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21 October 2020

Repeated testing can catch prostate cancer – but it also creates a terrible dilemma

I groaned inwardly when the results of Jeremy's MRI scan came through: a couple of “indeterminate” areas. Not the definitive all clear I’d hoped for. 

By Phil Whitaker

Eighteen months ago, Jeremy went to the bathroom and peed blood. Frank haematuria looks alarming: a little blood goes a long way when mixed with urine, making a haemorrhage appear far heavier than it actually is. But even though people rarely lose significant amounts, frank haematuria needs careful evaluation.

The real concern is that it might be the harbinger of a tumour. Bladder cancer is strongly smoking-related and Jeremy had never acquired the habit, but cancers of the kidney could certainly present at his age. And although still quite young, in his early fifties, prostate malignancy was also definitely on the cards.

There’s a standard investigation protocol: blood tests, a cystoscopy (a tiny camera inspects the bladder lining), and an ultrasound of the kidneys. Jeremy’s results were through within a couple of weeks. No tumour, and there appeared to be a stone in the left kidney. So far so reassuring. Yet there was a niggle: the prostate specific antigen (PSA), a blood marker associated with prostate cancer, was at the upper end of normal. Jeremy had undergone a private health screen when he’d joined a new production company the previous year. The PSA then had been half of what it was now.

It probably meant nothing, I explained: all test results undergo random fluctuations. We should arrange a repeat PSA a few months down the line. Plus, we would check urine samples to ensure the blood disappeared as it should.

The problem was, it didn’t. There had only ever been one episode of visible bleeding, but dipstick testing revealed persisting microscopic traces in Jeremy’s samples. The urologist was unhappy: could the ultrasound have missed an occult malignancy? So he arranged a CT scan, to provide higher resolution images.

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After a slightly anxious wait, nothing untoward was found. But the good news was tempered by the latest PSA – it was now running above the normal range. Fewer than one in 20 PSAs at that level will be linked to prostate cancer, but the urologist wanted an MRI scan to be sure.

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I groaned inwardly when the report came through: a couple of “indeterminate” areas. Not the definitive all clear I’d hoped for. More monitoring. Jeremy was trying to put the ongoing uncertainty to the back of his mind, but worries about his wife and daughters should the news ultimately prove bad were never far away. His next PSA was due this summer. I hoped for good news. Instead there was a shock: a sudden sharp hike.

On the face of it, this looked horribly like prostate cancer. Except that Jeremy had been riding his bike daily throughout lockdown. A repeat test after a short period of strict cycling (and sexual) abstinence saw the PSA reduce, though it remained abnormal – but this was not how malignancy would behave.

I rang with the result. This was a screening dilemma, I explained, nothing more. That episode of frank haematuria 18 months previously? It had been a one-off. The PSAs it had set us chasing? Most at this level were not a sign of cancer. And even if they were, knowing about it wouldn’t confer any benefit, because it was far from clear that tiny tumours picked up like this actually cause trouble.

Even as I was speaking, though, I could sense the hollowness of my words. There had been too many scares and reverses. Jeremy had had enough, as had his urologist, who swiftly arranged prostate biopsies. All 24 needle passes proved clear.

During our final discussion, Jeremy mentioned the urologist himself was now talking in terms of it having been a screening dilemma. But there can never be certainty: “He said the biopsies could still have missed a microscopic cancer. He recommended I get the PSA checked annually.” I smiled wryly and said I thought that was probably the very last thing he ought to do. 

This article appears in the 21 Oct 2020 issue of the New Statesman, Ten lessons of the pandemic