Prostate cancer kills more than 10,000 men in England each year and testing has never been more important or more debated.
For the past 32 years, urologists across the country have been collecting data on the benefits of screening men for prostate cancer using the PSA test (prostate-specific antigen test).
Now, the latest major study based on this research comprehensively shows that such testing can prevent deaths, with mortality rates falling by 13 per cent among middle-aged men who were screened. “This offers the strongest and longest-term evidence yet that PSA screening can reduce deaths from prostate cancer,” says Ivo de Vos, a researcher in the department of urology at Erasmus MC Sophia Children’s Hospital, and one of the study authors.
However, the UK’s National Screening Committee has decided against vouching for population-wide testing for all men of a certain age. In an announcement made in November, the committee decided only to recommend screening for men with certain high-risk genetic mutations. With former PM Rishi Sunak, actor Stephen Fry, and Olympic cycling gold medallist Chris Hoy – who has terminal prostate cancer – all declaring their disappointment at the news, Health Secretary Wes Streeting has vowed to examine the evidence ahead of a final decision in March.
While screening can save lives, the delicate balance between the risks and benefits of mass testing remains a thorny issue among academic experts. This is because of the inherent limitations of the PSA test.
While elevated levels can indicate cancer, it has a high rate of so-called false positives. For example, 75 per cent of men with a high PSA value do not have cancer, while the test does not discriminate between slow-growing cancers, which are unlikely to ever spread beyond the prostate, and the aggressive, life-threatening tumours.
The committee’s caution is thought to stem from notorious cases where men who either didn’t have cancer at all, or had relatively benign cancers, ended up receiving highly invasive investigations which left them incontinent or impotent. Even in the wake of his study, de Vos agrees this is a serious concern.
“Overdiagnosis often leads to overtreatment, including unnecessary surgery or radiotherapy, which can result in lifelong side effects such as incontinence and sexual dysfunction,” he says.
However, experts are concerned that the decision means that many men at high-risk of the disease will continue to slip through the net, and not be picked up until they have advanced cancer.
So, if the screening committee’s decision stands, who will get access to testing, and who will miss out?
Who will be tested?
Men with BRCA gene mutations
The National Screening Committee has recommended that men aged between 45 and 61, who carry mutations in the BRCA1 and BRCA2 genes should be put forward for PSA testing. While BRCA genes are best known for their link with breast and ovarian cancer, studies have also linked them to prostate cancer.
According to Professor Ros Eeles of the Institute of Cancer Research, approximately one in 300 men carry BRCA1 gene mutations which place them at an elevated risk of getting the cancer. “Men with the BRCA1 gene fault are more than three times as likely, compared with non-carriers, to have aggressive prostate cancers that are likely to grow and spread quickly,” says Eeles.
Research has also shown that men with BRCA2 gene mutations have nearly twice the risk of not only getting prostate cancer, but highly aggressive disease, as well as developing cancer at a younger age.
However, Eeles says that for the screening committee’s recommendation to really make a difference in reducing the incidence and mortality relating to prostate cancer, the NHS will need to expand its BRCA testing program. While there are up to 32,000 men in the UK aged 45-69 who could carry a worrisome BRCA variant, the majority of BRCA testing so far has been aimed at women.
“Unless BRCA testing is expanded, there are thousands of men who will miss out on this screening programme,” says Eeles. “The NHS needs to offer BRCA testing to more men, starting by offering testing to male relatives of BRCA carriers.”
