You probably know your blood pressure numbers, have a fair idea of your weight, perhaps even your waistline, but — gentlemen only — hands up if you monitor your prostate specific antigen (PSA) levels? Unless you’ve had prostate cancer, chances are you won’t have a clue how much PSA is swilling around in your blood. Or even if you should know.
Yet PSA testing, which has now been around for nearly 45 years, is still one of the best indicators of prostate cancer currently available. According to the most recent 13-year follow-up findings from the European Randomised Study of Screening for Prostate Cancer (ERSPC), published in The Lancet last August, screening men aged 55–69 with the PSA test resulted in a 21 per cent reduction in prostate cancer deaths, compared with a control group who did not undergo screening.
And experts have advised men to be more PSA-aware, with one leading urologist, Roger Kirby, who was treated successfully for prostate cancer last year, suggesting that men over 50 should be much more proactive in asking for a test at their GPs.
He said recently: ‘My advice to men over 50, especially those with risk factors such as a family history, is have a PSA test.’
The Department of Health’s policy however remains unchanged. While men over 50 have the right to a PSA test, following a discussion of the pros and cons with their GP, there are no plans for a national screening programme, unlike say for breast cancer.
Many men have been left baffled. If the test works, why can’t all over-50s get it routinely? They look to the US, too, where the PSA test is commonplace and often offered during routine medicals and at walk-in clinics.
‘PSA testing does have its place,’ says Dr Sarah Cant, director of policy and strategy at Prostate Cancer UK. ‘But you have to remember that it’s a test for prostate problems, not specifically cancer.
‘Of course we’d like a screening tool which could discern not only who has cancer, but also how aggressive it is, but the PSA is not designed to do that.’
Her words of caution echo those of Richard Ablin, the US scientist who discovered the PSA protein and created the test to measure the effectiveness of treatment for prostate cancer, and was shocked when he realised some urologists believed that it could be used as a non-invasive blood test.
He told me in 2010: ‘Had it not been for the test, yes, some lives might have been lost. But, woefully, due to the PSA test, many, many more cancers have been detected that have not merited any treatment.
‘The majority of these patients, an estimated million in the US, could have lived painlessly with their tumours until the natural end of their lives. Instead, they’ve undergone pointless and painful medical therapies from surgery and radiation to even possibly chemotherapy.’
And here lies the UK’s problem with PSA tests — the risk of overdiagnosis and overtreatment thanks to the false positives which it can throw up: three quarters of men with a raised PSA level won’t have cancer. (It can also miss cancers too — known as a false negative — one in seven, says Dr Sarah Cant.) According to the ERSPC study, a total of 781 men would need to be invited to screening and 27 to be diagnosed with prostate cancer to avert one death from the disease.
Which is not to say that doctors or the experts at Prostate Cancer UK don’t think the PSA test doesn’t have its place. As Sarah Cant explains: ‘PSA testing can highlight the need for further testing; at the moment, it is the best we’ve got.
‘But it can’t tell us if a tumour is benign or malignant, slow or fast growing. Some cancers are so non-aggressive that they won’t harm a man in his lifetime.
‘We need a smarter diagnostic test before we can consider the value of a population-wide screening programme.’
Research is under way for just such a test, but in the meantime, the US and Canada are coming round to the British way of thinking. The US Preventive Services Task Force (USPSTF) now recommends against PSA-based screening for prostate cancer, as does the American Cancer Society, which warns that PSA testing should only take place when men have been fully informed about the test’s uncertainties, risks, and potential benefits first.
The Canadian Task Force on Preventive Health Care concurred most recently, in October last year, with Dr Neil Bell, a member of the Task Force and chair of its prostate cancer screening working group, saying the potential for harm after PSA testing outweighs the benefits.
The same official view is taken in Australia, and in France, although PSA testing rates for men in the national health insurance scheme (which covers the majority of men over 40) are high. Meanwhile in Germany, PSA tests for prostate cancer screening are not covered by statutory health insurance funds, but many doctors offer the test as something that men can pay for themselves.
This doesn’t mean that prostate cancer diagnosis is at an impasse however.
Consultant urologist Mr Marc Laniado of Heatherwood Wexham Park Hospitals NHS Trust and Windsor Urology believes that we can get more from our PSA test at the moment — as long as it is not used in isolation.
‘It’s useful in the context of a risk calculator; if PSA levels are raised, then previously, men would be given a digital rectal examination (which can only assess the back of the gland missing one in four cancers), followed by a biopsy, which often led to infection.
‘If that showed up cancer, then the whole prostate would be removed, often leading to side effects including impotence and incontinence, which were extreme, given that we still don’t know which types of tumour are most aggressive.’
But the latest work in radiology suggests that if a raised PSA level combined with an assessment of other risk factors including age, ethnicity and family history, is followed by a pre-biopsy multiparametric MRI, which can show how tightly cells are packed and how blood flows in tissues as well as the chemical makeup of tissue, then, says Mr Laniado, ‘We can weed out most people who don’t have important cancer, before deciding whether to do a biopsy or not.’
He adds that surgical techniques have improved too: ‘In the past we didn’t have a good way of doing it — it was all via the back passage and vulnerable to causing infection. But now, we can investigate with MRI-targeted biopsies performed through the perineum, which is much safer and more accurate.’
The National Institute for Health and Care Excellence (Nice) currently recommends that men who have had an abnormal result from a PSA test that led to a biopsy in which no cancer was found should in future be offered a multiparametric MRI before having another biopsy. Bupa, explains Mr Laniado, is about to insist on this for its clients.
Looking further ahead, Mr Laniado points to a refined version of the PSA test which should be available in the States soon, and here not long after. Plus there is a new algorithm-based blood test being developed at Sloan Kettering hospital in New York, the world’s oldest and largest private cancer centre, by statistician Andrew Vickers. This test — called the 4K score — will, says Mr Laniado, be much more accurate and identify men at high risk.
He hopes too that the rise of precision medicine and the discovery of biomarkers will make individual prognoses more accurate. Then there is the development of Prolaris, a novel genetic test for prostate cancer from Salt Lake City-based Myriad Genetic Laboratories, which combines traditional risk factors with a molecular assessment of the aggressiveness of an individual patient’s cancer. This says Mr Laniado might offer a better estimate of cancer progression than the current estimates which are based around the Gleason grading system used for all cancers.
It’s not just diagnosis that is improving: therapies are becoming more sophisticated such as focal treatments which can now target an area of cancer within the prostate and potentially end the need for radical prostatectomies, leading to fewer side effects such as loss of erection.
‘The whole landscape for prostate cancer has changed,’ says Mr Laniado. ‘There is lots of good news.’
Dr Sarah Cant agrees: ‘We’re funding research to find a better diagnostic test — I’d hope, with global support, we’ll see one in the next decade.’
Men United is Prostate Cancer UK’s movement for men. Anyone who believes men are worth fighting for is urged to sign up. The growing army will be called upon to push forward real change that has a lasting impact on men’s health. With the help of this force, Prostate Cancer UK is pushing for more research to be channelled into finding a new diagnostic test and finding better treatments for men, as well as investing in this itself.
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