Prostate Cancer

Yes.

That is just plain wrong with the vast bulk of those with prostate cancer.

Which most who have prostate cancer don't have.

Fraid so.

But isn't what most with untreated prostate cancer get.

And with most with non aggressive prostate cancer it doesn't.

And that is in fact what most 70+ who have non aggressive prostate cancer get and the vast bulk of prostate cancers are non aggressive.

And that is because, as I said, hardly any of them will be killed by the prostate cancer and will die with it, not due to it.

But far more do not.

That is in fact the case with the bulk of the over 70s.

That's not right either when it is just needing to piss more than you used to have to. That is almost always just a benign enlarged prostate or prostate cancer that is so slow growing that it will not kill you.

I wouldn't call it advice.

I have read that most men over 70 will likely have an enlarged prostate. For some it will be sufficiently aggressive to shorten life, hence why it is so important for a proper investigation to discern the type. For many, it is true the prostate may well be an annoyance but the eventual death may likely be from an unrelated matter.

A few things here worth untangling.

You are right that most 70 year olds will have prostate cancer, 70% in fact. Actually, this is really easy to remember:

However, most of these people will never know because most of these cancers are indolent, will never generate symptoms or become a risk to life. We are only interested in identifying and treating significant cancers, and this is partly why the PSA threshold increases with age, to filter out indolent cancers. If indolent cancers are identified, the patient is offered increased monitoring and not expected to have it treated. This is part of the Active Surveillance and the Watchful Waiting treatment protocols. The stats of 1 in 8 men (1 in 4 black men) getting significant prostate cancer do not include indolent cancers - these are the people who need treating to preserve quality of life and longevity. Part of the challenge is identifying if a cancer is significant or indolent, and the over-treatment rate (treating indolent cancers which didn't need treating) is currently running at 4-5%, whereas failing to diagnose significant cancers in time (while still at Stage 1 or Stage 2) is running at nearly 50% and increasing due to pandemic disruptions and a massive shortage of GPs.

Enlarged prostate (Benign Prostatic Hyperplasia, BPH) is a completely different condition and unrelated to prostate cancer, and doesn't increase the chance of getting prostate cancer. It arises because in a significant proportion of men, the prostate doesn't stop growing at the end of puberty, and by age 50-70, it is significantly enlarged and interfering with urinating, generating the swathe of possible symptoms called Lower Urinary Tract Symptoms (LUTS). Sometimes very significantly enlarged prostates don't generate any symptoms. It is of course possible to have both BPH and prostate cancer, and it is often men going to their GP with LUTS which results in the discovery of prostate cancer, but this is usually an incidental finding as most men diagnosed with prostate cancer have no symptoms *of the cancer*. Prostate cancer is usually picked up by screening (specifically checking with a PSA and/or digital rectal exam in the absence of any symptoms) or as an incidental finding when investigating something else. Sadly some are only picked up because it's spread some distance from the prostate and is interfering with other parts of the body (Stage 4), at which point it's generally incurable - over 20% of diagnosis are already stage 4, and this is increasing.

We used to list all the LUTS and say if you have any of these, get checked for prostate cancer. However, there is no evidence of a significant link, and this advice was misleading in that those without LUTS could often incorrectly think they didn't need to be checked. There's a move now to assess risk instead, but ultimately it needs a national screening program for a detectable cancer with usually no symptoms while it's curable, which now accounts for the most commonly diagnosed cancer in the UK, having recently overtaken breast cancer.

Andrew

To my partially informed eye, a very good explanation, thanks.

williamwright wrote on 11/03/2022 :

There is a new UK screening test for prostate cancer, which they are trialing called HK2.

snip valuable detail

I'm selectively reading Ben Goldacre's Bad Pharma - not too sure whether it's a good source or not, but an interesting read.

Anyway, he points to some very shoddy testing of drugs pre-market in the sense that they may well cure the symptom (say, high blood pressure), but very little is said about known other possibly more serious conditions they cause.

You are obviously heavily involved in this area and well informed. Out of interest, can you add detail to these figures? The percentage of over-treatment of indolent cancers and undertreatment of significant cancers really needs to have the actual patient numbers. If, for example, 4 - 5% represents 40 - 50, 400 - 500, or 4000 - 5000 patients that's quite a difference! And if the 50% is 5, 50, 500, or 5000 that's quite a difference too, and they need to be looked at in relation to each other.

Did those *with* LUTS need to be checked for prostate cancer if BPH has no association with it (that's from your paragraph above)? Isn't that also a valid corollary of the statement you made and opposite to "...and this advice was misleading in that those without LUTS could often incorrectly think they didn't need to be checked"?

But lung cancer *kills* far more than breast or prostate, so should we be concentrating on that rather than increasing diagnosis of breast or prostate?

Well, we are in agreement that risk assessment is what's required, but there are many cancers of lower incidence which are silent until it's too late, such as pancreatic and gall bladder.

And ischaemic heart diseases kill far more than lung cancer so ...?

I'm happy to see not just more than one horse in a race but lots of different races - with NICE providing a methodology to compare the benefits of apples and pears. (Which is not to say there aren't political/public sentiment issues.)

There probably isn't a single drug which doesn't have side effects sometimes. Having been on many drugs over the last few years, this is something I'm only too well aware of. Some of the drugs are to counteract the side effects of other drugs, as was the case here. This one wasn't a life saving drug, more a quality of life drug, and I had to weight up if the damage it did to my liver was worth the improved quality of life in the longer term. Having sought advice that NAFLD was unlikely to do me any harm as a temporary side effect (in part because I don't drink anyway and didn't have high visceral fat), I decided to put up with it for a while, and my liver has recovered now.

I think the key thing here is to make an informed choice. Patients sometimes don't get sufficiently informed by their clinicians to do this. If you are sufficiently aware and appropriately educated, you can make yourself informed, but most people won't be able to do this. On the other hand, if you tell some patients, they'll never take the drug. I was once given a steroid as nose drops to try and clear a blocked Eustachian tube. When I read the side effects, I got to "may cause eye ball to bust", and decided it wasn't for me.

In this country, we have the MHRA Yellow Card scheme which updates drug side effects lists with the side effects which do actually happen in practice. I have filed a Yellow Card myself using this scheme.

One area that is particularly difficult to predict is multiple drug interactions, and if you are on more than 4 medications, you may well be treading some paths of interactions which are not well known.

Andrew

In message <t0n86j$c42$ snipped-for-privacy@dont-email.me, Andrew Gabriel snipped-for-privacy@cucumber.demon.co.uk> writes

Lots of snipping..

Interesting. I have found it difficult to convince the NHS that I don't drink (bitter shandy with a steak excepted:-) My mother's side seem to have FLD issues.

What caused yours to go away? Diet, exercise..

And enlarged prostate doesn't necessarily mean cancer.

Quite. Now tell Wodney who doesn't believe in testing.

Thanks again, Andrew. Nice to get some decent info here rather than the more usual old wife's tales - like most die with prostate cancer rather than because of it. Suggesting it is never anything to concern yourself with.

That was published in 1998! Considering how a better marker than PSA is desperately needed it either suggests that it didn?t turn out to be significantly more specific OR, research wheels turn very very slowly.

Tim

There are 5 or more different research projects running to get a better test for prostate cancer up and running, suitable for national screening. Some of these are:

Prostagram - bi-parametric MRI scan which can be analysed by AI (we don't have enough radiographers if it requires human intervention). The name is a modification of Mamogram used for breast screening.

Urine test looking for some specific markers.

Blood test looking for circulating tumour cells (CTCs).

Medical detection dogs sniffing out prostate cancer (which is possible now) leading on to an electronic nose being able to do so too.

However, these are all some way from rolling out, and they are to some extent being used as an excuse not to screen using PSA which is also possible and probably much cheaper (but not as a one-off test - needs risk stratified testing looking at rate of change rather than absolute values, and free PSA measurements which are very useful in the band where the PSA test alone is not clear.

Andrew

Depends on what you call a drug. Vitamin C used in sensible quantities doesn't.

It is more complicated than that with the PSA test which can see what turns out to be unnecessary risky other tests like a biopsy in the vast majority who show up as having prostate cancer in the over 70s, the vast majority of whom, as you say, won't see the prostate cancer doing them any harm at all.

Yeah, I got the same effect with a very significant injury to the back of the eye socket. The only downside I got was displaced image vertically in each eye with stuff that it very high up like the TVs you see in some waiting rooms. The MaxFax surgeon was keen to fix that with surgery but when I was told that there was a risk of something like a few in a thousand that end up completely blind, I decided that it wasnt worth the risk for something that is only a very minor nuisance.

I never said that. In fact I do get tested and my PSA is always fine.

I was JUST pointing out that the the claim that everyone MUST get tested is just plain wrong, particularly with the over 70s because as Andrew accurately stated, the vast majority do in fact have prostate cancer which will in fact never be a problem for them.

His numbers for the over 70's proves that it isn't an old wives tale.

Never said anything like that either.

In my father's case he was diagnosed too late and it killed him. Onc reason I had a PSA test last summer, - Negative.