Today, We are here to speak a little about prostate cancer. Prostate, to start with, is a gland which is found only in males. So if you think of the urinary system, the kidneys lie in two sides of our abdomen here, towards the back. Prostate gland is a gland which sits between the bladder and the urethra. Its main function is to produce nourishment for the sperm. So, as long as the person is desirous of fertility, desirous of parenthood, the gland is important. After that, the function of the gland is not at all important to our body. But why this gland is important is because, in terms of today’s discussion, the prostate is a commonest cancer in males in our country and worldwide. The commonest cancer that involves the male is prostate cancer.

Now, if you ask me how common it is, we don’t have a good data in India, to say how common the prostate cancer is. But a recent article published in the India Journal of Urology, has stated that the incidence varies from 1 in per lakh population in Manipur to 10 per lakh population in Delhi. It is not that Delhi has more prostate cancer and Manipur has less prostate cancer, it is because Delhi has a better cancer registry, so they have a better way of keeping a record of the cancer diagnosed. So, we do not know the exact incidence in our country, but yes, it will vary from maybe 10 in a lakh, but it is in fact the commonest cancer, effecting males in our country, so it is an important cancer to be discussed.

Now as I said, the prostate is a gland which basically serves the function for nourishment of the sperms during fertility. So after the incidence, now what are the risks of having a prostate cancer, means what are the things, you ask that what can I do to avoid prostate cancer risk. Now, the most important risk of prostate cancer is age and it is not modifiable. So, 65% of prostate cancer occurs in men greater than 65 years of age. men age less than 40, the risk is less than 10%. It is the most unknown and there is also a foreign literature which says so. So, for all working terms and condition, we say that prostate cancer is unknown in men less than 45, and it is more common, more than 65% occurs in men more than 65. So, age is the most important risk factor, it is non-modifiable risk factor.

Other important risk factors are genetics, so there comes family history. If you ask me, it is familial or not, only if your first-degree relative like your father or your brother had prostate cancer, then you are also at high risk of developing prostate cancer. Other than these two factors, the age and genetics, other risk factors which are said for prostate cancer is like having a possibility for, again comes under genetics, BRCA. So if your sisters and mother has a family history of breast cancer or ovarian cancer, which comes under the genetic of BRCA genes, you are in fact having a higher risk for developing prostate cancer. Other than that, a diet rich in red meat, an obese person, somebody who takes lot of fat in his diet, somebody who has a history of recurrent prostatitis, they have a higher risk. Good intake of fruits, vegetables decreases the risk. So obesity, red meat intake, increase in intake of saturated fats, oil and fat will increase the risk of prostate cancer, then vice versa, a good intake of vegetables and fruits, that will reduce the risk of prostate cancer. So there is nothing much you can do to modify risks of prostate cancer, it is all in your genetics and age and you cannot do much about it.

So now, since we are not able to do much about it, we should know that how we can best find it out and how we can treat it. Now, when we are talking about this diagnosis like to find it out, we think about there is two way of diagnosis, one is screening and another is diagnosis of symptomatic patients. Now, when I said screening, I mean that we screen the population with blood sugar to detect diabetes, we screen the population with BP monitoring to detect hypertension, we screen females that Pap smear to detect cervical cancer, and they have been found to reduce the mortality and morbidity drastically. By morbidity, I mean the pain which the disease gives. By mortality, I mean the risk of death of the disease.

But for prostate cancer, is screening good? It is a big question. As of today, it is said that prostate cancer screening is not beneficial, there is a lot of data in it. To summarize, prostate cancer screening is not beneficial in men more than 75 and in men less than 50 years of age. So, more than 75 and less than 50, there is no point in screening asymptomatic patients; I’ll tell you what are the symptoms. Asymptomatic patients, there is no point in doing a random PSA check for everybody to find out… Why? Once you detect this with screening then somebody has a possibility of developing prostate cancer, we will do a lot of unnecessary tests, we will do a lot of unnecessary treatment. Why I say unnecessary? Because many of these cancers would be in indolent, indolent means their likelihood of killing you is very less over a period of 10 years. To say something more in detail, for example, if somebody has a prostate cancer, which is confined to the prostate, it has not gone out of the prostate, his risk of dying in 10 years of prostate cancer is only 10%. So 10% is the risk, so only 10 out of 100 will die of prostate cancer, 90 out of 100 will not die of the prostate cancer. So, why to detect prostate cancer in asymptomatic patient when you know that the disease is more likely after 60, 60 or 65, anyway he will live more than 10 years without any problem. His risks of dying, say at the end of 15 years will increase from 10% to something 20%, so the risk of dying is not high. So, as of today, without going through this lot of confusion, there is no guidelines today, we say that you screen patients who is more than 75, who is less than 50. Between 50 and 75, we are supposed to screen patients. Screen means, again I repeat, patient is not symptomatic. We are supposed to screen patients who are at high risk of developing prostate cancer. High risk means somebody who is above 65, somebody whose family history of prostate cancer was there, they are the candidates on which you can screen to detect prostate cancer.

So, one part of the diagnosis is to screening. Another part of diagnosis is to find out people with symptoms. So what are the symptoms of prostate cancer? The symptoms of prostate cancer are the same as the symptoms of a normal prostatic disease which is known as benign prostatic hyperplasia or BPH. The patient will present… because the prostate gland lies between the bladder and the urethra, once it enlarges, cancer cells also enlarges. Symptoms are same, like the stream will be poor, the patient will have intermittent flow, patient has to strain while trying to pass urine, he may have to go again and again, he will have urgency like when he thinks of passing urine, he has to run to the bathroom, he cannot on for a long time. So these are the symptoms of prostate cancer: poor stream, intermittency, sense of incomplete evacuation, lot of time to start, he is on hesitancy, urgency, these are the symptoms. And when the cancer has spread, it will lead to pain in the bones, it will lead to difficulty in walking because of neurological spread, spread in the vertebrae is the common site of prostate cancer, so these are the symptoms.

When you have prostate cancer symptoms, we are supposed to do some investigation to find out whether that person has prostate cancer or not. So, the investigation includes screening and diagnosis, both are the same. The first investigation is a clinical examination in which the prostate is palpated by putting a finger in the rectum because the prostate likes just in front of the rectum, so we can put a finger in your rectum to palpate the prostate and see whether it is hard or not, this is known as digital rectal examination. Digital rectal examination and the second thing is serum PSA test.Test your Blood, do a PSA and DRE, which is digital rectal examination, to see that whether the patient can have prostate cancer or not.

PSA is something which is a very double-edged sword. So many times, we will find patients may have a very high PSA and he may not necessarily have prostate cancer, there are other diseases which can lead to prostate cancer, so we have to find out what value of PSA is significant. Now, it is said that when the PSA is more than 10, I have to tell this in two parts, first part, when the PSA is more than 10, the risk of having prostate cancer or harbouring prostate cancer is around 50%. So, 1 in 2 patients with PSA more than 10 will have prostate cancer that means another 1 in 2 will not have prostate cancer. Second, when the PSA is less than 4, the chances of having prostate cancer will be around 10% that means only 10 out of 100, but when the PSA is between 4 and 10, it is 25% that is 1 out of 4. So, when the PSA is more than 10, it is 1 out of 2; when it is 4 to 10, it is 1 out of 4; and when it is less than 4, it is 1 out of 10. So simple logic which can be derived out of it is when the PSA is more than 10, it is indeed significant, and when it is between 4 and 10, we have to perform other tests, important test is free PSA, when it is more than 25%, chances of cancer is very less. But when it is more than 10, what are the things you can do? Now, once you are screened, find out rectal examination showing hard, you always do a biopsy. You see the PSA is more than 10, now there are two things, the PSA is very high, say 100, 200, then we have to do a biopsy to find out, rule out prostate cancer. But if PSA is more than 10, the rectal examination shows a soft prostate or a firm prostate then there is no harm in giving antibiotics for some time, maybe the period of 2 weeks or 3 weeks, repeat the PSA after 4 weeks before going for biopsy. So somebody with the PSA of 15, with antibiotic, it comes down to 10, there is no harm in waiting for some more time to see if it comes further low because by that way, we can avoid unnecessary biopsies.

To summarize, when the PSA is more than 10, if it is not a very high like 70, 80, or 100, there is a point in giving antibiotic for 2 weeks, repeat the PSA after 4 weeks and then do a biopsy, especially in rectal examination, the prostate is not hard. So, this is a prudent way of avoiding a biopsy which is associated with a little discomfort, it is not totally painless, it has some discomfort.

So now, we have talked about the prostate, incidence of prostate cancer.  We have talked about the diagnosis, screening part and the diagnosis by the symptomatic part. Diagnosis entails rectal examination, PSA, and biopsy is required. Once this has been done, we have done a biopsy and we have found out prostate cancer, still there is a question, whether to treat or not to treat the prostate cancer which we have diagnosed. Why? Because once the biopsy is done, biopsy will give us whether the tumour is low-grade, medium-grade or high-grade. The thing is that for a low-grade tumour, the risk of dying is again just around 10% over a period of 10 years. So out of 100, only 10 will develop more aggressive disease, 10 will spread, 10 will die of prostate cancer. Why we are talking of all these things? Because the treatment of prostate cancer is associated with some morbidity, if not mortality, as of 2019, we have almost zero mortality today, but it is associated with some risks, the risk of impotence that is sexual dysfunction and the risk of incontinence of urine. Some incontinence is always there, if not total incontinence, some months, patient will have incontinence, so it is not a very easy treatment, unlike a simple surgery for appendix or gallbladder, or whatever. The treatment we do for prostate is not without any mortality or morbidity, so we have to decide whether to treat or not. So, very low-grade tumour, if the patient is old, as I said, somebody is 70 for example, he will anyway live till 80 without any problem, we can always keep him under follow up. But somebody is 50 with a low-grade, maybe he will require treatment because he is going to live for another 30 years, 80. Today, in the metro city, the life expectancy is around 80.

So, when we have decided a biopsy and get a low-grade tumour, we have an option of not doing anything and waiting, keeping the patient under follow-up and treat when required, especially if elderly, when the age is more than 70. More than 70, it is always prudent to wait for a low-grade cancer and not to treat, not to give him the trouble of treatment, the cost of treatment, wait for some time. But for high-grade, we will always treat. For a medium grade, again this is a decision to be made whether to wait to treat and follow up regularly, the disadvantage is you need to require a regular biopsy, or not to treat.

Now, once that point is finished, we discuss what is the treatment. A very simple way of devising treatment is to see the stage, like many cancers, we will have I, II, III and IV. So I is the stage where the cancer is within the prostate, small cancer within the prostate, II is also within the prospect, so I and II, cancer has not grown out of the prostate. Stage III, the cancer has grown out of the prostate into the seminal vesicles, which is another organ surrounding, or to the lymph nodes. Stage IV cancer, when it has grown far into the bones, into the liver or many other organs, maybe. So treatment involves staging, staging involves further tests. Important tests are MRI, doing a bone scan, these are the important tests today. MRI is very important. Most important is perhaps a bone scan, bone scan detects spread of the tumour to the bones. There are two groups, a class which will ask for CT Thorax and the CT of the upper abdomen to see for the thorax and the liver. There are some groups today who does PSMA scan, who does FDG-PET. FDG-PET is perhaps not a good test for prostate cancer because prostate cancer is not a very metabolically active cancer, especially when it is a low-grade or a medium-grade, so it will not show much in a PET scan. So FDG-PET scan, if the FDG is not so good but a PET scan… PSMA scan is also PET scan, maybe perhaps better. As of now, today the guidelines are varied and most people will do CT of the chest, CT of the thorax and the upper abdomen with a bone scan to see whether the prostate cancer has not spread. And if they spread, it becomes a metastatic disease. The treatment will entail medical treatment, and when it is not spared, the option is between surgery and radiotherapy.

Stage III, it is always radiation, never surgery. So, when prostate cancer has spread to the seminal vesicles, spread to the lymph node, please don’t go for surgery, it is always radiation, surgery is not to be done, radiation has been shown to be much, much, much better than surgery. But for the stage I and II disease, we can choose between surgery and radiation, literature says both are equally good. People who are doing radiotherapy says that the chances of incontinence maybe far less. People who are doing surgery say that radiation is a longer treatment, better treatment can be done with surgery, for last moment mortality and mobility with the advent of laparoscopy and robotics. So, still literature is right, so both is good, radiotherapy and surgery in the way I think for stage I and II disease. For stage III, treatment is only radiation.

For stage IV disease, it is today a combination of chemotherapy and hormone therapy. Now, what is hormone therapy? Now, prostate cancer is dependent on testosterone. Testosterone is a hormone produced by our testicles and adrenal gland, 99% is produced from the testicles, only 5% is produced from the adrenal gland. Testosterone is like fuel, like petrol for the prostate cancer cells, they cannot live without testosterone. So, if we can do something to take out the testosterone from the body, it means the source and this you can do by orchidectomy or remove the testicles in one way or if you can give drugs to block the action of testosterone, something which is known as LHRH agonist. So, both ways are equally good, we can prevent the prostate cancer cells to get the testosterone, so they will lie low for some time. Today, in the latest edition of the Urology Clinics, they have said that if you add chemotherapy Taxol, Docetaxel with it, the overall survival is better than giving hormone alone. So hormone therapy entails either removal of the testicles or giving something to block the testicles with drugs. Removal of the testicle is basically a onetime procedure with far lesser cost when you compare it to a hormonal therapy with medicines, which involves 3 monthly or 6 monthly injection, which will be lifelong, but both are equally good. If cost is the issue, somebody can choose orchidectomy. If somebody doesn’t want to get rid of his testicles and retain his testicles, he can choose hormone therapy. Both are equally effective, both are equally good, and to add on this, chemotherapy, so this is the stage IV at the beginning.

But one day as the stage comes when prostate cancer is not responding on hormone. The patient may have bone pain, patient may have issue with the neurology. So, then things like vertebroplasty which can be done surgically today by injecting things under radiology guidance, by pain care physicians, or by Nuclear Medicine comes in the role when radioactive Francium is given for severe bone pain in the body.

With all this today, we can make the life of prostate cancer patients very easy, but overall, this cancer is not a dangerous cancer. If somebody has prostate cancer, it is perhaps one of the best cancers after thyroid cancer, so the risk of dying with prostate cancer is less, most of the patient will die of age than that of prostate cancer. In a gist, I tried to say whatever I could on the treatment and on the diagnosis and what a common man or a primary care physician should know about prostate cancer. I did not go into the details of treatment, which is the urologist domain. My talk was intended for audience who are the patients themselves or the relatives or primary care physicians who comes in contact with prostate cancer, and then decide what to do.

So to summarize, PSA is not to be done for everybody, more than 75 years and less than 50, it is useless. Between 50 and 75, only for patients who are at high risk, it is good. Now, once PSA is done, if the PSA value is more than 10, not necessarily a biopsy will be required. Only if antibiotics has not resolved the PSA, has not brought the PSA down, only when rectal examination is very hard then only we ask for a biopsy. Next, once the biopsy is done, low-grade tumour in higher age, we can prefer not to treat, this is the third point. For young patients, less than 70, it is better to treat, this is the third. So first is about going to screen, second is what to use to screen, that is PSA and rectal examination. Third is about but what to do after the biopsy is done and fourth is about the treatment. As I said, stage I and II, radiation and surgery are equally good; stage III, should be only radiation and not surgery. Stage III means the tumour has spread beyond the prostate into the seminal vesicles. Stage IV means it has gone to the bones, it has gone to the liver, in this then again surgery is not required, it is only medical treatment , hormone treatment basically, it maybe surgical orchidectomy or medical orchidectomy with hormones. And when the disease has spread further, there is bone pain. Today, radioactive materials are available, chemotherapy is available, which can make the life of the patient very easy.