Approximately 10,000 men are diagnosed with prostate cancer each year and around 2,500 die from the disease. After the Swedish National Board of Health and Welfare (Socialstyrelsen) rejected the introduction of national screening using only PSA tests in 2018 on the grounds that it could lead to overdiagnosis, a number of initiatives have been taken to provide various forms of organised testing for prostate cancer in Sweden. Following large-scale development work involving collaboration between researchers and experts in urology, communications and IT, Region Skåne launched Organised prostate cancer testing, OPT in 2020.
OPT is based on a completely digitalised system. In a first step, a so-called pilot, 1,000 men aged 50, 56 and 62 were invited for testing. The men who accepted the invitation were automatically sent their test result. A so-called examination algorithm reads the PSA value and the man’s age and determines how he is to be examined and treated. The message may be a new examination in two years or in six years or very soon.
"Building the best algorithm is not simple. For example, the PSA level must be age-related. Our algorithm follows the recommendations of the national care programme. If the PSA level is a little too high, the patient should first get a magnetic resonance imaging (MRI) examination", says Anders Bjartell, Professor and Senior Consultant in Urology at Lund University and Skåne University Hospital.
Magnetic resonance imaging (MRI) and fusion biopsy
An MRI examination of patients with elevated PSA value is today a routine procedure in the diagnostic set up. With MRI, it is easier to find a tumour that is located in an unusual place in the prostate, but also to ascertain whether something looks harmless. After MRI, you can today proceed with targeted tissue samples using fusion biopsy equipment, where images from the MRI examination are combined with ultrasound. This means that you can avoid taking unnecessarily many and painful tissue samples, which has previously been the standard procedure.
The evaluation done after the first pilot shows that the fully digitalised system works well with small adjustments. The number of ascertained cases is well in conformity with the estimated number of cases. During 2021, Region Skåne has continued to invite men for testing. By the end of the year, 9,000 men aged 50 and above are to have received an invitation.
"When we now start rolling out the project on a larger scale, we will start with younger men. We will then see the capacity that we need to build up we are to expand the system as quickly as possible. If, for example, we had invited men at age of 68 for testing, we would probably not have had sufficient capacity this year to cope with this,” explains Anders Bjartell regarding the selection process.
A fairer system
Equality is a key aspect of organised prostate testing – anyone who wants to be tested for prostate cancer should have the opportunity to do so. The invitation that is sent out has been translated into English, Arabic and Somali.
"Studies show that the long-term mortality rate of prostate cancer is reduced in case of early detection. Here we follow the guidelines of the EU’s cancer plan – to prioritise early detection of cancer. Prostate cancer is one of the priority areas", says Anders Bjartell.
Erik Thimansson is a radiologist at Helsingborg Hospital, and he is working on a doctoral thesis focusing on OPT:
"Our organised prostate cancer testing is inadequate, as men with the highest risk of cancer are not always those who take a PSA test. We need a fair system in which all men have the same opportunity for being testing as women have with a mammography. We are not there yet, but OPT is a model for how such screening could work."
AI may become an important aid
An Achilles’ heel when scaling up organised prostate cancer testing is the analysis of the magnetic camera images. In Erik Thimansson’s research work, he focuses on how artificial intelligence (AI) can help radiologists save time when examining the images.
An important parameter in prostate cancer diagnostics is the correlation between the PSA value and the size of the prostate gland.
"AI can distinguish between what is and is not prostate, and provide us with a prostate volume. AI may be used for this going forward, and, in the longer term, AI may help us ascertain and rule out cancer. But we must proceed calmly, and validate each step, so that we feel secure", says Erik Thimansson.
He definitely believes that AI will be used much more within the next five to ten years, not least to evaluate the large databases with patient information that are created in connection with OPT.
"AI will not replace us radiologists, but it can be used for time-consuming tasks that are well suited for performance with AI."
Slight risk of overdiagnosis
The Swedish National Board of Health and Welfare’s rejection of national screening is based on concerns about overdiagnosis – that there is a risk of patients being diagnosed with cancer despite their cancer never having developed into a serious disease. But Anders Bjartell does not see such risks with OPT:
"Over time, we have learned that prostate cancer can have a mild and slow course. We do not offer treatment unless there are reasons for it, and we do not perform unnecessary surgery or radiotherapy, which was probably the case before. For the cancers that we assess as low risk or low-low risk, we initially do not offer surgery or radiotherapy, but merely follow-up. In this way, we avoid excessive treatment. "
Anders Bjartell also thinks that the healthcare system needs to listen more to prostate cancer patients.
“It may seem excessive to ascertain a tumour the size of a millimetre. But we need to listen more to the men who find themselves in this situation; how they experience being diagnosed with cancer relative to knowing that it has been discovered early, that it is not dangerous and that it is under control. It probably varies greatly from one man to another. Being diagnosed with prostate cancer is generally an awful experience for all men. Some may take comfort from feeling secure in knowing that their cancer is of a mild nature.
Important with more knowledge
Anders Bjartell, who both conducts research and works clinically, finds it important to emphasise another aspect of prostate cancer. Many patients he meets have an incorrect picture of what a cancer diagnosis and treatment entail. Many believe surgery and radiation mean the end of their life as they know it, including their sex life. He has met some men who have refused treatment, despite the risk that the cancer may have spread to the whole body in five years.
"It is important to be aware of and also conduct research into this attitude. We need to talk more about prostate cancer in society. The goal is for all men to be well informed about what it means to get prostate cancer and how it is treated. In this connection, patient associations have a huge task of providing good information when a patient diagnosed with prostate cancer calls them. "
November is the month for Prostata Cancer Awareness