A. Colin Buck, Consultant Urologist, in his book Prostate Cancer Q&A states:-
"Autopsy studies have shown that 30% of men over 50 years of age have histologic evidence of so-called latent prostatic cancer, disease that remains undetected during the patients lifetime. The incidence steadily increases with age, ranging from 10% in men in their 50's to 80% in men in their 80's; thus every decade of ageing nearly doubles the incidence.
It is clear, therefore, that the prevalence of prostate cancer seen on autopsy examination far outstrips the prevalence of clinical cancer. Curiously, and unique to the prostate, only about a tenth of these latent cancers will become clinically manifest during the patients lifetime; thus, nine of ten such cancers do not seem to matter."
Q. Is screening for prostate cancer worthwhile?
A. I regret there is no straight answer to this one either! Some medics feel that early diagnosis and treatment can cure prostate cancer, others do not. The problem is that there have been long term randomised clinical trials to show that any of the current treatments for prostate cancer prolong a patients life over and above watchful waiting. (i.e. monitoring the cancer and only beginning treatment when the cancer reaches a predetermined stage of growth, measured by a PSA test, or when symptoms become apparent.)
The UK Governments stance on this is that as existing treatments all result in major complications such as impotence and partial or complete incontinence, until such time that randomised trials are completed routine screening is not recommended.
Q. Why do survival rates for prostate cancer vary so much from UK to US?
A. You have been reading the papers again ! Dr Stuttaford in the Times was one of the first to place this fallacy firmly into the minds of not only the public but also the health correspondents of the nation. Now it appears to be repeated as a fact, used by journalists and cancer charities to promote their particular cause or point of view.
The headline normally runs like this:-
"Men in the USA and on the Continent have a better 5 year survival rate than men in the UK."
FACT - They are not comparing like with like. But it is a great headline maker. Quotes such as :-
"In Germany where regular PSA is standard practice the five year survival rate is 50% better than in Britain," and again in the USA "nearly twice as many are alive five years after diagnosis compared with Britain's." But let's look at it from a different perspective.
If you diagnose what can be a slow progressive disease five years earlier in the U.S.A. because you have regular PSA tests and then treat it and then compare the results with Britain where there is very little early detection, then the five year survival rate is going look better. It does not mean that the treatment you have given to the men in U.S.A. has necessarily increased the survival time, it may simply be because you have diagnosed the disease 5 years earlier !
In the U.S.A. the patient diagnosed with minute cancer cells, which may or may not affect his lifespan, has the worry of the diagnosis, the trauma of the treatments with any attendant side effects over the full five years (so called) 'extended' (?) survival time.
In Britain the non-diagnosed patient with minute cancer cells which may or may not affect his lifespan has no worry, no treatment side effects, (which usually means lifestyle changes for the 5 years). If symptoms then occur he has a choice of beginning treatment. I would refer you back to Colin Bucks paragraph when he states that nine out of ten such cancers do not seem to matter.
It could mean that the Americans are treating nine men out of every ten diagnosed for no good reason at all. Some might say that the U.S. medics have to be sure otherwise they would be sued, cynics would say they make a damn good living out of performing the operations.
There have been no long term clinical studies to show that any one radical treatment is better than doing nothing at all. Until medics can complete such trials, can positively distinguish between aggressive cancer and non- aggressive cancer, it is imperative that each man makes his own choice about screening and subsequent treatment assuming he has all the facts before him.
The PHA have a book 'Prostate Cancer' which will allow a man to gain knowledge about the disease, the tests, treatments and the treatment side effects. Knowledge dissipates fear and allows a man to take charge of his life, make decisions, decisions based on self knowledge.
Q. What are the risk factors for prostate cancer?
A. Afro-Americans have the highest risk factor, some 136 cases of prostate cancer for every 100,000 men compared to American whites at 44 per 100,000 men.
Conversely, the lowest incidence is in the Far East with China at 0.8 per 100,000 and Japan at 3.4 per 100,000. The UK rate is around 18 per 100,000.
Q. What are the latest treatment options for prostate cancer?
A. Radical prostatectomy. The complete removal of the gland.
External Beam Radiotherapy. Using a conventional machine which treats the prostate cancer from outside of the body.
Conformal Radiotherapy. Similar to the above but this new technique targets the prostate exactly. This means that there is less damage to adjacent tissue and organs. On side effects alone this would seem preferable to normal external beam treatment.
Seed implantation. The implantation of small radioactive iodine seeds directly into the prostate gland.
Hormone treatment. The suppression of the male hormone, testosterone, either by drugs or removal of the testes. (Orchiectomy)
Watchful waiting. As prostate cancer is often latent or can be a slow growing cancer and can take ten or more years before it begins to give a man any symptoms; rather than starting a man on treatments which can have side effects, the decision can be made to watch and wait.
In practical terms this means 'monitoring' the cancer and only beginning a treatment if it reaches a predetermined stage of growth. This allows the patient to continue with a normal lifestyle, (without any treatment or side effects). Indeed, in many cases the cancer may never develop to a degree to give him any problems at all depending upon his age.
Q. Most men are only on palliative treatment - why?
A. My dictionary meaning of the word palliative is 'alleviating without curing.' Strictly speaking as there have been no trials to show that any current treatment 'cures' or prolongs life over and above watchful waiting one could say that all prostate cancer treatment is palliative.
However, if we take the grouping of medics who believe that early diagnoses and radical treatment, surgery, seed implantation, or radiation, will cure, this leaves us with those men who see their GP with late diagnosed cancer i.e. the cancer has spread out and away from the prostate gland who 'in this groupings opinion' can no longer have radical treatment and are therefore given treatments to delay the progress of the cancers.
Here in U.K. most men do not see their doctor until the cancer has spread. With no early symptoms they feel fine until the spreading cancer begins to cause side effects. These can be tiredness, loss of appetite and weight loss, blood in the urine or sperm and bone pain from secondary cancers. As well as those more serious symptoms a man could also experience difficulty in beginning urination, a weak stream, urgency, frequency and night visits to the bathroom.
All these latter symptoms are much more likely to be the result of BPH. Be aware there is no connection between BPH and prostate cancer, there has been no evidence to show that BPH leads on to prostate cancer. You can have one without the other or both at the same time
At this point in this time the treatments available are Hormonal and/or radiotherapy via external beam or conformal methods. (I.e. palliative treatments.)
Q. What are the side effects of TURP?
A. The TURP operation, transurethral resection of the prostate, is regarded as the gold standard treatment for BPH. Yet it can have some serious side effects and will not necessarily treat the condition successfully.
Whilst the medical profession claim a success rate of some 80%, as there are no well documented follow reports this may not necessarily be accurate. Certainly it is true that the PHA charity normally only get letters from men who have had failed TURP operations which colours their perception of the treatment.
However, when letters appear which show men having three and four such operations over a year or two with no success and men who refuse to go back to see their GP's although they are no better, suspicion arises.
The TURP operation has a degree of risk, as has any operation.
First there is a mortality (death) risk, this ranges from 1% to 6% dependent upon your age.
There is a high percentage chance that you will no longer have a normal ejaculation. Instead the semen will travel back into the bladder where it will stay until you next go to the toilet, when it will pass out of your body with the urine. This will cause your urine to appear cloudy but will not have any other effects upon you. The retrograde ejaculation is not thought to change any feelings you have during intercourse, although some men claim that they can tell the difference.
Up to 90% of men will have this retrograde ejaculation. This means a man will probably be infertile, however, this is not guaranteed and is not a form of contraception.
Dr James Le Fanu writing in the Telegraph stated that some 5% of men complain of impotence following the operation, however, a study in Israel appeared to show that if the operation was clearly explained to men the incidence of apparent impotence fell.
But, it appears that impotence is also linked to perforation of the prostate capsule during the course of the operation. You would be wise therefore to ensure that if you are concerned about your future potency that you are operated on by a Consultant as opposed to say a Registrar.
It also appears that 20% of men have intermittent dribbling incontinence. Up to 5% of these men will find the condition is continuous. Time and medication can improve the situation. There is also a small chance that you will be incontinent.
Scarring of the urethra or bladder neck can cause a narrowing which begins to block off the urine flow again, this is normally remedied by a stretch procedure. 15-20% of men find that their symptoms return and they need another operation within 5-8 years.
Q. What are the side effects of hormonal therapy and what is the long term outlook?
A. Hormonal therapy can be either via a surgical removal of the testes, an orchidectomy (castration). This removes the majority of the testosterone from the body, or via tablets or injections which castrate chemically.
As the prostate cancer 'feeds' on testosterone such removal inhibits its growth, indeed it can reduce its size dramatically in the early months as is shown by a PSA test which can drop from high figures in the 100's down to zero point something. Prostate cancer increases the amount of PSA, prostate specific antigen, in the blood.
A few medics still use estrogen (stilboestrol) in the treatment of prostate cancer, this hormone treatment can cause breast growth and tenderness, depression, hot flushes, vomiting and nausea.
You may also come across Flutamide, Casodex, Cyproterone acetate and Goserelin.
Cyproterone causes less problems with the cardiovascular system than estrogen and seems to have a lower incidence of breast growth. It also appears to suppress the hot flushes that occur with orchidectomy.
In general, breast growth/tenderness and hot flushes, decreased or complete loss of sexual libido appear to be side effects of hormonal treatments.
The response to the treatment is approx. some 20 months. After this time the cancer becomes active again and the hormones fail to suppress it. Further alternative treatments are then available.
Having said that hormonal treatment does not cure prostate cancer but merely suppresses it for a time, Colin Buck says
"one in ten men with prostate cancer will survive for up to ten years without progression..... there has also been documented cases of 'cure' in which there was no evidence of cancer at autopsy."
Q. Are there any new treatments in the pipeline?
A. From time to time you will see announcements of new breakthroughs in prostate cancer treatment. It is suggested that you disregard these. Regrettably journalists are prone to exaggerate initial announcements by research organisations, who are themselves attempting to raise funds to continue their work and wish to show the world and their backers that they are making progress. Normally such announcements are made very early in the 'treatment' life. Many years of testing and trials lie ahead.
Often it will be five years minimum before they are available, assuming they last the course. In the past, Newspapers have proclaimed the benefits of puffer fish venom and photosensitive light. The writer has chased up such treatments several years later to find they have either sunk without trace or been redirected to other medical diseases.
But it appears that a gradual change is coming over the medics. The most strident calls have been for early diagnosis and radical treatment but over the past six months or so a new softer tone has developed which I hope will overtake the earlier demands.
Late in 1999 an Astra-Zeneca spokesman told an audience at the Sheffield Scientific Festival, "that the future appeared to lie in drugs that helped people to live with cancer." He also explained that, " existing methods of destroying cancer cells damaged healthy cells, resulting in patients suffering terrible side-effects." Strange isn't it that one medic says that the treatments for cancer produce terrible side-effects, yet those doing the treating assure their patients that the side effects are acceptable, bearing in mind that the cancer cells are being destroyed ?
It goes back to the quality of life that the patient has after the treatments are over.
The spokesman also pointed out that, "methods of curing cancer are not proving productive, despite occasional bursts of media hype."
And now we are in a new decade and recently Dr Karl Sikora, (Director of the Department of Clinical Oncology at Hammersmith Hospital), spoke about, "patients living with their cancer. Not a cure, but a stable situation." He described it as a "kinder treatment, similar to being a diabetic, with drugs keeping the cancer in check allowing the patient to pursue his normal lifestyle".
Q. Does cancer of the prostate run in families?
A. It appears that if you have relatives, brothers, uncles, father etc. who all had prostate cancer early in life then you are at greater risk. There may also be a chance of a higher risk if your female relations had breast cancer.
Q. Is there any alternative approach to preventing or treating prostatic disease - benign or malignant?
A. BPH.(Benign Prostatic Hyperplasia)
Leaving BPH until the prostate gland closes off the urethra and stops the urine flow totally, chronic retention, leaves your medics with no other choice but to operate. An early visit to your GP when you first notice flow problems and urgency means you have a choice of treatments.
Over-the-counter products you could try, once you have been diagnosed, are saw palmetto either on its own or in a combination, but be sure you choose a good quality product. Low cost normally means an inferior quality. There have been many trials which show that saw palmetto helps, and one U.S. trial using biopsies which showed it actually shrinks the prostate gland. Some men have reported improvement with beta-sitosterol.
Homeopathic treatment may help, so that is another avenue, but if these methods fail then your GP has alpha blockers such as Flomax and Doralese, these relax the prostate gland and allow for a better urine flow. They do not stop the growth however. For that the pharmaceutical company Merck have a drug called Proscar which can shrink the gland. It appears to work better on large glands and takes up to six months to achieve any results.
Heat treatments have not proved very popular with the specialists here in the UK. Microwave treatment had a bad press with cooling problems in the early 90's and has not really recovered.
Turapy, a radiofrequency, one hour, out patient treatment has not found favour either, probably because the surgeon does not have any work to do. The treatment is carried out by a computer. In the writers case for instance, the urologist and everyone else went off to lunch and left me in charge of the computer, no - that should read 'left the computer in charge of me' ! Long term diet may help, see below.
Prostate Cancer
There are a whole host of alternative treatments for prostate cancer, the question is would you wish to use them and do you have the cash to pay for them. They range from green tea and Japanese mushrooms to hydrogen peroxide and ozone. If you want to read about alternative cancer treatments then you need to read the book 'An alternative Medicine Guide to Cancer' ISBN 1 887299 01 7 It is an American book, try Amazon UK, and uite expensive.
For all prostate disease it appears that diet plays a large part. As mentioned earlier the occurrence of prostate cancer is extremely low in Asian countries compared to Western. This has been linked to diet and animal fat appears to be the main variable. Whilst we eat alot of it in the form of butter, cheese, meat, milk biscuits etc., your average Asian doesn't, unless he has succumbed to the western way of life.
The mainstay of an Asian diet are vegetables and soya. So what is being suggested is a change to this form of diet away from animal fats and meat. This appears to be of help, not only for prostate cancer, but for prostate disease in general.
