It can be awkward when a patient asks you about a report in their favourite tabloid detailing an amazing research breakthrough or a ‘cutting-edge’ new treatment / test and you don’t know what they are talking about! So this section fills you in on the facts.
Men with low risk prostate cancer must be offered option to ‘watch and wait’ instead of gruelling treatment
The Telegraph – 9 May 2019
One of the big developments in the last few months has been the publication of the updated National Institute for Health & Care Excellence (NICE) Prostate Cancer Guideline. Multiple news outlets ran with the updated guidance on active surveillance (AS) and several of those confused it with watchful waiting. In short, the new guidance (NG131) does not actually change the recommendations for AS, it does re-phrase the recommendation however. Previously the recommendations stated, “offer AS to men with low-risk disease who are suitable for radical treatment” (or words to that effect), the newer recommendations state “offer a choice between AS, radiotherapy and surgery”. A subtle change, but the new recommendations also now include lengthy tables of data to discuss with patients during the decision-making process. The data, much like the PREDICT website, informs patients of the likelihood of progression, metastasis, erectile dysfunction, urinary disturbance for each of AS, surgery and radiotherapy. I, for one, thoroughly welcome the addition of the new tables. I value having this kind of information to hand on which to ground consultations. The effect of this change though is to further reinforce the use of AS as a ‘good’ option, given the far lower risk of bowel, bladder and erectile difficulties associated with it. The new recommendations then are really a change to how AS should be presented as an option, rather than a change to actual management strategies. Time will tell, but perhaps this approach may prove a more cost-effective way of managing men with low-risk disease.
Curiously, the AS protocol offered for consideration has changed as well. Five years ago, the loose plan for AS included a recommendation for a repeat prostate biopsy at 12 months. This has now been dropped from the May 2019 guidance. In fact, the protocol no longer includes any ‘routine’ repeat biopsy. Instead, repeat biopsy is simply reactive and in response to PSA or MRI changes. I suspect many of us will greet this change in much the same way as one-year discharges of pTa G1 urothelial cancers were met. It leaves me feeling a little uneasy and I suspect there will be slow uptake on this particular change.
The race to beat prostate cancer: With new tests that spare men needless biopsies, which is right for you?
The Daily Mail – 29 April 2019
An audible groan escaped me when I read the headline. There seems to be a couple of stories like this one every year and I occasionally cover them here, because it will be the first thing the patient brings up when you recommend a prostate biopsy. I, probably much like you, take a degree of umbrage with the suggestion that I am performing ‘needless’ biopsies. Clearly, patients generally do not like having to have biopsies and I do not believe that any urologist relishes having to carry them out. They are simply the most definitive way we have of determining whether or not a man ought to be offered treatment.
The article gives a very good and thorough examination of available screening tests. Many are familiar (PCA3, serum kallikreins, etc.), the names of the newer ‘liquid biopsies’ (examining for key proteins in the urine) were not familiar to me. Of course, none of these tests are available on the NHS and none of them provide enough diagnostic accuracy to replace biopsy at this time. So, we are stuck with the ‘necessary evil’ that is prostate biopsy, at least for now. I greatly look forward to the day when it is no longer needed however.
Penis enlargements do NOT work and can make it SMALLER
The Daily Mail – 10 May 2019
The Daily Mail reports on the work of Mr Gordon Muir and his team at King’s College. Coming hot on the heels of Mr Asif Muneer’s recent recommendation against DIY penis surgery, Mr Muir’s team have published their paper ‘Systematic Review of Surgical and Nonsurgical Interventions in Normal Men Complaining of Small Penis Size’ in Sexual Medicine Reviews, warning of the outcomes of surgeon performed treatments. A total of 17 studies are included in the review, all studies with less than 10 patients were excluded.
A total of 21 different surgical and non-surgical interventions were performed in 1192 men and despite widely differing and weak methodology (with limited follow-up), outcomes were assessed in terms of patient satisfaction and complications. In a nutshell, patient satisfaction is poor (less than 20%) and complications were not infrequent, sometimes with scarring leading to loss of length. It validates what we already knew, that men who have an issue with their penis have deeper rooted issues and more than likely require counselling rather than surgery. The penis enlargement ‘industry’ has been steadily growing in recent years, despite a lack of evidence to support it, hopefully this publication and newspaper article will do something to redress the balance.
