The UK National Screening Committee has come out with its advice on prostate cancer screening in the UK. This is that men with only one breast cancer mutation gene (BRCA-2) should be offered a screening test, which is a single small blood test called PSA. To many of our surprise, the fact that black men are not offered screening was not included, although black men will be offered participation in a study of prostate cancer diagnostics. Black British men, as shown in work we did some years ago, have almost a three times increased rate of prostate cancer compared to other racial groups in the UK. and also they tend to get the disease a few years younger than white or Asian men.
We published a study back in 2007 when we showed that black British men were several times more likely to know a friend or relative who had prostate cancer but were only half as likely as white men to have had a screening PSA test. This strikes me as a significant health care inequity.
The rationale behind not favouring screening is that many men will develop a prostate cancer which is not lethal and the screening committee felt that there would be more harm done than good. I think this would have been true 10 years ago, but I don’t think it’s valid nowadays. Our diagnostics and treatmentshave become very much better and our patients are less likely to suffer harm as a result of those. We’re also much less likely to offer radical treatment to those men who have cancers which will not affect their life expectancy. I was reminded of this when I was asked to advise on a legal case recently where a man was being refused insurance care for a Gleason 3 + 3 prostate cancer.k This is a cancer most unlikely to cause harm and one we would normally keep under survellance What was surprising about this was not the insurance company’s approach but the fact that he had insisted in having a radical prostatectomy. This is the first man I’ve seen for many years who has had radical surgery for such a tumour and I think both my oncology and surgical colleagues are much better at not wading in with potentially harmful treatment for men who do not have a life-threatening cancer.
There is a big difference between prostate cancer and breast cancer. When I started urology, there was one penny spent on prostate cancer research for every pound spent on breast cancer research, despite the fact that nowadays more men are diagnosed with prostate cancer than women with breast cancer. It’s arguable there was less evidence for breast cancer screening when it was introduced and prostate cancer is now the only common cancer we do not screen for full stop.
This is a developing area and I could produce many patients who presented with advanced prostate cancer who would deeply regret the fact that they did not have a screening test years ago. Some of these were refused screening tests and it’s always very difficult to commiserate with these men who have lethal cancers which are beyond salvage. I will continue to advise that if men have a strong family history or they’re black, then they should be given the option of a screening test, understanding all that I’ve said above. We’ll see how the guidance develops. What we do know for sure is that men who are screened for prostate cancer will have a lower risk of dying of the disease. and lives will be saved.
The flip side of course is that we mustn’t be too gung-ho in treating men who do not need it, but I think the urology community has reached that point and this was not recognised in the recent NHS decision making.