Instant Genius - Prostate cancer: What is it and why is it so often missed?

Episode Date: February 21, 2025

The prostate is often misunderstood. And yet, this small part of the body is crucial. However, it is also one of the most common forms of cancer, affecting many men around the world. We spoke to Matthew Hobbs, director of research at Prostate Cancer UK who breaks down the big questions. What is a prostate, what treatments are available for prostate cancer and what does the future of diagnosis look like? Learn more about your ad choices. Visit podcastchoices.com/adchoices

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a bite-sized masterclass from the BBC Science Focus magazine, where we interview some of the biggest names in science and tech. The prostate is an area of the body you might not think about very often, but especially as we age, it can be a real concern. Prostate cancer remains one of the most common cancers for men, but still, for a lot of people, it's a mystery. Matthew Hobbs, Director of Research at Prostate Cancer UK, talks us through the risks and concerns of prostate cancer,

how to stay healthy, and most importantly, what actually is the prostate? With this kind of conversation, a great place to start is at the very, very base of it. So what actually is the prostate and what is it that it does? The prostate is a very important and either unknown or misunderstood organs. So it's a gland that sits around the ureter, so it sits sort of near the bladder. It's about the size of a walnut, so it's quite a small thing. But what it does is it's absolutely essential to life. So when men produce sperm, obviously sperm have to swim in something and the prostate

produces the liquid that sperm swimming. So without prostate, there is no reproduction, there is no life. But it has that one very specific function, which is obviously very important, but it is a kind of hidden, it's a hidden gland, it's a hidden organ, so not a lot of people think about it

until something goes wrong with it. So it's specifically that one role that it does that has that full focus on that. Yeah, absolutely. Obviously, the main risk with your prostate is prostate cancer. How common is that? And what are the signs

that people should be looking out for? Yeah, so two really important questions. the really important thing to know is that prostate cancer is incredibly common. So prostate cancer is now the most commonly diagnosed cancer. The lifetime risk of a man, so for any man in the population, about one in eight men will be diagnosed with prostate cancer at some point in their life. Your risk increases as you get older or maybe come back onto the risk factors a little bit later because that's an important point. So it's really, really common. A lot of the time, it is low risk, it's easy to treat. It might not even cause any problems at all. It's just

that there are cancerous cells in the prostate. But because it is so common, the relatively small percentage men who are diagnosed and get a very high risk disease or suffer, mean that it actually causes a lot of deaths as well. So just to give some numbers, around about 50,000 men diagnosed every year in the UK, and around about 12,500 deaths in the UK every year from prostate cancer. So really a very common disease and a very common cause of death in men. So that's how common it is. We talk a lot about risk factors, and the reason we do that is because symptoms is a really bad way to work out whether you need to start thinking about prostate cancer. And this is a bit of a sort of, I guess it's a sort of myth that's grown up over the

years, but for a long time, people thought that like most cancers, there would be a symptom or symptoms if you had prostate cancer. And because your risk of prostate cancer gets higher as you get older, your risk of having urinary symptoms also increases as you get older. And so there appeared to be an association between men having urinary symptoms. So the classic ones that we talk about are getting up a lot of times in the night to go for a way, not being able to fully empty to the bladder. Now, they can be a symptom of prostate cancer, but in the vast majority of cases, that's just a symptom of getting older and your prostate getting a bit bigger and things starting to sort of get a bit older.

And so now what we say is, don't wait for symptoms. Symptoms aren't a good indicator of a problem. The important thing to know is to know what puts you at higher risk. And as said before, men over the age of 50 in the general population, that's when you start to get to a risk level where you need to think about prostate cancer. Things that increase your risk are black ethnicity, so black men have got twice the risk of prostate cancer as white men and a family history. So if you've got a dad or a brother especially who's been diagnosed prostate cancer, and absolutely if you've got close family,

close male family relatives who've died of prostate cancer, you've got a much higher risk of prostate cancer as well. And so for those men, from the age of about 45, he needs to start thinking about it. And do we know why it's so common, or is that something that we just haven't worked out yet? It's a good question. I think scientifically, we probably don't know the, you know, the sort of the the ground truth to that answer. But really, it sort of is part of aging. You know, as we get older, our cells have turned themselves around. They've reproduced more and more times, and there's more chance that something go wrong. Prostate is just an organ that is particularly prone to developing cancerous cells that go wrong as we get older. So it's almost, you know, if we all lived to a very,

very old age, we would all have some cancerous cells in our prostate. It's kind of inevitable. But yeah, actually what we don't understand is what triggers prostate, normal prostate cells, to go wrong and become cancerous cells. And I think that is a really important area for future research. And if you are in that sort of group that is more likely to have it, you're older, any of those sort of factors, can you then go and get tested for it? And if you do, what would the diagnosis most likely be? Yeah, so diagnosis and the diagnostic pathway is a very hot topic at the moment in prostate cancer. So we don't have a screening program for prostate cancer. So the first thing to say is you won't remember receive a letter in the post from the NHS saying come for your

annual prostate cancer screening it's important to state that because we've done some public awareness work and we think about half of men in the population think that there is a screening program and they will be called so really important to know that that isn't the case at the moment what we do have is and maybe we'll come back on to why we don't have a screening program and how we think we get to what so we don't have screening program but we do have on the NHS a right if you like to to have a PSA test if you're over the age of 50 and crucially you've had a conversation with your doctor where you've discussed the pros and cons of having a PSA test so PSA test is the first test we use it's a blood test and it's sort of it's the first step in diagnosing the disease but it's not perfect and so that idea that you've you've got

to have that conversation so you can make an informed choice if you like about whether you want to go down that path is the key thing preventing us from having screaming at the moment I think the thing that we find difficult is as a charity and we think is a wider problem is, although that right exists to a PSA test, doctors aren't allowed to proactively have that conversation with men. So what it relies on is a man to understand prostate cancer to think about it, to know they're at risk, initiate a conversation with their GP, have the conversation, and then make the decision. And we think there is screening. We need to be sure of the evidence for screening.

And again, we should probably come on to that shortly. but at the very least we think that that is the fact that men have to initiate the conversation is leading to disparities and is driving a lot of the laid diagnosis we still see. So as part of the issue, do you think, is there isn't that understanding of it from the public of how to go about it and how to get diagnosed if they do need to? I think the, yeah, I think it's more a case that there's still just a general lack of awareness of prostate cancer. I think there is a huge number of men in the population who don't even know what prostate

it is or that they've got one, so it's really helpful for us to be able to get these kinds of messages out. There is almost a lack of knowledge of the fact that it's so common and so serious. So some people will know it's common but think it's not a serious disease. Some people think it's serious but don't really like how common it is. And then you've got the sort of the general kind of barriers to initiating that conversation. So, for example, men who aren't able to go to the doctor in the daytime, who might have a lower education level, who live somewhere rural, all of these factors make them less likely to be able to start that journey to a prostate and start a journey to an informed choice.

And as I say, I think the need for men to initiate is enhancing, is increasing those disparities at the moment and on something we really need to think about. The obvious solution to that is to have a screening program where men do get a letter through the post and are called every year or every two years for a standardized test. That is currently being assessed by the National Screening Committee. That's the group that decides whether the NHS screens or doesn't screen the diseases. And it is an area where we're kind of in a situation where in some ways the answer is obvious that we should screen. And in some ways, if you look at different evidence, it's obvious that we shouldn't screen.

I might be working just covering that a little bit. So basically, the reason we don't have screening to date is because the clinical trials that have happened, the screening trials have shown. Initially, there were three big screening trials. And in the first instance, they didn't show that you could reduce the number of many died of prostate cancer if you gave them a PSA test. However, two of those trials, a European trial and the UK trial, when the men were followed for long enough, and this is an interesting thing about prostate cancer, that even those aggressive cancers can take a long time to cause really serious side effects or death. But when the men in the trial were followed for 9, 11 or 15 years,

then we did start to see the number of men who died from prostate cancer come down. And so we've gone from a situation maybe 10 years ago where the evidence said, there is no evidence that PSA screening saves lives. To a situation now where we do have evidence, and especially the European trial, shows that around about 20% of prostate cancer deaths were prevented by screening with PSA. So the reason we now don't have screening is

because alongside that reduction in death, when you screen men with PSA or when you did in those trials at least, a lot of men, a huge number of men ended up going for biopsies. A lot of them had a negative biopsy, so it was a biopsy they didn't need. It's not a pleasant procedure. It does come with some side effects.

And a huge number of men were diagnosed with those clinically insignificant diseases that I talk about. And that clinically insignificant disease doesn't need treating, isn't going to cause any harm. We know that now, but does cause anxiety and does cause overtreatments. So where we got to, the most recent assessment of the evidence on screening is, yeah, there is benefit.

We do save lives, but our population level, we cause a huge amount of harm, and that's heavier than the amount of lives we save. It seems it's a really difficult concept when you think about it as an individual because for me, if I go for a PSA test I can only be, only my life is saved or unharmed, it's one and one and the harm is much less than the saving.

But a population level, because so many more men are harmed than saved, it does prevent us moving screening. But actually that changing diagnosis that I talked about, all of those screening trials were done with the old way of doing things where there was no MRI. And so prostate cancer UK, we've just done some analysis looking at real world evidence. and we think on the basis of that real world evidence

that around about 80% of the harm, so 80% of the men being sent for biopsy, they didn't need 80% of the men being diagnosed with clinical significant disease now doesn't happen because of that changing pathway. But no trials have ever tested that. So we've got almost an assumption, we think that's right, but we can't be sure,

and the screening committee might need us to be sure about that. And so we're waiting for them to tell us what they think. We've asked them as well to look at groups where we know the risk is higher. So we talked about family history and black ethnicity. Actually, if those men are twice likely to die from prostate cancer, which they are, they're probably no more likely to be harmed by a PSA test. And so the risk-benefit ratio is differing in those groups. So we're currently awaiting the evidence review and some modeling from the National Screening Committee to tell us whether we can start screening for prostate

cancer. In the meantime, prostate cancer UK thinks this is an area that's too important for men, and we haven't had screening for so long. So we've funded a very, very large screening trial that effectively is the next generation screening trial that builds on what's gone before. And that's going to test not only the pathway that we use today, which has never been tested in a screening clinical trial,

but also test pathways that actually look like they find cancers that are missed by the current pathway. So you do stuff like you use genetics to find many at higher risk, or you use MRI up front, so you find cancers that are there, but you don't see in PSA test. And so we launched,

that it's a 42 million pound trial. We've had co-funding from the governments through an HR to the tune of 16 million. And that trial is now launched and is due to start recruiting men in this year. Eventually, that's likely to recruit about 300,000 men. And the aim of it is two things, I guess. It's deliberately a very large and complex trial because we've got to guarantee that we can move things forward here. It's not enough to just carry on with the system we've got. And so the trial's designed to do two main things. For the current pathway, the way we test for prostate cancer now, it's to close all of the evidence gaps that still exist. So that we're no longer in a position where there are any assumptions, all of the evidence

is evidence, not assumption. But crucially, it's also to look at things that we think can do better and save more than 20% of lives. Because if we're only saving 20% of lives with current screening, there's another 80% of men being screened as to the other prostate cancer. And for those men, we've got to get a newer pathway still, and that's going to require evidence in that trial. So that's the picture on screening. It is a very live debate, and I think we've got to close the evidence gaps and also build the future pathways.

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supports patients every day. Financial aid and scholarships are available for those who qualify. Learn more at ACCCFuture.com. That's ACCCFuture.com. ACC cannot guarantee employment. This podcast is sponsored by Name, Audio, and Focal. With over 100 years of combined expertise, Name and Focal have been bringing music to listeners just as the artist intended. Since day one, this mantra has shaped every innovation in hi-fi design. technology and acoustic engineering, balancing craftsmanship and tradition with pioneering thinking. Name Audio pushes cutting-edge technology to ensure digital precision whilst sustaining Pratt,

pace, rhythm and timing, the elusive quality that makes music feel alive and gives it emotional texture. Today, in partnership with French acoustic specialist's focal, name audio creates systems that deliver exceptional sound, an unforgettable. listening experiences at home. Try it for yourself at a focal powered by name boutique. Visit focal powered by name.com for more information. And for someone who does end up going to get screened, they've got a diagnosis. What would the next steps then be? What does treatment currently look like for prostate cancer? So the way we diagnose prostate cancer now is in the UK, you'll go for a PSA blood test. If that blood test shows your PSA level,

is risen. So PSA is prostate-specific antigen. It's just a, it's a protein in the blood that is given off by the prostate. If that's above a certain level, so usually three nanogramph per milliliter, you'll then be referred. In the past, you were referred straight for a biopsy, and that baropsy was done without any imaging, and so it was done slightly randomly. Now in the UK, practices changed because research that happened a few years ago, somewhat which we funded. And now, rather than go straight for a biopsy, you go for an MRI scan. So the MRI takes a picture of a prostate. I mean, your listeners will know well about MRI. And the research showed that by doing that scan of the prostate, not only can you find about a third of the manner you would have biopsyed

who didn't need a biopsy at all, and you spared them that biopsy, that invasive procedure, you can also take a picture of the areas of prostate that are suspicious that most likely got the cancer and the biopsy can be targeted. And so that's dagost to biopause. So you have a PSA test, an MRI and then a biopsy, and it's only after the biopsy that we know for sure that there is prostate cancer in prostate. One important thing on that is in the past, a digital rectal exam, so the finger-up-bum test was used relatively commonly

to just try and feel the prostate to see if it felt wrong. Now we've got MRI, there's absolutely no need to do that test. In most cases, it doesn't really add anything to the diagnostic accuracy. And so most men will go right through the diagnostic pathway without having to have that test. That's really important because for a lot of men, that's one of the reasons they don't want to think about prostate cancer. And that is old practice, and it is, and very commonly now in the UK, it's not done.

And even if it is done, you can request for it not to be part of your diagnostic pathway. So that's kind of the way we diagnose. So then the treatment pathway for men prostate cancer is a really important point. And it kind of leads me on to one of the things that I think it's interesting and important to know about prostate cancer. And that is that it's a very complex disease. And one of the ways it's complex is that there are very, very, very important. different outcomes and very different treatment pathways depending on the exact characteristics of the prostate cancer that's diagnosed in a man. And so just to give an obvious example, I guess,

a lot of men when they're diagnosed would be diagnosed with low-risk prostate cancer that's still in the prostate. And the way we assess how aggressive a prostate cancer is, is by looking at the cells under a microscope and assigning a grade. It's called the Gleeson grade. It's just the measure of how different the cancer cells look to a normal cell. And depending on that, it gives us a an idea of how aggressive cancer is. And we know now that very low risk prostate cancer, so ones where they're given a Gleason grade group of one, so it's the lowest score. Or in the UK we sometimes use a different measure, which is called the Cambridge Prognostic group. Again, a score of one is the lowest grade. Those cancers are very, very unlikely to

ever spread or ever cause any problems, even if that man gets no treatments. So for those men, the advised and the best course of treatment is active surveillance. So that is the name suggests just very actively watching cancer and making sure it doesn't get any worse. And for those men, that means regular imaging, so regular MRIs, often it will mean regular PSA tests and regular biopsys, but they won't ever, a lot of men with backgraded disease will never have to have treatments at all, as we understand it. Contrast that with men who are diagnosed with very aggressive prostate cancer, even if it's still in the prostate. And for those when we know that the risk of it spreading is so high,

that we need to give them a treatment that treats the prostate, so surgery or radiotherapy usually, but also we need to give them drugs that will help control the spread or mob up any cancer that's already spread outside of prostate, and so that's a much more significant treatment and treatment burden. We've also then got men who've got prostate cancer, and it's already spread outside the prostate.

For those men currently, we cannot offer a curative treatment. So if the cancer is still in the prostate, the aim of treatment is to get rid of it completely and effectively to cure that man. wanted to spread outside the prostate, we currently can't do that, although it's a very active area of research about actually are there metastatic disease cases which we could cure. And so those where we'll have drug treatments primarily. So the main drug treatment of prostate cancer is androgen deprivation therapy.

So basically prostate cancer is fed by testosterone. And so to stop it feeding and stop it growing, we completely take testosterone out of the body. And there's various different ways that we do that. But that's kind of the first approach. I think before I finish this answer, one of the really interesting. and difficult for men, I think, areas of prostate cancer is those men who are in between that very low-grade disease and very high-grade disease, we've got a sort of intermediate risk prostate cancer. Most of those men will be cured by a treatment, and for them, there are probably

three different options. For men who definitely, they definitely need treatments, so we can't just watch it, but we know that the cancer hasn't spread, and it's not really highly risky that it will. they will be offered definitely surgery, also radiotherapy, increasingly focal therapy, so where you just treat the prostate where the cancer is, and largely for those men, all of those treatments are good options. It's very difficult from the side of which one they should choose. And so prostate cancer UK has a lot of health information we've got on a specialist nurse support line. And a lot of the questions we get, and a lot of the difficulty we have is about choosing the treatments.

And really it's because those treatments are all pretty good. And so the decision is often made on the basis of the different side effects and the sort of quality of life and the different kinds of side effects that can be expected rather than the ability to control the cancer because they're all pretty good doing that. We touched on it just a little bit there in that conversation, but are there, I guess, any treatments and development that could potentially be seen in the future that could make a big difference here? Yeah, so that brings me right onto my favourite area about research and Boref funding.

So prostate cancer UK is the biggest UK funder of prostate cancer research. And so, as you'd expect, we're seeing a lot of different, really promising sort of future developments that we're now funding to try and get them to the point where they make a difference for men. Again, it's really complicated because there are so many different types of prostate cancer and different men with different prostate cancer, especially those sort of different levels of risk and different levels of aggressiveness need completely different things from us and from research. So actually, the men with low risk disease, we often call that clinically insignificant disease now. and there's a debate about whether that should be called prostate cancer at all. What those men need is probably a diagnostic pathway that avoids diagnosing them entirely. So being diagnosed with those clinically insignificant prostate cancers can only cause you harm, but you don't need treating.

It's not going to cause the cancer itself isn't going to cause harm, but the anxiety and the thought that you've got cancer, even if you're told it doesn't need treatments. We know a lot of those men really struggle with that, with that sort of mental burden, and a lot of them go on to get treatments that they probably don't need to try to reduce that anxiety. That's kind of the problem.

There's not a treatment bit of research. It's more about sort of diagnostic accuracy, I suppose. I think the men who we do need to think about better treatments for other men who are dying from prostate cancer, and they fall into probably two or three groups. The first group of men is men who are diagnosed with those very high-risk, aggressive but localised prostate cancers. At the minute they get, probably they get radiotherapy,

a course of hormone therapy to temporarily take testosterone. strain their bodies out that causes huge side effects to note. But we know that even with those treatments, a lot of those men still go on to die prostate cancer. That's prostate cancer that's localized in the prostate and we should be able to find a way to cure them. So for those men we are looking at how do you treat them more intensively, what extra treatments do you give them? That's probably going to be treatments that we know that we're using in later stage disease, but just applied at front. Now, the key thing for them is it's what are the treatments that are can cure them and also how can we be precise about the men, the treatments we give and the amount of treatments

because the more treatment you give, probably the more chance you've got a cure on the cancer, but the more side effects, the lower quality of life goes and men will get. So actually targeting our treatments and being precise is the key thing for them. The other main group of men who are dying, well, the group of men who die from prostate cancer, the group of men we really need to think about in terms of how we treat differently is men who've got metastatic prostate cancer. So this is prostate cancer that's outside the prostate spreads around the body. Usually it goes to bones, so it's the site that prostate cancer will tend to go to secondary.

And just because of the amount of cancer they've got and the way the cancer develops, so your audience will probably know this, but cancer isn't a single static thing. It's almost like a living organism, and so it evolves. And as it evolves, it finds different ways to grow and different ways to avoid treatment. Once prostate cancer is spread around the body, there are often multiple different forms of the disease, all acting in different ways. And so combination therapies that are really important. And crucially, prostate cancer is very clever. And it finds a way to stop responding to treatments that work. So for a lot of men, the path is when they've got metastatic prostate cancer, they will start on

lifelong hormone therapy. That will work often for several years. For a lot of men, we've got other ways of blocking hormones or stopping those hormones having the effect that we want to prevent. And so a lot of men will live for many years, even with metastatic prostate cancer. but eventually their cancer will find a way to stop responding to those students. They'll find a sort of a side route around those treatments and start growing again. And at that point we need to find completely different ways to treat their cancers. So just blocking hormones for those men and that's the way we've treated prostate cancer for decades. And even getting a bit better at blocking the hormones isn't going to have the effect we want for them.

Their cancer will grow anyway. So for those men, the key is looking at completely different ways to treat the disease. so there's a lot of really, really exciting research going on. Can we find things on the surface of all the cancer cells, whether it's responding to hormones or not, that we can use to target different types of therapy, so either radiotherapy delivered by a sort of metal, so molecular radio therapy, if you like,

or chemotherapy, but we target it out into the cancer cells. So that idea of finding the precise mechanisms the cancer cells are using at all stages, and using that against it is, I think, what's really exciting. The other thing that I think where we are seeing a lot of progress is in taking drugs that we've got or treatments that we've got and moving them into different parts of disease or using them in combination or in slightly different ways. So just as an example, we're funding a couple of really exciting radiotherapy grants and clinical trials at the moment. Radiotherapy is a, it's a great treatment for men who've got local arthropal cancer. It's been curing those men for, again, for decades.

But now we're increasingly seeing whether we can use it to treat cancer that spread or treat cancer, that's just come outside the prostate. So I think there's probably some relatively short-term wins that we can have still by just taking the stuff that's working and trying to make it work in different places, using radiotherapy, for example, to irradiate the lymph loads, which is where prostate cancer has spread to first before it gets to the bones. So extending that ability to cure, or even using radiotherapy to target prostate cancer in the bones that's fully metastasized

to try and keep men responding to their treatments for longer. So a load of really exciting stuff. And then, you know, sort of further down the pipeline, And those are things that I think we will likely see happening within the next five to 10 years. Further down the pipeline, we're also funding some really exciting research that is a, you know, it's a bit more speculative, a bit more blue skies around. Can we do what other cancers have done and use the immune system to treat the cancer? It's been really successful in lung and skin cancer.

It's not been successful yet in prostate cancer. Can we use really exciting stuff around nanoparticles? Can we use nanoparticles to improve how we treat prostate cancer? Some early signs that we probably can, but it needs the research to be funded and delivered to actually make that reality. So we've got a lot of really exciting stuff coming. The challenge we've got is that prostate cancer is so diverse, it's really difficult to say.

None of those things are likely to work for all men. And eventually in 10, 15 or 20 years time, I think we'll increasingly move to kind of what you see in breast cancer a little bit, that different men with different types of prostate cancer get very different treatment targeted to, rather than just the clinical characteristics of their cancer, the biological characteristics of their cancer. So what genes are being expressed, what proteins are being expressed,

and I think that's the future. And you mentioned near the end of their nanotechnology. Obviously, we're now in the stage where we're seeing a lot of quite advanced movements in future tech, artificial intelligence is having a big moment. Genomics is doing great things, as you said, narrow technology. Can these sort of technologies maybe advance the speed at which we're trying to diagnose these or solve these problems. I think that's absolutely true.

I think all three of those things are going to play a role in the future of prostate cancer diagnosis and treatment. So I've talked a little bit about nanotech. I think nanotech, at the moment, it looks most useful as a, as a mechanism to deliver treatment in a targeted way. So you spurs around the tissues

and you make sure the treatment gets to the cancer cells. And I say, we're funding some really, really exciting work in that space. The other two are really important as well and worth spending a bit of time talking about. So AI is coming. You know, it's coming in all sectors, in all walks of life. It's definitely coming in the diagnosis and treatment of cancer.

I think in prostate cancer, it's going to have a huge impact in a lot of different ways. I think first and foremost, we'll see it have an impact in how we diagnose. So some of that complexity that I talked about, when you do imaging and when you do biopsies, you see that complexity in prostate cancer. It's not a simple image. It's not a simple picture. It's not simple. Oh, that's cancer or not cancer.

and the level of complexity makes AI potentially really important in that space. If we can train machines to see things that humans can't understand or see in those images, we can get more accurate, we can diagnose more accurately, we can treat more accurately, and we are seeing that coming. There are tools as one in particular where we've been working with the company, and we've funded some research around it, where effectively, when you take a biopsy in the past, what happened was pathologists would look at that biopsy under a microscope and sort of say, yeah, that's a grade four bit, that's a grade three bit, that's a grade five bit.

But now we can digitize all of those. And then, so literally that was a bit of, there was a sort of, it was cells on a microscope slide, and that microscope slide was put into storage. And now what happens, increasingly is the biopsy is dawn. And all of those slides, all those microscope slides are digitized, so they're just sort of scanned by a scale. The fact that they're digital then means you can get machines to look at them and read them, you can share those images, those, the biopsy becomes an image effectively.

And there's a tool that's been developed in the states, say is starting to be used already in prostate cancer and to some extent in the UK, which it does a much better job at making that call about whether this is an aggressive cancer that's going to cause harm or not an aggressive cancer that can be treated less. One of the really exciting things that that tool was is it tells us the men who need hormone therapy and the men who don't get any benefit from hormone therapy because side effects of that treatments are huge, you know, it effectively castrates men. And if men can get the, the kids, the kids, cure that they would get with that treatment, without that treatment, it's really important. And it looks

like that AI tool can identify about 60% of men who will currently get a hydrogen declaration therapy, or hormone therapy, who don't need it. It should be a huge reduction in burden for men and huge reduction in burden for the health system. So there's a cost saving a quality of life benefit. So I think AI is going to be really important. It's also going to have a massive role in drug discovery. There's no doubt about it. We've seen Google's tools that are fulfilled and similar. Doing a much better job of being able to screen billions and billions of different compounds to work out how we design drugs and how to develop drugs, I hope that will speed up, how we go from, here's an important thing, a important biological pathway to here's a drug that we've got and we can take it into

clinical trials. I think those are the key bits for AI in prostate cancer at the moment. The other one that talked about genomics is we're already kind of in that era. We're a little bit behind prostate cancer compared to other cancers. What we did, a couple of years ago, we did see the first ever targeted precision medicine prostate cancer. That's a really interesting story. It's actually a drug that was developed for women with ovarian cancer

with Brecker mutations. So Bracker is a gene that you can either inherit a faulty copy of. It's quite rare that that happens. But also some cancers develop a faulty bracker gene just in the cancer. So you can have this sort of brachem mutated cancer or a BRAC mutation

that runs in the family. So there's this drug that worked and stopped ovarian cancers, which were BRCA deficient from growing. And actually, some research we funded showed that if you looked at prostate cancers, and certainly late stage aggressive metastatic prostate cancers, quite a lot of them have a BRCA mutation or a mutation that does a similar job to BRCA. And so because of that work that we funded, the drug company that, the drug companies, there's actually multiple drugs that were being used in ovarian and had actually started

to be used in breast as well. they ran clinical trials in prostate cancer, but rather than just treating all men with advanced prostate cancer, they deliberately selected the ones that had those mutations that we thought would effectively give them a better chance to respond to that drug. And that's exactly what happened. So those drocks of PARP inhibitors are the first ever molecularly targeted prostate cancer drug.

That's about genomics. So that analysis you do to work out who responds to genomic analysis. Crucially, though, it's the cancer genomes, genes that are being used by the cancer, rather than necessarily the genes that are being used by the rest of the body. But that really is only a first step. We know that that's probably somewhere between 10 and 30% of very advanced prostate cancers. It's lower numbers in early stage disease. And we've got to take that approach and work out what are all the other different biological paths

and genomic mutations that cancers are using to grow. And actually, if we do that and we can get to a point where we say, okay, this is a cancer that will respond to a PARP inhibitor, this is a cancer that will respond to drug X, this is a cancer that will respond to drug Z. then I think we can, that is the way we're going to make progress. It's one other ways we're going to make progress in that very late stage disease. Do the thing is we've got to have the drugs. So we're all very well identifying the genomics and understanding the pathway.

But if we don't have the drugs, then we can't actually do anything without knowledge for men. That Bracker example was a really interesting and useful one because there was a drug out there already. And sometimes being behind other cancers allows us to just pick something off the shelf and say, let's try that in prostate cancer. You shorten development time by decades probably. But that isn't always case, and so sometimes we will need to develop new drugs as well.

So I think we've covered a lot here. I think a good place to sort of finalise and go over is just what sort of advice you would give to people whether they're thinking about prostate cancer, you know, when and how should they be addressing it and what should they know? Yeah, so I say prostate cancer is a very complex disease. We often try to give a very simple message just to make sure it lands. I think the simple version of this message is if you're a man over 50 or a black man or a man with family history over 45, you need to think about prostate cancer. And I mean think academically what I actually mean is go and have a look at the prostate cancer UK website.

We've got a risk checker tool which will tell you your risk. It's fairly basic the way it gives you risk. Effectively it will tell you what I said earlier. The men in those categories are at high risk and as you get older, your risk increases. but it will lead through into the evidence that we've currently got about diagnosis and some of the stuff that we don't know yet to allow you to start to decide whether to have a PSA blood test or not. I think that's the key thing.

The other thing is just recognising how common and how lethal it is, it is to say that we're not there yet. We don't know everything. We haven't got all of the tools and all of the treatments that we need. And so actually, this is a really good example of where research is going to be crucial, delivering what men and patients need in the future. Thank you for listening to this episode of Instant Genius. That was Matthew Hobbs talking about prostate cancer.

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