Oncology

Professor Dr Hendrik Van Poppel: Prostate cancer is the most frequently diagnosed cancer among men in Europe 1 but, if it is caught in the early stages, patients are able to access effective treatment options and experience fewer and more manageable side effects. Organised, early detection is paramount in reducing the morbidity and mortality rate of prostate cancer. 2 So, publication of Europe’s Beating Cancer Plan 3 and of the updated EU cancer screening guidelines, 4 along with the renewed focus on EU health policy, all mark important steps towards the eradication of inequalities in cancer diagnosis and treatment.

The new screening guidelines aim to support Member States in ensuring that 90% of the EU population who qualify for breast, cervical and colorectal cancer screenings are offered such screenings by 2025. For the first time, the new recommendation calls for population-based organised cancer screening to include lung, prostate and, under certain circumstances, gastric cancers.4 This is why we are making an urgent call for EU Member States to implement risk-based prostate cancer screening recommendations in national cancer plans, because outcomes for future patients with prostate cancer would improve if this step is prioritised by national policymakers.

There has been a relative decline in prostate specific antigen (PSA) testing in screening programmes for prostate cancer in Europe.2,5 The most important issue was the overdiagnosis and overtreatment of a relevant number of men with non-aggressive prostate cancer, which in 2012 led the US Preventive Services Taskforce to recommend against prostate specific antigen (PSA) testing.

Sadly, this now means we are seeing higher rates of metastatic disease and advanced prostate cancer at time of diagnosis, which in turn is associated with an increase in mortality, a poorer quality of life and a higher cost for national health services.

The situation is compounded by men feeling uncomfortable to talk about their health or to take the initiative to go and see a healthcare professional. In many cases, men may not be aware of what their prostate is or the need to be aware of their health, particularly as they age, or if they are part of high-risk groups such as men of African American origin, and those with a family history of the disease. 1

The new cancer screening recommendation is based on PSA testing to identify men with a PSA above 3ng/ml as having a high risk of significant disease. These men would not undergo biopsy immediately (as before) but would receive an MRI at follow-up and this, combined with active surveillance, is expected to significantly reduce overdiagnosis and overtreatment.4,1

Coupled with this, prostate cancer has been relatively low on the health policy agenda of the EU, as compared with breast and cervical cancers, for example. Across Europe, prostate cancer kills more men than breast cancer does women.1 Early detection is absolutely critical to improve patient outcomes and reduce mortality. It’s important that we work with national and international policymakers to prioritise prostate cancer on political agendas and dismantle stigma around the disease – it’s often viewed as an ‘old man’s disease’, that you rather die with than from, or men just simply think it won’t happen to them, but prostate cancer is a killer. It is the second most common male cancer killer in Germany and the number one in Sweden, before lung cancer. 8 To do this we need to ensure there are better resources so patients, partners and families can be fully informed about prevention, early detection, diagnosis, treatment and ongoing care. It is only by detecting cancer at earlier stages that it will be possible to not only reduce mortality but most importantly improve the quality of life of patients. 2

The COVID-19 pandemic had a significant impact on prostate cancer as it delayed both screening and treatment for patients, resulting in a record number of advanced prostate cancer cases.6 In fact, a recent report from The Lancet Oncology Commission states that the disastrous effects of the pandemic on early diagnosis and treatment could set back cancer outcomes in Europe by almost a decade, making urgent action a crucial priority. 7

The new recommendations mean prostate cancer screening should be systematically implemented on invitation with ample information on the pros and cons, using PSA testing and risk calculators to recognise those at risk for having significant prostate cancer. If so, magnetic resonance imaging (MRI) scanning will be done before considering a biopsy in those males at greater risk of having significant prostate cancer.4 The screening recommendation is paying particular attention to equal access to screening and targeting the needs of particular socioeconomic groups, people with disabilities and people living in rural or remote areas. 4Helpfully, the use of new technologies such as AI can enable the rapid processing of health data, which supports better targeted screening and may ultimately lead to quicker diagnoses. 3

The greatest risk factors for prostate cancer are age, being Black from African or Caribbean descent, or having a family history of the disease.1 Unfortunately, studies show that an increasing proportion of these individuals are diagnosed with metastatic or late-stage prostate cancer, 9 so raising awareness is vital if we are to see the situation improve.

In addition, ensuring the new cancer screening recommendations are implemented in full by every country within the EU will be critical alongside supporting health systems to treat patients holistically, with multidisciplinary teams and complementary therapies needed to circumvent, prevent and help people cope with the secondary effects of the treatment, like counselling, physiotherapy and sex therapy.

It is often argued that although lots of men get prostate cancer, it is fatal to few. This is not the case and prostate cancer is the first or second cause of male cancer death in most countries across Europe. Prostate cancer survival has improved in all EU countries in the last decade,10 and innovations in treatment and care across the prostate cancer pathway have offered greater opportunities to enable those affected to live longer lives.

However, treatment of prostate cancer is multifaceted. The effects of hormonal treatment, for example, will include sexual dysfunction and loss of libido, and this has an impact on quality of life for not only the patients, but their partners too. Everybody should be enabled to enjoy their best possible quality of life.

If EU Member States implement the recommendations for risk-based screening for prostate cancer, the result on mortality rates will have a substantial impact, with the aim being that men die with the disease rather than from the disease. The opportunity for improving the outcomes for patients in terms of psychosexual health will be significant too. We shouldn’t forget that treating depression as a result of side effects of treatment for late-stage cancer also costs money for health services. If we can avoid a patient reaching that stage in their treatment journey, then it’s not just important for their well-being, but it also reduces pressure on already stretched health services and on their families and partners.

There are three key Calls to Action from the Let’s Talk Prostate Cancer Expert Group.11 The first is to prioritise prostate cancer on political agendas, to increase the knowledge and understanding of the challenges facing patients, including breaking taboos associated with prostate cancer and the emotional and sexual health burden of the disease.

The second obstacle is healthcare inequalities. We’re calling for policymakers in Europe to support research into the inequalities that affect men with prostate cancer to close this gap. Finally, we are urging European governments to ensure a timely implementation of the EU recommendation on cancer screening within national cancer plans. It’s an extremely positive step to see prostate cancer be included in the screening recommendations, but we need the implementation to happen in the EU where health is still an issue of the Member States, if we are to see real change.

Compared with other tumours, such as breast cancer, prostate cancer has never recieved the attention it deserves and therefore has been relatively low on political agendas in the EU.1 This might well be due to the incorrect perception that prostate cancer is a less serious form of cancer, when in fact it had the highest estimated incidence rate among all cancers in 2020, with 159 new prostate cancer cases per 100,000 detected in the EU27 (in comparison breast cancer counted 143, colorectal cancer 72 and lung 67 new cases per 100,000). 12 Despite progress in recent years, there is still insufficient political pressure and policy action on early detection, diagnosis, treatment and postdiagnosis, to address the issues facing people with prostate cancer and this must change. The time to act is now.