This week we begin a fortnightly series called ‘Urology and You’ by Satyendra Persaud MBBS DM (Urol) of the Department of Urology, San Fernando General Hospital, Trinidad and Tobago. Dr Persaud, who is Guyanese, recently completed his training in urology at the University of the West Indies.
This is the first piece of a series on prostate cancer. I opted to start with prostate cancer since, given its prevalence (1 in 8 men will develop prostate cancer in his lifetime), chances are that we all know someone who is afflicted. It is a disease which is very variable in its presentation and in fact, often has no symptoms. I think it is important that we all have at least a working understanding of the disease
Prostate cancer is a concern in the Caribbean where large sections of the population are of African heritage. Research has shown that the incidence and mortality of prostate cancer are among the highest in the World. Although Afro-Caribbean men are at higher risk, men of all races may be affected. Men with a family history of prostate cancer are also at high risk
Symptoms
The man with prostate cancer may have no symptoms. Other common symptoms of prostate cancer include blood in the urine and difficulty passing urine. Advanced cancers may present with loss of weight and bone pain. Rarely the cancer may cause a blockage severe enough to cause the kidneys to fail.
What is the prostate?
The prostate is a small gland, about the size of a walnut and is found only in men. It is located below the bladder and surrounds the urethra which is the tube through which urine passes. It secretes fluid that helps to liquefy the man’s semen. It is prone to cancer and most commonly affects older men.
What is PSA?
Prostate specific antigen (PSA) is a substance secreted by the prostate and it functions to liquefy semen. PSA is found in the blood of every man and checking the blood levels is one of the tests doctors use to screen for prostate cancer. Not every raised PSA means cancer and other things may cause the PSA to go up including a large non-cancerous prostate, infections and even recent sex.
Your doctor will help you to decide if your PSA number really is cause for concern. He/she may even ask for a repeat test if they think it was falsely raised. A word of caution – antibiotics should not be used to treat a high PSA unless the man has symptoms of an infection.
Should I get tested?
You may have heard that PSA testing doesn’t work or isn’t recommended. The United States Preventative Services Taskforce made a recommendation against PSA screening causing much confusion among both patients and doctors. This recommendation, many feel, is flawed and many urologists all over the world are of the opinion that abandoning PSA screening will set us back decades to a time when men came to see their doctors with advanced cancers and it was already too late for a cure. We have large studies from Europe which have shown us that PSA testing can reduce PSA deaths by more than 40%. The American Urological Association advocates for screening in men aged 55 to 69 – starting as young as 40 should be considered if they are at risk by virtue of being of African descent or have a positive family history. It is recommended that you have a thorough discussion with your doctor to find out if screening is right for you and to discuss potential complications. Routine screening should not be done on older men (over 70) as diagnosing prostate cancer in this group is unlikely to affect their life expectancy. However, I do not feel that screening should be withheld from an older man in excellent health who requests it.
How do I get screened
for prostate cancer?
Testing is done using a PSA test and a rectal examination. During the rectal examination, the doctor feels the surface of the prostate by inserting his index finger in the rectum. He feels for hard spots on the prostate which may be suspicious for cancer. If done correctly it should be at most a minimal discomfort. There is some debate when this is necessary and I am often asked that question. My opinion is that it is an important part of the screening process as prostate cancer can occur at low PSA levels and an abnormal rectal examination may be the only clue that something is wrong.
What if I have a high PSA
test or abnormal prostate exam?
If either your blood test or your prostate exam is abnormal, your doctor/urologist will recommend a prostate biopsy. A biopsy simply means that the urologist will take a few samples from the prostate to check for prostate cancer under a microscope. This is done through the rectum using a small needle, and an ultrasound machine to see the prostate. The patient is awake during the procedure and a numbing solution is injected to prevent pain – done in this way, there is usually very little discomfort. There is a small risk of infection and minor bleeding is common following the procedure but usually resolves on its own.
Are there any other tests which can be used?
The answer is yes. Several new blood tests have been developed which, along with PSA, can be used assist your urologist in determining whether you need a biopsy. These include the prostate health index (PHI) and free to total PSA measurements. A new urine test called PCA3 may also be used. These tests are however, not always available in every Caribbean setting. Perhaps we can discuss these tests in a future article.
I am happy to answer any questions via email. satyendrapersaud@yahoo.com
