̽��ֱ�� of Cambridge - Vincent Gnanapragasam

Prostate cancer cases risk late detection due to misleading urinary focus

cjb250 — Thu, 04 Aug 2022 00:00:36 +0000

Prostate cancer is the most common type of cancer in men. According to Cancer Research UK, over 52,000 men are diagnosed with prostate cancer each year and there are more than 12,000 deaths.

Over three-quarters (78%) of men diagnosed with the disease survive for over ten years, but this proportion has barely changed over the past decade in the UK, largely because the disease is detected at a relatively late stage. In England, for example, nearly half of all prostate cancers are picked up at stage three of four (stage four being the latest stage).

Despite no evidence of a link between urinary symptoms and prostate cancer, national guidelines, health advice and public health campaigns continue to promote this link. In a review published today in BMC Medicine, Cambridge researchers argue that not only is this unhelpful, but it may even deter men from coming forward for early testing and detection of a potentially treatable cancer.

“When most people think of the symptoms of prostate cancer, they think of problems with peeing or needing to pee more frequently, particularly during the night,” said Vincent Gnanapragasam, Professor of Urology at the ̽��ֱ�� of Cambridge and an Honorary Consultant Urologist at Addenbrooke’s Hospital, Cambridge. “This misperception has lasted for decades, despite very little evidence, and it’s potentially preventing us picking up cases at an early stage.”

Prostate enlargement can cause the urinary problems often included in public health messaging, but evidence suggests that this is rarely due to malignant prostate tumours. Rather, research suggests that the prostate is smaller in cases of prostate cancer. A recent study – the UK PROTECT trial – even went as far as to say that a lack of urinary symptoms may in fact be an indicator of a higher likelihood of cancer.

Screening programmes are one way that cancers are often detected at an early stage, but in the case of prostate cancer, some argue that such programmes risk overwhelming health services and leading to men being treated for relatively benign disease.

Testing for prostate cancer involves a blood test that looks for a protein known as a prostate-specific antigen (PSA) that is made only by the prostate gland; however, it is not always accurate. PSA density is significantly more accurate than PSA alone in predicting a positive biopsy and is used in everyday clinical practice.

̽��ֱ��researchers point to evidence that there is a misconception that prostate cancer is always symptomatic: a previous study found that 86% of the public associated prostate cancer with symptoms, but only 1% were aware that it could be asymptomatic.

“We urgently need to recognise that the information currently given to the public risks giving men a false sense of security if they don’t have any urinary symptoms,” said Professor Gnanapragasam.

“We need to emphasise that prostate cancer can be a silent or asymptomatic disease, particularly in its curable stages. Waiting out for urinary symptoms may mean missing opportunities to catch the disease when it’s treatable.

“Men shouldn’t be afraid to speak to their GP about getting tested, and about the value of a PSA test, especially if they have a history of prostate cancer in their family or have other risk factors such as being of Black or mixed Black ethnicity.”

̽��ֱ��researchers say they are not advocating for an immediate screening programme, and acknowledge that changes in messaging could mean more men approaching their GPs for a PSA test, potentially resulting in unnecessary investigations and treatment. However, they argue that there are ways to reduce the risk of this happening. These include the use of algorithms to assess an individual’s risk and whether they need to be referred to a specialist, and for those who are referred, MRI scans could help rule out ‘indolent’ (mild) disease or negative findings, reducing the risks of an unnecessary biopsy.

“We’re calling on organisations such as the NHS, as well as patient charities and the media, to review the current public messaging,” said Professor Gnanapragasam.

“If men were aware that just because they have no symptoms doesn’t necessarily mean they are cancer free, then more might take up offers for tests. This could mean more tumours identified at an earlier stage and reduce the numbers of men experiencing late presentation with incurable disease.”

Reference
Gnanapragasam, VJ, et al. Urinary symptoms and prostate cancer—the misconception that may be preventing earlier presentation and better survival outcomes. BMC Medicine; 4 Aug 2022; DOI: 10.1186/s12916-022-02453-7

Men with early, curable stages of prostate cancer are missing opportunities to have their cancer detected because national guidelines and media health campaigns focus on urinary symptoms despite a lack of scientific evidence, say experts at the ̽��ֱ�� of Cambridge.

When most people think of the symptoms of prostate cancer, they think of problems with peeing... This misperception has lasted for decades, despite very little evidence

Vincent Gnanapragasam

Rick Gomez (Getty Images)

Black man looking out window

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Online tools transform outcomes for cancer patients

ta385 — Thu, 21 Oct 2021 06:00:00 +0000

PREDICT Breast and Prostate, powerful online risk communication tools developed by Cambridge researchers, have helped thousands of patients across the world reach better clinical outcomes, avoid unnecessary treatments and suffer less distress.

Vice-Chancellor’s awards showcase ̽��ֱ��’s societal impact and public engagement

ta385 — Mon, 14 Oct 2019 14:54:26 +0000

Now in their fourth year, the awards were made in four categories: collaboration, early career, established researcher/academic champion and professional service.

Winners in the collaboration category included PhD student Christoph Franck for an initiative creating a global air pollution sensor network driven by citizen science.

̽��ֱ��early career researchers included Jessica Miller whose project has changed understandings of mental health and trauma in UK policing, informing a new wellbeing service and leading to discussion in Parliament.

Among those commended as established researchers, Vincent Gnanapragasam developed a new tool to predict an individual’s prognosis following a prostate cancer diagnosis to help make decisions about the value of treatment. In a very different field, David Trippett was recognised for bringing an ‘indecipherable’ opera back to life through international performances, broadcasts and recordings.

In the professional services category Naomi Chapman from the Polar Museum Education team developed maps to enable young and partially sighted people to explore the Arctic and Antarctic by touch.

̽��ֱ��announcement was made at a prize ceremony held at the Old Schools on 14 October 2019.

Professor Stephen Toope, Vice-Chancellor of the ̽��ֱ�� of Cambridge, says: “This year’s nominations recognise impressive and inspirational individuals, and strongly reflect our mission to engage the public, tackle real-world problems and improve people’s lives. ̽��ֱ��award scheme focuses attention on the increasingly important role that institutions such as ours have to play in restoring faith in experts.”

̽��ֱ��Vice-Chancellor’s Research Impact and Engagement Awards were established to recognise and reward outstanding achievement, innovation and creativity in devising and implementing ambitious engagement and impact plans that have the potential to create significant economic, social and cultural impact from and engagement with and for research. Each winner receives a £1,000 grant to be used for the development and delivery of engagement/impact activity or relevant training.

This year’s winners are:

Collaboration Award

Emily Mitchell (Department of Earth Sciences)

Researchers and museum specialists collaborated on a museum exhibition and public programme, engaging a range of public audiences with research on the earliest fossils to illuminate the start of complex life.

Helen Strudwick ( ̽��ֱ��Fitzwilliam Museum)

This collaborative project engages audiences with our pioneering research on ancient Egyptian coffin construction and decoration, through a major exhibition, ‘Pop-Up’ museum targeting underserved audiences and digital resources.

Open-Seneca

Open-seneca is a student-led initiative creating a global low-cost mobile air pollution sensor network driven by citizen science. ̽��ֱ��aim of the initiative is to empower citizens with air pollution data to raise awareness, initiate behaviour change, and inform policy makers on environmental issues. ̽��ֱ��team are: Christoph Franck, Charles Christensen, Lorena Gordillo Dagallier, Sebastian Horstmann, Raphaël Jacquat and Peter Pihlman Pedersen.

Early Career Award

Saumya Saxena (Faculty of History)

Saumya’s research focuses on family law and gender in India. She advised the twenty-first Law Commission of India on reform of family law and worked with the Verma Commission on amendments to law relating to rape in India.

Jessica Miller (Department of Sociology)

Jessica’s project involved engaging with over 18000 police officers and staff to change the face of trauma resilience in UK policing, and inviting commitment from decision-makers to inform national policy and operational change.

Matthew Agarwala (Bennett Institute for Public Policy)

Matthew’s research on valuing natural resources is helping in the transition to sustainable economic growth. Having been adopted by the United Nations and other bodies, his work is shaping standards for measurement.

Zoë Fritz (School of Clinical Medicine)

Zoë’s research around resuscitation decisions led to the development of the ReSPECT process (“Recommended Summary Plan for Emergency Care and Treatment”), which has replaced problematic ‘DNACPR’s with tremendous impact on policy, practice, guidelines and beneficiaries.

Established Researcher and Academic Champion

Nicholas Thomas (Museum of Archaeology and Anthropology)

In 2018, Nicholas co-curated the landmark exhibition 'Oceania' at the Royal Academy in London. Based on collaborative research at Cambridge, the exhibition brought a dynamic, contemporary view of the art of an extraordinary region to European audiences.

Vincent Gnanapragasam (School of Clinical Medicine)

Vincent is the Chief Investigator for PREDICT Prostate, the first individualized prognostic tool accessible to both clinicians and patients to help make unbiased informed decisions about the value of treatment for newly diagnosed prostate cancer.

David Trippett (Faculty of Music)

An unheard opera by 19th-century composer Franz Liszt languished silently in a manuscript thought fragmentary and illegible. David’s meticulous reconstruction brought it to life, to global acclaim, through international performances, broadcasts and recordings.

Professional Service

Oliver Francis (Centre for Diet and Activity Research, and the MRC Epidemiology Unit)

Oliver’s leadership in communications has transformed the impact strategies at CEDAR and the MRC Epidemiology Unit. His innovative contributions span all aspects of the communications and impact portfolio.

Naomi Chapman (Scott Polar Research Institute)

With a local artist, Naomi developed innovative maps of the Arctic and Antarctic with which hundreds of young and partially sighted people have enjoyed a touch tour of polar research.

Twelve students, academics and professional members of staff from across the ̽��ֱ�� of Cambridge have received Vice-Chancellor’s Research Impact and Engagement Awards in areas as diverse as prostate cancer, family law, museum public engagement and police mental health.

This year’s nominations recognise impressive and inspirational individuals, and strongly reflect our mission to engage the public, tackle real-world problems and improve people’s lives

Professor Stephen Toope

Candy Welz

Airam Hernández and Joyce El-Khoury perform Sardanapalo at Staatskapelle Weimar

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Evidence-based web tool aims to better inform and refine need for treatment in early prostate cancer

cjb250 — Tue, 12 Mar 2019 19:00:20 +0000

̽��ֱ��tool, PREDICT Prostate, launches today to coincide with publication in the journal PLOS Medicine of the research that underpins it. It brings together the latest evidence and mathematical models to give a personalised prognosis, which the researchers say will empower patients as they discuss treatment options with their consultant.

According to Cancer Research UK, there were 47,151 new cases of prostate cancer in 2015. Progression of the disease, which usually presents in later life, is very variable: in most cases, the disease progresses slowly and is not fatal. It is often said that more men die with prostate cancer than from it. However, it is still the case that in a significant number of men, the tumour will metastasise and spread to other organs, threatening their health.

When a patient is diagnosed with prostate cancer, they are currently classified as low, intermediate or high risk. Depending on the patient’s risk group, clinicians will recommend either an ‘active monitoring’ approach or treatment. Treatment options include radiotherapy or surgery and can have potentially significant side-effects, including erectile dysfunction and urinary incontinence.

However, evidence suggests that these classifications, which are in the current guidelines provided by the National Institute for Health and Care Excellence (NICE), are only 60-70% accurate. This means that many men may elect for treatment when it is not necessary. In fact, a recent study carried out in the UK showed that for early prostate cancer (low and intermediate risk), treatment is no more beneficial in terms of ten year survival compared to no treatment.

Cambridge researchers have already shown that it is possible to improve the accuracy of the NICE-endorsed model to more than 80% by stratifying patients into five rather than three groups. Their next challenge was to use this information to give a more individual prediction of outcome to patients at no extra cost. ̽��ֱ��result is PREDICT Prostate.

PREDICT Prostate takes routinely available information including PSA test results, the cancer grade and stage, the proportion of biopsies with cancerous cells, and details about the patient including his age and other illnesses. It then gives a 10-15 year survival estimate. Importantly, the tool also estimates how his chance of survival differs depending on whether he opts for monitoring or treatment, providing context of the likelihood of success of treatment and risk of side effects.

“As far as we are aware, this is the first personalised tool to give an overall survival estimate for men following a prostate cancer diagnosis,” says first author Dr David Thurtle, Academic Clinical Fellow in Urology at the ̽��ֱ�� of Cambridge and Addenbrooke’s Hospital, which is part of Cambridge ̽��ֱ�� Hospital NHS Foundation Trust (CUH).

“PREDICT Prostate is designed for men who are considering whether to choose to monitor or to opt for treatment. This is the choice that faces nearly half of all men who are diagnosed with prostate cancer. We hope it will provide a more accurate and objective estimate to help men reach an informed decision in discussion with their consultant.”

̽��ֱ��research was led by Dr Vincent Gnanapragasam, ̽��ֱ�� Lecturer and Honorary Consultant at CUH, and undertaken by Dr Thurtle, both of the Academic Urology Group in Cambridge, and in collaboration with Professor Paul Pharoah of the Department of Cancer Epidemiology.

“We believe this tool could significantly reduce the number of unnecessary – and potentially harmful – treatments that patients receive and save the NHS millions every year,” says Dr Gnanapragasam.

“This isn’t about rationing treatments – it’s about empowering patients and their clinicians to make decisions based on better evidence. In some cases, treatment will be the right option, but in many others, patients will want to weigh up the treatment benefits versus the risks of side effects. It will also show men who do need treatment a realistic estimate of their survival after treatment.”

Data from the National Prostate Cancer Audit has shown that rates of treatment for low risk prostate cancer vary across different hospitals between 2-25%. ‘Radical’ treatment – surgery or radiotherapy, for example – costs on average around £7,000 per patient and treating these men unnecessarily wastes considerable resources as well as causing significant side-effects.

Dr Thurtle and Dr Gnanapragasam have since carried out a randomised study of almost 200 prostate cancer specialists in which they gave some clinicians access to the tool and a series of patient vignettes, while others received the vignettes only. In most cases, the clinician overestimated the risk of the patient dying from the cancer, compared to the estimate given by PREDICT, going on to recommended treatment in many cases and overestimate how successful this treatment would be. When given access to the tool, the clinicians were less likely to recommend treatment in good prognosis cancers.

Dr Gnanapragasam says that the development of PREDICT Prostate has only been possible because of the intactness of records available through Public Health England – the tool was developed using data from over 10,000 UK men recorded in the East of England. This regional registry, he says, is one of the highest quality and most comprehensive data sets available both in the UK and internationally. ̽��ֱ��data was then validated externally in a sample of 2,500 prostate cancer patients in Singapore. ̽��ֱ��web tool was developed in collaboration with the Winton Centre for Risk and Evidence Communication

̽��ֱ��researchers caution that the tool is strongly recommended for use only in consultation with a clinician. It is also not suitable for men with very aggressive disease or who have evidence of disease spread at the time of diagnosis.

̽��ֱ��research was funded by the Evelyn Trust and the Urology Foundation.

Reference
Thurtle, DR et al. Individual prognosis at diagnosis in non-metastatic prostate cancer: Development and external validation of the PREDICT Prostate multivariable model. PLOS Medicine; 12 March 2019; DOI: 10.1371/journal.pmed.1002758

Making prostate biopsies safer

Dr Gnanapragasam recently announced the start of clinical trials of CamProbe, a device to make prostate biopsies safer.

̽��ֱ��current method to retrieve samples from the prostate uses a transrectal ultrasound probe inserted into the anus to allow the biopsy to be taken. Patients who undergo this procedure are at risk of urinary infections or sepsis as the needle has to pass through the bowel wall to reach the prostate. Around 30-40,000 prostate biopsies are done every year using this method in the UK alone.

̽��ֱ��CamProbe, invented and developed in Cambridge, has been designed so the biopsies can be taken more safely through the skin under the scrotum (transperineal) and avoid the bowel.

“ ̽��ֱ��design of the CamProbe is a needle within a needle and allows us to collect tissue from the prostate through a more sterile part of the body,” says Dr Gnanapragasam, who co-leads the Urological Malignancies Programme at the CRUK Cambridge Centre.

“Most importantly it can be done under local anaesthetic in the out-patient department. Previously this kind of approach was only possible if a general anaesthetic was used with very significant additional costs.”

̽��ֱ��trial for the CamProbe is now underway using funding from the National Institute for Health Research (NIHR). It will run for a year at several hospitals around the UK including at the Cambridge Clinical Research Centre. If the trial is successful, the CamProbe could be adopted into mainstream use within two years.

“Our goal is to show that the CamProbe is a simple alternative for taking prostate biopsies which eliminates infection risks to patients and drastically reduces the need for antibiotics,” added Dr Gnanapragasam. “Its simplicity also means it will be a very low-cost device, and, in addition to reducing infections, the need for antibiotics and sepsis related admissions, could potentially save the NHS an estimated £7-11 million pounds every year.”

A new tool to predict an individual’s prognosis following a prostate cancer diagnosis could help prevent unnecessary treatment and related side effects, say researchers at the ̽��ֱ�� of Cambridge.

We believe this tool could significantly reduce the number of unnecessary – and potentially harmful – treatments that patients receive and save the NHS millions every year

Vincent Gnanapragasam

PREDICT Prostate

Researcher profile: Dr David Thurtle

Dr David Thurtle a clinician at Addenbrooke’s, Cambridge ̽��ֱ�� Hospitals, has spent the past two years pursuing a research doctorate in prostate cancer. As he comes to the end of his studies, he is preparing to return to focusing on his clinical work.

“I never see myself straying far from clinical practice,” he says, “but I hope to maintain research interests throughout my career to challenge and improve upon best practice, stretch myself and ensure I’m always up to date for the sake of my patients.”

It was during his final months at medical school at Nottingham ̽��ֱ�� when he carried out a four week placement in the urology department that David realised he wanted a career in this field. With its mix of medicine and surgery, utilisation of technology such as lasers and robots, and treatment of conditions that have profound impacts on patients’ quality and length of life “Urology has it all!” he says.

Since starting an Academic Clinical Fellowship in Cambridge in 2014, he has worked on a range of clinical prostate cancer related topics, collaborating with radiologists, engineers and epidemiologists amongst many others. “I love the daily interaction and satisfaction of clinical medicine and have always sought out research projects that are ‘close to the coal-face’ of clinical work.”

David’s research sets out to inform both patients and doctors about the long term survival outcomes for men diagnosed with localised prostate cancer.

“Prostate cancer has many different guises – some cases are indolent and may never impact upon a patient’s length of life, while others can rapidly metastasise causing significant problems and shortening life. So, management decisions are not as straight-forward as in some other cancers.”

Although treatments are improving, they each carry risks, so his work seeks to provide patients with as much information as possible about their cancer, and help contextualise it against their age and health otherwise.

“Men may have gross misconceptions about the outcomes from prostate cancer, and clinicians may have understandable biases towards certain treatments,” he says. “Our work seeks to ‘switch on the light’ and provide accurate, unbiased estimates of what benefit treatment might offer so that men can make informed decisions based on their own priorities.”

A strong track-record of prostate cancer research and world-renowned academics in cancer epidemiology make Cambridge the ideal place for David and colleagues to carry out their research. “Cambridge has an openness in collaboration that I have not seen elsewhere, with clinicians and academics from disparate disciplines keen to work together - and easy to work with.”

There is also another, perhaps unexpected, reason to enjoy the Cambridge environment. “Cambridge also has a distinct lack of hills which makes for far more enjoyable running and cycling – so much so that I’ve taken up triathlons!”

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