Detecting Prostate Cancer

Rob Bell: 
Our discussion this week centres around the differences between the old and the new improved way of diagnosing prostate cancer.

Amy Rylance:
So we talk about the new pathway as being clearly safer and more accurate than the old pathway.

You see this 2018 spike in men being diagnosed with prostate cancer because they started this conversation.

Tom Pellereau:
To me, it's to kind of finger up the bum with the glove test that a doctor starts wanting to talk to you about when you reach a certain age, whatever that might mean.

And to me, I'm miles off that age.

I'm still very, very young, but I'm really not now anymore.

Rob Bell:
Do you paint the greys into your beard?

Tom Pellereau:
Yeah, and my hair, yeah, it's all designer, actually.

Rob Bell:
Hello and welcome to Sketchplanations, The Podcast.

Consider us the 2024 French Open winner, Carlos Alcaraz of the episodic audio community.

A relative newcomer with rapid ascent into the world of podcasting, we're known for our agility and competitive spirit, not to mention our powerful ground strokes.

Our ability to handle pressure and maintain composure during high stakes conversations speaks to our mental toughness and resilience both on and off the mic.

This team's general demeanour is marked by respect for our opponents and the podcasting game itself.

And despite the rapid rise in the tennis world, sorry, podcasting world, they remain grounded and focused on continuous improvement.

I'm Rob Bell, always keen for an unjustified overhead volley smash, holding strong on the baseline and driving point building strategy with every stroke.

It's Sketchplanations stalwart, Jono Hey.

And cheeky as ever, there he goes again with another crowd pleasing slice drop shot just over the net.

It's wonderful to see at this level of podcasting.

It really is.

It's Tom Pellereau.

Hello, chaps.

Jono Hey:
I can absolutely picture Tom doing that shot actually.

Dropping it just over the net.

Yeah, he's lots of cheeky shots.

Rob Bell:
In any sport, he's cheeky.

Tom Pellereau:
It's a great game of paddle we had a few weeks ago.

Rob Bell:
It was a great game of paddle.

Paddle is a great game.

Tom Pellereau:
They just opened courts near me, actually I'm very pleased to say.

Rob Bell:
So you're gonna get even cheekier with some of those shots.

Tom Pellereau:
Yeah, yeah, paddle is a great game of cheekiness.

Jono Hey:
It's like tennis in a squash court, right?

Kind of.

And so you'd be quite fun to just mash up other sports, wouldn't it, and see what you get.

Well, I guess they have done that.

They can get like football golf, you can do, can't you?

Rob Bell:
Frisbee golf.

Tom Pellereau:
Yeah.

Rob Bell:
And you can mash anything with golf.

Jono Hey:
Tennis golf?

Rob Bell:
Why not?

Jono Hey:
Could be some new opportunities.

Rob Bell:
So Alcaraz, Carlos Alcaraz won the French Open, or Roland-Garros as it was known last weekend, alongside Ygis Viontech for the women's title.

But do you know why the tournament's called Roland-Garros?

Jono Hey:
Not a clue.

Rob Bell:
Nor did I.

I looked it up.

Right, bear with me.

In 1928, the main stadium that houses the tournament was built and the president of the Stade Francaise sports club who hosts the French Open, the president's chap called Emile Le Sueur, decided that this new stadium should be named in honor of the pioneering French aviator and World War I hero, Roland Garros, who was killed in action in the First World War and who was an old school friend of Emile's.

That's why it's called Roland Garros.

Tom Pellereau:
That's really random.

Rob Bell:
It is a bit of that.

Jono Hey:
Nice bit of history.

Rob Bell:
Good little bit of history.

Tom Pellereau:
Go and name it after a mate of yours.

One day, there'll be the Rob Bell Golf Guitar Podcasting Shop, created by Jono Hey.

Rob Bell:
Sure.

Sure.

But it is the time of year.

Once Roland Garros is out of the way, early summer, it's the time of year when we start to talk about this being a super summer of sport, which is exciting, isn't it?

Jono Hey:
I love this time.

We went and played tennis yesterday evening.

It was absolutely beautiful.

And it's always this time when the tennis courts suddenly get really busy because it's so lovely.

It's such a lovely thing to do.

Yeah, no, I love the summer of sports.

Just great to look forward to, isn't it?

Rob Bell:
And yeah, so coming up, we've got Wimbledon, obviously.

There's the Euros and the football.

There's the Summer Olympics.

There's the Women's T20 World Cup.

But isn't every year a super summer of sport?

Is it?

Don't we have this conversation this time every year?

Oh, it's a super, it's an amazing summer of sport coming up.

Jono Hey:
I mean, I'm a bit biased, but I feel for me, it's the even years a little bit more.

Rob Bell:
Because of Olympics?

Jono Hey:
No, because of the Euros and the World Cup alternate on even years.

But, you know, that's not for everyone.

Rob Bell:
Yeah, fair enough.

So last year we had Wimbledon, that's every year.

There's the Athletics World Championships, there's the Netball World Cup, the Invictus Games, the Ryder Cup.

Next year, there's Wimbledon.

There's the African Cup of Nations Ryder Cup.

Women's Rugby World Cup, Rugby League World Cup.

You know, there's a lot of sport on every summer.

Jono Hey:
Be nice if there's a bit more in the winter when you had a bit more time to watch it, wouldn't it?

Rob Bell:
Football, always football, always rugby.

Tom Pellereau:
The football, Jono, I can't help thinking, you mentioned it previously, and the football will never end, do you remember?

And the football, because it does feel like the football this year will never end, because by the time the Euros are finished, then we'll be back into the new Premier League season.

And the football will continue.

Rob Bell:
It is slightly special this year, because there's the Olympics, right?

This enormous international multi-sport event that brings the world together.

And it's just over the channel for us in France.

But Tommy, you're off to the Olympics, aren't you?

You've got some tickets, is that right?

Tom Pellereau:
I've got a lot of tickets, and we've got a VW camper van, so we're there almost every day of the whole thing.

We're there for the opening ceremony, or we don't have tickets for that, but it's there.

And then we go all the way to two days before it ends.

I'm a little bit worried about, because actually my kids love playing sport, but I'm trying to get them to sit down and watch sport has not always been that easy.

They love hockey, we've seen that a couple of times.

We've got some rowing, some canoeing, some athletics.

So yeah, this is gonna be a very big summer of sport for us, certainly.

Rob Bell:
That's good to hear, it is exciting.

Well, listen, I should say at this juncture that this is the last episode of series two.

Together, we've enjoyed 17 tasty morsels with you, the series listeners.

Thank you for listening and for all of your support and correspondence throughout the series.

For series three, we have more great guests lined up and more of Jono's intriguing sketches to explore.

So please do continue to send your thoughts and stories and comments about the podcast and any of the episodes we've put out in the last two series.

And we'll be going through your correspondence since last time at the very end of this episode.

And we're just gonna take a few weeks off.

So we'll be back, I don't know, around beginning of August kind of time.

So we will be smack bang in the middle of the super summer of sports, ready to come at you with more of the same level of dedication, passion, desire, physical prowess, and of course, the will to win.

So come on, boys, last 10, yeah?

Let's put it in.

Let's podcast.

Now, this episode falls halfway through International Men's Health Week, and with Father's Day coming up on Sunday, what better time for us at Sketchplanations, the podcast, to partner up with Prostate Cancer UK to talk about the second most common cause of death from cancer for men in the UK.

Our discussion this week centers around Jono's latest Sketchplanation that delves into the differences between the old and the new improved way of diagnosing prostate cancer.

And we'll also talk about what this means for men and their families and loved ones.

We'll get an understanding of some of the risks associated with prostate cancer and we'll learn what we can do to help reduce the number of late diagnoses.

And to help prevent us getting our knickers in a twist, keeping our facts straight and us walking the right path, I'm delighted to welcome Amy Rylance onto the show.

Amy is Assistant Director for Health Improvement at Prostate Cancer UK.

Amy, welcome to the podcast and thank you so much for coming on to help out with what in my mind is possibly the most valuable podcast episodes we will have recorded to date.

Amy Rylance:
Thank you.

Well, thank you.

Thank you for having me and I feel like there's a lot to live up to now.

Rob Bell:
I thought perhaps to start off, is it worth going through some of the headline statistics around prostate cancer?

Perhaps to set the scene for just how common a disease this is.

Amy Rylance:
Yeah, absolutely.

So I'm UK based, so I'm gonna focus on the UK, but I'll give you a little bit of international context as well.

So in the UK, 52,000 men diagnosed each year and just to kind of big numbers, quite hard to wrap your head around.

One in eight men in the UK will be diagnosed with Prostate Cancer in their lifetime.

Actually, if you're black, your risk is double.

And if your dad or your brother has had Prostate Cancer, your risk is also significantly higher.

So this is a really common cancer.

But the key thing about Prostate Cancer is actually the earlier you find it, the easier it is to treat.

So Prostate Cancer absolutely does not have to be a death sentence.

We wanna find it early.

We want to make sure that we are identifying the men at risk so that they can have an early diagnosis and be successfully treated.

To give it a bit of international context, The Lancet published a paper looking at Prostate Cancer across the world very recently.

Rob Bell:
What's The Lancet, sorry, Amy?

Amy Rylance:
So The Lancet is one of the big medical journals and they commissioned an international investigation into Prostate Cancer.

And what they found is that Prostate Cancer is the most common cancer in men in over 100 countries in the world.

So this is very much a common problem around the world.

At the moment, there are about 1.4 million new cases diagnosed each year across the world.

But actually that number is going to more than double to 2.9 million cases by 2040.

And the reason for that massive growth is actually what we're going to see is a huge growth in men being diagnosed in low and middle income countries.

And the reason for that is that one of the big risk factors for prostate cancer is age.

So your risk increases once you're over the age of 50.

And so what we will see as we see life expectancy going up across the world, which is a really, really good thing, but we will see prostate cancer then affecting more and more men.

So it's a really big global issue and it's an issue which is going to become more pressing around the world.

Rob Bell:
Within that landscape then, what is Prostate Cancer UK and what role does it play?

Yeah, I guess the name is partly in the title there about UK, but from what you've already said there, Amy, there is a field that there is.

And the prostate cancer bit.

Tom Pellereau:
It really sums it up a little bit.

Jono Hey:
Get the nail on the head.

Amy Rylance:
We do try to make it, yeah, not add to the confusion of it all.

No, we are here to try and make sure that no man is left to navigate prostate cancer on their own.

We have four kind of key pillars to what we do.

The first is to make sure that every man is aware of his risk and can make a choice about whether he wants to be tested for prostate cancer.

The second is to narrow the big health inequalities that we see in prostate cancer.

We know there are certain groups of men who have more than double the risk of dying from prostate cancer, in particular black men.

And so we want to narrow those inequalities.

The third is to really move the dial in terms of earlier diagnosis.

There are still 12,000 men who die of prostate cancer every year in the UK and we need that number to go down.

And the fourth is to ensure that every man is supported once he's diagnosed with prostate cancer and given the best possible opportunity to live with prostate cancer, to be cured from prostate cancer, to get the support that they need.

So in a nutshell, that is what we are here to do.

Rob Bell:
And we talk about prostate cancer as being, well, it is a disease that affects men, but it actually goes and affects the family and the friends and the loved ones of whoever that man may be as well.

So its effects are very widespread, right?

And it can touch, it could potentially touch everyone.

Amy Rylance:
Absolutely.

So I had the great pleasure two weekends ago of joining our March for Men, which is our big mass participation event.

It takes place once a year.

We were in Bermondsey Park in London, glorious.

The only sunny Sunday we've had this year, I'm pretty sure.

And we had about 2,000 walkers there walking in memory of lost loved ones, in support of people who had had prostate cancer diagnoses.

And what was so lovely about it was how multi-generational it was, how many women were there marching for their partners, for their dads, for their loved ones.

You know, prostate cancer is not just a cancer that impacts on men, it is a cancer that impacts families.

Rob Bell:
And so what is your role within Prostate Cancer UK, Amy?

Amy Rylance:
As the Assistant Director of Health Improvement, I have the great privilege of trying to look across the whole pathway.

So everything from how do we make sure that the average man understands whether he's at risk and what he can do about it if he is at high risk, through to how do we work with the health system to make sure that they respond appropriately when a man comes and speaks to his doctor.

How do we improve the way that care is delivered?

How do we make sure that research actually goes into practice because we're also a research funder.

We fund groundbreaking research, but we know, and this is an international issue, that there are huge time lags between proving that something works and it actually being adopted in healthcare.

And so part of what my teams do is look at the really exciting research and say, how do we get that into your local hospital so that you get the benefit of that fantastic science?

Rob Bell:
Now, I'm gonna bring something up here now because I think it may come up a fair bit in the rest of our conversation.

Could you tell us what the PSA is and what a PSA blood test is?

Amy Rylance:
Of course.

Rob Bell:
In the very informal conversations that you might hear or that I might have with relatives, older relatives or older friends, PSA comes up all the time.

Amy Rylance:
PSA stands for Prostate Specific Antigen.

So it's a protein that the prostate produces.

And when you do a blood test for it, you can measure the amount of that protein that's circulating in the bloodstream.

When a man has prostate cancer, the amount of that protein goes up.

So if you see a high level in someone's blood, that can indicate prostate cancer.

What makes it tricky is that there are other things that can push that level up as well.

So vigorous exercise can push that level up.

Having an infection can push that level up.

Just having some benign enlargement of the prostate can push it up.

And so when you hear people say, well, it's not a very good test for prostate cancer, that's what they mean is that it can be raised for reasons other than prostate cancer.

But we can come back to why actually it's quite a good sign now because of what happens afterwards.

Rob Bell:
What a brilliant segue, Amy, because I feel like we should probably talk about the sketch.

Now typically I'll come to Jono to talk us through the sketch.

I was thinking perhaps on this episode, maybe a bit of a joint project between Jono and Amy, as indeed the sketch was itself.

So first of all, Jono, do you want to give us an overview of what your sketch communicates?

Jono Hey:
Yeah, for sure.

Maybe I'll leave the details of what's on it and what's discussed to Amy.

But essentially what I was trying to get across was some of the way that the processes for detecting and screening for prostate cancer has changed.

And I was informed and educated on this by the team here.

And so really what I tried to do was go, okay, how do I make it so that you're not reading the Lancet, right?

Like you don't want people are not sitting down and reading the Lancet before they go, you know, get their prostate checked.

And so I wanted to do, I've sort of, the sketch is kind of a left right.

Here's the old way, starting with a chance conversation.

There's four steps and here's the new way, which has an additional step, but there are also a number of advantages, which I've tried to highlight along the way.

And also one of the key ones is that instead of having to wait for a chance conversation that you can go, go do an online risk checker, which they have one at Prostate Cancer UK, you can go do that right now.

It takes like 30 seconds to check your risk at the beginning.

And I think that was such an important piece.

And then there's lots of research which informs the changes in the other steps.

And I wanted to try and get across some of the benefits of that without getting lost in medical jargon, should we say, which people might stop looking at it.

And so it's a denser sketch than it might be normally, but then it's an important and it's a complex topic.

So that's what I did.

It's the old way versus the new way in the sketch.

Rob Bell:
And can I ask you Jono, how aware of prostate cancer and this diagnosis processes were you before we got involved in doing this with Prostate Cancer UK for the podcast and for Sketchplanations?

Jono Hey:
Yeah, so it's not something that I knew a lot about.

I think I probably had the odd email about it or you see something at the doctors and I'm coming up to that kind of age where it starts to become relevant and it says, well, maybe there's a test that you can do when you get to that sort of age.

But I'm mid 40s now, so just sort of getting there.

So I was kind of like vaguely on the radar, but I didn't personally know anybody.

I've never had discussions with somebody who's had it and been through that.

So definitely wasn't really on my radar and it's the sort of thing that could easily slip by and then you're too late and I don't want that to happen.

So it feels really good to be communicating that.

Rob Bell:
How about you Tommy, just out of interest?

Tom Pellereau:
Myself, to me it's to kind of finger up the bum with the glove test that a doctor starts wanting to talk to you about when you reach a certain age, whatever that might mean.

And to me, I'm miles off that age.

I'm still very, very young, but I'm really not now anymore.

Rob Bell:
Do you paint the greys into your beard, Tom?

Tom Pellereau:
Yeah, and my hair, it's all designed, actually.

Rob Bell:
So let's have a close look at the sketch then.

So on the left, we've got the old way and we've got four steps within there, four or five steps.

So what are those steps in the old way of detecting prostate cancer?

Amy Rylance:
So the old pathway, we don't invite men for screening, chance conversation.

If you then go and see your GP, you would have had a physical examination, a finger up the bum, it's known as a rectal examination and you would have had the PSA blood test.

If either of those was suspicious, you would have been sent for a biopsy.

And the prostate is typically, it starts about the size of a walnut and they wouldn't have known exactly where in the prostate they were looking, but biopsy needles would have been put in kind of across the prostate to try and detect any signs of cancer within there.

And if those biopsy cells on examination showed cancer, then you would have a diagnosis.

Jono Hey:
So that's the old way.

Amy Rylance:
Yeah.

If you go down the new way, one of the key things that Prostate Cancer UK believes in is that every man at risk should be able to make an informed choice.

And the way that we support that is that we've developed an Online Risk Checker.

So you can just Google Prostate Risk Checker, takes you to our Online Risk Checker.

You answer three quick questions about your risk.

And then it will tell you what your risk is, but crucially what you can do about it.

And the next step.

Tom Pellereau:
So I wanna quickly butt in here because I often see, do this 30 second survey.

So whilst Robbie was doing his introduction, I thought I will start doing this.

And it's not even 30 seconds.

It's very quick.

And I imagine it's built on a huge amount of data that's allowed it to be so quick, probably possibly because of my age, it may be very quick for that.

But honestly, everyone, find the link, do the check, not everyone, if you're a guy, find the link, do the checker.

It is very, very quick.

And I'm very impressed with your work.

Thank you.

Jono Hey:
Send it to a guy who you know, and it's irrelevant for, yeah.

Amy Rylance:
Always worried when somebody says that, they're gonna say, oh, it took me three minutes.

So even quicker than 30 seconds is all good.

Jono Hey:
15 seconds.

Rob Bell:
But from that then, Amy.

Amy Rylance:
Yeah, so if you decide I would like a blood test, so in the UK, every man over 50 is entitled to a PSA blood test from his GP for free.

And if you're at higher risk because you're black or because you have a close family relative who's had prostate cancer, it's from 45.

So you speak to your GP about blood tests.

What happens in the new pathway is that after you have this PSA blood test, if your levels are raised, you get sent for an MRI scan.

And MRI scan takes really high definition image of the prostate.

And what that means is that for a start, about a third of men get told, we can't see anything there.

Go home, you're fine, you're done.

You don't need any more checks.

The other two-thirds, there's something specific on that prostate that a doctor can see and they can say, actually, we can see a suspicious area on that prostate.

Let's do a targeted biopsy using that image to be able to see where to put the needles and we'll examine those specific prostate cancer cells under a microscope and we will see how aggressive those cells are.

And that's really important because that then means that, for a start, some of those men who actually get sent home and told you're fine will have actually teeny tiny amounts of very slow growing prostate cancer.

But we don't care.

Nobody wants to find the cancers that won't kill you because all that does is cause stress and anxiety and unnecessary treatments.

So if you can send them home, that's brilliant.

But actually also for those men where there are some men for whom we will find really aggressive cancers and we will have an opportunity to successfully treat and cure those men.

There are other men where we can say we saw one spot on your prostate, which was suspicious, but we've taken some samples and we can see it's the really slow growing types of cancer.

And so our best advice for you is do nothing.

We will keep monitoring you.

We will keep doing regular blood tests.

We will do some repeat MRIs a year's time, couple of years after that.

And if something starts growing and moving, then absolutely we can treat it.

But for now, leave well alone because we're trying to avoid treating those men who would have died with prostate cancer, not of prostate cancer.

Rob Bell:
So if we look at the difference between the old and the new way, Amy, at kind of headline level, is there an improvement in outcome?

And how does that manifest itself, that improvement in outcome between the old and the new way of diagnosing?

Amy Rylance:
So on the sketch, we have this lovely far right column, which is the list of viewers.

So fewer awkward exams, fewer unnecessary biopsies, fewer side effects and fewer overdiagnoses.

And that is the fundamental change in the pathway.

Rob Bell:
Because some of those, the awkward exams, the unnecessary biopsies, but the side effects of those unnecessary biopsies, they can be real barriers to some men getting something checked out, right?

Amy Rylance:
Yeah, absolutely.

So I'm actually really pleased that you talk about the finger up the bum as being the first thing that comes to mind, because actually-

Rob Bell:
That's what we're talking about, the awkward exams.

Tom Pellereau:
There doesn't seem to be any finger up the bum on the right-hand side, it's just totally missing.

Amy Rylance:
You're not alone in thinking that that is the first test.

Actually, we know that we've done big sampling of men at risk of prostate cancer to understand their views, and we know that about half of men assume that the first test that they will have to have is the finger up the bum, and that's the biggest thing that stops them speaking to a doctor.

Rob Bell:
Yeah.

Amy Rylance:
But they just won't have that conversation because they don't want to have that test.

But actually, the science on this is that that is not a very useful test.

So all you can feel with the finger is the very back of the prostate, whereas when you do an MRI scan, you get a high definition image of the whole prostate.

Rob Bell:
And a cancer could grow anywhere on the prostate, is that right?

Yeah.

Amy Rylance:
Yeah, absolutely.

And so there's been lots of studies and there's been kind of where they take all the studies and they combine them together.

And what those studies have shown is that when you're looking at men who are interested in screening for prostate cancer, so healthy men who come and say, can I have a test, the digital rectal exam, which is the technical term for it, does not find cancers that aren't found by a blood test.

And so you just do the blood test and then you send men for an MRI scan.

And actually doing the finger up the bum doesn't find any additional cancers, but it does risk putting a huge number of men off from ever coming forward.

And so what we strongly believe is that the doing that test actually does more harm than good.

And we have a paper in the British Journal of GPs, anyone who wants to get into the medical details can look that up and it really sets out all the evidence as to why it's not a very good test and it's doing quite a lot of harm.

Rob Bell:
So one big outcome is when it starts to be communicated much more widely and message starts getting spread around that it no longer is the rectal examination, the digital rectal examination, the finger up the bum.

Tom Pellereau:
Digital as in it's a digit.

Rob Bell:
Exactly.

Jono Hey:
It's digital computers.

Rob Bell:
Yeah, that hopefully will be one outcome.

Another outcome though, statistically, when you get to the end in terms of the diagnosis, is there an effect there as well?

I say it is there, because Jono has communicated this again in the sketch, but.

Tom Pellereau:
Have you looked at the sketch, Boris?

Rob Bell:
So what are we looking at then is probably the better question in that final line between the old way and the new way between that diagnosis line.

Amy Rylance:
So there was a big study done in the UK called the CAP study that looked at screening a very large number of men.

And what that found was that mostly you find those really slow growing cancers and they found far fewer of the significant cancers that you wouldn't want to find.

That was using the old pathway.

So just a blood test and then a random biopsy that was, you know, not knowing what it was looking for.

On the new pathway, we see that completely flip.

So the majority of diagnoses now are of clinically significant cancers.

That's what we call the cancers that we want to find.

And we find far fewer of those.

The medical term is actually indolent, which means lazy.

Lazy cancers aren't gonna do anything.

We don't want to find those.

And yes, the good news is that the new pathway finds fewer indolent cancers and more significant cancers.

Rob Bell:
Hopefully, the new pathway is a kind of double win then.

Fewer men being afraid and understandably afraid, I would say, but then more...

Jono Hey:
More accurate diagnoses.

I was gonna say that the bar charts or the column charts at the bottom are actually to scale with the numbers that I was given.

Rob Bell:
Oh, really?

Oh, great.

Jono Hey:
So the ones with the X are the ones of the proportion of cancers that are clinically insignificant.

And the ones with the check mark are the ones that are clinically significant, where you have to do something about it.

And so you can see that the old way, you get a lot more of the insignificant ones in proportion to the significant.

Rob Bell:
And that flips significantly with the new way.

Amy Rylance:
Yeah.

So we talk about the new pathway as being clearly safer and more accurate than the old pathway.

Jono Hey:
Amy, I was just wondering, you mentioned safer.

What do you mean by safer in this case?

Why is it safer?

Amy Rylance:
Actually, within the old way of doing biopsies, they did have a safety risk.

So because the way that biopsies used to be done, they were trans-rectal biopsies.

And that has a risk of infection, a risk of introducing infection into the prostate.

And at its most extreme level, that could cause sepsis.

And obviously, sepsis is a very serious medical condition.

But what's crucially different now is firstly, we're massively reducing the number of men who need a biopsy.

But also the way that we do the biopsy is different now.

So instead of doing a trans rectal biopsy, the standard procedure in the UK now is trans perineal biopsy.

And that's a much safer biopsy in terms of sepsis risks.

Rob Bell:
One question this does throw up, and indeed, I think it already has thrown up a question, because Jono, you put this sketch out at the beginning of the week, right, on your weekly mail out.

And you've already had some feedback about it.

I think one of the biggest questions that comes up is about the added expense of sticking an MRI in that process.

Let's address that, shall we?

First of all, is it more expensive, the new way compared to the old way?

Amy Rylance:
I'm gonna slightly cheat this question and start to leave out cost effectiveness rather than expenses.

So, you know, yes, having an MRI scan in there in pure pounds and pence of how much it costs to go from step one to the end of the pathway, yes, it is more expensive, but actually it is more cost effective.

And the reason it is more cost effective is because of all of those viewers that we have listed.

And so if we are finding more of the right cancers, if we are avoiding finding the wrong cancers, the indolent cancer that we don't wanna find, if we're avoiding the side effects.

And so, you know, in the UK, we have this body called NICE, who will assess all new technologies before they're allowed to be used on the NHS and essentially what NICE's job is, is to say, is this cost effective?

And NICE were very clear in 2019 that this is the cost effective way to diagnose prostate cancer.

Rob Bell:
NICE is an acronym, isn't it?

Amy Rylance:
Yes, National Institute for Care Excellence.

Rob Bell:
Yeah, it's brilliant.

Tom Pellereau:
It's brilliant how it goes about doing its stuff.

It can be a little bit controversial because it's basically based on how many years of quality of life something gains based on the financial benefit of it.

And they will take things into account.

The fact that a proportion of people are getting sepsis and the cost of that mounted up because we have this NHS that can look at the whole population and work out if a new process is better.

And it's fantastic that, so yeah, the MRI is more expensive, but the whole cost of care is factored out.

Jono Hey:
It made a ton of sense to me.

And I was trying to think that, you know, a lot of the challenge with some of this stuff is the inertia, an overcoming inertia to go do something now to have a benefit in the future.

And I was trying to think about the work.

We always had this problem, like people don't save for their retirement, right?

And it costs money now to save for my retirement, but the earlier I do it, and if I put money away now, then I'll be better off in the future.

Same with, you know, I don't have to go to the gym or pay for a gym or something like that, but obviously it will help me in the future.

And I don't have to service my car, but if I wait until it explodes, that's probably going to cost me more.

And so it sort of makes sense to me in that similar kind of way, but there may be some short term extra that you have to do, but in the long term and the overall, you might be having a significant benefit.

Tom Pellereau:
How does it affect waiting times though, in terms of getting an MRI appointment?

Amy Rylance:
So during the pandemic, one of the things that we saw was a massive drop in the number of men coming forward with prostate cancer.

And we saw 14,000 men missing a prostate cancer diagnosis.

And it was the most impacted of all of the cancers.

It was about a third of all missing cancers in the UK were prostate cancer cases.

And in February, 2022, we launched a big campaign in partnership with the NHS to raise awareness, to try and get men to do the risk checker and come forward if they were higher risk.

And it's been hugely successful and we have seen this great surge in men coming forward and finding those missing men.

But that has created strain on the system and weights are longer now than they were before the pandemic.

But in terms of whether you wait longer to have an MRI scan, I would say that absolutely it's worth the wait because of all of the benefits that it gives you.

And I think in the UK now, it's very much accepted practice.

And so I think you would struggle to argue with a doctor that didn't want an MRI.

I don't think there's many doctors in the UK now who would say, yeah, that's fine.

Let's just biopsy you because it'd be quicker.

Rob Bell:
When was the new way implemented?

Amy Rylance:
So it's actually really quite recent.

So the guidelines changed in the UK in 2019.

A few areas had gone before then because the big research study that proved that this was safer and more accurate was actually done in the UK and it was done across multiple centres.

So there were centres that had been offering MRI since about 2015, but since 2019, it has been the best practice, accepted practice that all hospitals should be offering to men in the UK.

Rob Bell:
I want to bring us on to the very first step of the pathway, if you can, because the old way we talk about a chance conversation and Jono's beautifully depicted that with two blokes in a pub and one of them maybe just been found out about prostate cancer and he's telling his mate and there is shock and surprise to the point where he's actually dropped his pint glass.

And this is, I guess, traditionally, historically, I should say, there's been an issue there with a lack of conversations being had amongst men, right?

And men of a certain age, I guess, about their health, which is why it's so great that we're talking about this now in International Men's Health Week.

Amy Rylance:
I think that is definitely something that is changing.

And we really saw the start of that change in 2018 when Bill Turnbull and Stephen Fry both talked openly about their diagnosis.

And they really were the first kind of people to really publicly talk about being diagnosed with prostate cancer.

It created a huge change.

It's actually, you can see it in the NHS records.

It's called the Fry-Turnbull Effect.

You see this 2018 spike in men being diagnosed with prostate cancer because they started this conversation.

And I think, you know, we've never quite gone back to the pre 2018 levels.

And there is clearly more dialogue now.

And that's a really, really good thing.

And, you know, at Prostate Cancer UK, one of our kind of foundational beliefs is, well, no man should die because he didn't know his risk.

And no man should die because he didn't know he could have a PSA blood test.

And so we really need to keep that conversation going.

And picking up on what Jono was saying, it really is the earlier you find it, the easier it is to treat.

And so not waiting for symptoms.

I think that's one of the things that makes prostate cancer really tricky.

Rob Bell:
Yes.

Amy Rylance:
Is that for a lot of men in those early stages, there won't be any symptoms.

And we know from some of our research with groups of men at risk of prostate cancer, that actually the vast majority of men say they won't speak to a GP unless they have quite serious symptoms.

And what we really want to learn the message is the earlier you find it, the easier it is to treat.

It often doesn't have symptoms.

So don't wait for symptoms.

Actually do the risk checker and act on the basis of your risk.

Rob Bell:
The reason that I work with Prostate Cancer UK and have done for a number of years in trying to communicate that message about not waiting, do the Online Risk Checker.

My dad was diagnosed with prostate cancer probably about 12, 13, 14 years ago now.

And he's very much of that generation where men didn't talk about their health too much.

Certainly less, let's say stereotypically, certainly less than probably men do now or men of our age in our mid forties now.

And thankfully he was diagnosed early and he was treated and he's still with us going strong, out leading Duke Vedenberg Award hikes and expeditions and going to football matches and having a lovely old time, which is fantastic.

And I'm incredibly grateful that that was the case and I'm aware of that.

Tom Pellereau:
It was great to see him on Friday.

He was on good form on Friday.

Rob Bell:
He was on very good form on Friday.

I got married on Friday, Amy.

Thank you.

But obviously that is very, very dear to me then and my awareness of prostate cancer just shot through the roof at that point.

Now that I'm 45, I've done the Risk Checker recently and I know because my dad was diagnosed with prostate cancer, I am at a greater risk.

And in fact, I don't mind saying this, my current status with that is that I did have a chat with my GP and I've had a blood test and I'm waiting on the results.

In fact, this is an excellent reminder for me to chase up my GP surgery to find out what happened with that and that will give a level of PSA.

As we've already talked about, that might not give us-

Tom Pellereau:
There's an opportunity missed.

You could have brought your PSA test results along I could have, couldn't I?

To the podcast.

Rob Bell:
A live opening.

Tom Pellereau:
We could open the thing, find out if we'll be having the next episode from an MRI.

Amy Rylance:
I don't think so.

Jono Hey:
I'm not sure if it makes great TV, does it?

Rob Bell:
Let's see.

Jono Hey:
Maybe it does.

Rob Bell:
But I am so, I'm so grateful that I have that information now, as you're talking about there, Amy, you know, nobody should be at risk because they don't know the risks, or nobody should be in danger because they don't know, don't have that information.

Tom Pellereau:
And you just, you do the tracker, you find out if you should then get a, towards your GP, you then have a blood test, which is it a finger prick or a needle?

Like it's probably only a small amount of blood for the blood test, is it?

Rob Bell:
It's in the arm.

Amy Rylance:
Yeah.

Tom Pellereau:
It's a small, small vial.

Rob Bell:
Yeah.

Small vial.

Tom Pellereau:
So yeah, and then you'll, you know, well, hopefully Rob, you won't have to do an MRI next, but you know, carry on the story if you did.

Rob Bell:
But no, but this is, but what you get from research, so I'm two and a half times more likely to have, to get prostate cancer because of that, because I'm 45 and my dad was diagnosed with it.

And you know, that's fine.

That's, they're the statistics.

They're, that's the risk.

And that's why I want to go and do something about that.

Because two and a half times you go, oh yeah, that's significant.

I feel like there's something I should do about that.

At least be wary, at least be proactive about it.

But being proactive doesn't, it didn't take me very long to do that, you know?

And now I feel like I'm in much more in control of that information and being able to take control of my health in that way.

And it feels great to have done that.

I do feel like we see prostate cancer talked about a lot more than ever before.

And you talked about the, was it the Fry-Turnbull effect?

Yeah.

Of two big name British personalities who had been diagnosed, Stephen Fry, and very sad that we lost Bill Turnbull to prostate cancer.

More recently, there's His Royal Highness King Charles III as well.

Amy Rylance:
Sorry, can I just clarify?

So he had prostate enlargement that was treated.

So that was a benign condition.

And then during the surgery, some cancer was identified, but they have been very clear it is not prostate cancer.

Rob Bell:
So what I will say then, no, because it's a good point.

I think, well, I will be the judge, but it's a good point.

Tom Pellereau:
As you're the editor as well, you can make it into a good point somehow.

Amy Rylance:
Yeah.

I mean, he was very public about going for surgery for benign prostate problems.

And we know that that did create a huge surge in people coming to our Online Risk Checker, because it's fantastic when somebody is willing to be open about something like that, because it gives people the confidence that it's okay to check, that it's okay to investigate these things.

And so it's incredibly powerful when well-known public figures are willing to talk about their experience with prostate cancer or with benign prostate conditions.

Rob Bell:
I'm wearing my little man of men here, which is the logo for Prostate Cancer UK.

Amy, you have yours on as well.

And a lot of people, you see this a lot more.

If you're a football fan, you definitely see a lot of it.

A lot of football pundits, a lot of football players, a lot of football managers.

I feel like the football community has really embraced prostate cancer as a movement.

And this is all about communicating, right?

Because you see this, you want to use that as a reminder, I guess, to get into that first step of that journey, which is the Online Risk Checker.

Amy Rylance:
Absolutely.

And a great conversation starter.

I get through loads of badges.

I keep people feeding them and they talk to me about it, start giving them away.

Rob Bell:
And I feel like it's done a really, really good job as well as those big stories of big names, Stephen Fry, Bill Turnbull and King Charles being associated, or at least communicating and driving people to be more aware.

Amy Rylance:
Yeah, absolutely.

And at the end of the day, it's about being able to make an informed choice about what's right for you.

And we keep saying it, but the earlier you find it, the easier it is to treat.

Rob Bell:
That's brilliant.

Jono Hey:
Amy, can I ask, you mentioned a number of things that the charity tries to do.

What do you think is the hardest part of your work?

Amy Rylance:
It's a difficult question, because I think the hardest bit is when you are trying to engage people with the evidence base.

You're trying to engage people with how the story has changed because what is happening now is different.

And there are some people who just don't listen.

And I think, you know, particularly when that's people in positions of power.

So for instance, when you have GPs who will say to you, you know, oh, I don't believe in the PSA blood test, it's rubbish.

And they're basing that on historical research.

And you say, well, hang on, because we can show you all of these studies, all of this evidence that shows how things have shifted.

But sometimes there are people who just want this and want to engage with that.

And that's difficult.

It's frustrating when you feel like you can't actually have a grownup conversation with somebody.

Rob Bell:
Is that a generational thing do you find as well, Amy?

Amy Rylance:
We certainly hear that, that younger GPs are much more open to the evidence base.

I think also there is a bit of a culture shift in terms of the kind of paternalism of the healthcare system.

So I think there is a little bit of a culture amongst older clinicians around kind of doctor knows best versus much more of a culture now of kind of shared decision making.

And actually, if you as a patient are informed and you understand the pros and cons of making a choice, that actually a doctor should be supporting you to make that decision, whereas perhaps, you know, and I think it's very much dying out, but if we think about the historical sense of a doctor as being the all-knowing expert who told patients what to do, I think that that kind of generational shift sometimes influences how willing a GP is to have a conversation with a man about things like the blood test.

Rob Bell:
Well, that was very much my experience with my GP.

You know, I went to them, I'm 45, my father's had prostate cancer.

I wasn't told what to do.

I was talked through that situation and then given options on how to proceed.

And then we decided together, myself and my GP, great, that's what we'll do.

And then this is how we'll proceed under, you know, if it comes back this way or that way.

And that was great.

That made me feel informed, which made me feel empowered.

As I said, as I mentioned earlier, to take a bit of control over my own health, which worked for me.

That felt good.

That felt like that was a process and a methodology that I wanted to engage with.

Amy Rylance:
Yeah.

And I'm really pleased, because actually what you're describing is exactly what the guidelines say should happen.

And that is what happens in the vast majority of cases.

I don't want anyone to think, oh god, I'm going to have to have a big battle with my GP.

In the vast majority of cases, that is exactly what happens.

We do, as a charity, sometimes get men contacting us saying, oh, my GP refused to give me the test.

And if that is ever the situation, do get in touch with us, because we can talk you through what your choices are in that situation.

Because actually you are entitled to a PSA blood test.

And in most situations, your GP will just have a chat with you about what your risk factors might be, whether you understand the pros and cons of that test, and support you to make that decision.

Rob Bell:
Great, yeah.

Before we round off, is there anything anybody else would like to add to this conversation that we haven't talked about, or questions for Amy that you haven't been able to ask yet?

Tom Pellereau:
I'd love to say, I think this is another fantastic example of how the medical profession is improving and how lives are improving, and how research and big studies and clinical evidence and then fantastic organizations like Prostate Cancer UK and communication are just improving.

And I think often we can think that the world is going to rubbish and these things are getting worse and I wish the good old days and blah, blah, blah.

But there are so many ways that the world is improving and this is just one of them and this sounds so much better than the old finger up the bum and who knows.

So thank you for all the hard work you do in your organization.

And Robbie, fingers crossed for you, mate.

Rob Bell:
Whenever you mention fingers now, Tommy, I'm like, sorry, I don't know how many times you've said.

Yeah, absolutely, I completely concur with what you say, Tommy.

Yeah, very well said.

Jono Hey:
I was reminded in doing visuals for this, I think I might have mentioned before of the time where I've given blood and you have to read the leaflet before you give blood.

And they started doing icons for all the different things, like, you know, have you ever injected and so on.

And then you get various ones about, you know, ever been given money for sex and different types of sex.

And then of course they stopped doing the icons at that point.

Rob Bell:
Yes.

Jono Hey:
So it's a challenging thing to find an icon that fits for a medical thing sometimes.

Rob Bell:
You did it very well.

It's the snappy rubber glove, right?

Jono Hey:
It is.

Rob Bell:
Which isn't that easy to depict in just a 2D image, Jono, but you've managed to do it incredibly well once again.

Jono Hey:
For something like this, and I don't do a lot of medical related topics because it's really hard, because things might be, first of all, evidence is very complex, it's very detailed.

A lot of it's in the numbers, but you can't easily get the numbers across in a way that people can interpret.

If you go to the typical thing with the science thing is a poster and it's huge and there's thousands of words on it and there's millions and then there's charts and it takes you half an hour to sit through it.

And the words as well, because words can be, you have to be very specific when you're talking about health or science.

And so it's a challenging thing to get visuals and words right.

So I was really grateful to work with Amy and the team to try and understand my way through it.

And I've certainly understood a lot more as I've gone through this as well.

So interesting challenge it certainly was, but already I've seen a number of people and people have reshared the sketch and a lot of people said, thank you, I've gone for a test or they said, this is great.

I had a test and I had to do these things and we should share this as wide as possible.

So that makes it all worth it.

Rob Bell:
It's brilliant.

And so let's bring this podcast to a close then.

And the summary for me, it's the call to action is do the Online Risk Checker.

You can Google Prostate Cancer Risk Checker, right, Amy?

Is that the right thing to Google?

Amy Rylance:
Yep, absolutely.

Rob Bell:
It's 30 seconds.

Tom, if that 30 seconds, if that less than shorter than a podcast intro, at least much.

Tom Pellereau:
Thank you.

No, not an outro, they can go on.

Rob Bell:
But I think also is the fact to spread that word as well.

So not just do that, tell other people as well.

And that goes for females who aren't affected directly, but indirectly are affected by all of those numbers that you talk about and all of those statistics that you talk about, Amy.

If you find the link, you can Google it and send it along or even do it on someone's behalf, perhaps.

I don't know.

It's a very simple thing to do.

And I think that is the summary from this podcast.

Do the Online Risk Checker.

Amy, thank you so much for coming on and for the fantastic work that you and all your colleagues at Prostate Cancer UK do.

I mean, it's a massive eye opener.

It was a massive eye opener for me when I first started learning about prostate cancer when my dad was diagnosed, as I said, but I've learned even more speaking with you on this podcast.

So thank you so much.

Thank you.

Amy Rylance:
Thank you.

And just a final thought, you asked me about the worst bit of my job, but just picking up on Tom's point, the best bit of my job, I work in health improvement and it's getting better all the time.

And it is that sense of continual improvement.

It's an absolute joy to work in this role.

Rob Bell:
Yeah, it's great to hear.

And for the benefit of us all as well.

Thank you.

Jono, thank you also, mate, for taking the time to research this and create a sketch that I hope, well, that we know already is encouraging people to take that 30 seconds out of their day.

So thank you, mate.

Even if one more listener does that, this podcast will be a raging success.

So thank you, mate.

Much appreciated.

And thank you all for listening and for helping us build this podcast over the last series.

As I mentioned at the very top, we'll be back in a few weeks with loads more intriguing, with loads more intriguing topics for series three.

We'll be opening The Post Bag in just a tick, but for series two, for the last time, I'll say go well and stay well.

Goodbye.

Cheers, everyone.

All right, we're delving into The Post Bag for the final time in series two.

And we've only got time for one message this week.

And this came in through the Sketchplanations Podcast website.

It's from Sarah.

It says, Hi guys.

And this is a message about the ever popular subject of egg corns.

I have a recent egg corn example my boyfriend said in response to making a mistake.

Instead of, oh, my bad, he said, oh, my bag.

Sarah says, I laughed whilst explaining to him the saying was definitely not my bag.

Poor Sarah's boyfriend.

Here we are all laughing at him.

We've all done the egg, we've all done egg corns, right?

Jono Hey:
We've all done it.

Rob Bell:
That is the beauty of it.

That's why.

Jono Hey:
Probably still do.

You just don't know.

That's the thing.

Somebody's going to get you.

Rob Bell:
Until you get called out on a podcast, you don't know.

Tom Pellereau:
We're trying to teach my son more vocabulary.

He's shown us a little bit of his English and we've got these cards.

My wife is like, we've got this card and it's the word grimy.

Do you know what grimy is?

I was like, what do you mean grimy?

Yeah, it happens to us all.

Rob Bell:
Along those lines, I went to a disco when I was about 13.

There was a hand-drawn poster up on the wall with the word W-I-C-K-E-D.

I was like, wicked?

What's wicked?

Why is wicked called wicked?

Jono Hey:
English is an impossible language, isn't it?

Yeah.

Rob Bell:
Just madness.

But there will be much more English coming to your ears in Series 3, listeners.

Thank you for listening, and we'll see you then.

All music on this podcast is sourced from the very talented Franc Cinelli.

And you can find loads more tracks at franccinelli.com.