Van: Health of minority ethnic communities in the UK namens Ash Paul
Verzonden: zo 14-3-2010 04:34
Aan: MINORITY-ETHNIC-HEALTH@JISCMAIL.AC.UK
Onderwerp: Re: Prostate screening, PSA test and the BME community
Dear Rose,
Many thanks for your reply and for your good wishes. I would like to add that there
are quite a number of BME consultants in public health medicine in the UK, including
academics like the illustrious Prof Raj Bhopal, Bruce and John Usher Professor of
Public Health at Edinburgh University and a member of this Group, Prof Aneez Esmail
who is Prof of Primary Care at Manchester University and Prof Aziz Sheikh at
Edinburgh University.
You have written that you would welcome a good debate on this subject, which is
the reason why I'm replying back to your email.
The PROCESS cohort study in the UK established that black men in the United
Kingdom have substantially greater risk of developing prostate cancer compared with
white men, although this risk is lower than that of black men in the United States:
http://www.sasi.group.shef.ac.uk/publications/2007/benshlomo_et_al_author_version.pdf
However, the UK-based PROCESS cohort study comparing black men with white men
found no evidence of differences in disease characteristics at the time of prostate
cancer diagnosis, nor of under-investigation or under-treatment in black men:
http://www.nature.com/bjc/journal/v102/n2/full/6605461a.html
There should be no question about the debate of the PSA test running on and on.
As I mentioned in my previous email, the inventor of the PSA test Prof Richard Ablin
has himself pointed out its severe limitations in the NY Times opinion-editorial
recently.
In addition, the two large 2009 studies 1. Mortality Results from a Randomized
Prostate-Cancer Screening Trial (The New England Journal of Medicine) and 2.
Screening and Prostate-Cancer Mortality in a Randomized European Study (The New
England Journal of Medicine) both show that the PSA blood test saves few lives and
leads to risky and unnecessary treatments for large numbers of men.
You have written in your email that you hope that some day a new test will be found
that can't be challenged. In my opinion, that is wishful thinking. What you meant to
say, if I'm not mistaken, is that you are hoping that soon some test for detecting
prostate cancer will be found that has a higher sensitivity and specificity than PSA. A
test with 100% specificity and 100% sensitivity (when the test can't be
challenged) for prostate cancer is very unlikely ever to be discovered. Assuming that
a replacment test for prostate cancer with higher sensitivity and specificity than
PSA is discovered in the future, as a NHS commissioner, I would still oppose a
universal prostate cancer screening programme until all the following criteria of
Wilson-Jungner were satisfied, especially points 9 and 10:
The Wilson-Jungner criteria for appraising the validity of a screening
programme
1.
2.
3.
4.
5.
6.
7.
8.
The condition being screened for should be an important health problem
The natural history of the condition should be well understood
There should be a detectable early stage
Treatment at an early stage should be of more benefit than at a later stage
A suitable test should be devised for the early stage
The test should be acceptable
Intervals for repeating the test should be determined
Adequate health service provision should be made for the extra clinical
workload resulting from screening
9. The risks, both physical and psychological, should be less than the benefits
10. The costs should be balanced against the benefits
I agree with you that men should be aware of the pros and cons of the test.
However, now that we have figures from the the two 2009 trans-Atlantic studies
which I have mentioned before, those pros and cons should be expressed in simple
to understand figures.
Commenting on the two studies, Dr. Peter B. Bach, a physician and epidemiologist at
Memorial Sloan-Kettering Cancer Center, says one way to think of the data is to
suppose that a patient has a PSA test in 2009. It leads to a biopsy that reveals he
has prostate cancer, and he is treated for it. There is a one in 50 chance that, in
2019 or later, he will be spared death from a cancer that would otherwise have killed
him. And there is a 49 in 50 chance that he will have been treated unnecessarily for
a cancer that was never a threat to his life.
I keep hearing all sorts of people commenting on survival rates of prostate cancer in
the UK being much worse as compared to those in the USA.
US political leaders like Rudy Giuliani have made similar political statements smearing
the NHS in 'The Times' on 1st November 2007.
The absolute truth of the matter is that the survival difference quoted in the US
figures is a mixture of length time bias and lead time bias, and has nothing to do
with the dangers of socialised medicine ie the NHS (Ref: Screening; evidence and
practice by Sir Muir Gray and Angela Raffle, 2007, OUP; Page 208).
In the USA, the home of the free to have a PSA (Prostate Specific Antigen) Test, the
extremely high rate in the USA (125 per 100,000) is 2.5 times the reported rate in
the UK (52 per 100,000). This is likely to be due to the high rates of PSA testing in
the USA.
It is estimated that 15-30% of men over 50 in the UK have histological evidence of
cancer in the prostate rising to 60-70% by the age of 80, but only 1 in 25 men (4%)
will die from this disease. In other words, men are more likely to die with prostate
cancer than
from it (http://info.cancerresearchuk.org/cancerstats/types/prostate/incidence/)
Following on from your statement that the pros and cons of the test should be
explained, with which I concur, I would emphasise that this needs to be explained
with figures in very simple language that most patients can understand ie Imagine in
your town 20 people die every year from prostate cancer, out of 40 diagnosed.
Survival is 50%. Then you start screening, and find you are diagnosing 80 every year,
but still 20 die every year. The total number of deaths remain unchanged but
survival has now shot up to 75%.
The Medical Journal of Australia in a November 2007 Editorial on 'The Media and
Prostate Cancer Screening', emphasises that the provision of incorrect information or
incorrect data interpretation does not serve anyone well
(http://www.mja.com.au/public/issues/187_09_051107/ste108241_fm.pdf).
For me, as a consultant in public health medicine, anecdotal evidence is the lowest
form of evidence in the hierarchy of evidence. I accept that you as a clinician, have a
duty of care to every individual patient, but as an NHS Commissioner, tasked with
spending a fixed pot of money, given to us by the UK tax-payers to spend on buying
maximum health gain/health outcomes for our populations, you need to remember
that I (or indeed any healthcare commissioner anywhere in the world) do not
commission for an individual but for populations. In addition, I cannot spend the
same pound twice, and therefore every pound spent inappropriately, bringing less
health gain, is an 'opportunity cost' for an equally, if not more deserving service that
will lose out. Sticking with the example of the BME community and spending on
cancer services, I would much rather spend a lot more cancer money on health
promotion and increasing coverage for breast and cervical cancer screening for BME
women (because that would bring me much greater health outcomes), instead of
spending the NHS's scarce resources on the marginally effective PSA test for prostate
cancer.
I would welcome a debate amongst other members of this group, to what some
members might very well regard as a controversial posting.
Kind regards and best wishes,
Ash
Dr Ash Paul
Medical Director
NHS Bedfordshire
21 Kimbolton Road
Bedford
MK40 2AW
Tel no: 01234795705
Email: ash.paul@bedfordshire.nhs.uk
From: Rose Thompson <rose.thompson11@NTLWORLD.COM>
To: MINORITY-ETHNIC-HEALTH@JISCMAIL.AC.UK
Sent: Sat, 13 March, 2010 2:53:28
Subject: Re: 2010 Prostate cancer Annual Evidence Update
Dear Ash
Delighted to hear that you are a consultant in public health medicine and a member of the BME
community. I hope more BME community members will take up a career in Public health. I appreciate
the fact that you have taken the time to respond to my previous message and I am aware of how the
test can be over used in the USA where there is a different health system, predominantly delivered via
Private companies. There are times that I wish there was currently a definitive test that could be used
to detect prostate cancer to end the ongoing debate about the PSA test. I agree the PSA test is
not definitive (as previously stated in my email) because it is well documented that about 2 out of
every 3 of men with a raised PSA level will not have prostate cancer. I also mentioned the fact
that men should be aware of the pros and cons of the test.
I just reviewed my comments as I am always up for a good debate and open to constructive
comments. I understand how you could have interpreted the case study but I was not advocating PSA
testing as a screening test, merely following the guidelines for suspected prostate cancer and
emphasising the importance of an awareness of the role of ethnicity in prostate cancer. Digital Rectal
Examination or DRE via the back passage is also recommended alongside the blood test.
I am a qualified radiotherapy radiographer and have treated hundreds of men with prostate cancer.
Men with advanced prostate cancer are more likely to have abnormally high PSA levels in my
experience, but even then it isn't entirely reliable. When I said the patient was advanced I should have
qualified the stage, his PSA level was abnormally high as expected. The debate about the PSA
test will run and run until a more reliable test is available and I for one will also be pleased when
something better replaces it.
The debate should really be about awareness raising, early detection and saving lives. 10,000 deaths
per year is not a figure to be dismissed. That is the number of men whose deaths are related to
prostate cancer. I also in my work have to look beyond the numbers. I see bereaved families and what
happens between diagnosis and death. The National Cancer Action Team are focusing on
Survivorship because this is what is important to members of the public affected by cancer.
Anecdotal evidence should not be dismissed, as hard statistical evidence does not always capture the
whole story. For example if you look at current stats for breast cancer, BME communities have lower
incidence rates. What isn't captured is the higher rates of a specific type of cancer in younger
premenopausal Black women. UK Black community members were concerned about the increase in
breast cancer in this age group prior to the evidence. Missing information (including anecdotal) is
important and without accurate data on ethnicity, results are questionable despite extrapolation.
The 2009 NCIN ethnicity report was one of the first serious attempts since the late 90's at bringing
together all the ethnicity data currently registered in the UK , yet report authors stated 40% of males
with prostate cancer were recorded as unknown ethnicity which makes interpretation of the stats
difficult. http://library.ncin.org.uk/docs/090625-NCIN-Incidence_and_Survival_by_Ethnic_GroupReport.pdf.
Finally I would review the last statement I would strongly oppose any prostate cancer screening
programme . (I know you meant PSA testing)
I do hope that statement will be retracted when the right test is found. The PSA test is not a screening
programme as there isn't currently one, but we all hope that some new test can be found that can't be
challenged. When that happens there a prostate cancer screening programme for men can be
developed. The one thing we do know from the other screening programmes is that they are
saving lives. I do hope that you will take some of the above into account in your Public Health role.
Best wishes
Rose
PS - I am aware that others may want to join in the debate, but would prefer if the group looks at the
data on the links provided via my last 2 messages.
From: Ash Paul [mailto:paulak22@yahoo.com]
Sent: 12 March 2010 21:47
To: Rose Thompson; MINORITY-ETHNIC-HEALTH@JISCMAIL.AC.UK
Subject: Re: 2010 Prostate cancer Annual Evidence Update
Dear Rose,
You might be interested to know that the inventor of the PSA test for prostate cancer
screening Prof Richard Ablin, in a very recent op-ed in the NY Times, today regrets his
invention and rues how it has led to a multi-billion dollar profit driven public health disaster
in the USA .
He writes ‘I never dreamed that my discovery four decades ago would lead to such a profitdriven public health disaster. The medical community must confront reality and stop the
inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue
millions of men from unnecessary, debilitating treatments.’
You can read the entire editorial at the following web-link:
http://www.nytimes.com/2010/03/10/opinion/10Ablin.html
As a consultant in public health medicine with a special interest in evidenced-based
commissioning of health services and screening services, and as a member of the BME
community, I'm afraid that I''m not in accord with your views expressed in your email. While
the circumstances of the patient that you mention are very tragic, they cannot in any way be
extrapolated to the population you describe, and needs to be regarded as anecdotal. 75% of
all men at the age of 80 will have some evidence of prostate cancer, but only a very small
minority of them will die from prostate cancer, inspite of having the disease.
I would strongly oppose any prostate cancer screening programme , and I'm willing to
debate this in any public forum whatsoever.
Regards and best wishes,
Ash
Dr Ash Paul
Medical Director
NHS Bedfordshire
21 Kimbolton Road
Bedford
MK40 2AW
Tel no: 01234795705
Email: ash.paul@bedfordshire.nhs.uk
From: Rose Thompson <rose.thompson11@NTLWORLD.COM>
To: MINORITY-ETHNIC-HEALTH@JISCMAIL.AC.UK
Sent: Mon, 8 March, 2010 21:10:55
Subject: Re: 2010 Prostate cancer Annual Evidence Update
Haven't read the , Prostate cancer Annual Evidence Update yet, but looking forward to reading it.
It is never surprising to me when BME groups are excluded, especially in areas with smaller BME
populations. I do understand that in some areas of the UK the numbers of African Caribbeans tiny and
we are still not seeing significant numbers of African Caribbeans on In Patient Wards or
in cancer treatment centres.
However I am still disappointed when the higher prevalence of prostate cancer in this group is not
highlighted. African Caribbean men are 3 times more likely to be diagnosed with prostate
cancers. Their tumours are more likely to be tigers (faster growing), than pussycats. I unfortunately
witness the outcome of what happens when this important validated evidence from the PROCESS
study (Prostate Cancer in Ethnic Subgroups), is not disseminated effectively. Professional lack of
awareness has an impact on African Caribbean patients and there is now little excuse. Some African
men are also at risk. Even the media have covered the subject on more than one occasion in the
national news and recently on the ITV 'This Morning' show.
Case Study
I am currently supporting an African Caribbean couple in the Midlands whose
lives have been devastated because health professionals missed the signs and
symptoms of the husband's prostate cancer . (I use this case study with their
consent). The husband had every symptom of prostate cancer except one. The
blood test to check his PSA level (a protein) was not done until the cancer had
advanced. Even though it isn't a difinitive test on it's own, it would have almost
certainly raised the alarm and this would have been helped if health
professionals were aware of the PROCESS study results. I
visited the husband in hospital when he was admitted for emergency
radiotherapy (RT) to his spine. This interrupted chemotherapy plans. Things
deteriorated even further when he fractured his femur walking from the toilet
with a nurse . He then had to go to theatre to have a pin inserted and more RT,
which further delayed his chemotherapy treatment.
The lives of the couple and their children have been turned upside down due to the fact that ethnic
data collection has taken so long to happen. In the UK there are still a significant amount of people
who are not asked the ethnicity question (Check the National Cancer Intelligence Network ethnicity
report, especially the section on prostate cancer). I hear the statement over and over again that staff
are wary about asking the question. It is a tired excuse and can easily addressed via a short training
session. I could empower a Cancerbackup Helpline nurse in 5 minutes. PCT's and other health
services will not fund cancer awareness raising without evidence (preferably local) and evidence
comes from data collection. Evidence then has to be interpreted accurately, disseminated and acted
upon.
As a Cancer Information Specialist, I am aware that many health professionals suffer from
information overload, but as prostate conditions are so common and prostate cancer is now the top
cancer in men (killing 10,000 men per year), it really is time to wise up. Doctors, especially GP's also
need to read the recently updated Prostate Cancer Risk Management Programme
document http://www.cancerscreening.nhs.uk/prostate/index.html .
African Caribbean men are presenting with prostate cancer at younger ages (about 5 yrs). GP's
should be aware that they are more likely to be diagnosed in their 50's than 60's. If they are over 50
and insist on a PSA test having received the relevant information on the pros and cons, they should
not be dismissed, especially if younger than expected close family members have already been
diagnosed. Early prostate cancer can be asymptomatic and early detection can save lives.
Best wishes
Rose
Rose Thompson (Director)
BME Cancer Information and Outreach Consultant
t. 0115 840 0709
m. 07813499535
w. www.bmecancer.co.uk
BME Cancer Communities is the trading name of
Cancer Communities Community Interest Company (Registered in England No 6612426)
From: Health of minority ethnic communities in the UK [mailto:MINORITY-ETHNICHEALTH@JISCMAIL.AC.UK] On Behalf Of Mark Johnson
Sent: 08 March 2010 14:47
To: MINORITY-ETHNIC-HEALTH@JISCMAIL.AC.UK
Subject: FW: 2010 Prostate cancer Annual Evidence Update
in view of the importance of this condition to males of african heritage (and if you did not know, this
group has higher incidence, worse outcomes, from Prostate cancer), I am somewhat saddened that
there seems to be little new evidence directly relating to this at-risk population. However, members
may find some of the clinical information of interest - such as the rebuttal of the suggestion that Vit D
or sunlight can reduce risks!
Mark R D Johnson
Director, MSRC/CEEHD
De Montfort University
Leicester LE2 1RQ
0116 201 3906
From: UK medical/ health care library community / information workers on behalf of Naila Dracup
Sent: Mon 08/03/2010 14:11
To: LIS-MEDICAL@JISCMAIL.AC.UK
Subject: 2010 Prostate cancer Annual Evidence Update
Prostate cancer Annual Evidence Update now available
http://www.library.nhs.uk/cancer/viewResource.aspx?resid=345246&code=5bda7cf8357aeace14230a10a82bb6b
5
Please find attached the latest Annual Evidence Update on Prostate cancer
which includes a guest editorial by Roger Kockelbergh (Clinical Director &
Consultant Urological Surgeon Renal and Urology Services Haemodialysis unit
Leicester General Hospital) and a list of clinical guidance and high quality
systematic reviews that have been published since March 2009.
Please forward this email to your networks and any colleagues you feel may
find it relevant.
Kind regards,
Naila
Naila Dracup
Information Specialist
Naila.Dracup@orh.nhs.uk
Tel: 01865 572044
NHS Evidence: Cancer
Research Institute,
Oxford Cancer and Haematology Centre,
Churchill Hospital,
Headington, Oxford
OX3 7LJ