The state of prostate cancer diagnostics in the UK - thoughts from Dr Tony Cooke
Prostate cancer is currently a favoured topic by the British media, due to multiple celebrities revealing their personal prostate cancer stories. A few years ago it was Stephen Fry and Bill Turnbull, now its Nick Owen and Simon Jordan. More awareness that urges men to act and take a test is good, but only if they can get a test, and if that test can find the condition early.
Last week I listened to a person from a well known cancer charity say that men needed to be tested by PSA, and even though “PSA isn’t a very good test, there aren’t any better tests currently available”. That is frankly not true! It would be correct to say that there aren’t any better tests available through the NHS, but globally, better tests have been available for quite a while. However, we all know it takes the DHSC, NHS and NICE years to approve any new tests for general use.
In 2019 when I joined what was then Lab21, now Cambridge Clinical Labs, we already had an alternative early detection test other than PSA, called Select Mdx. Since then we have added two more early detection prostate cancer test to the portfolio - Proclarix and Stockholm3. These are all CE marked tests, extensively validated but not necessarily in the UK.
“Here in the UK we have one of the worst survival rates for prostate cancer of any European nation”
I am passionate about improving prostate cancer diagnostics in the UK, especially early detection of the disease. I have been involved in clinical diagnostics for most of my working life and so being in the business of prostate cancer diagnostics I already knew the statistics around this disease:
• Prostate cancer is the most common cancer in men.
• Around 1 in 8 men will get prostate cancer in their lifetime.
• Prostate cancer mainly affects men over 50, and your risk increases with age. The risk is even higher for black men and men with a family history of prostate cancer.
• There are around 52,000 men diagnosed with prostate cancer each year in the UK, around 145 new cases each day.
• In the UK, around 475,000 men are living with and after prostate cancer.
• There are around 12,000 deaths from prostate cancer each year.
• Every 45 minutes one man dies from prostate cancer.
(Data from CRUK and Prostate Cancer UK)
The statistics don’t look good, but in addition, here in the UK we have one of the worst survival rates for prostate cancer of any European nation - 78% of men diagnosed with prostate cancer in England survive their disease for ten years or more, which is below the European average (2013-2017). In the USA, the 10-year survival rate is 98%.
(Data from CRUK and cancer.net)
The greatest difference is within the first year of the disease, suggesting that the UK performs poorly in early detection and follow up. Survival rates significantly improve if the cancer is detected early:
• For Stage 1 and Stage 2 prostate cancer, almost everyone (almost 100%) will survive their cancer for 5 years or more after they are diagnosed.
• For Stage 3 prostate cancer, around 95 out of every 100 men (around 95%) will survive their cancer for 5 years or more after diagnosis.
• However, for Stage 4 prostate cancer, it drops to around 50 out of every 100 men (around 50%) will survive their cancer for 5 years or more after they are diagnosed.
(Data from CRUK)
“It is clear that we need to test younger men with a better test”
We currently have no way to prevent this cancer occurring, however it is obvious that early detection is the key to survival. To do this it is clear that we need to test younger men with a better test. Although PSA testing has contributed to prostate cancer survival tripling over the last 50 years in the UK, its low specificity means it leads to overdiagnosis, which artificially inflates survival by identifying cases which would not have gone on to cause harm in a person's lifetime.
In the USA, 40% of prostate cancer cases are in men under 65 years old. In the UK, our average age is 10-74, which highlights the need for earlier screening and diagnosis in the UK.
(Data from the Prostate Cancer Foundation)
“Prostate cancer should be the UK’s 4th screening programme… using the latest tests at volume will make this financially viable”
Last month a new study was published regarding implementation of a national screening program and the cost implications: BC Health Service Research entitled “Impact of PSA testing on secondary care costs in England and Wales: estimates from the Cluster randomised triAI of PSA testing for Prostate cancer (CAP)” looked to estimate the likely budgetary impact on secondary care in England and Wales to inform screening decision makers.
The conclusions were: The introduction of a PSA testing programme for prostate cancer has the potential to have a substantial budgetary impact on hospital care, based on data from a large randomised controlled trial carried out in the UK. Decision makers wanting to implement such a programme should consider whether it is affordable within local budgetary constraints, and take affordability (based on realistic contemporary cost estimates) into account alongside measures of effectiveness and cost-effectiveness. This study has indicated that there could be substantial costs associated with the early years of a PSA testing programme for detecting prostate cancer. If all men aged 50–69 in England and Wales were to be offered the test simultaneously, the associated NHS secondary care costs arising from treatment of detected cancers could run to £628 million, which is unlikely to be affordable in the UK context, given NICE considerations.
https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-023-09503-7
However, they also stated in the study that limitations were: “more recent innovations have included the use of new biomarkers, and MRI-guided biopsy methods; model-based economic evaluations have suggested that these methods may be more cost-effective”
We already know health improvements cost money. The NHS currently has a budget of £180 billion. I would like to see some of that money be spent on improving the prostate cancer pathway. We need a national screening program starting at 50 for high risk individuals, those with a genetic predisposition/family history especially of aggressive prostate cancer. In this era of Next Gen Sequencing and personalised medicine how many genetic predisposition tests are done for prevention rather than cure, not enough I would say! Then general population testing needs to start at 55 and should use the latest early detection biomarker tests. Currently the argument against is that these tests cost hundreds of pounds, but that’s at low volume. The costs of these tests could be tens of pounds at higher volume and would help triage patients before mp-MRI or biopsy, reducing overall costing.
I believe we currently have only three national cancer screening programs in the UK - breast cancer, cervical cancer, and colon cancer. I would like prostate cancer to be the 4th.
I know this is a contentious subject but hopefully I can get a discussion going. You will be seeing a lot more from me in the coming weeks/months on this subject – stay tuned in.
Dr Anthony Cooke, CSO Cambridge Clinical Laboratories, UK