This is our last, best hope and we have to start NOW
THE debate over prostate cancer screening has been raging for two decades. Why is this? We know that more than 12,000 men every year in the UK die of this cancer and that screening with PSA blood tests can save lives. However, with any screening programme, there is a balance between the benefits of finding and treating cancer early, and the harms of screening.
First, we know many men without cancer will have a high PSA blood test and have unnecessary biopsies.
Second, we also know that one in three of the male population above the age of 50 will have tiny areas of ‘prostate cancer’ which do not grow or spread. So much so, that there is a separate debate raging over the past five years about whether we should even call them ‘cancer’.
Third, when a man has a high PSA blood test, the biopsy tests we used to do to find cancer were random, with tissue samples taken haphazardly from the prostate. As a result, there was a good chance we would find these low-risk cancers and men would be treated unnecessarily.
Fourth, biopsies have side effects and complications. Finally, treatments such as surgical removal of the prostate or radiation carry side-effects with risk of urinary, sexual and back-passage problems.
Over the past decade the UK has led the charge in reducing those harms. First, by using highly accurate MRI scans, we can find those cancers that need treatment and avoid finding many of the inconsequential low-risk cancers. Second, most men with low-risk and some with mediumrisk prostate cancer are managed safely with active surveillance rather than immediate active treatment. Third, surgical and radiotherapy techniques have improved.
FINALLy, targeted focal therapy to destroy individual areas of cancer rather than the whole prostate leads to vastly lower side effects and can be effectively used in two out of five men with early prostate cancer.
So if we have done so well in reducing the harms of screening, why do we not just launch a screening programme?
The problem is that all of these changes have been carried out in men who get referred by their GP. We do not know whether they are enough to reduce the harms, while retaining the survival benefit,
once we start screening hundreds of thousands of the male population. To shift the debate and convince everyone, the TRANSFORM trial is needed to weave together the benefits of screening in saving lives and the reductions in harm. This is our last, best hope for screening.
It will take many years and a huge amount of resources, but if we don’t start now we will spend the next two decades carrying on our debate on screening, and let down generations of men.