Prostate cancer on the rise

The steady increase in prostate cancer has prompted one urologist to publicly appeal for men who are at high risk to get annual assessments. Dr Philip Ayoung-Chee, urological surgeon at SurgiMed Clinic in San Fernando, said cancer of the prostate gland is an important disease and is a significant cause of mortality and morbidity. A preliminary study at the South-West Regional Health Authority found that Afro-Trinidadians had an incidence of 87.1/100,000 and Indo-Trinidadians had an incidence of 8.9/100,000. Jamaica has the highest reported incidence with 308/100,000. “There has been a steady increase in the incidence of prostate cancer. In many industrialised countries, prostate cancer has become the most common cancer diagnosed in men and the second common cause of cancer death.”

He recommends that men over 50 years should have annual digital rectal examination (DRE) and prostate specific antigen (PSA) assessments. Afro-Trinidadians are advised to start five years earlier. Dr Ayoung-Chee said people in high risk groups (family history of cancer diseases), should subtract five years. “Afro-Trinbagonian with a high-risk family should begin testing at age 40.” Dr Ayoung-Chee said that because advanced prostate cancer is only amenable to palliative treatment, there is considerable emphasis on early diagnosis and treatment “in the hope of a cure while the disease is confined to the prostate capsule.” He said the most realistic opportunity for cure is to detect prostate cancer at an early stage.

In TT, patients with localised or early prostate cancer are offered either radical prostatectomy or brachytherapy. Dr Ayoung-Chee said there are many screening methods available, including DRE, PSA and trans-rectal ultra sound (TRUS).  Patients with any abnormality in preliminary testing are advised to have a prostate biopsy. Although there are many different methods of screening, there is no controlled data to prove that screening is beneficial. Dr Ayoung-Chee said an effective method is yet to be established. Commenting on screening methods, he said DRE is used as a preliminary tool for evaluating the prostate. Outlining the benefits, he said it is easy to do, causes little discomfort to the patient and is inexpensive.  Dr Ayoung-Chee advised that while cancer of the prostate produces changes detectable in the DRE, the changes are not specific and many early cancers will not be detected.

DRE as a sole diagnostic tool is unacceptable. Dr Ayoung-Chee said the introduction of PSA has revolutionised the detection and management of prostate cancer. Age specific reference ranges has improved the sensitivity of detecting prostate cancer in younger men and the specificity in older men. He said this has resulted in higher positive predictive values and fewer unnecessary biopsies. Dr Ayoung-Chee warned that increases in PSA can also be caused by prostate enlargement and infection. TRUS is inappropriate for prostate cancer screening, although it is the most commonly used imaging procedure for the prostate. TRUS can detect lesions but these are not specific to cancer. Benign causes such as infection and infarction can also appear as lesions.

Dr Ayoung-Chee said it is highly recommended that patients with any abnormality of either the PSA or the DRE should proceed to a ten-core needle biopsy. This is a puncture of the prostate gland, following which there is removal of and microscopic examination of the tissue from the living body to establish a precise diagnosis. Dr Ayoung-Chee said this is done as a day procedure and requires no anaesthesia or hospitalisation. Pain is minor but the procedure, requiring repeated rectal examinations is very uncomfortable. Patients are required to be on antibiotics. The most common complications include blood in the ejaculate, or urine. The most feared complication is fever and infection.

Severe complications such as gross rectal blood loss, septicaemia (infection of the blood) and death. Less than one percent of patients require hospitalisation. The biopsy results will reveal — cancer, suspicious changes, no cancer. Dr Ayoung-Chee said patients must understand that detectable abnormalities do not necessarily mean there is the presence of cancer. “Only a biopsy may allay such fears.”