NEWSLETTER
No. 21. February/March, 2004
Editor: John Conroy
1. REPORT OF THE MEETING HELD ON: Tuesday, 3 February
a.) Apologies were received from Robin Casson, Richard Darmopil, and Bill Liney.
b.) We had the pleasure of welcoming new members David Bennett, Michael and Prim Cooper, and Freda and Ernie Treloar.
c.) We were very pleased to have Dr Phillip Mark Katelaris as our speaker for this month's meeting to give an update on the PSA debate. Dr Katelaris began by emphasising that he was giving his own point of view, which you may or may not agree with, according to your own experiences. There is a running debate as to what we should do and on ways to treat Prostate Cancer, or whether the treatment is worse than the disease itself. This said, he would suggest that men over 40 whose fathers had had Prostate Cancer should have an annual Digital Rectal Examination (DRE) and PSA test. The aim of screening is to pick up the disease and give treatment early. On the other hand, Dr Katelaris acknowledged that there might be over-screening for men over the ages of 70 and 80 years.
The case against screening centred on the accuracy of the PSA test and the need to treat the disease. The World Health Organization has published a list of criteria to determine whether or not a disease is an eligible candidate for a screening test. These criteria are that: it should be an important health problem; there should be effective therapy for patients with a localised disease; there should be facilities for diagnosis and treatment; there should be an identifiable latency period; there should be an effective screening technique. Prostate Cancer meets all these criteria, Dr Katelaris argues.
There are two major studies in progress (PIVOT and PLCO) to determine whether or not there were advantages in early treatment of men with Prostate Cancer. These are due to report in 2007. Detection of the disease is through a DRE and PSA test (giving a reading of at least
4-10 ng/ml - nanograms per millilitre). This is the best available test and, in fact, there is no similar test available for other cancers. However, while a single reading may be indicative, the trend in the reading has to be monitored. The free-to-total PSA ratio is now also a useful indicator (the higher the ratio, the lower the chance of disease).
Cost is another argument used against screening for Prostate Cancer. Comparative figures from the USA give the individual cost of screening for Breast Cancer to be $10 975, while that for a DRE and PSA test for Prostate Cancer is $2372. Also, the cost of early diagnosis and treatment has to be balanced against delay leading to expensive treatments. Treatments like Zometa and Strontium are very expensive.
It is argued that PSA screening leads to over-detection; that men die with rather than from Prostate Cancer. Dr Katelaris suggests that this is not so. A study from the Mayo Clinic in the USA compared the results of diagnosis through screening and through palpation (DRE) and found them to be similar and not to picking up insignificant disease. That is, cancer was not being over-detected.
Dr Katelaris speaks from a background of 15 years experience and of having performed 1000 radical prostatectomies. His conclusion is that a PSA test plus Digital Rectal Examination should be available for men between the ages of 50 and 70 years, and that men over the age of 40 who are diagnosed with Prostate Cancer should be offered treatment.. A guiding principle in advocating treatment might be: Is a cure possible in those for whom it is necessary? Is it necessary in those for whom it is possible?
Dr Katelaris reminded us of present treatment options available for Prostate Cancer, and emphasised that there is no definitive course of action.
Watchful waiting is appropriate for elderly men and for those with poor expectation of longevity.
Radical Prostatectomy is appropriate for younger men - for whom it is probably the treatment of choice. It would be selected for men who were fit, who had no other serious disease, and whose Cancer was confined. The technique was developed by Patrick Walsh, who detected the nerve bundle to preserve sexual function. Walsh treated 1000 men over 10 years and claimed that the procedure cures men when the disease was confined. There has been a reduction in mortality of 25% in the Western world (Australia, the USA, Austria and Scandinavia) according to figures collected in the early 90s. With more screening it's possible that the reduction could be even higher. A randomised controlled study reported in the New England Journal of Medicine reported that early intervention with surgery was better than watchful waiting. It is important to counsel younger men of the danger of doing nothing as well as of the side effects of Radical Prostatectomy. Quality of life is an important consideration and, notwithstanding the criticisms, evidence suggests that surgical treatment is doing a good job. If it can cure men with Prostate Cancer, it is worth taking the risk.
Brachytherapy may take the form of seed implant or dose escalation. Seed implant consists of injection under anaesthetic. The aim is to target the Prostate Gland in such a way as to minimise damage to the bladder and bowel. High dose rate combined with dose escalation are used to minimise collateral damage. Needles are inserted into the prostate, and wires are inserted down these and positioned to administer the dosage. 11% of patients may suffer urinary problems and 5% may incur bowel problems but the side effects are generally much lower than for External Beam Radiotherapy [EBRT]. A higher dose (up to 80 greys) can be administered and is well tolerated. It is too early to say whether Brachytherapy cures the disease but it does less damage. More time is needed to study the effects. The downside of the treatment includes:
Incontinence; (that is, incontinence which is socially disturbing) the indications are that only 4% of patients suffer leakage after three months.
Erectile dysfunction. This is often a pre-existing condition; 60% of men world wide have soft erections at 60 years of age, so it is not a big deal for Prostate Cancer. Sexual rehabilitation is an important point to consider. The condition may be preventable, and it is certainly very treatable. Men can get lasting benefits from penile implants.
Other treatments exist, such as Thermotherapy and Lasertherapy.
To summarise the arguments in favour of PSA testing:
The PSA test is useful Introducing PSA screening can result in cost savings. There is a need for treatment of Prostate Cancer (see the mortality figures). The harm is exaggerated; no more than 4% of biopsies result in infection.
In conclusion, Dr Katelaris took us through some examples of the process he follows in reaching a decision as to the most appropriate treatment options to put before a man diagnosed with Prostate Cancer. He will consider the man's age and his estimated longevity, his PSA and Gleason scores, the stage of the cancer, his bladder and sexual functioning, and his general health (for example, does he have heart disease or diabetes?). We were given several hypothetical case studies as illustrations of how, in offering treatment options, he will look at this patient profile, and match it with the treatment available.
A man diagnosed at 55 years of age with localised Prostate Cancer has an 80% chance that the disease will metastasise (spread to other parts of the body) by the age of 65. If this man has an estimated longevity of 25 years, then Dr Katelaris would recommend a Radical Prostatectomy.
If a man is diagnosed with a high grade disease at age 65 years, has an estimated longevity of 15 years, and also has hypertension and bladder problems, Dr Katelaris could offer good palliative care. He would be able to control the pelvic disease and relieve the bladder obstruction. However, he can't watch and wait; nor can he use EBRT, as this would worsen the bladder condition. In this case he would
suggest removal of the Prostate Gland as a palliative rather than a curative measure.
A man diagnosed at 70 plus years, with an estimated longevity of 10 years, would be given the recommendation of seeding.
A man aged 72 years who had a 10 year estimated longevity, who had a good bladder, but a bad prognosis would be recommended
Brachytherapy.
In the general discussion that followed the presentation, a question was raised about the use of Magnetic Resonance Imaging (MRI) in relation to Prostate Cancer. Dr Katelaris, who is directing a Prostate Cancer program in this respect at the Royal North Shore Hospital, suggested that it is early days yet. While it is potentially useful, it is not being used at present for detecting Prostate Cancer.
Another question was raised concerning hormone therapy. This may be used as a prelude to Brachytherapy, seed implantation and EBRT. Chemotherapy may be used where there is resistance to hormone therapy.
Finally, a question was asked about the significance of a variable PSA reading. This can often be an indication of benign disease, and this can be treated by a rebore (TURP). The clinical significance of a PSA test result is to know if it is an isolated occurrence or if it is significant relative to a man's normal level for his age.
2. THE HEALTHY MAN'S GUIDE TO PROSTATE PROBLEMS
The Brochure is printed. A copy is included with your Newsletter, and copies have been sent to all GP and Specialist consulting rooms in the Northern Beaches. Please contact me if you would like additional copies to distribute to friends or to locations in your area. Many thanks to Bill and Joan Lamont for help with the folding.
3. INFORMATION UPDATE
a.) New treatment. An article in the Sydney Morning Herald on 17/02/04 outlined a new treatment for prostate and other cancers that is under investigation in Britain, China and France. The new treatment under trial focuses sound energy on cells, and roasts them till they die. It works rather like using a magnifying glass in sunlight to burn a hole in paper. For Prostate Cancer, these ultrasound 'scalpels' are attached to rectal probes which 'cut out' small sections of a tumour in a series of two-second bursts. This is done without damaging surrounding tissue and with few side effects.
b.) Issue 9, Summer 2003/2004, of The Healthy Male has been published by Andrology Australia. This issue deals with the health of Aboriginal and Torres Straight Islander males. Copies can be obtained from the Monash Medical Centre, Clayton, Vic., 3168, or on-line at:
c.) Thanks to Bill Bending who joined me to do an interview about Prostate Cancer and our Support Group on Radio Northern Beaches. The program went to air at 9.15am on Monday, 23 February and will be repeated at other times. Watch the Time Out section of the Manly Daily for the radio frequency, and for scheduling details. Thanks, too, to Radio Northern Beaches for giving us the air space.
d.) Cancer Voices has asked me, as a cancer consumer, to represent them on a Committee of Radiation Oncology Medical Physicists. These are the people behind the scenes in radiation therapy and who have a direct connexion to Brachytherapy. I'm not sure yet what I can contribute, but I may be able to bring back some interesting information on developments is this area.
4. GOALS FOR 2004
Thanks to the help of several Members, we are already under way in working towards some of this year's goals. Publicity The Brochure is printed and is in circulation, and we have had an airing with Radio Northern Beaches. Can anyone help in getting our voice heard in any other media?
The web site is also under way. Ron Faulkner's daughter, Lee, has offered to help design it for us and she is working on the material.
Two members have also offered to help with the sponsorship. It will also require initial design of the website and constant updating. Again, any additional help from Members with computing skills will be very welcome.
Fundraising. This remains an important issue. There are many businesses in the Northern Beaches area which are willing to contribute to worthy causes. We need someone with a little time to make some approaches. Any offers, please?
Library. We are beginning to collect quite a useful amount of printed and other information. It needs to be organised so that it can
be readily available for borrowing. We would welcome any Member or partner who could help out with this task.
Organisation. With all these activities going on, our loosely knit handful of volunteers may need to be organised into a Committee.
Any offers of help here would be gratefully received.
5. REMINDER: DATES OF NEXT MEETINGS: (6.30 pm on the first Tuesday of each month in the Palliative Care Cottage, Mona Vale Hospital) All friends, partners, carers, and family members are welcome. Refreshments will be served.
2 March Dr Gordon O'Neil (Urologist at the St Vincent's Centre): All About the Prostate Gland: Its Structure, Function and Diseases.
Dr O'Neil has a dual practice in Sydney and in the far west of NSW. He has spoken at Support Groups, as well as awarenessmeetings in Bathurst, Dubbo and Warren.
6 April Dr Lisa Horvath (Garvan Institute, Sydney): Recent Research at the Garvan Relating to Prostate Cancer
YOUR CONTACT NUMBERS
Program Co-ordinator
Dr Peter Moore
Northern Beaches Palliative Care
9997 3555
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Group Leader
John Conroy
9918 9358
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NSW Cancer Council Cancer Support Helpline
13 11 20
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Prostate Cancer Foundation of Australia
1800 220 099
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