Why scientists are resistant to prostate cancer screening
If you could choose to never know you had cancer, even if it meant a slightly raised risk of death decades down the line, would you take it? Many may choose to say wilfully ignorant, especially if knowing would lead to a string of invasive procedures that could cause more problems than they solve.
This is the trouble with prostate cancer screening and why, despite ongoing pressure from charities, the National Screening Committee (NSC) and scientists are reluctant to add it to the list of routine NHS checks.
Put simply, it does little good and can cause significant harm.
The current screening tool is the prostate-specific antigen (PSA) blood test which is used in some European countries such as Lithuania.
But a 15-year trial, led by the universities of Bristol, Oxford and Cambridge, estimated one in six cancers found by PSA screenings were over-diagnosed, leading to unnecessary treatment of tumours that would not have caused any harm in someone's lifetime.
For every 1,000 men screened, it is estimated that testing saves just one life.
'It's a very emotional thing,' said Prof Freddie Hamdy of the University of Oxford, who has spent years researching the benefits of prostate cancer screening.
'You have celebrities who come up, and the obvious example is Chris Hoy, who was diagnosed at the early age of 48 with a disease which is seemingly not curable, and that triggers a lot of emotions, 'We must find all these cancers'.
'What people don't realise is all the consequences of trying to find these few cancers on the larger population.'
Men aged 50 or over can request a screening test, but the impact can be profound. What is often mis-sold as a simple blood test can set them on a lifelong path of scans, surgery, side effects and stress.
Arguably, those who are found to have low or intermediate-risk prostate cancer would be better off not knowing. Research shows that they have around a 97 per cent chance of survival for 15 years whether they choose radiotherapy, surgery or simply monitoring the tumour.
Many will be spooked into going ahead with procedures, even if there is little benefit.
'I saw in my clinic yesterday five new patients with prostate cancer,' added Prof Hamdy. 'Four out of five are unlikely to have benefited from knowing they've got cancer. Two chose to have radical treatments.
'It isn't just a blood test. You have essentially a man who is healthy, who has no symptoms, and told him he has cancer.
'Essentially what we've done, irrespective of how serious the disease is, we've given that man a new passport, a new identity, which he is going to have to live for the rest of his life. And that is a huge responsibility.'
Those who opt for treatment face the prospect of being left incontinent and impotent. A study by the University of Bristol found that around half of men experienced urinary leakage and needed to wear pads after surgery to remove all or part of the prostate gland.
Although it improved over time, one in five still experienced incontinence five years after the surgery. Likewise, research found that the number of men with impotency issues rose from around 33 per cent to 80 per cent following treatment.
Jenny Donovan, professor of social medicine at the University of Bristol, said: 'This really affected some men severely. Loss of sex life can be devastating.
'Will we cause more harm than good by screening? We think yes, if we repeat this cycle of over-detection and over-treatment.
'It's an intuitively nice idea. We're not in principle against it, it's just more complicated than it seems.'
Even those who do not choose invasive procedures, face a lifetime of active monitoring and the constant fear that each new appointment could bring bad news.
One man wrote in the study: 'When I first went for the active monitoring, I thought 'well this isn't going to be a problem, I'll be able to sail though this because I know the cancer is being contained and I know I am being monitored'.
'But then it wasn't in reality as simple as that because I knew that I had cancer and it messes things up. You think you can handle it, but it's always there niggling in your mind.'
If all the evidence suggests the benefits of screening does not outweigh the risks, why then do charities like Prostate Cancer UK advocate for a national screening programme?
The answer probably lies in the figures. Prostate cancer deaths are the second-most common cause of cancer death in the UK, killing 12,000 people each year, making it a major public health problem.
Something needs to be done, but screening could bring more challenges than it solves.
When Kazakhstan introduced population screening for prostate cancer in 2013, they were forced to close the program within five years because the health service could not cope the influx of low-risk prostate cancers, which did not need treatment.
Richard Martin, professor of clinical epidemiology at the University of Bristol said: 'What we don't want to do is compound that problem by adding harm and not reducing those 12,000 deaths a year. That would be a disaster.'
This week, Wes Streeting, the Health Secretary, declared his support for a national prostate cancer screening programme, adding that he was 'particularly sympathetic' to the idea.
Currently the National Screening Committee, which keeps a rolling review on the issue, is looking into whether certain at-risk groups could be targeted, but is unlikely to recommend a national programme.
Derek Rosario, honorary professor at Sheffield Hallam University and clinical advisor to the NSC, said: 'The NSC is still considering evidence around perhaps identifying high-risk populations, but the real difficulty is reliably identifying high-risk populations for prostate cancer. Lethal prostate cancer is not quite as straightforward as it might seem.
'So there is no formal review of national screening going on, but the space is moving all the time.'
In response to Mr Streeting's intervention, Prof Hamdy said: 'Fund research and we'll give you the evidence.
'There seems to be a lot more attention given to, 'let's find the cancers, and then we'll sort it afterwards'. And what we're saying is, before you put the needle in a man's prostate, just think.'
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