In the first part of our examination of how we shift the science to tame prostate cancer in ten years, Sophie Lutter discusses the role of better diagnosis and the PSA test.
Back in the early 80s, the Cold War was still a reality, snooker was the most watched sport on TV and the likes of Frankie Goes to Hollywood and Wham! were topping the charts. Prostate Specific Antigen (PSA) was also used to test for prostate cancer for the first time. It was a revelation for those working with, and at risk of, a disease that until then had really been a silent killer.
Even when it became clear that PSA testing was going to be controversial, there weren't any alternatives on the horizon. Today, PSA testing is still controversial: prostate cancer diagnoses are up but too many men are still being biopsied and treated unnecessarily. By that I mean that either they don’t have cancer at all or have a form of prostate cancer that would never harm them. In these cases, the high risk of infection from biopsy or side effects from treatment far outweigh the benefits of these actions. But at the same time, too many men are still unaware of prostate cancer and their risk of having an aggressive form of the disease. As a result of this, they’re diagnosed too late for curative treatment and their cancer is already terminal.
But don’t be fooled into thinking that this is yet another doom-and-gloom story. It really isn’t. In fact, the outlook for men at risk of prostate cancer is becoming much more positive. Far from having no alternatives to the PSA test, the scientific community is awash with potential genetic and protein-based diagnostic biomarkers. Our task now is to refine and validate this potential over the next 10 years, and that’s a task we’re well equipped to do.
First things first, as Director of Research, Dr Iain Frame said as we launched our new strategy: “we need to find a way to identify men at high risk of having aggressive prostate cancer, and then direct them into the most appropriate treatment route for them.” This isn’t a one-step process.
Chief Executive, Angela Culhane, put our money where our mouth is as she announced plans to commit £2m to fund the development of a new prostate cancer risk assessment tool.
This risk tool is a pretty big deal, and we hope it will fundamentally change the way that prostate cancer is diagnosed in this country. But while we’re not planning to reinvent the wheel – it will still include all the risk factors we already know about, including PSA level, family history, age and ethnicity – it will also adjust for the discovery and validation of new genetic and protein biomarkers. The Stockholm3 trial showed exactly how promising this new avenue can be, so as another ‘first step’ we’re also planning to fund the UK validation of this work.
But a man’s diagnosis isn’t restricted to the GP surgery. As Mr Ben Challacombe, who as consultant urologist at Guy’s and St Thomas’ hospital treats hundreds of patients a year pointed out: “Urologists are a combined diagnostic and treatment team. I have to tell five to ten men a week that they have prostate cancer.”
He went on to address the importance of targeted screening for men at high risk (clinical trials like PROFILE and IMPACT led by Professor Ros Eeles at the Royal Marsden Hospital are already underway in this area), as well as improving diagnostic imaging. That’s where mpMRI and the PROMIS trial comes in. This large scale, health services led, clinical trial is due to report later this year, and looks set to show that having an mpMRI scan before the biopsy can safely rule out biopsy for men who don’t have cancer.
If done well (and that’s the key here – have a look at our project page), this could reduce some of the risks associated with widespread PSA testing by reducing unnecessary negative biopsies. What isn’t clear yet is whether it will also help rule out biopsies for men with low-grade prostate cancer who can (and arguably should) avoid invasive treatment.
These are all questions we’ll be looking to answer over the next few years, and we hope that well within our 10 year timescale we’ll see improvements in the identification and monitoring of men at high risk of aggressive prostate cancer, as well as having a better way to get men at low risk out of the system before they experience unnecessary harm.
I think Dr Frame summed up the hope and expectation around this strategy pretty clearly, when he said: “Our time is now.”
With the support of the Movember Foundation, we're funding four PhD students in the crucial field of bioinformatics, using big data to help accelerate our understanding and treatment of prostate cancer.