An interview with Dr Sarah Rudman #Movember

Let's get men talking about their urological health

Movember is an entire month devoted to raising awareness of men’s health issues. We interviewed Dr Sarah Rudman, Consultant Medical Oncologist and In-patient Lead at Guy’s and St Thomas’ NHS Foundation Trust to find out more.

Can you tell us a bit about the different urological cancers that affect men?

The most common type of urological cancer in men is prostate cancer. Prostate cancer has a very wide range of different cancers within it, from very quiet, indolent, low grade cancers that sit in the prostate gland and may not give men any symptoms at any point in their life. But there are also very aggressive prostate cancers that do give men symptoms and unfortunately can also spread outside of the prostate gland.

Prostate cancer risk increases as men age but we see men with prostate cancer as early as in their 40s and we treat men until the end of their lives with prostate cancer and sometimes this is men in their 80s and 90s. Across the different types of prostate cancer there are a lot of men from the Afro-Caribbean and African populations and unfortunately those ethnic groups do get a more aggressive type of prostate cancer which means men of a much younger age can get it and that the outcomes for those men, despite our best efforts, aren’t as good. 

Another urological cancer that exclusively affects men is testis cancer. The men affected are usually much younger, from their late teens, usually in their 20s and 30s, but we do then see another smaller peak of men in their 60s and 70s. This is a much less common type of urological cancer but thankfully because of the age group that is usually affected the outcomes from treatment are extremely good. The vast majority of patients we would aim to cure from this cancer and many of these patients go on to have a normal life expectancy.

The smallest urological cancer is penis cancer which has a relatively low incidence rate compared to the others. It’s only treated in specialist centres because of the small numbers.

People may have heard of a PSA test and that its utility is debated. Can you tell us a bit about it?

A PSA test measures a protein called Prostate Specific Antigen. The normal prostate gland will make the protein called PSA so a man with a prostate gland can have a PSA test and have PSA measured in their blood. As PSA is made by a normal prostate gland it’s not considered the best test for picking up prostate cancer and there is often a lot of confusion amongst patients and healthcare professionals about how to interpret a PSA result. When a PSA is very high, in the 100s, it is very difficult for a normal prostate gland to make enough PSA protein for that high reading so this is usually because the patient has a prostate cancer. The normal PSA range is usually around 4-5 but men with prostate cancer can still have a normal PSA reading as their prostate cancer may not make lots of PSA. For that reason it sometimes makes it difficult to interpret PSA testing so usually PSA is most useful to us if it is extremely high. Any patients who have symptoms should definitely have a PSA test to get more information to build a story of what’s happening and PSA can be very helpful in those circumstances.

"It can be both our friend and our enemy but as long as you understand what you’re testing and what the possibilities are when you interpret the result then it’s very helpful in our clinical practice."

How do you use genomics in your clinical practice?

This is a really exciting time in prostate cancer treatment because genomics is beginning to creep into our clinical practice and be meaningful for patients. In NHS practice we don’t routinely screen patients with prostate cancer genetically at the start of their diagnosis but we very much hope in the coming months and years to be able to offer that to patients as soon their cancer is diagnosed. Currently patients might be offered participation in a clinical trial which would incorporate a whole genome sequence of their prostate cancer, this means taking their cancer tissue and testing it for a set of changes in their DNA which can tell us which are the ones that might make that prostate cancer grow. Until now the treatment of prostate cancer has involved giving patients a treatment according to where their prostate cancer is in their body or which treatments they’ve had before. Drugs are given in an order and to all patients with a prostate cancer in particular parts of the body, there’s no tailor-made treatment for that patient.

What we’re moving towards now is to be able to test an individual’s cancer tissue and look at the genetic changes that are causing that patient’s cancer to grow and to target those particular mutations. We participate in a number of clinical trials which test the patient’s prostate cancer and if a particular mutation is present, or a collection of mutations, the patient may then be offered access to a drug which we believe their cancer would be sensitive to. The natural progression of this is that patients will have early genomic screening of their cancers to identify what we call the driver mutations, the changes in the DNA that make the cancer grow, and we will target those with specific drugs. So the order of treatments, or the nature of the drugs, that a patient might receive may vary rather than everyone receiving the same drugs as they do now.

Urological symptoms to look out for:

What would be your key messages to men in Movember?

Movember is a really nice initiative because it raises the profile of urological cancers and almost gives patients and members of the public permission to talk about what they need to do to look after themselves and to investigate symptoms that they might have. Men may not be as willing to come forwards and talk about cancers and so in recent years we’ve seen a big change in that, particularly as prostate cancer is so prevalent that having celebrity role models and very high profile role models of patients who’ve had these cancers has encouraged other patients to get advice for symptoms and ultimately be diagnosed.

I would definitely encourage anyone who has any concerns at all about any of the symptoms that I’ve previously mentioned to seek advice from health care professionals. This year in particular it may be perceived as harder for members of the public to get advice but in recent weeks and months key NHS leaders have really tried to say to the public that the NHS during the COVID-19 is open for business so if anyone has any symptoms that they’re concerned about I would really encourage them, in particular in this month, to think about getting some advice about whether they are significant.

What should the general public be doing to protect their urological health?

There will be a number of patients that they have a slightly higher risk of urological cancer than other members of the public. There are families where cancer has been inherited through a family line and usually patients will know if an older relative has had a urological cancer or perhaps a relative of a similar age to you has been recently diagnosed. There isn’t a screening programme for cancers like prostate cancer in the UK however if you have an older relative with a prostate cancer then it’s important to seek advice from a GP about what that means for you. I would encourage anyone who knows of any family history to act on it and understand what it means for them, they should understand the symptoms that they may be looking for and what age group they might expect to be affected in order to notice any change early on. We know that men who have had a testicular cancer, their first-degree relatives are at a slightly higher risk of developing a testicular cancer compared to other members of the public. A higher risk doesn’t necessarily mean that it is destined to happen it just means there’s a greater chance that it may happen.

"During my time as an oncologist we’ve seen the life expectancy and cure rates for a lot of the urological cancers increasing and improving year on year. We hope not only that a higher proportion of patients will be cured but that they will live for longer with their cancers and have a good quality of life. We are committed to improving outcomes for patients but we really encourage patients to engage with us and present as early as they can so that we can catch cancers at the earliest stage and increase the likelihood of being able to cure them."

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With any Whole Genome Sequencing (WGS) test ordered, a Record of Discussion (RoD) form will also need to be submitted. This document is to record the patient’s consent for genomic testing and their choice on taking part in research. Guidance on the patient choice conversation can be found here
This RoD form will be available for clinicians to download from this webpage. Once completed with the patient, it can be send to the lab with the corresponding test order form and sample.
Tests available to order will be listed in the National Genomic Test Directory. A test order form will soon be made available for clinicians on this webpage to download and complete. This form will include the address of the laboratory that the appropriate sample and completed form needs to be sent to.
Until the new Genomic Laboratory Service goes live, please continue to follow existing test order processes.
Later this year, the online test ordering tool for Whole Genome Sequencing will be integrated into the National Genomics Informatics System (NGIS) and clinicians will be able to search or filter to find a clinical indication, confirm eligibility criteria and start the test request process for their patient.