Shared choice insurance policies result in excessive charges of PSA testing and inequity with minimal profit
Most excessive revenue nations, together with the UK, wouldn’t have a nationwide prostate most cancers screening programme, however as an alternative permit males with out signs to get a prostate-specific antigen (PSA) take a look at if they want, after speaking to their physician.
However specialists writing in The BMJ at present argue that these shared choice insurance policies have led to excessive charges of PSA testing and clear medical hurt, with minimal profit and inequity.
Andrew Vickers and a global group of colleagues argue that prime revenue nations ought to both implement a complete threat based mostly strategy to PSA testing – designed to scale back overdiagnosis and overtreatment – or discourage PSA testing by way of a transparent suggestion in opposition to screening, together with insurance policies that make it onerous to acquire a take a look at with out particular signs.
Prostate most cancers is the most typical most cancers in males, and the third main reason for most cancers dying in males in Europe.
However it’s nonetheless not clear whether or not the advantages of PSA screening, as at the moment practiced, outweigh the harms of overdiagnosis and overtreatment – when low threat tumours that may by no means trigger signs or shorten life are detected and handled unnecessarily.
Within the UK, for instance, it’s estimated that about 10,000 males are overdiagnosed with prostate most cancers yearly, exposing them to potential uncomfortable side effects of therapy with out receiving any profit.
Given this uncertainty, nearly all excessive revenue nations have opted for PSA testing based mostly on shared decision-making.
However the authors argue that counting on shared decision-making to information PSA testing has led to excessive charges of PSA testing significantly in older males, who’re almost certainly to be harmed by screening and least more likely to profit. The shared decision-making strategy additionally displays and reproduces well being inequities. For instance, in Canada and the US, PSA testing is much less frequent in individuals from ethnic minorities, whereas within the UK and Switzerland, charges of PSA testing are decrease in economically disadvantaged areas.
In distinction, they are saying implementing a complete, threat based mostly prostate most cancers early detection programme that fastidiously manages not simply testing, but additionally biopsy and subsequent therapy, may considerably cut back the harms of overdiagnosis and overtreatment which have accompanied PSA-based screening.
Alternatively, they counsel limiting PSA testing to males with signs, with attainable exceptions for a small variety of males at excessive threat, however they acknowledge that such insurance policies are largely untested and would require additional analysis.
“Though we imagine that early detection of prostate most cancers ought to contain shared choice making, the present strategy of figuring out testing by shared choice making has resulted within the worst attainable sensible end result of excessive ranges of PSA testing and medical hurt, with minimal profit and inequity,” they write.
“To make higher use of PSA testing, coverage makers ought to select between a complete, threat tailored strategy that’s particularly designed to scale back overdiagnosis and overtreatment, or limiting PSA testing to individuals referred to urologists with signs,” they clarify.
“That alternative might want to have in mind wider affected person and public perspective, in addition to well being financial issues,” they conclude.
Is the UK actually able to roll out prostate most cancers screening, asks a linked characteristic? It describes how proponents and optimistic information protection counsel a nationwide programme is “in pipeline” – however finds uncertainty, controversy, and a necessity for extra proof.
Vickers, A., et al. (2023) Present insurance policies on early detection of prostate most cancers create overdiagnosis and inequity with minimal profit. The BMJ. doi.org/10.1136/bmj-2022-071082.
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