Men delaying prostate screening

Men are going for prostate screening too late. Sixty to 75 percent of men are being diagnosed with advanced prostate cancer.

“Far too late for early aggressive therapy,” said Dr Leon Lilas, consultant urologist at the Eric Williams Medical Sciences Complex (EWMSC), Mt Hope.

The prostate is a small gland at the base of the bladder. It produces a protein called Prostate Specific Antigen (PSA) which turns semen into liquid form. Problems with the prostate, whether cancerous or benign may lead to problems passing urine.

In an interview at the EWMSC, Dr Lilas said prostate cancer can be clinically apparent in a man in his 60s but the cancer would have begun developing since he was in his 40s.

“We do have a high incidence. Most men over 50 years old in TT should consider checking on their PSA and have a rectal examination by a competent physician. That’s the way we would pick up if the patient is developing prostate cancer.”

The rectal exam can detect cancerous glands because they feel irregular and hard while non-cancerous (benign) glands feel smooth and soft.

Men with a family history of prostate cancer should begin screening in their 40s. Those with two relatives who have had prostate cancer are five times more at risk of developing this cancer while those with two or more relatives are ten times more at risk. Prostate cancer is higher in men of African descent than Indian.

Lilas said, “Prostate cancer is silent in the early stages and when it gets active it is quite advanced.”

General symptoms which should not be ignored are: problems urinating, swelling of the lower limbs, swelling of the scrotum, swelling of the penis from blockage of glands, chronic back pain (when it has become advanced prostate cancer) and weight loss.

Lilas said therapy is available when the disease is diagnosed early. A blood test determines the level of PSA. He said the “general accepted level was less than 4 ng/ml” but this was not appropriate for everyone.

Lilas uses an age-matched PSA when he is making a diagnosis. “If you have PSA of 3.5 and you are in your 50s or 40s that is too high. But a PSA of 4.5 in the 70s would be ok. The PSA generally goes up with age not just with cancer.” Enlargement of the prostate gland affects more than 50 percent of men over 60.

Lilas said a blanket PSA of four will not apply to all. Other factors which alter the PSA level are size of the prostate and bladder/prostate infection. The PSA alone is not used to make a determination of prostate cancer. “It should be combined with proper patient history and an examination,” he said

There is a misconception among some health providers that a trans rectal ultrasound (TRUS) can diagnose prostate cancer.

“So lots of people are sent off for the TRUS and they are told that the scan is normal and this is sometimes in the face of not even doing a rectal examination. This should be done first and I only order TRUS when there is an abnormality in the PSA and or the rectal examination,” he said.

Lilas uses the TRUS when a biopsy is done on the prostate. He said, “That is the appropriate use in general for the TRUS.”

Patients can have a false sense of security based on inappropriate use of the TRUS. Lilas said some of them end up at his clinic when their PSA continues to be high and by this time they have lost a year or two before a diagnosis is made.

He said based on the rectal examination, PSA and TRUS, “staging” is done to access how advanced the cancer is — localised — contained within the prostate, or advanced — outside the prostate for example in the bones. Lilas said a biopsy report is a critical part of diagnosis. Unfortunately, he found that some of the reports were not detailed enough.

“We need more detailed biopsy reports and that is something pathologists need to get together and standardise.”

When the cancer has spread to the vertebrae it can cause paralysis due to spinal cord compression. Lilas said this should be rare but not at the EWMSC because men were going for treatment too late.

The main option when cancer has reached an advanced stage is hormonal therapy since prostate cancer rarely responds to chemotherapy.

The life expectancy for men with advanced prostate cancer is three to five years. Lilas said the goal of treatment is to contain the cancer. This is done surgically by cutting the body’s supply of the male hormone testosterone, or with drugs.

Hormonal treatment can work for two or three years. After the cancer stops responding life expectancy can drop to six and nine months. “Other things can be done to prolong life, such as using steroids and giving female hormones to the patient,” Lilas said.

Lilas said counselling is necessary because surgery only relieves urinary problems but cancer can still develop. The shell of the prostate is often where cancer develops.

Localised prostate cancer can be treated with radical radiotherapy or radical surgery. Radical radiotherapy usually involves a six-week course at the St James Radiotherapy Centre

Lilas said, “Radical surgery is a formidable undertaking but offers a real chance to cure the disease.”

Brachytherapy — in which radioactive seeds are implanted into the prostate is another form of treatment but is not available in the Public Sector.

While preventing prostate cancer is difficult, a diet low in meat and fat and high in vegetables especially the green leafy kind and tomatoes is recommended.

Lilas said the drug Finasteride has shown promise in reducing the patient’s chance of getting prostate cancer (‘New England Journal’, Thompson et al, 2003). Finasteride is normally used to treat patients with an enlarged prostate. Do you want to test Lady Luck? Then this is for you!

“Whether you die of prostate cancer depends on the stage it is diagnosed. Some very old men have other medical problems. It’s a balance whether you do anything. Some men just require monitoring.”

A recent study by the Institute of Cancer Research treatments has found that radiotherapy and prostate removal surgery do not extend the life of a vast majority of low-grade prostate cancer cases in the age group 55 and 59.

Dr Chris Parker who led the research team was quoted saying that most men with prostate cancer detected by PSA screening “will live out their natural life span without the disease causing any ill effects.”