Britain’s national screening advisers have ruled that trying to find prostate cancer with the PSA test is likely to cause more harm than good for most men, but they have made a narrow exception for a small group of men with a BRCA2 gene variant and a family history of certain cancers. The final guidance, published on Thursday, recommends screening those men every two years between the ages of 45 and 61.
The decision matters now because it sets the country’s official line on who should be invited for testing and who should not, after years of pressure to widen access. The UK National Screening Committee said the final recommendation would cover only a few thousand men each year, a tiny fraction of the population that had been considered in earlier proposals.
Prof Sir Mike Richards, who chairs the committee, said the group understood the appeal of screening, but also the damage the disease can cause. “We absolutely recognise the strong support for prostate cancer screening among a large number of people, but also the very real harm that can be caused by the disease, which patients, and indeed their families, experience,” he said. He added that screening can reduce deaths from prostate cancer “to a small extent” but does not improve overall survival.
That judgment rests on a painful trade-off. The committee said the main harms of population screening include incontinence and erectile dysfunction in men who would never have needed treatment. It also said that once a cancer is found, doctors still cannot reliably tell which tumours will need treatment and which can be left alone. “Once a prostate cancer is found, we still can’t reliably tell which cancers need treatment and which do not,” Richards said.
The guidance narrows the earlier draft published in November, which had included men with a BRCA1 gene variant as well as BRCA2 carriers. BRCA1 carriers were left out of the final recommendation after evidence pointed to a lower risk than first assumed. Anneke Lucassen, who helped advise the committee, said previous studies had “hadn’t been able to clearly separate out” the risk linked to BRCA1 and BRCA2, but two large recent studies suggested the BRCA1 risk was “significantly lower.”
For men who do carry BRCA2, the risk is substantial. The committee said that among 100 men with the variant, between 21 and 35 will develop prostate cancer before the age of 80. Even so, the advisers stopped short of extending routine screening to other groups already viewed as higher risk, including black men, saying there is still uncertainty about whether screening would do more good than harm.
That caution remains the centre of the policy. The committee said advances such as MRI scans before biopsy after a positive PSA test have not removed the problem of overdiagnosis. Its answer, for now, is a highly targeted screening programme for a small set of men, and no broader national rollout for everyone else.
