Prostate cancer

Updated 29 May 2015

What you don't know can kill you

Caught early, prostate cancer does not need to invoke the absolute terror so often associated with cancer. But, note the key words - caught early.

Okay, okay, so we've been banging on a bit about prostate cancer. But it really is important. Caught early, prostate cancer does not need to invoke the absolute terror so often associated with cancer. But, note the key words - caught early. Unfortunately, the South African man seems to have adopted an ostrich, stick-your-neck-in-the-sand, attitude towards prostate cancer.

According to Dr Alan Pontin, senior urologist of the Combined Clinic at Groote Schuur Hospital, most South African men present the disease to a doctor when it's too late. Not clever. South African doctors are sought after all over the world, so international procedures and the latest techniques hold no mystery for them. And the very close co-operation between urologists, researchers, private and public academic sectors in our country means that you, the patient, come first.

South African doctors aren't competing against each other so much as competing against public ignorance.

"Public knowledge is all-important in fighting prostate cancer," says Dr Pontin. So, in an effort to educate the South African man, Men's Health got together with prostate cancer fundis Dr Alan Pontin, radiation oncologist Professor Ray Abratt, and various others, to give you the not-so-scary facts on prostate cancer. Here is a set of standard checks for the early disease stage and new advances which are worth knowing about. Come on, pull your finger out and get your butt onto a waiting room chair.

1. The standard routine Once you turn 50, you should start thinking about heading to your doctor to undergo a digital rectal exam (the finger) and a PSA (prostate-specific antigen) test every second year. If your total PSA reading is four nano-grams per millilitre of blood (ng/ml) or greater - a high count that suggests that cancerous cells may be producing PSA - your doctor might refer you to a specialist for a prostate biopsy. However, do not panic at this stage. There are lots of other prostetic conditions that can cause elevated PSA. Cancer is not the foregone conclusion.

New advances Start getting PSA tests at age 40 if you have a family history of prostate cancer. If your PSA level is between four and 10 your doctor should then perform a 'percent free' PSA test, which measures both free-floating PSA and those bound to other molecules, known as 'complex' PSA. This test, which has been around for three years, will indicate whether your condition is benign or not, thereby perhaps avoiding the necessity for a biopsy.

Also, ask your doctor if your PSA reading is normal for your age and race. In South Africa, urologists use a standard PSA of four for all races, but it is a fact that Asian men produce the least PSA, white men produce slightly more, and black men have the highest natural PSA counts. Most urologists would ignore a PSA reading of 3.3ng/ml in a 52-year-old black man, but if you're Japanese, that may be high enough to suggest cancer.

2. The standard routine Your prostate biopsy takes six tissue samples.

New advances Some doctors will suggest that you double the take. However, as with any medical procedure, the more you fiddle about, the higher the risk of complications arising. How many sample tissues you take also depends on the situation, says Dr Pontin. If you obviously do have cancer, only one sample may be necessary. Both Pontin and Abratt agree that the standard six is perfectly adequate in normal circumstances. However, should the gland be bigger than normal, they might go up to eight or 10. This is called an extended-sextant biopsy, and it scans a wider field to spot malignant cells. However many you have done, it is important that your doctor try to sample the whole prostate. Most private practices in South Africa now make use of ultrasound so that they can see exactly what is going on in your glands. Ask to be referred to such a practice if you are unsure of your results.

3. The standard routine Your doctor sends your biopsy to a nearby hospital for analysis.

New advances The word 'cancer' always seems to invoke a mad panic and you may be tempted to rush around looking for the best research hospitals and academics for analysis. This is totally unnecessary. The South African man can rest assured that the expertise within private practices is just as good as that within the academic field. The culture of co-operation between the two sectors in South Africa means that no matter where you go, you will benefit from all the latest advancements and techniques.

You may also benefit from a combination of tests, which you can insist on, such as cat scans and bone scans. Do ask about these as they can help determine how advanced the cancer is. This will help in determining what kind of treatment you get.

4. The standard routine Your urologist thinks your tumour won't cause trouble for decades, so he advises you to forego treatment and avoid side effects.

New advances Before you agree to 'watchful waiting', as this strategy is called, ask your doctor to explain the test results that make him believe the tumour isn't aggressive. Discuss your Gleason score, which rates how malignant a prostate tumour is. A University of Connecticut study found that those who had a Gleason score above six and underwent watchful waiting were five times more likely to die prematurely from prostate cancer - even if they were diagnosed when they were 74 years old - than watchful waiters with lower Gleason scores.

5. The standard routine Your urologist recommends that you have your prostate surgically removed (a radical prostatectomy). You schedule a consultation with a urological surgeon.

New advances If a urologist and a radiation oncologist agree that it's truly necessary to remove your prostate, find a urological surgeon who's skilled in doing 'nerve-sparing' radical prostatectomies. Don't take this point lightly; aside from the size of your prostate tumour, your surgeon's experience and skill level are the biggest factors in determining whether you'll enjoy sex and dry pants again.

"I would only trust my prostate to a surgeon who is highly experienced and who has a special interest in radical prostatectomies," says Dr Pontin.

On this note Prof Abratt adds, "The urological community in South Africa will, and does, centralise prostatectomies to certain surgeons who are interested and who therefore do the procedure most often." You can check on this. Your urologist will know all the best people to talk to and will either refer you to, or work with, a surgeon who has a recognised interest in prostatectomies.

"There is every reason to believe that you will benefit from the best possible treatment in South Africa," says Prof Abratt. Reports and results are proof of this.

6. The standard routine If you have a large tumour and undergo a radical prostatectomy, the surgeon may be forced to sever the nerves that control sexual function.

New advances Surgeons in a few facilities use a novel procedure to preserve the sex lives of men in this situation. "During prostate surgery, we harvest a nerve from your ankle to use as a graft to bridge the severed neurovascular bundle in the pelvis," says Dr Ronald Morton. "This has allowed about 60 percent of men to stay potent after surgery, whereas before this technique their odds of having an erection again were virtually zero."

It is important to note, however, "although interesting, this procedure is not mainstream," says Prof Abratt. "This an experimental procedure which may prove of value in the future."

7. The standard routine Your doctor suggests external-beam radiation therapy, so you undergo daily sessions for seven weeks to kill the tumour. The typical 'four-field' machine bombards your prostate with wide beams of radiation from the front, back, left and right. The chances that you'll be cured of cancer - and that you'll be impotent and incontinent - are slightly less than with a radical prostatectomy.

New advances Find a radiation oncologist who specialises in three-dimensional conformal radiation, or in special cases, intensity-modulated radiation therapy (IMRT), advises Prof Abratt. These two techniques concentrate thousands of radiation beams directly on the prostate, which maximises tumour-killing potential and spares the healthy tissue of the rectum.

Also, inquire about the dose. It is now understood that radiation dose is more important than initially thought. Various studies done found that those who received higher doses of radiation and more sessions were nearly twice as likely to have normal PSA levels five years later. Tumours should be treated with a dose of 70 Gray. Other advances in radiation technology are:

  • Development of CT scans - "We are now able to visualise the tumour much better than 10 years ago because of the development of CT scans," says Prof Abratt.
    Of interest here is that the initial work to develop CT scans, now used worldwide, was started by Dr McCormack in Radiotherapy Planning at Groote Schuur Hospital in Cape Town. Dr McCormack won a Nobel prize for his work.

  • Computer-based planning - Plans can now be done in three dimensions instead of only two because computer-based planning systems are much more sophisticated.

  • Better penetration - Radiation machinery can now penetrate the cancerous cells better because of the higher mega-voltage.

8. The standard routine Instead of external-beam radiation, your oncologist suggests that you have 60 to 120 radioactive seeds implanted in your prostate (a treatment option called brachy-therapy) to kill the tumour. Note: this is only done for very early, low-risk stages. He'll probably use images of your prostate taken several weeks before surgery to decide where to place the seeds.

New advances The exact placement of those rice-size seeds is critical. "Your doctor really should use ultrasound or computer technology right in the operating room to help them place the seeds precisely," says Prof Abratt. This allows the doctor to map the prostate tumour right before surgery, helping him position the seeds correctly.

9. The standard routine A decade after you had a radical prostatectomy or radiation treatment, your PSA count starts rising rapidly, which means that cancer cells have survived. Your urologist will now start you on hormone-blocking drugs. Prostate cancer growth can be inhibited by decreasing the level of the male hormone, testosterone.

One of the ways this can be done is the use of hormone blocking drugs. These will work for a period of between one and 10 years, averaging about two and a half years. But, eventually, the cancer won't respond to the hormones any more and at this stage the outlook may be limited, but it may be years.

New advances Ask about chemotherapy. It is very controversial, however. Most oncologists strongly believe that chemotherapy should be done in a study setting. This is endorsed by both Prof Abratt and Dr Pontin. They point out that studies haven't proved that men on chemotherapy live longer.

Some oncologists, including Prof Abratt and several other South Africans, are currently involved in international studies of new chemotherapy agents to see how good they actually are and whether they should be used at all. It still needs to be proven whether chemotherapy actually affects PSA levels, bone pain and survival.

"We really just don't know yet, that's the point of the trials," says Prof Abratt. "And aside from longevity, we are also checking quality of life. Quality of life should always be a very important consideration." You can ask for entry into a trial - ask to be referred to someone doing recognised studies. - (By Ron Geraci, additional reporting by Belinda Rose-Innes)

Read more:
What is prostatitis?
Screening tests for men


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