Europa Uomo chairman André Deschamps sets out the need for an improved approach to prostate cancer diagnosis and treatment

30 million men in Europe are confronted with a diagnosis of prostate cancer in their lifetime. Each year 75,000 men die from prostate cancer. A questionnaire amongst our members in 24 European states showed that:

• Less than 50% of all men are aware of the disease
• PSA-led early detection is promoted by healthcare professionals in only 50% of the countries
• Depending on the country, between 20% and 60% of all prostate cancer diagnoses are done in the metastatic phase
• A multidisciplinary approach is partially available; not all treatments are available in all countries. Inequality of care is the norm.

False economies

Some countries are still discouraging PSA-led early detection and claim that they do not harm their citizens with this. The arguments are mostly: less costs for the healthcare system, avoiding over treatment and that this policy has no influence on mortality rates – ‘men do not die from but with prostate cancer’.

Less cost for the healthcare system

Here are some figures: a PSA test costs less than €10, an mpMRI approximately €300, and treatment in early-stage prostate cancer roughly €5,000. The cost of treatment in the late metastatic phase, which can extend life by two years, is €500,000. I encourage you to do the maths long term.

Over-treatment

Over-treatment has been and still is a problem. But it does not need to be. The scientific methods are available to avoid it. PSA results are now used much more smartly than they were. PSAD and velocity have been added to the toolbox. Biomarkers can differentiate high and low risk. mpMRI detects more significant and ignores insignificant cancers. This reduces biopsies and over-diagnosis. Active surveillance disconnects diagnosis of cancer and subsequent treatment.

Mortality rate

Statistics show that the mortality rate decrease which was seen a few years ago has stopped. In some countries we see (figures from 2015 and 2016) a significant increase in primary detection in Stage IV (advanced and metastatic prostate cancer). This must be reflected in the mortality rate in the years to come.

Quality of life

Even more important and not often considered is the quality of life of the patient.

Unfortunately, men cannot influence whether or not they develop prostate cancer, nor whether or not it will be a slow-developing, low-risk or highly aggressive cancer. What men (and policymakers) can influence is an early detection of the cancer.

If you are diagnosed in an early stage, your quality of life is affected, but to a far lesser extent than detection in a metastatic phase – especially when treatment is carried out in a cancer centre with experienced surgeons and radiotherapists. Detection in a metastatic phase means a lifetime of hormone treatment, which often has the following side effects: impotence, fatigue, osteoporosis, loss of libido and, in a later treatment phase, chemotherapy.

A new strategy

We as patients urge our politicians and policymakers to adopt a change in strategy based on three pillars. All three must be implemented at the same time to ensure the best treatment and quality of life with a reduced overall cost. These pillars are:

• Increase awareness
• Promote informed PSA-led early detection
• Ensure treatment of prostate cancer in multidisciplinary cancer centres.

Increase awareness

It will be necessary to launch awareness campaigns as was done for breast and colon cancers. Men and their relatives need to be aware that prostate cancer exists and that curative treatment is possible, especially when detected at an early stage.

Promote informed PSA-led early detection

It is important that informed men are actively encouraged by the government and healthcare professionals to test their PSA level. The scientifically based advice on when to test is described in the newly published EAU guidelines. They insist on an individual early diagnosis in informed healthy men with a life expectancy of 10-15 years. If there is a suspicion of prostate cancer based on the PSA test, an mpMRI should be performed before deciding on a biopsy. Diagnosis starts at 45-50 years depending on risk analysis and family history. Depending on life expectancy, 70 years should not always be the end date of PSA-led early detection.

Ensure treatment in multidisciplinary cancer centres

Considering the best outcome for men, treatment in a cancer centre with a multidisciplinary approach is a must. Studies have shown that the extent and severity of the side effects of treatments are a function of the experience of the surgeon and or radiotherapist.

We expect cancer centres to measure the patient-related outcomes and have them published and freely accessible for patients.

The requirements for these cancer centres are described in many publications such as the position paper by the European School of Oncology.1 40 mandatory and recommended standards are defined. For example, in a prostate cancer centre the following disciplines should be part of the multidisciplinary team: urologist, oncologist, radiation oncologist, pathologist, specialised nurse, patient advocate, psychologist, clinical trials co-ordinator, sexual therapist, physiotherapist and geriatrician. The minimum number of patients to be treated is defined in order to ensure sufficient experience.

Different initiatives have been taken to establish prostate cancer centres. Germany, for instance, has developed its own requirements. From a patient point of view, as long as the general idea is maintained and all treatments are ensured we can live with these developments.

As multidisciplinary centres are mainly located in bigger cities, they should develop ways of working with local health services. In close co-operation and led by the centres, some follow-ups can be done at a local level. This is beneficial for the patient as it avoids unnecessary travel.

Active surveillance

The development of active surveillance treatment for men with low-risk prostate cancer is essential in order to avoid over-treatment and to ensure an optimal quality of life for the patient during the years he can stay in that programme. It is also important to realise that active surveillance is a treatment in itself, and should be considered as valid as any other treatment in Stage I and Stage II of the disease. Active surveillance should not be confused with the watchful waiting programmes in the later stages of the cancer.

In the last three years a lot of progress has been made and knowledge gathered on how to apply active surveillance safely. Generally, there is a belief that this treatment can be valid for up to 30% of patients – those with low or intermediate risk.

Conclusion

Since the PSA test has been in use (for more than a quarter of a century), men have not had to wait for their prostate cancer to become metastatic in order to get a diagnosis. This early diagnosis was and is not always done and depends on the knowledge of men and the healthcare policy. We also know now that many men with low-risk cancer might have avoided or postponed treatment with its life-changing consequences.

We now have the means and the scientific knowledge to do better. By refocusing our efforts, we can learn from the mistakes within the success of the past few decades. The emergence of a more informed and organised patient population stands ready to do its part.

First published in Health Europa Quarterly in February 2019.