EU remains firmly in control of the Brexit timetable
22 Mar 2019 – 11:24 | No Comment

The EU leaders have rejected Theresa May’s request for an extension to June 30. Instead, they have imposed two new dates — if Parliament approves May’s deal, Britain shall leave on May 22. If it …

Read the full story »
Health

Energy & Environment

Circular Economy

Climate Change

Security

Home » Cancer, EU Health, Europe, Health, Prostate Cancer

UK cannot continue to overlook prostate cancer

Submitted by on 01 Mar 2019 – 11:31

Prostate Cancer Parliamentary Reception
Prostate cancer is the third biggest cancer killer in the United Kingdom, with a majority of the deaths occurring because of a delay in diagnosis. Canvassing for a screening programme for prostate cancer, three of UK’s leading charities focusing on men’s health — CHAPS Men’s Health Charity, ORCHID and Tackle Prostate Cancer  — recently brought together key policymakers, members of the prostate cancer community and patients in a Parliamentary Reception to discuss the urgent need for prostate cancer screening.  In this article, Chris Booth, Clinical Director, CHAPS Men’s Health Charity, highlights the policy challenges in managing the commonest male cancer killer

The United Kingdom lags well behind its European neighbours for early diagnosis and cure of Prostate Cancer (PCa).  Every year 47,000 UK men are diagnosed with PCa and nearly 12,000 die from it1.  It is our commonest male cancer and second commonest male cancer killer with deaths now exceeding those for breast cancer2.

As there is no way of preventing PCa, our efforts should be to detect it early when it is confined within the prostate and thus curable.  The only practical way to do this is with the blood test PSA (Prostate Specific Antigen); there is no other simple, cheap marker on the horizon.

Since its widespread introduction as a PCa screening tool in the early 1990s, the death rate from PCa has fallen consistently in all countries making significant use of the test.  Unfortunately this came at the cost of substantial over-diagnosis and over-treatment of non-aggressive, insignificant PCa that has possibly outweighed the benefits of early diagnosis and cure for many other men.

This problem was highlighted by the United States Preventive Services Task Force who decreed in 2012 that these harms outweighed the benefits3.  As a consequence there has been a downturn in screening both in the USA and the UK, where the death rate has stopped falling and the presentation of cases of metastatic PCa has risen4,5, raising the spectre of the pre-PSA era when most men presented with advanced, incurable disease. This is unacceptable.

The longest, clinically valid trial evidence on the benefits and harms of PCa screening comes from Europe.  Speakers at the European Prostate Cancer Awareness Day 2019 presented clear, objective evidence showing that the benefits now easily outweigh the harms.

What follows is therefore not mere opinion, but hard, objective, scientific evidence from screening studies running for up to 20 years. 

The Facts

  • Since 2012, death rates from PCa in the USA and UK are rising4,5.
  • PSA-based screening trials have reduced PCa mortality by up to 64%6,7,8.
  • After 20 years’ follow-up the number of patients needed to screen and to diagnose PCa have fallen to 101 and 10 respectively to prevent 1 PCa death – figures substantially lower than for diagnosing colorectal cancer and breast cancer6.
  • Quality of life studies show that early treatment of PCa lowers the risk of complications such as incontinence and impotence whereas treatment of metastatic disease has a disproportionately negative effect on quality of life for both the sufferer and his partner9.
  • Early measurement of PSA in a man’s 40s can largely define his lifetime risk of dying from PCa.  Low risk men with consistently low PSAs (<1ng/ml) can stop screening in their 60s as subsequent risk of death from PCa is only 0.2%10.
  • Early PSA measurement should be linked to family history, ethnicity and freely available risk calculators to further define lifetime risk.
  • Second line biomarkers provide further information that assists identification of aggressive PCa11-14.
  • mpMRI scans should now be used before biopsy to better target significant disease and avoid the need for biopsy where significant disease is unlikely to exist15.
  • Active surveillance is a proven, safe, management option for “insignificant”, low-grade, low-volume PCa16.
  • In the UK treatment options are determined jointly by multi-disciplinary teams and informed patients to avoid over-treatment, the rate of which has fallen to 8%17.
  • The cost of early curative treatment is approximately €15,00018 compared with approximately €300,000 for long-term treatment of advanced PCa19.

Conclusion

The UK cannot continue to overlook PCa, our commonest male cancer, now that the twin threats of over-diagnosis and over-treatment are clearly outweighed by PSA-based screening programmes and recent advances in clinical practice.

The UK does not require further screening trials but should implement proven screening strategies20 based on multi-disciplinary international guidelines21.

More support and funding should be directed to PCa screening programmes and research.

The evidence is clear.  The only thing lacking is the political will.

References: 

  1. Cancer Research UK.  Cancer incidence.  Accessed 25/1/19.
  2. Prostate Cancer UK:  Feb 2018.
  3. Moyer, V.A., et al.  Ann Intern Med, 2012. 157(2): 120-34.
  4. American Cancer Association, Cancer statistics, 2019.
  5. https://www.bb.com/news/health-43669439. 2018.
  6. Hugosson, J., et al: Scand J Urol, 2018. 52(1): 27-37.
  7. Bokhorst, L.P., et al: Eur Urol. 2014. 65: 329-336.
  8. Alpert, P.F. Urology 2018. 118: 119-126.
  9. Roobol, M, et al: Presentation. European Parliament 22/1/19.
  10. Vickers, A.J., et al: BMJ, 2010; 341: C4521
  11. Vickers, A.J., et al: Eur Urol, 2018. 74(4): 535-536.
  12. Zapala, S.M., et al: Rev Urol, 2017. 19(3): 149-155.
  13. Loeb, S, et al: BJU Int, 2017. 120(1): 61-68.
  14. 13 Van Neste, L., et al: Eur Urol, 2016. 70(5): 740-48.
  15. Ahmed, H.U., et al: Lancet, 2017. 389(10071): 815-822.
  16. Hamdy, F.C., et al: NEJM, 2016. 375: 1415-1424.
  17. National Prostate Cancer Audit, 2017.
  18. Forsmark A., et al: Eur Urol. 2018. 74(6): 816-824.
  19. Wu, B., et al: J Clin Oncol, 2018. 36(suppl.): 88
  20. Arsov C., et al: Eur Urol. 2013. 63(4): 873-75.
  21. Melbourne Consensus: BJU Int 2014;113: 186-88.