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Prostate cancer: a growing challenge

Prostate cancer is the most common malignancy in men in the United Kingdom with over 37,000 new diagnoses and over 10,000 deaths each year.1 This means it has a considerable impact on the health of men and uses a significant amount of healthcare resource across the country. Although it is generally a disease of older men, a significant number of men will be diagnosed in their 40s and 50s. It is important that as nurses and practice nurses, we are aware of the issues and nuances surrounding this disease and how to treat them, to ensure the best outcomes for all involved.

The prostate
The prostate is a small chestnut-shaped gland found at the neck of the male bladder. It is very small in children but starts to increase in size at puberty, stimulated by the release of testosterone. The function of the prostate is to produce a liquefying component of semen which allows the sperm to swim freely on ejaculation. This liquid also contains a substance known as prostate-specific antigen (PSA) which is a glyco-protein important in the diagnosis of prostate cancer.


There are several conditions which can affect the prostate. As men get older, the prostate grows and can start to constrict the urethra, causing problems passing urine. This is known as benign prostatic hyperplasia (BPH). Another condition is prostatitis, which is an inflammation of the prostate that can cause pain and difficulty in passing urine. The other common condition is prostate cancer.
 
Prostate cancer obstacles
Getting the message across
Men have traditionally been poor at addressing their health needs and it is well documented that they seek healthcare less than women. It is a challenge for those in primary care settings to find ways to ensure that the cancer is diagnosed early enough to make a difference to long-term outcomes. Reaching men with this message is particularly important for those in the 'at risk' groups.

Unpredictable development
Another difficulty with prostate cancer is that the natural history of the disease is poorly understood, meaning it is not possible to distinguish how the cancer is going to behave. Some cancers will grow very slowly and will never cause any symptoms nor shorten life. Others are much more aggressive and may progress quickly. This issue results in men and their clinicians often facing difficult decisions in terms of which course of treatment to take, as the predicted development of the disease is uncertain. For this reason it is vital that men are given the full breadth of treatment options and information at every step of their journey.

Diagnosis
Currently, the initial test a man is given to detect any problems
in the prostate is a PSA test. This is a simple blood test which measures the amount of the prostate-specific antigen there is in the blood. A raised level of PSA can indicate a problem with the prostate. It is important that before having a PSA test men should NOT have:
    - An active urinary infection (PSA may remain raised for many months).
   - Ejaculated in the previous 48 hours.
    -Exercised vigorously in the previous 48 hours.
    - Had a prostate biopsy in the previous 6 weeks.
    - Had a digital rectal examination (DRE) within the previous week.
However there are a number of issues that mean this test is far from ideal, which is why it is important that men are made aware of the pros and cons before making the decision to have the test.

The advantages of the PSA test
   - It can lead to early detection of prostate cancer which allows for a good chance for curative treatment.
    - It is a simple blood test which is accessible through GP practices.
    - Having a series of PSA tests over time can allow doctors to monitor the behaviour of a cancer and make better predictions for the future.

The disadvantages of the PSA test
   - It is not a diagnostic tool. If a man's PSA is raised, it merely indicates there could be one of a number of problems with the prostate.
   - It may give a false reassurance - 15% of men with prostate cancer have a normal PSA.2
   - It may cause undue concern - two thirds of men with elevated PSAs do not have prostate cancer.2
    - It may lead to over diagnosis and radical treatment of prostate cancers that would never affect a man's quality or longevity
of life.

The screening question
There has been much debate about screening for prostate cancer using the PSA test, and the UK screening committee has decided against a national screening programme. This is a controversial decision with a variety of recent studies providing contradictory evidence for the benefits of screening.3 The prostate cancer risk management programme suggests that every man over the age of 50 who requests a PSA test should be given one after careful consideration. The problem with this is that many men who are at risk are still unaware of the significance of prostate cancer and that they are entitled to a PSA test. The Prostate Cancer Charity states that two thirds of men over 50 are not aware of the PSA test.4 If an elevated PSA has been identified, a digital rectal examination (DRE) of the prostate and a prostate biopsy could be indicated. Other factors would need to be considered prior to exposing a man to an invasive biopsy.

Conclusion
Ideally our screening tools will become more sensitive and be able to distinguish between those cancers which will need treating and those which do not. This, along with raising the awareness of prostate cancer and the common risk factors, is important in making the current Prostate Cancer Risk Management Program successful.

REFERENCES
1.  CancerHelp. Statistics and outlook for prostate cancer. Cancer
    Research UK. 2008. Available at www.cancerhelp.org.uk/help
    default.asp?page=3505.
2.  Selley S, Donovan J, Faulkner A, Coast J, Gillatt D. Diagnosis,
    management and screening of early localised prostate cancer. Health Technol Assess 1997,1(2):i,1-96.
3. Eckersberger E, et al. Screening for prostate cancer: a review of the ERSPC & PLCO trials. Rev Urol 2009(11)3:127-133.
4.  ICM Research interviewed a random sample of 1,000 men aged 50+ by telephone in February 2011, on behalf of The Prostate Cancer Charity.