Prostate Cancer and managing uncertainty

Uncertainty. How often do we come across that word in medicine and Primary Care specifically? As GPs, as well as being expert generalists we are also experts in managing uncertainty. We are constantly dealing with patients who have vague and undifferentiated symptoms, and trying to apply conflicting and messy guidelines to their individual circumstances, often based on limited (or only partially relevant) evidence.

Never is this more true than in the world of prostate cancer. You could stamp the word ‘uncertain’ on almost everything that has been written and published about prostate cancer - everything from the uneasy association between lower urinary tract symptoms and prostate cancer (as discussed in an excellent BMJ article BMJ 2018;361:k1202, unsurprisingly in their ‘uncertainties’ section), to the NICE cancer guideline NG12 on PSA testing ‘The evidence on the diagnostic accuracy of fixed and age-specific prostate-specific antigen (PSA) thresholds was very uncertain…’ 

This is all deeply frustrating for both us and those men who seek our help in this area, and we all know why. We have this very tricky dichotomy to tease out - prostate cancer remains the second biggest cancer killer in men causing almost 12,000 deaths/year which is 13% of all male cancer deaths, based on the latest Cancer Research UK figures; yet we know incidence has sky rocketed over the past 20-30 years, mostly due to the advent of PSA testing, and that many men picked up through this route will have indolent or slow growing cancers which may not affect them at all, all of which has led to substantial over diagnosis and over treatment. 

A recent review in the BJGP (BJGP 2022; 72 (714)) looked at the latest trends in urgent cancer referrals, and showed that 2WW referrals to urology have more than doubled in the last decade, the vast majority of which will be for suspected prostate cancer. This is not all bad, as over that time prostate cancer mortality has reduced by about 10%, but even so this is putting enormous pressure on secondary care systems. We know that many of those men will undergo unnecessary testing and treatment, yet knowing who will or won’t benefit is (you guessed it…) uncertain. 

There was a great piece in the latest BJGP (BJGP 2022; 72 (715)) ‘What are GPs for when the chips are down?’ citing a recent news article questioning what we actually do as GPs, and that (deep breaths now everyone…) our two roles historically are simply to be a trusted face and a gatekeeper to a rationed system. Really? Is that all I’m good for? The BJGP piece nicely debunks this fatuous and simplistic argument, and includes a small list of examples of where our true value lies as General Practitioners. And I’d like to add one more to that list - our expertise in dealing with uncertainty. We help guide which people may benefit from further assessment and treatment, and those that may not, taking into account the uncertainties inherent to their presentations, the evidence and the guidelines, and most importantly their own individual circumstances and wishes. Please do not label me simply as a ‘gatekeeper’. 

Navigating those tricky issues and uncertainties is apparent in most consultations on prostate issues. Should I have a PSA screening test? Are my lower urinary tract symptoms due to prostate cancer, or am I just fed up getting up four times every night for a pee and I want some treatment? My erections are getting weaker - am I worried about an underlying cause or do I just want some treatment to help this? 

We all know this is difficult area, so please join Dr Kate Digby who will help unpick these areas in a FREE Hot Topics Clinic on Prostate Cancer on Tuesday 22nd March based on the latest evidence and advice, including an important update in the NICE cancer guideline on prostate cancer and PSA testing.