Dr Mackin Talk April 2014 Meeting

Talk by Dr James Mackin, GP: some brief notes

Dr Mackin noted that prostate cancer was the most common cancer in men and was also the most common single cause of death in men. However, only 10% of cases are clinically significant as 80% of men in their 80s were found to have it and 90% of men in their 90s. This implies that most men die with prostate cancer, not of it.

This then means that it’s not necessarily a good thing to have made a diagnosis – consider the side effects of diagnosis and of treatment if 80% of 80 year olds have it – so some GPs avoid the issue while others say too much.

But some men die of it.

So, the answer to the question “Should I have the test, doc?” is not easy. Is there a history or just concern? There’s the PSA test, but not a screening programme. It may be possible to feel in in a DRE. And the (relatively recent) MRI scan can produce good images (ultrasound is not used for diagnosis now). And biopsy, now often after MRI, saves waiting for the biopsy damage to heal.

Symptoms – many have urinary symptoms (getting up at nights, difficulty getting started, weak flow, dribbling, low back pain, ED) but these are not necessarily symptoms of PC; worse, there’s a group with PC that does not have symptoms.

2/3 have raised PSA but do not have cancer: the usual limits are age 40 <2.5; 50-60 <3; 60s <4; over 70<5). It’s found that 70% of men with PSA >10 have cancer and if PSA >200 it will have spread.

10% of PC is definitely genetic/familial and there are breast/ovarian/prostate links. And there’s a genetic test available – but for this link the mother has to have the gene.

There is a proportion of men who do have cancer but have a low PSA.

So if the PSA is high, what then? PSA screening of ages 40-70 has been shown to reduce mortality by 20%. But more than 20% will have biopsy problems and then there are the issues which affect those who are treated but who would not have had PC problems if left untreated. Is there more harm than if we do nothing?

Low risk: PSA <10, Gleason 6, MRI makes up the information

Higher risk: outside capsule, PSA >20, Gleason 8+

Watchful Waiting - ad hoc, palliative, no cure, alleviate symptoms
Active Surveillance – defer treatment, assume cure available, so don’t step in to treat as there’s the same chance of a cure so avoiding problems (side effects) as long as possible, take account of age; but the need for further biopsies, more MRIs can also have a physiological downside, knowing you have cancer.

Was there an age beyond screening? European guidelines are 40-70 as there’s no reduction in mortality over 70; and an age beyond treatment? Possibly – but there are a lot of other factors, so age as such is not the determinant.