An Investigation of the Knowledge and Opinions of British Men Regarding

Prostate Cancer

By

Jedrik Martinez

A Dissertation

Submitted to

Bishop Vaughan Catholic School

As An Extended Project

16 May 2014

Acknowledgement I wish to express my sincere gratitude to Ms. Rebecca Finch, Head of Year, for her expert and valuable guidance extended to me.

I also thank my family and friends for their encouragement and support.

I take this opportunity to thank all who, directly or indirectly, have lent their helping hand in this study.

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ABSTRACTObjectives. Prostate cancer is the most common cancer in males in the UK. It is predicted that one in eight men across the UK will develop the disease. More than 10,000 die from prostate cancer every year. This study aims to investigate the knowledge and opinions of British men regarding the causes, age of onset and screening, treatment and counselling for prostate cancer and attitude towards persons who have prostate cancer.

Methods. Questionnaires were used to collect data for the study. All the respondents (n = 25) were British male with mean age 36.5 years and range 16 – 69 years. Excluded from the study were females; persons with family history of prostate cancer; persons who had been screened, diagnosed or treated for prostate cancer; medical students and doctors and persons involved in cancer research, awareness or treatment.

Results. Results of the study revealed that nineteen (76%) of the 25 respondents did not know the causes of prostate cancer and only 6 (24%) were aware of them. Eleven (44%) respondents suggested that prostate cancer develops over the age of 50. Only 3 (12%) respondents knew there was no screening programme for prostate cancer in the UK. Seventeen (68%) did not know the available treatment options for prostate cancer while 8 (32%) were aware of them. Twenty (80%) of the total respondents were willing to attend a screening programme for prostate cancer. Almost all of the respondents (96%) felt comfortable talking about prostate cancer and nineteen (76%) felt it was alright to see a female GP about it. Twenty-four (96%) respondents will not treat persons with prostate cancer differently and 22 (88%) felt that persons with prostate cancer could continue working.

Conclusion. Generally British men lack the knowledge regarding the causes, age of onset and screening and treatment for prostate cancer. However they show a positive attitude towards counselling and towards persons who have prostate cancer.

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Table of ContentsChapter Title Page

Title Page i

Acknowledgement ii

Abstract iii

Table of Contents iv

List of Tables & Figures v

1. Introduction 1

1.1.Background 1

2. Literature Review 2

3. Method 4

3.1 Questionnaire 4

3.2 Sampling 4

3.3 Ethical Issues 4

4. Results 5

5. Discussion 10

6. Conclusion 11

7. Evaluation and Recommendation 11

7.1 Evaluation 11

7.2Recommendation 12

8. References 13

9. Appendices 14

9.1 Appendix A 14

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Introduction

Background

Prostate cancer is the second most common cancer in males as stated by Longmore et al. (2010, p. 646), and now, the most common cancer in men in the UK (Cancer Research UK 2014). World Cancer Research Fund (2013) reports that in 2011 there were 41,725 new cases of prostate diagnosed in the UK. Prostate Cancer UK (2013) predicts that one in eight men across the UK will develop prostate cancer. It further reports that every hour one man dies from prostate cancer, putting it across as more than 10,000 every year.

Buckford et al. (2009, p. 7) suggest that there are several factors that increase the risk of developing the disease such as age, family history, ethnicity, and dietary factors. They further added that there are several treatment options for prostate cancer such as surgery, radiotherapy and hormone therapy.

Chances for successful treatment of cancer, according to the World Health Organization (2014), are greatly increased through early detection of the disease by way of education to promote early diagnosis and screening. Increased awareness through education like recognition of risk factors and possible warning signs and taking prompt action for early diagnosis can have a great impact on treating cancer.

The purpose of this dissertation is to investigate the knowledge and opinions of British men regarding prostate cancer. The author believes knowledge promotes awareness leading to early diagnosis and treatment, which, in turn, can decrease morbidity and mortality from the disease. The study aims to answer the following questions:

1. The knowledge of British men regarding the causes of, age of onset and screening , and available treatment for prostate cancer,

2. The opinions of British men regarding screening and counselling for prostate cancer, and3. The opinions of British men regarding their behaviour towards persons who had been

diagnosed with or being treated for prostate cancer.

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Literature Review

More than 40,000 cases of prostate cancer is diagnosed yearly accounting for almost a quarter of all cancers in the UK (Cancer Research UK 2014). The World health Organization (2014) includes prostate cancer as one among several types of cancer that cause the majority of cancer deaths. This type of cancer develops in the prostate, a gland in the male reproductive system. NHS Choices (2012) describes the prostate gland as one that produces a fluid that nourishes and protects sperm during sexual activity and makes up a greater part of the ejaculatory volume. According to Muruve et al. (2013) the prostate gland is “located posterior to the pubic symphysis, superior to the perineal membrane, inferior to the bladder, and anterior to the rectum.”

The risks and causes of prostate cancer, according to Cancer Research UK (2014) include age, family history, ethnicity and dietary factors. It further suggests bowel cancer, IGF-1 (Insulin-like Growth Factor) and vasectomy as additional risk factors. Buckford et al. (2009, p. 7) stress that age is the strongest risk factor with the average age during diagnosis at 70 – 74 years and average age at mortality 80 – 84 years. Prostate cancer is less common below the age of 50, however, the risk increases as the age increases. Another risk factor is family history. World Cancer Research Fund (2013) reports that around 5 – 9% of prostate cancer are linked to genes or family history. In addition, Prostate Cancer UK (2013) suggests that a man is two and a half times more likely to develop the disease if his father or brother has the disease compared to one who has no family history of prostate cancer. Regarding ethnicity as a risk factor, World Cancer Research Fund (2013) further reports that men of African Caribbean or African descent have higher risk of prostate cancer than white men. Lastly, Buckford et al. (2009, p. 8) suggest that research linking prostate cancer and diet has been inconclusive but mentions lycopenes and selenium as having protective effect while diet high in protein or calcium from dairy products may increase the risk of prostate cancer.

Benign and malignant growths in the prostate may present with similar symptoms which include urinating more frequently than usual especially at night, needing to rush to the toilet to urinate, difficulty in starting to (hesitancy) or taking a long time (straining) to urinate, and feeling the bladder is not completely empty after passing urine (Cancer Research UK 2014). These symptoms, however, are not evident until the cancer has grown large enough to put pressure on the urethra.

Public Health England (2013) reports that there is no organized screening programme for prostate cancer in the UK. However, it promotes an informed choice programme, the Prostate Cancer Risk Management Programme. It is the aim of the programme to ensure that men who are concerned about the risk of prostate cancer receive a clear understanding of the risks and benefits of PSA (Prostate Specific Antigen) test for screening, other possible screening tests and the available treatment for prostate cancer. Information packs are made available to help the primary care team in counselling men who require the screening test. A number of uncertainties have been recognized surrounding the PSA test and currently, there is no evidence that would prove a PSA-based screening programme beneficial over the risk of using it.

The Prostate Cancer Risk Management Programme (Buckford, et al. 2009) explains that the PSA test is currently the best method of identifying an increased risk of localized prostate cancer. However, the antigen may be elevated in men with other types of prostate problems that are not malignant such as benign prostatic hypertrophy. Although studies reveal reduction in rates of death from prostate cancer after PSA based screening, Buckford et al. (2009, p.15) suggest that there was an associated high risk of over-diagnosis and therefore over-treatment. There are other ways of determining the presence and/or extent of prostate cancers that Buckford et al. (2009, p.9) mentioned like digital rectal examination (DRE); transrectal ultrasound (TRUS); TRUS-guided prostate biopsy and histology; and imaging techniques (magnetic resonance imaging [MRI], computerized tomography [CT] scan, x-ray, bone scan).

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Buckford et al. (2009, p.13) provide several management options that are available for prostate cancer which include watchful waiting with serial PSA monitoring; active surveillance or active monitoring; radical prostatectomy; radiotherapy or high intensity focused ultrasound (HIFU); cryotherapy; and adjuvant hormonal therapy. It is recommended that treatment is considered individually for every man with prostate cancer.

According to Longmore et al. (2010, p.646), of men with prostate cancer, “10% die in six months and that 10% live more than ten years.” Willey (2014), on the other hand, reported that the proportion of men living ten years with prostate cancer has increased from 25% to around 80%. This has been attributed to early diagnosis, more targeted treatment and better preventive measures.

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Method

1. Questionnaire

The study made use of questionnaires in collecting data. After satisfying the inclusion and exclusion criteria, the purpose of the study and the questionnaires was explained to the respondents. The questionnaires consisted of closed ended dichotomous questions that asked respondents to answer in a yes or no with a number of these questions followed by open format questions to give the respondents an opportunity to express their opinions (Appendix A).

2. Sampling

A stratified sampling of 25 British men from different age groups was used for the study. The youngest age set for the study was 16 because at this age a child can give consent to medical treatment (Library of Congress, 2014). The oldest age group were respondents over the age of 50. No reference was made regarding ethnic background. Excluded from the study were:

Females Men who have or would have prior knowledge about prostate cancer such as:

those who had either been screened, diagnosed, treated or are undergoing treatment for prostate cancer;

those who have a family history of prostate cancer; medical doctors; medical students; and those who are or were directly or indirectly involved in any cancer research,

cancer awareness programme or cancer management, for example, radiotherapists, most especially for prostate cancer.

3. Ethical Issues

For confidentiality and ethical issues the names, address and contact details of the respondent were not required information in the questionnaire. All data obtained were kept in confidentiality. The respondents were advised that they can withdraw from the study anytime.

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Results

All respondents (n = 25) completed the questionnaire. Respondents’ mean age was 36.5 years, (median 37 years), and all were British male with no family history of prostate cancer (Table 1).

Results of the study revealed that nineteen (76%) of the 25 respondents did not know the causes of prostate cancer and only 6 (24%) were aware of them (Figure 1). Genes or family history as the most answered cause followed by diet and age (Table 2). Eleven (44%) respondents suggested that prostate cancer develops over the age of 50, 1 didn’t know when, and, 13 (52%) thought it developed before the age of 50 (Table 3). Among the respondents, 10 (40%) thought that, in the UK, men over 50 years old are screened for prostate cancer, 8 (32%) responded that it was before the age of 50, 4 (16%) did not know when, and, only 3 (12%) replied there was no screening programme for prostate cancer in the UK (Table 4). Seventeen (68%) did not know the available treatment options for prostate cancer while 8 (32%) were aware of them (Figure 2). Twenty (80%) were willing to undergo radiotherapy for treatment, 4 (16%) were not, and, 1 (4%) said it depended upon the success rate of the treatment (Figure 3). Fifteen (60%) of the total respondents would prefer surgery over radiotherapy even though this would take several weeks to recover, 8 (32%) would not, while 2 (8%) thought they would if it the only option left (Figure 4).

Figure 1. Knowledge Regarding the Causes of Prostate CancerQ1. Do you know what causes prostate cancer?

YES24%

NO 76%

Figure 2. Knowledge Regarding the Treatment Options Available for Prostate CancerQ10. Do you know what treatment options are available for prostate cancer?

NO 68%

YES 32%

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Figure 3. Opinion Regarding Radiotherapy as TreatmentQ11. One of the most popular treatments is radiotherapy. Would you feel comfortable undergoing this treatment with the effects of radiation?

YES

80%

NO 16%

Depends4%

Figure 4. Opinion Regarding Having Surgery Instead of Radiotherapy as TreatmentQ12. Would you prefer to have surgery rather than radiotherapy even though this would take several weeks to recover?

YES60%

NO 32%

Depends8%

Table 1. Study PopulationN = 25 Mean or N (%) Range Median

Age (years) 36.5 16 - 69 37Sex: M/F 25 (100%)/0British 25 (100%)Family history of prostate cancer

25 (100%)

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Table 2. Knowledge Regarding Causes of Prostate CancerQ1. Do you know what causes prostate cancer? If yes, please could you name the causes below.

Causes Total PercentageGenes/Heredity/Family history 5 35.7%Diet 3 21.4% Red meat 1 Carcinogens in food 1 Not specified 1 Age 3 21.4%Race/Nationality 1 7.1%Lifestyle (not specified) 1 7.1%Enlargement of prostate 1 7.1%

Table 3. Knowledge Regarding the Age of Onset of Prostate CancerQ3. What age do you think prostate cancer usually develops?

Age of Onset

< 10 10 – 19 20 – 29 30 – 39 40 - 49 50 -59 60 & above Don’t Know

Sample Population

< 20 0 1 2 1 1 0 0 0

20 - 29 0 0 1 2 2 0 0 0

30 - 39 0 0 0 1 1 3 0 0

40 - 49 0 0 0 1 0 1 2 150 & above 0 0 0 0 0 3 2 0

Table 4. Knowledge Regarding the Age of Screening for Prostate Cancer in the UKQ4. At what age are men screened in the UK for prostate cancer?

Age of Screening< 10 10 – 19 20 – 29 30 – 39 40 - 49 50 -59 60 & above Not Screened Don’t

KnowSample Population

< 20 0 1 1 1 1 1 0 0 0

20 - 29 0 0 2 0 1 1 0 0 1

30 - 39 0 0 0 0 0 2 2 0 1

40 - 49 0 0 0 0 1 0 1 2 150 & above 0 0 0 0 0 3 0 1 1

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Twenty (80%) of the total respondents were willing to attend a screening programme for prostate cancer while only 3 (12%) would not and the remaining 2 (8%) may possibly attend it (Figure 5). Almost all of the respondents (96%) felt comfortable talking about prostate cancer (Table 5). Nineteen (76%) felt it was alright to see a female GP about it and the remaining 6 (24%) did not (Figure 6). Twenty-four (96%) respondents will not treat persons with prostate cancer differently. Two (8%) felt that persons with prostate cancer could continue to work depending on their well-being, 1 (4%) disagreed while the remaining 22 (88%) thought they could.

Figure 5. Opinion Whether Men are Willing to Attend a Screening ProgrammeQ5. Would you attend a screening programme?

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Figure 6. Opinion Whether Men are Comfortable Going to a Female GP if Symptoms DevelopQ7. If your GP was female would you feel comfortable going to her when you first develop symptoms?

0%

10%

20%

30%

40%

50%

60%

70%

80%

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Table 5. Opinion Whether Men Feel Comfortable Talking About Prostate Cancer Q.6. Would you feel comfortable talking about prostate cancer if you thought you had this illness?

Sample Population

< 20 20 – 29 30 – 39 40 – 49 50 & above Total PercentageYES 5 5 4 5 5 24 96%NO 0 0 1 0 0 1 4%Total 5 5 5 5 5 25

Table 6. Opinion Whether Men Will Treat a Person Differently if He Had Prostate CancerQ.8. Would you treat someone differently if you knew they had prostate cancer?

Sample Population

< 20 20 – 29 30 – 39 40 – 49 50 & above Total PercentageYES 1 0 0 0 0 1 4%NO 4 5 5 5 5 24 96%Total 5 5 5 5 5 25

Table 7. Opinion Whether a Person with Prostate Cancer could Continue to Work Q.9 Do you think someone could continue to work even if they have prostate cancer?

Sample Population

< 20 20 – 29 30 – 39 40 – 49 50 & above Total PercentageYES 4 5 5 3 5 22 88%NO 1 0 0 0 0 1 4%Depends on well-being

0 0 0 2 0 2 8%

Total 5 5 5 5 5 25

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Discussion

Considering that prostate cancer is reported as the most common cancer in males in the UK, it is distressing to know that majority of men are still unaware of the causes and risk factors of developing the disease. A minority of men, however, are aware that age, family history and diet are risk factors for developing the disease. Only a few are aware that the risk of developing the disease increases at age over 50 years and continues to increase as one grows older.

There is no organized screening programme for prostate cancer. This situation does not help men who are at risk of developing the disease. Majority of men are willing to undergo the programme. They feel that screening for the disease can for assure them that they don’t have it thus give them peace of mind. Furthermore they believe that a screening programme can increase awareness of the risks, the signs and symptoms and treatment. They think that screening can promote early detection of the disease resulting to prompt management. However, some men are not quite sure they want to be screened because they feel it can be potentially embarrassing, and others feel the tests (PSA testing and biopsy) might be painful and stressful.

Most men are comfortable talking about the disease as this can increase their awareness, help them gain advice and understanding about treatment and outcome, and believe that this is serious thus should not be ignored. Talking about it can also help them gain support from family and friends and in turn may help others, too. Only one of the respondents found it uncomfortable to talk about the disease if he had it because he felt it was a serious matter. Generally they are comfortable seeing a female GP when symptoms develop, however, some may still prefer seeing a male GP.

On the whole, men’s attitude or behaviour towards individuals with prostate cancer would not change. They also agree that depending on their general well-being, those with prostate cancer could continue to work.

A great number of men are not aware of the available treatment of prostate cancer. A few of them know that surgery, radiotherapy and hormonal therapy are options available in treating the disease. Most men agree to radiotherapy as a form of treatment. Their choice of treatment, however, was dependent on success rate of the treatment and if it was the option suitable for their condition. Some would agree to surgery only if other treatments have failed and they are left with no other options.

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Conclusion

Generally British men lack awareness of prostate cancer – the causes and risk factors, the age of onset, the screening programme and the treatment available. Majority of men are willing to attend a screening programme for prostate cancer as preventive health measure. They are generally comfortable talking about the disease as well as consulting a GP about it. Basically they feel that their attitude towards individuals with prostate cancer will not differ and most agree that these individuals could continue working.

Evaluation and Recommendation

Evaluation

By doing the study and researching on the subject matter, the author had gained important insight regarding prostate cancer. He believes that the awareness would encourage him to live a healthy life and more importantly help others concerned about prostate cancer by sharing the knowledge he obtained throughout the course of the study.

Method. The questionnaire made use of closed format questions to collect data. Some of these questions were followed by qualitative questions like ‘why’ to allow the respondents to express their opinion rather than confining their responses to a yes or no. There were only 12 questions utilized that were short, simple and straight-forward. However the author agrees that the response options to the questions were limited. The response lacked uniformity because some of the respondents provided additional response options while others did not. The questionnaire failed to provide questions regarding awareness of signs and symptoms of prostate cancer and the source of respondent’s knowledge of the disease. Questions regarding adequacy or lack of awareness campaign on prostate cancer by authorities dealing with prevention and management of the disease were not included. Finally it has also been observed that hints or answers regarding the treatment of prostate cancer could be taken from the questions in the questionnaire.

Sample. The sample covered a wide range of age population, with respondents ranging from ages 16 – 69. The inclusion and exclusion criteria were specific to avoid exposure or acquired knowledge on the disease thus minimising bias in answering the questions. The race and educational level of the respondents were, however, not recorded. The author agrees that the sample size was too small to support a claim affecting the study’s reliability and statistical significance. He believes that his target population should have been an age group that were at risk of developing the disease for this would involve men who are likely to need such information in the future.

Ethics. For confidentiality and ethical issues the names, address and contact details of the respondent were not recorded in the questionnaire. For sensitivity issues, persons who had been screened, diagnosed, treated or being treated for prostate cancer were not included in the study. Although there was no written informed consent, persons who consented verbally were included in the study.

Practical Issues. The questionnaires were easy to print off and economical. The sample size was small and respondents were well within the author’s vicinity of daily activity, e. g. school and neighbourhood so it was not difficult and time-consuming to collect data.

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Previous research on the topic. An investigation on knowledge and attitudes of Australian men about prostate cancer by Arnold-Reed, et al. (2008, p. 312) revealed a similar lack of knowledge regarding the disease. However Arnold-Reed, et al. (2008) had a large sample size (n=503) and targeted men aged 40 – 80 who were highly at risk of developing the disease which this author believes, if done similarly, would have given more support to the significance of his own investigation.

Recommendation

For further study to be conducted on the matter, the author recommends increasing the sample size and improving the questionnaire by

providing different possible response options (e.g. Yes _ No _ Maybe _ ); including questions about awareness of signs and symptoms of the disease; asking the respondents the source of their awareness of the disease to help explain the extent

of their knowledge (e.g. What is the source of your knowledge regarding prostate cancer? Newspaper _ Television _ Radio _ Internet _ Posters/Flyers _ School _ Individuals with prostate cancer _ Family _ Friends _ Others _ ) ;

including a measure of the adequacy or lack of awareness campaign on prostate cancer (e.g. How often do you see adverts or campaigns regarding prostate cancer? Very often _ Often _ Sometimes _ Not at all _ ); and

avoiding giving obvious hints or answers by carefully structuring the questions.

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References

Arnold-Reed, D., Hince, D., Bulsara, M., Ngo H., Eaton, M., Wright, A., Jones, F., Kaczmarczyk, W., Marangou, A. and Brett, T. (2008) ‘Knowledge and attitudes of men about prostate cancer’, The Medical Journal of Australia, 186 (6), pp. 312–314. [Online]. Available at: https://www.mja.com.au/journal/2008/189/6/knowledge-and-attitudes-men-about-prostate-cancer (Accessed: 01/05/14)

Buckford , D., Kirby, M. and Austoker, J. (2009) Prostate cancer risk management programme: information for primary care. NHS Cancer Screening Programmes.

Cancer Research UK (2014) Prostate cancer risk and causes. Available at: http://www.cancerresearchuk.org/cancer-help/type/prostate-cancer/about/prostate-cancer-risks-and-causes (Accessed: 21/04/14 ).

Cancer Research UK (2014) Prostate cancer symptoms. Available at: http://www.cancerresearchuk.org/cancer-help/type/prostate-cancer/about/prostate-cancer-symptoms (Accessed: 21/04/14).

Library of Congress (2014) Child health and social welfare. Available at: http://loc.gov/law/help/child-rights/uk.php#ChildHealthandSocialWelfare (Accessed: 01/05/14)

Longmore M., Wilkinson I., Davidson, E., Foulkes, A. and Mafi, A. (2010) Oxford handbook of clinical medicine. 8th edition. New York: Oxford University Press Inc.

Muruve, N. and Gest, T. (2013) Prostate anatomy. Available at: http://emedicine.medscape.com/article/1923122-overview#aw2aab6b3 (Accessed: 16/11/13)

NHS Choices (2012) Know your prostate. Available at: http://nhs.uk/Livewell/Prostatehealth/Pages/knowyourprostate.aspx (Accessed: 16/11/13)

Prostate Cancer UK (2013) Prostate cancer facts and figures. Available at: http://prostatecanceruk.org/information/prostate-cancer-facts-and-figures (Accessed: 08/01/14)

Prostate Cancer UK (2013) What is my risk of prostate cancer? Available at: http://prostatecanceruk.org/information/who-is-at-risk/infographic-what-is-my-risk (Accessed: 08/01/14)

Public Health England (2013) Prostate cancer risk management programme. Available at: http:// cancerscreening.nhs.uk/prostate/ (Accessed: 18/11/13)

Willey, J. (2014) ‘Tipping point in war against cancer in survival rates soar’, Daily Express, 29 April, p.8.

World Health Organization (2014) Cancer mortality and morbidity. Available at: http://www.who.int/gho/ncd/mortality_morbidity/cancer_text/en/ (Accessed: 28/04/14)

World Health Organization (2014) Early detection of cancer. Available at: http://who.int/cancer/detection/en/ (Accessed: 28/04/14)

World Cancer Research Fund (2013) Prostate cancer – at a glance. Available at: http:// http://www.wcrf-uk.org/cancer_prevention/types_of_cancer/prostate_cancer.php (Accessed: 18/11/13)

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Appendices

Appendix A. Questionnaire

A Questionnaire to Investigate the Knowledge and Opinions on Prostate Cancer

You have the right to withdraw at any time. All data collected will be kept confidential. Thank you for taking part. All data will be used for research and study purposes.

Age:

1. Do you know what causes prostate cancer? Yes / No

If yes, please could you name the causes below?

2. Do you have a family history of prostate cancer? Yes / No

3. What age do you think prostate cancer usually develops?

4. At what age are men screened in the UK for prostate cancer?

5. Would you attend a screening program for prostate cancer? Yes / No

Why?

6. Would you feel comfortable talking about prostate cancer if you thought that you had this illness? Yes / No

Why?

7. If your GP was female would you feel comfortable going to her when you first develop symptoms? Yes / No

8. Would you treat someone differently if you knew that they had prostate cancer? Yes / No

9. Do you think someone could continue to work even if they have prostate cancer? Yes / No

10. Do you know what treatment options are available for prostate cancer? Yes / No

If yes please list below:

11. One of the most popular treatments is radiotherapy. Would you feel comfortable undergoing this treatment with the effects of radiation? Yes / No

12. Would you prefer to have surgery rather than radiotherapy even though this would take several weeks to recover? Yes / No

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