Annually in November, we see men compete to grow impressive moustaches to fund raise for Movember - the leading global charity for men’s mental and physical health, particularly for prostate and testicular cancer.
We thought we would contribute to raising awareness by interviewing Mr Jonathan Noël - consultant urological surgeon, based at Guy's and St Thomas' NHS Foundation Trust. He also leads in prostate cancer diagnosis at Lewisham and Greenwich NHS Trust for the South East London Cancer Network.
He is a double robotic surgical fellowship trained urologist and performed an excess of 100 robotic procedures in his first twelve months as a consultant (which is impressive compared to the average UK surgeon performing 46 per year!). He was born in the UK, then raised and attended medical school in the Caribbean. He is also a third generation surgeon, his father practices in the island of Grenada! You can find more about his work on his website.
Health awareness: prostate cancer
1. What is one thing you wish everyone knew about prostate cancer?
I wish people knew it has no symptoms at an early stage. It is important for families to talk to each other and understand their own risk, as a lot of people seek this out after their diagnosis. We need to see more openness and vulnerability around men and break down the “strong, mighty and never sick” stereotype - we are all human. It is also useful to know about the genetic relationship to breast cancer in families, which can also increase prostate cancer risk.
2. What are typically the most common first symptoms patients report?
Most patients that present with symptoms can do so when the disease is advanced, such as urinary symptoms = haematuria (blood in urine), back pain at night and flank pain. It is important to note that it is not an old man's disease! We can see people present as early as in their fourth decade.
3. Once a patient is diagnosed, what is the typical journey to go through to get treatment?
So most patients are referred by their GP following an elevated PSA above age specific normal range (blood test used primarily in clinical suspicion of prostate cancer) or a hard prostate discovered on examination. In a clinic, we go through a patient’s history, risk profile & perform an examination which is part of a clinical assessment. Next, we usually request a MRI scan which can avoid a prostate biopsy if it is normal. However, if there is an area of suspicion on the MRI, we perform a biopsy with precision to pick up clinically significant cancer, as opposed to without an MRI. If it is low risk or clinically insignificant cancer, we put these patients on active surveillance, which usually involves monitoring the PSA every 6 months and an MRI every 2 years. If it is intermediate or high risk prostate cancer, they tend to proceed to treatment which is discussed in a MDT (multidisciplinary team meeting where other specialists are present such as oncology and radiology) to recommend the best course of action such as radical surgery, radiotherapy or chemotherapy, or a combination!
4. How would you recommend men reduce their risk of developing prostate cancer?
Men can get check their risk with this tool created by Prostate Cancer UK: https://prostatecanceruk.org/risk-checker
Like all cancers, maintaining a healthy lifestyle is important - exercise, avoid excess smoking and alcohol consumption. These will improve a patient’s cardiovascular health as well. Actively being aware of your family history is important too, as you may be informed to enquire about PSA testing!
5. Do you think a national screening programme will come to fruition soon?
At present, the UK does not have a national prostate cancer screening programme due to concerns about overdiagnosis and overtreatment. However, we should consider this carefully, as we know that “Black men are disproportionately affected two times more likely than white men and three times more likely than Asian men”. Additionally, the National Prostate Cancer Audit (NPCA), led by the Royal College of Surgeons, have discovered that black, elderly and deprived men were all less likely to receive radical treatment for their high risk disease. Important evidence we have for screening from the US is from 2012, the US preventive services task force downgraded PSA screening. However, following a surge in advanced prostate cancer presentations, in 2018 the task force recommended PSA screening discussions for men aged 55-69.
6. Tell us more about the community health initiatives you have been involved with to raise awareness
Since 2019, I have been involved with an annual event hosted at a London barbershop owned by Kevin De La Rosa. It is converted into a mini auditorium and health fair complimented by cook-ups and music. It is a non-intimidating, relaxed environment to have discussions and learn a lot from patients. You can hear more about our initiative here: https://www.youtube.com/watch?v=p94UkqpyOzE
This has received great support from prominent figures including Errol McKellar, MBE (60 year old football coach, former garage owner and prostate cancer survivor).
Furthermore, local faith leaders such as Bishop Lennox Hamilton from Lewisham Greater Faith Ministry also hosted prostate cancer seminars in his community of south east london. I join these gatherings to speak about secondary care of prostate cancer diagnosis and treatment. I am honoured to receive perspectives on varied journeys from patients, which help us improve our service.
Career Insights
1. Why did you choose urology as a career and why should aspiring surgeons choose your specialty?
I’ve always wanted to do surgery and was particularly inspired by the technology used in urology. My mentor in Barbados, who I observed using a laser surgical system to treat prostate enlargement, is what sparked my decision to specialise in this field. In 2023, living in a digitalized world - technology in surgery is essential. This specialty lends itself well to balance between elective and emergency work. There are unknowns in prostate cancer, which makes it an interesting space to help build new knowledge in, particularly in respect to health inequalities. Also, you do not have to only do high risk surgery to make a difference in the field - it has everything for every career ambition. Urology offers the opportunity to make an impact with medical therapies in addition to surgical procedures.
2. What’s your favourite thing about your job?
It has to be the consultation at the beginning - I really enjoy speaking to people and learning about their decision and journey to a diagnostic clinic. I also enjoy the challenges of robotic prostate surgery - no single operation is the same, yet the outcomes are so important to get right.
3. Where do you see the future advancement of robotics in urology in the next 10 years?
Seeing additional specialties getting involved to improve on our robotic surgery further (we already see advances in colorectal, thoracic and ENT outcomes). It will be advantageous to see multiple specialty collaboration; when all surgeons in a hospital can use the system. For example, an iatrogenic bowel injury during prostate cancer removal and general colorectal surgeon performing robotic repair. I would like to see robot systems being more affordable, not only for developing countries, but for smaller NHS hospitals to use for the benefit of their patients. Additionally, it would be great to see smaller sized robots - at present they can take up a fairly large footprint in theatre!
4. Do you have any other final words for our readers?
→ We need to keep questioning the role of prostate cancer screening in the UK, particularly for groups of patients at higher risk than others.
→ Encourage your patients to know their risk! Use the risk checker and talk to their GP about PSA testing
→ I would not change my career. I encourage surgical trainees to find mentors and learn from their experiences. It gives fulfilment to mentors to support you and see you progress.
→ Robotic surgery is the future - everyone needs to get involved during training!
We hope you have found this interview insightful! We can all play our part in raising awareness and supporting men to be open about their health.
Dr Ellen Nelson-Rowe,
Melanin Medics Blog Lead