Health

Early de­tec­tion may be tricky but it’s over to men to in­sist on reg­u­lar checks be­fore symp­toms ap­pear.

New Zealand Listener - - CONTENTS - by Nicky Pel­le­grino

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.

Graeme Wood­side.

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