Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • RESOURCES
    • About BJGP
    • Conference
    • Advertising
    • BJGP Life
    • eLetters
    • Librarian information
    • Alerts
    • Resilience
    • Video
    • Audio
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
    • RCGP e-Portfolio

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
    • RCGP e-Portfolio
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
Advertisement
British Journal of General Practice

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • RESOURCES
    • About BJGP
    • Conference
    • Advertising
    • BJGP Life
    • eLetters
    • Librarian information
    • Alerts
    • Resilience
    • Video
    • Audio
    • COVID-19 Clinical Solutions
Research

Prostate-specific antigen testing and opportunistic prostate cancer screening: a cohort study in England, 1998–2017

Ashley Kieran Clift, Carol AC Coupland and Julia Hippisley-Cox
British Journal of General Practice 2021; 71 (703): e157-e165. DOI: https://doi.org/10.3399/bjgp20X713957
Ashley Kieran Clift
Professor of Clinical Epidemiology and Primary Care Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford.
Roles: Clinical research fellow
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Carol AC Coupland
School of Medicine, University of Nottingham, Nottingham.
Roles: Professor of medical statistics in primary care
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Julia Hippisley-Cox
Professor of Clinical Epidemiology and Primary Care Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info
  • eLetters
  • PDF
Loading

Published eLetters

eLetter submission guidelines

Submit a Response to This Article
Compose eLetter

More information about text formats

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Author Information
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g. higgs-boson@gmail.com
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Statement of Competing Interests
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Vertical Tabs

Jump to comment:

  • Prostate specific antigen testing and opportunistic prostate cancer screening
    Richard Martin, Emma Turner, Athene Lane, Chris Metcalfe and Jenny L. Donovan
    Published on: 06 February 2021
  • Prostate specific antifen testing and opportunistic prostate cancer screening
    Gavin Gordon
    Published on: 03 February 2021
  • Published on: (6 February 2021)
    Prostate specific antigen testing and opportunistic prostate cancer screening
    • Richard Martin, Professor of Clinical Epidemiology, University of Bristol
    • Other Contributors:
      • Emma Turner, Research Fellow, University of Bristol
      • Athene Lane, Professor in Trials Research, University of Bristol
      • Chris Metcalfe, Professor of Medical Statistics, University of Bristol
      • Jenny L. Donovan, Professor of Social Medicine, University of Bristol

    Clift et al1 aimed to estimate PSA contamination in the control arm of the CAP prostate cancer screening trial, concluding that there is " limited plausibility of deriving clear conclusions from trials of PSA screening". However, their conclusion failed to acknowledge that the CAP intervention significantly increased prostate cancer detection: during the first 18 months following recruitment (the screening phase) there was a 5-fold increase in rate of prostate cancer detection: 10.42 per 1000 person-years in the intervention group vs 2.18 per 1000 person-years in the control group (P < 0.001).2 Such a difference would be expected to lead to mortality benefits over long-term follow-up, but there was little evidence of any subsequent mortality reduction from earlier detection. Relying on how urinary symptoms are coded may overestimate opportunistic PSA screening. In our analysis of 558 UK general practices,3 28% of men received a PSA test, but a raised PSA (≥3 ng/ml) was rarely followed with a prostate biopsy (6% of tests) or prostate cancer diagnosis (15%), as would be clinically expected for screening. In our trial, the corresponding figures were 85% undergoing biopsies and 34% diagnosed with prostate cancer. The CAP trial excluded London, the South East and West Midlands. In the Clift et al paper, 21% of men were from London and PSA screening was 34% hi...

    Show More

    Clift et al1 aimed to estimate PSA contamination in the control arm of the CAP prostate cancer screening trial, concluding that there is " limited plausibility of deriving clear conclusions from trials of PSA screening". However, their conclusion failed to acknowledge that the CAP intervention significantly increased prostate cancer detection: during the first 18 months following recruitment (the screening phase) there was a 5-fold increase in rate of prostate cancer detection: 10.42 per 1000 person-years in the intervention group vs 2.18 per 1000 person-years in the control group (P < 0.001).2 Such a difference would be expected to lead to mortality benefits over long-term follow-up, but there was little evidence of any subsequent mortality reduction from earlier detection. Relying on how urinary symptoms are coded may overestimate opportunistic PSA screening. In our analysis of 558 UK general practices,3 28% of men received a PSA test, but a raised PSA (≥3 ng/ml) was rarely followed with a prostate biopsy (6% of tests) or prostate cancer diagnosis (15%), as would be clinically expected for screening. In our trial, the corresponding figures were 85% undergoing biopsies and 34% diagnosed with prostate cancer. The CAP trial excluded London, the South East and West Midlands. In the Clift et al paper, 21% of men were from London and PSA screening was 34% higher in London than the East Midlands; 46% higher in the South East; and 20% higher in the West Midlands. The CAP trial was overseen by independent, international Trial Steering and Data Monitoring Committees to ensure robust inference. We believe the CAP trial conclusions remain important: single PSA screening detected significantly more prostate cancers compared with ad hoc testing but had no significant effect on prostate cancer mortality after 10-years follow-up.

    References
    1. Clift AK, Coupland CAC, Hippisley-Cox J. Prostate-specific antigen testing and opportunistic prostate cancer screening: a cohort study in England, 1998–2017. Br J Gen Pract 2021; 71(703): e157-e165. doi: 10.3399/bjgp20X713957
    2. Martin RM, Donovan JL, Turner EL et al. for the CAP Trial Group. Effect of a Low-Intensity PSA-Based Screening Intervention on Prostate Cancer Mortality: The CAP Randomized Clinical Trial. JAMA 2018; 319(9):883–895. doi:10.1001/jama.2018.0154.
    3. Young GJ, Harrison S, Turner EL et al. Prostate-specific antigen (PSA) testing of men in UK general practice: a 10-year longitudinal cohort study. BMJ Open 2017; 7(10): e017729.
     
    Show Less
    Competing Interests: None declared.
  • Published on: (3 February 2021)
    Prostate specific antifen testing and opportunistic prostate cancer screening
    • Gavin Gordon, F2 Doctor in GP Rotation, East Durham Medical Group

    This is a comprehensive and well-researched project on the uptake and access of prostate cancer screening. The authors correctly characterise the transition into a ‘post-trial world’ as the trend of prostate screening research is moving away from PSA testing. For an up-to-date overview of the issues surrounding prostate cancer screening I direct readers to the urology news summary article published last year.1 Most promising is the prospect of an MRI ‘prostatogram’ made feasible due to recent advances in speed of MRI scanning. Multiple trials are ongoing, including a Canadian randomised controlled trial comparing MRI and PSA screening. However, at time of writing the PSA test remains the primary screening modality for prostate cancer available to GPs.

    For me, an aspect of PSA screening that still raises confusion clinicians and patients is what constitutes informed consent. As mentioned in the article, current NICE guidance suggests men may opt-in to screening through shared decision making with their GP. The authors defined opportunistic PSA testing as testing performed on individuals without urinary symptoms. I am curious about the author’s views on how to communicate information on opportunistic PSA testing to men in the primary care setting. There is mention in the article that the status quo is informal, testing based on clinical suspicion and risk factors. However, as the shown by the data, PSA testing upta...

    Show More

    This is a comprehensive and well-researched project on the uptake and access of prostate cancer screening. The authors correctly characterise the transition into a ‘post-trial world’ as the trend of prostate screening research is moving away from PSA testing. For an up-to-date overview of the issues surrounding prostate cancer screening I direct readers to the urology news summary article published last year.1  Most promising is the prospect of an MRI ‘prostatogram’ made feasible due to recent advances in speed of MRI scanning. Multiple trials are ongoing, including a Canadian randomised controlled trial comparing MRI and PSA screening. However, at time of writing the PSA test remains the primary screening modality for prostate cancer available to GPs.

    For me, an aspect of PSA screening that still raises confusion clinicians and patients is what constitutes informed consent. As mentioned in the article, current NICE guidance suggests men may opt-in to screening through shared decision making with their GP. The authors defined opportunistic PSA testing as testing performed on individuals without urinary symptoms. I am curious about the author’s views on how to communicate information on opportunistic PSA testing to men in the primary care setting. There is mention in the article that the status quo is informal, testing based on clinical suspicion and risk factors. However, as the shown by the data, PSA testing uptake is subject to significant variation based on demographic factors.

    As far as I am aware there is no standardized process informing men of the opt-in nature of PSA testing. Furthermore, there is an ethical dilemma over whether practices should proactively inform men of the option for PSA testing. If an informed, shared decision making approach is best practice, should all men beyond a specified age be informed of opt in PSA screening? On the other hand, it could be argued that a proactive approach to shared decision making is simply a form of PSA screening with an additional step.

    Reference

    1. Urology news.  MRI screening for prostate cancer: a step towards a ‘prostagram’  2020.  Available at: www.urologynews.uk.com/features/features/post/mri-screening-for-prostate-cancer-a-step-towards-a-prostagram

    Show Less
    Competing Interests: None declared.
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 71 (703)
British Journal of General Practice
Vol. 71, Issue 703
February 2021
  • Table of Contents
  • Index by author
Download PDF
Download PowerPoint
Article Alerts
Or,
sign in or create an account with your email address
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Prostate-specific antigen testing and opportunistic prostate cancer screening: a cohort study in England, 1998–2017
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Prostate-specific antigen testing and opportunistic prostate cancer screening: a cohort study in England, 1998–2017
Ashley Kieran Clift, Carol AC Coupland, Julia Hippisley-Cox
British Journal of General Practice 2021; 71 (703): e157-e165. DOI: 10.3399/bjgp20X713957

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Prostate-specific antigen testing and opportunistic prostate cancer screening: a cohort study in England, 1998–2017
Ashley Kieran Clift, Carol AC Coupland, Julia Hippisley-Cox
British Journal of General Practice 2021; 71 (703): e157-e165. DOI: 10.3399/bjgp20X713957
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • Abstract
    • INTRODUCTION
    • METHOD
    • RESULTS
    • DISCUSSION
    • Acknowledgments
    • Notes
    • REFERENCES
  • Figures & Data
  • Info
  • eLetters
  • PDF

Keywords

  • cohort studies
  • primary health care
  • prostate cancer
  • prostate-specific antigen
  • screening

More in this TOC Section

  • Is there an association between long-term antibiotics for acne and subsequent infection sequelae and antimicrobial resistance? A systematic review
  • Factors associated with potentially missed acute deterioration in primary care
  • Domestic abuse among female doctors: thematic analysis of qualitative interviews in the UK
Show more Research

Related Articles

Cited By...

Advertisement

BJGP Life

BJGP Open

 

@BJGPjournal's Likes on Twitter

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers
  • RCGP e-Portfolio

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7679
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2021 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242