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Understanding prostate cancer risk: Interview with Frank Chinegwundoh MBE

As part of our Cancer Care 2024 programme, Public Policy Projects have continued conversations with Prostate Cancer experts to bring together some insights into the challenges and opportunities within prostate cancer care. This month we spoke to Professor Frank Chinegwundoh MBE about his experience as a Consultant Urological Surgeon with a special interest in prostate cancer.

By Rachel Millar

Firstly, can you tell me a bit about why you chose urology as a specialism?

For me, I wanted to do a surgical speciality and as part of my rotation I did urology and found it interesting – in urology you see men and women, old and young, using high-tech and low tech equipment, so it’s very varied.

You are credited with finding out that Black men have a higher risk of prostate cancer in the UK, how did this finding come about?

I was working as a urologist in East London, and I noticed that my clinic had high numbers of Black men with prostate cancer. I knew that in America, figures suggested that Black men were more likely to develop prostate cancer than other ethnicities and so I rang the office for national statistics to ask about data in the UK. There was no data – it hadn’t been collected – and so I decided to set up a study in Barts hospital. I got all the prostate diagnoses in a given area over a period of time and looked at the ethnicity and compared this to the proportion of Black men in the catchment area. With some careful statistics and epidemiology help, I was able to demonstrate that Black men in East London have a 2.3-fold risk of being diagnosed with prostate cancer. I then joined with other researchers to look into other areas of the country and we were able to show this risk was true across the UK.

From your research, you have shown the elevated risk in Black men in the UK, and this is true in the USA. Is this something that is seen in other countries, for instance, in African nations also?

One of the challenges is that in African countries there isn’t the same level of cancer registration and unfortunately, due to difficulties in the cost of healthcare and in accessing health care, many men may die before being seen by doctors. However, it seems, from the data we do have, that prostate cancer is extremely common in West Africa where we have looked at populations, and in the Caribbean and in Brazil.

Source: Prostate Cancer UK

Do we know why Black men have an elevated risk?

There are studies looking at possible reasons for this increased risk in Black men, but as yet, we aren’t sure. I am involved in two studies looking at this, one called MADCAP, led by Professor Tim Rebbeck at Harvard, and another led by Professor Folakemi Odedina at the Mayo Clinic. These studies have partners in West Africa and the data is suggesting some genetic reason behind the increased risk. For example, there are genetic differences in the androgen receptor, and this is the receptor that testosterone attaches to fuel the growth of the prostate. So, this is an active area of research.

As a clinician that sees prostate cancer patients on a daily basis, what are the challenges in the UK’s prostate cancer pathway that are negatively impacting patients?

I think the biggest issue is late diagnosis. Far too many men present with late prostate cancer; 16-20 per cent men on diagnosis have got advanced disease that has spread either locally in the pelvis or to the bones or lymph glands. Although we have good treatments, they aren’t curative and so the way to cure prostate cancer is to catch it early. Unfortunately, early prostate cancer doesn’t have symptoms and so to me, it seems that the only way to catch it early is to screen for it. If we went ahead with a screening programme we would cure more men.

I think the benefits [of PSA testing] outweigh the risks and that a screening programme will save lives.

Professor Frank Chinegwundoh MBE

There’s a well-known Belgian Urologist, Professor Hendrik Van Poppel, who said to the EU commission that in Europe, no man should die from prostate cancer. He felt able to say that because if it is caught early, which is eminently possible, it can be cured. What currently happens is that men who are health literate proactively seek PSA tests. Sometimes, a GP might be more proactive in suggesting a PSA test, but this is not on a national basis – that is missing. There was a big study called the European Randomised Screening Trial of Prostate Cancer and that showed conclusively that if you screen using the PSA test, that would reduce the mortality by 25 per cent or more. There are downsides to screening – some cancers may be missed by the PSA and not all prostate cancers will need to be treated, but overall, I think the benefits outweigh the risks and that a screening programme will save lives.

The PSA test has been criticised due to its low sensitivity. Is there another test that is more sensitive?

There has been a lot of research to find a more sensitive test for prostate cancer. There is another blood test, the Stockholm 3 for instance, which is more sensitive but it is very expensive so isn’t for mass use. There are also ways of making the PSA test more sensitive, for instance by looking at PSA density, relating the level of the PSA to the size of the prostate and taking forward men with a higher PSA density. There are studies looking at a prostagram (similar to a mammogram), a 10-minute rapid MRI, which is bi-parametric rather than the multi-parametric MRI that is currently done. The initial results suggest that the bi-parametric scan gives the relevant information in terms of prostate cancer risk. The recently announced UK TRANSFORM trial will look at whether a prostagram might be preferable for prostate screening going forward. I suspect that it will be a combination of PSA and MRI to refer for biopsy.

Currently, despite its limitations, the PSA is still the best screening tool that we have at the moment.

You mentioned great treatments for prostate cancer, can you talk me through those?

If we are talking about early prostate cancer, where it is localised in the prostate and hasn’t spread, there are many different effective treatments. These include:

  • Radical prostatectomy
  • Low dose and high dose rate brachytherapy
  • Focal therapy
  • External beam radiation
  • Active surveillance

These all have their advantages and disadvantages, so it is up to the man and clinician to determine what the best treatment is for that individual. For instance, I perform a lot of low dose rate brachytherapy – this is the permanent implantation of radioactive iodine seeds into the prostate. The seeds gradually release their radioactivity over 6 months typically, which kills the cancer cells. The advantage of this is that it is a day treatment and has a short recovery period.

In terms of best practice what would you like to see more of across the country?

Assuming you’ve had a PSA and it’s raised for your age, best practice would be to make a rapid assessment as to whether you have prostate cancer or not. This means getting your PSA confirmed on site by a urologist on your first visit. Going through to an MRI scan on the same day or next day at the latest and if abnormal, having a biopsy that week, getting the results in 48 hours. So, all in all a maximum of 7 days from referral to diagnosis. This is rare. I believe that Imperial College is close to achieving this, but in most places there simply isn’t the capacity in the system. You may wait two weeks to see someone, two more weeks for an MRI and two weeks for a biopsy and longer for the results. This pertains in much of the country due to limited resources in terms of staff capacity and MRI capacity. But best practice would be to shorten that to seven-10 days.

If you could do one thing for prostate cancer, what would you do?

I would institute a national screening programme. The only way to save the 12,000 men that die of prostate cancer annually is to catch it early, and the only way to do this is to screen.

Is there not enough attention paid to people living with advanced prostate cancer?

The NHS is generally concerned with diagnosis and treatment and there is less attention paid to the consequences of treatment and long-term mental health, financial issues, and side effects. That’s where the voluntary sector helps support men and their families. There are peer support groups and helplines. There’s a big role for the voluntary sector.

Do you think health inequalities play a big part in prostate cancer?

I come across too many Black men that are turned away from having a PSA test because GPs aren’t aware of the risks for Black men. Not all health professionals are aware of the disparities in risk. Also, we find that Black men feel less supported by the NHS and have a less favourable experience. Some of this is cultural awareness, language issues, the feeling of being understood. To change this, we need to educate staff, particularly in areas that have high numbers of Black men. I also think buddying systems help, whereby when you have your diagnosis, the specialist has a list of men that have lived experience that are happy to support newly diagnosed men. And I think good signposting to the voluntary sector is important, as well as financially supporting these third sector, often grassroots, organisations.

Are you optimistic as an NHS leader in the future of the NHS?

I think the NHS is still a wonderful institution, despite its challenges in workforce, finances and estates. I have travelled to other parts of the world and seen other healthcare systems where poor people suffer and die as a result of not being able to access healthcare. If you’ve seen this, then you know, we must preserve the NHS which is free at the point of delivery. Of course, there will always be challenges but I think it’s not beyond us as a society to preserve and improve the NHS and keep it fit for purpose as our population ages.

As our Cancer Care Programme 2024 continues, look out for our forthcoming report, Reducing the variation in prostate cancer care, which will be launching in September.

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