The Tribune

By Greggory Pinto

This article represents the fourth article in a five part series dedicated to educating the public in this prostate cancer awareness month. Covid-19 continues to disrupt our daily lives and dessimate our health care system. Prostate cancer continues to lead to the death of over 220 men in this country every year and hundreds more Bahamian men and residents are sadly diagnosed with advanced, incurable prostate cancer. The Bahamas has the 14th highest per capita incidence of prostate cancer in the world.

The good news: prostate cancer if detected early, can be successfully treated with a 96 percent prostate cancer specific survival ten years after treatment. Advances in prostate cancer detection in the past 20 plus years have led to the advent of the prostate cancer management option of active surveillance; whereby clinically insignificant early, low volume prostate cancer can be actively monitored until the disease requires curative treatment. Many men with insignificant prostate cancer of been able to delay prostate cancer treatment for as long as 8, 10, 12 years before curative management.

The unfortunate news: Bahamian men have a one in six chance of developing prostate cancer in their lifetime. African ancestry is a risk factor for a more aggressive form of prostate cancer that affects such men six to seven years earlier on average than their other racial counterparts. BRCA gene 1 and 2 mutations have a relatively high occurrence in Bahamian men. The BRCA gene mutation increases the risk of prostate cancer four-fold and the BRCA gene 2 mutation increases the risk of prostate cancer eight-fold by the age of 70 years old.

The use of multiparametric MRI magnetic resonance imaging of the prostate for cancer diagnosis and management has evolved considerably in the past 20 years. Long term data from multiple clinical trials has shown that multiparametric MRI can be an invaluable tool in the diagnosis, staging and active surveillance of prostate cancer. Pre prostate biopsy use of MRI has been a significant game changer in the detection and stratifying of prostate cancer. MRI prostate cancer imaging can with high sensitivity and specificity determine which patients require prostate biopsies and the imaging of the MRI prostate allows cognitive or real time image directed biopsies of suspicious prostate lesions. Traditionally, prostate cancer has been diagnosed using biopsy needles directed into the prostate gland with ultrasound guidance. Ultrasound imaging does not generally show the location of prostate cancer lesions. The ultrasound guidance allows for the anatomical directed biopsy of the prostate. Ultrasound guided prostate biopsies can miss prostate cancer altogether or biopsy low grade prostate cancer and miss higher grade prostate cancer. It is estimated that 25% of ultrasound guided prostate biopsies under stage or fail to detect prostate cancer that is present. Urologists can now use MRI prostate images in real time with ultrasound guidance and specifically biopsy suspicious prostate lesions and thus provide highly accurate prostate cancer detection. MRI prostate imaging has led to a considerable reduction world-wide in unnecessary prostate biopsies, whereby biopsies are not performed if the MRI has not shown prostate cancer suspected lesions.

PARP (Poly ADP-Ribose Polymerase) inhibitors for prostate cancer are an important advancement in prostate cancer research and treatment in 2019. PARP is a substance that blocks an enzyme in cells. In prostate cancer treatment PARP may aid in keeping cancer cells from repairing their damaged DNA, leading these prostate cancer cells to die, as a part of targeted prostate cancer treatment. PARP inhibitor treatment has an important role in BRCA gene mutation related prostate cancer. Research continues with great future promise for the use of PARP inhibitors in treating prostate cancer.

The development of immunotherapy and future vaccines for prostate cancer is currently being investigated and has shown great potential. One type of prostate cancer treatment vaccine called Sipuleucel-T (Provenge) has FDA approval for the management of advanced metastatic prostate cancer patients with few symptoms. Provenge helps the immune system to target prostate cancer cells.

An important development in prostate cancer on the horizon is a simple urine test introduced in 2019, that makes use of urine samples taken at home. The PUR (Prostate Urine Risk) test has been pioneered to detect aggressive prostate cancer and predict which patients will require prostate cancer treatment within the next five years. The PUR test has the advantage of men being able to provide urine samples at home without the need for an uncomfortable rectal exam. The PUR test looks at gene expression in urine samples and provides critical information as to whether prostate cancer if detected, is low risk or an aggressive form. The PUR test research continues and it will hopefully be part of future prostate cancer diagnosis.

Genetic testing for BRCA gene mutations are available locally so that men, particularly with a strong family history of prostate cancer and breast cancer, may determine their lifetime risk of prostate cancer and be even more diligent in early prostate cancer diagnosis. Targeted more intense prostate cancer screening for Bahamian men with BRCA gene 1 or 2 mutations will help prevent prostate cancer deaths by enabling earlier detection in this high-risk group for prostate cancer.

Doctors Hospital has available to residents of the Bahamas, the state of the art 3T MRI magnetic resonance imaging, that is an important advancement in the diagnosis, surveillance and management of prostate cancer locally.

Prostate cancer is a very treatable disease but yet hundreds of Bahamian men are diagnosed every year at an incurable stage and far too many die unnecessarily from this disease.

From the age of 40 years old, have a PSA prostate specific antigen blood test every year. Early detection is the key to the cure of prostate cancer.