The Tribune

By DR GREGGORY PINTO

Bahamian men are predominately of African ancestry and have a disproportionately high rate of obesity - both of which are risk factors for developing a more aggressive form of prostate cancer and a greater risk of suffering from prostate cancer at an earlier age. Bahamian men also have a high prevalence of the gene mutations for the BRCA 2 gene, which is a risk factor for developing prostate cancer. And the Bahamas has the 14th highest per capita incidence of prostate cancer in the world.

Sadly, hundreds of Bahamian men are diagnosed with prostate cancer at an advanced stage and they are not candidates for a cure.

Early diagnosis leads to excellent cancer specific survival rates of 99 percent at five years and as high as 98 percent at ten years. Therefore, for the successful curative treatment of prostate cancer, early diagnosis is the key.

Prostate cancer must be detected when the prostate cancer is low volume and confined to the prostate for the best chance of a cure.

Advanced prostate cancer can lead to multiple negative heath consequences such as spread of the cancer to bone, the spine and organs; kidney obstruction that could cause acute or chronic kidney dysfunction, spinal cord compression that could potentially lead to lower limb weakness or even paraplegia, loss of function of both legs.

Early prostate cancer usually has no symptoms; therefore prostate cancer surveillance is imperative in order to treat prostate cancer for cure.

At age 40 years of age, every Bahamian man should commence having yearly prostate specific antigen (PSA) blood tests and clinical exams as warranted. Men with a strong family history of prostate cancer, whereby two or more first degree relatives were diagnosed with prostate cancer at an age less than 50 years old, should start PSA blood test screening at the age of 35 years old.

It is important to compare the PSA routine blood results for an individual from one year to the next as a high PSA velocity, a large increase in PSA blood value over time requires further investigations, even if the PSA value is still in the normal range.

The normal range for PSA values is below four nanogrammes per millilitre, with values between 4 to 10 ng/ml being considered a grey area that requires further investigations such as the free PSA percentage and calculating the PSA density.

A PSA value can be elevated by factors other than prostate cancer, for example having a very large non-cancerous benign prostate hyperplasia (BPH), having an infection of the prostate, prostatitis or having incomplete bladder emptying.

Medications such as Avodart/Dutasteride and Proscar/Finasteride, which are commonly prescribed to manage the urinary symptoms of BPH, artificially halve the PSA values after these medications are taken for five months or more. Men taking Avodart or Proscar should have their PSA values doubled so that the prostate cancer screening exercise remains accurate for men taking these five alpha reductase inhibitor medications.

There are multiple curative treatment options for prostate cancer. The key again is early diagnosis and the detection of prostate cancer when the disease is organ confined. Surgery is not a necessity to cure prostate cancer.

Curative management options for prostate cancer include:

1. Active surveillance

Prostate cancer that is localised, early stage, low-volume and organ-confined, may be actively surveilled with curative management delayed until the disease upstages or increases in volume.

All prostate cancer curative treatments have some risk of future negative side effects such as a reduction in erectile function and possible stress urinary incontinence or leaking urine with exertion. Active surveillance for men with the required prostate cancer disease parameters can allow for the delay in the curative treatment for prostate cancer, for in some cases for a period of eight, 10 or even 12 years.

A patient is actively surveilled with scheduled clinical exams, repeat PSA blood tests, Magnetic Resonance Imaging (MRI) of the prostate and/or repeat image guided prostate biopsies usually at one, three and seven year marks.

Any upstaging in the prostate cancer disease in terms of clinical findings, PSA values, volume or grade of disease, will prompt the implementation of curative management of the prostate cancer.

Some men find it too stressful to be on the active surveillance pathway as they prefer that even the presence of clinically insignificant prostate cancer be treated immediately. There is a recognised fear that men on active surveillance face when anticipating routine follow-up with PSA blood tests; 'PSAdynia' is a term used to describe the emotional stress and anxiety experienced by men on active surveillance following up with active surveillance protocols, with the sometimes overwhelming fear of the need to commence treatment of the prostate cancer.

Prostate cancer active surveillance candidates must fulfil not just the strict prostate cancer parameters, but they also must be willing to follow up with the required follow-up regime and they must have the required emotional fortitude.

2. Surgery

Radical prostatectomy is the surgical removal of the entire prostate gland and seminal vesicles as a curative form of treatment for prostate cancer. The surgery may also require the excision of related lymph nodes. The surgery may be done by an open surgical technique or minimally invasively with the assistance of the da Vinci Robot, or laparoscopically.

The surgery may be done with attempted nerve sparing so that erectile function is maintained. A relatively common complication of radical prostate curative surgery is stress urinary incontinence that often resolves overtime, particularly with the aid of postoperative pelvic floor physiotherapy.

3. Radiation therapy

• External beam radiation therapy is a curative treatment option for prostate cancer. A focus of radiation is directed towards the prostate cancer under the care of a radiation oncologist. There are several forms of radiation therapy for prostate cancer, including using conformal radiation therapy (CRT) that utilises computers to precisely map out the area of prostate cancer and direct radiation only to that afflicted area, so that healthy surrounding tissue is not damaged by radiation.

• Hypofractionated radiation therapy implements the use of higher doses of radiation, but for shorter periods, to cure prostate cancer. The higher doses of radiation therapy used however may lead to a higher risk of side effects from the radiation.

• Intensity-modulated radiation therapy (IMRT) is another form of external beam radiation used in the curative management of prostate cancer. This treatment modality uses CAT scan images to create a three-dimensional representation of the prostate cancer so that the dosage of radiation required to destroy the prostate cancer may be calculated, which allows for the use of higher doses of radiation without damage to adjacent healthy tissue.

• Proton beam therapy uses proton rays instead of X-rays to destroy prostate cancer cells. It is more expensive and not as readily available as tradition radiation therapy.

4. Brachytherapy

Brachytherapy is a form of internal radiation therapy that involves the placement of either low dose or high dose radiation seeds into the prostate to destroy only prostate cancer cells and leave healthy prostate cells intact.

Brachytherapy may be used with other treatment modalities such as with external beam radiation therapy or androgen deprivation therapy.

Men with a high-risk prostate cancer may be receive external beam radiation therapy, androgen deprivation therapy and either a low dose or high dose of brachytherapy.

For low-risk and lower-risk prostate cancer, several studies have shown that the prostate cancer specific survival is equal to or superior to curative rates with the da Vinci Robot-assisted radical prostate cancer surgery, and with a lower side effect profile.

5. High-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) therapy that is a form of localised curative focal therapy for prostate cancer. An ultrasound probe is inserted into the rectum and sound waves are directed towards the cancer within the prostate gland. This localised treatment allows limited damage to healthy prostate tissue and adjacent structures. The US Food and Drug Administration approved HIFU for prostate cancer curative treatment in 2015, but this modality has been used extensively throughout Europe and other parts of the world for more than 15 years.

6. Androgen deprivation therapy

This is a form of hormonal blockage by which the male hormone testosterone is lowered to slow down the progression of the prostate cancer. Androgen deprivation therapy (ADT) may be used in several prostate cancer treatment scenarios such as palliative therapy for advanced metastatic prostate cancer, treatment for prostate cancer recurrence, treatment of locally advanced prostate cancer or for curative intent to be implemented with other treatment modalities.

ADT, unfortunately, often has many negative side effects that impact the quality of life and this treatment also increase the risk of cardiovascular complications. The treatment options for advanced or metastatic prostate cancer is a future article in itself.

Prostate cancer has excellent cure rates for early detected disease. Bahamian men can live another potential 20 or 30 years of good quality life if they have prostate cancer detected at an early stage and the appropriate management is used. Far too many men are dying needlessly from prostate cancer because of late diagnosis. Seek confidential, compassionate and comprehensive prostate cancer therapy and treatment.

• Dr Greggory Pinto is a board-certified Bahamian urologist and laparoscopic surgeon trained in South Africa, Germany, and France. He can be reached at Urology Care Bahamas at the Surgical Suite, Centreville Medical Centre, #68 Collins Avenue/Sixth Terrace, Nassau. Call (242) 326-1929, e-mail welcome@urologycarebahamas.com, or visit the website, www.urologycarebahamas.com.