“For years, prostate cancer screening was synonymous with overdiagnosis and overtreatment. However, with modern approaches to PSA values and the use of biomarkers we can more effectively differentiate between clinically significant and insignificant tumours. As a result of MRI imaging, we can be more selective about which patients require biopsies. With active surveillance we can further reduce overtreatment.”
The introduction of PSA-based testing has historically led to a significant drop in prostate cancer mortality since the early 1990’s. But with criticism directed at the risk of overdiagnosis and overtreatment, the drop in mortality is stagnating, and in some specific countries, mortality is increasing again: “In the UK, over 65% of the cases of prostate cancer is currently diagnosed in more advanced stages, when cure is more difficult to achieve, and more toxic. In the metastatic stage they are incurable and will become castration-resistant,” says Van Poppel.
Cost is also an important factor: early detection and treatment can significantly decrease the costs associated with the management of more advanced prostate cancer. Prof. Van Poppel: “The cost of a PSA test is very low. It can be performed by a nurse and does not require any further actions, unlike screening for breast cancer, colon cancer or cervical cancer.”
“Timely detection means more effective and cheaper treatment options, like radiotherapy or radical prostatectomy. If we detect prostate cancer at too late a stage, the costs can exceed €250,000 per individual to extend someone’s life by one or two years. As urologists, we can detect prostate cancer in an earlier stage when treatment can be offered with fewer side-effects like impotence or incontinence, a higher quality of life, and before the disease progresses.”
“PSA sampling remains the basis of our early detection options, despite the fact that for many ‘PSA screening’ has negative associations based on earlier screening programmes. Based on the initial PSA test, we can these days avoid overdiagnosis and overtreatment that may be harmful to our patients while still being able to treat those patients who would benefit from early treatment.”
More than 92,000 European men die of the disease every year, and in some countries prostate cancer has become the second cause of male cancer death after lung and before colorectal cancer.
The EAU’s approach
Prof. Van Poppel lays out the EAU’s strategy to dramatically reduce prostate cancer mortality in Europe. “Our approach is three-pronged," he says. "Encourage early detection from a medical standpoint, lobby to bring prostate cancer on the European political agenda, and inform patients and the healthy male population about the risks and benefits of early screening.”
In 2003, the European Commission recommended screening for cervical, breast, and colorectal cancer, but declined to include prostate cancer screening because of the risk of overdiagnosis and overtreatment. In 2020, new recommendations are expected to come from the European Commission, and Van Poppel sees the addition of prostate cancer to this list as vital for men’s health in Europe.
Examples of initiatives that the EAU has supported or (co-)organised on a European level are the bi-annual European Prostate Cancer Awareness Day (EPAD) at the European Parliament, as well as the #EUpledge4prostatecancer that encourages individuals members of the European Parliament to bring prostate cancer to the agenda.
Van Poppel: “Healthcare is very much the realm of individual member states, and their laws and departments of health, rather than the European Union. However, through the European Commission’s recommendations we hope to start changing national policies across the continent. Our diagnosis and treatment options have improved significantly since 2003 and, together with patient organisations, we feel that the time has come to add prostate cancer to the screening recommendations. It’s up to individual countries, but the EU can send a strong message.”
The EAU’s standpoint is summarised in a recently published Policy Paper on PSA Screening for Prostate Cancer, which is available for download here.
The informed patient
The third prong in the EAU’s approach to reduce mortality and encourage early PCa detection is to inform Europe’s male patients on its benefits and risks. By encouraging awareness in the general population and at-risk men in particular, interest and demand for early detection can be increased. The EAU supports patient advocacy organisations and indeed addresses (potential) patients directly with information campaigns.
Appropriately, patient groups are also an important part of the EAU’s strategy to improve care for prostate cancer patients. The EAU Patient Advisory Group or EPAG held its first General Assembly at EAU19 in Barcelona. EAU-affiliated healthcare professionals and patient organisation representatives from bladder, kidney, and prostate cancer groups came together to discuss ideas and needs and explored ways to collaborate. EPAG’s objective is to increase patient empowerment and engagement in the development, dissemination, and impact assessment of guidelines and patient information and to support educational events for patients and patient advocates.
Van Poppel: “Patient organisations perform a valuable task in raising awareness about conditions and can sound the alarm in the face of increased PCa-related mortality. They lobby their national governments and generate attention among the general population.”
“We think that the well-informed patient is an essential component of our attempts to reduce PCa-related mortality. To that end, the EAU’s Patient Information Working Group is in the final stages of preparing a leaflet on prostate cancer screening. This leaflet will plainly outline the advantages and disadvantages of PSA-based early detection, and explain possible consequences for the patient after detection. If something is detected, this might result in a biopsy, or perhaps active surveillance will suffice. At the very least, mortality will decrease.”
“Once people realise that structured PSA-based screening at age 40-45 can pre-empt much more invasive treatment of more advanced prostate cancer, we expect the demand for PCa early detection to increase. By persuading the European Commission to support screening for prostate cancer and by increasing awareness among patients, we think we can be successful in changing national healthcare legislation in European countries.”
This article is adapted from an article which originally appeared in the August/September 2019 edition of European Urology Today (page 1).