Lower urinary tract symptoms and prostate cancer: is PSA testing in men with symptoms wise?

INTRODUCTION

The best evidence to date shows that, overall, the harms of prostate cancer screening in asymptomatic men outweigh the benefits. A 2013 Cochrane review found that screening asymptomatic men did not save lives from the disease, and leads to detection of indolent prostate cancers that would not have gone on to cause harm in a man’s lifetime.¹ This is known as overdiagnosis. Further weight was added to the results of the Cochrane review in the recent 10-year follow-up results from the cluster randomised trial of PSA testing for prostate cancer (CAP), which found that one-off PSA testing of asymptomatic men did not save lives from prostate cancer.²

For symptomatic men, however, the clinical situation is different. Current clinical guidelines from the National Institute for Health and Care Excellence (NICE) recommend that GPs consider a PSA test and digital rectal examination (DRE) in men presenting with lower urinary tract symptoms (LUTS) to investigate suspected prostate cancer.³

For the purposes of this article we defined LUTS as: nocturia, urgency, frequency, incomplete voiding, intermittency, terminal dribble, hesitancy, straining, weak or split stream, and/or post-micturation dribble. LUTS are very common in men, and have been estimated to be present in around 80% of men aged >60 years.⁴

The 2013 Cochrane review stated that ‘... the presence of LUTS, typically due to benign prostatic obstruction, are very common in the ageing male and are not considered to …