The Times (PC) 11-Jun-08

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Q&A with Dr Thomas Stuttaford on prostate cancer

Dr. Thomas Stuttaford

Q1: I read with interest your humanitarian services in responding to questions from people who find themselves suffering from prostate problems. I am about 55 years old and all fingers point to people of that age bracket to be vulnerable to symptoms or actual victims of the problem.

Could you kindly tell me about the diagnosis and treatment of prostate/prostate cancer? The clinic at my place of work talk about benign prostate symptoms when I complained to them that I go urinating two to three times a night and that the flow is not as rapid as it ought to be.

I live and work in Ibadan, Nigeria where things are not easy medically and otherwise, and I believe your assistance can go a long way to stabilize my troubled emotion, since I hear it costs so much to venture an operation, which might not be permanent solution to some, after all. Many thanks. A. Williams

A1: There are two constantly repeated clichés about prostate disease that are misleading. The first is that far more men die with prostate cancer than from prostate cancer. This is not only misleading but dangerous. I suspect that it is quoted as often as it is in order to cut down on the numbers of men having regular tests so that their prostate cancers might be diagnosed at a stage when there is a better chance that they might be cured of it.

It is true that a large number of elderly men who have a post mortem for some other condition are found by chance to have malignant cells in their prostate glands but that these played no part in their death. It doesn't follow that a distinct cancerous tumour can be left in the prostate on the assumption that the patient will necessarily die from some other disease.

The mortality figures that show that over ten thousand men die every year in this country from prostate cancer demonstrates the absurdity of this argument. Every effort must be made not only to detect early prostate cancer, when the PSA is still low, but to have a biopsy of the malignancy so that the nature of its threat can be judged from the examination of the cells in the cancer and an estimate made of their likely level of malignancy.

Another aspect of this axiom, so beloved by government officials and laissez faire doctors who want to postpone action, that is dangerously misleading is the lack of understanding of the relationship between some of the deaths from other causes from patients with prostate cancer and its association with the cancer.

For complex reasons patients with a malignancy are more likely to suffer from thrombo-embolic problems including heart attacks and strokes. The likelihood of this happening varies according to the nature of the cancer but prostate cancer is about the second or third cancer that is most likely to cause this.

Many years ago I was told that one in four people with prostate cancer have a sudden death from strokes and heart attacks. I understand that, as the men with prostate cancer are often older, they would be more likely than younger people to suffer strokes and heart attacks and could be incidental. I also realise that the surgeon who told me this may have been exaggerating but it remains that many of my patients who have prostate cancer that is held in remission do die suddenly from these causes. Inevitably a non interventionist doctor will say "I told you so, men with prostate cancer die with it and not from it" but I don't believe it.

The second misleading oft repeated comment is that if a patient waits until he has symptoms from the cancer he will have waited too long and is already doomed. Sometimes this is true but often patients who have symptoms from the cancer have them early. The cancer is then not only treatable but can be cured. The time that cancer causes symptoms with bladder function depends to some extent as to where the cancer is in the gland and on the nature of the cells in the tumour.

The way in which cancer is detected, if there are no symptoms, is usually because the PSA, a simple blood test, is raised. If it is the patient has a biopsy, parts of the gland are taken out through a needle, and pathologists look at the specimens obtained to see if there are any cancer cells in them. In order to direct the needle the patient is ultra sounded and this guides the radiologist as to where to take the specimen. More about this test in answer to other questions.

The symptoms that can lead someone to speculate that they could have prostate cancer are - if it is an early case and there has been no spread beyond the gland - the same as those of benign prostatic hyperplasia, the enlarged prostate that affects most older men sooner or later. A list of these symptoms includes the following:

A. A feeling that the bladder is incompletely emptied immediately or soon after the man has urinated.

B. Frequency of urination so that a man has to pee soon after the last pee and certainly if less than two hours afterwards.

C. The man has noticed that he has intermittent urination. That is to say he stops and starts while peeing. More often he has no sooner done up his buttons or his zip than within a matter of a few minutes he wants to return to the loo.

D. He has urgency. He doesn't only need to go to the lavatory but he needs to rush to it and may even leak if he doesn't get there in time.

E. The stream is poor. It dribbles or nearly dribbles out and possibly has no clear cut off point. Often after the person has tidied himself up he discovers that he is still dripping on. The stream may from time to time be forked, like a snakes tongue so that the aim into the lavatory basin is poor.

F. The patient has to strain to pass urine

G. The patient has to get up several times a night to pass urine.

Many men have also noticed that their sexual prowess starts to fail and there is increasing impotence or poor erections even though their libido is unaltered.

If the cancer has spread beyond the gland the most likely place for it to go is bones so that any older man who complains of unexpected bone pains certainly needs prostatic investigation and scanning.

Treatment of prostate cancer varies according to the patient. A patient's general condition and age as well as the site of the tumour, its microscopic appearance, whether it has spread beyond the gland, the size of the prostate and the PSA will all influence the choice of treatment. If there is to be active intervention the choice lies between a radical operation to remove the whole gland - this is major surgery - or irradiation.

Irradiation is either delivered by computer controlled external beams or as brachytherapy the implantation of irradiating material under computer control into the prostate gland. In selected cases it seems that a combination of brachytherapy and external beam radiation may give almost as good a result as radical surgery.

Cases in which the cancer is small, the level of malignancy (the Gleason score) and the PSA are relatively low and not increasing rapidly may be treated by active surveillance. The patient has full tests every few months to make certain that there has been no change in the situation. This was referred to as watchful waiting but this didn't describe the careful regular tests the patient would need and far too many were recommended to have watchful waiting and then forgotten. Many waited until a time when their symptoms would inevitably lead to their death.

More advanced forms of prostatic cancer are treated by external beam irradiation usually associated with hormone treatment. In some cases the hormone treatment is continued after the radiation course is over.

Q2: I am 70 years of age, in very good health and spend time mountaineering and cycling every week. My blood pressure is extremely healthy and on the low side.

After strenuous exercise my pulse returns to normal very quickly. About two years ago I suddenly had urinary retention on one occasion. The consultant told me I had an enlarged prostate (BPH) and prescribed Xatral XL, taken once daily and that I would have to take them for the rest of my life.

The information accompanying with these tablets warns of side effects, one of which is postural hypotension (dizziness or faintness when getting up). I have taken these tablets religiously, until just recently when I began to feel the effect of feeling faint when getting up. Without consulting my GP I decided to see what effect stopping to take these tablets would be. The immediate result was that I have no longer experienced any dizziness. There is no difference whatsoever in the way I pass urine, albeit I do have to get up a couple of times in the night as I have been doing.

I appreciate that the purpose of these tablets is to decrease and soften the prostate in order that there is not so much pressure applied to the urethra.

What do you think? Should I continue to stop taking the tablets for a while and see what happens? The worse case scenario is that I will experience urinary retention again, but I can cope with that. I know that Dr Stuttaford had his prostate removed some years ago and also appreciate that was cancerous.

On a lighter note does Dr Stuffaford know that he got a mention in Cherie Blair's recent memoirs? Name and address supplied

A2: This is an enlarged prostate, benign prosatic hyperplasia (BPH). It is usually treated initially with pills of which Xatral XL is one. This drug is a selective alpha 1 blocker, it is also known by its generic name alfuzin. It is one of two groups of drugs that are used to control the symptoms of an enlarged prostate. This one, as you say, acts by relaxing the smooth muscles in the prostate so that the urethra, the urinary tube, is not squeezed as the prostate enlarges. The other group used to treat BPH are the 5 alpha reductase inhibitors, they act by changing the glands' hormonal control so that the glandular tissue shrinks. They usually give relief from the symptoms for a longer period. If the pills cease to be effective transurethral resection of the prostate (TURP) surgery is necessary.

Patients who have a benign enlargement of the prostate should have flow studies carried out so that an estimate could be made as to how bad the obstruction is. It would perhaps be a good idea to have your flow studies done now so that you can see if you will be liable to suffer symptoms of outward obstruction of the bladder by an enlarged prostate. The worry is that without your daily pill you might suffer acute obstruction, this could be inconvenient especially if you happen to be on holiday. Usually once a man starts on treatment of this sort it is necessarily necessary to continue.

You are absolutely right selective alpha 1 blockers may cause dizziness, a change in ejaculation, headaches and postural hypotension - the patient feels faint if they stand up too rapidly.

Thank you for your note about Cherie Blair's memoirs, I have only read it in the extracts in the newspapers but I shall now go off and buy a copy.

Q3: What is your opinion on the use of vitamin B17 in the treatment of cancer? Arthur Beale

A3: B17 is better known to doctors as amygdalin. It is found in almonds, apricots and the root of cassava. It has in the past caused fatalities and in the USA its promotional sale is specifically banned by the authorities. It is not used by doctors in this country and I wouldn't take it myself.

Q4: I am a 72 year old male and was diagnosed with prostate cancer in January 2006. My PSA was 491. Hormone treatment injections were started immediately and over time the PSA went down to 2.2 during latter part of 2007. Since then however the PSA has fluctuated wildly up to a max of 134 and is now at 110.2 and I have started CASODEX tabs 150mg. The treatment over the 2.5 year period has had very severe side effects (I also have Crohns disease) and pulled my health down to a very low level last year. I have never had ANY symptoms AND unless I had read your article in 2006 I would not have had any PSA done. So Dr Stuttaford you have probably saved my life, for which of course I am very grateful. Unfortunately because of the Crohns no biopsies have ever been taken to substantiate the original diagnosis. The medics are one hundred percent certain that I do have the disease because of the high PSA. Would you agree with that? I am now transferred from the urology dept to oncology at Truro Hospital. Peter Clark, St Austell, Cornwall

A4: Thank you for kind remarks. I am only sorry that you are one of the many men who have serious trouble from prostate cancer and have only found out about it by chance when it was too late for treatment to affect a cure.

A combination of Crohns disease and advanced prostate cancer would, I am afraid, make anyone feel that their health was really at a low ebb. Have you had bone scans? This is the way in which most advanced cases of prostate cancer are confirmed but since your PSA dropped so dramatically once you had hormone treatment we can be assured that the initial diagnosis was correct. I have been taking Casodex 150 mgs daily for five years, it has several tiresome side effects but doesn't make me feel ill. I suspect that the symptoms you now have are related to the high PSA because of the spread of the cancer and the Crohns. I hope that the oncology department at Truro are able to find other treatments that will help you feel better.

Q5: At the end of March I had a prostate biopsy which found nothing and am still trying to get rid of the predicted residual infection. I am 69 and otherwise very fit and well. The hospital has said that I should have another PSA test later on and if it still shows a higher reading then they would like another biopsy. Naturally I would prefer to avoid this.

My two question are:

(i) Given that PSA tests are notoriously unreliable, and if the next one is up (mine vary and I suspect could be stress-related) should I submit to another biopsy?

(ii) If a second biopsy did in fact discover cancer, can science tell us if it is harmless or not? We are after all assured that most men die with prostate cancer and not of it.

Keep up your wonderful column. John Alexander, London

A5: Although there is much discussion about infections after prostatic biopsy it only affects two in every hundred cases, and many of these have had inadequate antibiotic cover. As you will have found out the biopsy is as the doctors say "uncomfortable". This varies between the truly uncomfortable, but not painful, because the ultrasound and the rest of the kit has been inserted into your bottom and sharp but bearable (just) pain. The pain seems to be proportional to the size of the prostate and the liability or otherwise to bleed.

If your care needs another biopsy you should submit to it. The PSA tends to be more likely to cause troubles by being a false positive (an expensive nuisance) rather than a false negative (dangerous). We know that patients who have false positives, as you had, caused by an increased PSA also have an increased risk of later developing prostate cancer so that further tests are necessary - it is the difference between the dangerous watchful waiting and the tiresome active surveillance.

Science can tell you whether it is likely that any cancer you have, if you ever have one, is likely to be quiescent, need immediate treatment or is likely to be a serious trouble and needs urgent treatment. We can now distinguish pussies by the fireside from tigers lurking in the bushes.

Q6: Can you please advise me what signs to expect if I have prostate cancer? Thanks. John Pepin

A6: See answers to question 1 and question 4. In my opinion all men over fifty should have annual PSA testing. If they have a strong family history of prostate cancer they should start these tests at the age of forty. I know that it will be expensive for the state and the treatment and testing will strain NHS resources as well. However so far as my patients are concerned it is their lives that are at stake and I have more interest in them that the NHS budget.

Part 2 of Dr Thomas Stuttaford's forum on the important topic of diagnosis and treatment of prostate cancer can be viewed if you Click Here

To view the original article PART 1 Click Here

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