Prostate Cancer- a follow up
Last year I wrote an article in the BALPA Log regarding prostate cancer. I outlined my diagnosis and treatment of the disease which now affects over 45,000 men a year in the UK. The recent publicity surrounding the deaths from the disease of well know personalities such as Sir Alec Guiness, Cardinal Basil Hume and Archbishop Runcie has brought about a new public awareness. 11,000 men in the UK will die of the disease each year. 4% of all deaths amongst men is attributable to prostate cancer. What it has highlighted is the lack of financial resources, particularly in the field of cancer research. Last year of the £300 million spent on cancer research, only £4 million was spent on prostate cancer. Nearly as many men now die of the disease as women do from breast cancer, yet there are no plans for the similar screening of men. It is now nearly 18 months since I had my operation and the battle for a cure continues. I hope my experiences will be of assistance to anyone who may be confronted with treatment decisions and their long- term implications.
I was diagnosed with prostate cancer at the age of 60. I had no symptoms but I had over the past 10 years had had a regular P.S.A blood test that is an indicator that the disease might be present. It runs in my family and has killed an uncle and a cousin. I was left with three options:
[list=1][*]Do nothing (known as watchful waiting). Prostate cancer is a slow growing disease and most men die with the disease, not because of it. [*]Treat the disease with radiotherapy or radioactive seed implants. [*]Have the prostate surgically removed, also know as a prostatectomy.[/list=a]
As long as the cancer is confined to the prostate, either radiotherapy or a prostatectomy are considered the gold standard cures for the disease. After an MRI scan and the advice of my consultant, I decided to have a prostatectomy.I had one of the most experienced surgeon’s in the north of England perform the operation which spare the erectile nerves on the right hand side. Possible impotence or incontinence are the two main risks involved with the operation and similar problems can arise with radiotherapy. Fortunately, my ‘leakage’ cleared up in 4 weeks but impotence (the ability to achieve an erection) problems still exist. I mention this as there is no doubt that the threat of impotence is probably the prime concern of most men (even though they will not openly admit it) who consider having the operation.
Viagra, which is dispensed free on the NHS for all men who have had a prostatectomy, has not really worked for me. The other treatment for achieving an erection is the injection technique. You’re probably thinking, "No way would I ever stick a needle into my penis!" but it a common treatment for this problem. It requires a tiny needle and a watery mixture of drugs; usually prostaglandin E. It is the exact same mechanism that creates a natural erection, except it is triggered by a drug rather than a nerve impulse. You need to find the correct dosage as too much of the drug can make for a rather painful and prolonged erection.
The post-operative treatment for a prostatectomy is to have follow up PSA tests, usually every three months. Even though the prostate has been removed, if there has been any ex-capsular invasion of cancer cells, this will be indicated by a rising PSA as the cancer cells will still release PSA into the blood. It is now well accepted that if the PSA starts rise after a prostatectomy, it is an indication that the operation has failed and that there has been a recurrence of the disease.
My surgeon had advised me after the operation that the histology report showed evidence of microscopic extension of cells beyond the prostate capsule and that there was a 50% risk that I might need adjuvant or additional treatment. The Gleason scale, which measures how aggressive the cancer is, was as also higher than what was found by a pre-operative biopsy. The first 4 quarterly PSA tests each showed .1, which is considered a zero reading, however, the next test showed .5 and my next one increased to 1.5.
Since my operation I had continued to educate myself via the internet about the disease. There are numerous web-sites in the US which are excellent and many case histories are openly discussed with qualified consultants. I discovered that I was not alone. Failed radical prostatectomies are a common occurrence, indeed one report claimed that 30% fail if measured by rising post-operative PSA levels. The same can also be said for radiotherapy treatments. The real key to being cured is early diagnosis and to make absolutely sure that the disease is organ confined. Americans are well advanced in this field and it seems that more effort is put into early diagnosis through a battery of tests before deciding on the type of treatment.
If the recurrence is in the prostate bed or fossa, then salvage radiotherapy to that area is an option. Very often the surgeon has not been able to get a negative margin around the prostate and some cancer cells will have remained. Often the rising PSA is due to the disease being systemic which means that the microscopic cancer cells have spread throughout the body. The treatment for systemic spread of prostate cancer is adjuvant hormone therapy.
It has long been known that there is a connection between testosterone and prostate cancer. In the early 1940’s Dr Charles Brenton Huggins removed the testes,where testosterone is manufactured, from a number of men suffering from prostate cancer. In almost every case, castration shrank their tumours. For his work,Huggins was awarded the 1966 Nobel Prize in medicine and physiology. Testosterone acts like a traffic signal for prostate and prostate-cancer growth. When molecules of this hormone enter the gland via the bloodstream, they give prostate-cancer cells the green light to grow and divide. Their absence brings this activity to a screeching halt.
There are two types of hormone therapy, surgical castration and medical castration with the later mainly in used today. Various drugs are available to reduce testosterone levels and they fall into two groups:
[list=1][*]LHRH Agonists: Compounds called LHRH agonists mimic the size and shape of the lutenisinzing-hormone-releasing hormone, the molecule that starts the cascade of reactions leading to testosterone production. The drug works by flooding LHRH receptors on the surface of the pituitary gland cells, making the pituitary pump out LH non-stop and in much larger quantities than it is used to. After a few days, the exhausted pituitary begins adsorbing LHRH receptors from its surface and shutting down LH production. The upshot is that testosterone falls to castration levels. Examples of such drugs are Lupron and Zoladex.
[*]Antiandrogens: Several compounds have been discovered or developed that essentially blanket prostate and prostate-cancer cells with a protective coat that prevents testosterone and other androgens from getting inside. Trade names of such drugs are Casodex and Eulexin (flutamide)[/list=a]
Hormone therapy normally involves a combination of these type of drugs however monotherapy with such drugs as Casodex are now approved in the UK. The main problem in turning off the production of testosterone are side effects and these can lead to impotence, loss of libido, hot flashes, loss of energy and breast enlargement. The intermittent use of HT is now being used quite extensively. The drugs are usually administered for a period of one year until the PSA levels become undetectable and then discontinued. Some patients are sometimes off treatment for periods up to 5 years. Once the PSA starts to climb, HT is re-started.
When presented with the problem of my rising PSA, I came across a procedure used in the States called Prostascint. It involves the use of a radioactive ‘dye’ that has an affinity for prostate cancer cells. This is injected into the blood and then scanned by a dual-head Gamma Camera that will show up any recurrence in the prostate bed or in adjacent pelvic lymph nodes. The procedure is not yet approved in the EEU but I did find that Prof. Keith Britton at Barts School of Nuclear Medicine in London had a similar imaging procedure under development in London. He agreed to give me the test and I might add that BUPA, my insurer, agreed to pay for the £800 scan. I have doubts that my local health authority would have picked up the bill for what is a relatively new treatment, a word of warning if you don’t have private health care.
A week later the results in the form of glossy photographs drop through my letterbox. It showed no recurrence in the prostate bed or pelvic lymph nodes. If it had, no doubt the results would have gone directly to my consultant. My consultant now feels that the rise in the PSA is due to microscopic cells that escaped the prostate prior to my operation. He pointed out that it would be pointless to attempt salvage radiotherapy and that intermittent adjuvant hormone therapy was the next step. As I write this, I am about to start a high dose monotherapy with Casodex a drug that has limited side effects and should maintain a reasonable quality of life. Hopefully, the PSA should drop to undetectable levels and my ‘on’ treatment period should only last a year. Although I retired from flying 6 months ago, it will be very interesting to see if the CAA will pull my licence. My consultant has given then regular reports on my PSA levels since my operation.
I have learned a great deal about this disease since my diagnosis and most of my information has been through the Internet, particularly American websites.Dr Charles Myers, a leading prostate cancer specialist and a sufferer himself, has stated that none of the treatments for prostate cancer are perfect and none have been proven effective. For early prostate cancer, we have a choice between surgery, radiation therapy, hormonal therapy or watchful waiting. Serious questions remain about the effectiveness of each of these approaches. Dr Myers believes there is no single right choice for all men. Treatments need to be tailored to the individual. His recommended approach is:
Go for cure, kill as many cancer cells as possible and then do what you can to slow the re-emergence of this cancer, slow the disease as much as possible without compromising your quality of life, or ignore the cancer as long as possible.
I would offer the following advice:
[list=1][*]If you are over 50 years, have a PSA blood test and Digital Rectal examination every year. If it runs in your family, start in your 40’s.[*]If diagnosed, educate yourself. This is one disease where the patient must get involved in the treatment decisions. If you are not on the Internet, get a computer.[*]Treat the disease as early as possible. Your prognosis will be much more favourable if the disease is organ confined.[*]Always seek the best advice and look to centres of excellence when it comes treatment.[*]Don’t let it get you down. Get on with your life.[/list=a]
Odds of being diagnosed with prostate cancer
Age
- 20-39 insignificant
- 40-44 1 in 48,640
- 45-49 1 in 9,085
- 50-54 1 in 1,943
- 55-59 1 in 624
- 60-64 1 in 240
- 65-69 1 in 122
- 70-74 1 in 81
- 75-79 1 in 65
- 80-84 1 in 58
- 85+ 1 in 63
Sources: number of cancer cases by age from the American Cancer Society.
Edited for formatting only
[This message has been edited by Capt PPRuNe (edited 27 September 2000).]