Prostate Cancer

[Doc Alan]

June is Prostate Cancer Awareness month in the Philippines, and Father’s Day has been another reason to raise awareness in the UK.


In the UK 1/8 men develop prostate cancer in their lifetime, the same proportion as women developing breast cancer. It is much commoner in black African / Caribbean men ; less common in Asians. Over 40,000 are diagnosed – causing 10,000 deaths - each year in the UK. Far fewer are diagnosed in the Philippines ( true frequency unknown ), but it is still thought to be the third commonest male cancer, after lung and liver.


The prostate is a male pelvic gland ( " walnut sized " ) surrounding the urethra ( the tube taking urine from bladder to penis ), which helps production of semen.


Symptoms arise if the prostate affects urine flow through the urethra – passing urine more frequently, with poor flow – but even these are commonly due to benign ( non cancerous ) enlargement, which may be treated by drugs / fairly minor surgery.



Apart from race, age is a risk factor – most occur after 50. Family history is the third most important factor. As with breast cancer, 5-10% of prostate cancer cases are thought to be due to genetic factors. For example, men carrying " faulty " genes ( also linked to female breast cancer ) BRCA1 or BRCA2 have several times higher risk of prostate cancer.



Other factors are less clearly linked to risk – vasectomy probably doesn’t increase risk, while coffee and " superfoods " ( fruit and vegetables containing anti-oxidants ) may lower risk. As with so many diseases, other dietary factors ( fat ), lack of exercise, obesity, and smoking may increase risk.



If breast cancer screening is controversial, prostate cancer screening is more so ! PSA ( prostate specific antigen ) is a protein produced normally in this gland, but with cancer it may be measurably raised in the blood. Unfortunately the test is neither specific ( false positives occur in inflammation and " benign enlargement " ), or sensitive ( false negatives occur in true cancer ). Middle aged men with very high levels are thought to be at increased risk in future years.



As with breast cancer, however, there is a chance of unnecessary further tests and treatment of many, in order to prevent lethal cancer in relatively few. In the Philippines the cost of PSA testing ( at least P 600 ) is another disincentive. Other " markers ", such as PCA3 in urine, are now being tested.



Doctors also commonly use DRE ( digital rectal examination; " thumb up the bum " ) to feel prostate enlargement. This is uncomfortable; not itself a diagnosis of cancer ; and accepted less well in the Philippines than UK !


Biopsy of tissue " cores " from various parts of the prostate – taken with hollow needles across the rectal wall – which are examined by microscopy - can not only diagnose cancer, but also grade its " severity / aggressiveness ". But the procedure is painful and carries risks like bleeding / infection. Scanning ( MRI, ultrasound ) – if available - would allow more accurate biopsies.


Early stage cancer, confined to prostate, if it’s low grade, may simply be monitored by " watchful waiting " / " active surveillance ". This is because (over) treatment, to lower testosterone, on which the cancer depends - either with drugs or castration - are drastic and reserved for aggressive cancers. In the UK around 2/5 have drug treatment or radiotherapy. 1/10 have surgery ( with risks such as urine incontinence and erection problems ). Smaller proportions are diagnosed and treated in the Philippines.


In many cases this cancer is slow-growing and will not be lethal. Only if has spread to other parts of the body ( such as bones of pelvis ) is it incurable.



While it mainly affects older men, all of us should be aware of it – whether directly, or as a partner / relative – stand by your man !


http://www.nhs.uk/Conditions/Cancer-...roduction.aspx

http://www.nhs.uk/Conditions/Cancer-.../Symptoms.aspx

http://www.bansalan.com/henry/prostate.htm

http://www.bmj.com/content/346/bmj.f2023

[grahamw48]

Thanks Alan....something that we all need to be aware of.

[imagine]

good post Doc Alan

[Arthur Little]

Alan ... Myrna's elderly cousin, Rafael (76) recently [last week] underwent laser surgery on his prostate.

Thankfully, all seems to have gone satisfactorily according to his daughter, Myla - a Filipina nursing graduate currently living and working in Hartlepool - in spite of specialists' earlier concerns regarding his fitness to withstand the operation due to chronic heart illness ~ complicated by general frailty and COPD.

So ... for Myrna and I, this thread of yours has been a virtual godsend in that, we're both very fond of the old chap and his wife, Exal - with whom we stayed throughout my two visits in 2008 and 2009, respectively. Indeed, it was *Exal's influence that led to Myrna's decision to enter the teaching profession back in the early '80s ... having *herself taught for many years - latterly in a supervisory capacity as Head of Domestic Science for her home region.

[Steve.r]

How did I miss this post, good to bring it to the top again, thanks Alan

[mickcant]

Thanks Doc,
I have had urinating problems for some years and am taking Tamsulosin tablets and have a yearly blood test to check for cancer .

I still have to get up a few times during the night but more or less do it in my sleep.

I have had the finger in the bum check only once thankfully.
Mick.

[Doc Alan]

Thanks for your kind comments Graham, Stewart, Arthur, Steve and Mick .


UK members may know that 78 year old chat show host Sir Michael Parkinson has announced that he is being treated with radiotherapy for this cancer. He said he’s expected to make a full recovery after early diagnosis, and has a positive attitude, raising awareness without trivialising the condition.


Prostate cancer affects men, but it should also concern women, and young people, so it’s good that a few members have read and responded to this thread. Not being famous like Michael Parkinson, it’s my small contribution .

[Arthur Little]

I have had urinating problems for some years and am taking Tamsulosin tablets
Mick.

... Snap, Mick ... I'm on Tamsulosin, too!!

[bigmarco]

Interesting post for us Doc thanks

[mickcant]

... Snap, Mick ... I'm on Tamsulosin, too!!

And we could not be further apart to borrow tablets if in dire need
Mick.

[Michael Parnham]

Interesting topic Alan, I had a urinating problem approx. 10 years ago but luckily for me it was a Stricture and a minor operation cured me, but I must admit prostate cancer did cross my mind at the time, so not all urinal problems are cancer related!

[Doc Alan]

In case any member wondered – but didn’t like to ask – Arthur and Mick are taking Tamsulosin for what we call benign prostatic hyperplasia ( BPH ). It’s one of the “ alpha blockers “ which relax smooth muscle, thus helping urine flow and obstructive symptoms ( like retention of urine in the bladder ).


BPH is common from middle age onwards, and appears to be due to altered male hormone production. There is an overgrowth of fibrous tissue, glands and muscle in the prostate which interferes with urine flow.


Size IS important – BPH may result in enlargement far more marked than with cancer. BPH is by definition NOT cancer. Of course such patients need clinical follow up and possibly surgical removal of part of the prostate if the drugs aren’t working.


Thanks ( again ) to Arthur and Mick, Marco and Michael, for contributing .

[Doc Alan]

For those who are interested, NICE ( National Institute for Health and Care Excellence ) has just updated guidelines on prostate cancer.


They remind us that around a quarter of these cancers occur in men younger than 65. Basically NICE are saying that prostate cancer isn’t always NASTY. They’re emphasizing a “ wait and see “ approach for men of any age whose cancers have NOT spread and which appear ( microscopically ) to be non – aggressive. They call this “ active surveillance “.



Probably about 1 in 5 men with this cancer will be offered active surveillance - half of these will not require treatment and will eventually die of something else. Blood tests and examinations every few months may be unpleasant. They are better than side – effects of ( over ) treatment with drugs, surgery, and radiotherapy - like sexual dysfunction, bowel problems, tiredness, while not necessarily curing the cancer.



This “ wait and see “ approach may not be ideal ! What’s needed is progress in identifying the most aggressive cancers and less drastic, more targeted treatment – as with other cancers.


For many years there has been work on trying to strengthen individuals’ OWN immune systems to fight cancers of various types. One drug acting in this way has been successful for some skin cancers ( melanomas ) and may also work for prostate or lung cancer. Specially tailored drugs may become available as we understand more about the genetic changes in different cancers. Many new cancer drugs are now being investigated. Demand is likely to increase as people live longer, and become more likely to get cancer.


There is also hope for a future prostate cancer vaccine after early successful UK studies in preventing / reducing prostate cancer growth in mice.



Research and treatment does not come cheaply for prostate or any other cancer type, but there are reasons to be cheerful in the “ war against cancer “ – and progress with the commonest cancer in men .


(
http://publications.nice.org.uk/pros...reatment-cg175
).

[Michael Parnham]

Excellent Alan, keep up the good work!

[cheekee]

Doc Alan.

I read recently that pregnancy testing kits can detect prostate cancer as the cancerous cells produce beta HCG. Is that true ?

[Doc Alan]

HCG ( human chorionic gonadotrophin ) is a hormone normally produced by the placenta during pregnancy. It MAY also be produced by cancer cells, including those of prostate, but also others like testis, ovary and liver ; and non-cancerous conditions, like liver cirrhosis.


There are in fact many substances produced by various cancers. Most of these are also made by normal cells. Cancer cells tend to “ lose their inhibitions and behave inappropriately “ , producing proteins or having gene abnormalities which can be detected in body fluids ( blood, urine etc ) or cancer tissue removed surgically. No single “ marker “ can detect any / every cancer type.


At least a couple of dozen markers MAY be used to help detect, diagnose, and manage cancers. The best known marker for prostate cancer is PSA ( prostate specific antigen ). Others include CA-125 ( ovary ) and ER / estrogen receptor ( breast ).


The problem is that none of these markers are specific or sensitive enough. ( Specificity = ability to identify people with a disease, and few false positives ; sensitivity = ability to identify people without a disease, and few false negatives ).


PSA is used for early detection of prostate cancer, but is controversial because it’s neither very specific or sensitive. It may be raised in the absence of cancer and low when cancer is present. A raised level might result in tests and treatment for a low grade or non-existent cancer. My personal opinion ? Without symptoms, I wouldn’t have PSA measured .


The best use for cancer markers - so far - is during treatment of known cancers, when they might help to show recurrence, which would need confirmation by other tests.

[Doc Alan]

There have been recent media reports with headlines such as " Vasectomy research heightens cancer fears " and " Having ‘the snip’ raises prostate cancer fears ". These resulted from a 24 year follow up study of about 50,000 men in USA

(http://jco.ascopubs.org/content/earl...O.2013.54.8446
).
It compared the risk of prostate cancer in men who had a vasectomy to the men who hadn’t.


• They found vasectomy to be associated with a 10% increased overall risk and 19% increased risk of the uncommon " aggressive " type of this cancer ( spread to other organs (metastatic) and / or causing death ).


• This type of study can’t prove that vasectomies cause prostate cancer, as there could have been differences in the men that opted for vasectomy that the researchers did not adjust for.


• While a quarter of men in the study had vasectomies, nowadays it’s more like one in six men in the USA and UK.


• The small increase in relative risk, reported but unexplained in this study, should not mean " the snip " being ruled out as a method of contraception

(http://www.nhs.uk/Conditions/contrac...ilisation.aspx ).



• There are genetic abnormalities increasing the chance of developing the cancer, but the increased risk is slight – as with vasectomy. The same genes predisposing to female breast cancer also predispose to prostate cancer. The cancer is relatively common in the UK and USA ; even commoner in black populations ; and still appears much less common in Asia, including the Philippines

(http://www.thelancet.com/journals/la...451-0/fulltext ).



• If you are male, or you have a male relative, aged over 50, especially if there are symptoms like increased frequency / urgency of urinating, then your GP can have PSA measured for free on the NHS. This should only be done after consultation and examination.


• Routinely screening all men with a blood test to check for PSA is still not recommended in the UK. It’s not reliable and other tests / investigations are needed to diagnose this cancer

(http://www.nhs.uk/Conditions/Cancer-...revention.aspx ).
Investigations should now include MRI scan with biopsy samples guided by the appearances on scan.


• Please be reassured that although this cancer is one of the most common cancers in men worldwide, it usually develops slowly, and the same urinary symptoms may often be caused by non-cancerous enlargement of the prostate .

[Michael Parnham]

Thanks for your very informative update Alan and keep up the good work, much appreciated!

[grahamw48]

Thanks Alan.

I go a lot....but I think it's all the coffee I drink.

[Arthur Little]

Alan ... thankyou for this update to your thread ... like Graham, I tend to a lot - especially at night! But I do, in fact have a [benign] prostate enlargement.

However, I undergo regular screening at my local doctor's surgery; indeed, my PSA levels were checked very recently with - I'm to report - satisfactory results.

[Dedworth]

Good thread Doc. A bit in todays paper about the Prince Michael of Kent

Brave Prince Michael of Kent speaks out about his secret battle with prostate cancer

• Grandson of George V, 72, underwent surgery for prostate cancer
• Prince confirms details of illness in support of others with the disease
• Queen's cousin was diagnosed early and treated successfully, aide confirms
• 40,000 men in Britain each years are affected by prostate cancer
• One in eight will develop the illness, which is most common in over-65s
• Prince's wife Marie-Christine, 69, was treated for skin cancer in 1999

Read more: http://www.dailymail.co.uk/news/arti...#ixzz37ijyyHo4
Follow us: @MailOnline on Twitter | DailyMail on Facebook

[Doc Alan]

Thank you Michael, Graham, Arthur and Dedworth. I’m glad the thread is of some help . Dedworth’s link includes a helpful video .


Prince Michael of Kent is not alone – he joins the list of well known men from all walks of life for whom the diagnosis of prostate cancer was public knowledge – including Michael Parkinson, Roger Moore, Robert De Niro, Ian McKellen, Colin Powell, Francois Mitterand, and Charles Haughey.


Prostate cancer is the most common UK cancer in men - together with lung and bowel cancers, over half of new cases. Survival is relatively good - over 4/5 survive 10 years, compared to 1/25 for lung and about 3/5 for bowel. This is partly because greater awareness and PSA testing has meant more cases of cancers with a very good outlook. As with breast screening, at least some of these would never have spread or killed the patient, even without treatment.


Considering how common this cancer is, it’s disappointing that diagnosis remains difficult. The prostate does gradually enlarge with age which produces the symptoms well known to many men over the age of 50. Conversely, prostate cancer may not produce these symptoms. I can understand why men might be reluctant to visit their doctor, and are confused about the PSA blood test.


The latest figures I can find for the Philippines still show how uncommon this cancer is there – which may reassure those with older male relatives. Sadly it does have a relatively greater death rate - because it’s diagnosed later, at a more advanced stage. Around 2,700 cases were diagnosed in 2010, but 1,400 were thought to have led to death (
http://business.inquirer.net/173258/...rostate-cancer
).


Obviously I can only give an opinion on the Forum. I’ve already said I would not have PSA measured, and don’t have symptoms to make me visit my doctor. " The Great Prostate Hoax " (http://www.economist.com/news/books-...r-help-or-harm ) may not help that decision !

[Doc Alan]

• A study quoted in another thread was an analysis of 150 patients with advanced prostatic cancer, which had already spread to other parts of the body ( " Cell ", Volume 161, Issue 5, 21 May 2015, Pages 1215-1228 ). Most men with advanced disease are resistant to treatment which works in less advanced cases. As with other cancers the way forward is to treat individuals according to the genetic profile of their particular cancer.


• While this cancer is the most common among men in the UK, and one of the commonest worldwide, it’s far less common in the Philippines and elsewhere in Asia.


• Apart from increasing age, and increased risk in certain men ( African-Caribbean descent ), or those with a family history, the cause(s) should be, but are not, well understood.


• The cancer usually develops slowly – and is most often localized at the time of diagnosis ( even in the Philippines where late diagnosis means relatively more are advanced ). Of over 40,000 cases diagnosed each year in the UK, there are 11,000 deaths. Men may live for decades with no symptoms ( and eventually die WITH, but not FROM , prostate cancer ).


• Such genetic analysis of the minority of this type of cancer which is either diagnosed at an advanced stage OR has eventually become advanced MAY be the basis for future treatments, IF controlled trials of drugs show them to be safe, and affordable.


• In the meantime, of FAR more importance would be early and reliable diagnosis of localized prostate cancer for which individual treatment could be given, with possible cure. In any case, treatment is NOT always immediately necessary - benefits and risks need to be balanced. There is NO single reliable test. " PSA " is cheap but there may be false positives or false negatives ; staging by " MRI " scan is expensive and not always available; biopsies are only samples. There’s no point in identifying " cancer " that will never harm a man – especially if the treatment has serious side effects - not least worry for the patient and cost. Genetic profiles of EARLY cancers might be more helpful.


• We’re increasingly realizing that many people are overdiagnosed and overtreated for a wide range of conditions. This is why the UK Academy of Medical Royal Colleges are trying to identify tests and / or treatments which we now know have questionable value. Such an initiative is well worthwhile ! The results could be useful, not only in the UK, but also in the Philippines - where cost of treatment has mostly to be found " up front " for a majority of the population.
• See http://www.bmj.com/content/350/bmj.h2308