The natural history of prostate cancer is varied with autopsy studies suggesting that the majority of elderly men have a focus of prostate cancer by the time they die.6
Consequently, accurate prediction of progression for screen-detected prostate cancer remains uncertain. Most men with low-grade tumours will incur no loss of life expectancy, no symptoms and are likely to die from another cause.7,8
The ultimate aim of screening will be to detect the localised aggressive cancers which can be cured by radical treatment if detected in time.9
The converse to this is men with clinically insignificant tumours which do not require treatment will be detected through PSA testing and exposed to the associated morbidity of radical therapy or the anxiety of active surveillance.10
Consequently, treatment is detrimental to such a low–risk population, leading us to await the outcome of on–going assessments of risk stratification to balance the benefits and harm of screening.11,12
The American Urological Association (AUA) recommended screening to be offered to all men over 50 years of age with a life expectancy of greater than 10 years. Yet the US Preventive Services Task Force states that there is insufficient evidence for the benefits to outweigh the risks thus illustrating the lack of consensus regarding the subject.13
To confound patients and clinicians further, the optimal management of prostate cancer to reduce disease–related mortality, maintain quality of life and improve life expectancy has not been confirmed.14
It is evident that most men in our study who had their PSA tested had initially presented to their GP with LUTS and only a minority (3%) actively sought to find out their own PSA. Two-thirds of men failed to recall having had a PSA test; furthermore, a similar figure (64%) stated that their level of understanding was not as one would expect prior to making such a potentially important decision. Similar studies in the US showed varied results in primary care of male awareness of prior PSA testing. One study of university–affiliated veterans and a further one during ‘National Prostate Cancer Awareness Week’ showed 19–33% of men younger than 80 years could not recall having had their PSA tested.15,16
In these studies, the time from testing to completing the questionnaire after testing was longer than in our study. In a small study in Oxford (n
= 52), almost all patients analysed remembered having had a PSA test, but stated that they had received little information at the time of the test.17
More men in our study reported a lack of awareness in the general practice referred group compared to those men tested in secondary care. In the primary care setting when patients present with LUTS or to request PSA testing, there is often insufficient time to have a lengthy discussion to cover all of the ramifications of PSA testing unless the patient books an appointment specifically for prostate cancer screening. With the issues over introduction of a screening programme and lack of knowledge regarding the optimal treatment of prostate cancer, some clinicians may be unclear how to inform their patients proficiently.
Following consultation, some men may forget or may not have understood the information that they had been given by the physician.18
Our analysis did not take into consideration education level amongst the men questioned. Other studies have shown evidence that lack of understanding of the PSA test was more prevalent in men with poorer school education.19,20
It is also possible that they were never informed of having the test or given information on prostate cancer when consulting with the attending physician at the time of their PSA being tested.
Our study and data from other studies highlight the importance of counselling these men to help make an informed choice on testing. The question needs to be asked how improvements can be made to increase men's knowledge about PSA before having the test. This is not an easy question to answer because aforementioned factors need to be taken into consideration. The use of shared decision videos have shown to significantly improve men's knowledge of detecting prostate cancer and the possible treatments in the decision to have the test.21
By increasing knowledge surrounding the limitations of PSA testing and controversies over prostate cancer treatment through videos, internet and fact sheets, more men are likely to decline the test.18,22
In our sample who were given verbal information on PSA testing, 10% of men were unsure or felt that the test should not be used widely as a screening tool given its limitations. This suggests that better aids are required to help men seeking advice from a physician on PSA testing to help in their understanding and decisions.