Denying prostate cancer screening 'no longer rational'

A study comparing outcomes after prostate cancer and breast cancer screening has shown that both are effective at diagnosing cases, reducing deaths, and avoiding unnecessary harm.

The analysis – reported at the European Association of Urology (EAU) annual congress in London, UK – shows that it is "no longer rational to reject prostate cancer screening on one hand while endorsing screening for breast cancer on the other," according to the researchers behind the work.

They do recommend some caution in interpreting the results, however, as the study compared a clinical trial in prostate cancer with a population-based screening programme for breast cancer, but point out that several prostate cancer screening trials in Europe have revealed a reduction in mortality risk equivalent to breast cancer screening.

Prostate cancer screening has become a hot topic in the UK, after the National Screening Committee (NSC) recommended a targeted approach – only for men with a confirmed BRCA1 or BRCA2 gene variant who are at an elevated risk of developing prostate cancer – in a recommendation published last December. A final decision is expected later this year.

While breast cancer screening programmes have been in place in Europe for decades, prostate cancer has lagged behind, mainly due to concerns around the effectiveness of the PSA blood test and the risks of overdiagnosis and overtreatment.

The new study compared outcomes in around 40,000 men who took part in the PROBASE trial and had a PSA test at age 45 or 50 to a database of 2.8 million women aged 50 to 69 who had a mammogram in Germany's breast cancer screening programme.

A similar proportion of men and women were referred for biopsy, and the percentages of invasive cancers identified were similar across both prostate and breast cancer screening, but biopsies in the prostate cohort were far more likely to identify significant cancer, at 50% to 68% versus 10%, according to the researchers behind the study.

On the other hand, PSA blood testing followed by an MRI scan led to a higher number of false positives than mammography (37% to 42% vs 10%), according to their analysis.

"Until we have a population-based screening programme for prostate cancer, we can't make an exact like-for-like comparison with breast cancer," commented lead researcher Dr Sigrid Carlsson, head of the German Cancer Research Centre (DKFZ) in Heidelberg.

"But we can make some informed assumptions based on the data from our trial, which shows that if prostate cancer screening were extended to the wider population, then the outcomes are likely to be very similar to breast cancer," she added.

"Although our study used German data, the findings are applicable to other countries. The final question we now need to answer is: what will this cost compared to what we are already paying for opportunistic screening? And that work is already underway."

There has been a mixed response to the results. Prof Sam Hare, chief executive of the HLH Imaging Group and previously NHS England's national speciality adviser for imaging, said the result "lends further weight" to a risk-stratified, PSA and MRI-based approach to screening for prostate cancer, in a study population that is similar to the UK.

He also suggested that the high false-positive finding could be tackled with the implementation of AI and training for radiologists involved in a screening programme.

Dr Alastair Lamb, a prostate surgeon and clinical reader at Barts Cancer Institute, suggested that "breast cancer screening is an odd benchmark, given that not many experts would claim breast screening as a success."

He also said that surgery for breast cancer rarely causes harm, although it certainly can cause aesthetic and psychological impact, while "pretty much all prostate cancer treatment can cause many functional harms," such as bladder, bowel, and/or erectile dysfunction.

Simon Grieveson, assistant director of research at Prostate Cancer UK, said the study "has revealed some interesting correlations, unfortunately, there still is not enough evidence here to prove that introducing screening will save the lives of men with aggressive cancer while also protecting men with slow-growing cancer from potentially harmful treatments they don't even need."

He said evidence may be generated by a £42 million ($55 million), large-scale TRANSFORM study, which started in 2024 and is testing various approaches to prostate cancer screening, including MRI pathways and saliva-based genetic testing.

Image by Gerd Altmann from Pixabay