Black men have a two- to three-times higher risk of prostate cancer diagnosis, but are so under-represented in screening trials that those who make decisions on screening can argue the evidence isn't robust enough to support it. Yet.

It's no, again
The UK's National Screening Committee (NSC) has again rejected prostate cancer screening for men, other than a targeted programme for those with a confirmed BRCA gene variant.

The reason, as before, is that from what we currently know, the harms and costs will likely outweigh the benefits on a population level. This is a draft NSC recommendation anyone can respond to until 20 February.

Any man over 50 or at higher risk because of family history and/or ethnicity can ask their GP for a prostate specific antigen (PSA) test, although GPs' enthusiasm for it varies. MD has been tested, because at 63 I have some lower urinary tract symptoms. However, I'm also old enough to remember the PSA test being labelled "Promoting Stress and Anxiety".

The evidence for...
The best evidence of modest screening benefit comes from the European Randomised Study of Screening for Prostate Cancer (ERSPC), which included 162,236 men aged between 55 and 69 at the time of randomisation and had 23 years of follow-up.

This showed one death from cancer prevented for every 456 men screened, and one man had his life extended for every 12 diagnosed and treated.

The evidence against...
The NSC concluded that around 40-50 percent of prostate cancer cases detected by PSA screening will be slow growing and would never cause harm.

Screening, further testing and treatment for these slow growing cancers would lead to high levels of overdiagnosis and overtreatment, causing unnecessary anxiety and lifelong side effects.

For every 1,000 men aged 50-60 who are screened with a PSA test, up to two lives would be saved; but overdiagnosis would occur in up to 20 men, including 12 who would be likely to be overtreated. Almost 20 percent of men who undergo surgery after a positive diagnosis of prostate cancer experience leaking urine, and 50 percent experience erectile problems. Almost 40 percent of men who have radiotherapy experience erectile problems, and around 5 percent experience bowel problems.

The good news is that more focused treatments – such as robot-assisted, high-pressure waterjets – are being trialled for localised prostate cancer, in the hope of reducing side effects.

The grey black area
The NSC also said that if black men were screened every four years from the age of 50 to 62, an additional 571 prostate cancers would be detected and 7-11 deaths prevented over 15 years. However, there is "significant uncertainty" about this, as there is a lack of strong evidence from large trials about the balance of harms and benefits for this group of men.

Less than 2 percent of men in prostate cancer screening trials were of black ethnicity, and most of the data came from the US. The NSC argued that for it to recommend extending screening to a wider group, a more accurate test than PSA was needed, and there needed to be more data on screening black men and men with a relevant family history.

TRANSFORM trial
On 21 November, the National Institute for Health and Care Research (NIHR), which is funded by the Department of Health and Social Care, announced a £42m TRANSFORM prostate cancer screening trial, with £26m coming from the charity Prostate Cancer UK.

The trial will evaluate more accurate testing strategies than the PSA test alone, such as using magnetic resonance imaging and genetic risk. At least 10 percent of invitations to join the study will go to black men; and the aim is to recruit 16,000 men for the first phase, before ramping up to 300,000.

You can't volunteer, but if I got an invitation, I'd accept it.

There is, inevitably, some politics involved. The trial will go far beyond "existing evidence, testing new ways to diagnose the disease that could find the cancers that today's methods miss. However, the trial will also quickly produce robust new information about the tests we currently use.

If the NSC decides there is insufficient evidence to recommend screening now, these early results could help shift the evidence in favour of screening in as little as two years." Just in time for the next election, perhaps...

The Stockholm3Test
Two problems with PSA screening are that lower levels don't rule out aggressive cancer, and lots of men have MRI scans and biopsies that may not be necessary. The Stockholm3 test combines protein biomarkers, genetic markers and clinical data with an algorithm to help identify both groups.

A large Swedish screening trial of men treated for prostate cancer used a combination of PSA and Stockholm3 tests. It found that few clinically important cancers were missed when biopsy was deferred in men with PSA ?3 ng/ml (nanograms per millilitre) but low Stockholm3 scores (<11).

High Stockholm3 scores identified some men with PSA <3 ng/ml who later developed recurrent or fatal cancer, showing that it can detect aggressive disease that PSA alone may miss.

Using Stockholm3 with PSA may help decide who can safely avoid biopsy and who may need closer evaluation, but it is only available privately in the UK.

An August 2022 briefing from NICE (the National Institute for Health and Care Excellence) concluded: "Experts agreed that the technology has the potential to improve diagnostic accuracy leading to a reduction in unnecessary MRI and biopsies. The technology is not yet used in the NHS and the main barrier to adoption is the lack of current initiatives or programmes for prostate cancer screening in primary care, and the additional financial cost to the NHS... There is currently no evidence assessing the effect of the test on clinical decision making and long-term clinical outcomes in the NHS. Data about Black, Asian, and minority ethnic populations is currently limited."

The TRANSFORM trial is not currently evaluating the Stockholm3 test.

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