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Shared decision policies result in high rates of PSA testing and inequity with minimal profit

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Shared decision policies result in high rates of PSA testing and inequity with minimal profit

Most high income countries, including the UK, should not have a national prostate cancer screening programme, but as a substitute allow men without symptoms to get a prostate-specific antigen (PSA) test in the event that they wish, after talking to their doctor.

But experts writing in The BMJ today argue that these shared decision policies have led to high rates of PSA testing and clear medical harm, with minimal profit and inequity.

Andrew Vickers and a global group of colleagues argue that prime income countries should either implement a comprehensive risk based approach to PSA testing – designed to scale back overdiagnosis and overtreatment – or discourage PSA testing through a transparent suggestion against screening, together with policies that make it hard to acquire a test without specific symptoms.

Prostate cancer is probably the most common cancer in men, and the third leading explanation for cancer death in men in Europe.

Nevertheless it’s still not clear whether the advantages of PSA screening, as currently practiced, outweigh the harms of overdiagnosis and overtreatment – when low risk tumours that will never cause symptoms or shorten life are detected and treated unnecessarily.

Within the UK, for instance, it’s estimated that about 10,000 men are overdiagnosed with prostate cancer yearly, exposing them to potential uncomfortable side effects of treatment without receiving any profit.

Given this uncertainty, just about all high income countries have opted for PSA testing based on shared decision-making.

However the authors argue that counting on shared decision-making to guide PSA testing has led to high rates of PSA testing particularly in older men, who’re most definitely to be harmed by screening and least more likely to profit. The shared decision-making approach also reflects and reproduces health inequities. For instance, in Canada and the US, PSA testing is less common in people from ethnic minorities, while within the UK and Switzerland, rates of PSA testing are lower in economically deprived areas.

In contrast, they are saying implementing a comprehensive, risk based prostate cancer early detection programme that fastidiously manages not only testing, but in addition biopsy and subsequent treatment, could substantially reduce the harms of overdiagnosis and overtreatment which have accompanied PSA-based screening.

Alternatively, they suggest restricting PSA testing to men with symptoms, with possible exceptions for a small variety of men at high risk, but they acknowledge that such policies are largely untested and would require further research.

“Although we consider that early detection of prostate cancer should involve shared decision making, the present approach of determining testing by shared decision making has resulted within the worst possible practical consequence of high levels of PSA testing and medical harm, with minimal profit and inequity,” they write.

“To make higher use of PSA testing, policy makers should choose from a comprehensive, risk adapted approach that’s specifically designed to scale back overdiagnosis and overtreatment, or restricting PSA testing to people referred to urologists with symptoms,” they explain.

“That alternative might want to take into consideration wider patient and public perspective, in addition to health economic concerns,” they conclude.

Is the UK really able to roll out prostate cancer screening, asks a linked feature? It describes how proponents and positive news coverage suggest a national programme is “in pipeline” – but finds uncertainty, controversy, and a necessity for more evidence.

Source:

Journal reference:

Vickers, A., et al. (2023) Current policies on early detection of prostate cancer create overdiagnosis and inequity with minimal profit. The BMJ. doi.org/10.1136/bmj-2022-071082.

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