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Dr Stuttafbrd’s SURGERY The prostate debate
A FORMER PATIENT of mine was diagnosed with cancer of the prostate six or seven years ago. He has asked me what I thought about the recent peer- reviewed Cambridge study, published in the British Journal of Cancer, which suggests that specialists correctly assess the malignancy of patients’ tumours in only half the cases of prostate cancer.
Years ago I warned him and my other patients that in my opinion the preferred treatment should be radical. Probably the safest choice now is radical robotic surgery, although radiotherapy with the latest computer controlled external beam equipment or brachytherapy, which is computer controlled implantation of radioactive ‘seeds’ or wires, provide good chances of a very long remission - arguably a cure. When I was practising I sometimes thought that my patients should have dual therapy: surgery and radiotherapy, as I eventually had. If there was any chance that spread had already occurred beyond the capsule of the gland, I would also immediately throw into the mix hormone treatment with Casodex (bicalutamide).
The report in the British Journal of Cancer doesn’t tell us anything new but adds valuable statistics confirming that the standard method of assessing the malignancy of prostate cancer is inadequate. The problem is that a raised PSA (prostate specific antigen) increases the likelihood that the patient has a malignant tumour, but determining the degree of malignancy, i.e. the answer to the question ‘Is my cancer a pussy cat or a tiger?’ is then dependent on tumour biopsy and microscopic examination of its cells. The significant weakness of the current diagnostic process is that biopsy, even by the most skilled, is not guaranteed to find the tumour or tumours. In my own case the biopsy - transrectal biopsy with ultrasound guiding - discovered only one seriously malignant tumour, yet the postoperative examination of the removed prostate revealed two seriously malignant tumours and a prostate gland permeated with pre-malignant changes. It should also be remembered that not all patients with prostate cancer have a raised PSA.
Finding tumours and spearing them with a needle thrust through the rectal wall is a regrettably haphazard method of detection. It is easy to miss. The prostate is shaped like a walnut, and walnuts, as we remember from the little sailing boats we made from them as children, have a prow and a stern. The prow of the prostatic walnut is easily hidden by the pubic bones. Cancers in the prostate are found most often in the outer layers of the gland which are easily concealed by surrounding tissues. Little wonder that recent research has shown that just over half of the aggressive cancers - the tigers rather than the pussy cats - are missed.
Optimists mutter about the limitations of the system but suggest that the number of false reassurances given to patients will be reduced if care is taken with diagnostic procedures. The statistics from Cambridge show that this is not so. The pessimists have been right all along. Relying on current methods of transrectal biopsy is dangerously chancy. Before the admirable statisticians and research workers from Cambridge assessed the situation, observant doctors had already- spotted that an alarming number of patients with a raised PSA, who’d been reassured with a pat on the back, returned several months later with an even higher PSA and an established cancer.
However even pessimists, or possibly realists, like me, have good news. The Americans and many other Western countries are now using MRI scanning to locate precisely where the tumour or tumours are, and under MRI guidance the probing biopsy needle can be thrust into the cancer. This can then be examined and the all-important Gleason score that separates pussy cats from tigers can be determined. This is not the end of the story. Even after this meticulous process is carried out, and if immediate radical treatment is not indicated, the patient will still have to be actively surveyed, and will need regular and frequent examinations. The old procedure known as watchful waiting is now not only non-PC but is regarded as a disgraceful and slovenly protocol. Advocates of the current system of assessing the malignancy of a tumour have suggested that all would now be well because of MRI scanning. They, at best, should be saying all could be well, as currently very few British centres are offering biopsy under MRI scanning. False negatives will therefore continue to endanger large numbers of men.
Nearly 17 years ago I had a radical prostatectomy to remove my prostate with its two resident tigers. Six years later I had a recurrence of the cancer near to where the prostate had been.
This was successfully treated by computer controlled radiotherapy for several weeks together with Casodex, which I am still taking. I had also been taking statins for several years before developing cancer of the prostate. Perhaps a lucky chance - for very recently, Professor Noel Clarke of Manchester University and his team have presented evidence that statins may alter the shape of any wandering prostatic cancer cells so that they are less likely to penetrate the bone, the most common site for secondary prostatic cancers to start.