Should PSA test be standard for anyone over 50?

Photo taken from my film re the PSA testing event in Stroud

The UK’s prostate cancer statistics compare poorly in relation to those of its European neighbours. So what about the role of the PSA test?

What is the PSA test?

"The PSA test is a blood test that can help diagnose prostate problems, including prostate cancer. It is a blood test that measures the amount of prostate specific antigen (PSA) in your blood. PSA is a protein produced by normal cells in the prostate and also by prostate cancer cells. It’s normal to have a small amount of PSA in your blood, and the amount rises as you get older and your prostate gets bigger. A raised PSA level may suggest you have a problem with your prostate, but not necessarily cancer. You can have a PSA test at your GP surgery. You will need to discuss it with your GP first. At some GP surgeries you can discuss the test with a practice nurse, and they can do a test if you decide you want one." Prostate Cancer UK 

Statistics from Cancer Research here

If you are having the test it is important to understand the advantages and disadvantages - but certainly seems important to have the test if you have symptoms and in some cases even if you don’t have symptoms (i). See more at the Prostate Cancer UK website.

As many reading this will know, the PSA test is by no means ideal. Research shows that it can help diagnose people earlier and reduce the risk of death (ii) - but it is important to bear in mind that the raised PSA is only a sign that could mean an enlarged prostate, prostatitis and/or prostate cancer. It is also worth noting that a number of other factors can lead to raised PSA like a urine infection, vigorous exercise, ejaculation, medicines and more. Furthermore to confuse matters, some people with prostate cancer don’t have raised PSA levels. 1 in 7 men with a normal PSA level may have prostate cancer, and 1 in 50 men with a normal PSA may have a fast-growing prostate cancer.

What is the national position regarding PSA testing?

The national Prostate Cancer Risk Management Program run by NHS England gives advice to GPs and others about prostate cancer. The advice is; "The PSA test is available free to any well man aged 50 and over who requests it. GPs should not proactively raise the issue of PSA testing with asymptomatic men’"(iii). However this has led to GPs in Gloucestershire behaving very differently; some testing readily, others not. 

Prostate Cancer UK write: “It isn’t clear that screening with the PSA test would have more benefits than disadvantages. Some studies have found that screening with the PSA test could mean fewer men die from prostate cancer. But it would also mean that: many men would have a biopsy, which could cause side effects, a large number of men would be diagnosed with a slow-growing cancer that wouldn’t have caused any symptoms or shortened their life and a large number of these men would have treatment they didn’t need, which could cause side effects. Other studies have found that screening may not reduce the number of deaths from prostate cancer.”

Certainly my biopsy created additional problems and there are also those who have concerns about biopsy’s and their impact on our health - but that is for another blog.

What is Cotswold Prostate Cancer Support Group’s view (iv)?

They write: “Our charity...strongly supports the use of PSA testing as an easy first indicator of the possible need for follow-up investigation for prostate cancer.” They also actively plan and fund free public PSA test events like the one in Stroud I attended with nearly 500 men over 50. There is also a good video filmed at a similar event to the Stroud event, featuring retired consultant, David Baxter-Smith, who explains the PSA test very well.”  See the ten minute film at: https://youtu.be/o-YJvJ-3hGU

As someone who hadn’t got any symptoms but was picked up as having a high PSA by one of the group's free public PSA test event, I am very sympathetic to this view indeed!

Why does the UK has some of worst rates of prostate cancer in Europe?

The Association of the British Pharmaceutical Industry writes (v): "The UK’s prostate cancer statistics compare poorly in relation to those of its European neighbours. The incidence rate for prostate cancer is 111.1 per 100,000 in the UK, compared to a European average of 105.5 per 100,000. Furthermore, the rate of newly diagnosed cases of prostate cancer in the UK is 3% higher than the European average of 23%. Incidence of prostate cancer is increasing across the whole of Europe…. The mortality rate for prostate cancer in the UK is also higher than the European average. Whilst the mortality rate in the UK is 22.8 per 100,000, it is 18.9 per 100,000 in Europe. The UK has a disproportionately higher share of cancer deaths due to prostate cancer than the EU, with the share of deaths caused by the condition standing at 13% and 9% respectively."

Sadly chances of survival for UK patients to five years after diagnosis are also much lower than in Europe. Whilst over 84% of patients with prostate cancer in Europe will survive for five years, in the UK only 78% will survive with the condition for five years after diagnosis.

One of the reasons for this higher incidence is around the more frequent use of the PSA test in the UK and the earlier detection. However this does not translate into higher five year survival usually associated with early diagnosis. We need more research looking at referral processes and patient access to treatment and care to see what is impacting on rates in the UK. It is quite shocking that one in five men with prostate cancer in the UK stated that they did not understand the treatment options available to them; we urgently need improvements in increasing patient awareness of different treatments options (vi).

Public Health England statistics 2015; see here

Is it about money?

The Association of the British Pharmaceutical Industry writes (v): "The UK’s spending on healthcare overall, as well as on cancer and prostate cancer specifically, fall below the European average...The UK spends €497 million per year on prostate cancer...This is significantly lower than the highest spending countries in Europe such as Germany or the Netherlands, which only have marginally higher incidence rates than the UK. Whilst the Netherlands spends nearly €5 more per capita on prostate cancer than the UK, Germany spends more than double the amount on the condition with €20.40 per capita. Although the UK spends a similar amount per capita on prostate cancer as Finland, this is not reflected in outcomes. Finland’s five year survival rate is higher, suggesting that further improvements can be made to the way in which the UK spends its resources."

Public Health England statistics 2015; see here

Clearly healthcare is provided in different ways and it is not so easy to compare countries. Furthermore other aspects of health like the impact of varying diets seem rarely to be considered in thsi context. However all this makes it sound to me like there is work to be done! If other countries can get better survival rates then I am sure we can too. We clearly need a better test than PSA but at the moment that is what we have got. Is there a better way of using it?

Is it time for a baseline PSA test?

In a talk (vii) at the Cotswold Prostate Cancer Group with Dr Jon Rees (who was surgeon and researcher and more recently a GP), he argued against a national screening with PSA as most of the screening is done to men in their 70s and 80s. He argues instead we should be targeting, with PSA tests, men in their mid-50s and early 60s who have a family history or Afro-Caribean backgrounds. He also suggests we need to pay attention to baseline testing; someone at 49 is very low risk but it is still worth doing a PSA test as you can get a reading without the benign enlargement of the prostate. 

Research in Sweden with the blood from 160,000 men, has shown that if your PSA is above average in your 40s (normal is about 0.7) then your risks of prostate cancer are much greater. Hence Dr Rees argues that it is useful to test so that you can see whether further testing might be wise. In other words the the aim of a baseline PSA test is not to help diagnose prostate cancer, but to help work out your risk of getting prostate cancer in the future. If the test suggests you're at higher risk, you and your doctor can decide to do regular PSA tests. This looks like it might be a good way to spot any changes in your PSA level that might suggest prostate cancer.

PSA; more harm than good?

Finally it is worth mentioning the conclusions of the American Preventive Services Task Force (PSTF) who say that PSA tests for prostate cancer do not offer men any tangible benefit in lifespan or quality of life, and conclude that many more men are injured than helped by PSA tests (viii). Chris Woollams, of CANCERactive writes (ix): "The PSTF research concluded that only one man in a thousand tested would derive any real benefit whereas a staggering 100 will receive false positives. Many of these people will then have biopsies which can cause complications including infection."

It is said prostate cancer is "caused" by oestrogen. Oestrogen turns testosterone into DiHydroTestosterone, or DHT and it is this DHT that is the aggressor. The oestrogen may be human or chemical. It has been suggested (mainly in the US) that measuring this might be a more accurate measure of the aggression of the cancer (ix).

What next?

It seems to me that exploring the baseline approach further is overdue. Why if Sweden have found such useful results do we not explore this further? We also urgently need to find a better way of testing for prostate cancer. One of the suggestions at a recent Cotswold Prostate Cancer Support Group meeting was to see if the Gloucestershire Cancer Patient Reference Group might be a way of tackling this issue locally. Certainly the issue is fraught with challenges but it is surely time that we do better. I would hugely welcome any information that might help clarify or correct issues I’ve raised here; either comment or contact me direct.

See also my blog post on biopsies here.


Notes

(i) https://www.prostatecanceruk.org/prostate-information/prostate-tests/psa-test#who-can-have-a-psa-test

(ii) Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet 2014;384(9959):2027-35.

(iii) https://www.gov.uk/government/publications/prostate-specific-antigen-testing-explanation-and-implementation

(iv) https://tacklegroups.org.uk/site-19/

(v) http://cancercomparator.abpi.org.uk/resources/ABPI%20prostate%20cancer%20briefing%20July%202017.pdf

(vi) Quality Health, 2015 National cancer Patient Experience Survey, 2016, available at: https://www.quality-health.co.uk/surveys/national-cancer-patient-experience-survey , accessed February 2017.

(vii) See Dr Jon Rees talking: https://youtu.be/7c_JcR2H7Ac

(viii) http://www.junkscience.co.uk/2012/06/junk-science-number-18-the-psa-test-for-prostate-cancer/ 

(ix) https://www.canceractive.com/cancer-active-page-link.aspx?n=171&Title=Prostate

Whats the CCG? And how can we influence services?

So last week at the Cotswolds Prostate Cancer Support meeting there was over 40 guys plus some partners to hear Becky Parish, the Associate Director Engagement and Experience of Gloucestershire Clinical Commissioning Group (CCG). She started by giving a six minute overview of the CCG. You can see edited highlights in my film below.

There is also a great animation by the King’s Fund who give a whistle-stop tour of how the NHS works in 2017 and how it’s changing: https://www.youtube.com/watch?v=DEARD4I3xtE

Paving at Penny Brohn

The second part of the talk (see my film below) went into more about how the CCG engages with folk in Gloucestershire; this included how complaints and comments help shape services, the use of surveys, patient groups in GP surgeries, the Info bus that gets out and about across Gloucestershire and the Gloucestershire Cancer Patient Reference Group. I think this Cancer Reference Group is the only medical condition that has such a group and it is also not common to have such groups in other parts of the country. However it sounded like a powerful way to get the patient voice heard and has already helped set up a new Support Group for people with Colon Cancer and helped shape the MacMillan Next Steps programme.

I’m not sure I’m ready to dive into being a member of that group yet, but can see it could be a useful vehicle to raise many issues that I hear from others with cancer…although not all relevent to the Reference Group we always have some great questions and conversations at the Support Group. At the meeting last week here are some of the issues discussed:

Why is the message about diet/exercise/lifestyle not coming more from doctors? 

Why are folk cut off from both oncology services and Macmillan support when they seek private treatment? 

How can we improve consistency around PSA testing? 

Why can’t there be a more open conversation about complimentary medicine?

Could we do more PSA testing in the County?

I understand the Group will be inviting CCG representatives again so hopefully a chance to explore some of these issues further.

Thanks to Becky Parish for allowing me to film at very short notice; the editing is all mine so apologies if any of the editing makes Becky’s talk less clear.

Prof Dr Alexander Herzog: Hyperthermia and Cancer

I had transurethral hyperthermia treatment last November in Bad Aibling, a blog soon about that, but in the meantime I caught up with Alexander Herzog who used to work at the clinic I attended. He wasn’t there when I was, as he has established his own hospital in Nidda-Bad Salzhausen, where he has continued to specialise in oncology and develop hyperthermia treatments. His view is that some orthodox treatments showed benefits but that often the side-effects could be extreme. He therefore has worked on the use of complementary therapies to maximise the effects of orthodox treatments whilst reducing side-effects.

Alexander gave us a talk at the Guildford Wellness Day. I’m hoping that the whole talk will be available soon on the internet. He started his talk explaining hyperthermia was about heating up tumour tissues. The treatment has a long history - see the photo from an old medical text book using hot water bottles!

Of course it has developed over the years and there are various approaches that can enhance chemotherapy and radiation treatments but also used to treat cancer. Alexander took us through a whole series of case studies like the photo below which shows a rectal cancer disappearing - and explained some of teh science behind it.

In the talk Alexander looked more closely at orthodox, complimentary and alternative approaches. He feels that there is often mutual demonisation with orthodox being seen as being about science and aggressive cold, harmful treatments, whereas alternative medicine is soft, safe, warm and about emotions. He thinks this feeds uncertainty in patients and sometimes leads to wrong decisions.

Alexander suggests that up to 80% of all patients with cancer are looking for complimentary and alternative treatments - yet most don’t tell their oncologists. One of the reasons for this he suggests is that doctors have such little understanding or training of complimentary medicine and many are dismissive. Certainly some complimentary treatments don’t have lots of studies but many do - and many can significantly impact on quality of life.

Health practitioners are often coming from different positions. Orthodox medicine wants to ‘hit' the cancer whereas complimentary is about building the strength of the body to tackle the cancer. In the talk Alexander outlined some of the complimentary treatments that offer some important benefits, including mistletoe therapy, Japanese mushrooms, Ozone therapy and more. See my previous blog about the mind-body revolution that is unedrway - and that Dr H is very much a part of.

Chris Woollhams has a great website with info about cancer. His pages on hyperthermia are worth a look. See his overview at: https://www.canceractive.com/cancer-active-page-link.aspx?n=3078

See more about Dr Herzog at: https://www.hospitaldrherzog.de/

Grant Hatch; what matters in life?

Grant talking at Wellness Day in Guildford

It was great to hear Grant Hatch talk about his cancer journey and in particular the importance of finding meaning in life. I caught up with him at the Guildford Wellness Day where I also spoke with other thrivers like Kris Hallenga and Jane McLelland. In my interview with Grant below he shares his top three questions to consider.

The author, Dr Kelly A. Turner, of the wonderful ‘Radical Remission, Surviving Cancer Against All Odds’ (i), looked at over a thousand cases of radical remission, people who have defied a serious or terminal cancer diagnosis with a complete reversal of the disease. She pulled out common factors amongst those who had healed their cancer and found that nine of these emerged more often; one of these was having strong reasons to live. 

In her research Kelly found that this desire to live ‘had to come from the deepest core of his or her being, and it has to be unquestioning.’ This is again about that mind-body connection, the mind leading the body. We know the power of this, a thought or emotion can lead to powerful hormones being released that can have beneficial or detrimental effects on our immune system. Kelly notes that to get excited about living we often need to get in touch with our deepest desires or callings, putting creativity back in our lives.

Well I’m fortunate to have much meaning in life, but have recently been wondering about the joy in it. There is a study from the University of Pittsburgh showing that a sense of joy, is the second most important factor for predicting  cancer recovery (ii). Yet somehow I manage to be stuck too often in my 'to-do list world' of doing this and doing that. Yes there are many times in my day to appreciate nature like the mushroom I found in Standish Woods (see photo), laugh with a colleague or love the smell and taste of my morning coffee. I’m good at joy like that, but often find stress creeping into my schedules….and we know very well the connection between stress and cancer (iii). How can there be more joy?

Standish Woods

I can feel another blog coming on in the future about stress and how we manage it, but for now there is no question that cancer has given me a wake up call. Grant’s talk was a great reminder that we need to consider what does really matter. For me this is all linked, so means revisiting deepest desires, finding better ways to manage my ‘to-do list’, looking again at stress and much more! Cancer certainly gives us lots to think about  - and work on!

This blog also appears on the website of the Holistic Centre in Surrey.

Notes

(i) Kelly A. Turner, of the bestseller ‘Radical Remission, Surviving Cancer Against All Odds’ (2014): https://radicalremission.com/about/the-book/

The 9 key factors identified were:

Changing your diet

Taking herbs and supplements

Taking control over your treatment

Having a social support structure

Releasing suppressed emotions

Following your intuition

Increasing positive emotions

Deepening your spiritual connection

Having Strong reasons for living

(ii) Survival hazards analysis in first recurrent breast cancer patients: seven-year follow-up:
https://www.ncbi.nlm.nih.gov/pubmed/3186895

(iii) Impact of stress on cancer metastasis:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3037818/

Meet founder of breast cancer charity Coppafeel!

I recently heard the totally inspiring Kris Hallenga talk about her diagnosis of ‘incurable’ breast cancer at the age of 23. Two months after this diagnosis she started to set up CoppaFeel! She saw that there was not much info about cancer for young people and many thought that breast cancer only affected women over 50. Since then she has been on a mission to ensure that more young people catch their cancers earlier so that there is a higher chance of surviving.

I find hearing such stories of how people have managed their cancer and found purpose and meaning in their lives totally uplifting. Below is my two minute interview with Kris after her talk in Guildford - and I also recommend her Do Lecture talk which tells her story and how she set up the charity, Coppafeel! See:
https://www.thedolectures.com/talks/kris-hallenga-live-a-life-that-you-love

Of course it is worth mentioning that men also have some breast tissue in their chest and under their armpit, so it is important they get anything unusual checked out too. Almost 400 men are diagnosed with breast cancer in the UK every year.

• 1 in 8 women will be affected by breast cancer in their lifetime.

• Around 400 men are diagnosed every year.

• Breast cancer is still the most commonly diagnosed cancer in women under 40.*

• Every year in the UK, around 5,000 women under the age of 45 are diagnosed with breast cancer.*

*Statistics from Breast Cancer Care and Coppafeel website. See more about Coppafeel! at: https://coppafeel.org/

Update 22.11.22: Here's a great list of resources about breast cancer: https://www.websiteplanet.com/blog/breast-cancer-survivor-resources/