Prostate news article, June 2005
| THE COMPLETE
GUIDE TO OVERCOMING PROSTATE CANCER, PROSTATITIS AND BPH By Peter T Scardino and Judith Kelman Book review by Iain Millett A patient with interest in prostate diseases |
This well presented and readable book outlines the history and key developments in the diagnosis and treatment of prostate disease - after a French surgeon, Ambroise Pave, in the 16th Century, discovered the prostate gland when he took home cadavers to practice his medical expertise.
The incidence of prostate disease increases with age as the gland enlarges in late middle age contributing to BPH and other disorders. Peter Scardino comprehensively outlines both the urinary and sexual processes within the male and the role of the prostate gland, including the statistic that an average male ejaculate contains a whopping 100 million sperms - enough to repopulate Mexico.
As this aging process proceeds however, from age 40, testosterone levels begin to diminish leaving some 20% of men without erectile function at age 50 (incrementing by 1% per year through to age 80.) Nevertheless, this leaves the pleasing prospect for some 50% of men, at age, 80 to enjoy their love life to the full.
Peter Scardino believes that regular PSA testing combined with digital rectal examinations (DREs) are the best defence currently available against being diagnosed with advanced (and incurable) prostate cancer. Despite PSA screening being widely adopted in the US, prostate cancer still kills some 20% of men diagnosed there. If left untreated, localised prostate cancer on average will metastasize in 10 years and kill in 15.
The risk factors, along with age, that single out men for prostate cancer are described, these include obesity, being of Afro-Caribbean descent, and having family incidences of the disease - along with a number of dietary and lifestyle issues that are believed to reduce the chance of contracting the disorder.
Once prostate cancer is suspected, the biopsy (for some an uncomfortable experience) and staging processes are fully explained including the recommendation to seek a 2nd opinion on the pathology findings. The Gleason grading of prostate tumours remains a subjective process within a disease fraught with subjectiveness. Should the biopsy be 'negative' against a background of increased risk - up to 3 further biopsies should be undertaken before the absence of tumour can be confirmed with any confidence.
Whilst the final staging process helps describe the extent of the cancer and its location - it is through the use of the Partin Tables and nomograms largely developed at Memorial Sloan-Kettering that the likely prognosis can be made. These tables and nomograms are detailed in the book and widely available over the internet.
Peter Scardino's book has a most useful section on the psychology of prostate cancer - entitled 'Understanding Yourself' - which proposes ways to cope with the challenge of facing up to the uncertainties the disease brings with it. Not the least it most comprehensively guides the patient through that greatest challenge - what to do? The old dictum in psychiatry is quoted '.that the thing you're most afraid to talk about may be the most crucial matter to discuss.' Men are not naturally made to open up on matters erectile or incontinent.
The expertise of the medical team is emphasised as being more important than the choice of treatment and Peter Scardino identifies ways in which the patient (more appropriate perhaps to the US) can set about finding his surgeon or oncologist. He also provides the measures he considers should be used to judge their competence.
Surgery is believed to confer survival benefit in the long term, say 10 or more years, even when a degree of extra-capsular extension exists. Men of 70 plus, in general, are advised to seek out radiotherapy or hormone therapy. Once again, nomograms are identified to assist with treatment choice and the pros and cons for each choice clearly presented. Radiotherapy using the latest 3D conformal therapy with IMRT as an alternative to surgery minimises risk to other adjacent organs such as the bowel. Brachytherapy is more appropriate for smaller less aggressive disease. Other newer developments such as cryotherapy, thermal and photodynamic therapies are also explained.
Peter Scardino explains in some detail the 3 dreaded consequences of local therapy: urinary, sexual and bowel complications. As far as surgery is concerned some 8% of patients are left incontinent, less so with expert surgery. Brachytherapy conversely can cause lower urinary tract irritation in 30% of patients which can take 2 or more years to subside.
Of all complications from surgery, erectile dysfunction looms large with only 40% of men recovering potency within 2 years. The nerve sparing procedure has however cut this risk so that between 75% and 90% of such patients recover erectile function. Should erectile dysfunction result from local treatment, the various options to manage such impairment are fully explained.
Developments within nerve sparing radical prostatectomy now include nerve grafting where one or both erectile nerves have had to be removed. In this procedure, a nerve from the side of the foot is used to restore erectile function - successfully in some 40% of men who otherwise would be permanently impotent. This rises to 50% with medication such as Viagra. Overall 60% of men treated at Memorial Sloane-Kettering subsequently live out their lives without recurrence and with erectile function - 80% of men are cured of their cancers. Only 7% of Peter Scardino's patients have finally died of their cancers.
Despite improvements in surgery and other radiotherapy treatments, between 25% and 40% of patients will encounter a rising PSA requiring further intervention. The process whereby these later treatment decisions are arrived at closely follows the original staging process with radiation and hormone therapy being the principal weapons.
Peter Scardino's book does not major in the areas of hormone therapy or the management of advanced metastatic cancer, but it does, at its heart, provide in a very readable form a comprehensive guide to the treatment options for what can be a frightening and challenging experience.