You may be aware of the recent announcement by the National Screening Committee of their decision not to recommend the development of a screening programme for prostate cancer. For the reasons listed below, we believe that the decision that was made was the wrong one and that if the committee had considered the latest evidence, and had not made invalid assumptions and inaccuracies, that they would have concluded that the evidence in favour of screening for prostate cancer now clearly outweighs that against it. We believe that this conclusion should be challenged by all who have at heart the well being of men at risk of prostate cancer.
We call on all those who have men’s health at heart to sign the petition, calling for an unbiased and urgent review of the latest data and patient management pathways. Please leave comments below. Click here to sign our petition
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| Sandy Tyndale-Biscoe
Hon Chairman, Prostate |
Doug Gray
Leader, National Screening |
Christopher Eden
Consultant Urologist |
Summary of Flaws in NSC Decision
Our concerns about the process by which the NSC decision was arrived at lie in four key areas.
1. Evidence has been ignored that clearly shows the benefits of screening.
The NSC decision was based on the report commissioned from the Sheffield School of Health and Related Research (ScHARR). This report draws extensively on the European Randomised Screening for Prostate Cancer (ERSPC) studies which conclude that PSA screening would reduce the number of deaths from prostate cancer by up to 31% for men who are screened. However, on the basis of mathematical sleight of hand, the ScHARR report concludes that there is only a small reduction in death from prostate cancer due to prostate cancer screening, and no evidence for lives being extended because of early diagnosis and treatment. Thus, the ScHARR report effectively neglects the benefits demonstrated by the ERSPC studies. The ScHARR report also completely neglects the findings from the 2009 Göteborg trial which showed that PSA testing reduces the number of deaths from prostate cancer by 56% for men who are screened. Referring to the results of the Göteborg trial, Prof David Neil has written (The Lancet – Oncology; Vol 11, August 2010): “These outcomes compare favourably with well-established screening programmes for breast and colorectal cancer …”.
The underlying problem is that there was insufficient rigour in the process used to check the validity of the contents of the ScHARR report. For example, we were able to find numerical errors in this report which were acknowledged but still remain uncorrected. When the NSC issued the ScHARR report for peer review, our attempts to engage with the NSC and the ScHARR team to ask serious detailed scientific questions were largely ignored. Finally, despite receiving extensive comments during the consultation process, the ScHARR report remains completely unchanged.
2. The decision is based on out of date assumptions about prostate cancer treatment
As so much of the source material for the ScHARR report is old research, some of it going back nearly 15 years, it is based on treatment standards and clinical practices that no longer apply. As a result, assumptions are made about decisions to treat, and morbidities associated with treatment, that bear no relation to what actually goes on in a modern prostate cancer clinic. One of the most obvious of these is the impact of the increasing use of Active Monitoring for low risk disease, which is revolutionising the negative impact of the risk of “over-treatment”. The ScHARR work makes little acknowledgement of this. Similarly, the report is based on assumptions about the levels of morbidities (e.g. incontinence and sexual dysfunction) that were common in the last century, and takes little account of the enormous advances in clinical practice that have taken place over the past ten years. Were these factors to be properly taken into account, the disadvantages of screening assumed in the report would be greatly reduced.
3. The decision is based on demonstrably false assumptions about the QoL impact of prostate cancer detection and treatment
The ScHARR report seriously exaggerates the disadvantages of screening, particularly where they relate to morbidities associated with treatment: it completely ignores studies on risk-based screening, which is designed to reduce the level of overtreatment; it makes the extraordinary and arbitrary assumption that sexual dysfunction, caused by prostate cancer treatments, reduces the quality of life of patients by 10%, thereby equating the loss of life of a prostate cancer patient to ten men suffering from sexual dysfunction; it takes no account of the enormous loss of QoL implicit in treatment for late stage disease, including the psychological effect of knowing that a “death sentence” could have been avoided by earlier detection.
The ScHARR researchers would appear to have their own answer to the question “how many men with treatment complications is one man’s life worth?” but it is not detailed, and its validity cannot therefore be confirmed, nor is there evidence that this crucial factor entered into the calculations that led to the NSC’s decision.
4. The report of the decision falsely implied a level of consensus that does not exist
The claim, in the published minutes of the NSC meeting that made the decision, that “the consultation replies and the stakeholder meeting which took place on 11th October 2010 to discuss the findings from the review were in the main content with the recommendation …” is a misrepresentation of the actual tenor of the replies, and of the general discussion at the stakeholder meeting. At the meeting it was acknowledged that the ScHARR report has used data which is out of date. For example, based on data from 1994, it was assumed that patients diagnosed with Gleason <=7 invariably had radical treatment. In 2011, a high proportion of these patients are managed with Active Surveillance. This alone would make a considerable difference to the over-treatment argument. It was pointed out that the fact that Urinary Incontinence and Erectile Dysfunction can be treated was ignored, as were new minimally invasive techniques which can only be carried out if the cancer is caught early enough. Most significantly, as described above, the Swedish Göteborg Study was ignored. All of the above shortcomings in the analysis supporting the NSC decision were acknowledged by NSC staff at the stakeholders meeting, but had been forgotten by the time the NSC meeting took place.
All men over the age of 50 have been entitled to a free PSA blood test at their local GP’s since Prostate Risk Management Problems packs were sent out to all GP’s by the Department of Health in – 2002 the only problem being with that – brilliant step forward, is that nobody thought to inform the over 50 year olds. Male GP’s who to a man, if they had any sense, have had a PSA Test.
On Sunday, March, 20, 400 free PSA Tests are being offered at the Plymouth, Devon, Guildhall on a first come first seen bases, between 2pm and 5pm: even if they produce just one positive test it will have been worth it.
Men are sometimes seeing, four GP’s before a fifth; before another GP’s spots the signs of a Prostate problem for the fifth GP is too late – one man having a PSA reading of 975 and a Gleason level of 4+4 when initially he could have been treated and cured. GP’s who to a man, have no doubt been screening themselves since – 2002
http://www.10000men.org
http://www.10000men.org
It’s about time somoene wrote about this.
The real reason why the UKNSC did not recommend screening for prostate cancer is cost. The cause ‘more harm than good’ is a smokescreen to avoid debating cost. We all know that old men are a burden on society and after retirement they cost the government a significant amount of money (bus passess, winter fuel supplement, retirement pension, free subscriptions, free this and that, etc.). Old men are at the bottom of the food chain when it comes to spending priorities in the NHS, especially as they have already made their investment in the state with their income tax, VAT, spending all their money, bringing up families, etc.
In calling for another review we should request that cost should not be considered at this stage.
Screening is a MUST for all men over 50.
Had there been a screening programme in place 10 years ago, I would not have had to suffer 10 years of Hormone Therapy, Radiotherapy and Chemotherapy, at a phenomenal cost to the NHS – a radical prostatectomy would have done the trick.
So the introduction of a screening programme is a must, the sooner the better.
see above
My father is facing a similar situation, Norman.
A screening programme must be put into operation.
I wish you the very best of luck in your fight against the disease.
See comment as above.
I fully support psa screening test,and more publicity to make people more aware of its benefits
I support anything which will bring the need for the psa test to the attention of the public
A chance comment from a friend was the only thing that caused me to ask for a PSA to be added to a routine blood test. I had no symptoms to prompt me and I would have still been happily unaware of my cancer.Yes, I’ve had a fairly rough time with all the various treatments (radical, hormone and radiotherapy), but I’m certainly glad that I took the test.
Nearly two years on and so far , so good.
Incidently, I’m one of three brothers. We all had surgery within three months of each other.
What do you think I’m going to tell my son?
After visiting my GP over a 3year period (because I just did not feel right) and being sent for various test none of which resulted in resolving the problem and then as a result of the Bob Monkhouse PC advertising campaign I asked my GP for a PSA test which resulted in me being given a positive diagnoses of advanced PC. Had there been a national screening programme in place in 2003 I could have been diagnosed earlier when the PC may have been curable.
I have a son and two grandsons and am very concerned for their future health so I fully support the call for a national screening programme for men in thier 50′s and perhaps even earlier where there is a history of PC in the family.
A must for the over 50s
I was diagnosed by pure luck. I had to have a blood test as a follow up to my blood pressure and my GP luckily ticked the PSA box.
If he hadn’t I would not have been diagnosed!
There is a test and screening programmes for the gender-specific female cancer but not for gender-specific male cancer.
Early screening is pure common sense to catch the cancer within the capsule and successfully treating the disease to keep anxiety and treatment cost to a minimum. If this goes report goes unchallenged, then early detecting procedures and devices will not come to the medical market and every male is at risk.
If women can have early screening why can’t the males have the same provision?
My GP initiated a PSA test for me in February 2010. The result was finding a PSA of 30.2. Subsequent tests confirmed prostate cancer with a gleason factor of 3+3 and possible type T3a on the LHS. The prostate itself was 150 cc. Following a successful robot-assisted laparoscopic prostatectomy at Guys Hospital in November, I was recommended a course of 4 * 10 mg Cialis tablets per week for erectile dysfunction. (My incontinence was cleared within 6 weeks of the operation.)
After two months my GP reduced my prescription for Cialis tablets to 1 * 10 mg per week. When I enquired why he told me that the PCT had told tim to do so to reduce costs. He added that he had also been told not to encourage PSA testing of patients – also to reduce costs. He was not pleased. Nor was I. If he had not taken the initiative and have my PSA level tested in the first place, I may never have known that I had prostate cancer until it wss too late.
My view is that any national initiative to inhibit PSA screening is a cynical attempt to save money at the risk of NHS patients and is tantamount to deliberate, criminal neglect.
It was only a chance bloodtest that caught my cancer at a relatively early stage so you can imagine how grateful I am to my doctor. Please do not leave others to chance.
I was diagnosed with prostate cancer after having a PSA test. My brother died of Prostate Cancer because it was not detected early enough. As I have a son and six grandsons I strongly feel that there should be screening test for 50 year olds and also for men who have this disease in their family
I think the fact one of the articles I wrote for MaleHealth following PC diagnosis, radical and recovery at a relatively young age was titled ‘I said to my GP if I’d followed your advice I’d be dead now’ speaks volumes for the lack of understanding of PC on both sides of the divide. The only possible reasons I can think of for not introducing screening are based on cost and potential outcome. An already over-stretched NHS being inundated with thousands more confirmed PC sufferers? Somehow I don’t think this will happen. It’s amazing to think that in a civilised society money, or the lack of it, controls life-saving decisions.
The Gottenburg study did almost nothing to resolve the critical dilemma of prostate screening–particularly PSA screening: there remains no “gold standard” to determine–upon biopsy–which cancers will ultimately result in mortality and those which will not.
Most problematically, the assumption that screening results in 50% increased survivability is fraught with mathematical inconsistencies: if you extrapolate the stats for a 14-year followup to mortality per 10,000 men, screened men die from prostae cancer at a rate of approximately .0032; unscreened men at a rate of approximately .0078–a difference of four men per thousand and 4.6/10,000.
Furthermore, the authors of the Gottenburg study acknowledge that for every life saved by screening, 293 must be screened and 12 treated.
Consider, too, the frequency of “major complications” from screening procedures such as transcectal ultrasound. Rectal bleeding requiring surgical intervention or persisting for more than 2 days occurred in approximatley 0.6% of the time.
More worrisome still, two days ago the San Francisco Chronicle reported the following, quoting Peter T. Scardino, chief of surgery at the Memorial Sloan- Kettering Cancer Center in New York, which does about 2,000 of the tests annually:
“We’re all beginning to see more and more sepsis as a result of resistant bacteria after prostate biopsies… . This is an extremely worrisome problem.”
Similarly, Florian Wagenlehner, head of urology at University Hospital Giessen, near Frankfurt, who is researching infectious complications from prostate biopsies in Europe stated, “If you have 1 million procedures a year in Europe and you have a 1-to-5 percent infectious complication rate, it’s unacceptable.”
She described such complications as a “significant threat.”
Reason, therefore, suggests that rather than acquiese to research which speaks to relatively large populations, men consider screening in light of variables not addressed in mostresearch, or from ambiguous conclusions, and incorporate personal variables into their decision making: family history, indices such as PSA velocity relative to age, and tolerance for risk.
Just as history is said to be written by the victors, anecdotes of the life-saving potential of prostate screening are written by those fortunate few–roughly one in every three hundred men–whose lives were saved by screening.
The 99.6% of men screened but for whom screening did not save their lives do not have inspiring stories to tell, nor do the nine out of 10 men who submitted to treatment futilely.
Very valid, pithy, succicnt, and on point. WD.
… and pretty much irrelevant. The only drawback you mention to a man knowing his PSA relates to what the clinicians do with that knowledge, i.e. perform a biopsy. No-one ever suffered from knowing his PSA. Biopsy is the problem, not the PSA test. With the adoption of a risk based assessment, and increasingly useful results from MRI, we can begin to look forward to an end to the archaic and crude practice of biopsying as an inevitable consequence of a mildly raised PSA.
But the news from Gothenburg is much better than that. The figure of 1 life saved for every 12 treatments is better than that for all the other cancers for which screening is offered except cervical. Furthermore, what this bald figure takes no account of is the vastly improved lives of those men whose cancers, whilst they may still kill them eventually, can be kept at bay for many good quality years.
I would really like to emphasise that all men over 50 should have a yearly PSA test, as is their right, and also a DRE (digital rectal examintion ). I had a annual PSA test for 10 years ( not always easily acheived !) which fortunately highlighted a doubling of PSA in 2009 over 2008 ,although still within NICE limits of 5 . Thanks to advice from Sandy at Pcaso I followed this up and had a biopsy which gave 3 samples of Gleason 8 & 9.
I have had wonderful treatment at UCHL but the point I am trying to make is the importance of building a PSA history and questioning signifcant increases in PSA year on year, ie doubling. in my case 1.9 to 4.5
We women are screened for cervical and breast cancer after a certain age, so why aren’t men screened for prostate cancer?
Does the National Screening Committee truly believe that the cost of routine screening outweighs both the heavy financial cost of hormone injections/chemo and the fact that families are losing fathers, husbands, brothers and uncles to this disease?
Come on, NSC, show some common sense and some compassion.
The British government over recent months in 2011 has wasted a sum equal to the amount needed to set-up National Screening for Prostate Cancer in the UK on military ordinance (military aircraft bombing Libya, Cruise missiles launched fron Nuclear submarines and warships – cost money to operate etc., etc). Men, British taxpayers dying due to ineptitude and twisted priorities – not money.