The male ‘walnut’

AGE WELLm
By Dr CHRISTOPHER C.K. HO

The prostate is a walnut-sized organ in males that can undergo abnormal changes with advancing age.

THE prostate is a walnut-sized gland found only in men, which is positioned below the bladder and in front of the rectum. It forms a ring around the urethra, the passageway that carries urine out of the body from the bladder.

Prostate cancer is a disease where normal prostate cells undergo changes, and these abnormal cells grow out of control. It is more commonly observed in the West. In Malaysia, prostate cancer is the fourth most common cancer among men.

Risk factors

The risk of prostate cancer increases with age. It is rarely found in men younger than 50 years old. Those of African-American background are also at higher risk of having prostate cancer. Men with a first-degree relative (father or brother) who has prostate cancer, is also at a higher risk of getting prostate cancer.

A diet high in animal fat or low in vegetables may also increase the risk of prostate cancer.

Prostate cancer may present as blood in the urine or semen, needing to urinate more often than usual, urine flow that is slower than normal, and erect ion difficulty.

Most of the time, there are no symptoms. However, prostate cancer can present as blood in the urine or semen, needing to urinate more often than usual, urine flow that is slower than normal, and erection difficulty.

Please note that other conditions, like benign prostatic hyperplasia (non-cancerous enlargement of prostate), infection, and bladder stones can cause these symptoms as well.

Diagnosis

If the doctor suspects prostate cancer, he/she will first perform a digital rectal examination by inserting a finger into the anus to feel the prostate. Since the prostate is in front of the rectum, the prostate can easily be felt by pressing the finger on the rectal wall. The surface of the prostate cancer will usually feel irregular and hard.

The doctor will also order a blood test called PSA, which stands for prostate specific antigen. If the level of PSA in the blood is high, there is a high chance that there may be cancer in the prostate.

However, there are other conditions which may falsely cause a high PSA, and this includes urinary tract infection, inflammation of the prostate (prostatitis), benign prostatic hyperplasia, trauma, and sexual activity. Therefore, the doctor may prescribe antibiotics before repeating the PSA test.

It is also advisable to refrain from riding a bike or ejaculating 48 hours before getting a PSA test. If the PSA remains high, a prostate biopsy is recommended.

A prostate biopsy involves using an ultrasound probe which is inserted into the rectum to visualise the prostate. A needle is then used to take prostate tissue samples via the rectum. The number of biopsy samples needed will depend on the man’s age and prostate size. Between six to 12 biopsies are usually taken.

This procedure is not without its complications, namely bleeding, infection, and blood in the urine and semen. A prostate biopsy will be able to confirm the cancer, but a negative test does not rule it out. There is a possibility that the biopsy missed the area which contained the cancer.

In this case, a saturation biopsy where 20 to 30 biopsy samples are taken, may be needed.

Screening

Screening means carrying out tests to detect cancer. For the prostate, it involves performing a digital rectal examination and PSA test.

A large European study has shown that men who had PSA testing had a 20% lower chance of dying from cancer after nine years compared to those without screening. In addition, men with cancers detected by PSA screening have earlier-stage cancer compared to those without screening.

However, most of these early stage cancers detected via screening are unlikely to cause death or disability. Therefore, a number of men will be diagnosed with cancer and potentially suffer the side effects of treatment for cancers that would never have been found without prostate cancer screening.

Indeed, if cancer is detected early, it is not clear in all cases that it must be treated. The European study actually showed only one man in every 1,400 screened benefited from PSA screening. About 75% of men with abnormal PSA who proceeded to have a prostate biopsy, did not have any cancer.

Therefore, should you have a prostate cancer screening? You should discuss this with your doctor. It is advisable if you are symptomatic and have the risk factors, as discussed earlier.

A course of antibiotics will be given before and after the procedure to reduce the risk of infection. Local anaesthesia, either with injection, or gel through the rectum, will be administered.

The whole procedure may take about 15 minutes. The tissue biopsy will then be examined by a pathologist.

The stage of the cancer is based upon how far the tumour extends from the prostate to the surrounding tissue, whether the lymph nodes are involved, and whether the cancer has spread to other organs like the bone.

Magnetic resonance imaging (MRI), computerised tomography (CT) scan, and a bone scan may be needed to stage the cancer.

Stage I and II are localised cancers, stage III locally advanced, and stage IV advanced or metastatic cancer.

In addition to that, doctors also look at the PSA and Gleason grade (based on how the tumour looks under the microscope) to determine how aggressive the tumour is.

Treatment

Treatment will depend on the stage, age, and overall health of the man. When it is at an advanced or metastatic stage, it is not curable. The aim of treatment would then be to control the cancer for prolonged periods of time, reduce symptoms, and improve quality of life.

The options of treatment include watchful waiting, active surveillance, radical prostatectomy, radiation, and androgen deprivation therapy.

In watchful waiting, treatment is deferred until symptoms occur. It is reserved for those with localised prostate cancers and a limited life expectancy, or for older patients with less aggressive cancers.

The rationale is that most cancers detected early rarely cause problems, and instituting treatment has its side effects and may reduce quality of life.

Active surveillance entails more aggressive monitoring and instituting treatment when there is progression of the cancer.

Radical prostatectomy removes the prostate gland and reconnects the urethra and bladder. It can be done via open surgery, laparoscope (placing instruments and a small camera via small incisions), and robot-assisted.

In robot-assisted prostatectomy, the machine performs the surgery via small incisions, under the control of the surgeon from a console. In Malaysia, it is currently available in Kuala Lumpur Hospital, Kuching Hospital, and Prince Court Medical Centre.

Radiation therapy can be either external beam or brachytherapy. External beam radiation uses a machine that moves around you, directing x-rays at the pelvis to kill off the cancer cells.

Brachytherapy involves placing a radioactive source directly into the prostate.

Androgen deprivation therapy decreases the level of androgen hormones (most commonly, testosterone) that fuels the growth of prostate cancer. It can be done via surgery to remove the testicles (orchidectomy) or medicines that interfere with androgens.

If all these fail, the next option is chemotherapy.

The newer approach to treating advanced prostate cancer uses cancer vaccine. This immunotherapy involves isolating the white blood cells (dendritic cells) from the patient’s blood, stimulating them outside the body with various chemicals to build the body’s immunity against the cancer, and then reinjecting them back into the patient’s body. These dendritic cells will then mount an immune response against the cancer cells.

Vitamin E and selenium were previously thought to be able to reduce the risk of prostate cancer, but studies done have proven otherwise.

Finasteride and dutasteride have been shown to reduce the risk of developing prostate cancer by about 25%, but it must be weighed against the cost and potential side effects of these medications when taken long-term.

So, if you have risk factors for developing prostate cancer, discuss with your doctor about screening for it. Treatment depends on a lot of factors. Therefore, a discussion with the doctor will result in the best treatment option.