Many of you regular readers of this column have been waiting patiently for me to address prostate cancer. Well here we are at last. September is prostate cancer awareness month. However, it is also childhood cancer awareness month (some emphasis on leukemia/lymphomas) and it is also gynaecological cancer awareness month (emphasis on ovarian cancer).
Just to make sure we are on the same page, prostate cancer is only found in men as only they have the prostate gland. Don’t feel shy if you didn’t know this. Many a medical student will tell you they have stumbled there and they get a whole year of anatomy! Typically it affects elderly men in their 7thdecade of life but in our African population we seem to see it earlier, more frequently and it seems to be deadlier. Though this observation is long established the reason behind the fact is still being rigorously investigated and reported. Geographically it occurs more developed countries this is sometimes attributed to the more intensive screening activities. It is not uncommon for prostate cancer to run in some families and associations with certain genetic mutation syndromes are known.
In all this the most common issues surrounding prostate cancer involve sexual health. Does dysfunction precede the disease of vice versa? The answer to that is due to the age group prone to getting prostate cancer certain symptoms are associated with physiological changes of an enlarged prostate. The only sure way of knowing is being screened for the cancer. We will discuss later how some treatments may affect sexual health and why some patients may shun the conventional approach because of this.
Some other risk factors that we know are common in prostate cancer patients but we are not very clear on their correlation are diet, obesity, smoking, chemical exposure, sexually transmitted diseases and vasectomy.
A change in diet in particular including eating more fruits and vegetables and less red meat lowers the risk of prostate cancer. Increased physical activity and staying a healthy weight also adds benefit.
The good news about prostate cancer is that we have screening tests that are effective. The most common one is the prostate specific antigen (PSA) test, which is a blood test. It is very sensitive to the presence of prostate cancer. However, it is also non-specific. This means that if one has diabetes, an infection or even ejaculated a couple of hours before the test it can produce a false positive test. This is why ideally your test should be accompanied by a consultation with medical personnel who can guide the next steps of your screening process.
From our interactions I know most of you will have read about recommendations against PSA screening. This is still a roaring debate and the last I checked local experts in Zambia recommend that the test be conducted. When you read information online make sure to understand the context of where the information is coming from. This is why it is best to discuss with specialists in the field, as they are able to dissect information and apply it. Remember your health choices are not a one-way dictation from doctor to patient but rather shared decision-making process.
The other test performed in screening is a digital rectal exam. Most men do not like this but I think it is worth the discomfort. Ideally a normal prostate is the size of a small guava (4 cm length). Our friends in the west say the size of a walnut but how many of us have actually seen walnuts? If someone has a better local analogue please email me on the address below so that more people can be on the same page. It has a rubbery texture and is smooth with a groove midline. When a man reaches 40 years his prostate starts enlarging and if this is benign the groove may disappear but the hypertrophic organ retains its rubbery texture. In cancer the gland tends to be lumpy and hard. A qualified medical person should be able to elicit this.
Usually a combination of a suspicious history, raised PSA and positive clinical examination warrants an invasive procedure called a transrectal prostatic biopsy.
Again this is unbearable for most men. They find themselves being put in a physical position they never envisioned themselves to ever be. Over the years the technique has improved to a more comfortable one so be wary of stories from people who had their procedures many years ago.
Once the results come in a urologist or an oncologist will determines the ‘risk’ group which can fall in low, intermediate and high. The decision to treat or not depends on one’s risk grouping. The three parameters used are PSA, Clinical stage and Gleason score. The Gleason sore is a combination of two numbers representing the most common pattern of disease. And can range from six to ten.
The kinds of treatment available are watchful waiting, active surveillance, external beam radiotherapy, hormonal, chemotherapy, radioisotopes and targeted agents.
Due to space limitation I will address the issue of doing nothing or something.
Lets start with doing nothing. The debate on the useful of PSA screening comes about in the fact that some groups of researchers found that certain patients prostate cancer was of such a low grade, growing slowly and non aggressive such that something else in their list of health problems would lead to their demise. Or sometimes another health problem is so great that it is unlikely the cancer will be the reason for mortality. As such two approaches can be taken.Observation is where the patient gets no further tests but only comes back if a symptom as a result of the cancer becomes a problem. For example if the cancer causes urinary retention or a broken bone. The doctor then treats the problem and that’s it. Active surveillance is used in more healthy individuals where the PSA is monitored and if it continues rising at a rapid rate treatment is initiated. If it takes years some patients may even end up with repeat biopsies.
The above two options are not entered into lightly and serious consideration of all factors socio-economic and otherwise must be made.
Doing something may involve one modality or more. Brachytherapy, which is placing the radiotherapy source directly in the prostate either by, seeds permanently or temporarily through catheters, can be used comfortably for those with favourable intermediate risk and below. For those with unfavourable intermediate risk a combination of brachytherapy and external beam must be used or an escalated dose of external beam alone.
In addition to the radiotherapy hormonal therapy must be used as prostate cancer is a cancer fed by testosterone. Blocking testosterone kills the cancer cells very effectively, however, it also causes sexual dysfunction, which can be very distressing for patients.
The topic of prostate cancer is so wide with many layers. I look forward to receiving your questions and comments this week. And remember to keep smiling its good for you.