The Arguments “For and Against” National Screening

Introduction

This document dated October 2009 has been produced by Love Your Prostate (LYP) to present the arguments being used by those who believe national screening for prostate cancer is required to save lives and increase the life expectancy and those who believe that that the benefits of national screening do not justify the resulting increase in complications caused by the unnecessary treatment of the disease.

For ease of presentation, the arguments “for” and “against” national screening are provided using diagrams, charts and bullet points under the section headings of:

• The Arguments For National Screening
• The Arguments Against National Screening

A conclusions section is provided at the end of the document based on the key arguments presented. This document is also provided to enable the reader to make an informed decision when voting “For” or “Against” the need for national screening on the www.loveyourprostate.co.uk website.

The Arguments For National Screening

1. 35,000 men are diagnosed with prostate cancer every year in the UK.
2. About a third of these prostate cancers are diagnosed at an advanced stage when they are incurable thus resulting in eventual death from the disease.
3. 10,000 men die each year of prostate cancer in the UK.
4. Like cervical cancer and breast cancer in women the earlier prostate cancer is diagnosed the greater the probability of a cure.
5. Like cervical and breast cancer in women the later prostate cancer is diagnosed the more life threatening and incurable the cancer becomes.
6. The reason why the UK was recently ranked only 19th out of 22 countries in Europe for cancer survival beyond 5 years is late diagnosis.
   Note: The UK was at the bottom of the Western European Countries table. Only the Eastern European countries of Poland, The Czech Republic and Slovenia were ranked lower than the UK.
7. The 5 year survival rate for prostate cancer in the USA is 91.9% compared with only 51.1% in Britain.
8. The USA has a national screening programme for prostate cancer but the UK does not.
9. If the UK had the same survival rate as the USA there would only be 5,500 deaths compared with 10,000 deaths a year.
10. A recent “European Randomised Study of Screening for Prostate Cancer” concluded that around 20% of lives can be saved each year by national (Population) screening.
11. If the UK had the same survival rate as that indicated in the “European Randomised Study of Screening for Prostate Cancer” there would only be 8,000 deaths compared with 10,000 deaths a year.
12. From the “European Randomised Study of Screening for Prostate Cancer” 48 men would need to undergo surgery to save one life. Because around 20% of men suffer complications, some severe and some relatively mild, less than 10 men would need to suffer some form of complication to save one life.
13. The treatments available for prostate cancer are shown in figure 1 below.
    
    Figure 1: Treatment Options for Prostate Cancer Stages
14. When prostate cancer is detected at an early stage, known as localised prostate cancer, there are seven treatments available.
15. When prostate cancer is detected at a later stage, known as locally advanced prostate cancer, there are three treatments available.
16. When prostate cancer is detected at a very late stage, known as advanced prostate cancer, there is only one treatment available to help extend life.
17. Localised and Locally Advanced prostate cancer can be cured whereas Advanced Prostate Cancer is incurable, thus resulting in eventual death.
18. The number of treatment options are increasing as new technology becomes available.
19. The use robotics such as the De Vinci Robot reduces the risk of human error by Surgeons thus reducing the risk of complications.
20. The use of RapidArc Radiotherapy reduces damage to good tissue surrounding the prostate thus reducing the risk of complications.
21. In some cases there are no symptoms of prostate cancer until it is too late for curative treatment, which means the only way the cancer can be detected earlier enough for curative treatment is by screening.
22. The Prostate Specific Antigen (PSA) blood test can indicate “False Negatives (indicates cancer when there is no cancer present)” and “False Positives (indicates no cancer when cancer is present)” and is also unable to distinguish between the slow growing non life threatening “pussycat” type of prostate cancer or the aggressive life threatening “Tiger” type of prostate cancer.
23. PSA testing can more accurately indicate prostate cancer when “Rate of Change” testing is used to compare results over a period of time, typically 3-6 months. In some cases this rate of change testing can also indicate whether a cancer is the slow growing non life threatening “pussycat” type or the aggressive life threatening “Tiger” type.
24. A marker has been recently discovered in the USA called Sarcosine which is reported to easily identify prostate cancer in urine and establish whether the cancer is the slow growing non life threatening “pussycat” type or the aggressive life threatening “Tiger” type.
25. National screening for cervical cancer reduced deaths as can be seen from graph 1 below.
    
    Graph 1: Cervical Cancer Deaths 1971 to 2007
26. National screening reduces deaths for breast cancer has can be seen from the graph 2.
    
    Graph 2: Breast Cancer Deaths 1971 to 2007
27. There is no reason why national screening for prostate cancer will not save lives as national screening has done for cervical cancer and breast cancer.
28. As a consequence of not implementing a national screening programme, the Department of Health does not proactively provide any publicity (leaflets, posters, public information broadcasts, etc.) on the causes, symptoms and risk factors of prostate cancer.
29. As a consequence of no publicity and lack of information, men are being diagnosed with prostate cancer later than expected thus increasing death rates and reducing survival times.
30. The main cause of late diagnosis of prostate cancer in the UK is lack of awareness of the symptoms and risks of the disease which is estimated to be around 50% of men in the “at risk” age group.
31. The majority of men who are unaware of the symptoms and risks are blue collar workers.
32. The Prostate Cancer Risk Management Programme (PCRMP) has been produced by the Department of Health to enable GPs to advise men requesting a PSA test of the advantages and disadvantages of the test before deciding whether to proceed with the test.
33. Very few men are aware of the PSA test and the PCRMP.
34. A diagram illustrating the reasons for lack of public awareness of the symptoms and risks of prostate cancer are shown in figure 2 below.
    
    Figure 2: Reasons for Lack of Public Awareness
35. A national screening programme for prostate cancer will:
    1. Save lives and Increase life expectancy
    2. Initially stretch the resources of the NHS
    3. Cost the Government a significant amount of money
    4. Increase the number of complications caused by current treatment procedures
36. A national awareness campaign by the Department of Health, using appropriate medias, such as public information broadcasts on national TV and Radio, bulletins in the national press, posters in Doctors Surgeries, etc., will also:
    1. Save lives and Increase life expectancy
    2. Cost the Government some money
    3. Increase the number of men requesting tests for prostate cancer
    4. Increase the number of complications caused by current treatment procedures

The Arguments Against National Screening

1. The UK Department of Health will not implement a national screening programme for prostate cancer until screening and treatment techniques are sufficiently well developed claiming that the number of men suffering complications such as infection, impotence and incontinence outweighs the number of lives that could be saved with screening.
2. The screening and treatment techniques which are not considered sufficiently well developed are the Prostate Specific Antigen (PSA) blood test and biopsy procedures that can lead to unnecessary surgical treatment of a cancer which in some cases can result in complications.
3. PSA screening tests can indicate “false positives” and “false negatives” for prostate cancer.
4. A prostate biopsy can indicate “false negatives” for cancer, because the number of samples taken from the prostate tissue may miss the cancer.
5. When prostate cancer is confirmed by a biopsy, the type of cancer may be very slow growing and no threat to life expectancy even though precautionary surgical treatment is sometimes carried out.
6. The stress and anxiety caused by undergoing unnecessary biopsies and surgical treatments is considered unacceptable.

Conclusions

Based on pure common sense and logic the two main conclusions are:

1. National screening will undoubtedly save lives and extend life expectancy for men who develop prostate cancer.
2. The Government’s justification to delay national screening until screening and treatment techniques are sufficiently well developed does not make sense based on the information provided above, particularly, the number of lives saved versus the number of men who experience complications.