The news of King Charles’ recent prostate issues and subsequent cancer diagnoses has brought the issues of such health problems into the public consciousness. It seems that the King doesn’t have prostate cancer, but he has been widely praised for raising awareness on the issue, especially for older men.
The charity Prostate UK has been asking men, via billboards up and down the country, to check their risk of cancer and see their GP if there are any warning signs such as frequent, difficult-to-control urination. However, prostate cancer remains a complex and nuanced condition.
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The prostate gland sits under the bladder and tends to get larger with age. The urethra – the tube that drains urine from the bladder to the outside world – passes through it. This means that when the prostate enlarges, it presses on the urethra, slowing down the passage of urine and giving rise to other symptoms such as dribbling or needing to pee more often. Overall, it’s a very common condition.
Similarly, the development of cancer forming in the prostate gland is also very common. In fact, autopsy studies suggest that 36 per cent of Caucasians and 51 per cent of African Americans have prostate cancer when in their seventies.
Another study even suggested that as many as 5 per cent of men under the age of 30 were living with prostate cancer. This sounds alarming – but these were cancers found by performing autopsies on men who died of other causes. There’s even a saying that has endured amongst medical professionals that goes: “More men die with prostate cancer than because of it”.
This is the big problem associated with prostate cancer – it exists in forms that don’t seem to do much harm at all, but there are also forms that are potentially lethal and can spread into the pelvic organs and metastasise to the bones.
How dangerous is prostate cancer?
Prostate cancer is currently responsible for around 12,000 deaths in the UK annually, making it responsible for about 4 per cent of all male deaths.
The key to tackling the issue lies in working out which ones are likely to do harm as treatments such as surgery, radiotherapy and hormone therapy can cause side effects such as long-term erectile and bowel dysfunction and incontinence.
It’s obviously important not to needlessly cause harm due to treatments the patients don’t need and couldn’t benefit from.
The problem is, at present, we don’t have an accurate and easy way to separate the aggressive tumours from the quieter ones. There is a blood test, known as PSA (prostatic specific antigen), which was developed to monitor men’s response to prostate cancer treatment in the 90s.
After its introduction, the number of prostate cancers diagnosed shot up, but there was no clear corresponding reduction in death rates.
This led to Richard Albin, the scientist who came up with the PSA test saying that its “popularity has led to a hugely expensive public health disaster”. This is because PSA doesn’t only detect prostate cancer – it can provide a false positive as a result of infections, benign enlargement of the prostate or even different types of sexual activity.
In the US, the Preventive Services Task Force independently analyses research evidence and makes recommendations for or against screening for this.
They say “PSA screening may slightly lower the chance of death from prostate cancer in some men. But many men are at risk of harms from screening, like false-positive test results that lead to more testing, as well as diagnosis of problems that wouldn’t have caused symptoms or death.”
In other words, more screening in the US may have led to worse health outcomes for men – they either received a positive test result when they didn’t have the condition, or they pursued treatments for problems that wouldn’t have caused death.
Even so, death rates from prostate cancer in the US have slowly fallen over subsequent decades, despite rates of testing declining from the peak in the nineties. This is likely due to better treatment programs. Nor is benign prostate enlargement linked to cancer, meaning that limiting testing to men with symptoms of prostate enlargement won’t stop unnecessary cancer treatment.
Elsewhere, trials of screening for prostate cancer in Sweden have reduced the death rate from prostate cancer from 1.7 per cent to 0.98 per cent. But this took the diagnosis of 13 men to prevent a single death.
What is the solution?
To combat this, and avoid unnecessary treatment, a strategy of ‘watchful waiting’ has proven to be effective. A recent UK study carried out over 15 years found that, when prostate cancer was localised, the death rates were lower whether treatments included radiotherapy, prostate removal, hormone therapy or monitoring. This points towards invasive treatment not producing any real advantages.
So what can be done? In the UK, the National Screening Committee recommend against PSA screening for prostate cancer. This is regularly reviewed. Research in the last few years has pointed towards the possibility of using screening MRI scans of the prostate to identify harmful cancers – but the evidence is lacking on whether it can reduce death while avoiding excessive treatment.
Meantime, simplistic messages have been rolled out to men about the benefits of screening, without explaining the downsides. Mass screening events have even taken place at sports events by well-meaning charities. I would argue that informed consent is essential. Otherwise, we are offering both false promises and reassurance – hardly a step forward for men’s health.
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