November, also known as Movember, is prostate cancer awareness month.
Prostate cancer affects men of all races and was previously reported to be a disease of older men.
However, in Zambia we are increasingly seeing it in younger men particularly those with a strong family history.
Currently, we do not have a population based screening programme in Zambia, but the local experts recommend screening with prostate specific antigen (PSA) and digital rectal examination from the age of 40 years.
The digital rectal examination is an uncomfortable thought for many people so let me try to demystify the principles around screening and early diagnosis.
Screening for cancer is a procedure that attempts to find disease before it shows its symptoms.
For prostate cancer, this can be a slightly tricky as the symptoms are non-specific and can mimic other non-cancerous processes such as benign prostate hyperplasia and infection.
Screening is best done in an environment with infrastructure to manage any conditions that will be discovered.
For prostate cancer, the screening tests the ‘infrastructure’ is simple – a doctors finger with a brain that can detect discrete nodules and a blood draw for the PSA.
I cannot emphasize enough the need to do screening only if a pathway for subsequent management of findings is present.
I often get a bitter taste in my mouth when I hear how some patients are screened and left fending to who will manage the abnormal findings of the screening test.
PSA is produced by the prostate gland and in large quantities by cancerous cells.
PSA can be temporarily raised due to an infection (prostatitis or urinary tract infection), following sexual intercourse and manipulation of the prostate.
It is very important that the person conducting the screening counsels the client and mitigates the chances of a false positive.
A single raised PSA result is not an indication for prostate biopsy, which carries relative risks of infection and bleeding as an invasive procedure. Typically, if a gentleman has had serial PSA done since the age of 40 years, it is easy to see the upward trend associated with malignant transformation.
The second screening modality of digital rectal examination also requires a certain level of skill to detect abnormalities.
Volumetrically the prostate gland is shaped as an upside down cone with a groove running down its back surface that we can feel.
The base of the cone lies furthest from the anus and seminal vesicles sit on them falling to either side.
The consistency of a healthy prostate is rubbery like a squash ball.
A firm or nodular prostate typically points to a pathology warranting extra investigation.
If screening reveals a convincing abnormality, the next step is to obtain imaging that will assist in establishing the local disease.
An ultrasound is now the standard of care particularly if simultaneous biopsy is required.
This allows safe reach on the anterior aspects of the prostate.
A better method worth the infrastructural development is MRI guided biopsy.
MRI imaging with a rectal coil allows us to really characterize the cancerous nodules and differentiate them from non-cancerous ones. Using a special accessory called a transperineal template the most accurate sampling of the prostate is made possible.
Prostate cancer is a heterogeneous disease.
The risk of death from prostate cancer is determined by the grade of the actual tumour called the Gleason score, the PSA value and the extent of involvement of the gland determined by the clinical exam and imaging.
Low risk prostate cancer can be managed conservatively and treatment deferred to a necessary point.
This requires regular visits and repetition of diagnostic tests to ensure the disease has not transformed into a more malignant aggressive type.
We have found that the side effects on the quality of life in such men may out weigh the benefit of treating the disease.
I must once again emphasize that this is only safe if managed by a highly qualified specialist who understands all the parameters and evidence supporting this approach.
It is not a decision for generalists to make.
In fact such a decision is best made in a multidisciplinary team meeting.
Intermediate risk and high-risk prostate can require immediate intervention once diagnosed.
However, the magnitude of treatment varies.
Intermediate risk prostate cancer is treated with equivalent success by surgery and radiotherapy.
Radiotherapy can be by external beam or brachytherapy.
I favour brachytherapy because of the good side effect profile compared to external beam.
I also like the fact that with brachytherapy patients can complete treatment in one (if low dose rate) or two visits (if high dose rate).
This is very convenient and cost effective.
Surgery also has its variation.
It can be open traditional prostatectomy, laparoscopic or robotic.
The morbidity is said to decrease with each subsequent mentioned but the financial toxicity increases.
Most value oriented oncologists struggle to justify the cost of robotic prostatectomy compared to laparoscopic.
For intermediate and high risk disease hormonal treatment is a significant component.
Intermediate risk prostate cancer requires six months of androgen deprivation therapy (ADT).
High-risk disease requires up to two to three years depending on the grade.
Hormonal therapy or ADT has numerous side effects that patients need to understand well before commencing.
All are associated with the disruption of the very important hormone testosterone.
Bone density loss is a major side effect.
Patients must mitigate this by employing strengthening exercises and taking calcium supplements.
Due to the treatment side effects using milk and other dairy products can be a difficult balance to achieve.
Another reason dairy products are discouraged and exercise is encouraged is that the levels of cholesterol need to be controlled.
ADT predisposes to increased levels of bad fats in the body.
This leads to higher incidences of cardiovascular events due to arterial clogging.
These aspects of managing a patient with prostate cancer on ADT are very important.
I often have patients who want express service on everything.
They want to have a special arrangement where they walk in and they walk out in five minutes after receiving their monthly or three-monthly injections.
It is not that simple.
The profile of parameters in the blood needs to be looked at.
Lastly, mood swings and hot flashes induced by medication can be quite overwhelming for patients.
Meditation and therapy may help mitigate these.
Prostate cancer is not the next man’s problem.
It is our problem.
Let us be proactive but appropriate in our approach to beating this disease in Zambia.
The author is a Brachytherapist Clinical Oncologist based at the Cancer Diseases Hospital in Lusaka Zambia.
Follow her on Twitter @lombe_dorothy and visit the cancer information blog Oncocurae.com on www.dorothylombe.com.