Prostate Cancer and Stephen Fry’ Aggressive Little Bleep.
Steven Fry hit the headlines this week with a moving and informative podcast about his recent experiences (http://www.stephenfry.com/2018/02/mischievous/) .
Stephen was recently diagnosed with a Gleason score 8 prostate cancer, subsequently upgraded to Gleason score 9 after his prostate was removed. Gleason scoring adds together two scores, the commonest grading in the tissue and the most aggressive grading in the tissue. The grading goes from 1-5 and so grades can be 2-10 in total.
Gleason scoring ranges from 2 to 10 for prostate cancer, 2 is a mild form which may never progress to aggressive metastatic cancer, 10 is very likely to metastasise and kill the patient if left untreated. I am very fond of Stephen Fry and hope his cancer is cured and that he has many happy and productive years ahead of him.
It has again raised the profile of prostate cancer screening, something we include in our Well Man Check, where we combine it with a prostate gland examination.
The question is ‘Does screening reduce mortality’?
The evidence is confusing. We can look at individual cases such as Stephen Fry, who would undoubtedly develop metastatic cancer within a fairly short time. Surely without screening, his case would have been hopeless? We do not of course yet know if he will develop a recurrence of his cancer further down the line.
On the face of it, large studies suggest that more cancers are detected by screening. But 27 additional cases of cancer would need to be treated to prevent one death. These results, from a large European study, suggest a lot of screening needs to be performed in order to save one life. If you happen to be that one person, you may feel it was all worthwhile.
However, is more focused screening likely to improve these figures? We do not yet know.
There are two types of PSA in the blood. Free PSA is associated with benign enlargement of the prostate (normal in men as they age). Bound PSA is associated with malignancy. A low ratio of free to bound < 25% may be indicative of cancer. The ratio of free/bound PSA is not currently provided by most NHS laboratories but is available privately.
A fascinating study, The Malmo Preventative project, took 21000 men and stored their blood between the ages of 27 and 52. They found that a higher PSA concentration in this group correlated with the risk of prostate cancer metastases up to 30 years later! At age 45-49 they found that a PSA in the highest 10% of the cohort (>1.61ug/L) contributed almost 50% of the deaths from prostate cancer over the next 25-30 years. So, we can now identify a high risk group who should be regularly screened.
On the other hand a single PSA test result <1ug/l , when performed in men in their 60s, confers a life time risk of prostate cancer death of only 0.2%. So we can strongly reassure this group that their risk of death from prostate cancer is extremely small.
So, what would I do? Well, I did. I had a PSA at age 50 and had my prostate removed at age 54 with a Gleason grade 7 tumour. Five years on, with an undetectable PSA, I feel it was a very good decision. I hope Stephen is as lucky.
I believe a test at 45-49 will identify the high-risk group that should be screened regularly, my test would have firmly placed me in this group and I would have been more vigilant than I was. Conversely, if you are in your 60s, a single test with PSA <1 ug/l will reassure you that your risk of dying from prostate cancer is exceptionally low.
If you would like a Well Man Check or a prostate screen and examination through Private GP Healthcare, please contact us 01227 730125.
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