Screening for prostate cancer is controversial. Findings from studies conclude that currently there is insufficient evidence to recommend its introduction because of concerns that it may not improve survival or quality of life and may actually cause more harm than good (38).

Evidence is limited for the benefits of treatment for localised cancers detected through screening whereas the evidence for harm is clear. Screening has so far not been found to reduce mortality(39).

Although there is no organised screening programme for prostate cancer, an informed choice programme ‘Prostate cancer risk management’ has been introduced.

‘The aim of Prostate Cancer Risk Management is to ensure that men who are concerned about the risk of prostate cancer receive clear and balanced information about the advantages and disadvantages of the PSA test and treatment for prostate cancer. This will help men to decide whether they want to have the test (40).

Information packs have been given to GPs which will help guide them when counselling men on the benefits and disadvantages of having a PSA test. The NHS Cancer Screening Programmes has worked with Cancerbackup to produce a booklet about the PSA test for men requesting further information about prostate cancer and the PSA test.

ProtecT trial

Cancer Research UK and the Department of Health are funding an extension to the ProtecT trial which is looking into the treatment for prostate cancer. The extension will compare the outcomes for men from those practices that were offered PSA testing with ProtecT, with men from other practices.

The possible advantages of having a PSA test are that:

• it could give men reassurance if the test is normal
• it can find cancers before any symptoms develop
• and treatment in the early stages could help a person live longer (although there is no good evidence that this is so).

The possible disadvantages are:

• the test could be false negative and falsely reassure a person
• the result could be a false positive and could lead to a biopsy even though there may not be cancer present. A biopsy itself carries the risk of infection
• the PSA test can lead to anxiety even though a man may not have cancer
• treatment of early prostate cancers may not help a person live longer.

At present, prostate specific antigen testing can lead to harmful consequences for some men 41. They may receive treatment that is unnecessary (because the cancer is too extensive for the treatment to be curative or because the cancer would never have presented clinically). Also, treatment such as prostatectomy or radiotherapy may cause incontinence, impotence and other complications.

International prostate cancer screening trials

Currently there are two large international trials looking into prostate cancer screening. In Europe the large ERSPC trial has recruited patients from eight different countries (42). In the USA the PLCO trial has closed and those taking part are now being followed up. The combined results of these trials are due in 2008 (43).

Trials looking at risks and causes of prostate cancer

The risk of developing prostate cancer is higher in some ethnic groups for example African-Caribbean men. The PROCESS study will investigate possible reasons for this. This was carried out in Bristol and London; it began in 2002 and completed in 2005. It is a comparative study of incidence, clinical presentation and access to health care in the UK. Results of the study are not yet published (44).

About 10% of prostate cancer is thought to be familial: the risk is about 2.5 times higher with an affected first degree relative (father, brother, son). Risk also appears to be related to age, with relatives of a 50-year-old man with prostate cancer being at twice the risk compared to relatives of a 70-year-old (45).

Research has also shown that men who have inherited mutation in the BRCA1 and BRCA2 genes may be at an increased risk of developing prostate cancer.

There is currently a trial (IMPACT trial) screening for men who may be at an increased risk of developing prostate cancer (46). This is an international targeted prostate screening study in men with alterations in BRCA 1 and BRCA 2 genes. The study aims to look at substances which may be markers for prostate cancer in the blood and urine of these men. Men eligible for the trial are not affected by prostate cancer and aged 40 – 69, with an alteration in BRCA 1 or BRCA 2 genes. Male relatives of these men who do not have the gene mutation are also eligible. The study will involve an annual blood and urine sample for 5 years and completion of a short personal history questionnaire.