Editorial

Prostate Cancer placed last in two week referral priority

The Government has set a target that all urgent cases of suspected cancer should be seen by a specialist within two weeks of referral.  Further, they intend that this target be met for all cancers by the end of this year.

This is a most commendable step forward.  Already the target is being met in the case of breast cancer.  When it is implemented for all cancers, it will be a great feather in the cap of the cancer Tsar, Mike Richards.  One wonders, however, whether the timetable can be met.  Implementing it for breast cancer, by putting in place specialist teams in Hospitals, has cost the NHS a great deal of money.  The customers seem happy but are the book keepers of the NHS?

We are doubtful whether there is enough money to repeat this sort of exercise for all cancers.  If there is not, then the sufferers will be those at the back of the queue, which includes men suspected of having prostate cancer.  We also wonder whether there will be enough consultant urologists to meet the demand in the specific case of prostate cancer.  Even if this is a problem, the Department of Health must not lower the criteria which determine the urgency of cases simply because of a shortage of urologists.  Far better to put back the implementation date, while maintaining standards.

Government timetable for implementation of two week standard:

Prostate Research comments on the DoH guidelines

In preparation for implementing the above two week referral standard, the Department of Health has drafted some guidelines to help GPs to identify those patients who are most likely to have prostate cancer and who therefore require urgent assessment by a specialist.  Equally it is hoped that the guidelines will help GPs to identify patients who are unlikely to have cancer and who may appropriately be observed in a primary care setting or who may require non-urgent referral to a hospital.

Prostate Research Campaign UK have read the Department of Health guidelines most carefully, consulted as widely as we could and sent in our comments by the due date of January 7 this year.  This is the full text of our comments:
 

1  These guidelines offer nothing to the many men under 70 who have clinically significant but largely asymptomatic prostate cancers that are amenable to cure.

Many studies have demonstrated that at least 1.5% of men in the 50 to 70 age range are in this situation (Chadwick et al 1991) and further studies using more refined PSA assays indicate that this percentage is more likely to be in the region of 3% to 5% (Partin et al, Urology 1996 and Catalona et al, J. Urol 1997).
 

2  To restrict the guidelines for urgent referral to:  a) Bone pain, abnormal DRE and/or PSA over 20 or b) Abnormal DRE and PSA over 20 will, except in rare cases, simply identify men with metastatic or locally extensive disease where cure is no longer achievable.

It will do nothing to address the appalling statistic that overall 5 year survival in the UK is only half of that in North America. It also ignores that for the first time mortality rates are declining in the USA.  It would be foolish, not to say churlish, to deny the probable role of early detection and proactive management in this regard.
 

3 A guideline of over 20 is absurdly high.

The relationship between PSA levels and pathological stage have been well defined (Partin et al, J.Urol 1993) and have shown that for PSA of 4-10, 53% of cancers are confined within the prostate but this falls to 23% for a PSA over 10 and to 7% for a PSA over 30.  It follows that in order to adopt a curative rather than a palliative management strategy we need to have a standard of PSA for urgent referral of less than 10.

Again the evidence from large scale screening studies is that 22% to 27% of men with a PSA of 4 to 10 have significant prostate cancer (Hudson et al 1989 and Blower et al 1992).

The guideline for GPs and primary care professionals, should be to view all PSA assays over 4 with suspicion and, if accompanied with evidence of abnormality on DRE, should, without question, be considered as urgent from the point of view of referral from primary to secondary care professionals.
 

4  It must be deplored that only one Urologist, Mr M. Wallace FRCS comprised the working party on urological cancers, who also sat on the steering committee.

This represents gross under-representation of current views.  It also makes a nonsense of what is said in the introduction to the document sent out for consultation namely that "...The guidelines for each tumour group were prepared by Working Parties chaired by an expert in the relevant cancer area with input from primary care, public health medicine, nursing, radiology and other disciplines as appropriate...."

In the meantime, the Royal College of Radiologist's Clinical Oncology Information Network (COIN) and the British Association of Urologists (BAUS) guidelines have been published in the December issue of the British Journal of Urology International.  Whilst Mr Wallace is not a member of the COIN/BAUS working party, it is reasonable to suppose that he had access to the report in advising the DoH.  Whilst the COIN/BAUS report is an excellent document it does contain some ambiguities.  We would certainly accept, as far as national public health policy is concerned, that population based screening should only be undertaken in the context of a controlled trial (if indeed this is now possible given current and rising public awareness).  One needs, however, to make a distinction between population based screening and early detection or case finding activities.  There is increasing public awareness and expectation in relation to prostate cancer and increasing litigation in relation to delayed diagnosis.  The proposals as currently formulated may not be sufficient to protect individual health care practitioners from the legal process.  If improved survival in prostate cancer is to be achieved the indications for urgent referral need to be revised.
 

5  The DoH guidelines for urological cancers should have a footnote or a paragraph providing guidance on the issue of PSA testing.

We would propose the following:

a) That a PSA assay should be made available to all men over 50 who request it. (There is, indeed, a case to stipulate all men over 40 years).

b) All men over 40 with a family history of prostate cancer (defined as having two or more first degree relatives with proven prostate cancer) should be offered an annual PSA assay.

c) All men over 45 years with lower urinary tract symptoms should have a PSA assay.