Addressing uncertainty in PSA screening and testing intervals

Practice does not reflect evidence or guidelines Testing for prostate specific antigen (PSA) remains controversial, as reflected in clinical guidelines and different—and at times contradictory—recommendations. Testing, if recommended, is suggested for one of two indications: screening asymptomatic men to detect prostate cancer at an early stage amenable to curative treatment,1 and diagnostic testing among men with symptoms potentially attributable to prostate cancer, such as haematuria, lower urinary tract symptoms, erectile dysfunction, low back pain, or weight loss. Notably, the National Institute for Health and Care Excellence (NICE) guideline does not recommend prostate cancer screening but rather sees its main role, alongside digital rectal examination, as a diagnostic test for men with symptoms or those considered at increased risk based on family history.2 Current guidelines disagree about whether screening has benefits that exceed harms. Guidelines recommending screening differ on age, PSA threshold for abnormality, and rescreening interval. Consensus is, however, growing that decision making about screening (and diagnostic testing) should be based on shared decision making that engages patients in conversations about benefits and harms, and their preferences and values for outcomes associated with the testing cascade. Indeed, almost no European country has population based screening programmes.3 While some guideline recommendations, such as those of the US Preventive Services Task Force, have changed over time, NICE guidelines have changed little since 2015 and focus on PSA testing for diagnostic purposes. …