§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. McFall.]11.15 pm
§ Mr. Christopher Fraser (Mid-Dorset and North Poole)
I confess at the outset that I am not an expert on prostate cancer, its research, screening or treatment—nor do I have any medical training. I am also pleased to say that I do not have prostate cancer. For this debate, I have consulted widely within the medical profession; I am extremely grateful for the advice and guidance that I have received. I particularly grateful to Dr. James Dobbie, senior clinical research fellow at the university department of surgery at Edinburgh royal infirmary, for the time that he took to explain the issues involved.
I decided to move outside my field of knowledge because I realised that prostate cancer, its protection and treatment, is a matter of great concern to many of my elderly constituents and to the elderly male population of this country. However, prostate cancer and its associated problems can develop at a relatively early age; as with other cancers, it must be sensible to have periodic checks when young to detect it.
Nearly everyone to whom I have spoken about the subject knows someone who has been diagnosed as suffering from prostate cancer. It is the third most common cancer death in men—after lung and large bowel cancer—with a mortality rate of about 34 per 100,000 males. Currently, it kills more than 10,000 men a year in this country; by 2015, the figure is predicted to double. It has become a real threat to men's lives, yet many in my constituency believe that it has been largely ignored, whereas medical research on other cancers has been much more generously funded.
Cynics among us might think that, if the prostate were a female organ, we would be far further advanced in establishing a strategic approach to treatment. As a man, I bow to the dedication with which women campaign vigorously for research into the cancers that affect them, and for the ever-widening screening programmes that are available to them. I suspect that the male of the species is much more reluctant to discuss such intimate matters; many of us believe that our aches and pains will go away if ignored. Sadly, that is not always the case. The Institute of Cancer Research is campaigning to bring men's health issues to light, and to ensure that, where possible, cancers are caught early. I hope that this debate will add weight to that campaign.
The incidence of prostate cancer increases with age—it is sometimes described as an old man's disease. Only 12 per cent. of clinically apparent cases arise before the age of 65. The prostate is a male sex gland, about the size of a walnut, located below the bladder and in front of the rectum. Symptoms of prostate cancer include difficulties or delays in urinating, urinating more often than usual, pain during urination, a weak stream or blood in the urine, and pain or stiffness in the lower back or hips.
In contrast to other types of tumour, a unique feature of this cancer is the relatively high incidence of what is known as latent cancer in men over 50. The incidence increases steadily with advancing years, such that more than half of males over 80 have small focal areas of tumour in the prostate.
284 Is it any surprise that many of my constituents are fearful for the future, and distressed that so little is apparently being done? They may not appreciate the fact that only in a restricted number of individuals will those small areas of tumour become aggressive and extend outside the gland to cause clinical problems, and ultimately, for some individuals, death.
The difficulty is that the medical profession cannot predict with any great accuracy which of the small areas of latent tumour, when detected, will in time become aggressive and life-threatening. The on-going clinical debate concerns how one should treat the finding when a doctor discovers evidence of a focus of latent prostate tumour.
The characteristic features of a prostate tumour and its behaviour are absolutely central to understanding current medical consensus on the issues of the diagnosis and treatment of prostate cancer. As the House will know, there is currently no national screening programme for prostate cancer. In the absence of such a programme, patients diagnosed with the disease have usually sought help from their doctor following the classic symptoms that I described. Their discomfort is such that their condition is often well advanced.
Most informed opinion is in favour of careful clinical monitoring of the patient, together with regular blood tests for a protein specifically released by the prostate, known as prostate-specific antigen, or PSA, the level of which in the blood rises if the tumour changes from latency to local expansion and spread.
§ Dr. Ian Gibson (Norwich, North)
Is the hon. Gentleman aware that the PSA test is not absolutely reliable—many women with breast cancer also give off PSA—and that we really need a sensitive genetic test, which will probably come from the human genome project, allowing us to determine whether a benign cancer will move into the malignant state? Treatment could then be targeted accurately to the individual.
§ Mr. Fraser
I agree entirely. The problem concerns the way in which the research is done and how the gene is to be identified. Currently, there is literally a wait-and-see process, which is unhelpful and desperately upsetting for those who suffer from the cancer.
The patient and his family suffer considerably, because it is not clear how the cancer is caused and what can be done when it is diagnosed. It has been said that the majority of sufferers die with, and not of, prostate cancer. My concern is that that clichéd prognosis is breeding complacency.
§ Jane Griffiths (Reading, East)
The hon. Gentleman mentioned the Institute of Cancer Research. Its campaign, designated Everyman, concerns male cancers in general. Early diagnosis is important, but so is early awareness on the part of the patient and his family. It is especially important to be aware that symptoms such as he described will not be attributable simply to old age, but may indicate a disease that can be treated. With early diagnosis, the trauma can be minimised.
§ Mr. Fraser
I thank the hon. Lady; I am indeed aware of that, and such awareness is spreading across a wide age group.
285 I am concerned that funding for vital research is far too low. Prostate cancer research receives less than £1 million a year, compared with £16 million for breast cancer and £40 million for heart disease. Prostate cancer, however, is the third most common cause of male cancer death. It is predicted that it will overtake both lung and breast cancer, and become the most common cancer in the United Kingdom by 2018.
One obvious possible reason is the increasing age of the population, but we do not know what causes prostate cancer. We do not know whether diet or the environment are relevant factors. There is evidence that men with brothers or fathers who develop the disease are at a higher risk, and incidence is thus likely to spiral. To address that grim future, the medical profession must now actively seek ways in which to treat the cancer, and to try to reduce the number of deaths from it.
There are three ways in which the medical profession can do that: prevention, the development of more effective treatment methods, and early detection. Although much work is being done on treatment strategy, only early detection is currently available—but here we return to the problem of predicting the future behaviour of any latent focus of the disease.
In the past few years, a considerable professional and public debate has developed in the United States. Urologists, oncologists and primary care practitioners—along with health planners, health economists and the lay press—have struggled with the complex issues of early detection and screening. That has given rise to both American and European randomised studies in screening for prostate cancer.
The aim of a screening programme must be to identify, as early as possible, latent tumours that will become aggressive, and to offer treatment that will increase the quality and length of life. Huge strides in molecular genetics are beginning to offer the prospect of more effective screening and more successful treatment. Surely, however, society cannot wait 10 to 15 years until the unequivocal results of the efficacy of early detection and treatment are provided by several international studies that are currently under way.
I accept that screening creates its own problems, including the over-detection of cancers that are not necessarily life-threatening; the unknown natural history of the disease in different individuals; the fact that screening is costly—although there is a relatively cheap prostate specific antigen test—the natural anxiety associated with screening tests; and the potential harm involved in investigating healthy men. There are also ethical and legal implications, as well as people's natural concern about their insurance premiums.
We must remember, however, that screening programmes have been accepted by women, who recognise that there may be something wrong with them and who clearly welcome the fact that they are taking control of the situation. The disadvantages that I have listed are considered to be a price worth paying when they are offset against the advantage of early detection and early treatment.
§ Mr. Howard Flight (Arundel and South Downs)
The health authority in my constituency is phasing out 286 screening, on the basis that it is unreliable. I think the gist of what my hon. Friend is saying is that, given the likelihood of detection, phasing out screening is a mistake.
§ Mr. Fraser
We are talking about a combination of factors—not just screening, but the research that accompanies it. If screening is not efficient and effective, it can be argued that there is no point in proceeding with such a programme, but if research will lead to better screening, health authorities should take it more seriously.
If we are to make progress on all fronts, we need vital information that can be gained by screening for prostate cancer.
For example, does treatment for localised prostatic cancer result in a reduction in morbidity and mortality? Do screening tests identify patients who are curable and need to be cured? What are the best screening tests, and in whom, for whom and how often? Can we afford a national screening programme? That is a major consideration.
The interim recommendations of the American Urologic Association and the American Cancer Society are:All men over 50 years of age should have an annual rectal examination and Prostatic Specific Antigen blood test performed".In this country, the Institute of Cancer Research has expressed grave concern about widespread ignorance among the population about male cancers, including prostatic and testicular cancer. Through its Everyman campaign, as previously mentioned, it is seeking to raise awareness of, and funding for research into, male cancers. I add my voice to that campaign.
We must work to determine what causes prostate cancer and how to treat it. Then we must establish a national screening programme to give early warning of the disease. Without more funds and a strategic and aggressive research programme, prostate cancer will threaten the lives of increasing numbers of our aging population. We must not allow that to happen.
§ The Parliamentary Under-Secretary of State for Health (Mr. Paul Boateng)
The hon. Member for Mid- Dorset and North Poole (Mr. Fraser) is to be congratulated on having raised an important and topical matter. The Government certainly recognise that prostate cancer poses a serious threat to men's health: 8,254 men died from it in England in 1996. Although it is encouraging that the overall mortality rate has fallen somewhat over the past five years, prostate cancer remains second only to lung cancer as a cause of cancer deaths in men. Unfortunately, as he recognises, there is no clear evidence about its causes. Unlike with lung cancer, where we know that smoking greatly increases the risk, we cannot advise men of ways in which they can reduce the risk of developing prostate cancer.
Given the circumstances, it is understandable that there should be considerable interest in the prospect of a screening programme similar to the breast and cervical screening programmes to detect prostate cancer at an early stage. It was as a result of, and in response to, those concerns that the Department of Health standing group on health technology made prostate cancer one of its original priority areas for health technology assessment. The Department commissioned two systematic reviews 287 of the diagnosis, management and screening of early localised prostate cancer from the university of Bristol and the Institute of Cancer Research.
The results of the two reviews were published early last year, and produced a clear recommendation that the current evidence does not support the introduction of a national screening programme for prostate cancer at this time with the available technology. I am well aware that that recommendation came as a disappointment to some, but it is important to understand the reasons for it. The contributions of my hon. Friends the Members for Norwich, North (Dr. Gibson) and for Reading, East (Jane Griffiths) raised some of the difficult and complex issues involved.
Current evidence suggests that the introduction of a screening programme would result in unnecessary, painful and potentially harmful treatment for many men. The age profile of those experiencing and living with this problem suggests why that might be. Although prostate cancer can be a killer, the evidence suggests that many prostate cancers are slow-growing, and unlikely to cause clinically important symptoms during a man's life, not least when they develop late in life, when other forms of illness responsible for death are more likely to bring about death than the cancer in question. Autopsy studies show that 30 per cent. of men over 50, who had no symptoms of prostate cancer while alive, had histological evidence of prostate cancer at the time of death. That percentage rises to more than 50 per cent. in men over 80 years of age.
Measurement of serum prostate-specific antigen is the most commonly advocated method of screening for prostate cancer, and my hon. Friend the Member for Norwich, North brings his considerable experience to bear on the issues surrounding PSA. After blood tests showing raised PSA levels, men would be asked to undergo transrectal needle biopsy—TRNB—of several segments of the prostate under ultrasound guidance. It is estimated that between two thirds and three quarters of men undergoing TRNB would not have any form of prostate cancer. Studies also suggest that two thirds of the prostate cancers detected by PSA screening would not be clinically significant.
Detecting a cancer early is of little value if patients cannot be offered effective treatment. Unfortunately, there is currently no medical consensus about the best way to treat prostate cancer. The most common policy in the UK is "watchful waiting", which may be accompanied by regular PSA testing or physical examinations.
Radiotherapy is one alternative to watchful waiting. Unfortunately, that treatment may have serious side-effects: damage to adjacent organs such as the gastro-intestinal tract and bladder occurs in 36 per cent. of patients and impotence occurs in 40 per cent. Radical prostatectomy, entailing the removal of the entire prostate, is a common first-line treatment in the USA, and is increasingly used in the UK as well. Again, that treatment entails substantial risks to the patient, including incontinence or impotence. Currently available research indicates that survival with watchful waiting, radiotherapy and radical prostatectomy is relatively high, and does not suggest any significant difference in mortality between the three methods.
To sum up, there is no reliable evidence to determine whether early detection and treatment of prostate cancer improves survival. The considerable uncertainty about the 288 natural history of prostate cancer, the accuracy of screening tests and the best form of treatment all hamper our ability to make an accurate assessment of the costs and benefits of any screening programme. No one can deny that annual PSA testing will detect a number of clinically important cancers. The health technology reviews suggest, however, that annual testing would also lead to unnecessary anxiety and discomfort for many men, and the possibility of potentially harmful and costly treatment bringing uncertain benefits.
It is ethical to offer someone a screening test only when it is likely to do more good than harm. Ethical considerations undoubtedly affect judgment as to whether screening is the best way forward. The hon. Member for Arundel and South Downs (Mr. Flight) spoke of the judgment made by his health authority on that question.
Given the lack of evidence of benefit and the possibility of harm, the reviews concluded that a national prostate screening programme simply could not be justified. It was on the basis of those studies that the national screening committee recommended that there was no case for a national prostate screening programme. That recommendation was accepted by Ministers, and EL(97)12, issued in June of last year, advised health authorities that prostate cancer screening should not be routinely offered to patients.
This debate gives us an opportunity to look briefly at what the future might hold, because there is undoubtedly a need for further research into prostate cancer. The Government welcome initiatives such as the Everyman campaign launched by the Institute of Cancer Research last year, seeking to raise awareness of male cancers as well as funds for research. There is much that we can learn from campaigns spearheaded in respect of cancers suffered by women, just as there is much that we can learn from women about the importance of self-examination, and of men being less hung up about discussing our bodies, either with each other or with our GPs. We men understand the problems we experience on that. We have to learn to overcome our natural reticence, in the interests of our health.
The Government are aware of the work of the Prostate Cancer Charity and the Prostate Research Campaign UK. We want to work constructively with the voluntary sector to find the best way to tackle prostate cancer. Several journals, organisations and programme makers also contribute to raising men's awareness of the importance of taking action to assist in the early diagnosis of the condition.
Prostate cancer remains a priority in the Department's health technology assessment programme. Five proposals for a trial of treatments for the spectrum of prostate cancers likely to be identified by a screening programme are being considered. The average cost of the proposals is £2.5 million. A funding decision is expected next month.
That will be a significant Government investment in prostate cancer research, giving us a greater understanding of the disease and possible methods of treatment. That knowledge should enable us to make progress in tackling the condition. Although no change in the policy on screening is envisaged in the near future, the national screening committee will continue to keep the issue under review in the light of any new evidence that emerges. As the hon. Member for Mid-Dorset and North Poole has said, it is important to keep research under review.
289 The Government are committed to seeking to provide equal access to high-quality health services. We are giving particular priority to improved cancer services, including those for prostate cancer. We have fully endorsed the recommendations of the Calman/Hine report, "A Policy Framework for Commissioning Cancer Services".
The report recommended improved organisation and delivery of cancer services through the development of a skilled, multi-disciplinary work force, better co-ordination between primary, secondary, tertiary and the voluntary sectors, and a greater involvement of patients in care and prevention through improved public education, information and counselling. That is already happening in many hospitals and centres of excellence, from district general hospitals to the great teaching hospitals. The Central Middlesex hospital in my constituency is doing important work.
A great deal of work is under way in the NHS to implement the Calman/Hine recommendations. We shall continue to work on identifying units and centres where, with local agreement, we can ensure that specific cancers are treated at hospitals where particular expertise is being developed. In many regions, that has involved site visits by multi-disciplinary teams to assess cancer provision against agreed standards, to identify strengths and weaknesses, and to agree a time scale for change and improvement.
In the White Paper "The New NHS", we have set targets for urgent referrals to cancer specialists to catch the problem as early as possible. Everyone with suspected 290 cancer will be able to see a specialist within two weeks of their general practitioner deciding that they need to be seen urgently and requesting an appointment. We shall guarantee those arrangements for everyone with suspected breast cancer by April 1999, and for all other cases of suspected cancer by 2000. The initiative will benefit all cancer patients, including those with prostate cancer.
I am confident that last year's decision not to introduce prostate cancer screening was correct. The decision was taken responsibly in the light of all the available evidence and after carefully weighing up the potential benefits, the possible harm and the uncertainty surrounding many of the important questions.
Tonight's short debate has enabled us to consider several issues across the Chamber and for the benefit of a wider audience concerned about the problem. I assure the House that we shall continue to keep the issues under urgent review, taking forward the cause of research. We cannot allow complacency or indifference to creep into our consideration of the issues. Men are challenged to take seriously issues concerning their own health. We look forward to working with the voluntary sector and all those concerned about improvements in men's health.
I thank the hon. Member for Mid-Dorset and North Poole for enabling the House to debate the issue. We shall continue research in the area. We look forward to a satisfactory conclusion of that work, and an amelioration of the suffering that prostate cancer causes.
Question put and agreed to.
Adjourned accordingly at fifteen minutes to Twelve midnight.