It’s time to take action, or it could be you…
Considering that prostate cancer is effecting one in nine men, there are chances that 51 MPs, 67 members of House of Lords and 52 MEPs already have or will develop the commonest cancer of men if policy makers don’t take immediate action. Prof. Jonathan Waxman, Professor of Oncology, Imperial College London gives a complete lowdown on the deadly disease and discusses what needs to be done from a policy perspective
The Government Gazette is distributed through the United Kingdom Houses of Parliament, and the European Parliament. There are 459 male MP’s, 609 male Lords and Bishops, and 473 male MEP’s. Prostate cancer is now the commonest cancer in men, effecting one in nine men. So, the chances are that 51 MP’s and 67 members of the House of Lords, and 52 MEP’s have or will develop prostate cancer. So it could indeed be you, and you of course do have a vested interest in understanding prostate cancer and encouraging advances in research and treatment into this very common disease at a UK national and European level.
What do you know about prostate cancer?
It’s surprising that almost less than 20% of men and women only know where the prostate is and what it does. The prostate is a gland at the base of the bladder, and because of the gland’s location, enlargement of the prostate by any benign or malignant growth of the prostate can cause difficulty with urination. The prostate makes a fluid that mixes with sperm to form the seminal fluid which contains high concentrations of fructose, a sugar that nourishes the sperm in its perilous voyages in foreign parts. The number of people affected by prostate cancer has increased incredibly over the last 50 years. In the UK, in the mid 1960’s, around 6000 men were diagnosed with prostate cancer per annum. The latest available figures show that 41,736 men were diagnosed with prostate cancer in the UK in 2012. This increase is replicated around Western Europe where currently 343,174 men were diagnosed. Mortality rates are around 30% both in the UK and in the rest of the EU.
What is the cause of prostate cancer?
Prostate cancer is generally a disease of older men, increasing in incidence with age so that it is found in some form in up 80% of 80 year olds.. As the average age of death in the UK has increased by ten years over the last fifty years it might be thought that the change in prostate cancer incidence reflects the changes in the demographics of our society. But not so, because when age is factored in the massive change in incidence is not explained. There is no obvious genetic cause. No single genes have been found to be altered and cause prostate cancer. However multiple genetic abnormalities are seen and are likely to be a secondary event, reflecting the impact of environmental factors on the genome. The evidence showing this has been available from the 1960’s. Entire galaxies of studies have shown that the increase in incidence of prostate cancer is likely to be due to changes in diet, with the star dust firmly sprinkled on meat and dairy products, and in particular on to processed and smoked foods.
How is prostate cancer treated?
Prostate cancer can be divided into two main types, a mild form that requires no treatment and a more aggressive form that can be confined to the prostate or have spread to involve other organs. Mild prostate cancer looks only slightly different from normal tissue when examined microscopically and is generally associated with low PSA levels. This is a ‘cancer’ that has an excellent outlook and can usually be managed without treatment merely requiring regular follow up blood testing and clinical monitoring. When the more aggressive form is found, and is confined to the prostate, the patient is offered treatment with radiotherapy or surgery. The results of treatment are exactly the same and radiotherapy has much less side effects. The addition of hormone treatment and chemotherapy provides a survival benefit for some subgroups of patients treated with radiotherapy. For patients whose cancer has spread, treatment is with hormonal therapy that blocks the effect of the male hormone, and with chemotherapy. In the UK, doctors are unable to use all the drugs that they would like to use to treat their patients because of the restrictions applied by the National Institutes of Clinical and Health Care Excellence (NICE).
What to do about prostate cancer?
So how do we act to decrease mortality? We do so by developing national preventive strategies, by encouraging screening, by stimulating basic science research, improved patient care, and through facilitating and making available treatment advances so that new drugs can be given to patients. In some cancers public health campaigns have been effective in reducing cancer incidence. For lung cancer for example, public health campaigns have reduced smoking levels to under 20% of the population, and this has led to decreases in death rates. In many cancers national screening programmes have led to fabulous falls in death rates for common cancers. Cervical cancer screening has led to a decrease in mortality rates by over 50%. Breast cancer screening is associated with a fall of 30% in death rates, and there is very strong evidence that colonoscopic screening for large bowel cancer is effective in reducing death rates but faecal occult blood testing which is cheaper, is relatively less effective.
How about national prevention strategies?
In prostate cancer public health campaigns would need to focus on dietary educational campaigns, battling against vested interests, as a very long term strategy to reduce prostate cancer incidence. We need you as our national representatives to campaign on such important public health matters.
But, what about prostate cancer screening?
Why is there no national screening programme for the early detection of prostate cancer? Firstly it is still not clear that early detection and treatment does lead to a fall in death rates. Secondly we do not have good diagnostic tests. Current screening is based on the PSA blood test. PSA is an enzyme that is produced in the prostate where it acts like biological washing powder to keep the tiny internal tubes clear of gunk, as we clinical scientists call it! PSA spills over into the blood stream and can be measured. Unfortunately, the PSA test is not specific and where blood levels are raised to double the normal range, the chance of a patient having prostate cancer is around 25 – 40%. As a result, if PSA is used to screen normal populations a lot of unnecessary further tests are done. In a recent analysis of over 350,000 men involved in PSA screening campaigns, no benefit was found for screening. So, should you as our national representatives, be calling for investment in new tests for the development of national screening programmes in prostate cancer? Yes! We need a better test that distinguishes between the two different forms of prostate cancer.
And basic science research?
In the UK in 1996 around £46,000 of public money was allocated to prostate cancer research, a hundredth of the allocation to breast cancer. As a result of a national campaign led by the Daily Mail, I met with Yvette Cooper who was the Minister of Public Health. The minister then announced that central funding for prostate cancer research would be increased to a par with breast cancer, to around £4million pa. A great step forward, but inconsiderable in the context of the cost of developing a new drug for cancer which is around £1.3billion. Basic science research is left to charity, where the major funder in the UK is Prostate Cancer UK, an organisation that I founded to remedy the lack of funding for information, clinical services and for research. But we cannot leave matters of such importance to charity alone. So please focus on targeting national research in this area of great public concern.
Improving patient care
Breast cancer was taken as a campaigning issue by women, and led by the glorious radicals of the 1960’s. As a result of feminist campaigns, the care of breast cancer patients has been taken from paternalistic surgeons and into the realms of the multi-disciplinary teams, led by oncologists. Care in breast cancer has been transformed. This standard has not been applied to prostate cancer, where the cancer specialists unfortunately remain distanced by the surgeons, who fail to refer on to their colleagues. As a direct result, in a recent survey we found out that just 1 in seven men who would be considered for chemotherapy for prostate cancer receive treatment, denying these men additional time with their families. In a further survey that I carried out some time ago less than 50% of men with prostate cancer got referred on for radiotherapy to palliate pain, or to Macmillan services. So, we need help in applying the standard for breast cancer care to men with prostate cancer.
Making treatment advances available
The survival time for of men with advanced prostate cancer has almost doubled over the last 20 years. This is due entirely to the introduction of new drugs for prostate cancer. But not all the available new drugs are given to men with prostate cancer, and this is for two reasons. The armies of the drug companies marched late into the battlefield of prostate cancer. Some time was spent in realising that there was a significant ‘market’ for prostate cancer drugs. The battle has been engaged and new drugs have been developed, but once developed not all the drugs that could have been given to men with prostate cancer in the UK have been allowed by NICE, on the basis of wonky cost calculations. This is because NICE uses an appraisal system that applies a universal model for judging cancer drugs that is not relevant to cancer. The subjective scoring system calculates cost as judged by the addition of a year of quality added life and is based on the cost of a drug given to 100% of patients for one year. Now, generally 40 – 50% of cancer patients will benefit from a new drug and take that drug for around 6 or 9 months. 50 – 60% stop the drug after a couple of months as it is not working. So the equation comes out of the back of bovines. The bizarre cost formulae championed by NICE and based on research in the 1950’s needs to be reformed.
You — as our national representatives, have a vested interest in making things better for prostate cancer patients. It could be you, it could be, but there is a chance that it might not be you if you do something for prostate cancer.