🤔 Prostate Cancer vs Politics: The Fight Over PSA

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Today’s Deep Dive is all about Prostate Cancer, PSA screening and Politics.

Let’s delve deep to get to the core of this ongoing debate.

If you want to read any previous editions of The Handover, you can on our website.

“To PSA or not to PSA. That is the question”
-William Shakespeare(GP Partner, 2025)

For decades, politicians and science have stood at odds with each other: 

“Don’t worry, pregnant women – Thalidomide is totally safe for morning sickness 👍”

…👀

“Don’t worry, healthcare workers – this PPE will absolutely protect you from COVID 💯”

…👀

And now, the latest hot topic to hit Parliament’s inbox is this:
Why the hell don’t we screen everyone for prostate cancer?

I mean, everybody seems to have a take. Rishi Sunak. David Lammy. David Cameron. Wesley Streeting.

Celebrities, athletes, my beloved Stephen Fry (what a guy).
All are weighing in on PSA testing.

Which is funny, because last time I checked... none of them have a medical degree 🤔

Now, look – everyone’s entitled to their opinion(even when it’s wrong.)

But the thing is, this isn’t just another health debate fuelled by vibes and questionable intentions. There’s a genuine body of evidence – from highly respected journals – suggesting that a screening programme ain’t so ridiculous.

So today, we’re diving in.
The history. The controversy. The evidence. The bias.
Then you can decide for yourself whether it’s time for a Prostate Cancer National Screening Programme

I hope you’re comfortable.
This can be a lot to take in…

Sooner or later, you’ll finish medical school.
And when that happens, your university will brutally murder your @ac.uk email address 🪦

No more UniDays. No more StudentBeans.
Just full-price misery and that Gmail account you made in Year 5.

Your colleagues don’t need to know about [email protected] or [email protected]
No one does…

But there is a solution.

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Prostate cancer was another medical boogeyman.

For most of the 20th century, a poor bloke would present with weight loss, night sweats and trouble peeing. A finger up the back passage would give you an idea of what’s going on.

By the time the words “it’s cancer” left the clinician's lips, the bone pain had already started.
The disease had metastasised, and it was too late. 

The world was begging for an early-diagnostic solution.

So it’s no surprise that when T.Ming Chu and crew discovered “purified human prostate antigen” in 1984, it was quickly adopted. 

It only took a handful of years before it was approved by the FDA. In the 90s, UK urologists also started using the blood test for early prostate cancer detection. It shortly became a quick, easy and routine blood test to check for. Used as casually as FBC’s, U&E’s and LFT’s. 

The formula was simple:
PSA + DRE + Clinical Chops = Prostate Cancer Diagnosis

But the PSA honeymoon didn’t last.
It turned out this little protein is far from a perfect cancer alarm. 

This little protein turned out to be pretty unreliable. It had all sorts of issues:

It became increasingly clear that PSA levels weren’t quite the cancer killer it was thought to be. This led to a marked decline in PSA testing worldwide.   

Unlike the States, the UK took a more sceptical approach from the jump.
We never actually implemented organised routine screening using PSA. Instead, we’ve had the “Prostate Cancer Risk Management” scheme, which stipulates:

Any man over 50 who asks for a PSA test can have one free on the NHS, but GPs should not actively call in asymptomatic men for screening.

In short: if you ask, we’ll do it. But we’re not sending a letter.

This policy was heavily guided by the National Screening Committee’s early assessments and the results of UK trials. Notably, a huge UK trial (the CAP study, involving over 400,000 men) tested a one-off PSA screening invitation. 

The outcome, published in 2018, was disappointing for PSA fans: after a decade of follow-up, there was no significant difference in prostate cancer mortality between the men who got a PSA test and those who didn’t.

So, things were looking pretty damning scientifically. PSA was not the one 🙅

So… if the evidence is clear. What’s all the ruckus about? 

Outside of anecdotal evidence from the media and celebrities, there may be a genuine, scientific case for a national screening programme. 

Case 1: The European Study of Prostate Cancer Screening

Published in NEJM exactly 30 days ago, this study followed over 160,000 men over a 23 time horizon to see if PSA screening actually reduced prostate cancer mortality. 

This multicentre international RCT randomised men to either:

The results were that after 23 years, the screening group had a 13% lower death rate compared to the control.

To add some colour: roughly 22 fewer prostate cancer deaths per 10,000 men screened. i.e 1 in 450. I know that sounds a bit pants, but that's in the same ballpark as other screening programmes. 

For example, the number-needed-to-screen to prevent one death from breast cancer with mammography is 1 in 400. Few would argue with the importance of that screening regime. 

This massive study would suggest that, despite its flaws, the effectiveness of PSA screening in preventing death, although modest, is real and sustained over the long term.

Perhaps not so pants after all…

Case 2: Technological advancement

We’re no longer in Kansas.
The wild west of prostate cancer is quite a way behind us.
Now we’ve got all kinds of nice gizmos and tools to help us get really specific on whether a prostate biopsy is needed(much to the relief of men everywhere)

At the helm is the ever-famous Multiparametric MRI.

Long-short: Anything that smells like prostate cancer gets popped in the scan. A clear MRI has a high negative predictive value for significant cancer. If it's all clear, you’re all good. Otherwise, you’re fated to the biopsy 😨

But, newsflash: that's not even that bad anymore. Innovations with the transperineal route significantly reduce complications. 

We’re essentially filtering all the PSA results through this accurate test, potentially negating the shortcomings of the PSA test. 

Beyond that, MRI tests(which are dumb expensive to run), are getting more efficient - Biparametric MRIs were non-inferior to the Multiparametric cousin in the PRIME study => wider access to accurate diagnosis across the UK. 

In short:
PSA screening today isn’t PSA screening in 2005.
It’s smarter. It’s safer. And it’s getting harder to argue that the juice isn’t worth the squeeze…

As attractive as a screening programme may be lookin’, it’s essential to look into why many, many, many clinicians still say: “No… just no.”

Starting with a concept I like to call 

Lead-time bias:

Let's take two made-up identical twins.

Let’s call em Zack and Cody.
After a fulfilling childhood growing up in a hotel and cruise ship, they both go on to live beautiful lives, and unfortunately, both die of prostate cancer. 

At their joint funeral(😢), we reflect on the suite life of these brothers and how they both came to die at 70. 

Zack was largely innocent of the knowledge.
He never got screened. He felt fine until age 67, when bone pain led to a diagnosis of advanced prostate cancer. Despite treatment, he passed at 70.

Zack survived with cancer for 3 years.

Cody, ever the careful twin, went to his GP at 60 for a PSA test. It flagged high. Biopsy confirmed cancer – the exact same type Zack had. It couldn’t be helped. Despite early treatment, he also passed at 70 years. 

Cody survived with cancer for 10 years.

Now, if you look at these numbers on paper, Zacks' 5-year survival was 0%, whereas Cody's was 100%(he lived 10 years after diagnosis)

“Wow!” you might say.

“We should’ve screened Zack! Cody lived so much longer – screening must’ve worked!”

But did it actually extend Cody’s life? No – both men died at 70. 

The screening just started the clock earlier for Cody. He got to spend an extra seven years knowing he had cancer (years which might have included treatments and stress, by the way), but ultimately, he died at the same age he would have without screening. 

In terms of mortality – which is what matters – screening did nothing for Cody in this scenario. Yet the survival statistics make it look like Cody did great.

And this isn’t just hearsay. PSA screenings find cancer approximately 5-10 years before symptoms arise. So survival-from-diagnosis shoots up, even if actual deaths in the population don’t change 🙁

Famously, American politician Rudy Giuliani missued this stat: 

He noted that the 5-year prostate cancer survival in the US (with aggressive PSA screening) was around 98%, whereas in the UK (no screening) it was around 50% at the time. He proclaimed this as proof that the US “prostate cancer system” was superior and that screening was saving lives.

In reality, he was just picking up insignificant tiny cancers, thus stat padding. Confusing lead-time bias and overdiagnosis with real improvement (classicly clumsy Americans). 

Bottom line: Don’t be fooled by raw survival statistics in screening. 

Next The Big Daddy...

Overdiagnosis

This is still enemy number one. Pretty much a double click on the point above – a screening programme will lead to the diagnosis of prostate cancers that would have never caused harm.

This will lead to decades of anxiety, surveillance, and biopsies(the worst part imo). The knowledge of knowing “I have cancer inside me” is a huge psychological burden that could(theoretically) have been avoided. 

This is why the “get tested” movement could cause more harm than good.

In short, screening doesn’t just detect cancer. It creates patients out of men who would have otherwise lived in peace, oblivious to the microscopic passengers in their prostates.

Of course, let’s not skip over the other problems:

Looping back to the original question. To PSA or not to PSA? Idk, I’m just a guy. It’s not a simple yes or no. 

And that, in itself, is the key point to convey to patients and colleagues: it’s complicated.

Whilst things are improving technologically and more lives can be saved, it doesn’t come for free. The cost is the chain of consequences that befalls many other men who undergo screening.

Without turning this into an article on ethics, the likely path ahead will be a targeted, risk-based approach. 

Much like screening high-risk individuals with BRCA mutations, we could do the same in prostate cancer. Black men are known to be at a much higher risk, so there is something to go with.

We’ll know more as data emerges, but the direction is clear: 

Nuance and individualisation. Not “screen everybody” (too blunt) and not “screen nobody” (too nihilistic), but rather “screen smartly”.

Thanks for listening to my Ted Talk 🤝

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