Looking for prostate problems
Andrew Lloyd Webber is often in the Mallorca news. He had his sixtieth birthday here in March last year with various celebrity friends at La Residencia and he has recently put his considerable talent and influence behind the UK’s flagging prestige in the Eurovision Song Contest. He is frequently in the international news with his phenomenal success as a composer and producer but recently he has been in the news for much less glittering and happy reasons. He has very early prostate cancer.
Prostate cancer affects around 35,000 men in the UK each year and kills just over 10,000. It is the most common cancer in British men, accounting for a quarter of all new cases of cancer in men. It is a cancer which mainly affects men over the age of 50, and may produce urinary symptoms and, as it progresses, it can produce pain in the lower back, pelvis and hips.
The prostate produces secretions which form the bulk of seminal fluid and it is located around the lower part of the bladder. The exit tube from the bladder runs through the prostate. When the gland increases in size with age, as it does for some men, the exit tube becomes squeezed and narrowed. This inevitably leads to urinary symptoms such as difficulty starting to pass urine, poor stream and then dribbling afterwards – sometimes men also complain of an increased need for bladder emptying through the night.
These urinary symptoms are a clear indication of prostate enlargement which more often than not is benign rather than cancerous. Rectal examination by a doctor can give some idea whether the gland feels benign or sinister and a blood test for prostate specific antigen PSA is usually raised in definite cases of prostate cancer. The next step is a prostate biopsy by a specialist to establish the definitive diagnosis.
We will not know the circumstances of Andrew Lloyd Webber’s medical presentation. It could have been urinary symptoms or unexplained pains or he could have been feeling fine and had a raised PSA level detected in a private medical check-up.
The possibility of an early warning through a simple blood test raises the question often asked by men as to why the PSA test is not offered generally to older men as a screening test analogous to, for example, cervical screening in women rather than relying on a private check up at the patient’s initiative. This is a very good question and the answer hinges on several criteria used to justify a screening test.
For a screening test to be justified the disease must be detectable in good time before symptoms and must be common enough to be worth the effort. The screening test must be sensitive so that people with the disease correctly test positive and those unaffected correctly test negative (low false negative rate) and must also be specific for that disease to avoid confusion with other less serious conditions (low false positive rate). The test needs to be cheap, easy and as painless as possible and, after all that, the detection needs to make a difference to the outlook and the population programme needs to be cost-effective.
Unfortunately, the PSA test has a significant overlap with results from benign prostatic enlargement and would commit a lot of men to unnecessary prostate biopsy which is also not without problems. In other words, PSA is an ambiguous tumour marker which does not justify population screening. Understandably some men will still make the choice to pay for the test and are prepared to follow it through with a biopsy. For them it may produce an early diagnosis of prostate cancer but sometimes this is an additional worry for the very elderly who already have one or more serious other conditions. (It is significant that early prostate cancer can be found in elderly men who have needed a post-mortem and these individuals have lived in blissful ignorance). A further weakness of the test is uncertainty that the early diagnosis by this method offers a clear advantage using treatments currently available. The hunt is on for better tumour markers.
Dr Ken Prudhoe, MCA Approved Doctor, can be contacted at Club de Mar Medical Centre, Palma de Mallorca.