Prostate screening urged for early detection

In 2007, 556 men in northeastern Ontario had a heart-to-heart talk with their urologist. Prostate cancer ranks ahead of breast, colon and lung cancer in terms of the number of cases reported every year, but trails all three in terms of morbidity.

"There is this saying that you're more likely to die with prostate cancer than from it, but I don't like it because it de-emphasizes the fact that it does kill and men die of prostate cancer on a regular basis," said Dr. Bishwajit Bora, medical director of the surgical program at Sudbury Regional Hospital.

Province-wide statistics available for 2004 report 1,379 deaths from prostate cancer, including 81 in the northeast and 44 in northwestern Ontario.

Dr. Bora, a urologist, applauds the Ontario government's recent decision to cover the cost of annual PSA tests for men beginning in January 2009 and urges family doctors and other primary care providers to screen for the disease.

"Some argue that it's not a test that should be routinely done, but there are two camps on that and I'm in the camp that says you should do it regularly."

The PSA test is far from perfect, but it's the best we have, he said.

"We know that PSA can help detect prostate cancer earlier because cancer typically produces PSA, so if you see a high PSA level, that's an indication that the patient may have cancer. I say ‘may' because PSA can also be elevated by a number of other things. This is one of the challenges we have."

Dr. Bora also urges primary care providers to perform a digital rectal examination on men over the age 50.

"It's an uncomfortable test, not only for the patient, but also for the physician, but it's an excellent way to detect cancer. It's a good way to see how big the prostate is, but you can also feel its texture. You can evaluate the contour or consistency, looking for nodules, or lumps, or if it's firmer in one particular area."

Patients receiving a prostate cancer diagnosis have four options. The simplest and least aggressive is to just monitor the disease "because not all prostate cancers progress quickly enough to be a problem." The next most aggressive treatment is androgen ablation, also known as medical castration.

Testosterone

"It's testosterone that drives most prostate cancers, so by knocking it out, you can keep the cancer under control without actually curing it," said Bora. The most common side effect of androgen ablation is hot flashes -"not a symptom you typically hear men complain about" - but there is also a risk of impotence.

The third and fourth options are radiation and radical prostatectomies.

Both are capable of curing the disease, but are not without risks and are usually only recommended for men expected to live at least another 10 years.

Dr. Bora is currently overseeing a major study on access to care for prostate patients in northeastern Ontario.

The focus until now has been on reporting wait times from the day a treatment decision is made to the day treatment is provided, he said.

"This study goes back a step. We want to know what happens to patients before they get to the point of a decision being made."

The study, due to be released in June, looks at the resources available in the region and where prostate cancer patients go for care. It assesses the quality and appropriateness of care, the use of guidelines, the timeliness of care and wait times.

The objective is to streamline what can be a potentially long and complicated process involving biopsies, X-rays, CT scans and consultations with urologists, radiation oncologists, surgeons, social workers and family doctors.

One option for streamlining the process, said Bora, is to adopt a more multidisciplinary approach using teleconferencing, if necessary.

"In my opinion the best thing for the patient after a diagnosis is to meet with everybody, preferably at once, to discuss the options and come up with a solution."

Surgery is quite common as a treatment choice, said Bora. "It's a major operation with its share of risks, not the least of which are erectile dysfunction and incontinence, but it's appealing to the patient if the cancer is completely removed."

Patients opting for radiation have several choices: conventional external beam radiation and both low and high dose rate prostate brachytherapy.

Low dose rate brachytherapy, offered at Sudbury Regional Hospital for the last year and a half, involves the insertion of between 60 and 120 radioactive seeds into the prostate itself.

Performed by Dr. Randy Bissett and Dr. Julie Bowen, both radiation oncologists, the procedure takes approximately one hour under general or spinal anesthetic. The seeds, approximately 5 mm in length and 1 mm in width, contain Iodine 125 and provide localized radiation over the course of several months. Conventional external beam radiation, by contrast, requires daily treatments (Monday through Friday) for seven consecutive weeks.

The seeds come preloaded in long needles that are inserted into the prostate through the perineum using a transrectal ultrasound probe for guidance.

"We position the needles in the prostate where we want the seeds to go," explained Dr. Bissett. "We try to arrange them so the entire prostate is covered by the radioactivity. That way, we don't miss the cancer.

Lower PSAs

"Most of the PSA levels we see a year after the procedure are under one. A normal PSA is under four, so it's a very effective treatment."

Side effects are usually limited to impaired urine flow caused by swelling and bruising of the prostate, but low dose rate brachytherapy, said Dr. Bowen, is not a recommended treatment for all prostate cancers.

"It's really for low risk patients with a PSA level of less than 10 and a Gleason score of less than six," she said.

So far, 59 low dose rate prostate brachytherapy procedures have been carried out at Sudbury Regional.

Thunder Bay Regional Health Sciences Centre (TBRHSC) is poised to begin offering high dose rate (HDR) brachytherapy, said Dr. Peter McGhee, TBRHSC director of medical physics. This treatment delivers high doses of radiation over short periods of time through 12 or more catheters inserted into the patient's prostate. The catheters are connected to a machine that releases radioactivity into them. In this way, radiotherapy is delivered at high doses directly to problem areas of the prostate.

HDR brachytherapy is typically used to boost the effects of external beam radiation and is applicable to a broader ranger of prostate cancers, including stage one, two and three cases.

Thunder Bay has been performing HDR bracytherapy in a fully shielded OR for several years, but primarily for gynecological cancers.

"We couldn't perform HDR brachytherapy for prostate cancer until now because we needed special equipment, including a special ultrasound device to assist with the guidance of the needles, and we had to train our staff."

According to Thunder Bay medical physicist Bans Arjune, patients typically require three HDR brachytherapy treatments. External beam treatments are usually administered in combination with HDR brachytherapy, but there fewer of them - 29 instead of the usual 44.

"Because there are so many options out there, it can be very overwhelming when you get the diagnosis," said Bora. "You practically have to become an expert in prostate cancer before you can decide what's best for you, and it's difficult for a health-care provider to tell you what to do. The best we can do is to give the patient the best information available so he can make an informed decision."

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