PROSTATE CANCER. Should I be concerned?

Modern men are becoming increasingly aware of male health issues. The recent formation of a prostate cancer support group in Gibraltar reflects the growing concern about this treatable disease in the local male population and whilst much information is available, many people are concerned and confused by the data that is published on the Internet and within the media. This article is aimed to try to explain about the incidence and presentation of prostate cancer and how it differs and mimics other diseases of the prostate gland. The article also explores the myths and truths of Prostate Specific Antigen (“PSA”) testing, and explores what can be done for those who are concerned.

Before proceeding it is important to remember that whilst prostate cancer affects 1 in 12 men during their lifetime, 6 times more men (1 in 2) will develop simple benign (non cancerous) enlargement of their prostate during their life. Consequently most men who experience urinary symptoms will have benign prostate enlargement rather than cancer.

What can go wrong with the Prostate Gland?

The most common problems of the prostate are benign (non-cancerous) enlargement, inflammation and infection. Cancer is relatively infrequent when compared to these other conditions. 

Unfortunately however the symptoms of benign prostate enlargement and cancer can be very similar. This is why doctors are keen to check all patients with symptoms such as a poor urinary stream, dribbling at the end of urination, the need to pass urine more frequently, an inability to wait or hold on to urine (urgency)), poor bladder emptying, and a need to get up at night to pass urine (nocturia). Many men suffer these symptoms without realizing that they can be alleviated or cured. To complicate things, not all men with an enlarged or diseased prostate will have symptoms.

Conversely, patients with an inflamed prostate or prostatic infection tend to experience some of the above symptoms, plus burning or pain at the base of the bladder during urination, and patients with these symptoms should see their GP or a urologist.

What are the symptoms and risk factors of prostate cancer?

There are no specific diagnostic symptoms associated with prostate cancer however symptoms such as frequent visits to the toilet, getting up at night to pass urine, rushing to get to the toilet (and a period of pause before starting to urinate), having a slow flow of urine and dribbling at the end are all associated with prostate enlargement. Whilst most patients with these symptoms will have benign prostate enlargement, sometimes the cause is underlying prostate cancer and therefore it is advisable to get checked if you have any of these symptoms.

Furthermore, a family history of prostate cancer increases an individual’s risk of developing prostate cancer so patients with a positive family history should seek medical advice. The disease is also more common in smokers.

When you see your doctor with any of the above symptoms, the doctor might order a PSA blood test (see below) and / or perform a digital rectal examination to assess the size and texture of the prostate gland.

The good news is that with modern treatment, it is now possible to cure prostate cancer if it is detected early.

Who is at risk?

In the UK, prostate cancer is the most common cancer in men. Currently it accounts for nearly a quarter (24%) of all new male cancers diagnosed each year in the UK. Recent epidemiological studies of local cancer incidences indicate that the local disease incidence in Gibraltar reflects that elsewhere in Europe.

Although the medical literature reports a huge rise in prostate cancer incidence over the last 20 years, most of this increase is simply because of the incidental discovery of small areas of prostate cancer in the tissue removed during surgery for presumed benign prostate enlargement. In other words, modern diagnostics enable doctors to diagnose very small cancers which have in the past probably been missed – but which have also been cured simply by removing the prostate gland when the cancers were very small. More recently, the use of the PSA testing has led to disease diagnosis in patients with very few symptoms.

Interestingly though, during the last 20 years, although the incidence of the disease has increased, mortality rates from the disease have not increased significantly. Indeed modern treatments have led to prolonged survival rates.

In 2008, there were 37,051 new cases of prostate cancer diagnosed in the UK. This equates to around 101 men every day or one man every 15 minutes!  From these data it has been estimated that the lifetime risk of being diagnosed with prostate cancer in 2008 is 1 in 9 for men in the UK. Prostate cancer is however rare in men under the age of 40 but the incidence increases with age and peaks in men aged between 70 and 79. For men aged 55-59 the incidence rate is 155 per 100,000 men; ten years later, at age 65-69, the rate more than triples to 510 per 100,000, and by 75-79 the rate is almost five times higher at 751 per 100,000. 

Men who have had a close family member (father/brother) diagnosed with prostate cancer at a younger age (under 55) are three times more likely to be affected. Inherited faulty genes can also be a cause.

Men, who have an increased family risk of prostate cancer, may wish to have regular screening once they are over the age of 40 or 50, to monitor against the potential onset of the disease.

What is a Prostate Specific Antigen (PSA) test?

PSA is a protein produced by the prostate gland the level of which is measured by a blood test. It is a non specific test and its use is therefore controversial, however it is useful in directing doctors to look more closely at the prostate and telling doctors which treatment may benefit patients with benign prostate disease or prostate cancer. It can also be used to monitor treatment for prostate cancer.

A raised PSA should prompt doctors to investigate the prostate gland and if present, will help them detect prostate cancer at an early stage, often before any other symptoms develop.

It must be remembered however that not all men with a raised PSA level will have prostate cancer. A raised PSA level can be due to many non cancerous causes, such as increasing age, benign prostate enlargement, urinary tract infection, perineal trauma (for example distance cycling on a regular basis), sexual intercourse and bladder investigation (cystoscopy), therefore as a test on its own, PSA is not diagnostic and a raised PSA level does not necessarily mean that you have prostate cancer. 

What happens if my PSA test is abnormal?

If the PSA test comes back elevated it will alert the doctor to a potential problem with the prostate. Some further tests will probably be requested which usually include a urine sample (to test for infection) and a digital rectal examination.  

If you have an infection you should receive a course of antibiotics, and if the digital examination of the prostate is unremarkable, your doctor may chose to monitor your PSA level without further investigation. 

If however there is no infection or rectal examination of the prostate shows an abnormal texture of your prostate gland, you will be advised to undergo a prostate biopsy.

What is a Prostate Biopsy?

These days, prostate biopsy is a routine day-case procedure performed under local anaesthesia.  It can be performed in the clinic or hospital setting.

Following suitable preparation and consent, a thin finger shaped ultrasound probe is placed into the back passage to scan the prostate gland. This allows the doctor to take various size measurements and allow injection of the local anaesthetic into the tissues prior to taking a number of biopsies (small samples of prostate tissue), which are sent for analysis. 

You will need to take some antibiotics for a couple of days around the time of the biopsy to prevent infection. After the procedure, it is common to see some blood when passing urine and also from the back passage which usually clears after a day or so.

You will have a follow up appointment to discuss the biopsy results and any ongoing treatment that may be necessary.

What should I do?

Most men will probably not have symptoms and therefore will not need to do anything. If however you have any of the symptoms described above, you should seek the advice of your GP or a specialist urologist.

PSA testing and analysis along with prostate assessment and biopsying is now routinely performed by the visiting Specialist Consultants from the “Edinburgh Urological Specialists” who hold regular clinics in the Specialist  Medical Clinic, in the ICC building, Gibraltar.

For further information contact the Specialist Medical Clinic, 1st Floor, ICC, Casemates Square,

Tel no. +350 2004999

Fax no. +350 200 68999

Email: reception@smg.gi

 

Edinburgh UrologicalSpecialists (EUS)-European Division at the Specialist Medical Group. Gibraltar.

www.specialistmedicalclinic.com

www.edinburghurologyspecialists.com