The Tribune

By DR GREGGORY PINTO

The prostate gland is a walnut-sized organ underneath the bladder that plays an important role in male fertility.

The statistics are staggering in that one in six to one in seven men in the Bahamas will develop prostate cancer in their lifetime. In fact, prostate cancer is the most prevalent cancer among Bahamian men.

Men of African ancestry and obese men develop a more aggressive form of prostate cancer, thus early detection is very important for Bahamian men in particular.

No dreaded digital rectal exam

The good news is that early detection of prostate cancer can lead to a very high cure rate and the use of the digital rectal exam for routine prostate cancer screenings is no longer supported by international governing bodies and associations.

The digital rectal exam has been found to be very subjective and it has not reduced mortality rates. It has actually has often led to a high number of false positives that has in turn led to unnecessary prostate biopsies and the over-diagnosis and over-treatment of prostate cancer.

Bahamian men stay away from prostate cancer screenings in the thousands due to the embarrassment and feeling of violation of a potential digital rectal exam that is no longer supported or in use for routine testing.

All Bahamian men should have a prostate specific antigen (PSA) blood test annually, starting at age of 40. However, if there is a strong family history with first-degree relatives having developed prostate cancer at a relatively early age then PSA screenings should start at age 35.

A landmark prostate, lung, colorectal and ovarian study found that less than two percent of men with an abnormal digital rectal exam and normal PSA were diagnosed with clinically significant prostate cancer.

The prostate specific antigen test

PSA blood tests can be elevated and have values in the abnormal range due to benign causes that are unrelated to prostate cancer.

The PSA may be elevated by stimulation of the prostate, by prostatitis – infection of the prostate – by acute or chronic urinary retention or by having a large benign prostate.

The commonly prescribed medication, Avodart-Dutasteride, which is a five-alpha reductase inhibitor;,cuts the value of the PSA in half if taken for five to six months. This halving of the PSA with the regular use of Avodart is very important in routine prostate screening, as the PSA must be doubled in these patients to obtain an accurate PSA result.

The normal PSA for one man does not necessarily correlate with the normal PSA for another man, as PSA blood values are very individualised and it is important to not just review a PSA value in isolation, but compare the rate of change of one PSA with a subsequent PSA taken for example one year later. The PSA velocity is an important parameter in determining the rate of PSA increase over time.

PSA density is also an important calculation that should be done by urologists, which takes out the equation the input of a very large non-cancerous prostate causing a higher PSA.

There are further more sensitive and specific blood tests and a urine RNA test that is 98 percent specific in determining not only detecting prostate cancer, but also differentiating high-risk from low-risk prostate cancer.

Imaging

Imaging is a necessity in the modern urology screening, staging and management of prostate cancer. Multimodality imaging is essential in providing the best therapy for men with prostate cancer. MRI (magnetic resonance imaging) which does not involve exposure to radiation, can detect prostate cancer at very early and very low volume stages. MRI is also a valuable tool in confirming that detected prostate cancer is organ-confined and there are no positive nodal diseases and no metastasis.

Bone scans are also an important imaging modality to rule out spread of prostate cancer to bones. A PSMA-PET scan is state of the art imaging that targets prostate specific membrane antigen and thus it is highly specific.

Again, early detection leads to a very high cure rate for prostate cancer.

Advances in modern prostate cancer detection and treatment has led to the role of active surveillance in prostate cancer, whereby prostate cancer is detected at such an early and clinically insignificant stage that these men can have surveillance of their prostate cancer, in many cases for many years, until a curative treatment is required.

The key is to detect prostate cancer at a low grade and low volume when the disease is still confined to the prostate so that a cure is highly likely.

Treatment

The curative treatments available for prostate cancer include brachytherapy – radioactive seeds are placed minimally invasively into the prostate to kill the prostate cancer cells, while leaving the normal prostate cells intact.

Brachytherapy for prostate cancer is a new concept to the Bahamas, but it is the most commonly employed curative prostate cancer treatment in many First World countries and it has been in existence over 20 years.

Brachytherapy allows for curative treatment of prostate cancer minimally invasively in less than one hour and minimal to no recovery period needed.

External beam radiotherapy is radiation to kill the prostate cancer cells. Then there is radical prostatectomy surgery, which may be done with a Da Vinci robot or laparoscopically, or by open surgery.

In some cases a combination of these methods is needed to cure prostate cancer. A short-term hormone/androgen blockade may also be employed for cure.

Prostate cancer usually does not have any specific symptoms until the disease is advanced and spread beyond the prostate. Urinary symptoms such as increased day or night urinary frequency, urgency and weak urinary stream are more commonly is due to benign prostate hyperplasia and not prostate cancer, or less often due to a urethral stricture.

Unfortunately, hundreds of Bahamian men are still dying needlessly from prostate cancer that could have been likely cured if detected early.

Hundreds more Bahamian men endure the debilitating symptoms of advanced incurable prostate cancer, such as renal failure, bone pain from metastatic disease or even paraplegia from spinal cord compression from metastatic prostate cancer affecting the spinal cord.

A simple blood test starting at age 40 years old could potentially save your life and prevent years of suffering from a very preventable often agonising slow death from metastatic prostate cancer.

The dreaded digital rectal exam for routine prostate cancer is no longer advocated.

Bahamian men, there can be no excuse! Get your PSA blood test with your annual physical exams.

• Dr Greggory Pinto is a Bahamian urologist who has trained in South Africa, Germany and France. He is a member of the European Association of Urologists. Dr Pinto can be reached at Urology Care Bahamas at the Surgical Suite, Centreville Medical Centre, Collins Avenue and Sixth Terrace. Call 326-1929, e-mail welcome@urologycarebahamas.com, or visit urologycarebahamas.com.