The Dilemma of Identifying and Treating Life limiting Prostate Cancer:
Prostate Check may be the future of Men’s cancer screening
Written by David Galvin MD FRCS(Urol), Associate Professor, UCD
Consultant Urologist, Mater and St Vincent’s hospitals
Dublin; Paul Sweeney, Consultant Urologist, Mercy hospital, Cork and Padraig Daly, Consultant Urologist, University hospital Waterford
On Behalf of the Irish Society of Urology (ISU)
In February 2021, the European Commission (EC) announced the EU Cancer plan, to tackle Cancer across Europe, from prevention, to screening and diagnosis, to treatment and palliation. One of the more sensitive goals was the expansion of screening from Breast, Cervical and Colorectal cancers, to include Lung, Stomach and Prostate. This was not greeted across Europe with enthusiasm in all countries, as it would require significant resources and place a major strain on a number of healthcare systems across the EU. In order to inform a European early detection / screening program, further information and research is required. Previous screening programs in prostate cancer have been established around the world without patient engagement, and led to poor outcomes, over-treatment and screening was therefore generally not recommended. The European Association of Urology has led a successfully application (known as PRAISE-U) involving 25 countries across Europe who over a total of 6 work packages in 3 years will provide the much needed information to inform a successful screening program. Work package 4, involves the establishment of national pilot programs in 5 countries, and Ireland, through the Irish Society of Urology (ISU) has been invited to establish a research screening program.
Irish Pilot: Prostate Check
The ISU, the National Screening Service (NSS) and the National Cancer Control Program (NCCP) have developed an innovative prostate cancer screening pilot program, known as Prostate Check that is being funded by the EC through PRAISE-U . The program will involve doctors (both GPs and Urologists), Irish men (aged 50-70 years) and their families. Feedback from all involved will inform the design of a future PSA based risk-stratified national screening system. The Irish data collected will be fed to the PRAISE-U Investigators (based in Erasmus University in Rotterdam) who will put together a European wide report to the European Commission by April 2026. The Irish proposal brings together two partners, firstly an academic hub in University College Dublin (UCD), and secondly the Health Service Executive (HSE).
Men aged 50-70 years will be randomly identified from the Screening service, and will be invited to the pilot, giving their consent if they wish to be involved and for their data to be collected (via the website prostatecheck.ie). Partnering with a test provider, a home based PSA blood testing kit will be sent to the patient, who will perform a finger prick blood sample and return the sample for PSA testing in the mail to the laboratory. This means that GP practices will no longer be burdened with blood testing and referrals. All the data will be stored securely in UCD. All of the pilot programs will follow the EAU algorithm (Image 1). Men with high PSA readings will be seen automatically in the successful Rapid Access Prostate Clinics (RAPC) for MRI imaging, possible biopsy and treatment if needed. This data, and feedback from doctors, patients and families will all be analysed centrally by the EAU Investigators. In essence we will have Irish data, on Irish men assessing a novel home PSA testing system as a potential screening method in our commonest male cancer. We will learn from the experience of other European countries, and they from ours. Other work packages are examining the current status of screening across Europe, the needs of countries and the design and implementation of a screening protocol through knowledge sharing.
The EAU Screening Algorithm
So what’s new ? Don’t GPs already have guidelines on PSA testing from the NCCP ?
Men who visit GPs get blood tests. In other words, diabetics, those on statins and the chronically morbid, alongside those on medical cards or who can afford GPs, get diagnosed most often in Ireland. This is ad-hoc and opportunistic screening is very different from targeting the population of men most at risk at dying from prostate cancer, in fact these are probably the co-morbid population that would not be the target of a screening program.
Data shows that at the age of 45-50, men with the highest PSA levels are most at risk from developing serious prostate cancer (ref 1). In fact, 90% of men who subsequently die from prostate cancer, the vast majority are in highest quartile (top 25%) of PSA levels aged 45-50, suggesting that early diagnosis and intervention in this group, will have a considerable impact on mortality (ref 2). At the other end of the spectrum, we know that men whose PSA is <1ng/ml at the age of 50, and <2ng/ml at the age of 60, have very low risk of prostate cancer death, and therefore PSA testing can be deferred in this low risk population as per the EAU algorithm (ref 3).
All men aged 50-70 years, particularly those with a first or second degree relative with prostate cancer, or BRCA carriers are most at risk. Those with PSA readings >3ng/ml will be referred in to the RAPC. There, men will be risk stratified using their family history, prostate size and the EAU risk calculator (known to reduce the need for biopsy). In this way, the valuable resources in hospital will be respected, and used efficiently. And reduce the burden on GP practices and the need for blood testing in the community. MRI imaging allows for the use of the standardised prostate imaging score (PIRADS) which will determine the need for a targeted biopsy. All of this is designed to reduce the number of unnecessary biopsies, over-diagnosis and subsequent over-treatment, which many screening programs can fall foul of. If necessary men can avail of active surveillance, focal therapy and either minimally invasive surgery or radiotherapy. Our cancer centers are now supported by advanced nurse practitioners (ANP) in prostate cancer survivorship and self-supported follow up pathways funded by the NCCP and HSE.
Over the next 3 years, Ireland plans to complete this pilot study. Men will be invited to screening from mid-2024 over a 12 month period, and just 5000 men will be recruited in the initial pilot. It is our hope that the home finger prick blood sample will appeal to men, and can piggyback on the already well established and successful bowel screening efforts. Certainly this smart and humble approach to male cancer screening will hopefully avoid the mistakes of the past, and perhaps will lead to a new paradigm, where men will engage in their own healthcare through cancer screening programs that can be scaled to include other diseases in the future.
Image 1. EAU Prostate Screening Algorithm
References available on request