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Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

There is some evidence to support the proposition that early diagnosis and treatment of prostate cancer may be beneficial and could reduce the mortality from the disease. Despite this, the introduction of a screening programme similar to those in place for breast and cervical cancer cannot be justified on current evidence. In the absence of alternative strategies to reduce mortality from prostate cancer, early diagnosis in appropriate circumstances should be encouraged. The establishment and funding of adequate programmes to test the validity of population screening should be sought by BAUS and such programmes should be supported by all urologists. Opportunist screening, without prior consent of the patient, by general practitioners (GPs), as part of health-check protocols, hospital admission investigations, etc. should be discouraged. Patients requesting PSA testing should be considered sympathetically, but PSA testing should only be performed after full counselling. It is reasonable to comply with a patient’s request if based on such information. Similar counselling should be given to patients with a family history or other risk factors if they seek diagnostic testing. There is no evidence to support opportunist screening of such men, but men with a family history will seek advice and this should be available. It is recommended that all prostate assessment clinic protocols are reviewed and as a minimum, patients given written information that a PSA test is included in the protocol and an opportunity to opt out of the test if they wish. Patients over 75 years old (or of an age to be agreed in local protocols) and those with conditions severely affecting life expectation, should only have their PSA measured if there is clear clinical evidence that they may have prostate cancer for which treatment will be needed. Urologists must agree with their referring GPs and with their hospital colleagues on protocols of PSA use. Transrectal ultrasonography and prostatic biopsy must be carried out in units with adequate equipment and expertise. Clear criteria for biopsy must be agreed between those referring patients and those performing biopsies, be they radiologist or urologist. A protocol for further follow-up of men with raised PSA levels after a negative biopsy must be agreed, to minimize anxiety and allow early discharge. The BAUS Section of Oncology must establish criteria for designating prostate cancer clinics where patients being considered for radical prostatectomy or other active treatment can be counselled. Urologists performing radical prostatectomy ideally should be attached to such centres, and should participate in audit as laid down by the Oncology Section, and contribute to appropriate national trials

Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

Cancer of the prostate is an important disease and a significant cause of mortality and morbidity [1]. Because advanced prostatic cancer is only amenable to palliative treatment there is considerable attraction in seeking early diagnosis and treatment, in the hope of cure while the disease is confined to the prostatic capsule. This approach is largely accepted in the USA, where regular measurement of PSA followed by radical prostatectomy in those confirmed to have cancer are routine.

No controlled data currently exists to prove that screening is beneficial. A screening study carried out in Quebec has reported a reduction in cancer mortality in the screened group, but it has several defects, including a low response rate among those invited to undergo screening [2]. No adequate large-scale trials comparing treatment modalities with each other and against watchful-waiting have been completed. Although reports of surveillance have indicated that many men with early prostate cancer may have a long survival, criteria for inclusion in such cohorts differ from those in reports of radical treatment. Similarly, criteria for selecting patients for radical prostatectomy and radiotherapy differ, making cross-modality comparison difficult.

In 1997, the NHS Centre for Reviews and Dissemination published a document ‘Effectiveness Matters’ on the early diagnosis of prostate cancer [3]. This rightly identified the lack of evidence to support routine screening for prostate cancer. It also took a proscriptive attitude to radical surgery and radiotherapy. Many urologists, with widely different opinions about the diagnosis and management of prostate cancer, felt unhappy about this document. While the factual information on which it was based is not in dispute, the document seemed inappropriately negative. All clinicians who treat men with prostate cancer see it as a very important disease, which forms a large part of the practice of most of them, and from which many men die each year. The support given to establishing trials of screening is welcomed, but meanwhile the issues raised in the document cannot be ignored and urologists (and those referring patients to urologists) are having to cope with them. An agreed moratorium on population screening (pending the results of studies) has nothing to do with case finding, and the lack of clear distinction between screening and case finding in the ‘Effectiveness Matters’ document may confuse purchasers of healthcare. The public are receiving different and confusing advice, resulting from urologists’ uncertainties about this controversial issue. The BAUS Working Party was established following the publication of ‘Effectiveness Matters’ with the remit of finding an agreed approach which, with the support of BAUS, will maintain a benchmark for British urological practice that will develop as the results of scientific investigation unfold.

Prostate cancer—incidence and mortality

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

The increase in reported cases of prostate cancer in recent decades probably does not reflect a true change in prevalence, but results from increased surgical treatment for benign disease, improved diagnostic techniques, better cancer records and longer life expectation [4]. The Surveillance, Epidemiology and End Results Programme (SEER) results from the USA, plus population-based data from individual cancer registries, indicate that the age-adjusted incidence per 100 000 individuals peaked in 1992. In 1988 the mean incidence for five registries was 115/100 000 and in 1992, 196/100 000 [5]. Data are now available from these registries for 1994 and 1995, showing that the incidence has fallen to almost that prevailing before PSA testing was available [6[7]–8]. This fall in incidence may be due to earlier detection of cases in previous years, resulting in fewer detectable cases on repeated screening [9,10], and decreasing levels of screening due to publicity in which the advisability of screening has been questioned. Screening may also have decreased because of the possible inhibiting effect of a decreasing case yield. A major contribution to the incidence of prostate cancer is the increasing age of the population [4]. This increase is, from a public health perspective, real and as life expectation increases, cannot be ignored.

The apparent reduction in mortality and prolonged survival times with increased case-finding are to be expected as a result of lead-time and length bias. Although the perception in countries with an aggressive response to screening is that the numbers of men seen with metastatic disease has dramatically reduced [8,11], the time course expected for early disease to progress to metastases makes it unlikely that such a change can have occurred so soon. Prostate cancer mortality rose steadily from 1973 to 1991 in the USA [12]. Recent reports from the SEER programme show that mortality rates declined by 6.3% in 1991–95 (National Cancer Institute Web Site; http://www-seer.ims.nci.nih). The SEER population database of 59 876 men has shown higher 10-year survival for men treated radically (radical prostatectomy 67%, radical radiotherapy 53%, watchful waiting 45%) for high-grade cancers, which was apparent even 5 years after treatment, with relative survival compared with an age-matched population of 0.98, 0.92 and 0.61 for prostatectomy, radiotherapy and watchful waiting, respectively [13]. Radical prostatectomy was also associated with improved 10-year survival for men with grade 2 cancers (radical prostatectomy 87%, radiotherapy 76%, watchful waiting 77%). There were no differences between management options in grade 1 cancers. However, no randomized trials comparing different management options have been completed and at present there is no direct evidence to show that PSA screening decreases prostate cancer mortality rates. Prostate cancer has a long natural history and the delay in the measurement of treatment effects on mortality means it is unlikely that any influence of earlier treatment of PSA-detected cancers has been fully realized. Amongst these cancers there will be substantial numbers of those that were biologically irrelevant and others which would be lethal irrespective of the treatment given.

In England and Wales, the incidence has risen steadily, with 13 481 (54.5 per 105 ) new cases of prostate cancer registered in 1990. Between 1971 and 1993, mortality rose by 40% (13% in men under 75 years old). In 1993, 8689 deaths were recorded (33.5 per 105 ). Some of this increase, especially in elderly men, is due to increased accuracy of data collection and changes in coding, but there has been a true rise in deaths in this period [1].

In the Welsh screening study, 2078 patients of the 5000 invited to participate were screened. Sixty-one cases of cancer of the prostate were diagnosed, and 21 patients underwent radical prostatectomy (W.B. Peeling, personal communication). If these values applied to the whole population of the UK, screening would identify 60 000 cases (144 000 if the whole invited population was screened) and result in 20 000 radical prostatectomies.

Advanced prostate cancer

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

Management of advanced prostate cancer

If advanced disease could be cured there would less incentive for screening (as with testis cancer). Hormonal treatment remains standard therapy for metastatic disease. Despite earlier expectations, combined androgen blockade has not notably improved the effects of hormone treatment [14]. Other developments, new drugs and intermittent androgen suppression, are unlikely to have a major impact. Earlier use might increase survival periods [15,16], but until the cause of hormone-refractory disease is understood and unless it can be prevented, hormone treatment can only be seen as palliation. Chemotherapy has a limited role in managing the disease and other new developments currently are directed to improving the limited survival and quality of life of men with hormone-refractory disease. With no immediate prospect of curing advanced disease, identification and cure of early confined disease which would with certainty progress within the patient’s life span is a valid and indeed commendable goal. Whether the aims expressed in the previous sentence are currently realizable is the source of the present controversy.

Screening and diagnostic PSA testing in advanced prostate cancer

An argument against screening is that it will uselessly identify patients with advanced and incurable disease. Evidence is accumulating that early hormone treatment in advanced prostate cancer may delay progression, reduce complications and improve survival [15[16]–17]. If so, earlier diagnosis of even advanced prostate cancer would be valuable. However, any benefits in diagnosing either early or advanced disease are unlikely to apply to elderly patients, and a clear case can be made for restricting PSA testing in those who for reasons of advanced age or comorbidity are unlikely to benefit unless there are sound clinical reasons to suspect they have the disease and that treatment would be indicated.

Diagnostic tests in prostate cancer

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

DRE

Although cancer of the prostate may produce changes detectable on a DRE, these are not specific and many early prostate cancers will not be detected on DRE [18]. Attempts to use a DRE alone as a sole screening test before the availability of other methods proved it to be unacceptable [19]. The DRE will identify tumours associated with a normal level of PSA and thus is normally recommended for inclusion as a diagnostic test [20].

PSA

PSA is an indispensable test in the management of established prostate cancer [21] and is available in most Biochemistry Departments. PSA is thus readily accessible, as is a DRE, to those wishing to diagnose cases of early prostate cancer. PSA has radically improved the diagnosis of early prostate cancer and enables men with clinically undetectable disease to be identified, and for that disease to be diagnosed by subsequent biopsy [9]. If cancer can be diagnosed when localized to the prostate, it creates the possibility of curative treatment when undiagnosed the disease might not present until an advanced and incurable stage. However, as a diagnostic test, PSA is accepted to have limitations because it is not specific for cancer, especially in the range associated with confined and hence potentially curable prostate cancer [22]. The evidence that PSA density [22[23][24]–25], PSA velocity [25[26]–27] and age-related PSA ranges [25,28,29] increase specificity is conflicting.

Prostatic biopsy (see below) has a significant false-negative rate [30]. The combination of a screening test with low specificity and a confirmatory test with a significant false-negative rate creates uncertainty, which causes anxiety both to patient and urologist.

More recently, the use of the ratio (or percentage) of free to total PSA (f/tPSA) has been proposed as a more specific test to reduce the number of negative biopsies in men with PSA in the range of 4–10 ng/mL, and possibly to improve sensitivity enabling cancer with a PSA of <4.0 ng/mL to be identified [31,32]. The f/tPSA should be available but its use confined to patients with a tPSA in these sharply defined ranges. It follows that access to f/tPSA should be restricted and clear guidelines for its use developed with chemical pathologists. If the f/tPSA is more specific than tPSA alone, it could reduce the number of men with benign disease who undergo unnecessary biopsies. It may also help in identifying men with false-negative biopsies and reduce the follow-up necessary for men with a negative biopsy but raised PSA level. Achieving these aims would enable the use of the f/tPSA ratio to improve the screening process and make it more acceptable (Appendix I).

TRUS-guided biopsy (Appendix II)

TRUS alone can identify abnormalities in the prostate [33]; these are not specific and many early cancers are not visible. TRUS alone is not an appropriate screening or diagnostic test [34]. In diagnosing prostate cancer, the true role of TRUS is as an indispensable tool to guide a biopsy needle to areas of visible abnormality and to ensure even sampling of normal appearing gland [35].

A positive biopsy may not identify the true extent of the tumour, or its true grade [36], despite recommendations that treatment decisions are based on this information [37]. Where patients who have had negative biopsies have been re-biopsied, a significant proportion of positive biopsies has been obtained [9,30].

TRUS-guided biopsy has a definite complication rate, e.g. from bleeding, urinary infection and septicaemia [38]. Morbidity is significant and death after biopsy has been described [39]. Antibiotic prophylaxis is considered essential in this procedure. However, most patients find it to be an acceptable test which they would undergo again [40].

While digitally guided biopsies are still appropriate in men with obvious locally advanced prostate cancer, biopsy in those with suspicious prostates or those in whom the only indication is a raised PSA level should always be done under TRUS guidance. TRUS and prostatic biopsy are procedures which require experience and skill to obtain accurate diagnostic information, with minimum morbidity. TRUS can be carried out either by a radiologist or a urologist with appropriate training. Where performed by a radiologist, good communication with the urologist is essential. There is a need to develop standard protocols for TRUS and biopsy.

TRUS-guided biopsy in patients identified by DRE and PSA testing can diagnose prostate cancer, with probable potential to progress, at a stage when it may be confined to the prostate and hence considered curable [41]. A proportion of these tumours, if untreated, will progress to locally invasive and/or metastatic disease. However, the natural history of tumours diagnosed in this way is uncertain and the proportion which progress and the rate of progression is not clear.

Management of patients with negative biopsy

Most men investigated on the basis of a raised PSA level will have negative biopsies. Some of these will have cancer [30], which may be identified on later biopsy [9]. The follow-up of these patients is an increasingly large part of urological practice; this causes much anxiety. A protocol for managing these patients is urgently needed; clear criteria for safe discharge would be of immense benefit to both patient and urologist. At present, each individual has to be considered separately. GPs would appreciate advice on the frequency of PSA testing in such circumstances.

Tumours identified on biopsy

Pathologically, Gleason grades of tumours identified as a result of biopsy after PSA testing [42,43] are comparable with those identified sporadically, as reported in the SEER database [12], and thus may be expected to have a similar natural history.

Screening and diagnosis

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

The term ‘screening’ is used in different contexts and this causes confusion; this report uses the definitions below. Currently, the issue of population screening is rightly in abeyance pending appropriate studies. The Working Party recommends that BAUS develops an agreed policy on the diagnostic areas described in the following sections, to enable urologists to advise their colleagues on opportunist and patient-initiated screening, and to determine the correct use of PSA testing within urology departments.

Population screening

Individual invitations to the whole of a relevant population to undergo screening, as is done with breast and cervical cancer, requires specific resources and is only justified if it can be shown to be effective in reducing mortality and morbidity at an acceptable cost [1]. Limited studies in small populations have shown the ability of DRE and PSA to identify asymptomatic prostate cancer in 2–5% of men tested [9,40,44]. While it is generally accepted in the UK that it is not yet appropriate to introduce population screening, there is support for appropriate screening trials. If these trials show a positive benefit, it would then be a political and economic decision whether to finance screening.

The values from the Welsh screening study are an indication of the implications of a screening programme. It could create the need for a substantial number of radical prostatectomies. In addition to the expense of screening, at a notional cost of £3500 per operation (A. Walker, personal communication), these operations might cost £70 million, likely in practice to be spread over several years. For urologists, the implications are significant; unlike in the USA, in the UK urological manpower is restricted. It is accepted that only a proportion of urologists will be adequately trained to undertake radical prostatectomy (see page 24). Radiation oncologists will also be affected. If the introduction of a screening programme were to be considered, it is essential that the implications for training and numbers of appropriate specialists are considered at an early stage. In the absence of population screening, a likely increase in diagnosis of early prostate cancer must be considered in planning future urological services. Although the recommendations in ‘Effectiveness Matters’ [3] might be used to deny this need, BAUS and its associated bodies will need to be vigilant in ensuring adequate expansion to provide satisfactory care of men with prostate cancer, without detriment to the management of other urological conditions.

Opportunist screening

The measurement of PSA (with or without DRE) in men consulting their GP about unrelated disease, attending urology and other hospital departments, or inclusion of PSA in protocols for ‘health checks’ is subject to the same considerations as population screening. Opportunist screening is not currently justified. The Working Party is particularly concerned about the introduction of PSA tests into ‘health screening’ protocols without the patient’s prior knowledge (see below).

Patient-initiated screening

Publicity about PSA [45] and a general perception by the public of the desirability of early diagnosis of cancer leads increasing numbers of men to seek PSA testing. While the practical consequences are similar to opportunist screening, the initiation of the process by the patient alters its context. It is unreasonable to refuse all such requests [46], but PSA should be measured only after counselling, which should include information about the significance of PSA, the incidence of false-negative and false-positive results, explanation of the nature, discomfort and risks associated with biopsy and the controversy surrounding the management of early prostate cancer.

As the aim of screening is to diagnose and ‘cure’ early cancer, it is reasonable to advise an asymptomatic man for whom such treatment would not be appropriate (e.g. men with a life expectation of <10 years [47]) not to be tested. The requirement for counselling also applies to commercial health-screening checks, in which PSA is often included with no prior explanation. This does not preclude PSA from such checks if the Working Party’s recommendations on counselling can be accommodated.

Purchasing contracts, guidelines for practice and clinical audit should require evidence that men undergoing PSA testing have received counselling, preferably supported by a written information sheet (Appendix III) and possibly a formal signed consent form.

Screening patients with risk factors

There is a view that an increased risk of developing a disease is an indication for screening. In prostate cancer this applies to men with a strong family history [48] and to black racial groups [49]. Screening of patients at risk can be opportunist, by invitation, e.g. to patients identified from general practice records, or patient-initiated. Except as part of a scientific study, there is little evidence to support actively seeking men at risk, but requests from men with a family history require sympathetic handling.

Those with a close family history of prostate cancer or other risk factors may well be more anxious about the risk of the disease and may thus seek investigation. The chance of a positive result will be higher; a negative result will reassure someone who is worried about a family history. Otherwise, the arguments against screening apply as much to these patients as the general population, although dissuading a man requesting screening is probably harder.

Case finding in symptomatic men

The Working Party agreed that once a man has sought advice about LUTS, the relationship with his GP or urologist is different from that of the asymptomatic man who is seeking screening simply to exclude cancer. Such a man is asking for a diagnosis of the cause of his symptoms. There is concern that failure to diagnose early prostate cancer which later presents clinically as advanced disease, or indeed the failure to exclude cancer now in a man who later develops it, might have medicolegal consequences.

The dilemmas of early prostate cancer equally apply to the symptomatic man. To what extent do symptoms absolve the urologist from the need to counsel such a patient before measuring his PSA? Men with LUTS often are first seen in Prostate Assessment Clinics (PACs) [50] where a standard protocol of investigations, usually administered by a nurse-practitioner, is applied. Such protocols frequently include a PSA test and it is usually only when this has indicated the possibility of cancer that it is discussed with the patient. Indeed, in some clinics, men with a raised PSA level may be referred for biopsy before being seen by a urologist.

A recent report [51] recommended that PSA testing should not be routine and should only be offered after full counselling of men about the implications, although it did state ‘This (recommendation) is likely to require regular review’. The Working Party on Early Prostate Cancer discussed this at length and, considering the response of urologists to the RCS/BAUS Report, feels this recommendation to be too rigorous. There were some differences of opinion within the Working Party as to the extent and nature of counselling necessary for symptomatic patients before PSA testing. However, it should be recognized that for some patients, coping with a positive PSA test carried out without warning can be distressing, and urologists, GPs and others dealing with men with urinary symptoms must be alert to the problems which can result from the routine use of PSA tests.

If the final consensus is to encourage counselling of men attending PACs it should not undermine any advantages which have accrued from the development of such clinics and be equally applicable to before consultation and to GP open-access clinics. A reasonable approach would be to include, in the information packs sent to the patient with his appointment, an explanation of PSA testing (Appendix IV). The Working Party does not consider that written consent is appropriate in these circumstances, but would encourage the development of local practices for dealing with those men who wish counselling before PSA testing.

Where a GP has open access to a PAC, or is considering PSA testing in a man with LUTS, the same considerations apply. The Working Party recommends that urologists cooperate with their local GPs to establish a uniform practice for PSA with LUTS. If Nurse Practitioners running PACs are trained in counselling there is no reason why the need for counselling should interfere with the current trend towards purely nurse-run clinics. Indeed, this might facilitate a fast-track entry to TRUS and biopsy for those patients who wish it, as at present patients with a raised PSA level may have to attend a consultant urologist’s clinic for this counselling before undergoing TRUS. The Working Party suggests that the symptomatic patient ‘opts out’ of having PSA testing, whereas for the asymptomatic man, counselling is the prerequisite to having the test.

Confirmation of suspected prostate cancer

As the most readily treatable form of advanced cancer in elderly men, it is appropriate to maintain a high index of suspicion of prostate cancer in men with back pain and other symptoms. PSA testing is often appropriate in such cases, regardless of the patient’s age, although correct interpretation of the result is essential.

The place of diagnostic PSA testing

A proscriptive attitude to PSA testing is impractical and unreasonable. However, guidance and direction as to its use is needed, also for the subsequent management of prostate cancer diagnosed by these means. A clear distinction must be made between screening in asymptomatic men, case finding in men with LUTS and diagnosis in those with symptoms or signs suggestive of prostate cancer. While carefully planned research to determine the role of screening in the diagnosis and the optimal treatment of early disease should be supported, men are seeking diagnosis now, and even without screening and case finding, early prostate cancer will be diagnosed. The current dilemma is how to handle these issues until the results of future research are known.

In a recent survey involving 200 GPs [52], 86% routinely measure PSA in their patients. Of these, 75% measure PSA in all men presenting with ‘prostatic’ symptoms and 52% in all men who request it; 10% use PSA as a screening test (i.e. opportunist screening) in asymptomatic men. However, 69% always counsel patients before PSA testing, although there is no information on what form such counselling takes.

In the same survey, of 50 urologists questioned, 64% measure PSA in all men with LUTS, 56% in all men who request it and 6% in all asymptomatic men. Information on counselling by the urologists in this study is not available.

Patients and GPs may wish to know whether repeat PSA testing is advisable after a normal test. The Working Party does not consider that there is sufficient evidence yet to advise on this, but in these circumstances would recommend that the minimum period between PSA tests should be one year. The appropriateness of performing the test should be reviewed on each occasion. If the PSA level is abnormal, the situation is different, in that it is difficult to exclude prostate cancer with certainty, and more frequent testing (but no more often than 3-monthly), may be appropriate.

Counselling of patients

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

In an area with so much controversy, patients need advice and information at almost every step about the uncertainties and dilemmas in diagnosis and treatment. There is a clear need to reduce the number of inappropriate PSA tests in elderly men, which produce much anxiety for little benefit. Equally, in a free society, if a man wishes to be tested, provided he is fully informed of the nature of the test and the likely consequence of both positive and negative results, refusal of such a request is unreasonable.

After the introduction of screening programmes for cervical and breast cancer, the public has been educated to believe in the merits of the early diagnosis of cancer in general. This is at odds with the concept that it may not be beneficial to diagnose and treat early prostate cancer. Consequently, the knowledge that a diagnostic test for prostate cancer is available will produce requests for it to be done, and an expectation that it will be used in investigating LUTS. Much information in the media or other sources (including the Internet) may be unbalanced, and when fully informed of the issues, a man’s attitude to PSA testing may change.

There is general agreement that counselling is needed before measuring PSA in asymptomatic men and in deciding on the treatment of a man with early localized disease. The situation of a man being investigated for prostatic symptoms is more controversial (page 22). Many PACs include PSA testing in their protocols as routine [52], despite the view expressed in the recent BAUS/RCS guidelines on BPH [51]. There is no clear consensus among urologists on this point. The members of the Working Party reflect this, but have agreed that some form of information on PSA testing should be given in advance to all men attending PACs.

Counselling should include information about the sensitivity and specificity of PSA testing, on the nature, reliability and complications of prostatic biopsy, and on the management of prostatic cancer, including that of advanced disease.

Management of early prostate cancer

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

Diagnosis of prostate cancer

While there is a lack of high-quality data to support the introduction of screening for prostate cancer or to show a benefit from treatment of localized disease, this does not exclude the possibility that screening might prove to be of value [53], nor that radical treatment would benefit at least a proportion of men with early disease. The absence of evidence for benefit does not mean there is no benefit. While purchasers should not fund screening programmes for asymptomatic men, it would be unreasonable to withdraw funding for diagnostic PSA testing in all circumstances [46], provided there are clear guidelines for its use. Purchasing contracts should encourage participation in well-designed randomized studies into the issues raised by early prostate cancer. These methods for diagnosing prostate cancer will inevitably identify increasingly more men with early prostate cancer [4].

Men with LUTS are a significant proportion of the patients seen by urologists. Whether in a conventional urology clinic, or in a pre-consultation clinic, many have their PSA checked and some will have prostate cancer. Notwithstanding the existence of these diagnostic tests, up to 18% of men undergoing TURP for clinically benign disease will have prostate cancer [54], which may be coincidental to the benign disease causing their symptoms. Although the practice of sending apparently benign prostatic tissue for histopathology has been questioned [1], this is such established practice that TURP will continue to identify cases of prostate cancer. While a policy on the management of early prostate cancer is a separate issue, it is one intimately related to that of screening and case finding.

Treatment of early prostate cancer

The management of early prostate cancer is central to the controversy surrounding screening, but in the absence of screening, or indeed active case-finding, early prostate cancer will be diagnosed and patients with the disease will need managing. The public perception is that treatment of all early cancers is desirable and furthermore that the usual and best treatment is surgical removal of the tumour [45]. As a result, a universal adoption of watchful-waiting is neither reasonable nor possible. Equally, the question is not whether radical treatment is beneficial (it is inconceivable that no one would be cured by surgery or radiotherapy) but for whom treatment should be offered, whether alternatives are appropriate and whether the benefits merit the potential complications [43,55].

Much publicity has been given to radical prostatectomy, the treatment of most interest and relevance to urologists [45]. While radical prostatectomy, correctly performed, will eradicate the disease if it is confined to the prostate, confined disease can only with confidence be diagnosed once the prostate has been removed, and even in expert hands, in a screened population capsular penetration is present in up to 45% and positive margins in 15% of cases [56]. Until it is possible to accurately identify confined disease preoperatively, a substantial proportion of men ‘suitable’ for radical prostatectomy will not be cured, and in the absence of comparative trials, an absolute statement that radical prostatectomy produces a better outcome than radiotherapy is untenable.

Radical prostatectomy is the only treatment which accurately defines the true disease stage [13,57]. This provides prognostic information unavailable from other methods. However, reporting results based on the tumour stage in the light of the postoperative pathology report can bias results compared with other modalities [13], as can the opportunity to exclude patients with node-positive disease by intraoperative node biopsy [13,58].

It is inappropriate for a man to undergo radical prostatectomy without being made fully aware of these issues and without information on the alternatives. In discussing treatment, it is difficult to support the view that radical prostatectomy is better or worse than radiotherapy. Each has their own side-effect profile and a clear understanding of the likely or possible consequences of each treatment (including that of watchful-waiting), preferably backed by written information, must be available to patients for whom treatment is being considered (Appendix V).

It is important to distinguish between short-term side-effects (postoperative pain is an acceptable complication of surgery, as is temporary bowel disturbance after radiotherapy) and long-term complications. The values given for ‘damage to adjacent organs’ in ‘Effectiveness Matters’ [2] were those for temporary proctitis and cystitis, and gave a misleading impression of the problem.

Counselling of this type does not mean total abdication of the clinician’s responsibility; watchful-waiting for a patient under 60 years old probably would not be advised by most urologists, and few would advocate radical prostatectomy for a man over 75 years [47]. However, there are many men between 60 and 70 years old for whom the decision is less clear. Ideally, these men should be considered for entry into clinical trials; if such trials are not available, treatment should only proceed after detailed counselling and the Working Party feels that prospective data collection on all men being so treated should become standard.

Prostate cancer clinics

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

There is good reason to question the current results of radical prostatectomy. Even in the best departments, positive-margin rates are obtained which would be unacceptable in other tumour types [56]. It is clear that selection of patients and good surgical technique can improve results.

Radiotherapy results, particularly for morbidity, are likely to be better when treatment is given by those with experience and expertise. Conformal radiotherapy (and possibly in future brachytherapy) and experience with neoadjuvant hormone treatment may be necessary to achieve optimum results with radiotherapy [59].

The correct management appropriate for an individual patient requires careful counselling, involving both a urologist and oncologist, and ideally the patient’s GP. This can only be achieved where a urologist and an oncologist with the necessary skills, experience and commitment work together, and there is an inescapable case for patients with early prostate cancer, however diagnosed, to be managed in designated joint clinics.

In large population centres, a few surgeons specializing in radical prostatectomy are referred patients by other urologists for surgery. While there is no good reason why the counselling should not be provided by the referring surgeon, it does seem a good general principle for this task to be the responsibility of the operating surgeon, although unbiased information might best come from a counsellor trained in this area. It is in such areas that a dedicated prostate cancer clinic would be most appropriate.

Referral to a specialist clinic for management, rather than to a surgeon for an operation, is the more satisfactory arrangement and may facilitate involvement in clinical trials, as a patient may be less prepared to consider participation if he is already expecting an operation.

Guidelines and information

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

Screening, case-finding and active treatment of early prostate cancer should be regulated rather than abandoned, and purchasers and all involved clinicians should cooperate to develop clear guidelines. These guidelines should define those men for whom screening and case-finding are inappropriate, and emphasize the need for information and counselling before decisions about testing, diagnosis and treatment are made in the remainder.

Future research

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

Although the opportunity for research and development funding of a study of screening was welcomed [60], support at present is only to be given to an uncontrolled pilot study which cannot provide a definitive answer to the dilemmas surrounding screening, and indeed may delay a conclusion to this controversy. If screening studies are set up, British urologists should support them, as they should support studies and trials of treatment. Both the advocates of radical prostatectomy and those who do not currently advise active treatment must accept that neither approach is based on scientifically valid evidence. The failure of the MRC PR06 study (total prostatectomy vs radiotherapy vs no immediate treatment) [53] should not necessarily preclude attempts at further studies. For a substantial proportion of men who might be considered for radical prostatectomy (relatively fit men in their late 60s) there must be considerable doubt as to the merits of such treatment. If the public in general can be made aware of the issues, and if these men in particular are correctly counselled, the acceptability of trials would be increased. A larger body of urologists confident and experienced in radical prostatectomy, and more patients being diagnosed with early disease, will reduce individual surgeon’s enthusiasm for taking every opportunity to operate, and indeed the reduction of pressure on limited operating time resulting from a trial might be as welcome to the urologist as to the purchaser. The financial implications of treating this common cancer are substantial; purchasers have a substantial interest in the outcome of such research and could exert a critical role in encouraging such research through their purchasing contracts.

Conclusions

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

There is insufficient evidence available either to support or deny benefits from diagnostic PSA testing. Thus different organizations in different countries give conflicting advice (Appendix VI). The Working Party feels that currently British urologists cannot take a definite view on this issue. Not to take a view is not to condemn PSA testing and early diagnosis. Diagnosing early prostate cancer will be beneficial in some cases; the possibility that it will have an overall benefit must be admitted. It is clear that many men would wish to avail themselves of this possibility. Equally, uninformed assumptions about the value of PSA testing are to be resisted, as they will lead to inappropriate expectations, and dissatisfaction if these are not realized.

The unthinking use of PSA, particularly in elderly men where it causes distress and anxiety, must be prevented. The role of urologists must be to cooperate with colleagues in other specialities to prevent totally inappropriate investigation (e.g. as a ‘routine’ on admission to a geriatric unit), and to ensure that in other circumstances PSA testing is only carried out after appropriate counselling.

Many of the issues raised in this document will only be resolved with a fuller understanding of the underlying mechanisms of development and progression of prostate cancer, the identification of prognostic factors and new treatments. Encouragement of basic laboratory research into the disease is a matter of some priority.

Recommendations

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References

(i) The role of population screening and of radical treatments of early prostate cancer must be subjected to scientifically valid controlled trials.

(ii) Diagnostic tests, particularly PSA measurements, should not be used in those for whom they are inappropriate. This mainly applies to the very elderly but also to those with diseases severely limiting their life expectation. Urologists have a responsibility to ensure that GPs and colleagues in other specialities are aware of these limitations.

(iii) An asymptomatic man who requests PSA testing should not undergo tests for prostate cancer without adequate counselling as to the possible consequences. If, when fully informed, he still wishes to proceed with screening, it is unreasonable to refuse such a request. This applies in all circumstances and as in (ii), urologists must take an active educational role, develop guidelines and agree on counselling procedures with their colleagues.

(iv) The role of PSA as part of a routine protocol for investigating men with LUTS is more controversial. Although there is no clear consensus that testing in these circumstances should be preceded by counselling, it is suggested that written information on PSA should be given to men before attending a PAC, or before PSA tests are carried out in general practice.

(v) TRUS and biopsy must be carried out by trained operators with appropriate equipment. Where performed by a radiologist, there must be regular communication and clear agreement with the urologist on management policy including biopsy, numbers of cores and antibiotic prophylaxis. Cancer units and cancer centres should review arrangements in their locality and ensure that all men proceeding to TRUS and biopsy have access to properly regulated and audited facilities.

(vi) Application of these recommendations should facilitate the diagnosis of early prostate cancer, but will identify it in those who need or would desire treatment for confined disease.

(vii) Early prostate cancer should be managed in designated clinics where the patient has access to a urologist and an oncologist, who must both be involved in the counselling process before selecting the appropriate treatment (including watchful-waiting). Criteria for such clinics must be developed by BAUS in association with its Oncology Section, the Faculty of Clinical Oncologists and other interested parties, including the British Prostate Group. The Working Party envisages that these clinics can be in either cancer units or cancer centres according to local arrangements, and that the criteria for designation and audit arrangements already being introduced by the BAUS Oncology Section will identify those urologists who will participate. It is likely that all urologists with expertise and desire to perform radical prostatectomy can be accommodated within these arrangements.

(viii) Increased diagnosis of prostate cancer has significant implications for future urological and oncology services. In particular, introduction of a screening programme would require funding for the training and employment of sufficient urologists and radiation oncologists to treat the patients identified.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Prostate cancer—incidence and mortality
  5. Advanced prostate cancer
  6. Diagnostic tests in prostate cancer
  7. Screening and diagnosis
  8. Counselling of patients
  9. Management of early prostate cancer
  10. Prostate cancer clinics
  11. Guidelines and information
  12. Future research
  13. Conclusions
  14. Recommendations
  15. References
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