Early detection may be tricky but it’s over to men to insist on regular checks before symptoms appear.
Early detection of prostate cancer may be tricky but it’s over to men to insist on regular checks before symptoms appear.
First the bad news: prostate cancer remains the most common cancer in men, with around 3000 new cases a year in New Zealand and no sign of a national screening programme. This walnut-sized gland, between the bladder and the penis, can cause a lot of trouble as men age. We don’t know why or have any proven prevention strategy, but there is some good news: we are getting better at diagnosis and treatment.
Although there remains no single, accurate test to diagnose prostate cancer, that might soon change. A New Zealand company, Caldera Health, is developing a urine test that has the potential to be a game changer.
In the meantime, the best option is still a PSA test to measure the level of a protein in the blood that, when elevated, may – but not necessarily – indicate cancer.
PSA status is useful as a risk assessment, but like the other test, the digital rectal exam, is not an accurate diagnostic tool. So some patients were ending up having unnecessary biopsies. But MRI scans are sparing increasing numbers of men from biopsies if they are judged as having a low-grade tumour that is unlikely to be a major problem during their lifetime.
The other significant development is the availability of a scan that uses a radioactive tracer to find out whether the cancer has spread from the prostate to the lymph nodes and beyond.
“Traditionally, we’ve not been great at picking up the spread of disease outside the prostate,” says Auckland interventional radiologist Remy Lim. “We’d do a CT scan to look at the size of the lymph nodes but that is a crude way of determining whether they were diseased or not.”
Metastasised cancers – those that have spread elsewhere – were missed in some men. They were having
61% of patients had no symptoms when the cancer was diagnosed.
surgery to remove a tumour when, as Lim puts it, “the horse had bolted” – the disease had spread and the surgery wasn’t going to cure them.
This newer, more sophisticated imaging procedure looks for proteins, called prostate-specific membrane antigens (PSMA), on the cancer cells and so provides an accurate road map of where the disease has spread.
The PSMA test isn’t available in the public health system. Late last year, Lim finished a study he hopes will make a case for that to change. Fortynine patients with aggressive cancers were recruited, all planning to have surgery. Scanning them for PSMA, Lim found a quarter had the disease outside the prostate and required a systemic treatment, such as chemotherapy or hormone therapy.
“What that means is, if we scan four high-risk men, we save one from futile surgery,” Lim says. Surgery is expensive – about $30,000, as opposed to $3000 for a PSMA scan – and has unpleasant side effects including erectile dysfunction and urinary incontinence.
Graeme Woodside has headed the Prostate Cancer Foundation for five years and in that time has seen other signs of progress. New drugs are available and in development, and he believes there is more awareness among men that they need to get checked regularly – the recommendation is yearly between the ages of 50 and 70 unless there is a family history of the disease, in which case screening should start at age 40.
Woodside has identified an issue at at the grass-roots level of GP surgeries, where the approach is inconsistent. It’s pot luck whether you get a doctor who is proactive about suggesting getting tested or one who discourages it unless there are symptoms – these include problems starting and stopping the flow of urine.
“We quite frequently get calls from people saying their GP has said there’s no point getting tested,” Woodside says. “And that’s dangerous, as to wait for symptoms is typically leaving it too late.
“We’ve just done a survey among a database of 500 patients and 61% had no symptoms when they were diagnosed. It’s well recognised that it’s more treatable when it’s in the early stages.”
The women’s health lobby has done a tremendous job, says Woodside, and now men need to catch up with initiatives such as Blue September, the prostate cancer month (blueseptember.org.nz), to build awareness and raise funds for further research.
“The tide is starting to turn for men, but it will take some time.”
On the case:Remy Lim.