Prostate Cancer is responsible for more deaths in Jamaica than any other cancer. And so today, World Cancer Day, Jamaica Moves will highlight vital information about Prostate Cancer, and other common cancers in Jamaica in an effort to encourage everyone to be vigilant and for those at risk to screen for the disease.
We spoke with veteran Urologist and lecturer of Urology at the University of the West Indies, Mona, Dr. William Aiken, who shed some light on the potentially debilitating disease.
What is Prostate Cancer?
The prostate is a small, walnut-shaped gland in the male reproductive system that produces and stores fluid that helps to make semen, and is involved in regulating bladder control.
When the prostate is involved with a cancerous change, it is called prostate cancer.
There is low risk prostate cancer which generally refers to early stage prostate cancer and prostate cancer with a low risk or progression. There is locally advanced prostate cancer, which means the cancer is no longer within the prostate, it is now outside of the prostate but it hasn’t yet spread to distant organs. And then there is metastatic prostate cancer which means that the cancer has spread to other parts of the body.
In our population, and generally in the Caribbean, there is a high proportion of men presenting with either locally advanced or metastatic prostate cancer compared to first world countries. So in populations like ours where a lot of screening does not happen and where men do not do preventative check-ups, the majority of men present with either locally advanced or metastatic prostate cancer. In other words, they present late.
What are the risk factors?
There are three that are established: Age, family history and race.
Age. Men below 40 hardly ever get prostate cancer. It’s exceedingly rare but as you advance in age the risk becomes greater.
Family history. If you have a brother or a father who has prostate cancer, and especially the younger that relative develops prostate cancer, the greater the risk is. The important thing is that although family history is a risk factor for prostate cancer, 90% of prostate cancer occurs in the absence of a family history. So a man not having a family history of prostate cancer should not take comfort in that fact.
Race. Men of African descent are at highest risk compared to other races.
According to Dr. Aiken, there is a lot of epidemiological and basic science evidence that suggests that diet also contributes to an increased risk of prostate cancer. Some things that have been linked, in various research, to an increased risk for prostate cancer include:
Processed meat such as bacon, salami, bologna.
Chronically overeating. Overindulging on a chronic basis seems to put you at risk for prostate cancer.
Signs and symptoms
It is important to note that prostate cancer does not have any signs when it’s in its early stages. A man can have prostate cancer and experience absolutely no symptoms until the cancer is advanced; at that stage it is no longer readily curable.
The same age group of men who are affected by Benign Prostatic Hypoplasia (BPH), or what we call non-cancerous enlargement of the prostate, are also affected by prostate cancer. Many times a man will have symptoms of BPH, he will go to his doctor and in the process of evaluating this man, he may be found to have a coexisting prostate cancer that’s small enough to not be causing any symptoms. So the symptoms are not due to prostate cancer per se, they are due to BPH.
The majority of prostate cancers occur in the part of the prostate called the peripheral zone, that’s away from the urethra (urine passage). So the cancer has to get to a significant size for it to impinge on the urethra; the cancer is usually locally advanced before there are any signs and symptoms.
Symptoms for locally advanced (same as BPH)
Long time to initiate urinating
Interrupted urinary flow or weak urine stream (it comes in trickles; doesn’t flow continuously)
Incomplete empty or double voiding (After urination, he may have the sensation that his bladder is still not empty and the need to urinate immediately after doing so)
Sudden urgency to pass urine
Blood in the urine
Blood in the semen
And in advanced cases, acute urinary retention (stoppage of water)
Is there a relationship between genetics and prostate cancer?
The reason prostate cancer runs in families is because of a genetic predisposition. If your father had prostate cancer but he developed it in his 80’s, the risk is lower versus if he developed it below the age of 55.
So the younger your first degree relative (father or brother), and the greater that number of relatives, the higher the likelihood that there is a specific gene that is causing increased risk.
Whereas the older the relative, there may not be a specific gene that can be isolated. Or if prostate cancer occurs in successive generations, then there is usually a specific gene that is increasing that risk. And that is a subset of familial prostate cancer which is known as hereditary prostate cancer.
What are the treatment options for Prostate Cancer?
The treatment options are dependent on the stage of the disease, extent of spread of the disease, the age of the patient, patient’s preferences, availability of the treatment and the presence of comorbidities (pre-existing conditions that may also need treatment) that would determine that patient’s life expectancy.
For early prostate cancer, the main treatment options are:
(1) watchful waiting, (2) active surveillance and (3) surgery (radical prostatectomy) which may be done in a number of ways. In addition, there are external options such as radiation as well as brachytherapy.
In Watchful waiting, the patient usually has a short life expectancy and is not necessarily expected to die from their prostate cancer but with it, and therefore they are continuously monitored. If they develop symptoms of metastatic disease (the cancer is spreading), then they are treated at that point in time. So that would be done for a man who has early prostate cancer but he’s in his 80’s but not likely to die from prostate cancer and no further intervention or follow up is necessary; that is watchful waiting.
This is done in men who have low risk disease; either low risk or very low risk prostate cancer and you don’t want to “over treat” them. So in active surveillance the disease is monitored by doing serial Prostate-Specific Antigen tests (PSA), rectal examinations and repeating the biopsies at intervals with the understanding that if there’s any progression of the disease, the monitoring or active surveillance would be aborted and the patient would be treated in a preferred manner, in an effort to avoid “over treatment”. The aim of active surveillance is to prevent the over treatment of men with low risk or early disease.
Radical Prostatectomy is the complete surgical removal of the prostate. This is done very competently here in Jamaica using an open surgery approach. And there is at least one Jamaican urologist who does the key hole surgery or laparoscopic approach. The robotic approach to this surgery is not available in Jamaica.
In Jamaica there are Linear accelerators that are able to do intensity modulated radiotherapy which is a very sophisticated form of treatment. There is curative radiotherapy, which is a curative form of treatment given in when a man has early stage prostate cancer. Radiotherapy is also given in locally advanced disease in combination with hormone treatment. There is also palliative radiotherapy for men with advanced disease or metastatic disease as well. So radiotherapy is used at all stages of the disease but the dosing, schedule and the intensity is different whether curing or just palliating the disease.
Can prostate cancer be prevented?
There is no known way of primarily preventing prostate cancer.
However in order to prevent death from prostate cancer, which is the critical thing, secondary prevention is key through screening. And currently screening or testing for the disease includes the Prostate-Specific Antigen blood test (PSA) and the Digital Rectal Examination (DRE). Men who are 40 years and older are recommended to undergo routine (yearly) screening using the PSA test. Screening detects early prostate cancer and helps to prevent death from prostate cancer.