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Man Alive

Joining OnFocus in this episode to discuss prostate cancer screening, NHS data sharing and maintaining wellness is GP and Men’s Health specialist Dr Jeff Foster. Dr Jeff is the author of Man Alive in which he examines the most commonly misunderstood aspects of men’s health. His expertise on testosterone deficiency, erectile dysfunction, prostate health, cardiovascular disease and nutrition & wellness has been shared widely through media and applied in his clinical practice.

 

Clare Delmar

Hello and welcome to On Focus brought to you by The Focal Therapy Clinic, where we connect you with issues facing men diagnosed with prostate cancer that are little known, less understood, often avoided and even ignored. Prostate cancer is now the most commonly diagnosed cancer amongst men in the UK, and with this sombre fact comes a multitude of challenges and opportunities. I’m Clare Delmar. Joining me today is GP and men’s health specialist Dr. Jeff Foster, author of Man Alive, in which he examines the most commonly misunderstood aspects of men’s health. His expertise on testosterone deficiency, erectile dysfunction, prostate health, cardiovascular disease and nutrition and wellness has been shared widely through media and applied in his clinical practise. Dr. Jeff, thank you so much for coming today and welcome to On Focus.

Jeff Foster

Thanks very much for having me.

Clare Delmar

One of the things that introduced me to you was obviously your book, which we can talk a little bit about later. But you recently had a piece in The Times which got a lot of attention where you talked about screening for prostate health, screening for prostate cancer specifically. And I wanted to just sort of start off on that and ask what your observations have been over the last 18 months during the pandemic on screening for prostate cancer. And why you think this is important? What’s changed and what do you think men can anticipate going forward?

Jeff Foster

Yeah, sure. So at the initial start of the pandemic, the uptake in all forms of screening and almost all primary health care just stopped almost dead to the point where it would probably be the first time since I qualified that we had clinics and you would have space and there was time and no one actually came in asking a question. And this lasted through the initial period where everything stayed very calm. And then, of course, there’s a degree of acceptance and understanding about what was happening. And then gradually people’s health needs, health anxieties started to go back up again. And now we’re seeing the opposite. And it’s the rebound effect because in a lot of these scenarios, the end result in terms of patient user demand works out the same, except we’ve got a big gap where nothing happened so suddenly we’re now trying to cram all that stuff back into the same amount of working day, which means obviously it’s a big challenge to do.

Clare Delmar

And how does that play out with screening for prostate cancer and specifically around PSA testing?

Jeff Foster
The big thing for PSA testing, from my perspective, is that it’s how you use the PSA that’s important. And we regularly, I would say our practise has just short of sixteen thousand patients in the NHS practise, we would have maybe one or two patients a week who would just request to have a PSA test. They wouldn’t necessarily want to see a doctor to discuss that, but would just send an e-consult or a medication request and on that would say, can I just book for a PSA test?

Clare Delmar

OK

Jeff Foster

These are not the same guys that have symptoms and these are not the same guys that are already under urology or may have other urological problems. But just that understanding that some people know about PSA, they’ve heard of it and they think I just want it tested. The problem that we have is that obviously you then say to your patient, well the PSA is not a widely accepted national screening tool for all forms of prostate cancer. It doesn’t work that well. But on the other hand, you also say, but on the other hand, it’s the best we’ve got for now. So you have to have this middle ground. You have to really counsel every patient to say, what is your risk, your age group, what is your expected level of PSA? And then you can start to give them a bit of informed choice about what they want to do with that test and whether it’s going to be useful, and even if they do have it. What do you do with that result in maybe six months a year, five years time.

Clare Delmar

But you made a comment a minute ago about what your expected PSA. I think that’s how you phrased it. I mean, do you see a point where every man should have a baseline PSA and then they maybe eventually begin to self track?

Jeff Foster

A single PSA by itself I would consider to be useless. And obviously, as part of the book we spoke to several urologists about this and there is so much discussion around when and at what point we should start looking at people’s PSAs. I think a PSA is very useful if it’s initially screened properly and then it’s used cumulatively. And the whole thing about medicine now, it’s moving away from subjective feelings and symptoms of disease. And we’re looking to gain as much objective data as possible. And patients want to see their PSAs. And if you can say I’ve got a guy’s PSA every six months for five years, then that’s useful data. And you can do something with that.

Clare Delmar

Yeah, but I guess that’s what I meant when I suggested self-monitoring or self tracking. I mean, do you foresee a point where you have your initial baseline done through a GP like yourself, but then you are able to monitor regularly whatever period that regularity is, Do you see, that is something in the future?

Jeff Foster

Probably not, to be honest, purely because again, there are too many variables around the local labs and what their PSA might be. How do you reliably get your patient to get from…. If they are not getting it from primary care, where are they getting the PSA from? Who’s responsible for that test if it comes back abnormal, if you didn;t order it?

Clare Delmar

Indeed.

Jeff Foster

Is there anything better than a PSA you could use that more to fill that gap.

Clare Delmar

Well, I’m going to come on to that, that you raised a really interesting point and I am going to come on to that. But but again, you use the word variability, and that’s something that we’ve been looking at a lot because we hear about it so much from our patients who, again, you talk about data, you know, we can track patients who have had such variable experiences across the NHS, whether it’s from different parts of the country. And I guess that’s something that I wanted to explore a little bit with you, that this variability in both the screening and in the diagnostic pathway that follows. How do you think this can be addressed in the sort of medium term and ultimately in the longer term? Because it can’t stay that way, if one person gets tested one way and has a different type of biopsy or a different type of imaging or different type of treatment. How do you see that playing out?

Jeff Foster

The inherent problem with the pathway is the PSA itself. So if you are to compare, for example, with breast screening, a patient has a mammogram, based on that result, it then goes to a specialist who will then review patients. The follow up process is very, very clear. And the operating procedures are so well established, you can apply them to a national accepted screening process. If you have a test like PSA, which no one really agrees what use it really is, then you can’t apply a very well regulated process to go with it. There’s rough processes and NICE guidance and two week criteria still fits and if you’ve got some enormous PSA you can just refer your patient. But of course there’s so many variables around that. I mean not everyone get referred and some hospitals will run the results of those PSA differently to others.

Clare Delmar

So now, I do want to come back to your point you made earlier about the PSA being that the best we have, I think, is how you expressed it. You know, amid this kind of controversy, we’ve actually begun to see a new approach in imaging that’s emerging that it could be used for screening. And in fact, you mentioned mammogram is already being compared to a mammogram. In fact, it’s being called the prostagram. Do you see a role for this in primary care in future?

Jeff Foster

If you could devise a screening test that was cheap, reliable and minimally invasive and you could get men to engage with that, then it would easily surpass the PSA. And if you could have a national screening prostagram service or something similar comparable to cervical screening or breast screening, and it allowed men to be walking in for a quick image which was non-invasive, had a very good pick up rate and was relatively cheap to do, then we could get rid of PSA as a screening tool in primary care completely.

Clare Delmar

Are you familiar with the prostagram? In its current form it’s still being trialled.

Jeff Foster

Yeah, and the problems with it at the minute would be the cost is too prohibitive. You couldn’t use that as a GP referral source because everything we have to do has to be justifiable in primary care. It’s a very odd scenario, whereas if you’re a hospital doc and you work in the hospital, for the majority, 99 percent of stuff, you can just test for it if you need it, there’s no look at the budget. Whereas in primary care, you are budgeted on everything you do. And if you over investigate, you are penalised for it.

Clare Delmar

Interesting. Gosh, I could talk about this one for a while, but I won’t. I want to come back to, again, something you referred to earlier, which is around data. There’s been a lot of discussion around how the NHS is using patient data and particularly GP records. What are your views on this and how do you see the NHS data being used to support and advance men’s health?

Jeff Foster

It’s all about what you feel you want your data to be used for and what understanding you have in terms of what your data offers. So to clarify, what I mean is, a lot of people are very fearful of giving their NHS data out, as if in some way this is going to impact on their ability to function in life, as if in some way this is personalised stuff that we don’t want Big Brother to know, that sort of thing is very hidden. Whereas actually what we’re finding also as we move to the electronic system of prescribing and hospital sharing of notes, is that actually data in the NHS is not particularly well protected anyway, and it is shared amongst various groups within the NHS quite freely. If you then say you want to sell it on to third parties, well of course that has to be with the explicit consent of the patient because you’re crossing that that boundary from what is NHS agreed. When you signed up to this, you agreed to do that. Well, actually, I might have BUPA, Virgin, Nuffield, any secondary company might decide, actually, they’ve got your data and they might be able to advertise something to you. Now, if this is the way that the NHS could fund it’s shortfall, then perhaps people might agree. And it might be a very easy way of plugging a financial gap that’s badly required. On the other hand, people are also very protective of the NHS and the NHS data, and they feel that their health records are very personal to them. So I think you probably could do it and you probably could do it quite successfully. But I think the way it’s been done almost surreptitiously and with a lot of behind closed doors sort of feel behind it has meant that for many patients it has not been a very positive experience into the data sharing.

Clare Delmar

Which is such a shame. If we could square the circle, because, as you said, it potentially plugs a financial shortfall. But also, as we’ve seen during the pandemic, when clinical trials themselves are being compromised, data has become the way we actually do our studies and look at how we actually will advance various problems in health care. I mean, so you’ve got this resource, but somehow it’s kind of stuck.

Jeff Foster

Yes, I totally agree. And the bigger issues around this are that firstly data in the NHS is not linked. So, for example, patients always imagine that the hospital guys can see what we write in our electronic notes, which they can’t. And the hospital also imagine that the district nurses can see what I write in the notes, but they can’t. And this kind of separated piles of data, the amount of information out there is just unbelievable. And if it was more readily available, the difficulty behind research would be surmounted so much more easily.

Clare Delmar

Well, again, this is something that’s going to, I think, plough on and on. And I guess at the end of the summer, we’ll see what kind of decision gets made on that. So just to close out, pull this back down to the patient level, so to speak, and that Times article that I referenced earlier was quite popular. And I’m really interested to hear what you have to say about how you would advise men, you know, at certain benchmarks, 40, 50, 60, and what the top thing is they could do in managing their prostate health.

Jeff Foster

I think the best thing you can do is don’t just focus on your prostate and to focus on any gland, any organ, any specific item in your body is the route to failure. Because if you are truly interested in men’s health and you’re interested in your own body and you’re interested in getting better quality of life, then you want to focus on your entire self, this holistic idea. So you would always say to every patient, when you’re 40, 50 and 60, you want to get a full blown health check and you want to look for everything that you can try and look for in terms of disease risk profiling. The reason that’s important in terms of looking at prostate health is because it has ramifications. So if, for example, you pick up one form of disease that may have implications on your overall prostate disease or prostate cancer risk, for example, there’s tenuous evidence, or slightly better evidence suggests that vitamin D supplementation could reduce your risk of prostate cancer. People don’t make that connexion, especially if they are thinking, crickey I need to look after my urine flow or to get a PSA test. But if you look at it as a wider picture, there’s lots of stuff you can do to improve your overall prostate health. So MOTs in the first plcae, get a health check every decade or even more frequently if you are able to. I think the NHS ones are very good in terms of the financial restrictions that we have. We can only screen you for the most common things, the diabetes, heart disease. We can’t really screen you for prostate cancer. We can’t look at the risk factors behind that. And I think after you’ve done the screening, the other thing to look for, what are those elements of my life that I could improve, that would decrease my overall prostate disease risk. And if you think of prostate cancer, I mean, yes, it is incredibly common for men, but it’s just another cancer. And if you think to yourself, what do I need to do to reduce my overall cancer risk? Well, there is very good evidence that for prostate cancer and others, if you’re just more overweight, that’s going to increase your prostate cancer risk. If you don’t exercise enough, that increases your cancer risk. Interestingly, large amounts of calcium, which seems to be more an isolated risk to prostate cancer than most others, but we’re talking pretty excessive amounts – necking pints of milk every day. Eating healthy diet is the most banal and what usually is unhelpful phrase, but you should eat a healthy diet, because you can make TV programmes out of it. But it really does work. And the sad thing is that it really decreases prostate cancer risk. If you can effectively keep your overall body healthy by not being overweight, by exercising and eating a healthy diet. Those are the best things you can do to remove prostate cancer risk.

Clare Delmar

Well, good advice. Well, on that note, I think we’re going to close out. I want to say thank you so much for speaking with me today. It’s been a pleasure for me and I know our listeners will find this extremely helpful. So thanks for joining me. Dr. Jeff.

Jeff Foster

Thank you.

Clare Delmar

Links to Dr. Jeff’s book, website and media pieces are available on the programme notes. Further information on prostate cancer diagnosis and treatment is available on our website, along with a transcript of this interview and additional interviews and stories about living with prostate cancer. Please visit www.thefocaltherapyclinic.co.uk and follow us on Twitter and Facebook at The Focal Therapy Clinic. Thanks for listening, and from me, Clare Delmar, see you next time.

 

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