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Prostate cancer and early detection

To mark Prostate Cancer Awareness Month (March) Vincent Gnanapragasam, Clinical Director for ProstateHealth UK, talks about the importance of screening and how greater awareness can help save lives.

First of all, can you describe how you came to be involved with prostate cancer?

It’s quite a long story! In short, I'm a consulting urologist at Addenbrookes in Cambridge, dealing mainly with prostate cancer, but I am also a lecturer at Cambridge University. So, I spend half my time on research into prostate cancer and the rest involved in clinical delivery of services for prostate cancer – and for general urology as well. I have been involved in research into prostate cancer since 1999, so I now have 17-year experience exploring all aspects, from basic science to clinical research and everything in between. My specific areas of interest are in early and high-risk localised prostate cancer, as opposed to metastatic and advanced disease.

We talk a lot about "awareness" but what can be gained from increased awareness, and what should people be aware of?
In terms of prostate cancer, the first thing that we need to be aware of is that it is a very common disease, affecting around 40,000 individuals a year in the UK – and this is projected to rise to 70,000 a year by 2030. Prostate cancer is, in effect, asymptomatic, which means that many men will have no symptoms when they have the disease. There's a common fallacy that urinary problems are linked to prostate cancer, but that's just not true – unless the cancer is very advanced, this is unusual. So, it's about being aware of the disease, knowing more about it and going along to your GP and getting a health check that includes a blood test to pick up indications of the disease – which, I would say, would be advisable for men over the age of 50. If detected early, prostate cancer can be treated very effectively, and in fact is one of the best cancers with regard to being able to effect cure.

Are we getting better at detecting this disease early?
In terms of detecting prostate cancer, things have changed quite rapidly in the last few years, which have seen the introduction of better and more accurate tests – not just blood tests, but imaging tests as well. These days, if someone is suspected of having prostate cancer, there are quite a number of sophisticated tests that can be done. On the NHS, the primary test remains the PSA blood test, but very often that will be augmented by an MRI scan, before deciding whether to proceed with a biopsy. Of course, in terms of other tests, which do have to be paid for at the moment, there are some very accurate tests – better than PSA – and Check4Cancer uses one of these, the 4Kscore test. This has been shown to be far better than the standard PSA in predicting the likelihood of having prostate cancer, but is not yet available on the NHS.

Unlike breast or bowel cancer, prostate cancer has no NHS screening programme. Why is that?
Screening that is dependent on the PSA test – the standard test used by the NHS at the moment – is not considered a good thing, as PSA testing is not considered accurate enough. Also, although we can pick up many cancers by other means, it's now recognised that a lot of prostate cancers don't necessarily need active treatment, so you can end up with a diagnosis of cancer causing a lot of worry without actually benefiting the patient.

Do lifestyle factors affect risk of prostate cancer?
There are factors affecting prostate cancers that are inherited, although that's a small proportion of the overall number. Unlike other cancers, there are very few lifestyle factors that have been proven to affect prostate cancer, and to be honest the effect on risk is quite small, so I would not advise anyone to rapidly change their lifestyle to try and achieve that. For example, there has been much talk about tomatoes and lycopenes being beneficial, but the truth is no one knows exactly how much of these things one has to consume to provide any benefit. So from a dietary point of view, it's probably not worth changing anything. But having said that, having a healthy diet and a healthy lifestyle are all good for health in general, which is clearly a good thing.

Are there new developments on the horizon, either in detection or treatment?
There are lots of things happening all the time which improve the choices of treatment and detection. But to be honest, the biggest thing that we need to think about is actually how to best use existing techniques – things such as new tests, MRI scans, trying to understand how best to use them and how and when we do biopsies. We need to think about how we combine these into standard practice. At the moment, the risk is we could become like America, where the methods offered depend on where you go and who you see. The key benefit of the UK system is that it aims to be equal and similar for all, and that's something that we need to consider when looking at all these new tests that we now have access to.

Are more people accessing these tests?
I think that as awareness grows, people are very keen to get checked out and there is a growing phenomenon of the patient actually going outside the NHS and GPs for this. This is where services offered by Check4Cancer are useful. The key thing is the interpretation, and what to do with this test. There can be the converse side that people become concerned about a test outside the health service, the meaning of which they perhaps don't quite understand. So, while I think there should be access to such tests, they have to be backed up by a good system to advise people on what their results mean and what action to take.

What is the key advice to men who are worried about prostate cancer?
I think with detection, the main things people need to be aware of are that they should go to their GP and get checked out, and see what to do after that. The key thing is not to avoid the issue, and to at least get assessed first. Then the most important thing to understand is that even though you might find a diagnosis of prostate cancer, the cure rate is very, very high. In fact, in many cases, knowing about prostate cancer is enough, and often all you need to do is keep an eye on it. But unless we know early, we can't do any of these things.

vincent gnanapragasam bw2Vincent Gnanapragasam, BMedSci, MBBS, MA, PhD, FRCS, FRCSEd(Urol) is an academic consultant urological surgeon at the University of Cambridge and Addenbrookes Hospital, Cambridge. He was the first urologist and surgeon to be awarded a Cancer Research UK Clinician Scientist Fellowship and is a recipient of a Hunterian Professorship from the Royal College of Surgeons of England. His clinical work has included undertaking robotic radical prostatectomy, advanced diagnostic techniques (e.g. image guided template perineal prostate biopsies) and management of men on active surveillance for low-risk disease.

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