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Three and a half years ago the artist Sir Terry Frost died from prostate cancer. Last week the Beaux Arts Gallery, London opened an exhibition of his paintings, which are as colourful and vibrant as their painter had been. Frost, who continued to paint until his death, had a remarkable life. Military routine in the Royal Warwickshire Yeomanry proved too uneventful for him, so he volunteered for the commandos in 1941. He learnt to paint in 1943 while a prisoner of war in Poland and Bavaria: the bright and energetic colours were an antidote to the lack of colour and drabness of prison camp life. He was as brave when dying from cancer as he was as a commando in Crete, and refused to allow it to stop him painting or writing to his admirers.

On the same evening as the preview of Frost’s exhibition in Cork Street, Professor Jack Schalken, from the University of Nijmegen in the Netherlands, was speaking at the Royal College of Physicians. Jack Schalken, together with Dr Marion Bussemakers of the University of Nijmegen and Dr Wil-liam Isaacs at Johns Hopkins University in Baltimore, were the geniuses who discovered the PCA3 gene that is produced by prostate cancer cells. It is a discovery that may well revolutionise the diagnosis and treatment of the disease. If the test for the presence of the PCA3 gene is positive this is an almost certain sign that a significant tumour is present in the patient’s prostate and needs urgent treatment.

The PSA test is the standard, easy and comparatively cheap blood test that the American Cancer Society suggest all men over 50, or over 40 if they have a strong family history of the cancer, should have done annually. This advice stands even if unfortunately the PSA test gives rise to a large number of apparently false positive results. This means that more prostate biopsies are carried out than would be necessary if a more specific test than the PSA was available, so the PCA3 may be an answer. The biopsy may also give a false result as the cancerous cells may be missed. Conversely some of the most malignant cancers don’t cause an abnormal level of PSA, although close examination of serial results will usually show that the PSA, while not unusually high, is increasing at an unacceptable rate.

Even though the PSA, the biopsy or the ultrasound cannot give a definitive result these tests are, and will remain, essential diagnostic tools. If a biopsy detects cancerous cells, these give the doctors a good indication of the malignancy of the tumour, and how radically it needs treatment. Far too many men lose their lives because of late diagnosis or because they were wrongly treated with watchful waiting, rather than a potentially curative treatment. Watchful waiting has acquired such a sinister reputation with patients that the regime now has, or should have, been replaced by a carefully and cautiously prescribed formula known as active surveillance.

The PCA3 gene discovered by Professor Schalken and his colleagues is isolated from prostatic cells in a sample of urine passed after a digital rectal examination. This dreaded, but in fact no more than uncomfortable, procedure releases prostatic cells into the urine and the resulting assessment of the PCA3 score gives a remarkably accurate guide to the presence of a cancer, and its likely significance. The PCA3 doesn’t replace the PSA but is indicated when the PSA results and other diagnostic methods are inconclusive. It will be of particular value if a patient has had one or more negative biopsies despite a raised PSA. The PCA3 will reduce the need for recurrent biopsies in those with an apparently falsely positive elevated serum PSA.

It is also useful for a patient with a strong family history of the disease, suspicious findings on digital examination or a rapidly rising but still normal PSA and for patients assigned to an active surveillance treatment regime.

Prostate is now the most common major cancer in males in the United Kingdom. The death rate from it will fall only if early detection of aggressive tumours is improved. The PCA3 offers this hope but the PSA will remain an excellent means of detecting those patients who need further investigation, and is and will remain the best method of detecting any return of the cancer and of monitoring its later progress.

Professor Schalken said in London last week that he still hears the nonsense that it is impossible to distinguish the aggressive prostate cancer, the tiger, from the relatively benign condition, the pussycat. He said that a good urologist given the data – PSA, Gleason score (this measures the cancer’s malignancy), tumour size and now the PCA3 result will immediately recognise the difference. He added that it would take him less than three minutes to decide the correct treatment, and who would live and who would die without it once he had these statistics.

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— The Prostate: Small Gland, Big Problem, by Roger Kirby

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