UK NSC’s draft recommendations on prostate cancer screening: Our Response

Prostate Cancer Research (PCR) welcomes the UK National Screening Committee’s (UK NSC) review of prostate cancer screening, including its first consideration of targeted screening scenarios for high-risk groups. However, based on PCR’s commissioned independent critique by the York Health Economics Consortium (YHEC) and clinical expert input, we are concerned that the current draft recommendations are underpinned by a modelling framework with structural features that materially influence its conclusions. The issues identified in this response are not isolated technical disagreements; they relate to core assumptions that shape the direction and magnitude of estimated harms, benefits and cost-effectiveness.

Several critical limitations remain unaddressed in the current assessment, including the:

• Absence of comparator scenarios that reflect some degree of substitution for, rather than addition to, existing opportunistic PSA testing
• Reliance on diagnostic and treatment data from legacy trials that do not reflect contemporary MRI-led pathways or current UK management patterns
• Omission of risk-stratified screening approaches that could reduce harms and system costs compared with uniform, interval-based strategies
• Insufficient modelling of high-risk populations, including failure to model family-history screening scenarios using granular definitions of inherited risk
• Absence of explicit equity analysis reflecting the substantially higher lifetime risk and earlier presentation of prostate cancer in Black men, and the implications of these disparities for proportionate and targeted screening strategies
• Limited use of contemporary UK audit and service data, particularly regarding MRI triage and active surveillance uptake
• Lack of scenario testing for alternative diagnostic thresholds and reflex testing strategies (including modelling the Stockholm3 intermediate triage test)
• A narrow economic perspective that does not adequately reflect wider healthcare utilisation and the burden associated with late-stage and metastatic presentation

In several of these areas, more contemporary UK data are available, and clinically accepted alternative approaches could reasonably have been modelled as scenario analyses. Their omission means the model does not simply reflect imperfect evidence, but modelling choices that materially influence the conclusions reached. Collectively, these limitations mean that the SCHARR model evaluates a version of screening that is unlikely to reflect how organised screening would be delivered in contemporary NHS practice.

Subsequent scenario testing conducted within the existing modelling framework demonstrates that modest, clinically plausible adjustments can materially alter cost-effectiveness estimates, in some cases moving screening strategies below the Committee’s benchmark. This underlines the sensitivity of the current model to key structural assumptions.

PCR does not argue that screening is without risk. Rather, we argue that a fair and policy-relevant assessment must evaluate screening as it would realistically operate today and not as if it was functioning in earlier eras.

Given that the economic model will materially shape prostate cancer early detection policy for years to come, the threshold for confidence in its structural validity must be correspondingly high. In addition to the issues highlighted above, the SCHARR report also falls short of best practice in economic modelling reporting, further undermining the transparency and intelligibility of its findings. In its current form, the modelling does not provide sufficient assurance that the conclusions drawn fully reflect contemporary clinical practice, evolving diagnostic strategies, or the NHS’s equity commitments.

The recommendations made by Prostate Cancer Research in this submission are intended to strengthen the evidentiary robustness, transparency and equity relevance of the UK NSC’s final conclusions.