From telegraph.co.uk
High risk men still avoid testing, often because outdated myths about screening make them embarrassed to seek help
It’s long been known that men are less likely than women to voice their health concerns. They are less likely to attend routine health appointments, or present with symptoms, even when those symptoms are interfering with daily function. Research by NHS England found that 45.8 per cent of women compared to just 33.5 per cent of men had attempted to make contact with their GP for themselves or someone else in their household in the last 28 days.
Men make up far fewer hospital outpatient appointments too (even discounting women’s pregnancy-related ones) and are less likely to register with a dental practice or use a pharmacy. When you add to this the intimate nature of concerns around prostate health, it’s hardly surprising that men are often slow to present for testing.
New research by Prostate Cancer Research (PCR) has found that a number of common misconceptions around the screening process are keeping men away – and eight in 10 men agree that “embarrassment” about tests and treatment is a key factor.
Dr Reem Hasan is a GP and also the chief medical officer for InHealth, the UK’s largest provider of diagnostic screening services. In addition to this, her father had prostate cancer and she is keenly aware that we need better conversations about symptoms, risk and next steps.
“Many men just put their worries into Google and that can really direct them to inaccurate, out of date information,” says Dr Hasan. “As a starting point, I direct men to the infopool. It has the latest evidence-based, easy-to-digest data and information about testing, diagnosis, treatments and choices.”
So, what are the key myths?
Myth 1: The first step when you see your doctor will be a rectal examination
One in three men surveyed by Prostate Cancer Research believed that a Digital Rectal Examination (DRE) (the “finger up the bottom test”) is the first step in checking for prostate cancer in men with no symptoms.
“This is something that urgently needs correcting,” says Dr Hasan. “The one in three figure doesn’t surprise me at all as I hear it all the time from patients who look visibly relieved when I tell them that I’m not going to do one. It’s embarrassing and invasive, and men often say, ‘If I’d known that I wouldn’t need one, I would have come sooner!’”
Historically, the DRE was the standard, and at one time only, method available for evaluating prostate health. However, we now have far better, less invasive and more accurate first steps, starting with a conversation with a GP and then a simple blood test, the PSA test.
“In fact, this year, the British Association of Urological Surgeons put out a statement to say that the DRE is no longer useful,” says Dr Hasan. “The main reason is that when we do it, we often miss things because you can only feel a part of the prostate. You might miss a very small lesion or it might be on a part of the gland that we can’t access.”
The DRE only enables a doctor to feel the back wall of the prostate, and most prostate cancer develops on the front wall so it’s easily missed. “In addition, if you have a DRE and then a PSA blood test, it’s possible that you agitate the prostate and artificially elevate the PSA result,” says Dr Hasan. “Most GPs I know would not even consider giving a DRE for prostate cancer now.”
Myth 2: My sex life will suffer if I put myself forward for testing
Nearly three in four men surveyed by PCR believed that men’s worries about sexual function deters them from getting tested for prostate cancer.
“Historically, this view is understandable,” says Dr Hasan. “In the past, treatments were much more limited and could very often have lasting side effects which includes impact on sexual function.
“Modern medicine and the evolution of how we understand and treat the disease have changed that picture completely,” she continues. “So now, many times that prostate cancer is found, men don’t actually need immediate treatment – it’s active surveillance, watch and wait. They are safely monitored. When men do require intervention, the surgical and radiotherapy techniques are far more precise and that significantly reduces the risk of the side effects men worry about most – which includes sexual function but also incontinence.”
A key example here is the development of nerve-sparing radical prostatectomy where the whole prostate is removed but the neurovascular bundles that control erections and pass close to the prostate are carefully preserved. “Most important, the earlier the diagnosis, the safer and simpler the treatment and the less likely you are to have side effects,” says Dr Hasan.
Myth 3: Taking any tests for prostate cancer can put me on the pathway to unnecessary treatment
This is a very common belief that stems from old pathways which took men with an elevated PSA straight to a biopsy. “It comes back to modern medicine and our better understanding which means we can now gather a much more detailed picture and make better decisions about whether a biopsy is necessary,” says Dr Hasan.
“The utilisation of the multi-parametric MRI has really improved this picture, and AI is improving it further – there are amazing trials going on now.”
A multi-parametric MRI combines several imaging techniques to provide a more detailed picture of the prostate. As the “next step” after an elevated PSA test, it means fewer men will require a biopsy. “Learnings from global data and our better technology also means that we can more safely monitor people – for example, someone with a borderline PSA – without necessarily needing any further investigation or treatment.”
Myth 4: I feel healthy so I don’t need testing
Most men don’t understand the risks around prostate cancer. Research by PCR showed that 61 per cent did not believe a test was necessary when they had no symptoms.
“Early-stage prostate cancer often has no symptoms,” says Dr Hasan. In fact, symptoms might not appear until the cancer has metastasised – and these can be so general, for example, pain in the lower back – that they fall under the radar. A quarter of men surveyed by PCR wrongfully believed that one in 25 men will be diagnosed with prostate cancer at some point in their lifetime – in fact, the statistic is much higher. The risk for white men is one in eight, for black men one in four and South Asian men, one in 13.
“That’s very broad though and it’s important to personalise risk in order to really understand whether you should be tested,” says Dr Hasan.
“Risk rises with age – at 50 for white men and 45 for black men. A family history raises it more.” A close relative with prostate cancer increases the risk of developing the disease and this becomes greater if the relative was diagnosed before the age of 60. Less commonly, the presence of the BRCA mutations, BRCA1 and BRCA2, which are more commonly associated with a family history of breast and ovarian cancer, can also significantly raise the risk of prostate cancer, including a more aggressive form.
“Men sometimes come to me as a GP to discuss their risk and I really welcome the conversation,” says Dr Hasan. “Sometimes, it might turn out that their risk is very low and they don’t need a test – or it might be that they really do.”
Confusion around early testing, treatments and risk factors is partly why charities like Prostate Cancer Research are campaigning for a targeted national prostate cancer screening programme. If men at high risk are automatically invited for screening, there would be less room for fatal misconceptions.
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