Prostate news article, November 2004
| DR THOMAS STUTTAFORD
ANSWERS YOUR QUESTIONS ON PROSTATE CANCER
Dr Thomas Stuttaford, OBE, MRCS, LRCP Trustee, Prostate Research Campaign UK |
Please note that Dr Stuttaford is not familiar with all the circumstances in individual cases and can only deal with the points raised in general terms. Patients should always discuss any specific problems they have with their own doctor.
What are the symptoms of prostate cancer?
John Doe, Swindon
Although prostate cancer will eventually bring about symptoms that stem
from the tumour causing changes and damage to the waterworks and the genitalia,
initially prostate cancer is symptom free. Eventually after the cancer
has spread to other organs and tissues they will be involved too. The
bones are especially vulnerable but there may be symptoms from any part
of the body. To wait for symptoms may be to wait too long as by the
time they are obvious the cancer may already have become too well established,
or even spread.
The first symptoms that are noticed are usually those related to urination. There
may be urgency, the patient may find it difficult to hold on to their urine
and is always dreading being caught short. Coupled with this there
may be a feeling of incomplete emptying, or what most men refer to as dribbling
on. Although a small drip, especially in the uncircumcised, is not
unusual in older men it shouldn't be more than one or two drops (- if that).
There will frequency of urination. The man with a prostate that is
causing trouble will have to get up to pass urine more often at night. During
the day he may have to pass urine twice within a couple of hours. When
he starts to pass water the stream may be less strong than it was, the
stream may be intermittent or its jet may be forked. If the prostate
is very large, or if the tumour is pressing hard on the urethra, the patient
may find that he either has to press on his abdomen to pee, or he may find
that he can only pass urine standing upright.
There is debate about the extent to which early prostate cancer may affect
sexual performance. However some men are quite certain that their
potency was reduced before the cancer had eventually been diagnosed. Another
sexual problem is that very occasionally the semen is pink and blood stained. This
is usually not the result of malignancy but it can be, and therefore anyone
with this symptom, known as haematospermia, needs investigation.
The most usual evidence of advanced cancer of the prostate is pain from
bones and/or joints, especially back ache.
My partner had a nerve-sparing radical prostatectomy in July 2004 following
diagnosis of prostate cancer (PSA of 7.2 and Gleason score of 6). His
potency recovered very quickly after the operation and has now reached
the stage where erections are often spontaneous. The first three
monthly PSA results were less than 0.5 and the result a year after surgery
showed a result of zero. I have heard that even with these reasonably
negative results a year after the operation the PSA can start to rise. If
this should be the case would you recommend radiation treatment and if
so how is this likely to affect potency?
Diana Barnes-Cook, London
A very good question and one that is now being much debated. There
is no doubt that if everyone who has had a radical prostatectomy that showed
that the Gleason score was 8, 9 and 10 then followed the surgery with either
radiation or hormones such as Casodex, or both radiation and hormones their
chances of long term survival without recurrence would be greater. Once
the Gleason is over 8, however encouraging the other signs were at surgery,
only one in four enjoy long term survival. There is therefore a good
argument for giving the patients with a high Gleason other treatment immediately
after surgery. Impotence and later enlarged painful breasts together
with a feminine distribution of body fat may worry some men. The
consolation of taking Casodex is that 75 per cent of those men that do
don't lose their sexual interest, and many still have an orgasm even if
impotent.
Few doctors would recommend such extensive treatment to somebody with a
Gleason score of two, three, four these are the pussycat cancers, rather
than the tigers. There are some doctors however who think that irradiation
as a supplement to the surgery should be considered.
The 5, 6 and 7 Gleasons are the difficult ones. Recent papers have
shown that Casodex given at the same time as surgery, or similarly irradiation
given then, improves the outcome. It is a philosophical question
as much as anything else - what aspects of a sex life will someone sacrifice
for a more certain chance of long term survival, say ten years plus.
I had a PSA of 8.2 and two tumours one Gleason 8, one Gleason 7. My PSA
remained at below 0.05 for five years and climbed again in the sixth. The
chance that the recurrence is in the pelvis around the former prostatic
bed is greater when there is a late recurrence. If the patient hasn't had
radiation before then it is now certainly indicated (and in my view, but
not every doctors, so is Casodex). 14 per cent of men with a late
recurrence will be "cured" by the radiation.
What steps should one take to ensure that there are no signs of
any tumours in one's prostate gland? I understand PSA readings
alone cannot give 100 per cent assurance. Thank you.
NH, London
No one can be certain but annual PSA tests for those over fifty and for those over forty if there is a family history will go a long way to finding tumours. Even if the PSA is normal but it rises quickly and has, as they say, a steep slope or the doubling time of the PSA is short, further investigations are needed. Rectal examination will pick up a few of the type of cancers that are missed by the PSA. Once the PSA is raised and there is no obvious cause ultrasound and biopsy is needed.
At 74 a chance finding of a PSA of 30.5 led to chemical castration
and Zoladex (no symptoms). Three months later, a PSA of 0.2 and
it remains the same after 18 months (no biopsy or radiotheraphy). Are
there any symptoms or signs other than a raising of the PSA that would
indicate is the tumour is active?
Name and address withheld
There can be difficulties in interpreting a PSA before a malignancy has been diagnosed. Once diagnosed and treated any subsequent rise in the PSA is important. If there is an appreciable rise a bone scan is usually carried out. Early diagnosis of a secondary is important as there is evidence that third line treatment is much more effective if it is started quickly, even though the patient is still feeling well.
All my life I've had the "problem" of peeing a little
and often, and with a weak jet. I was also a bedwetter until about
mid-teens. After a few pints of beer I find myself heading for
the toilet at an embarrassingly regular rate. Could this be a prostate
problem? If so, is it only a prostate problem and not prostate
cancer?
Name and address withheld
You don't tell us how old you are but your problems, unless you are middle aged or older sound, very much as if you have bladder problems of the type that for years has been known as a weak bladder but are now referred to as overactive bladder syndrome or unstable bladder. Vesicare made by Astellas is useful as is the anticholinergic Detrusitol XL. If your bladder function has changed at all you should see your doctor, as indeed you should if your present symptoms are a nuisance.
In your article in The Times on October 27, you implied that a
PSA reading of 2.5 was giving cause for concern. Mine is 3 which
my GP says is OK and nothing need be done unless it rises beyond 4. Grateful
for your comments, please.
Derek Thom, Cheltenham
Our reader's PSA of 2.5 was important because he had had surgery, and
after this the PSA had dropped to less than 0.5, but was now rising. Once
someone has had their prostate removed their PSA should be less than 0.05
for any rise is likely to signify a recurrence of the tumour. Quite
rightly this reader was given radiotherapy. Many doctors like to treat
recurrences when they are less than 0.1 or 0.2, it is never too soon to
start. I have always taken 3 as the upper limit of normal for all
PSAs. Some doctors regard any PSA over 2.5 as suspicious in a man
of under 50. They would accept a PSA of 3.5 between 50 and 59. After
sixty their upper limit would go to 4.5. It is always a balance between
recommending so many investigations that they cause patients anxiety or
being absurdly over optimistic as a doctor and thereby possibly sacrificing
a patient's chance of a long life.
If there is any doubt about a PSA's significance another should be taken
a few months later (either three or six months) and the rate of increase
in the PSA as well as its height taken into consideration.
My father has been having to get up to pee three to six times
a night for several years. Some time ago he very reluctantly had
a prostate operation, of which we had high hopes, and was told he did
not have an enlarged prostate, but some work had been done on the neck
of the bladder (sorry to be vague on detail). Unfortunately he
still has disturbed nights. He has had other problems, briefly
:finds eating very difficult and weighs just seven stone, and is now
quite frail and virtually housebound. No physical problem has been
diagnosed underlying this, and he is undoubtedly depressed, but his sense
of taste does appear disturbed. Is now so underweight that anti
depressants etc are contraindicated. I feel if the nightly waking
could be reduced it would improve his and my mothers quality of life
somewhat. Would be grateful for any useful advice.
Name and address withheld
You don't tell us how old your father is but at any age with all these problems he would be well advised to discuss them with his doctor and with a kindly urologist. Not all benign prostatic hyperplasia (benign large prostates in older men) needs treatment with surgery for modern medication is getting better and better at controlling it. There are still a few physicians who specialise in the problems of the elderly and it would be worthwhile consulting them about his diet and weight. Contrary to common belief depression can be treated in older people, so called senile melancholia is more difficult to treat than classic depression in a younger person but that doesn't mean that it is impossible, only time consuming.
Are there any preventative measures, e.g. vitamins, supplements,
annual testing, that a healthy twenty-something can do that might decrease
his chances of developing prostate cancer later in life?
Brian Haman, Vienna, Austria
A most important question. Apart from age and race hereditary is the most, important factor. There is evidence that in families that have this trouble the cancer is becoming active at an earlier age in successive generations. Anyone with a family history should start having PSAs checked annually at forty. Lycopene, the anti oxidant found in tomatoes (non salad lovers can take Lyc-O-mato) and in even greater quantities in tomato sauces, cooked tomatoes and even in our old favourite tomato ketchup. Selenium may also be advantageous as is a low fat diet. There is considerable evidence that excessive fat in the diet encourages carcinoma of the prostate, as does smoking. There is a suggestion that a multiplicity of partners may also be related to carcinoma of the prostate but the evidence of this is not strong.