The prostate is a wal­nut-sized gland lo­cat­ed be­tween the blad­der and the pe­nis that serves a role in sex­u­al re­pro­duc­tion. A ma­lig­nan­cy or can­cer is a dis­ease where cells in the body grow out of con­trol. A ma­lig­nan­cy that de­vel­ops from the tis­sues of the prostate gland is known as prostate can­cer and is one of the most com­mon can­cers and cause of death among men world­wide. Fac­tors that put males at risk of de­vel­op­ing this can­cer are age (>55-69 years of age), ge­net­ics (a fam­i­ly his­to­ry of prostate can­cer) and race (African an­ces­try). What makes this can­cer a silent killer is that, many men with it may nev­er de­vel­op symp­toms un­til ad­vanced dis­ease has set in.

The epi­demi­ol­o­gy of prostate can­cer in the pop­u­la­tion of T&T, with its di­ver­si­ty in an­ces­tral groups, has not yet been de­scribed. How­ev­er, based on case re­ports, the mor­tal­i­ty rate is pre­sumed to be one of the high­est in the world. This would in­di­cate a high in­ci­dence and preva­lence of prostate can­cer in T&T, putting a large num­ber of Trin­bag­on­ian males with­in a high risk group for prostate can­cer. Be­ing a high risk group of such a fa­tal dis­ease that of­ten is symp­tom­less, would mean that screen­ing for this dis­ease is es­sen­tial to di­ag­nose it at an ear­ly stage so that prompt, ef­fec­tive and ap­pro­pri­ate treat­ment can be in­sti­tut­ed to pre­vent it be­ing a cause of death (by spread­ing).

Screen­ing is look­ing for the pres­ence of dis­ease be­fore it caus­es symp­toms. With­in the con­text of prostate can­cer, the goal of screen­ing is to find it at this ear­ly lo­calised stage when it is symp­tom­less and may be of high risk of spread­ing if not treat­ed. Screen­ing for prostate can­cer be­gins with a dig­i­tal rec­tal ex­am (DRE) and a blood test called a prostate spe­cif­ic anti­gen test (PSA test). A DRE in­volves your doc­tor pass­ing his in­dex fin­ger in­to the back pas­sage and feel­ing the size and con­sis­ten­cy of the prostate gland. In the pres­ence of prostate can­cer the gland may be asym­met­ri­cal in shape and hard and can help your doc­tor iden­ti­fy more se­vere le­sions if present. PSA is a sub­stance made by the prostate and is what is test­ed for in the PSA test. Blood PSA lev­els are el­e­vat­ed above nor­mal val­ues in con­di­tions that af­fect the prostate, es­pe­cial­ly when prostate can­cer is present. As a gen­er­al rule, the high­er the PSA blood lev­el, the more like­ly a prostate prob­lem is present. An el­e­vat­ed PSA lev­el is not spe­cif­ic for the pres­ence of prostate can­cer on­ly, how­ev­er, may al­so in­di­cate a prostate in­fec­tion or an en­larged prostate (be­nign prostate hy­per­pla­sia). It may even re­sult from us­ing cer­tain med­ica­tions or af­ter cer­tain med­ical pro­ce­dures like a prostate ex­am. Al­so, there is the pos­si­bil­i­ty that the test could give a false pos­i­tive of an el­e­vat­ed PSA. As many fac­tors re­sult in an el­e­vat­ed PSA, your doc­tor would need to rule these out be­fore go­ing to the next step of a prostate biop­sy or fur­ther in­ves­ti­ga­tions to rule out a di­ag­no­sis of prostate can­cer as the cause of your el­e­vat­ed PSA.

The ben­e­fit of screen­ing for prostate can­cer with the PSA test is that prostate can­cer, that may be at high risk of spread­ing, may be found and treat­ed be­fore it spreads. Thus, the chance of death from prostate can­cer in some men is low­ered. How­ev­er, a false pos­i­tive test can re­sult in a bat­tery of un­nec­es­sary tests, like a prostate biop­sy, which may cause un­nec­es­sary wor­ry about one’s health. Men in the age range of 55-69, es­pe­cial­ly with a fam­i­ly his­to­ry of prostate can­cer and of African an­ces­try, should make an in­di­vid­ual de­ci­sion of be­ing screened for prostate can­cer with a DRE and PSA test. Be­fore mak­ing that de­ci­sion, they should be in­formed by dis­cussing with their doc­tor the po­ten­tial ben­e­fits and risks of screen­ing for prostate can­cer.

Men who are 70 years or old­er should not be rou­tine­ly screened for prostate can­cer. If it is present in this age group, it is so slow grow­ing that death will like­ly be from an­oth­er cause and in­sti­tut­ing treat­ment may not im­prove the out­come and like­ly to cause more dis­tress to the pa­tient. How­ev­er, this should not be a de­ter­rent to seek­ing your doc­tor’s ad­vice (if you have symp­toms that should con­cern you).

As a man ages, the prostate tends to in­crease in size, and be­cause of its lo­ca­tion, this nar­rows the ure­thra re­sult­ing in de­creased urine flow. This is known as be­nign prostate hy­per­pla­sia (BPH as men­tioned above)—al­so an­oth­er cause for a rise in PSA. In prostate can­cer a sim­i­lar sit­u­a­tion may arise that may lead to the fol­low­ing symp­toms:

Dif­fi­cul­ty start­ing uri­na­tion.

Weak or in­ter­rupt­ed flow of urine.

Fre­quent uri­na­tion, es­pe­cial­ly at night.

Dif­fi­cul­ty emp­ty­ing the blad­der com­plete­ly.

Pain or burn­ing dur­ing uri­na­tion.

Blood in the urine or se­men.

Pain in the back, hips, or pelvis that does not go away.

Painful ejac­u­la­tion.

How­ev­er, dif­fer­ent peo­ple have dif­fer­ent symp­toms with prostate can­cer, and re­mem­ber, as men­tioned above, it of­ten has no symp­toms. Thus, screen­ing is es­sen­tial in the ab­sence of symp­toms, es­pe­cial­ly if you fall with­in a high risk group as de­fined by the risk fac­tors men­tioned above. If how­ev­er, you do have symp­toms that wor­ry you, a vis­it to your doc­tor is rec­om­mend­ed. Keep in mind that these symp­toms may be due to a prostate con­di­tion oth­er than prostate can­cer.

If your PSA lev­el is found to be high­er than the nor­mal range for your age and your doc­tor has ruled out oth­er caus­es for an el­e­vat­ed PSA, he may then pro­ceed to rul­ing out the di­ag­no­sis of prostate can­cer by ask­ing for a prostate biop­sy. A biop­sy is when a small piece of prostate tis­sue is ob­tained and looked at un­der the mi­cro­scope for can­cer cells. It can al­so in­di­cate via a spe­cial score the like­li­hood of the can­cer spread­ing if it is present. It is the main tool for di­ag­nos­ing prostate can­cer. How­ev­er, to en­sure the biop­sy is made in the right place and can­cer is not missed, your doc­tor may em­ploy oth­er tech­niques such as ul­tra­sound or mag­net­ic res­o­nance imag­ing (MRI) to guide in tak­ing the biop­sy.

If can­cer is di­ag­nosed, oth­er tests may be need­ed to de­ter­mine if there is spread. This is called stag­ing and is nec­es­sary to de­ter­mine what treat­ment needs to be in­sti­tut­ed. There are dif­fer­ent modal­i­ties of treat­ment of prostate can­cer de­pend­ing on the stage. These range from con­ser­v­a­tive­ly mon­i­tor­ing, surgery, ra­dio­ther­a­py, chemother­a­py and hor­mone ther­a­py. De­tails of these are be­yond the scope of this ar­ti­cle and may be ex­plored in fol­low­ing ar­ti­cles.

Not every­one needs to be screened for prostate can­cer, but those who fall in­to the high risk group as de­fined by age (55-69), a fam­i­ly his­to­ry of prostate can­cer and of African an­ces­try, need to make an in­formed de­ci­sion whether to be screened or not af­ter dis­cussing with their doc­tor. Once the de­ci­sion is made, DRE and PSA tests are done. If both are neg­a­tive then screen­ing can be re­peat­ed in two years. If the DRE is neg­a­tive and the PSA el­e­vat­ed or the DRE is ab­nor­mal re­gard­less of the PSA val­ue, fur­ther eval­u­a­tion will be re­quired to make the di­ag­no­sis and treat.

As an in­formed pop­u­la­tion we are bet­ter equipped for the fight against can­cer. Let us do our part to win the war.

Dr V Bhimull

MBBS, diplo­ma fam­i­ly med­i­cine