In this article, Dr Chinegwundoh discusses the symptoms, diagnosis and treatment of prostate cancer, and in particular the incidence of the disease in black men in the UK.
Prostate Cancer is the most common cancer in men in the UK
Prostate cancer is the most common cancer in men in the UK, accounting for a quarter of all male cancers. Approximately 37,000 new cases are diagnosed each year, which is approximately 100 new cases per day. It affects mainly men in late middle age and old age. In the UK, a man has a one in nine chance of being diagnosed with prostate cancer.
About 10,000 men a year will succumb to prostate cancer. The outlook for a man with prostate cancer is good if the disease is caught early before it has spread. Unfortunately, in the UK approximately 22% of prostate cancer is diagnosed when the illness cannot be cured, although there are treatments that will prolong life.
Black men and the risk
In 2006, preliminary research that was subsequently confirmed in larger studies, showed that black men in the UK have a three-fold greater risk of being diagnosed with prostate cancer than their white counterparts. This echoed data from the USA. The reason for the racial disparity, which is the same all over the world, is currently unknown. Research is concentrating on genetic factors. Whether higher rates of prostate cancer translate into a higher death rate is the subject of debate. American data suggests that black men are more likely to die of their prostate cancer than white men, but preliminary UK data does not support this. Of course the health systems in the UK and the USA are different.
Prostate cancer and urinary symptoms
It is important to appreciate that prostate cancer may be present even if there are no urinary symptoms. It can be linked with urinary troubles, such as a poor urinary flow, passing urine frequently or at night, or having to reach a toilet in a hurry. Recent onset of erection difficulties may also herald prostate cancer. Most men with urinary symptoms will not have prostate cancer, but it is only by seeking expert medical advice that prostate cancer can be excluded.
Crucial to the diagnosis is the blood test PSA, which stands for prostate specific antigen. This is a chemical made by the prostate gland and extruded into the bloodstream. The normal PSA should be below 4 ug/l. A level above that suggests that prostate cancer may be present. Prostate cancer is also suggested by the prostate feeling “hard” on digital rectal examination as opposed to the normal “rubbery” feel. Many black men are reluctant to have a rectal examination. The charity, Cancer Black Care, reassures black men that this quick examination is nothing to fear and indeed can save their lives.
Every man over the age of 50 years is entitled to a PSA blood test, which can be requested through their GP. The earlier prostate cancer is diagnosed the more the treatment options and the greater the likelihood of cure. Waiting for symptoms may be too late. As black men generally develop prostate cancer at a younger age than white men, they should start PSA testing at age 45 years. As prostate cancer can run in families, patients must make their GP aware of their family history, as this should trigger PSA testing.
If the PSA is raised or the prostate feels abnormal, the GP will refer the patient to an urologist, a specialist in urinary system disorders. There is an obligation on the NHS to be seen by the specialist within two weeks.
The urologist will organise a biopsy of the prostate. This is called a transrectal ultrasound guided biopsy (or trus biopsy for short). Commonly, 12 samples (cores) of prostate tissue are sent to the pathologist for analysis. If prostate cancer is confirmed, further tests are done to gauge the extent of the disease. The tests may include a MRI scan, CT scan or bone scan. These will determine if the disease is confined to the prostate or not.
Each case is discussed by a multidisciplinary team, comprising urologists, nurse specialists, oncologists (cancer experts), radiologists (imaging specialists) and pathologists, to recommend a treatment plan for the patient. These deliberations are fed back to the patient, who is consulted on how best to deal with the cancer.
Treatment is usually under the care of the cancer centre, which may be some distance from the local hospital. In the cancer centre, there is a critical mass of human expertise and equipment which leads to better results.
Treatment for prostate cancer is not always required
Not all prostate cancers need treating. It is a truism that many men die with their prostate cancer rather than from it. Especially where the cancer is small and the PSA relatively low, there is a good chance that the cancer may lie dormant and never cause a problem. Thus some cancers can be kept an eye on (active surveillance). Monitoring is by PSA and repeat prostate biopsy at intervals. A more detailed biopsy, called a transperineal template biopsy gives more information whether it is safe to observe the cancer.
Treatment when cancer is confined to the prostate
Where the decision is to treat the prostate cancer, there are various options when the disease is confined to the prostate. Such options include radical prostatectomy surgery to remove the prostate gland altogether. This removal can be effected through a traditional open operation through the lower abdomen, by “key-hole” surgery, or by the new technique of using a robot to assist the surgeon (robotic radical prostatectomy).
An alternative to surgery is the use of external radiotherapy in small doses daily for seven weeks. For some patients it is possible to offer brachytherapy, an out-patient procedure, involving planting radioactive pellets into the prostate, where they remain permanently and give off radiation to destroy the cancer. The radioactivity lasts for a few months, but by then the cancer is destroyed.
Other techniques of eradicating the cancer are less widely available but nonetheless sound treatments, such as high intensity focused ultrasound (utilising heat energy to destroy the cancer) and cryotherapy (utilising extreme cold to target the cancer). The patient is advised to discuss availabilities of treatments and the advantages and disadvantages of each.
Side effects do need to be considered. These may include sexual problems and urinary leakage issues. Both the urologist and he clinical nurse specialist can further advise the patient on how to deal with these. There are also charity help lines that can assist. It is not an easy decision as to which treatment to go for.
Treatment when cancer has spread beyond the prostate
For those men whose cancer has already spread by the time of diagnosis (metastatic cancer), the mainstay of treatment is hormonal. Drugs are used (or the surgical removal of the testes) to reduce the testosterone levels. This is because testosterone fuels the growth of prostate cancer, therefore lowering it stops the cancer in its tracks. There are side effects of such treatment, but these are tolerable. While hormone therapy is effective, it eventually fails. The PSA which falls on treatment begins to rise again on monitoring.
Where first line hormonal therapy fails, which can be several years down the line, the oncologists has several new drugs in the locker. Such powerful drugs, such as docetaxel, abiraterone, cabazitaxel and others, prolong survival but are unable to cure prostate cancer.
Taking responsibility for prostate health
Whilst in the UK there is no national screening programme in the UK at present (under review at the Department of Health), this does not mean that men should not take responsibility for their prostate health. A good diet is important; fresh fruit and vegetables, low fat intake, less red meat more fish and white meat and avoiding obesity are thought to be of value in reducing the risk of prostate cancer.
Information and support for black men with prostate cancer
Voluntary organisations, such as Cancer Black Care, provide a valuable source of information and support. Such groups are an adjunct to the statutory services and are worthy of support from the community. Awareness needs to be raised in the black community about prostate cancer. Men should be encouraged to get themselves tested annually.
Further information is available from: