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Table of Contents
Abstract........................................................................................................................ 3
Introduction:.................................................................................................................. 4
Background.................................................................................................................. 5
Results......................................................................................................................... 7
Policies at International, national and local level.................................................................9
Determinants of the public health issues.........................................................................10
Agencies, approaches and strategies............................................................................. 12
Legal and ethical issues................................................................................................ 13
Recommendations....................................................................................................... 14
Conclusion.................................................................................................................. 15
References:................................................................................................................ 15

2
Abstract

Prostate cancer is the most common cancer occurring in males and it is also the second
leading cause of death. The research is going on in this area and no specific symptoms
have been declared to be evidence of the cancer at early stages but some symptoms
are present in the later stages of cancer. The diagnosis and treatment evidences are
continuously changing with the research. The paper has the aim to review and discuss
all the background information, research, strategies and policies to provoke and
highlight the issues handled by the urological community. There is a review on the
prostate-specific antigen screening, targeted therapy and many other treatments of the
prostate cancer. There are some evidences that the prostate cancers are alike with
greater occurrences in the black men but no differences in the mortality rates in different
ethnicities. The paper may be helpful to find out what possible cancer treatments
pathways and opportunities are available for men being at potential risk of developing
prostate cancer on the basis of the data supporting more occurrences at the later age of
60 and above.

3
Introduction:
Prostate cancer is the prostate gland cancer that is a part of male reproductive
system (ProstateCancerUK.org, 2017). It is located on the inside of body just below
penis, in front of rectum. There are glandular and fibrous tissues packed in the
convective tissues. Normal working of the prostate is based on the male hormone
testosterone and it produces semen carrying thee sperms. Prostate cancer has been
number one cancer in men in United Kingdom almost 1 in 11 men develop this cancer in
their lifetime in the population of United Kingdom (ProstateCancerUK.org, 2017). . Over
eighty percent of the cancer cases are diagnosed in men in sixth decade of life. From
1973 to 1987 the risk of cancer has been elevated almost 47% percent with a general
increase of 2.6% in almost every year (Stephenson et al, 1996). On an international
scale, this is the second most common cancer in men and fifth leading reason for death
in men. 1.1 million Men suffered this type of cancer in 2012 and it led to the death of
307, 000 deaths in diseased men (ProstateCancerUK.org, 2017). . Detection rates of
the cancer has been increased quite significantly over past few decades however, in
30% cases where men die of unknown reasons, 30% have the prostate cancer and
most of them are above the age of 60 (Cancerresearch.org, 2014).. According to some
researches, black men around the world have higher chances of getting prostate cancer
as compared to other ethnicities. The purpose of the paper is to educate about the
prostate cancer, creating awareness as well as reviewing the diagnosis, treatment and
other policies affecting in these area at local and international level.

The prostate cancer was first explained in 1536 by an anatomist Niccol Massa
and illustration was done in 1538 by Andreas Vesalius. The cancer was not been
diagnosed till 1853 and was considered a very rare disease as there was small life
expectancies and bad methods of diagnosis. Surgical removal of this type of cancer
was performed for first time in 1890, however, this practice had very limited success
rate. Later chemical castration with the help of estrogen had been devised by Charles
B. Huggins in 1941 that also won a Nobel Prize. Radiation therapy was first started in

4
early twentieth century and also contained the intraprostatic radium implants
(Johansson et al, 2004). Later another therapy called External beam radiotherapy was
used successfully and other ways of treatment included Brachytherapy with implanted
seeds and Systemic chemotherapy (Aus, 2006).

Background
The exact cause of the prostate cancer has not been the common knowledge
however, according to the researchers; this cancer is developed over many years with
slight changes in the cells with age (Weed, 1999) There is no research till now that
claims the exact reasons of the disease, however, some possible causes have been
suggested to e hormonal effects, genetics, lifestyle and environmental elements, viruses
and sexually transferred disease etc. in may researches of prostate cancer, the data
from the population have given ambiguous or opposite results. Genetics and hereditary
is thought to be very important reason for prostate cancer and risks are involved for
diseased mens relatives. However, there are some studies that do not support this
information. According to some research, a diet rich in fats can be the cause of cancer
over years.

The cancer cells in prostate cancer can pass one body part to other especially in
lymph nodes and bones. In most of cases, the prostate cancer is slowly progressing but
in some cases it is very fast growing (Bradlyn et al, 1995). There are no exact
symptoms of this cancer in the earlier stages but over time, as the disease progress
there are problems in urinating, pain in the pelvis, blood during urinating and some later
symptoms are fatigue due to less number of blood cells (DAmico et al, 2008). However,
there is a disease named as benign prostatic hyperplasia that can produce the same
signs. The disease is somehow linked with the gonorrhea; however the reason has not
been identified.

The prostate cancer has been diagnosed with the help of biopsy, later medical
imaging is done to check if it has been spread to other areas of body or not. Cancer

5
screening in prostate is quite controversial as prostate-specific antigen (PSA) can help
in the detection of cancer but is not helpful on decreasing the mortality (D'amico et al,
2004). Hence, in many preventive services, the screening of prostate cancer is advised
to be avoided as many times the cancer diagnosed stays asymptomatic. Hence, the
benefits of the testing dont outweigh the harmful impacts of the screening that are
expected. 5-reductase inhibitors on the other hands decrease the risk of the low level
cancer but are not seen to affect on the high grade cancers hence these are also
advised to be avoided. Also, no level of supplementation has been research to have any
impact on the occurrence or risk of cancer (Byar et al, 1987; Sboner et al, 2010).

There are many other treatments like hormone therapy, surgery combinations,
and radiation therapy (Scl'lwartz et al, 1990). When the cancer is present only to the
prostate and limited then it can be curable, however in cases where the cancer has
been spread to the other parts particularly the bones, then some other treatments like
pain medications, targeted therapy and biphosphonates could be helpful (Potosky et al,
2004). Results and impacts of the therapy and treatment are based on the age of the
person and many other health factors and also on the grade of cancer and the type. In
many cases, people do not die because of the prostate cancer and there is usually 5-
year survival rate (Boyle et al, 1995). An annual screening of men over the age of 50
has been recommended and the people who consume a lot of animal fat particularly red
meat are expected to be at more risk (Hanks et al, 1997)

Results
In United Kingdom, Prostate cancer accounts for 26% of all the cancer cases in
men and there were 46,690 reported cases of prostate cancer in men in 2014
(ProstateCancerUK.org, 2017).the European age-standardized incident rates are quite
lesser in Northern Ireland and Scotland as compared to Wales and England. No other
important differences have been observed between the constituent countries of United
Kingdom. The cancer is very much related to the age and incidence is far higher in older
males and in years 2012-2014 almost 54% of cases were diagnosed in males above the
age of 70 (cancerresreachuk.org, 2014).. Age related occurrences increase sharply at

6
the age of 50 and above and is at the maximum level in the age 70 and above. There is
later drop in the cases at the age of 80 and above (cancerresreachuk.org, 2014). Almost
13% of the deaths related to cancer are linked with the prostate cancer in 2014, 11, 287
deaths have taken place in UK due to this type of cancer. However, there are no certain
differences between the countries regarding the European age-standardised mortality
rates (AS rates). The lifetime risk of suffering this cancer is 1 in 8 in United Kingdom,
roughly around 35 % in black men, 15% in white men and 7-10 percent in Asian men.
However, the mortality rate is quite similar in all these ethicalities in the case of this
cancer. Black men show a poor prognosis of the disease as compared to white men and
some link is due to the poor socio-economic condition

Source: cancerresearchuk.org

The reasons for the increased risk of prostate cancer in black men are still not
understood (Jemal et al, 2005). Clinical trials have been conducted in European

7
Randomized Study of Screening for Prostate Cancer and the Prostate, Colorectal,
Lung, and Ovarian Cancer Screening trial. There are no evident differences in the
diseases characteristics at the time of the investigation of the disease. Black men have
more likeliness to undergo the radical treatment as compared to the white men (Jemal
et al, 2006). No specific differed in the survival rates of the black and white men have
been seen in the UK process studies.

Policies at International, national and local level

An independent task force has been set up by the United Kingdom government
in 2015 that had to develop a new cancer strategy of five years and it was inclusive of
all men whether diseased or healthy. The members of the taskforce along with the
prostate cancer specialists used many new models for cancer support and the funding
was acquired from the Movember foundation. Hence, now a feedback has to be
collected from all the patients about the services and the treatments of the disease. This
is a comprehensive strategy for post-treatment support for people who are living with or
without cancer.

A large capital has been fixed to be spent on the diagnostic equipment,

implementation of post-cancer support and additional staff. A great experience of
treatment is the access of men to the Clinical Nurse Specialist (CNS), and this leads to
better patient care. Hence the strategy has been made to make sure that more and
more patients get aces to CNS. There are also cancer alliances in different regions
offering better chances of partnership among patients and the services and the funding.
Also the provider, clinical leaders and local authorities have been the part of this
process. These cancer alliances have access to the local data about the cancer
research to check if there is any need of improvement in the pathway of cancer
treatment. Hence, it is made sure that the resources are being used at paces where
normally men are unable to get good treatments, services and support. NHS England
has given guidance to the local areas for providing the services to support the men

8
living with or after cancer and also to support men facing treatment-induced erectile
dysfunction (Prostate Cancer UK, 2017)

In the implementation of this strategy, Patient experience is the key element and
it keep the cancer patient experience survey in account to see the insights from various
communities. There has been approach to get the feedback and insight from the people
of all the races, and ethnicities, that will be used to enhance the program named Men
at Risk that focuses especially on black men as they are more prone to face the issue
of prostate cancer (Cooperberg et al, 2005). However, there is not much focus on the
early diagnoses as there are no symptoms of prostate cancer that can be recognized at
early stages (Auanet.org, 2007). Hence, more focus is given to the screening program
of prostate cancer. More and more resources are being used to increase the capacity of
diagnosis in the men and there are designed risk assessment tools.

There are cancer support societies in different countries that assure that the men
have complete insurance coverage in the case of prostate cancer screening exam.
There are many ideas about the use of exam and lowering the incidence of prostate
cancer. Men get free consultation with the doctors. However, routine testing has not
been recommended by cancer societies. Information is also advised to be offered by the
healthcare providers and the doctors on the possible risks and the benefits of the
prostate-specific antigen (PSA) testing hence, it allows them to take informed decisions
whether they want to get tested or not (Fowler et al, 2000).There have been a number
of laws regarding the prostate cancer like health insurance coverage for screening of
prostate, research funds for prostate cancer and public education on the disease. The
private health insures also cover the tests of the prostate cancer including the DRE and
PSA test (Stock et al, 2006). There are also other health plans which offer coverage to
the prostate cancer test screening. The main mission of the authorities is to raise funds
for developing the strategies and programs for public awareness, support, prevention
detection and treatment of the prostate cancer. People with disabilities are
independently respected and give same opportunities.

9
Determinants of the public health issues

People facing the problem of prostate cancer normally face different issues in
awareness, media coverage, funding and research hence a normal low level treatment
and poor results are common experience (Thompson et al, 2007). In 2001 in United
Kingdom there were 3000 Nurses who were training for breast cancer while only one
was training for prostate cancer. Also the waiting time for diagnosis after referral was
three months for prostate cancer while only two weeks for breast cancer. For every one
drug of prostate cancer in the market there were seven drugs for breast cancer
commercially available in the market (Prostate Cancer UK, 2017).There was also an
anti-make bias found in the case of funding and the level was four-to-one by both the
government and charities like cancer Research United Kingdom (Prostate Cancer UK,
2017).

The equality seekers and campaigners have been trying their hard to get the
favor form the governments to look in the negligence that has been going on in the case
of prostate cancer. There was also biased approach in the area of diagnosis and there
was no funding by the government to get the prostate cancer screening as mandatory
while there were full funded support programs for diagnosis of other types of cancer.
However, later the insurance coverage was mandated both in United States of America
and United Kingdom (Sandblom et al, 2011). However, there is normally less media
coverage in case of prostate cancer however a prostate cancer awareness cause has
been promoted in which a blue ribbon is used in the month of September for awareness
(Krahn et al, 2003)

When a patient is diagnosed with the prostate cancer, they are better informed
because of the multiple times screening with PSA and multiple visits to the urologists
and primacy health care providers. The patients can request for a second option by
other doctors and the specialists of radiation and oncology (Cooperberg et al, 2010).
There are many clinics where they are multidisciplinary specialists offering opinions to
the patents. After the opinions are considered by the patients a choice is made about
the further pathway of cancer treatment based on the facts and reports collected about

10
the disease. The possible pathways can be external beam radiotherapy, interstitial
prostate brachytherapy, active surveillance, and radical prostatectomy along with the
other treatments starting after two or three months later to diagnosis and identification of
the disease (Khatami et al, 2002). There are many complex decisions following the
diagnosis; however the most technical decisions are the choice of the type of surgery
like robotic prostatectomy or open versus laparoscosspic. Also there are decisions to be
made on the matter of choice of the type of brachytherapy isotope, and in some cases a
combination of different things is used like external beam radiotherapy or brachytherapy.
Limited information is preset on the mentioned interventions like in high-dose rate
interstitial prostate brachytherapy, high-intensity focused ultrasound, primary hormonal
therapy and cryotherapy etc. hence there are no expectations or anticipations known
regarding the outcomes of these therapies and treatments.

Agencies, approaches and strategies

A man with the problem of localized prostate cancer is unique from the men with
the prostate cancer spreading form last 20 years (Sandblom et al, 2011). With the
advancement in the technology of prostate-specific antigen (PSA) screening a dramatic
improvement in public awareness can be notice. This strategy started in the late 1980s
and is still progressing benefitting the men with prostate cancer and providing options to
diagnose the cancer. Normally a person suffering from the prostate cancer has
experienced the PSA testing many times in their life before they developed the prostate
cancer diseases and they could be possibility if many negative prostate biopsies.
However, cancer is mostly detected at later age. It is substantially detected at earlier
stages with PSA test screenings that is often a clinical stage and is detected with the
biopsy. Normally a patient knows its complete PSA history and there are multiple
experiences of visiting an urologist or primary health care provider in the lifetime for the
prostate cancer detection. The Gleason score for most common patients is expected to
be on 6 to 7 of the disease (Gleason, 1977).

11
 There are many agencies funding the research of the prostate cancer as
mentioned above and many policies are being followed to facilitate the patients with the
helpful services of intervention, treatment followed by the post-treatment support and
also support with the life after the treatment either with or beyond cancer. The policies
that are adopted for the screening needs to be appropriate and this is based on the
agony of suffering from the prostate condition, efficiency, possible negative outcomes
and the expenses of the screening. The present screening satisfies the primary
requirements however, the account for benefits, potential harms and the expenses have
uncertain data. The screening tests that are available based on certain antigens can
diagnose the cancer at earlier stages but there are no evidences to support and predict
the clinical results of the treatment if the cancer is diagnosed at the earlier stages (Byar,
1973).

The potential drawback of screening around 28 million men above the age of fifty
include many unrelated and unrequited checking of the thousands of men who are not
suffering from the disease or having just minor insignificant conditions that doesnt not
affect anything in their heath. Billions of dollars are spent on the effort to detect these
patients with prostate conditions and it consumes too many resources form the health
care service providers (Debes & Tindall, 2004). There are clinical trials that are
continued and are expected to provide the evident data. The public policy in the
meanwhile must emphasize on the services that can help prevention with the data that
is already available on the effectiveness of certain technologies. The patients must be
extensively informed about the potential harms and benefits of the interventions they get
while screening the dancer for detection before even going for it.

Legal and ethical issues

One important aspect of the prostate cancer screening and detection tests is the
area of provision of information to the patients. In most of the western countries it is a
requirement that people must be informed about what they are going to experience with
a possible intervention. The government may have been supporting and encouraging
the screening of prostate cancer, there is no need to make it compulsory for everyone.

12
The autonomy of a person provides her the rightfulness to refuse to these tests (Woolf,
1994). Hence, both legally and ethically, the persons autonomy is considered very
significant. Responsible authorities of healthcare make an informed consent and a
legally informed consent is very important aspect in the screening tests of the prostate
cancer.

Most important areas to consider are that consent is only valuable when the
person giving consent is fully aware of the potential outcomes with all the aspects.
Hence informed consent is very important and also the person must voluntarily give the
consent to go through the screening test of the prostate cancer (Schwartz, 2002). It
should not be only limited to the signing of the form to get a consent of the person. A
person must be given the details of the complexity of the situations and decisions they
are making prior to the test. A good practice takes a lot of time and it must be
compulsorily in the undergoing screening tests on all age groups of men (Markham,
1998)

An important ethical area to consider is that sometimes the social pressure can
affect the process of informed consent. People tend to face the anxiety during the
process of making the decisions whether to opt for the screening or not because of the
glorifying of certain facts and undermining the other. Hence social pressure can make
people convinced for certain decisions that are not rather achieved by legislative ways
(Woolf, 1994). It must be understood that this is not likely ethically to convince or
compel the individuals for undergoing certain screening tests without or with giving
information to them. Clinicians are forbidden to carry out this practice by compelling the
individuals to do so. It must be a common knowledge that the outcome of these
screening tests are not enough to outweigh the potential harms or compromise on the
health. Apart from the consent and educating the population, the other legal issue is the
confidentiality. Legally it is very important even when in United Kingdom there are many
exceptions on the law in this matter (Dunn & Kirk, 2000).

Law requires disclosure to help in the investigation of the serious risk to the
health to a specific person or to the common population. Hence, here the disclosure is
very important for the performance of the statuary or public duty and also it facilitates

13
the public interest. When a person is screened for prostate cancer, many other parties
have to get access to the information that is achieved from the screening. The partners
of the screened person may also like to now the genetic risks for the reproduction
reasons, the insurance companies and the employers also want to know the health of
the person as reliable information is needed about the individual for certain policies and
schemes (Leplege & Hunt, 1997). However, In UK the insurers must regard this genetic
screening in a way similar to the medical testing and it must be declared on the formal
forms only. Medical Reports Act 1988 shows that the announcement of the test results
must be on the discretion of the screened person. In many cases the confidentially is
given but ht practice is somehow very tricky (Thompson et al, 2007). When a person
learns about his genetics it has impact on the whole immediate family.

Recommendations
There must be more awareness created for the potential risks of the prostate
cancer screening and the governmental agencies must spend their res4oucses on
letting people know about the reasons of why a prostate screening is a very important
decision. An explicit consent of the person is very important before releasing the
information to the family, employers and the insurance providers. There can be potential
harms in screening of the prostate so there must be research to devise otter ways of
screening that protect the patients for harms and may result in earlier diagnosis of
cancer at initial stages. Further, the time of the diagnosis and the intervention is very
larger ranging from two to three months that must be decreased.

Conclusion
Prostate is the common most cancer in most of counties and especially in UK
where it is the second most common cancer leading to death. There are no clear
symptoms being declared as evident for the earlier stages of cancer and research is
going on for the matter. The screening of the prostate cancer is carried out at national
level which implicated many legal and ethical concerns. It may also expose the person
to some potential harm that must be in common knowledge before a person can opt for

14
the screening procedures. According to some researches, black men around the world
have higher chances of getting prostate cancer as compared to other ethnicities. The
purpose of the paper is to educate about the prostate cancer, creating awareness as
well as reviewing the diagnosis, treatment and other policies affecting in these area at
local and international level.

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18