Not so NICE

It seems clear to me that ceasing to screen for prostate cancer using the Prostate Specific Antigen (PSA) blood test has resulted in more men being diagnosed at advanced stages and caused increased potential of mortality.¹

Changing recommendations

Historically, screening using PSA testing was said to “cause more harm than good,” which was primarily as men were over-treated when a high PSA level was recorded. A high reading could also lead to biopsies that in turn could lead to infections.

However, the diagnostic pathway has now changed out of all recognition compared to the “bad old days!” Here in the UK, biopsies should only be done after a multi parametric MRI scan and the biopsy should be done transperineally. This can lead to more accurate biopsies, reduced chance of infection, better more accurate diagnosis and, very importantly, reduce over-treatment.^2,3

In the words of a leading urological consultant, “the scales have tipped in favor of PSA testing in the right patients.”

Encouraging men to get a PSA test

As an awareness speaker here in the UK, I normally do 25-30 talks per annum trying to persuade men to ask their GPs for a PSA blood test. And I use my own story to highlight why it’s so important to do so. The most common comment I get is, “My GP said I’m too young,” or, “You’ve got no symptoms, so there’s no need.” I’ve even been told of a man with a family history of prostate cancer being refused a PSA test.

I think this is scandalous. A friend recently told me about burying his friend, saying he'd asked for a PSA test years ago, but his GP said it was unnecessary. By the time they found the cancer, it was everywhere, and within a few months he was gone.

Stunned by the guidelines

I looked at the guidelines from our National Institute for Health and Care Excellence (N.I.C.E.), who dictate health policy, and was staggered by what I read!

It starts well when it says to offer a PSA test to men over 50 who request a test, but then goes on to say, “PSA testing should not be offered to asymptomatic men.” Let’s analyze that in a bit more detail. What about men over 45 with a family history and Black men aged over 45? We know that the risk is much greater in these groups, so why should they be excluded?⁴

We also know that most men diagnosed with early-stage prostate cancer are asymptomatic. It’s also clear that many men, including me, are diagnosed at stage 4 despite having had no symptoms. I think these guidelines are akin to a death sentence for men!

The pros and cons

The guidelines then talk about what advice to provide men about PSA testing, and I find it ridiculously skewed toward discouraging men from having a test. It also seems to me to completely ignore the latest diagnostic pathway and be based on the historic way of doing TRUS biopsies, rather than templated mpMRI guided biopsies.

I think the guidelines only give a very vague nod towards the implications of late diagnosis when they say "detecting prostate cancer early before symptoms develop may extend life, or facilitate a complete cure." Again though, we know that many men don’t develop symptoms!⁴

I think it also doesn’t highlight the very harsh reality of diagnosis at stage 4 which, from a treatment perspective, can be chemical castration with the horrendous side effects of that and then potentially a premature and painful death. If we are going to highlight the pros and cons, let's at least be honest about the worst possible con!

Needing to do better

I’m also aware that, although it’s not specifically mentioned in these guidelines, men over 70 are discouraged from being offered a test because of their lower life expectancy. However, that seems to me to totally ignore the fact that we are living longer.

I have to conclude from this that we have to do so much better and that N.I.C.E. are not very nice at all! We simply cannot carry on refusing PSA tests, increasing stage 4 diagnoses and mortality risks as a result!