Professor David Cranston FRCS is a consultant urological surgeon and comes on the podcast this week to talk about prostate cancer and PSA testing. Should you get PSA screening? The evidence doesn’t support national screening programmes but individuals can still choose to be tested. Some urologists do, some don’t. It’s an opportunity to delve into some of the evidence and complexities in an important health topic for blokes with an experienced and distinguished surgeon and researcher.
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Note: The Blokeology podcast is, of course, all about the audio and the transcript misses out on emotion, nuance and the conversational elements. I think you’ll get more out of it listening to the audio but I hope the transcript remains a useful addition. The transcript is generated using a combination of speech recognition software and Mark 1 human – so there may be errors.
David Cranston: So, yeah, so I qualified in 1975 having failed my medical finals and had to do an extra six months and then ended up doing a job down in Bournemouth and at Whipps Cross in London. Then went back to Bristol, which is where I trained to do, anatomy demonstrator. And then went down to Exeter where I got FRCS, first time, having failed finals first time. And then I went to Bath, as a registrar for two and a half years. Went up to Oxford in 1983 to do a research in kidney transplantation. Did a DPhil in that with Peter Morris who was head of department, they are leading transplant surgeon in the world and uh, then actually almost fell into urology by mistake. I applied for quite a few jobs, vascular and transplantation, um, but ended up in urology, which has actually been a wonderful career. Just retired from the NHS, but I’ve always had a very big research interest. Um, in the, on the urological side, it’s been on the major kidney cancers and we had an auto transplant program, national auto transplant program, which I helped to set up whereby we were taking the very complex renal tumors from around the country, taking the kidney out, dissecting the tumor out, putting the kidney back together and then transplanting it back into the patient because we think that there were about all 40 patients every year with bilateral renal tumors or tumors in a solitary kidney, which just had their kidney removed and went onto dialysis. We reckon we could stop about half of that. So that was my urological interest. Um, in terms of specialty, in terms of research, my current research is linked with high intensity focused ultrasound, um, across all specialties. We have a big research link with China, which we’ve had for the last 20 years and going out there again in July. So this is looking at ultrasound at very high intensity for treating uterine fibroids. Um, we are hoping to, although you can treat prostate cancer, transrectally with a high intensity focus ultrasound machine, um, we’re hoping to modify that in association with China and get a better high intensity focus ultrasound treatment for prostate cancer. So that’s my major interest at the moment is um, high intensity focused ultrasound. You know, the whole realm of prostate cancer has been of interest to me in especially in terms of the fact that you need to operate on about 30 people to save one person’s life. And I think the whole question of what one does and what one doesn’t do with that is very interesting. And although I haven’t, I don’t do the operations for prostate cancer, I have a major interest in, as it were, the management of it in terms of what one should be doing, what one shouldn’t be doing.
Euan: Sure, absolutely. I absolutely want to explore prostate cancer a little bit more. The first thing I should ask you because you have been in the NHS since 1975, I think you said you’re qualified there and you just recently retired. What have been your reflections on the changes in the NHS in the past 40 years?
David Cranston: Yes. Well, I think, uh, it’s, it has changed considerably. I’ve had a very, um, a wonderful career in the NHS. Um, I think that the things that I’ve seen, which have been sad over the last few years in particular is the lack of the team spirit. Uh, you know, I think as juniors we worked incredibly hard, but you always felt very much part of a team. I remember, um, you know, early one morning as a houseman when my, uh, phone, the switchboard and said get hold of Dr Cranston and they said, oh, Dr Cranston’s not on until nine o’clock today. And he said, when I’m on he is on, just get him for me. Uh, but actually it made you feel really part of the team and I think one’s lost that team atmosphere. I think there’s a huge amount more paperwork now. Um, I think there are more complaints amongst people. I think, you know, when I started in the 1970s, 1980s, I think, you know, the older generation were hugely grateful for the NHS. I think, there tend to be more complaints now about it. There’s a huge amount more paperwork. Um, and you know, from that point of view, I think it’s sad. I mean, having said that, I still think that if you’re in a major accident or need major surgery or specialist surgery is still a fantastic place to be. And certainly if I was in a major road traffic accident or if I’d much rather be in the NHS than anywhere else.
Euan: It’s certainly a system under pressure. I mean there are, there are multiple factors aren’t there? I think all health care systems are suffering from that challenge of being able to cope with, you know, an aging population and increasing consumer demands and the NHS remains, it’s a fantastic, you know, the fact that it is available to all remains a tremendous positive. But yes, it’s quite different place to perhaps the, you know, even the last 10 or 20 years it’s moved on rapidly, hasn’t it?
David Cranston: Yeah, absolutely.
Euan: Right. So I thought we could, we should move on to prostate cancer. And find out a little bit about that. Now it’s, it’s a, perhaps it’s a slightly different type of cancer to some in that. It’s got such a variety in the way it presents and the kind of the potential different types of it. And I wondered if you could just a few sentences give a little pen picture of… we’ve got, we’ve got a range of listeners… Some of them will be doctors and medics, but many people are listening won’t be on that side of things at all. A little bit about prostate cancer and exactly just to give an overview of it as a disease.
David Cranston: Well, so I think the thing about prostate cancer is that a huge number of men have it. Probably most of them don’t know that they’ve got it. People have looked at postmortem specimens of the prostate of men who’ve died of other causes causes and you know, probably 50 to 60% of 60 year olds, if you looked at the whole of their prostate, we would have a tiny focus of prostate cancer. You know, 70% of 70 year olds, 80% of eighty year olds. So, and most people die of something different rather than the prostate cancer. Having said that, it is still, uh, a large number of people do die of prostate cancer in this country, but far, far fewer than those who actually have it. And there was an American surgeon years ago who said: if a cure is possible, is it necessary and if a cure is necessary, is it possible. Well, I think we may have moved on from that somewhat, but certainly not completely. And, you need to treat about 30 people now to save one person’s life. Now the other thing to say about prostate cancer is that there are ways of diagnosing it: you grade with the so called Gleason grade. And you look at the most aggressive, uh, number of cells and graded basically a Gleason three. Uh, there are so called Gleason ones and twos, but we certainly don’t use them in this country. So Gleason three is the lowest grade of prostate cancer. Gleason four is the next. And Gleason five is the most aggressive. And what you do is when you have a biopsy you look at the number of cells, the number of cancer cells and you grade them, if the most are grade three, then you put a grade three first. And then if there is a secondary, lot of grade four, then it might be Gleason grade three plus four, which is seven or it might be Gleason three plus three, which is six. Or it might be if the more aggressive ones are Gleason four. And the, then the next, uh, number is three. It might be the other way around. So it might be four and three. So you get this grading and basically Gleason three plus three is the lowest grade, at least that’s a Gleason sixth grade. In fact, some insurance companies would not recognize that as cancer. And uh, a lot of people, if you have a Gleason three plus three cancer, would suggestd that active monitoring is the sensible thing for that. So basically there is the localized prostate cancer. Um, you also of course look at the PSA blood test and there it the localized prostate cancer. And then there are some people who have metastatic prostate cancer, where the prostate cancer is spread elsewhere throughout the bones. And those often people often have a PSA level, you know, may be in the hundreds or even thousands. And in those cases, certain, if they’re not suitable for localized treatment, but they are a suitable for hormone treatment. A chap called Huggins got the Nobel Prize for showing that prostate cancer in the majority of cases is hormone sensitive. Um, so if the testosterone makes the prostate cancer grow, and I had a patient once when I was talking to him about giving him some treatment to take away/decrease the testosterone levels. He said, oh, you mean it’s a bit like if you take away the cheese, the mice die. Which I thought was a lovely analogy. I’ve often used that on other patients. So with very advanced prostate cancer, the way that you treat it is by stopping the testosterone levels, which you, we used to do by removing the testicles. Nowadays we do medically with various tablets and drugs and so on.
Euan: Hormone treatment is obviously a very important part of treatment of even advanced prostate cancer. Slightly terrifying, the prospect of having your testicles removed for chaps, I guess that’s one of the fears of prostate cancer. What perhaps one of the most important things to get across as you’ve described in their prostate cancer is this, you know, this enormous spread from the kind of, you know, aggressive metastatic disease, it’s in your bones and there’s been some highly publicized celebrity cases of men that have died of metastatic prostate cancer in recent years. Um, versus the kind of, you know, you’ll die with it rather than because of it. And that’s one of the real challenges with prostate cancer and the difficulties of finding treatments that are, um, that are effective. As well as the hormonal treatment for the more for you know, for particularly for the more aggressive or um, worrying prostate cancers, what does prostate cancer treatment tend to look like these days?
David Cranston: Well, if it’s localized prostate cancer, then there are a number of different options. It’s quite interesting because if you have acute appendicitis then nobody disagrees with the fact that you need your appendix out. But if you ask people how they treat localized prostate cancer, then there are different options depending on the state and the grade. Active Monitoring, of course is the, uh, least, uh, aggressive. But then there’s radical prostatectomy, which is often done with the Da Vinci robot these days. There is radiotherapy, there is seeds, radioactive seeds you can put into the prostate. There is high intensity focused ultrasound treatment of the prostate. And so there’s quite a spectrum of um, treatments that you can have for localized prostate cancer. The interesting thing is that most people who have localized prostate cancer suitable for treatment, the majority would be diagnosed on the basis of a raised PSA level and they are unlikely to have any symptoms; if they have symptoms and they’re suitable for local treatment then most of the symptoms are likely to be from the benign side of the prostate rather than the prostate cancer. If you’ve got symptoms that are due to prostate cancer then you are less likely to be eligible for local treatment because it probably means that it is locally quite advanced.
Euan: Yeah. Again, there’s an important thing to differentiate that I wanted to make sure we mentioned was the difference between, we’ll come back to this with PSA in a minute, but the difference between screening, of course, and men with symptoms and that’s an important thing for us to be clear, certainly from the GP perspective, that if you present with symptoms, doing a PSA is going to be part of that assessment, but if you’re asymptomatic and we’re getting into the realms of screening, then the discussion about PSA is is subtly different.
David Cranston: So you know there is no approved national screening program for prostate cancer just because of all the issues associated with it, in terms of is it actually going to reduce the number of people dying of prostate cancer, as opposed to, I mean one has to weigh up the benefits and the risks. You know, a lot of people who have localized treatment for prostate cancer start off with no symptoms but are diagnosed on the basis of a raised PSA then end up having a treatment which potentially will make them impotence or incontinence and uh, you know, maybe less so than in the old days, especially with the Da Vinci robot but nevertheless there is a substantial degree, of certainly morbidity associated with those treatments.
Euan: Yeah. I certainly want to make sure we mentioned that because I think that’s the, the risk of overdiagnosis with screening or over treatment perhaps with screening is the real, um, is one of the reasons that PSA as a screening test tends to fall down. It hasn’t been widely adopted as a, as I kind of, you know, a national screening program. It’s those side effects that we can from the treatment, from your urinary ones that are saying continents, bowel symptoms as well, isn’t there and erectile dysfunction, other sexual dysfunction kind of problems that can happen. I don’t, we don’t want to scare people who are potentially going to have that kind of treatment, but it’s about being realistic that a small percentage of men will get those problems. And if you’re only fixing a small percentage of men with the test weighing up those risks and benefits, um, and has so far it hasn’t come out in favor of PSA as a screening test.
David Cranston: No, that’s right. I mean obviously it also depends on the age and so on. I mean, I think if you’ve got a high PSA, the younger age group, fairly aggressive prostate cancer treatment is advisable… if on the other hand, you know, you’re in your, 60s or 70s and the PSA is particularly high and it’s a low grade cancer than uh, or active monitoring is often the much better treatments. And it’s interesting in some of the papers that have been published recently, my colleagues Freddy Handy who is the Nuffield Professor of Surgery in Oxford, and one of the leading prostate cancer surgeons in the UK did a big randomized study was involved in that. And what they said is obviously the thing that has the most impact on the quality of life is actually the diagnosis of prostate cancer. So if you can delay that diagnosis without any adverse effects to the patient, then you’re probably doing them a good…
Euan: Yeah. So let’s talk a little bit more about PSA, prostate specific antigen. I mean, a little bit about its history as a test and how it’s been, how you’ve used over the years.
David Cranston: Certainly when I, um, started, um, we looked at the acid phosphatase level and so PSA but PSA testing for prostate cancer’s been around for probably 30, 30 plus years. And, uh, the question is what level is it that you take as a level for being worried about prostate cancer? And I mean, that’s debatable. There is this level, um, it’s obviously age dependent, um, but the levels that are normally talked about depending on age: three, four, five. So if you sort of take four as the level, the thing about that is that there are a lot of people who’ve got levels that are above four, who do not have prostate cancer and there would be people with levels below four who do have prostate cancer. So if you put the level down to three, if you put the level down to two and a half, you’d pick up a lot more people with prostate cancer. But that’s not necessarily a good thing because a lot of these people would not need treatment anyway. So it always has struck me as slightly, um, obscure as to why a level of four was chosen. And certainly my argument is that, you know, would allow, if you raise the levels of 10, would you decrease the, would you increase the death rate for prostate cancer too? Which I personally doubt. And there are certainly people who have PSAs higher than 10 that do not have prostate cancer. If you have a very large prostate, your PSA tends to be high. I have patients with PSA of 20, you’ve been extensively investigated and no prostate cancers been found. There are other things that put it up as well. For example, prostatitis will put the PSA up a lot. So, um, you know, you have to sort of bear these things in mind. So I mean the classic, um, guidance at the moment is if your PSA, is let’s say about four, then you’d investigate prostate cancer and then you’d go on to have, well, these days probably MRI scan of the prostate plus or minus prostate biopsies; some people would do the two regardless. Other people would say, well, if the PSA, if the MRI scan doesn’t show prostate cancer, then we wouldn’t do a biopsy. So again, you know, you talk to different people and you find different uh, uh, things that people will say about that.
Euan: Yeah. And um, I think the sensitivity and the specificity of the PSA test is the thing has just never been that great. Um, the MRI is, there’s all of a sudden that risk with over investigation at being at four that everybody gets referred. And as a GP, if you see somebody as soon as their prostate’s raise, you’ve probably got to send them up to the urologists to have that conversation about further investigation. MRIobviously is not invasive and but you know it takes up a bit and anxiety associated with it of having tests and all that kind of stress. There’s the old, there’s the old kind of joke that PSA stands for promotes stress and anxiety. That’s been kind of used that PSA, that’s often used by GPs when speaking to patients, but once you get to that point and once it’s done and you find it’s up. You’re not got a lot of choice but to go ahead and investigate. Even biopsies have some risks, don’t they, there is a risk of bleeding. There was a risk of infection as well.
David Cranston: Yes sepsis with biopsies, although it’s incredibly unusual there have been people who’ve died after prostate biopsies. There’s certainly a risk of infection and sepsis.
Euan: Yeah, but no question either. We’ve all heard stories as wellof the men who’ve been nagged to go in to get their PSA checked by their relatives and have been discovered to have, you know, go through the process being found to have prostate cancer and would regard themselves as having had their lives saved or significantly improved by having had that. And PSA is responsible for that. So we’ve all, we all hear those tales as well.
David Cranston: Yes, that’s absolutely right. And I mean lots of celebrities who said that now that’s not necessarily true that their lives have been saved by it. But of course it depends on how, you know, you know, their perception. I remember years ago when I was in the United States, um, uh, who historically have been much more aggressive in actual treatment of prostate cancer, although you wonder how much that sort of financially driven and certainly when people get more financial reward for, um, active monitoring and seeing patients again and again over a period of time, the, um, rate for radical treatment has gone down. Um, but I remember somebody saying, you know, as soon as he was diagnosed with prostate cancer, regardless of the stage or the grades, he said it was like having a rattle snake in your pocket and he wanted it out. And so there are a lot of people who, the very word cancer means, um, “I want to get rid of it”. So I think, you know, and often say to people, you know, I don’t stop people having radical treatment. Sometimes I see… to say, you know, I saw the surgeon, he said, all these options are open. And then I said to him, my wife said to him, you know, what would you do? And he wouldn’t tell me what he do. He just said, well, these are the options. You know, you need to decide, which I don’t think is very good as a professional because people come to for professional advice and, um, you know, it’s, it’s difficult because on the one hand, surgeons tend to promote surgery. Radiotherapists tend to promote radiotherapy, um, but people do need some guidelines as to as to what they do. Um, so the whole thing is quite difficult.
Euan: Yeah, I think as GPs, we probably are guilty of promoting watchful waiting. That’s our, the one that we turn to. But it’s a very patient choice driven kind of philosophy these days isn’t it? And sometimes there aren’t good choices and it’s very hard not to impose your personal view on those patients as well sometimes. And as you say, sometimes patients want that personal view they you know, either in such a bind they don’t know which way to go that actually they just need that kind of, I don’t know, not to tell them what to do but to help guide them.
David Cranston: And I always say that sometimes actually it’s as much as what’s in your head as what’s in your prostate actually. Because um, you know, some people can’t stand the thought of cancer and want it removed at whatever cost. And other people are sort of fairly in a much more relaxed about the fact that, you know, I think if you say to people, you know, the chances of coming to any harm if we just watched this for a while and see what your PSA does and if it continues to rise, then you know, treatment is available later on. It was, it was very interesting in some of the studies that have been done, um, when they tried to get people into randomized studies, when the surgeons, you know, when they went to see the surgeons, um, and we’re given the option of watchful waiting, radiotherapy or having a radical prostatectomy. A lot of the surgeons would say, um, well, you know, you’ve got cancer, we can take it out and get rid of it. Or you can have radiotherapy, which should probably get rid of it. Or if you don’t want either, then I guess we could just watch it. And then of course, you know, people hear that and they say, well, you know, I’d much rather get rid of it. When they recorded some of these interviews and then trained some of the nurses to do it. Um, you know, then then the nurses would say, well, you know, there are three options. You know, you can, we can remove it now. We can give you radiotherapy now, but or we could just monitor it and by monitoring it, it means that we will just look at the PSA, we will see what happens to the BSA and you’re not going to be barred from having treatment later on if things seem to change. And the evidence at the moment is that it’s unlikely to do you any damage if we just monitor it carefully and just watch things. And you know, if you present it to the people like that, then a lot of them are much happier just to sit and watch it. So it does very much depend on, you know, what you say and how you present it as to what people will do.
Euan: Yeah. There’s an interesting dynamic there I think with that kind of approach. And as you say, I think there’s a real societal fear of cancers, you know, not helped perhaps by constant, I understand that, you know the constant telethons and charity events and there’s raising awareness and I know that they’ve moved away slightly from this sort of the fear element, but I think it does play into that, that people do think that, you know this, you could almost be better describing some of this is prostate disease rather than prostate cancer. That isn’t, you don’t necessarily rush in and chop it all out immediately. And those options don’t cease to be available in the future if you choose to watch for for a short period.
David Cranston: I think that’s the important thing. So it’s just the idea of sort of active monitoring of it and you know, see what the trend in the PSA is decided from when you’re going to do an MRI, if it goes up, are you going to do another MRI, et cetera.
Euan: And it’s probably worth pointing out there are some groups where there’s slightly stronger evidence of benefit, isn’t there for PSA testing, particularly screening.
David Cranston: Yes. I think that’s right. And I think if you, you know, there is, if you’ve got a very strong history of prostate cancer in the family, if you’ve got, so if you’re picking it up at a young age, um, you know, in your 50s and so on. So yeah, so I’m certainly not against, um, uh, you know, advising people to have radical treatments in, um, in appropriate situations.
Euan: Yeah. I think… So your family history is one thing. Um, the younger man sort of 55 to 69, there are a bit more, once you got beyond the age of 70, it becomes, it’s an individual decision of course, but it becomes less likely, I think African American, um, ethnicity as well. They’ve got an increased risk, they are no better off being tested… perhaps might have more to gain from screening.
David Cranston: Yes. I think the thing is that, you know, if you’re operating, you don’t, you know, it’s, you can’t, cannot, um, look at the mortality basically of people cause you will, in terms of mortality, you need, uh, 10, 15 years, which is why, you know, somebody at the age of 70 or 75 is picked up with prostate cancer…. you’re not gonna see any benefits to life expectancy probably for 15 years. So it also depends on morbidity, mortality. I mean, I saws a patient a few weeks ago who had a PSA of 12 at the age of 82 and was given radiotherapy, which I think is almost almost negligent. And he had incontinence, impotence, haematuria and a huge amount of symptoms over the last three years. And now he’s at the age of 86 and if he had just been monitored… Or even if it just been given a low dose of hormones, he wouldn’t have had those symptoms. I think that was a very bad medicine.
Euan: Yeah, there’s a really interesting, I think Margaret Mccartney wrote about this in our book, the Patient Paradox. And there’s really interesting, um, aspect around screening and treatment that you’ve mentioned there that once you know about it, it’s like the rattlesnake in your pocket as you described it, that gentlemen, it’s very hard for people if they’re, and if they’re not given appropriate support by healthcare professionals, just to let it go. But the paradox is that patients are grateful with even bad screening programs. They’re grateful… because if they haven’t got the disease, then they’re happy. And if they have got the disease, they’re delighted because they think, well, I can now get rid of it. And the risks of overdiagnosis, the risks of overtreatment and the side effects almost never get taken into consideration. So I mean, if I had one message for people when they’re looking at this is just a really look hard. There’s not, it’s not a straightforward subject. There are, there are, there are a lot of complications and nuances, but what we perhaps underestimate really badly are the potential risks and harms of the treatments and the investigation process as well.
David Cranston: Yes. I mean, I think part of the problem is that you get on a treadmill, which is then very difficult to get off. Um, you need a sensible discussion with a sensible, uh, you know, urological surgeon or radiotherapy doctor if you are having, you know, if you’re diagnosed with it. I think if you on the NHS system, if you go, and know, get on, you know, see a junior doctor, you know, there are certain protocols that they will follow regardless in terms of, you know, if it’s above four you need to have an MRI scan, you need to have potentially prostatic biopsies and then once you’ve had the diagnosis, then um, you know, you have all the sort of discussions of treatment and some surgeons are much more aggressive than others in treating you. So, uh, it is a bit like if you’re not careful, you get on a treadmill that you can’t easily get off.
Euan: Yeah. You get into the system. So, um, let me ask you this final thing, David. What’s your personal view on PSA? Where do you, where do you fall on this? Whether you’d have a test or not.
David Cranston: I’ve thought long and hard about this. As one can imagine being a urological surgeon involved in it. Um, I did have my PSA done when I was 50. It was 2.2. It’s been rising slowly since. It’s above four now. Um, although not much above four, it’s been fluctuating up and down in my mid sixties. I have decided that I am not going to have anything done until it reaches 10. If it reaches 10 by the time that I’m probably 75, I might have an MRI scan. If I get to the age of 80, I um, would let it go up to 40 probably. And then I would think about going on to something like 50mg of biclutamide… I think the other thing that I would just like to say is that even when you have metastatic disease, it doesn’t mean that you’re going to die within a few months. I had a patient some years ago at the age of 80, who had a PSA of 2000. He had multiple metastatic disease throughout his bones. He was in a wheelchair, we put him on hormone treatment – within about three months his PSA came down to six for the next 8 years he was flying out to Austria on holiday every year until it finally caught up with him. So even if you have metastatic disease, actually there is a treatment available.
Euan: Yeah, absolutely. So I think my feeling personally is that I wouldn’t have a PSA test. I’m still, I’ve got, I’ve got three or four years until I’m 50 but um, I think I probably wouldn’t because I am more in fear of the consequences of over treatment as it stands. But I think it’s important that you had it and to highlight that you had it. But we don’t come down too negatively on the side of PSA because it is still an individual decision. And I know it’s offered on the NHS and the evidence kind of, you know, the evidence is marginal in some regards.
David Cranston: I mean I have a urological surgeons who are high profile in the British Association of Urological Surgeons who are approaching their sixties who’ve never had their PSA tested, and do not want to have it tested. Others on the other hand have had it tested and some have had radical prostatectomies. So within, you know, the urological surgeon community alone, there is a huge range of whether people want to have it done.
Euan: Yeah, that highlights, just highlights the challenges nicely, doesn’t it? David, thank you so much. I should ask you where could we find out a little bit more about what you’re up to, your work and research these days?
David Cranston: The best thing is the Nuffield Department of Surgery, website in Oxford which is www.nds.ox.ac.uk. which has got my research interests, especially the ongoing one, which is high intensity focused ultrasound and my links with China, which I’ve had over the last 20 years.
Euan: David that is fantastic. Thank you so much for taking the time.
David Cranston: That’s a pleasure. Very nice to talk to you.