Chris Hoy and cancer screening: is celebrity campaigning a bad way to make policy?
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2604 (Published 22 November 2024) Cite this as: BMJ 2024;387:q2604
Media coverage has been rightly sympathetic to Chris Hoy, one of the most successful cyclists in history, who recently disclosed that he has metastatic prostate cancer. The press has also taken up Hoy’s call that more men should be tested for the disease. He told the BBC that the age at which men can obtain a prostate specific antigen (PSA) test should be reduced from 50. “It seems a no-brainer,” he said. “Why would they not reduce the age? Bring the age down and allow more men to go in and get a blood test.”1
In a commentary the Independent said that Hoy’s intervention could save thousands of lives: “Some 12 000 men die from prostate cancer each year, many after begging their doctors to be tested—after which they are told they only have months to live. The Olympic cyclist’s call for a rethink of GP screening could be a game-changer.”2
The health and social care secretary, Wes Streeting, told the BBC that Hoy made a “powerful” argument, adding, “That’s why I’ve asked the NHS to look at the case for lowering the age . . . It’s obviously got to be evidence led, clinically led decisions.”
But few things are quite as vexed as screening for prostate cancer. Despite the charity Prostate Cancer UK advertising for all men over 50 and black men over 45 to speak to their GP about PSA screening, this is not official NHS advice. In fact, the UK National Screening Committee recommends against such screening, and government guidance is that GPs shouldn’t proactively raise the issue of PSA testing with asymptomatic individuals.3 This is because PSA screening performs poorly in reducing mortality and incurs overdiagnosis and treatment. However, men over 50 in the UK can request a PSA test on the NHS.
Hashim Ahmed, chair of urology at Imperial College London, says that it’s “absolutely fine” to raise awareness but that this needs to be “coupled with an honest and transparent exposition of harms and benefits.” He explains, “Men are capable of making decisions on their health without being scared into doing something that the current evidence does not support. Whilst feeling for the sad news of an individual being diagnosed with advanced prostate cancer, when it comes to screening we have to consider the population as a whole.
“That means listening to the silent majority who have had harms of over-biopsy and harms of over-treatment. We do have to absolutely and equally keep in mind those men who have cancer that affects their quality of life or shortens their life.”
Evidence review
Ahmed is even more sceptical of screening men under 50. “MRI scans are less accurate in this group,” he says, and they can lead to frequent biopsies as a result. “Watchful waiting,” where men are monitored rather than treated, can be difficult to maintain, leading to aggressive treatment such as radical prostatectomy. “That has harms,” says Ahmed. “With 20-30% having leakage of urine needing pads, and 30-50% losing erections, that is 30-40 years of poor quality of life with little to no benefit from being treated for such disease.”
In 2006, news that the pop star Kylie Minogue had breast cancer at age 36 saw a subsequent 40% rise in booking for breast screenings in her home country of Australia. In the UK, one breast clinic in Wales reported an increase in referrals by 61%; however, no associated increase was seen in the absolute number of breast cancers diagnosed, which were in keeping with projected numbers.4
Chris Twine, now a consultant surgeon, was working in the unit investigating those referral rates. He says, “It appeared that women were more aware or concerned about breast cancer after the story was reported so had seen their GP and been referred on. This large increase in benign referrals meant that people who had breast cancer had their appointments—and diagnosis—delayed, as clinics were full.”
A survey by Cancer Research UK subsequently reported that most women thought the risk of breast cancer was higher in women under rather than over 70.5 A press release at the time posited that the “Kylie effect” may be “very beneficial in that it raises awareness of breast cancer. But the downside is that it may also set up a chain of panic among young women while misleading older women to think that ageing is not a relevant factor in breast cancer.”
A planned evidence review of prostate cancer screening by the UK National Screening Committee is already under way. The health minister Andrew Gwynne said this month that the review would include “different potential ways of screening the whole population from 40 years of age onwards, and targeted screening aimed at groups of people identified as being at higher than average risk, such as black men or men with a family history of cancer.”6
The question is, then, how health services and politicians respond to headlines. Sensible politicians would surely use the National Screening Committee as an asset rather than a roadblock. Ahmed is chief investigator of the Transform trial, which is using MRI and blood testing to trial prostate screening.7 He says, “It is charity and government funded because independent national and international experts, commissioned by the Prostate Cancer UK charity and the UK government through the NIHR, agree that the current data does not support screening at any age in any group. A government political decision to over-ride such expertise is, by definition, not a correct one.”
Footnotes
Competing interests: None.
Provenance: Commissioned; not externally peer reviewed.