PSA testing and prostate cancer — KFP-style written assessment

KFP 1 (10 marks)

A 58-year-old accountant attends for a driver medical. He has read that 'the PSA test saves lives' and requests it. His father was diagnosed with prostate cancer at 65 and died at 72. He is well, no urinary symptoms, examination unremarkable. ^[19]

1. What framework governs whether to order this test, and what must it include? (3) ^[19]
2. Quantify the benefit and harm sides using ERSPC's final analysis. (4) ^[1]
3. How does his family history modify your discussion? (3) ^[15]

Model answers

1. Informed choice through shared decision-making — PSA-based screening combined with SDM is guideline-recommended. The pre-test consultation must cover realistic benefits (reduced prostate-cancer death), harms (overdiagnosis rising with age, false positives, biopsy morbidity including sepsis, treatment-related functional effects), proposed interval, and his own values about each. There is no organised programme; his request starts, not replaces, the conversation. ^[19]
2. Benefit: at 23 years ERSPC showed 13% lower prostate-cancer mortality (RR 0.87), absolute reduction 0.22% — one death prevented per 456 men invited, one averted per 12 cancers diagnosed. Harm: cumulative incidence ran 30% higher in screened men (RR 1.30) — overdiagnosis — with downstream biopsy risks (PROMIS documented serious adverse events in 5.9% including sepsis) and treatment-related functional harms. At his age overdiagnosis remains relatively low (~16% projected for detection at 50, rising thereafter), which supports testing now rather than deferring. ^{[1] [7] [14]}
3. A first-degree relative affected at 65 justifies an earlier start to informed-choice discussions and closer intervals than average-risk men; baseline PSA then stratifies his future — in ERSPC, men aged 55–69 with baseline PSA below 1.0 ng/mL had only ~1.2–1.5% 16-year risk of clinically significant cancer (delay or stop screening), while 3.0 ng/mL or above carried 13–14%. Document the agreed plan and interval. ^[15]