This site is intended for Healthcare Professionals only

Ending inequality

In-depth bookmark icon off

Ending inequality

A new report highlights the inequalities faced by prostate cancer patients. What is the condition and what are the treatment options for sufferers?

Prostate cancer is the most common male cancer in England. It affects around one in eight men at some point in their lives and there are over 41,000 new cases diagnosed each year. And, in 2012, just over 10,800 men died from the disease. Currently, a staggering 250,000 men in the UK have survived or are living with prostate cancer, which is set to be become the most common form of cancer globally by 2030.

Over the past two decades, prostate cancer death rates have steadily declined, thanks to earlier diagnosis, advancing treatments and NHS service improvements. Yet according to Orchid, the UK charity dedicated to male-specific cancers, the quality of care that men receive varies significantly. The Rt Hon Paul Burstow, former health and cancer minister, says: “The level of discussion about prostate cancer is unacceptable. There’s almost a discrimination against men.”

A new report published by Orchid – More to do: Identifying and tackling the unmet need in prostate cancer care – urges the NHS, policy makers and politicians to end inequalities among men battling prostate cancer.

The report highlights the inadequacy in the quality of information and support provided to patients, with prostate cancer sufferers reporting worse provision of care than other cancer patients.

“We know from recent cancer patient experience surveys that there is significant variation in the quality of services,” says Paul Burstow. “Why should men with prostate cancer have to cope with second-rate services, a lack of vital support and limited access to world class drug treatments and clinical trials?”

Orchid hopes that the report’s findings will influence policy change and help to ensure that all patients have access to the best possible resources. Rebecca Porta, the charity’s chief executive, comments: “In launching this report, we wanted to acknowledge just how far we have come in the treatment and management of prostate cancer, but also to highlight the changes that must happen to ensure men get the support they need.”

What is prostate cancer?

“The prostate is a gland usually the size and shape of a walnut,” explains Rob Cornes, male cancer information nurse specialist at Orchid. “Its main job is to make most of the fluid that carries sperm.”

The prostate gland often enlarges with age, but why prostate cancer develops is largely unknown. The majority of cases occur in men over 50, with more than 80 per cent of men in their 80s being likely to suffer. “The ageing population leads to the need for improved care provisions,” says one of TV’s most well known GPs, Dr Hilary Jones. “Older generations didn’t talk ‘below the waist’, but it’s no longer a taboo subject.”

As well as age, being of African-Caribbean or African descent is a recognised risk factor, while the condition is less common in men of Asian descent. Having a close male relative with the disease increases an individual’s risk 2.5 times and having a close female relative with breast cancer also heightens the risk.

“Early prostate cancer tends not to have any symptoms as most develop in an area away from the urethra,” says Rob.

Symptoms are more often caused by benign enlargement of the prostate or advanced prostate cancer. Some men report:

  • An increased need to urinate
  • Straining during urination
  • Difficulty beginning to urinate
  • A sudden urge to urinate
  • A weak flow during urination
  • Feeling the bladder is not fully emptied.
The level of discussion about prostate cancer is unacceptable. There’s almost a discrimination against men

How is it diagnosed?

There is no definitive test to diagnose prostate cancer. If a patient describes the above symptoms, their GP may perform a test to measure the level of prostate specific antigen (PSA) in their blood. PSA circulates in the blood and the level naturally increases with age. However, a raised amount can be a sign of early stage prostate cancer. Despite this, there is no PSA screening programme in the UK – a controversial topic in the medical world.

Some countries do recommend that all men over 50 have an annual PSA blood test. One European study revealed that deaths could be reduced by 20 per cent if a routine screening programme was introduced. Whereas only one additional life would be saved for every 48 men who undergo treatment.

Routine screening is not offered in the UK as it can be unreliable and produce false positive results that encourage men to have painful, invasive procedures for no purpose. “A PSA test can help pick up prostate cancer before symptoms, or a fast growing cancer at an early stage. However, 76 per cent of men with a raised PSA level don’t have prostate cancer,” says Rob.

Instead, the UK offers an informed choice programme that aims to educate men on the benefits and risks of PSA tests. If a man over 50 requests a test, this can be arranged free of charge via his GP.

A PSA blood test in conjunction with a physical digital rectal examination (DRE) is more accurate in identifying potential prostate cancer. This involves inserting a lubricated, gloved finger into the rectum to feel the surface of the gland, which may be hard and bumpy if cancerous. According to Rob, men’s reluctance to have a DRE can prevent diagnosis. “A DRE only takes a few seconds to perform, but can be temporarily uncomfortable,” he says. “There appears to be an issue with regard to it being an affront on men’s sexuality.”

A DRE alone is unreliable, as many prostate cancers cause no change to the gland’s texture. However, it can rule out benign prostatic hyperplasia, which makes the prostate feel smooth. If a GP suspects cancer, they may refer the patient for a biopsy.

During a biopsy, the prostate is visible, but tumors are not, causing up to one in five cancers to go unidentified. Therefore, many men undergo an additional biopsy if their symptoms persist or their PSA levels continue to rise. Biopsies can identify low-risk cancers that do not require treatment, but they do increase patient anxiety, prompting men to undergo treatment that has little benefit but could cause side effects.

What are the treatment options?

Due to the slow development of prostate cancer, treatment is unnecessary in many cases. All treatments carry the risk of side effects, such as erectile dysfunction or urinary incontinence. Therefore, many men delay treatment until there is a risk that the cancer may spread.

If the cancer is diagnosed in the early stages and isn’t causing symptoms, a policy of ‘active surveillance’ may be undertaken. “Active surveillance is a treatment for men with early localised prostate cancer that is usually confined to a small area within the prostate gland,” says Rob. “It is used for men when prostate cancer is not expected to progress rapidly and does not require imminent treatment.”

Another approach is ‘watchful waiting’, which is often used for older men, or those who are not fit enough to undergo treatment or who do not show symptoms. If the side effects of treatment outweigh the benefits, the aim is to control the cancer so that it doesn’t shorten life expectancy or impact on everyday life.

Certain cases can be cured via radiotherapy, hormone therapy or surgical removal of the prostate. Unfortunately, many cases are not diagnosed until the late stages of cancer progression, when it is likely to have spread to other parts of the body – typically the bones. Here, treatment focuses on relieving symptoms and prolonging life.

All cancer patients should be cared for by a multidisciplinary team (MDT). This often consists of a specialist cancer surgeon, an oncologist, radiologist, pathologist, radiographer and specialist nurse. The MDT decides on the best treatment option, considering the cancer’s size and grade, as well as the likelihood of it spreading and the patient’s general health. “This will be relayed to the man and if there are several possible treatments, it will be an individual choice,” says Rob.

 

Backing clinical nurse specialists 

Orchid’s report – More to do: Identifying and tackling the unmet need in prostate cancer care – highlights the importance of clinical nurse specialists (CNSs) in improving the lives of those with prostate cancer.

A recent evidence review carried out by Macmillan Cancer Support revealed that some of the benefits of CNSs include:

  • Improved patient care and safety
  • Increased productivity and efficiency
  • Fewer emergency admissions
  • Reduced length of hospital stay.

“CNSs are not to be underestimated,” says Rebecca Porta, CEO of Orchid. “They have a critical role – after a consultation with a doctor, they pick up the pieces and offer a soothing, caring arm.”

Yet a 2007 study by the Prostate Cancer Charter for Action identified significant variation in the provision of CNSs for different tumors. Increasing financial pressures on the NHS could compromise the provision of CNSs too. Rebecca adds: “We would like every patient diagnosed with prostate cancer to have a named CNS who they can see regularly. We understand there’s a lack of funding and cut backs are happening, but it’s a waste of resource and specialism to send a CNS elsewhere.”

Copy Link copy link button

In-depth

Share: