45. Rock, Paper, Scissors and Dumba**

Rock Paper Scissors 2Fresh with the horrific statistics that I present to them, at just about every talk that I give on prostate cancer I am asked the question “Why is there not a national screening programme for prostate cancer?” Related to that, If you were one of the many proactive men that went to go and see your GP about getting a PSA test and ended up being dissuaded from, outright refused or even lied to the origins of that may be rooted in a health paper that was published just over three years to the day…

‘Prostate cancer risk management programme (PCRMP):benefits and risks of PSA testing – Published 29 March 2016’

Was commissioned by The Prostate Cancer Risk Management Programme (PCRMP) and based on the recent UK National Screening Committee (UK NSC) evidence review for prostate cancer screening2 which incorporates information from research developments and the recommendations of the National Institute for Health and Care Excellence (NICE) in the Prostate cancer: diagnosis and treatment guidelines3. It was reviewed by GPs and members of the PCRMP scientific reference group prior to publication.

Blah, blah.

Jumping ahead, having read all of the paper, that last sentence should have read, “It was reviewed by suspect GPs and selected members of the Muppets and Simpsons scientific reference group prior to publication, for your disbelief and entertainment.”

It starts off with telling us what we already know about prostate cancer. It is the most common cancer in men and will be the biggest cancer regardless of sex by 2030 in the UK. We also know that not all men that have a raised PSA will go on to have either cancer itself or a cancer that requires immediate treatment.

This first great quote from section 3, from these people with titles before and after their names and supposedly much more cleverer than me and you goes like this,

‘The PSA test is available free to any man aged 50 or over who requests it, after careful consideration of the implications. GPs should not proactively raise the issue of PSA testing with asymptomatic men.’

In laymen’s terms if a man does not ask for a PSA test and he is not presenting any symptoms the GP should not suggest that he has one. I had to read that sentence a couple of times when I first saw it. Had my locum GP – who I now know to be called Dr Okpara, not bothered to go that extra mile and suggest that I add the PSA test to my health MOT, I dread to think what the outcome could have been. The whole point about prostate cancer is that most men do not have any symptoms until its at a later stage and therefore potentially worse side effects or even death. Not one of the guys at PCUK that I have spoken to had any symptoms before they discovered that they had prostate cancer.

Not one !

The report then goes on to identify that there are specific groups that have a significantly higher incidence and mortality of prostate cancer. These groups are, black men, men with a family history of prostate cancer and men who are overweight or obese (specifically for advanced prostate cancer). A glaring omission is the proven risk factor that having a BRCA 2 gene mutation on the female side of the family or breast cancer can have with regards to prostate cancer for a man.

Quote from section 6 the paper,

‘To date, there is no evidence screening black men at high risk for the disease will reduce their risk of prostate cancer-related death’

!@$\\\@#%*

I wish these were quotes that I was just making up. They are in black and white.

We already know that there is a hereditary trait to prostate cancer and that black men are twice as likely to contract it than white men. This could have been merited as the dumbest quote out of the whole paper had we not only reached section 6.2 out of 17 sections.

Trust me they make full use of it. So just before the first commercial break. Jim our host, with the most – what are the scores on the doors,

Effective ways to kill Peter = 2

Glaring contradictions = 0

Quote from section 7

‘Localised prostate cancer (confined within the capsule) is usually asymptomatic. Prostate cancers, unlike benign prostatic enlargement (BPE), tend to develop in the outer part of the prostate gland. It is unusual for these early cancers to cause any symptoms, but they may be palpable by digital rectal examination (DRE). Localised cancers range from just a few cells to more extensive disease that is considered ‘clinically important’.’

You have to wonder if the construction of this paper could be compared to a really bad pre-fabricated building. Where one set of measurements written in metric and the other imperial and then in different countries. Let’s make one of those countries North Korea to just make it more interesting.

So here they are readily admitting that it is unusual for these early cancers to cause any symptoms but you have already said that GP’s should not be giving a PSA test to any man that does not have any symptoms. Stick with me we are just warming up.

Imagine that you have just finished cooking the Christmas turkey or if you are a veggi the green or brown brick. Boiling hot juices are slowing seeping out from all angles. The hot steam brushed your face as you opened the oven and the heat continues to bellow out. Now my head has been called many things in its day. However ‘asbestos head’ was never one of them. If I was to put my head inside the oven I wonder if I am likely to get burnt??.

Quote from section 9,

‘Men who have a PSA test increase their chance of a prostate cancer diagnosis.’

You don’t say! Doh!

Section 9.1 which list the benefits of PSA testing is an even better read,

  • It may lead to the detection of cancer before symptoms develop
  • It may lead to the detection of cancer at an early stage when the cancer could be cured or treatment could extend life
  • Repeat PSA tests may provide valuable information, aiding a prostate cancer diagnosis

The test limitations or risks, which is a much longer list than the advantages is fair comment. However if you have a threshold of say 3.5 and a man has a PSA of 8, then its fair to say there is a problem.

What’s the scores so far Jim?

Effective ways to kill Peter = 2

Glaring contradictions = 1

Section 11 continues the happy trend,

‘The management of localised prostate cancer is central to the controversy surrounding screening. Men considering a PSA test should understand that:

Early detection and treatment of prostate cancer may be beneficial’

You don’t say!

Especially as you have potentially killed me twice over earlier in the nonsense paper. Where are those damn scissors.

Wow !  Now I know what it feels like to make a noble prize winning discovery like penicillin or DNA.

I must at this stage apologise to the wonderful Muppets and Simpsons. I have done you a complete dis-service mentioning you in the same sentence as this pile of nonsense.

The penultimate section 15 gives us this great couple of sentences,

‘Despite the benefit of PSA screening to reduce prostate cancer mortality by at least 21%, in some studies, there are still significant gaps in our knowledge of overdiagnosis and overtreatment of clinically insignificant prostate cancers as well as identifying the optimum treatment. The potentially harmful effects of prostate screening are significant.

While some early cancers would be detected and lives saved, the introduction of a PSA-based screening programme at this stage would undoubtedly lead to some men with indolent disease unnecessarily experiencing the side-effects of radical treatment, including sexual dysfunction, urinary problems and, in extreme cases, death.’

Some men could potentially have unnecessary treatment because either they don’t have cancer or it is so slow growing they would have been likely to die of something else in the meantime.

I get that absolutely. While other men that have the disease could be subject to a delay that could make their outcome far worse or even kill them.

It then continues,

‘The UK NSC has therefore recommended against a prostate cancer screening programme in the UK at this time. Instead, the PCRMP exists so that asymptomatic men who ask about a PSA test can make an informed choice, based on good quality information from their GP or Practice Nurse, about the advantages and disadvantages of having the test.’

And the conclusion is. Drum roll…

‘Prostate cancer is a significant health problem, mainly affecting older men. There are problems surrounding the early diagnosis and treatment options for the disease, and to date there is no evidence to say whether the introduction of a population screening programme would reduce mortality in the UK without significant numbers of men being overtreated.

Due to the uncertainties surrounding PSA testing and treatments for prostate cancer, it is imperative that men who request a PSA test receive balanced information about the pros and cons to assist them in making an informed choice about being tested.’

And there you have it. The reasoning behind why there is no national prostate cancer screening program in the UK.

I understand that the NHS could not afford a screen programme for every man over forty years of age but this paper does not even offer a partial solution. If this paper was followed by every GP its obvious that there would be potentially thousands of men eventually seeking treatment for a cancer that could have been caught at a much earlier stage. That would include me as well.

The authors of this paper have a lot to answer for.

Now where is that damn rock ?

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