The use of prostate-specific antigen testing in the detection of localized prostate cancer: current opinion and urological practice in the United Kingdom

Background: The prostate-specific antigen (PSA) test and its interpretation plays a crucial role in the detection of early localized prostate cancer. However, inaccuracy of the test, inability to predict the aggressiveness of the disease and the lack of evidence about the comparative effectiveness of treatments have led to major dilemmas in considering whether to employ the PSA test and which cut-off points to use in interpreting its results. The aim of this study was to evaluate current urological practice in the UK regarding the use of PSA testing. Methods: A postal questionnaire survey of all consultant urologist members of the British Association of Urological Surgeons was conducted. Statistical analysis included proportional odds regression models to examine factors associated with urologists' preferences for different definitions of 'normal' PSA cut-off levels. Results: The survey response rate was 60%. The majority of consultant urologists applied the PSA test routinely. There was a high level of agreement amongst UK urologists on normal PSA cut-off points (<4.0 ng/ml) for asymptomatic men under 60 years of age. There was very wide variation in the definition of normal PSA cut-offs for older (≥60 years) asymptomatic men. A preference for lower cut-off points, leading to investigation with ultrasound and biopsy, was significantly associated with larger urology department size, the presence of a prostate cancer subspecialist in the department and relatively short length of specialization in urology. Conclusions: Prostate cancer screening and early detection practices and reported incidence rates of the disease are likely to be influenced by variation in urologists' interpretations of PSA. Despite increasing evidence in favour of lower PSA cut-off levels, particularly for younger men (<60 years), urologists in the UK are divided over their interpretation. Men, particularly over age 60 years, have varying chances of further investigation following PSA testing. Any trial of prostate cancer screening or treatment should take this potential variation into account. Standard protocols for PSA interpretation should be implemented.