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Prostate Cancer

Need not affect your life and family

   Way back then, it was unthinkable for men to have Prostate Cancer if they were below 70 years old. Prostate Cancer was not such an issue in the Seventies and early Eighties than it is today. It is  affecting more younger men today, even those in their 40s, and to a certain extent, in their 30s. Previously, the incidence of Prostate Cancer increased only at a rate of 2.3% annually between 1975 to 1985, then it jumped to an annual increase of 18.4% from 1989 to 1992 (Hankey et al., 1999). 

   I believe this increase in the incidence of Prostate Cancer is too glaring to ignore. If we have to find a solution to this growing menace, we have to recognize the potential factors that led to it. 

 

I. What Causes Prostate Cancer

   To stand a chance to treat or prevent Prostate Cancer, we have to start by knowing what causes it or how it develops. Several risk factors were noted like Genetics, Race, Fatty diet, Environment, Hormones, Old age, Vasectomy and several others, but none of these have direct correlation to the Prostate Gland.

   However, in recent years, several studies have shown accumulated evidences on how an infection or inflammation had led to Prostate Cancer. But the problem is, despite these various studies, little interest is still given to diagnose and treat Prostatitis in the hope of preventing Prostate Cancer or at least to help treat it.

II. Issues on Diagnosing Prostate Cancer

   During the Seventies and Eighties, the original Prostate Cancer screening test was through a Digital Rectal Exam (DRE) whereby a physician inserts his gloved and lubricated index finger into the anus to palpate or feel the back part of the Prostate. If a suspicious mass is felt with the examining finger, a fine needle biopsy directed at the mass is usually recommended. 

   If the biopsy turns out to be positive for Prostate Cancer, this is usually in a more advanced stage, meaning, the Cancer has grown big enough to be palpable which makes the diagnosis of Cancer more accurate or certain as the needle biopsy could be directed at the mass.

   Unlike today, because of PSA screening, most of the cancers or tumors detected are still microscopic and not yet palpable (T1c), thus many of these needle biopsies are directed on 6-12 designated spots in the Prostate and with no specific target as none are still big enough to be palpable, just like a witchhunt. Early detection of Prostate Cancer poses more risk of diagnosing a cancer that does not exist, just a mimicker. 

   As early detection of Prostate Cancer became popular, the incidence of Prostate Cancer tremendously increased during the start of the era of PSA testing from 1989 to 1992 and in places where PSA were routinely done for early detection of Prostate Cancer. With this rise in incidence comes a potential increase of diagnosing an Indolent Prostate Cancer or a mimicker. 

   We have to bear in mind that, although the standard norm in diagnosing Prostate Cancer is by a biopsy, this is not absolute, especially when using a needle biopsy and in early or PSA-detected Prostate Cancer (T1c).

   This has been previously noted by Pathologists Magi-Galluzzi et al. that "The diagnosis of Prostate Cancer, especially when present in small amounts, is often challenging. Before making the diagnosis of prostate carcinoma, the pathologist should consider the various benign lesions that may mimic Prostate Cancer" (Genitourinary Pathology 2007). 

   A patient who is diagnosed with a non-palpable or PSA-detected Prostate Cancer (T1c) is faced with several dilemmas. First is whether the diagnosed cancer is real or just a mimicker. The second dilemma is whether the said cancer is aggresive (life-threatening) or slow growing (Indolent), which may not even manifest in the patient's lifetime. 

    These issues have been pointed out by Carter et al. (2007) that screening will result in overdiagnosis (i.e., detection of a cancer through screening and over treatment of some men. Treatment of Prostate Cancer regardless of the management option chosen can result in unwanted side effects - a poor trade off if the treatment resulted in no benefit in terms of years of life saved.

   What good will detecting cancer early when the treatment he will receive will not lengthen his life and would just subject him to unnecessary side-effects of the treatment. In the past, Prostate Cancers were being detected when it was already palpable or bigger, and yet their mortality rates are still comparable with the present despite the Prostate Cancers detected today still being very tiny or non-palpable. What advantage then is there in making an early diagnosis of Cancer?

 

III. Therapeutic Options for Prostate Cancer

 

        Standard Treatment:

  1. Watchful Waiting

  2. Active Surveillance

  3. Radical Prostatectomy

  4. Radiation Therapy

    4a. External Beam Radiotherapy

    4b. Brachytherapy

        New Types of Treatment:

        (Being Tested in Clinical Trials)

  1. Cryosurgery

  2. High Intensity Focused Ultrasound (HIFU)

  3. Proton Beam Radiation Therapy

 

   The third dilemma of a patient who is diagnosed with Prostate Cancer is how to determine the treatment that will be to his best interest and yield the maximum quality of life. Most cancer patients are in a state of panic and afraid to make decisions. 

   Cancer patients tend to look for doctors who will tell them what to do. On the other hand, the doctors have the awesome responsibility of serving their patients' best interest without imposing their own biases. 

   This was clearly depicted in a study by Fowler et al. which showed that specialists had a natural bias as they overwhelmingly recommend the therapy that they themselves deliver (JAMA, June 2000).

In 2001, Dr. Thomas Stamey, a urologist  from Stanford University, once said, "When faced with a serious  illness beyond our comprehension, (each of us) becomes childlike, afraid, and looking for someone to tell us what to do. It is an awesome responsibility for the surgeon to present the options to a patient with Prostate Cancer in such a way that he does not impose his prejudices which may or may not be based on the best objective information."

   Would you rather have your doctor tell you what to do or be a part in the decision-making process of the most important judgment you may have to make in your life? Whatever you choose, the decision will always be yours. Whether you have chosen to participate in the judgment or not, you made that choice. But you could also find strength in knowledge and stop being afraid.

   A study by Wilt et al. called Prostate Cancer Intervention Versus Observation Trial (PIVOT) showed no statistical difference in the 12-year survival and mortality rate among the men who had surgery (Radical Prostatectomy) against those who were not treated or were just under observation (Watchful Waiting) (New England Journal of Medicine, July 2012).

   A 20-year outcome following conservative management (Observation) of clinically localized Prostate Cancer by Albertsen et al. showed a stable mortality rate after 15 years from diagnosis, which does not support aggressive treatment for localized low-grade Prostate Cancer (JAMA, 2005).

   Since a diagnosis of a non-palpable Prostate Cancer by early detection using PSA (T1c) is far from being absolute, this merits an exhaustive validation of the diagnosis or several peer reviews of the biopsy specimen, a more conservative approach to treatment such as Watchful Waiting and due consideration on the life expectancy of the patient in relation to his quality of life should be given due importance.

   Even articles analyzed from 1966 to 1993 on cases of palpable Prostate Cancer (T2b) treated with Radical Prostatectomy, Radiation Therapy, Brachytherapy or Surveillance (Watchful Waiting) found no clear-cut evidence for the superiority of any one treatment (Middleton, 1996).

   Since there is really no unequivocal proof that by diagnosing and treating Prostate Cancer early (when it is not yet palpable) will yield a longer life for a patient, compared to one who elects to have no treatment or Watchful Waiting, would it be justifiable then to let a patient suffer the side effects of the treatment 10 years ahead of time and even spend money for it if this will not lengthen his life. 

   The main consideration in Watchful Waiting is to avoid or limit the morbidity related to treatment and give value to quality of life, especially if  treatment options for Prostate Cancer has not proven to have lengthened the lives of patients.

   I believe that Watchful Waiting is generally a good choice for men diagnosed with early or non-palpable Prostate Cancer.