Simon van Rij et al's paper1 on the use of PSA screening is an excellent illustration of the problems of ad hoc screening programmes. The National Screening Unit2 lists the requirements to justify setting up a national screening programme and observes that to justify a screening programme some criteria need to be met including: there is effective treatment, the health system is capable of supporting all the necessary elements, social and ethical issues are considered and cost benefit issues are considered.I applaud research aimed at determining whether PSA screening is effective...but also how cost-effective such screening is. Given that the jury is still out on effectiveness, cost-effectiveness cannot be determined. Doing 1271 PSA tests to find one case of prostate cancer (as reported in 40–49 year olds) or a total of 18,469 tests in men over 80 years of age can't be seen as cost-effective in anyone's language.Ad hoc screening programmes such as this inevitably increase health outcome disparities by servicing the worried well, and because the public system has become burdened with biopsy work more of the treatment is done in private.I am one of the GPs who was surveyed who does not initiate discussion about PSA testing in asymptomatic men. I work at Newtown Union Health Service that is a Very Low Cost Access Practice. Our budget was cut 7.8% this year. We cannot afford to employ enough staff to adequately treat diagnosed problems. According to the NZ Health Survey3 nearly 1 million people had an unmet need for primary health care last year.We cannot afford to waste health spending on useless (testing 80-year-old men) or marginally beneficial tests that increase our already bad health outcome disparities. This money would be better directed to improving access to primary care for the most disadvantaged in our community.

Simon van Rij et al's paper1 on the use of PSA screening is an excellent illustration of the problems of ad hoc screening programmes. The National Screening Unit2 lists the requirements to justify setting up a national screening programme and observes that to justify a screening programme some criteria need to be met including: there is effective treatment, the health system is capable of supporting all the necessary elements, social and ethical issues are considered and cost benefit issues are considered.I applaud research aimed at determining whether PSA screening is effective...but also how cost-effective such screening is. Given that the jury is still out on effectiveness, cost-effectiveness cannot be determined. Doing 1271 PSA tests to find one case of prostate cancer (as reported in 40–49 year olds) or a total of 18,469 tests in men over 80 years of age can't be seen as cost-effective in anyone's language.Ad hoc screening programmes such as this inevitably increase health outcome disparities by servicing the worried well, and because the public system has become burdened with biopsy work more of the treatment is done in private.I am one of the GPs who was surveyed who does not initiate discussion about PSA testing in asymptomatic men. I work at Newtown Union Health Service that is a Very Low Cost Access Practice. Our budget was cut 7.8% this year. We cannot afford to employ enough staff to adequately treat diagnosed problems. According to the NZ Health Survey3 nearly 1 million people had an unmet need for primary health care last year.We cannot afford to waste health spending on useless (testing 80-year-old men) or marginally beneficial tests that increase our already bad health outcome disparities. This money would be better directed to improving access to primary care for the most disadvantaged in our community.