The medical and scientific community has made enormous progress in its war on cancer, with survival rates improving across the board as a generation of targeted therapies begin to have an impact. So, last week’s news that deaths from prostate cancer are on the rise – exceeding 12,000 in one year for the first time, according to the Office for National Statistics (ONS) – has come as a disappointment.
And it gets worse. Angela Culhane, Chief Executive of Prostate Cancer UK, said: “By 2030, prostate cancer is set to be the most diagnosed of all cancers in the UK.” Awareness of male cancers has never been higher – thanks to global campaigns like Movember and Men United, and the testimonials of high-profile sufferers such as former BBC Breakfast presenter Bill Turnbull, who in 2018 revealed he was living with advanced prostate cancer. And, overall, a man diagnosed in 2020 has a much-improved chance of survival than a man diagnosed 10 years ago, as long as the cancer is picked up early.
So, given figures like these, why is there still no national screening programme for prostate cancer as there is for breast and bowel cancer? According to Professor Anne Mackie, Director of Programmes for the UK National Screening Committee (UKNSC), it all comes down to the failures of the PSA (prostate specific antigen) blood test.
“The reason why a national screening programme for prostate cancer isn’t currently offered,” says Prof Mackie, “is that the PSA test still isn’t very good at predicting which men have cancer. It will miss some cancers, and often those cancers that are picked up when using the PSA test are not harmful. “Treatment for prostate cancer can cause nasty side effects, so we need to be sure we are treating the right men and the right cancers. There is a lot of research into screening and treatment for prostate cancer and the UKNSC are currently reviewing the evidence.”
In agreement is Dr David Montgomery, Executive Director of Research at Prostate Cancer UK, although he stresses the urgency of change: “It’s really important we get a screening process up and running,” he says. He agrees that PSA testing is not the answer. “PSA levels are important as an indicator of disease,” he explains, but most usefully as a marker to show if a treatment is working; the more effective the measure such as hormone suppression, the lower the PSA count falls. Ideally, it never rises more than 4 millimoles per litre (mmol/L).
For some, like retired heating engineer Julian Delaney, monitoring of levels can be enough to detect a small change that needs intervention. Delaney, 68, who has five children and lives near Cardiff with his wife, explains: “I’d had a PSA test when I was younger, but hadn’t thought too much about it. But, after a talk at my local Rotary Club with a speaker from the charity Prostate Cymru, I was encouraged to have another one.”
The speaker had explained that, as Delaney was from an Afro-Caribbean background, his risk was higher. “I was told that one in four black men will get prostate cancer,” he says, “compared to one in eight men overall.” Delaney’s test, in May 2016, came back as slightly elevated at 4.4 mmol/l, but then a repeat in August showed a rise to 5.6 mmol/l and he was referred to the University Hospital of Wales for more tests. “I spent my 65th birthday having an MRI scan,” he says, “and then I had a biopsy – a sample of prostate tissue taken by needle to be examined.”
Delaney was diagnosed with prostate cancer and, in January 2017, underwent a radical prostatectomy to remove the whole prostate. “It was a success,” he says. “I didn’t need any other treatment and, since then, I’ve been monitored and there’s no sign of the cancer returning.” Delaney is aware that the PSA test is not enough on its own to diagnose cancer, but points out that it gives a baseline from where monitoring can start.
Consultant urologist Marc Laniado, Prostate Cancer lead at Wexham Park Hospital in Berkshire, agrees that we have to begin somewhere. “Potentially, we are ready to have some form of screening programme,” says Laniado. “We can identify men from 45 years old and stratify the risk from then on, based around factors like ethnicity, age and PSA levels. This could direct men at risk for high-quality MRI scanning and, from those, the ones who need a biopsy. For everyone else, it’s a safety net.” He adds: “We may not have all the evidence, but we are 95 per cent there.”
However, Laniado does worry that, while the basics for a risk ratio are understood, there are practical and postcode problems with diagnosis when it reaches the scan stage. “In this country,” he explains, “the quality of MRIs – both the scanners and among those who interpret them – varies considerably depending on location and knowledge.”
There is a potential problem in primary care, too: “GPs are overworked and under pressure. Detecting prostate cancer is not a clinical priority. So some GPs may agree to check PSA levels, and others will dissuade patients who have no symptoms.” To the argument that PSA levels don’t actually detect cancer (only its growth), he points out: “We test for cholesterol, which alone can’t prove heart disease. We test because it is useful as one factor on a risk calculator.”
A screening programme would have found 67-year-old Mike Schofield’s cancer before it spread and became metastatic. Schofield, a retired teacher from Nottingham, had been experiencing urinary issues for a while – changes to frequency and urgency can be a sign of cancer (as well as other benign prostate conditions).
But then, in 2018, he saw Bill Turnball talking about his own symptoms on TV. “My wife said it sounded like me,” says Schofield. “She thought I should see my GP and ask for a test.” After a digital rectal examination (DRE) and the PSA blood test (which registered 16.9 mmol/l), Schofield was referred to Nottingham City Hospital for scans and a biopsy.
“They told me I had stage four cancer,” says Schofield, “which means it had spread beyond the prostate.” His Gleason score was 9; this rates how aggressive the cancer is from 1-10, with 9-10s spreading fast. “My heart dropped at that,” says Schofield.
Scans showed the cancer had moved into his spine and bladder and, although surgery to remove the prostate wouldn’t help, Schofield underwent chemotherapy last year. His PSA count dropped as a result, and is now measured at just 0.4 mmol/l, but screening would surely have made a difference to the timing of his diagnosis: “You know prostate cancer is out there – but I wasn’t aware of the symptoms. I blame myself really but it’s all part of what life throws at you.” While his pragmatic attitude is to be applauded, couldn’t we get a little closer to a position where one doesn’t have to be stoic about late detection?
Researchers at the University of East Anglia may hold the key, with their work developing the Prostate Urine Risk test, a home kit that can predicts whether patients will require treatment up to five years earlier than standard clinical methods. Researchers believe it would make monitoring for cancer more cost-effective and easier for the patient, too – removing the need for DREs. That’s still not a national screening process, though.
But, as Julian Delaney points out, anyone can be proactive. “I’ve spread the word,” he says, “persuading my three brothers to get PSA-tested. I will encourage my sons to do so to when they get older. “My cancer was picked up early and stopped early. Whatever you say about PSA tests, mine was the start I needed.”