Why men need to be screened, too: Cancer of the prostate claims 8,000 lives a year, four times as many as cancer of the cervix, yet there are no routine checks. Annabel Ferriman meets doctors fighting for a change of policy

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JOHN JAUNCEY discovered he had cancer of the prostate when he was only 55. He was travelling in India when he noticed blood in his urine. He rushed back to England and within two weeks was undergoing radiotherapy at St Bartholomew's Hospital, London.

'I had been having symptoms for a long time without realising it,' he says. By the time of diagnosis, his cancer was advanced. Irradiation did not fully eradicate it and now, two years later, the disease has spread to the bones.

Not surprisingly, Mr Jauncey is angry over the lack of information and publicity about the disease. He and an increasing number of other men are beginning to wonder why the Government is spending more than pounds 54m a year on screening women for cancer of the breast and cervix but offers nothing similar for men's cancers.

Cases of cancer of the prostate have doubled in the past 30 years, and it kills almost 8,000 men a year, four times as many people as cancer of the cervix. Yet the Government spends about pounds 30m a year screening for the latter and nothing on the former. The Cancer Research Campaign calls it the Cinderella of cancers because it is under-studied and under- recognised.

Mr Jauncey, a former journalist living in Brighton, did not realise that the increase in times he had to urinate could be a symptom. He wants to see the disease's profile raised. 'It is surrounded by taboos. There should either be population screening or concerted publicity campaigns to make men aware that this disease exists and is likely to get them.'

It is often said that men know more about their wives' ovaries than about their own prostate. The gland, situated just below the bladder, produces a fluid during ejaculation that forms part of the semen. In middle- aged and elderly men, it often becomes enlarged, obstructing the neck of the bladder and impairing urination.

Until recently, no effective screening method was available, but now a blood test - the prostate-specific antigen test, or PSA - in conjunction with a digital rectal examination by the doctor, can provide a relatively cheap initial assessment. If abnormalities are indicated, the patient can have an ultrasound examination, then a biopsy.

Large numbers of men over 55 can thus be screened, but whether such a programme should be undertaken has split the medical profession. A strong group of surgeons is demanding that the Government set up a large-scale trial to evaluate its use, but an equally vociferous faction is claiming that would be impractical and uneconomic.

In January, Private Patients Plan, the second largest private insurance company in Britain, will add the PSA test and a rectal examination to its screening programmes. But the numbers requesting such checks are small, and the wider issue of government policy remains.

The anti-screeners point out that the disease is predominantly a disease of old men. Studies have shown that two-fifths of men over 65 who have died from other causes are found also to have had prostate cancer. Similarly, one-tenth of men who have an operation for enlargement of the prostate are found to have cancer. A recent example is believed to be that of President Francois Mitterrand.

Some prostate cancers are known to develop slowly and are considered unlikely ever to kill the patient. A seven-year study of 120 men in Manchester with untreated localised tumours showed that, during that period, 4 per cent died from the disease and 40 per cent from other conditions.

But several pressing arguments should be weighed against these facts. More than 50 per cent of the cancers are discovered after the disease has spread beyond the prostate, and half the patients consequently die within 2 1/2 years. If these tumours were detected earlier, the patient could be cured. Treatment for advanced disease is only palliative, and usually consists of orchidectomy (removal of the testes) or hormone treatment, which shrivels up the testes.

'The only way to resolve the controversy is to do a proper study,' says Mr Roger Kirby, consultant urologist at St Bartholomew's. 'You need to take a group that you screen and one that you do not. If you can reduce deaths from cancer by, say, 20 per cent in the first group, it is worthwhile. You need about 40,000 people, and it would take about 10 years.'

In the meantime, Mr Kirby has set up a study with the Lister Hospital, Stevenage, and a GP practice in Letchworth, Hertfordshire, where his brother, Michael, works. 'We used our computer to identify all our men patients between 55 and 70, and that generated a list of 600,' Dr Michael Kirby says. 'We are inviting them, six at a time, to a clinic.' The response has been good: three-quarters of those notified are attending.

So far, the practice has screened 200 patients and found five cancers. 'There is a lot of hidden prostate disease,' Dr Kirby says. 'Men are often embarrassed to talk about it, or think the symptoms are normal. Some are getting up two or three times a night to urinate and have a poor stream, but thay think that is part of the normal ageing process.'

When the study is complete, the brothers intend to publish their results, and use them to persuade the Department of Health to fund a larger study.

So far, the department remains unmoved. Earlier this year it rejected a request for such a trial from a group of urologists in the British Prostate Group. The group presented the results of a survey in Bristol, where urologists from Southmead Hospital and local GPs screened almost 500 men, 68 of whom went on to ultrasound tests and 29 of whom underwent biopsies. Seven cancers were found, whose detection was estimated to have cost pounds 1,700 each.

Clive Gingell, consultant urologist at Southmead Hospital, who organised the study, says: 'We picked up cancers in men who did not know they had them. Of course it is worth doing. The Government's White Paper, The Health of the Nation, is full of targets for screening for cancer of the breast and the cervix but has nothing about cancer of the prostate.

'I am very disappointed that there is no directive from the Department of Health about it. Cancer of the prostate is the second biggest cancer killer in men.'

One problem, he says, is that men in Britain are not used to having rectal examinations. In the United States, it is normal for men over 50 to have annual checks, including rectal examinations for cancer, and in France, Germany and Italy such examinations are much more common. 'In this country, it is almost perceived as an assault,' he says.

Other surgeons say that British GPs are somewhat inhibited about doing rectal examinations, despite the old medical student adage: 'If you do not put your finger in it, you put your foot in it.'

Experts at the Cancer Research Campaign, one of the two largest cancer charities in Britain, concede that there is a serious problem of ignorance about prostate cancers, but they believe the value of screening has yet to be established. 'I do not think the benefits of screening have yet been proved,' says Professor Gordon McVie, its scientific director.

'We need to await the results of the large, random trial in the US that is being conducted by the National Cancer Institute at a cost of dollars 60m ( pounds 35m). But we do need to raise awareness of the disease, because education messages are thin on the ground.'

The organisation is planning a big publicity campaign for 1993. Until then, no doubt, prostate cancer will remain the Cinderella of cancers and more men will continue to suffer symptoms that, if they were better informed, would prompt them to seek medical help.

(Photograph omitted)

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