Pelican's position on prostate cancer
We believe that:
- Too many men are over-diagnosed and over-treated for prostate cancer
- More precise detection and treatment options should be made available for patients
- Funding for precise prostate cancer detection and treatment is a priority
Our aim: Better planning for precision treatment.
This document encapsulates Pelican’s view on how we can add value and help patients to receive better treatment for prostate cancer. What we want is a way to identify whether a man has clinically significant prostate cancer, and then have precise and appropriate treatment.
Pelican Cancer Foundation was created to improve bowel cancer treatment. Professor Bill Heald realised that more precise surgery could dramatically reduce the number of patients dying from lower bowel cancers. Today his procedure – Total Mesorectal Excision - is accepted throughout the world as the gold standard. His insistence on precision treatment has also led to MRI being used to plan all lower bowel cancer surgery. We argue that we are in a similar situation with prostate cancer. The patient pathway can be refined.
Prostate cancer facts
- 50% of men in their 60s and 80% of men in their 80s have prostate cancer
- 2% of men (10,000) die of prostate cancer every year
- Prostate cancer incidence is significantly higher in Afro-Caribbean men
A diagnosis of cancer is intensely worrying. Prostate cancer is one of the ‘big four’ cancers (lung, breast, prostate, bowel) - it is the most common cancer in men.
In contrast to some other cancers, prostate cancer has two different characteristics. It is true that aggressive prostate cancer (known as a ‘tiger’) is dangerous and causes death - but the majority of prostate cancers are `pussycats`, unlikely to cause harm during a man’s lifetime.
As more men are tested for prostate cancer, at an earlier age, there are more harmless prostate cancers found. So the important question is not ‘have I got prostate cancer?’ but whether a prostate cancer is clinically significant. The statistics tell us that the majority of men have harmless prostate cancer - this is termed clinically insignificant.
Increasingly there is a call for Prostate Specific Antigen (PSA) test screening. Although research has shown that screening may improve overall survival it also shows that up to 48 men have to be treated for it to benefit one man over 14 years.
Two out of three men who have a raised PSA test do not have prostate cancer, but it is also true that men with a low PSA can have prostate cancer. So the advantages of the PSA test have to be carefully balanced. Two-thirds of men with a raised PSA go on to have a biopsy.
NHS GPs are advised by NICE not to offer the PSA test too quickly due to the number of false-positive and false-negative results. It could be that some NHS patients are not being diagnosed, particularly men in lower socio-economic brackets, as they are reluctant to visit a doctor and then easily put off pursuing a diagnosis.
Wealthier patients, with private health insurance, are likely be offered an early PSA test and therefore more likely to be over-diagnosed and over-treated – harmful treatments for harmless disease. In the USA, nearly all men are given annual PSA tests and there is also very high instance of radical treatment for prostate cancer.
Many of us assess risk every day - when we’re driving, or in our working life. Risk-calculators are being developed to estimate an individual’s risk of high-grade prostate cancer. The calculator looks at a man’s PSA level, rectal examination findings, age, ethnicity, family history and previous history, to estimate risk. If the calculator finds that the risk is low, then a patient can avoid having any further investigation. Risk calculators have been shown to successfully reduce the number of men having invasive and painful treatment while not having an impact on the number of significant prostate cancers treated.
A shot in the dark
Most men with a raised PSA are offered an ultrasound-guided transrectal biopsy (TRUS). This has 6 – 14 needles that take sample cores from the prostate. Unlike any other internal organ cancer biopsy testing, this is ‘blind’ – the ultrasound can only guide the needles into the gland and then provide no evidence of the exact position or size of a cancer tumour. The transrectal biopsy cannot reach 25% of the prostate gland at all.
A number of men with a positive biopsy say that they want surgery at this stage – they want to get rid of the cancer and have read favourable reports about the possible side effects. It should be borne in mind that a man is only said to be incontinent if he requires more than one pad (nappy) a day!
Advances in MRI are producing good results as a ‘triage’ for men with a raised PSA and other risk factors of having prostate cancer. If patients can have an MRI before their first biopsy, then those patients who are identified as not having any cancer or not having significant cancer at this stage (approx 25%) can avoid a biopsy. They will be advised to contact their doctor if they are concerned in the future.
MRI is best at identifying cancer lesions greater than 0.5ml which has been accepted as a characteristic of clinically significant cancer. Men who are detected by MRI as medium to high risk have a map of where their cancer is situated, how large the tumour is, and if more than one tumour, if one is larger than any others.
The MRI provides a map of sufficient detail for the biopsy to target the right part of the gland. This map provides detail of position of any significant cancer. Since prostate cancer only takes up 5–10% of the prostate gland this information is useful to help guide the biopsy needle.
There is resistance to using MRI before biopsy – it is a change in practice, radiologists are struggling to get good results and there is a lack of scientific evidence. The health economics of so many MRIs is not clear but if this triage can reduce the number of biopsies by 25% and reduce the number of men having radical (and expensive) treatment that causes side-effects which need to be treated, then it could be economically prudent.
The Pelican-supported unit at UCL has had excellent results and we will support further research in this area.
Men who have an MRI that identifies clinically significant cancer require a biopsy and sometimes even repeat biopsies. Until MRI is accepted as an imaging test for prostate cancer, rather than a blind biopsy, a template biopsy could be carried out for precision diagnosis and mapping of the cancer. Patients have a general anaesthetic and a 5mm grid guides up to 60 biopsy needles into the prostate. Biopsy samples, still in this grid pattern, are sent to a histopathologist to report on whether there is cancer in each sample and the Gleasonscore. This method gives a very precise map of any disease in the prostate and can inform the surgeon about how to treat the prostate.
Note on the Pelican Statement
There are many points in the above statement that are highly contentious - however, we believe that there is sufficient evidence to pursue this line of thought.
The Gleason score is taken from biopsy results to assess the nature of the core samples. The higher the Gleason score the higher the risk of aggressive cancer. It is generally accepted that a Gleason score above 3 + 3 is indicative of aggressive disease, but some urologists and oncologists also think that some small Gleason score 7 cancers could be watched rather than treated.
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