Rights for men! PSA testing

Sir,

I am writing this from a trainee viewpoint.

I was delighted to read your article on rights regarding PSA testing in February [1]. I know it’s not February or Valentine’s Day now, but men’s rights regarding PSA testing is a central issue. When compared to breast cancer, and women’s rights, men’s rights regarding PSA testing are lagging behind.

At a patient conference, prostate cancer survivors made comments on problems getting their PSA levels tested before being diagnosed with prostate cancer. Whilst some had symptoms of LUTS and had been to their GP to be tested, there were patients who had no symptoms and were unable to get a test. These were all patients who, after being tested, required radical intervention. So where do we as healthcare professionals stand?

I was very happy to note the Melbourne Consensus Statement. This clearly advocates PSA testing, especially for those in the younger age groups, and acknowledges its role as part of a multivariate approach towards detecting prostate cancer [2]. At the same time, it also centralises the use of PSA in the older age group as part of a watchful waiting treatment plan [2]. However, no document clearly specifies or reiterates a screening process for prostate cancer. As a result, patients who potentially may have prostate cancer are left in the dark with regards to their rights. This should lead us to the age-old adage of ‘when in doubt, test’. Men clearly presenting to healthcare professionals have been proven to have a high incidence of prostate cancer. So then what happens to the patients who present to healthcare professionals and are refused a PSA test?

At the same time, there have been many screening trials, such as PLCO and ESRPC [3, 4]. This data demonstrates equivocal results between prostate cancer screening and testing. Screening for prostate cancer has always been weighed against treatment priorities of over diagnosis and overtreatment. On the other hand, the extended results of the ESRPC study demonstrated screening does significantly reduce deaths from prostate cancer [4]. However a longer follow-up period is required for this study. Whilst not screening benefits patients by preventing over diagnosis and overtreatment, it does not help the patients struggle to get tested. The inequity is not that PSA is an imperfect test, but the way it is used is far too variable and non-evidence-based as a result. As a biomarker, it currently outperforms cervical screening and mammography.

Cancer campaigns such as the one run by Prostate Cancer UK have helped create awareness about prostate cancer and just how problematic it can be. However, whilst the patient being more aware is a good thing, it does not help if they struggle to get the one test that will allow diagnosis and treatment to occur.

Sanchia S. Goonewardene* and Raj Persad**
*Spr, Urol University of Warwick, **Professor of Urology, Southmead Hospital Bristol

References

1. Dasgupta P. Valentine’s Day PSA. BJU Int 2014; 113: 177
2. Murphy DG, Ahlering T, Catalona WJ, et al. The Melbourne Consensus Statement on the early detection of prostate cancer. BJU Int 2014; 113: 186-188
3. Hayes RB, Sigurdson A, Moore L, et al. Methods for etiologic and early marker investigations in the PLCO trial. Mutat Res 2005; 592: 147-154
4. Studer UE, Collette L. What can be concluded from the ERSPC and PLCO trial data? Urol Oncol 2010; 28: 668-669