According to Cancer Research UK, over 52,000 men are diagnosed with prostate cancer each year in the UK, and there are more than 12,000 deaths. Over three-quarters (78%) of men diagnosed with the disease survive for over 10 years, but this proportion has barely changed over the past decade in the UK, largely because the disease is detected at a relatively late stage. In England, for example, nearly half of all prostate cancers are picked up at stage III.
Despite scant evidence of an association between urinary symptoms and prostate cancer, national guidelines, health advice, and public health campaigns continue to promote this link. In a review published today in BMC Medicine, Gnanapragasam et al argue that not only is this unhelpful, but it may even deter men from coming forward for early testing and detection of a potentially treatable cancer.
“When most people think of the symptoms of prostate cancer, they think of problems with peeing or needing to pee more frequently, particularly during the night,” said Vincent Gnanapragasam, PhD, Professor of Urology at the University of Cambridge and an Honorary Consultant Urologist at Addenbrooke’s Hospital, Cambridge. “This misconception has lasted for decades, despite very little evidence, and it’s potentially preventing us picking up cases at an early stage.”
Prostate enlargement can cause the urinary problems often included in public health messaging, but evidence suggests that this is rarely due to malignant prostate tumors. Rather, research suggests that the prostate is smaller in cases of prostate cancer. The recent UK PROTECT trial even went as far as to say that a lack of urinary symptoms may in fact be an indicator of a higher likelihood of cancer.
Screening programs are one way that cancers are often detected at an early stage, but in the case of prostate cancer, some argue that such programs risk overwhelming health services and leading to men being treated for relatively benign disease. Testing for prostate cancer involves a blood test that looks for prostate-specific antigen (PSA), which is made only by the prostate gland; however, it is not always accurate. PSA density is significantly more accurate than PSA alone in predicting a positive biopsy and is used in everyday clinical practice.
False Sense of Security
The researchers point to evidence that there is a misconception that prostate cancer is always symptomatic: a previous study found that 86% of the public associated prostate cancer with symptoms, but only 1% were aware that it could be asymptomatic.
“We urgently need to recognize that the information currently given to the public risks giving men a false sense of security if they don’t have any urinary symptoms,” said Dr. Gnanapragasam. “We need to emphasize that prostate cancer can be a silent or asymptomatic disease, particularly in its curable stages. Waiting for urinary symptoms may mean missing opportunities to catch the disease when it’s treatable…. Men shouldn’t be afraid to speak to their [primary care provider] about getting tested, and about the value of a PSA test, especially if they have a history of prostate cancer in their family or have other risk factors such as being of Black or mixed Black ethnicity.”
The researchers say they are not advocating for an immediate screening program, and acknowledge that changes in messaging could mean more men approaching their primary care providers for a PSA test, potentially resulting in unnecessary investigations and treatment. However, they argue that there are ways to reduce the risk of this happening. These include the use of algorithms to assess an individual’s risk and whether they need to be referred to a specialist, and for those who are referred, magnetic resonance imaging scans could help rule out indolent disease or negative findings, reducing the risks of an unnecessary biopsy.
“We’re calling on organizations such as the [National Health Service], as well as patient charities and the media, to review the current public messaging,” said Dr. Gnanapragasam. “If men were aware that just because they have no symptoms doesn’t necessarily mean they are cancer free, then more might take up offers for tests. This could mean more tumors identified at an earlier stage and reduce the numbers of men experiencing late presentation with incurable disease.”
Disclosure: The study authors reported no conflicts of interest.
