Often the best treatment for prostate cancer is no treatment at all. Sylvia Thompson reports
Prostate cancer is sometimes called the silent killer because a man in his 50s or 60s can have it for many years without suffering from any physical symptoms whatsoever.
Widely recognised as a slow-growing tumour, prostate cancer usually only becomes a terminal illness when it has spread beyond the prostate gland into the bone causing fractures, paralysis and excruciating bone pain.
This worst case scenario will, however, become a reality for less than one-third of the 1,500 cases of prostate cancer currently diagnosed in Ireland.
The difficulty lies in identifying these patients earlier for curative treatment while not scaring a much larger group of men into believing they have terminal cancer just because they have been given a diagnosis of prostate cancer.
Prostate cancer is a disease of older men and, as more and more men in their 50s and 60s have PSA (Prostate Specific Antibodies) tests in GP surgeries, the issue is as much about managing those with a positive diagnosis in the knowledge that one-third of men with prostate cancer require no treatment whatsoever.
It is about offering patients with organ-confined and advanced stage disease the best treatment options.
"Men diagnosed with prostate cancer are very unlikely to die from it because quite simply their diagnosis usually comes late in life and they will die from something else sooner," says Dr Denis Murphy, consultant urologist at Beaumont Hospital, Dublin.
At a recent Dublin conference on Advances in Prostate Cancer, speakers from the Memorial Sloan Kettering Cancer Centre in New York explained how the disease model for prostate cancer has changed over the past 15 years as up to 40 per cent of American men have regular PSA tests.
In Northern Ireland, about one-third of men have a PSA test.
In the Republic, there are no figures on the percentage of men having PSA tests.
Yet, as more and more men discover they have prostate cancer through an initial PSA test followed by digital rectal examination and tissue biopsies, they are opting for surgery, radiation therapy or, more recently, brachytherapy.
The latter involves implantation of radioactive seeds into the prostate gland and is currently only carried out for early stage prostate cancer at the Mater Private Hospital in Dublin.
Questions have been raised, however, as to how appropriate or indeed necessary some of these treatments are in all cases.
Dr Murphy admits that many men would be better off not knowing they had prostate cancer at all because once they have the diagnosis, they almost always want treatment, regardless of whether treatment is genuinely the best course of action.
He cites a group of 77 patients at his clinic in Beaumont Hospital, only seven of whom were prepared to opt for no treatment.
Defined as "watchful waiting", this no-treatment option includes repeat PSA tests every six months and biopsies every 18 months.
However, the risks of over-treatment have to be weighed up against the risk of missing patients who would greatly benefit from treatment.
Dr John Thornhill, urologist at Tallaght Hospital, believes that up to 70 per cent of prostate cancers still go undetected in this country.
And while we can assume one- third of these wouldn't require treatment, we also have to consider what treatment would be best for the other two-thirds.
With already limited resources in public hospitals, there is concern that increased diagnoses of prostate cancer will lead to even longer waiting lists for treatment.
With or without a waiting period (depending of course whether you are a public or private patient), the current practice is to offer patients with organ-confined prostate cancer radiotherapy to shrink the cancer and/or surgery to remove the tumour.
Both treatment options can result in impotence and incontinence for a period following treatment.
Brachytherapy also carries a high risk of impotency and a low risk of incontinence.
Overweight patients with cardiacvascular and/or other health problems are also at a higher risk of complications following surgery and other treatments.
Some patients including those who suffer a relapse following these treatment approaches are then offered hormone therapy.
In essence, this involves drugs - administered by injection and/or in tablet form - which block the production of the male hormone, testosterone.
Side-effects include loss of sex drive and reduced energy levels.
Patients with advanced prostate cancer are considered incurable and the palliative care approach aims to improve quality of life by offering effective pain relief.
Here, new research has advocated giving chemotherapy drugs alongside standard pain-relieving drugs such as morphine and steroids.
Trials which included Irish patients found that the addition of chemotherapy drugs reduced pain and prolonged life for some patients for a number of months.
So what does the future hold for Irish patients with prostate cancer?
Dr John McCaffrey, medical oncologist at the Mater Hospital, Dublin, and Cavan General Hospital, believes two different trends will emerge.
"I believe the well-informed and well-read private patients will put themselves forward for PSA tests which will lead to early detection and a change in the course of the disease while outside the large urban areas, there will be other men who have advanced prostate cancer suffering from a lot of pain and confined to wheelchairs," Dr McCaffrey says.
Prostate Cancer: The Facts
With about 1,500 cases diagnosed annually, prostate cancer accounts for 12 per cent of all cancer cases in Ireland.
Prostate cancer is currently the second leading cause of cancer death in Irish males with 500 Irish men dying from prostate cancer every year in Ireland.
Lung cancer is the leading cause of death from cancer with 140,000 deaths per year and 155,000 diagnosed cases of lung cancer.
Prostate cancer is a slow growing tumour which often shows no physical symptoms for years following diagnosis. The cancer is initially diagnosed with a PSA blood test (now carried out by GPs).
The diagnosis is confirmed following a digital rectal examination and tissue biopsies.