Prostate Cancer
I wish members an early good afternoon. The first item of business is a members' business debate on motion S1M-1122, in the name of Maureen Macmillan, on screening for prostate cancer. The debate will be concluded without any question being put after 30 minutes.
Motion debated,
That the Parliament supports the routine screening of middle aged men for early indications of prostate cancer, a disease which causes the second highest number of deaths from cancer among men in Scotland and which can be successfully treated if discovered at an early stage.
One of our most important jobs as elected representatives is to highlight important issues that struggle to get attention. I am therefore very pleased to have secured today's debate. I want to take this opportunity to pay tribute to those bodies that seek to raise the profile of prostate cancer, some of which are represented in the Parliament today. Prostate cancer awareness week will come to an end on Saturday, and it is only fitting that the Parliament should mark such an important week.
Some members will be familiar with the pain of having a friend or relative who has cancer. It is encouraging to note that cancer is more talked about now than at any time in recent history. For women, the importance of screening for breast or cervical cancer is recognised, but the situation is different for men.
In August, I attended a meeting of the Highland prostate cancer support group, and was left in no doubt about the seriousness of the situation. The meeting was a large gathering of men and their wives, some of whom had travelled up to 80 miles to be present. One man who was there worked for a general practitioner, but he had never heard of prostate cancer until he was diagnosed. Before I attended that meeting, I was unaware of the true situation. I was startled to learn that many patients may have had prostate cancer for up to 10 years prior to diagnosis.
Prostate cancer is the second biggest cancer killer of men and is on the increase, yet many men are unaware of it. I can see no reason why men cannot seek screening for detection. As with any cancer, early diagnosis is crucial. Some men may be embarrassed by the symptoms, or may ignore them because they seem trivial. Whatever the difficulties, it is essential that we get across the message to men that early screening is vital if they are to stand a chance of fighting prostate cancer; if they have symptoms, they should be able to go for screening. Doctors should make their male patients aware of the cancer and offer screening to those with a family history of it. I have heard of doctors who refuse to screen patients, dismissing prostate cancer as an old man's disease.
More resources are needed for the promotion of awareness through health boards, the provision in doctors' surgeries and hospitals of leaflets produced by the Health Education Board for Scotland, television adverts and so on. That is perhaps the most obvious and easiest course of action.
Research has been done in the United States on the links between diet and prostate cancer. Our western diet may be a cause for the rise in the incidence of prostate cancer. Men must be given greater encouragement to eat healthily, to use food supplements such as selenium and to take vitamins E and D. That approach can reduce the incidence of cancer by 50 per cent, according to recent research.
The second issue is that of the most appropriate screening test. I know that the prostatic specific antigen test, which is a simple blood test, is not infallible—there are false positive and negative results. However, I am told that results can be very accurate when the test is combined with other tests, such as direct rectal examinations, or when a series of PSA tests are taken, allowing the increase or rate of increase in the antigen to be determined.
A group in Scotland is researching ways in which to improve screening. Funding for that research is important. Some people maintain that the research has already been done in other countries and that we do not need to reinvent the wheel. However, I believe that men must be encouraged to ask for screening and that research from other countries should be taken seriously.
There is also a debate on how best to treat the cancer when it is discovered. There seem to be different types of prostate cancer—some attack aggressively, while others can lie dormant for years. The most appropriate forms of treatment will be established only when there is greater research. Some pharmaceutical companies are conducting clinical trials, but a more concerted effort is needed, which will require Government, companies and patients to work together. At the moment, there seems to be no consensus on treatment and some health boards seem unnecessarily draconian. Quality of life is paramount in the treatment of prostate cancer.
For too long, the perception that prostate cancer has been forgotten has been allowed to persist. Action on some of the issues that I have raised today could change that. The Parliament can play a role. I urge the Health and Community Care Committee to consider the issue so that we can show that men who suffer from prostate cancer have our support. We must promote awareness of prostate cancer and encourage more research into screening and treatment. As a first step, we must at least promote screening for men who have a family history of the disease.
Four members have asked to speak from the floor. That will be possible if they keep their remarks to three and a half minutes.
In a previous existence, I worked as a clinical biochemist in the national health service so I am aware of the difficulties that are associated with some of the screening procedures for prostate cancer. It is true that the test for prostatic specific antigen is not on its own a diagnostic test, but it is useful for monitoring the disease process; as the level of the antigen rises, clearly something active is happening and intervention can be made.
The test is a useful tool in helping to determine the likelihood of someone having the disease. Certainly, if the test were more widely available, many concerns would be eliminated. Such testing would not exclude the possibility that prostatic disease was present, but at least it would mean that that was unlikely. If someone has raised levels of antigen, the likelihood of them having the disease is high.
Screening programmes are available for a variety of diseases, but it is unfortunate for men that screening for prostate cancer is not more widely available and more widely encouraged.
I welcome the fact that Maureen Macmillan has brought this subject before Parliament today, and I whole-heartedly endorse the campaign, in spite of the weaknesses in the tests that are available. Those weaknesses highlight the fact that more research must be done to improve the techniques for diagnosing the disease. In the 25 years that I worked in the health service, significant improvements were made. The PSA test is much better than some of the earlier tests, which were weak. Undoubtedly, as we devote time, energy, money and resources to the science, we will come up with better diagnostic tests.
I thank Maureen Macmillan for raising this subject, and congratulate her on securing the debate, especially during this special week.
Like many cancers, prostate cancer suffers from the silent treatment. According to Professor McVie of the Cancer Research Campaign:
"If more people talked about the disease we could raise awareness and save lives."
I first became interested in the subject following the death of one of my friends, at the tragically early age of 60, from complications caused by prostate cancer. In December, I asked the Executive a question regarding research into prostate cancer and was given the figure of 3,644 deaths from the disease in Scotland between 1994 and 1998. The Herald of 12 May gave the figure of 2,000 deaths a year.
A by-product of my question was raised concern about the commitment to the screening of men in Scotland. As is often the case, one thing led to another and facts began to emerge. The Scottish five-year survival rate of 48 per cent compares with 86 per cent in the USA. Dr Richard Simpson told me that that is because the USA usually resorts to radical surgery. Cases of prostate cancer have risen by 49 per cent since 1986, compared with a rise of 27 per cent in the same period for breast cancer. Apparently, 100,000 men have died in the UK from prostate cancer since 1990.
The current policy, described as watchful waiting, has been followed so far because of the risks of the side effects of treatment, such as impotence and incontinence, and uncertainty about the PSA test. Unfortunately, there is no evidence that PSA screening reduces mortality, but studies show that PSA testing strongly predicts cancer deaths. It is acceptable and feasible to screen for PSA, and urgent studies to evaluate its potential have been called for. As Maureen Macmillan and Brian Adam said, there is evidence that early detection leads to good survival rates. In Austria, a trial that screened 65,000 men led to a 42 per cent decrease in the number of deaths. Where screening was not offered, death rates remained unchanged.
However, there is hope. Yesterday, I was given information by Dr Alexander and Dr Habib of the University of Edinburgh, which points out that it is less certain that current screening methods have the same benefits as breast screening. The test that is used does not differentiate between men who have prostate cancer that requires treatment and those who do not. Often, prostate cancer does not cause any clinical problems. It is also extremely common. Studies show that eight out of 10 80-year-old men have the disease, but many of those men will never know that they have it and will die of unrelated causes.
On the other hand, if the cancer is detected and treated, treatment itself can lead to serious complications. What is needed is a screening test that will distinguish those men who have prostate cancer that is likely to advance to a life-threatening disease, so that they can be given the necessary treatment.
It is to be hoped that the research that is being carried out at the University of Edinburgh will lead to a test that can predict which men will succumb to this life-threatening disease.
An e-mail that I received yesterday said:
"Spending on women's health is eight times greater than spending on men's health. According to the Government's 5-point plan, there should be equal access to the highest standards of care and equal access for new treatment. We think it is not unreasonable to ask that men be given the same equal consideration as women."
It concludes:
"I was 48 when I was diagnosed with advanced prostate cancer. I don't want my son or anyone's son to miss the opportunity for successful treatment if prostate cancer should strike at them."
That plea should strike a chord in the Scottish Parliament.
I, too, commend Maureen Macmillan on securing this members' business debate. We have won the battle to raise awareness of breast cancer; we have the same battle to win on prostate cancer.
Routine screening should be available. I was contacted by the Aberdeen and north-east prostate cancer support group with the same statistics that have just been quoted about the effectiveness of a screening programme in Austria. Screening for prostate cancer could lead to earlier detection of tumours, before symptoms present themselves. Long-term survival increases with early detection and treatment.
I commend the motion and hope that we can do for prostate cancer the good work that has been done for breast cancer.
I thank Maureen Macmillan for lodging the motion.
We recognise that people sometimes fall through the social work and community care nets. In my experience, they also fall through the education net, not always as a result of any flaw in the net, but because of human error or because the networks are overstretched.
The problem with prostate cancer is that there is no net for potential sufferers to fall through. There are not even the threads of a system of screening. It is clear that there are no immediate plans to provide such a system, although I am sure that everyone's intentions are honourable. However, intentions are not enough. Time is of the essence. As Nick Johnston did, I will read from an e-mail that I received this week. I am a year older than the person who wrote it.
"I am a prostate cancer patient, diagnosed last year a few months before my 60th birthday. The tumour is too far advanced for surgery. As such, may I implore you to support the motion for screening for prostate cancer that has been tabled by Maureen Macmillan's office and which has been selected for debate in the House this Thursday, 14th September.
It is too late for myself but could help save others by catching the disease early."
That e-mail is the best argument there is for supporting Maureen Macmillan's motion.
I add my congratulations to Maureen Macmillan on securing the debate. She is an assiduous pursuer of members' business and has touched on many issues that impact on the lives of all our constituents.
As we know, prostate cancer is known as the silent killer. I understand from the statistics that one in every 12 men runs the risk of contracting prostate cancer during their lifetime. It is the most common cancer in men.
It has been interesting to watch how the subject has been dealt with in Parliament. I have in front of me a substantial list of parliamentary questions on the subject that have been asked by members of all parties over many months. I see the Minister for Health and Community Care nodding—she is obviously well aware of those questions. In anticipation of today's debate, all of us have received e-mails, letters, faxes and telephone calls, not just from our constituents but from many other people and interested organisations.
In the interests of brevity, I will not repeat points that have been made. However, I will turn to an e-mail that I received this morning from one of my constituents, Ronald Pittendrigh from Fochabers, who works as a cancer therapist and counsellor. My colleague Brian Adam and other members may know of Mr Pittendrigh, as he does voluntary work for CLAN—Cancer Link Aberdeen and North East. It might be useful to put Mr Pittendrigh's e-mail in the library, as it contains so much information. I will pick out an extract that may be helpful to the minister when she responds to the debate.
"I was a guest speaker at the Scottish National Conference of Cancer Carers a couple of weeks ago in Crieff. As always, I spoke of the unnecessary deaths caused by the silent killer, Prostate Cancer. I spoke of the need for regular PSA tests for all men over 45 or 50.
Afterwards, five of the men present came up to me individually, to talk about their symptoms.
Two of the men seemed in real danger, but as a non-medical person I could only urge them to see their doctor and ask for a PSA check urgently. The other three men were worried about their nocturnal urine frequency. Sometimes this is just an indication of normal benign prostate enlargement"—
many of us are aware of that.
"I suggested that they also get a PSA check up . . . just in case. It is very important to remember that men can have a very advanced tumour, with secondaries, and be totally unaware of it . . . until it is too late."
Mr Pittendrigh also highlights the lack of support facilities.
As Maureen Macmillan, Nora Radcliffe and Nick Johnston rightly said, in addition to research, much information is available already for examination. We must also examine the PSA test, to determine whether it is possible to implement a screening facility for men over the age of 45. We should also consider how best to offer support to the support groups that do so much to help people after they have been diagnosed, when they are often suffering and in acute pain, with all the distress that that can cause their families.
I call Susan Deacon to respond to the debate on behalf of the Executive. Minister, you have quite a lot of time—about 14 minutes. You may speak until the First Minister's statement at 2 o'clock or, if you finish before then, I will suspend the meeting for a few minutes.
I am grateful to Maureen Macmillan for raising prostate cancer as a matter for members' business. I am also grateful for the speeches of other members in the cross-party debate.
Since the establishment of the Scottish Parliament, a number of members have taken an interest in prostate cancer—I have also taken an interest in the issue and examined it in some detail. I assure members that my interest will continue.
I hope that the debate will help to increase understanding of prostate cancer, given that the disease is diagnosed in more than 1,800 men a year in Scotland, as other members said.
I stress that the Executive is committed to tackling cancer in all its forms and in the most effective ways possible. We are investing a great deal of time, energy and resources in this area and we will continue to do so. Screening is included in that work, as is, in particular, the putting in place of effective screening programmes that will detect cancers reliably and early. Early detection means that treatment can start earlier, which, in turn, is likely to lead to more successful outcomes. In short, the Executive is pledged to ensure better prevention, earlier diagnosis and faster and better treatment for cancer in all its forms.
As far as the introduction of routine prostate cancer screening is concerned, it is important that I set out some of the issues that I must take into account, including, in particular, some of the limitations of population screening, as well as the benefits. It is also important that members are clear about the basis on which the Executive reaches decisions in this area.
As was noted earlier, a screening test is not a diagnostic test. Screening is aimed at apparently healthy people, so that the small number who may develop cancer can be detected; they might then be diagnosed and receive effective treatment sooner rather than later.
The Executive is given expert and independent advice on screening programmes by the National Screening Committee, a UK expert committee with Scottish representatives. Work continues all the time to investigate screening issues. In considering new possibilities for screening programmes, the National Screening Committee works to criteria that include two key requirements: first, that there should be a screening test that is accurate, simple, quick and easy to interpret; and secondly, that there should be a recognised and clinically effective standard treatment for the condition. At present, the National Screening Committee's advice is that the test and treatment for prostate cancer do not meet either of those key requirements.
I recognise the widespread concern about prostate cancer. Like other members, I have seen its effects at close quarters, so I understand why people are searching for the most effective way of making progress. I therefore understand the attraction of a routine screening programme of the kind that has helped so much in the fight against cervical cancer and breast cancer.
However, I stress that, in the case of prostate cancer, the issues are different. The available tests have not been found to be reliable enough. They cannot always distinguish between prostate cancer and other conditions, such as infection, or between different types of prostate cancer. As members have mentioned, current treatments for prostate cancer have serious side effects, including impotence and incontinence. On the basis of advice and consideration by the experts on the National Screening Committee, it has been concluded that we cannot rely on a national screening programme to deliver the benefits that we have seen for some other cancers.
Prostate cancer is a complex disease, which behaves in different ways in different men. Prostate cancers grow at different rates; some grow very quickly, while others grow very slowly and may never cause problems in a man's lifetime. Currently available tests cannot differentiate between the more aggressive and the slower-growing prostate cancers. The appearance of both in the test results is the same, which makes the evaluation of prostate cancer screening difficult.
In most other cancers, a positive diagnosis would result in a decision to treat immediately. In prostate cancer, however, the treatments themselves may cause significant unwanted side effects. Those are some of the reasons why the situation with regard to prostate cancer screening is different to that for screening for other cancers.
I do not claim to be a technical expert on the subject, but the information that I have received states that, although a PSA screening result of level 4 is acceptable, a result of level 7 or 12 would require immediate further investigation. Surely that would be at least a first step towards ensuring that we can spot prostate cancer at an early stage.
The issue of PSA is important and I shall go on to say more about that in a moment. However, while Mrs Ewing was speaking, some of her colleagues were shaking their heads. Although it is important that members of Parliament raise issues that are important to the people we represent, we must look to the best possible medical and scientific advice that is available before making policy and investment decisions about how to progress.
Men with prostate cancer tend to have higher levels of PSA in their blood than is normal. However, some men who have prostate cancer do not have raised levels of PSA, and two thirds of men who have raised levels of PSA do not have prostate cancer. Raised levels of PSA can be caused by other conditions affecting the prostate gland, such as infections. It is important to understand that a great many men who develop prostate cancer and have an elevated PSA level do not, in fact, go on to develop clinical signs of symptoms of the disease. The tumour remains within the prostate and does not grow or spread. The current PSA test cannot distinguish between those cancers, and a large number of men might be treated inappropriately if we were to rely more heavily on PSA testing.
It is important, however, to emphasise that men who have symptoms indicative of prostate cancer or a family history of the disease can be offered the PSA test, along with full counselling and information about the risks of the test. We will continue to investigate and to assess the situation based on the best research available.
Will the minister take an intervention?
Will the minister take an intervention?
We will take Brian Adam first.
I appreciate the difficulties that are associated with the PSA test. Will the minister indicate how the Executive hopes to improve diagnostic capability for prostate cancer? What help is she prepared to give to research projects that aim to make the test more successful? Does the minister agree that if a test result shows a raised PSA level, and the test is then repeated within a reasonably short period of time and the level has risen further, that is most helpful in indicating that some kind of disease is active and that intervention is needed?
Dr Simpson, did you want to intervene on the same point?
Yes.
We will take both points in that case.
I apologise to members for arriving late. I had another meeting. I congratulate the minister on her exposition of a very difficult subject.
Will the minister indicate her support for a research project into prostate cancer screening? The window of opportunity to carry out such research is small—it has almost gone. Such research cannot be done in America, as they are too far advanced. There is just the possibility that it could be done in the UK. PSA is not appropriate as a screening test at present.
I should have declared an interest—I have a grant from the Scottish Executive for research into prostate disease.
I am grateful to both members for their comments. I fear, however, that we have been lulled into a false sense of security about the time. Having been given extra time, I am concerned that we may now run out. I will attempt to address the comments raised by Brian Adam and Richard Simpson by considering some of the wider work that is under way.
We are all agreed that there is a need for us to learn more about the disease, to improve testing techniques and to achieve greater clarity about treatment. That can only be a good thing. There has been a drive within the NHS in Scotland and in England for some time to take action in all those areas. Much of that work was encapsulated in the recent prostate cancer action plan, published by the Department of Health last week. The Department of Health expert group that drew up that plan included one of our expert advisers, who also works closely with the Scottish cancer group. The actions that are outlined in the plan and the additional research that is proposed will be of benefit to men throughout the UK, not just in England. That is only one example of our involvement in, and commitment to, the fight against cancer in general, and prostate cancer in particular.
In the few minutes that remain, I will give members a few examples of other work that is under way. An expert advisory group has been set up by the Scottish cancer group to examine the recognised and difficult challenges in treating prostate cancer. The group is expected to report early in 2001 and is likely to make recommendations on further research requirements, treatment and the education and training of specialists.
In addition, the Executive remains committed to improving services with faster, better diagnosis and treatment for everyone with cancer, more one-stop clinics, shorter waiting times and up-to-date equipment. As evidence of that commitment, eight one-stop prostate assessment clinics have been established. There have been investments in diagnostic and treatment planning equipment for cancer and there is a modernisation programme for radiotherapy equipment, all aimed at shortening waiting times and improving patients' experience.
For prostate cancer, as well as other urological cancers, we have invested in a nationwide programme of clinical audit, which will, for the first time, provide a comprehensive picture of patient pathways, treatment and outcomes. More widely, the preliminary results from the European randomised study of screening for prostate cancer, although not expected until 2009, will give an indication of whether population screening for prostate cancer is effective in reducing mortality rates.
A proposal for a UK prostate cancer screening trial is currently being considered by the Medical Research Council. Scottish research experts are actively involved in that.
I hope that those examples serve to indicate the Executive's commitment to taking work forward in this important area. We must acknowledge that improvements to the current testing techniques and treatments are required before further consideration can be given to a routine screening programme. Such improvements will not happen overnight, but we are seeking them actively. I acknowledge the desire, expressed in today's debate, that we should do so with determination and urgency. I am pleased to give the commitment that the Executive will do just that.