Why it’s too early for prostate cancer screening and how Yorkshire is shaping its future

The debate about prostate cancer screening has intensified following the UK National Screening Committee’s recent recommendation that screening should not be introduced for all men.

Prostate cancer is the most common cancer in men in the UK, yet it’s the only major cancer without a national screening programme.

In this blog we explore the reasoning behind the expert panel’s decision, the impact of prostate cancer in Yorkshire and how Yorkshire Cancer Research is helping to shape what happens next. 

After reviewing the risks and benefits, the National Screening Committee, which advises Government ministers and the NHS on screening, has published draft guidance recommending men aged 45 to 61 with faulty BRCA genes should be screened for prostate cancer using a PSA test every two years.

In Yorkshire, 5,135 men aged 18 and above are estimated to have a genetic change that affects the BRCA gene, which means they have a significantly higher risk of developing prostate and breast cancers, and a slightly higher risk of developing pancreatic cancer compared to men without a faulty BRCA gene. Of these men, 1,390 are currently within the proposed 45 to 61 screening age.

Offering men who know they have a faulty BRCA gene a PSA test - one that measures the level of a protein associated with prostate cancer called ‘prostate-specific antigen’ in the blood - could save lives by finding cancers early or providing regular monitoring so appropriate treatment can be received as early as possible.

However, most people with a faulty BRCA gene are unaware and so this approach does not consider the thousands of men who do not know they are carriers of this genetic change. And there remains a lack of fair, consistent and systematic route to early detection for men from other high-risk groups, such as Black men, those with a family history and those from deprived backgrounds.

There are 46,884 Black men living in Yorkshire who have double the risk of developing prostate cancer compared to White men. 12,668 of these men are aged 45 to 61.

In addition, 600,068 men live in deprived areas of the region, where they are significantly more likely to be diagnosed with prostate cancer at a late stage. Of these men, 160,732 are aged 45 to 61.

In fact, this approach could exacerbate inequalities and leave high-risk men at greater risk of late diagnosis and death from prostate cancer.

It’s essential that any screening programme addresses cancer inequalities and ensures that those most at risk are not left behind.

But without clear evidence that the benefits of screening these men outweigh the risks, the National Screening Committee is unable to recommend that they are included in the proposed new guidance. 

The challenge with prostate cancer screening lies with the PSA test itself. While it’s currently the best tool available for detecting prostate cancer early, it’s far from perfect.

A PSA test measures the level of a protein called ‘prostate-specific antigen’ in the blood, which can be raised for many reasons including vigorous exercise or ejaculation – not just cancer.

This means the test can produce false positives, leading to unnecessary worry and diagnostic tests that can cause side effects.

PSA testing can also lead to unnecessary treatment in men with slow-growing cancers, who may never have known they had cancer had they not requested a test. These men are often offered ‘active surveillance’, which involves regular scans and tests to monitor the cancer. But half of men who choose active surveillance eventually go on to have surgery or radiotherapy due to rising PSA levels, even though the cancer may never cause harm.

It is estimated that 5,000 men in the UK – including 370 men in Yorkshire – are unnecessarily treated for prostate cancer every year, and go on to experience the physical, emotional and financial toll of cancer treatment that often causes side effects.

The PSA test can also produce false negatives, giving men reassurance when cancer is actually present. This is particularly true for some rare prostate cancers which can be fast-growing but don’t produce much PSA and can’t be picked up by the PSA test.

Some men with normal PSA results go on to be diagnosed at a late stage, when the cancer has spread and is harder to treat.

This is one of the reasons why there isn’t a national screening programme yet – the evidence isn’t strong enough to show that PSA testing alone saves lives without causing harm. There also hasn’t been enough research to determine whether other screening methods do offer more benefits than harm.

Research is critical to ensuring more men in Yorkshire and beyond are diagnosed with cancer at the earliest possible stage.

Science needs to keep pace with the demand for a nationwide screening programme. Until an effective and impactful method is identified, the introduction of screening must wait for robust evidence.

The National Screening Committee has now opened a consultation on its recommendation, and the charity is committed to working with policymakers to share its expertise and make sure the needs of men in Yorkshire are not overlooked.

As part of its aim to address cancer inequalities in Yorkshire, Yorkshire Cancer Research is funding the IMProVE clinical trial to test whether a screening programme that combines PSA blood tests with MRI scans can save lives. This will aim to help resolve the issues presented by PSA testing alone.

Yorkshire Cancer Research is also funding a clinical trial called Finesse, which aims to support the introduction of prostate cancer screening by finding new ways to reduce harm from unnecessary treatment.

Half of men who choose regular monitoring for slow-growing prostate cancer eventually go on to have surgery or radiotherapy due to rising PSA levels, even though the cancer may never cause harm.

One approach to avoiding overtreatment is active surveillance, where men receive regular tests and monitoring so treatment is only given if the cancer progresses.

Finesse is investigating whether an active medication that slows cancer growth can help men remain on active surveillance longer, reducing the need for surgery or radiotherapy. If successful, this could ease concerns about men having treatment they don’t need.

Yorkshire faces particular challenges when it comes to men’s health. In Yorkshire alone, more than 4,000 men are told they have prostate cancer every year.

It is the third most deprived region in England, and more than half of its local authority areas fall within the most deprived fifth of the country. People in these communities are less likely to recognise cancer symptoms and face more barriers when seeking help, such as getting an appointment at a time that works for them. When it comes to prostate cancer, this is compounded by the absence of a screening programme.

Men in Yorkshire are significantly more likely to be diagnosed at the most advanced stage of prostate cancer (Stage 4) than men living in London. Over a fifth (21%) of men in Yorkshire and the Humber are diagnosed at this stage, compared to 14% in the capital.

The impact of the lack of screening is clear in the data: more than half of men with prostate cancer in Yorkshire and the Humber are diagnosed at a late stage (Stage 3 or 4). In comparison, 14% of women with breast cancer, who have access to a well-established screening programme from the age of 50, are diagnosed at a late stage.  

But these men aren’t just statistics. They’re fathers, brothers and friends.

Crucially, the IMProVE trial will be designed to bring testing closer to the people who need it most. PSA tests will be offered at a mobile unit in local communities, and MRI scans will then take place in community diagnostic centres at the Sheffield Olympic Legacy Park and Thorpe Park Leeds.

This approach will make it easier for men to take the first step and ensure they can benefit from advanced imaging tests.

As part of the trial, the research team will also explore the perspectives of men most at risk of prostate cancer, including those from Black or economically disadvantaged backgrounds, to understand their views on prostate cancer and any factors that might encourage or discourage them from taking part in screening. The findings will then be used to help shape the trial.

IMProVE will complement the research being conducted through the TRANSFORM trial, which is funded by Prostate Cancer UK, the NHS, the National Institute for Health and Care Research (NIHR) and the UK Government. It will bring screening opportunities to more men in Yorkshire while contributing to the evidence needed for the Government to consider introducing screening for more men at risk of prostate cancer.      

Current testing for prostate cancer is complex and, for many men in Yorkshire, fundamentally unfair. At present, men over 50 without symptoms can request a PSA blood test from their GP, but guidelines advise doctors not to raise the issue proactively, even with those at highest risk. This means the responsibility falls on men to know their risk and have the confidence and knowledge to ask for a test, which many don’t.

In the absence of a screening programme, the PSA test remains the best tool we have for early detection.

It may take a few years for the evidence needed to be generated, so in the meantime the Government must:

• Advise GPs to proactively discuss PSA testing with men at high risk of prostate cancer
• Look to innovative methods to support men to continue to be closely monitored through ‘active surveillance’ so that unnecessary treatment is avoided.

Yorkshire Cancer Research is calling for clearer, evidence-based guidelines that will help men with prostate cancer make more informed decisions about their treatment plans.

You can make an appointment with your GP to talk about the advantages and disadvantages of the PSA test. The test is available to anyone with a prostate, including trans women and some non-binary people.

If you’re at high risk of prostate cancer – including if you’re Black, have a family history or have a faulty BRCA gene - we recommend speaking to your GP about the PSA test from the age of 45.

Before your appointment, think about what matters most to you and ask about the benefits and risks of testing.  Your GP can help you make an informed choice.