should also know that it can trigger a chain of potentially hazardous interventions and treatments that may not benefit them—as well as the impact of uncertainty and a diagnosis.
The NHS website should be much more proactive in highlighting evidence based advice and should stop linking to charities who promote screening when the UK National Screening Committee does not.12
