Current Newsletter - July 2005

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" height=120 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="03f8dfe1esnpes.jpg"> <div> <B>July 2005</B></div> <bR> <div> <A HREF="id3.htm" TARGET="_top" TITLE="Calendar"><U><B><U>Calendar</U></B></U></A><A HREF="id3.htm" TARGET="_top" TITLE="Calendar"><U><B> </B></U></A><B>  |   </B><A HREF="id60.htm" TARGET="_top" TITLE="Carers Group"><U><B><U>Carers Group</U></B></U></A><B>   |   </B><A HREF="id2.htm" TARGET="_top" TITLE="Group Guidelines"><U><B>Group Guidelines</B></U></A><B>   |  </B><A HREF="id61.htm" TARGET="_top" TITLE="Library"><U><B> </B></U></A><A HREF="id61.htm" TARGET="_top" TITLE="Library"><U><B><U>Library</U></B></U></A><B>   |  </B><A HREF="id4.htm" TARGET="_top" TITLE="Current Newsletters"><U><B>C</B></U></A><A HREF="id4.htm" TARGET="_top" TITLE="Current Newsletters"><U><B><U>urrent Newsletters</U></B></U></A><B>   |   </B><A HREF="id16.htm" TARGET="_top" TITLE="Archived Newsletters"><U><B><U>Archived Newsletters</U></B></U></A><B>   |   </B><B><U>Pamphlets</U></B><B>  |  </B><A HREF="index.htm" TARGET="_top" TITLE="Northern Beaches Prostate Cancer Support"><U><B><U>Hom</U></B></U></A><B><U>e</U></B></div> <div> </div> </td> </tr><tr> <td valign="top" height=360 BGCOLOR="#CCCC99" TEXT="#080000" bgproperties="fixed" background="03f8dfc3.jpg"> <div> <B><U>NEWSLETTER</U></B></div> <bR> <div> No.36.  July, 2005</div> <bR> <div> Editor: John Conroy</div> <bR> <div> <B>1.   COMING  EVENTS</B></div> <bR> <div> a)    6.30 pm,  Tuesday, 5 July Dr Philip Katelaris:   Prostate Cancer:  Recent Developments </div> <bR> <div> Dr Katelaris is well known to our members.  His consulting rooms are in Hornsby and he has close professional contact with the Sydney Adventist Hospital.  Dr Katelaris is a passionate advocate of screening for Prostate Cancer in order to effect early treatment. He has recently attended the Conference of the American Urological Association where he gleaned much information on current practice and research in relation to Prostate Cancer.  His presentation will be informal, with plenty of opportunity for questions from the audience.</div> <bR> <div> b)    Tuesday, 2 August Dr Caroline Mountford:   Institute for Magnetic Resonance Research </div> <bR> <div> This will be an afternoon visit to the Institute at the Royal North Shore Hospital, St Leonards, to see first hand the work in progress at the Institute.  Details will be announced in the August Newsletter.</div> <bR> <div> Meetings are normally held in the Palliative Care Cottage, Mona Vale Hospital. All welcome. Please note:  During meetings, all discussion and comment about members' individual circumstances and experiences are confidential and should not be repeated outside the Cottage walls!</div> <bR> <bR> <div> <B>2.</B>    <B>REPORT OF THE MEETING HELD ON TUESDAY, 7 JUNE, 2005</B></div> <bR> <div> Apologies were received from Lee Brown, Jo-Ann Steeves, Ernie and Freda Treloar, and Philip and Wallis West.</div> <bR> <div> A video-tape, jointly produced by the Rural Health Education Foundation and the Australian Department of Health and Aging, and titled Prostate Cancer  -  Treatment and Access, was shown to members.  It was originally a satellite broadcast of the Rural Health Network, broadcast in 2004, and intended for rural GPs.  It consisted of a panel of experts, made up of:  Dr Norman Swan [Chair, from the ABC Health Report], Dr Suzanne Steginga [Psychiatrist, from the Queensland Cancer Foundation], Dr Glen Wood [Urologist, from the Brisbane Urological Clinic], Dr Matt Byrne [General Practitioner and Consumer, from Wangaratta, Victoria], Dr Sandra Turner [Radiation Oncologist, from  Westmead Hospital, Sydney] and Mr David Sandoe [Consumer, from the Prostate Cancer Foundation of Australia].</div> <bR> <div> The chairman of the panel, Dr Norman Swan, began by reminding the viewing audience that 1 in 11 men in Australia will be diagnosed with Prostate Cancer before he turns 80, and this figure is rising.  So what are the options if a man¹s PSA and biopsy are positive?  How does his doctor communicate the choices open to him?  How does the doctor frame the data on which to base discussion with the patient?  How does the doctor give the patient an idea of what treatment, if any, to choose to suit him and his circumstances?  These are some of the questions to be considered in this discussion. Dr Swan then asked each member of the panel what was the key message he/she wanted the audience to take away from the session.</div> <bR> <div> David Sandoe, the 'consumer' representative, said he hoped there might be greater community awareness about Prostate Cancer.</div> <bR> <div> Dr Matt Byrne said that GPs are often asked the question: "What would you do, Doc?"  With the overwhelming number of choices that are possible, he hoped GPs would be able to help patients get through the minefield of information to make what we hope is a correct choice.</div> <bR> <div> Dr Suzanne Steginga pointed out that a diagnosis of Prostate Cancer is a major life threat, and she hoped that the session might discuss ways in which GPs can support their patients.</div> <bR> <div> Dr Sandra Turner hoped that patients might be helped to understand the options, all of which are valid.</div> <bR> <div> Dr Glen Wood hoped to be able to dispel some myths and affirm some truths.  One myth is that men are more likely to die with Prostate Cancer and not of it, and this prompted some doctors not to treat many cases.  But 2 500 men are dying from it each year, so there is a significant population who do need some form of treatment.  The options are many, and none should be regarded as second best.  Another myth is that of "stage migration" of the cancer.  After the initial staging of the Gleason score, there is no evidence that the cancer gets worse;  there is just more of it.  It is also necessary to put into perspective the treatment side effects, which are often blown out of proportion.  It must also be remembered that it takes time for patients to make decisions on treatment options.</div> <bR> <div> Dr Matt Byrne discovered he had Prostate Cancer during a routine check for colon  cancer.  His PSA was normal at 3.2 but his doctor felt a nodule on Matt's prostate.  A biopsy revealed a Gleason score of 6. This experience is a good argument for men having a DRE [Digital Rectal Examination]. He had, subsequently, a radical prostatectomy.  Although it was an alternative, he had no thought of brachytherapy as he didn't know enough about it.  At the time, not enough was known about its long term effects.  Dr Byrne's prostate was difficult to get at and he suffered damage around his sphincta.  He suffered moderate to severe incontinence for two years which meant using up to eight pads per day.  However, he managed to get back to normal life playing cricket and, four months previous to the broadcast, he had an artificial sphincta fitted which has been absolutely fabulous.  He also experienced erectile dysfunction; it took well over a year, with the aid of drugs, to get back to a normal sex life. Often, the reaction of men when they are told they have Prostate Cancer is to "get it out", and 1 in 12 men are helped by the operation. The effect on spouses is often more marked than for their husbands. The man tends to get on with things, whereas the woman worries constantly.  Dr Byrne found that there was a big impact on a range of other people, not only himself as the patient.  He counselled his patients over his own illness, and his experience made people more aware that he is only human.</div> <bR> <div> Next, Dr Glen Wood described Prostate Cancer as a malignant growth, - a collection of abnormal cells in the Prostate which undergo uncontrolled, autonomous growth. These cells have the ability to invade, to spread, and to survive in distant sites [to metastasise]. Prostate Cancer is the second most common cancer in men in Australia after skin cancer;  approximately 2 600 men die of it annually;  there are 10 000 new cases diagnosed each year [more than 50% of new cases are found in men over 70 years of age]; and 1 in 11 men can expect to develop it before turning 80.  Risk factors include: advancing age;  race and ethnic factors [Afro-Americans have a high incidence; little is known about the incidence among Australian Aborigines]; and family history [if a man has a first degree relative who had had Prostate Cancer, then the relative risk of developing the disease is two and a half times greater than that of another age-matched man in Australia]. Environmental and diet have never been proved as contributing factors but there has been some query about high fat diets.</div> <bR> <div> The diagnosis of Prostate Cancer is histological [based on a tissue sample taken on biopsy].  DRE findings, PSA elevation or velocity, and incidental findings such as abnormal x-rays of bones are only suggestive. Diagnosis is rarely based on symptoms;  early stages are usually without any symptoms.  Frequent urination at night or urgency usually indicate Prostate enlargement.  Confirmation of a diagnosis rests with actual sampling of Prostate tissue. If there is a family history, or if the patient is concerned, then the GP should investigate.  It is usually picked up by a DRE, or a PSA abnormality, or a combination of both.  The DRE is vital in detection, as 20-30% of men can have a normal PSA but have an abnormal DRE. If there are symptoms, it often means that the cancer is late and advanced, presenting with blood in the urine or semen, or with pain when urinating. In extreme cases there is pathological spread, such as bone fractures.</div> <bR> <div> Once Prostate Cancer is diagnosed, a trans-rectal, ultrasound-guided biopsy is made.  However, most cancers are not seen on ultrasound. The nodule felt on DRE is often not seen, and the best result is a finger-guided biopsy in addition to the ultrasound-guided biopsy.  The validity and application of biopsies is still a little in the air, as the Gleason table is based on radical prostatectomy samples, not biopsy samples. The large majority of tumours are heterogeneous;  that is, one growth pattern of cells predominates, and a second is there to a lesser extent. The Gleason score is made by adding the two tissue scores, and ranges from 1+1 to 5+5.  Cells in the Gleason range 1-4 are well-differentiated and don¹t look too different from the normal cell. They produce large amounts of PSA, are slow growing and patients may go for decades without needing treatment.  Cells in the range 5-7 are moderately differentiated.  Most patients will survive 10-15 years without therapy [based on Swedish data].  Cells with a score 9-10 are poorly differentiated and may resist even radical therapies.</div> <bR> <div> In a traditional biopsy, the Prostate is divided into a left and right lobe, and each lobe is then divided into a base, middle and apex zone, and a sample is taken form each of these six sections. The biopsy is now normally done under sedation.  Practice has now moved to taking 12 biopsies, which increases the pickup rate by about 8% without increasing the complications [for example, bleeding or septicaemia].  Pain occurs only in the process itself, not afterwards. Dr Wood would also do two additional finger-guided biopsies of the nodule.  False positive diagnoses from biopsies are very low.</div> <bR> <div> The next step may be to stage the disease by bone scan, though this is not universal practice for men with a PSA less than 10.  A CT scan may be given to check for lymph node spread.</div> <bR> <div> Next, a TNM [primary tumour] classification may be given, but this is usually only used by the medical profession:  Stage T1 indicates a small tumour that can't be felt by DRE; T2 indicates a tumour that can be felt by DRE but is confined in the Prostate; T3 is a tumour that extends beyond the Prostate; T4 is spreading beyond the seminal vesicles into the adjacent organs. The more important way of staging for ease of therapy is to describe the tumour as localised, localised advanced or metastatic advanced.</div> <bR> <div> The next step is to decide on a therapy.  This is based on tumour factors, patient factors, treatment and side effect factors, and what the patient wants to achieve. There is no rush to make a decision, as the tumour is slow growing. There may be some significant risk indicated by the velocity of rise in the PSA.</div> <bR> <div> On the issue of watchful waiting, Swedish data suggest that after 15 years, 87% of patients are alive but, beyond that time, there is a substantial dip in survival and a large number of developing distant metastases, and quality of life is lower [for example, levels of anxiety and coping with the disease].  For radical prostatectomy, with PSA undetected over five years, the cure rate was 98% in 20 years.  If a man has an actuarial survival of 10-15 years, then active intervention is suggested if he wants to enhance survival, and therefore watchful waiting is inappropriate.</div> <bR> <div> The panel was then presented with a case study of a 52 year old man whose PSA is 4.5, a DRE is clear, but a biopsy shows a Gleason score of 3+3. What would the team recommend?</div> <bR> <div> GP Dr Matt Byrne said that Prostate Cancer seemed a probability in this case.  He would raise the patient's knowledge of the alternatives available and with the different complications possible,  He would also talk to the spouse and stress that there is no hurry to make a decision, and to choose what the patient feels would work for him.</div> <bR> <div> Psychiatrist Dr Suzanne Steginga said that diagnosis of cancer is a major life stress. There is not only the devastation of the knowledge of cancer. There is also the need to make a decision about treatment in an unfamiliar, complicated context.  Is the cancer localised or advanced? What are the likely side effects?  It is difficult to weigh up the alternatives, so the patient should take his time.  In her support work, Dr Steginga tries to look at how people make decisions.  Often these are non-systematic. For example, it is preferable to present people with alternatives in terms of chance of survival rather than of dying.  Also, the patient is influenced by past experiences and will go for options based on past knowledge rather than suitability of the treatment for himself.  Or he may choose what his GP suggests [in response to the question:  "what would you do, Doc?"].  Shared decision making is the best approach. The GP should find out what the patient has found, what he understands, and go through this and ask what he feels is most important. The GP should find out what are the patient's concerns; provide information;  discuss questions and concerns, giving plenty of time;  help the patient consider his priorities;  listen and make a joint decision.  If the patient can't make up his mind, he should write down the pros and cons of the alternatives. This gives a visual representation of which way he is leaning.  Psychological distress is a reality, especially in relation to decision-making, and the patient is specially needing support during the process.  Hence the GP should constantly check on how the patient is doing.</div> <bR> <div> Radiation Therapist Dr Sandra Turner supports the notion of the 52 year old man in the above case study having a radical prostatectomy. However, the radio-therapy options available are:  i] External Beam Radiation Therapy [EBRT], which may be suitable for all stages, grades and PSA levels;  ii] low dose-rate [seed] brachytherapy, which is an alternative to radical prostatectomy and suits early [low risk] cancers, and where the seeds stay in the Prostate permanently and take 4-6 months to deliver their dose;  and iii] high dose-rate brachytherapy, suitable for higher-risk, localised cancers, and is administered via needles inserted in the Prostate Gland, and is given in conjunction with EBRT.</div> <bR> <div> EBRT is given as an outpatient treatment and usually involves a 30 minute daily visit for seven weeks [but not at weekends].  The machine [a linear accelerator] is on for about 10-15 minutes maximum, and is conformal; that is, it conforms as closely as possible to the area that is being treated.  Normally there are six beams angled round the body to add up in the middle so as to give a high dose and spare as much surrounding tissue as possible. The rectum, in particular, doesn¹t like high doses of radiation.</div> <bR> <div> The ano-rectal side effects of radiation therapy can include urgency, anal discomfort, bleeding, mucus, and loss of muscle tone.  This may be as high as 80% during treatment, and 5-7% in the long term, but these conditions are treatable in most cases.  There may be a loss of sexual function in the long term; - up to 50% at two years.  However, the data are confusing, as most radiation therapy is given in older age and you have to know what was normal sexual function prior to radiation therapy.  Therefore the doctor has to consider how important an issue sexual function is to the man and his partner at the time of decision-making.</div> <bR> <div> Seed brachytherapy has been reborn in the last 15 years in the USA and is becoming more common. It has re-emerged in Australia over about the last five years. It lodges high doses of radiation over short distances in the tissue being treated. It usually extends no more than 1mm beyond the Prostate and so is more sparing of surrounding organs, especially the rectum.  Data collected over 15 years suggests that side effects are most favourable with well-conducted seeding programs.  A grid is used to locate the seeds accurately;  for example, to avoid the urethra, bladder and rectum.  Also, 70-80% of men who had a good sexual function before treatment retain erectile function in the long term, which is better than for radical prostatectomy.  Urinary problems in the medium term can be substantial and men need to be warned of this.  For example, problems related to frequency, urgency, strictures and dysuria can affect 75% of cases over the first few days or months, and 5-10% may need a catheter. In the longer term, 5% of cases may be affected, but this is rare if there has been no TURP ['rebore'] within 12 months on either side of treatment. However, most of these problems are treatable.</div> <bR> <div> There may be residual PSA after treatment, because the Prostate is still there. There may be a PSA 'bounce' within 12-18  months, which may cause a scare for the patient, but the level usually drops back.</div> <bR> <div> Although he is a surgeon, Dr Glen Wood regards brachytherapy as very exciting. The only limitation is the absence of long term follow-up. His rule of thumb is:  for men under 60 with Prostate Cancer, radical prostatectomy is appropriate;  for men 60-70, seed brachytherapy;  and for men over 70, go fishing!  There are no randomised trials to determine which therapy is better.  We are never likely to get such information because of the difficulty of randomly allocating men to treatments, which flies in the face of all that has been said so far as regards decision-making.</div> <bR> <div> With regard to the case study above, he would recommend multiple visits, and multiple information inputs, not merely pamphlets to read. The GP and Urologist have a  shared care role in the whole educational process. The patient should bring his partner to discuss the sexual implications, as it affects them both. The case mentioned is not good for watchful waiting because for a life expectancy beyond 10 years we should need to think of active intervention. This fits the patient for radical prostatectomy, set in the context of radiation therapy and brachytherapy. The Urologist can't make a decision in isolation and will often refer the patient on to the radiation therapist for a fuller explanation.</div> <bR> <div> In relation to surgery, Dr Wood takes his patient through the procedure in detail. The operation takes 2-3 hours under anaesthetic.  An incision is made from the umbilicus to the pubic hair.  Trans-perineal procedures are not usual in Australasia, the USA or Europe, because there is no access to the lymph nodes and no good vision of the nerves.  The Prostate is dissected from attachments, the urethra is divided and the bladder and Prostate are excised, removing part , if not all of the seminal vesicles, the vas deferens is tied up, and the bladder and urethra are reconnected. The operation is major surgery and carries a number of risks, including myocardial infarctions, strokes, pulmonary embolisms, and infection. There is even a death rate, - equivalent to two years driving on Australian roads. The patient can expect a survival of 10-15 years. Once awake, the patient is returned to the ward with a catheter in place.  Discharge should occur within 5-6 days, at which time the catheter is removed, though in some cases it may be left in for up to 21 days. There is no literature or evidence to suggest that one method is better than the other.</div> <bR> <div> On return home the patient may have reliance on 'pelvic floor' exercises to recover continence because the main sphincta has been removed. A high proportion of men will experience incontinence in the initial phase. Then the pelvic floor strengthens, and that can be aided by exercises, such that at three months, approximately 60% of men will attain full continence, and at six months this will be reduced to 9%. Some 4% will be left with a degree of incontinence;  for example, a few drops leaking when lifting heavy loads. Total incontinence may be experienced by 1 in 100.  However, there are a number of procedures to counteract the problem, including:  injecting collagen to buffer the bladder neck and sphincta to gain control;  placing slings around the urethra;  and artificial sphincta devices, - all of these with good effect.</div> <bR> <bR> <div> Impotence may be another major side effect.  Autopsies show that some 70% of men have erectile nerves running through the Prostate, so, if it is excised, the nerves are excised and the patient is impotent.  Nerve sparing is in vogue and, in many cases, nerves can be identified and safely removed from the edge of the Prostate with minimum dissection and, albeit with some delay, potency is maintained. It can be up to three years before erectile function is attained, according to the American Urologist, Scardino. The large majority need augmentation with medication, such as Cialis, Levitra or Viagra.  But many men are left with impotence which doesn't correct itself. This doesn't mean they can't have sexual gratification and a satisfactory sex life, although most expect an erection that will enable vaginal penetration. There is a range of alternative means, including vacuum devices, injections, medications to augment, and penile prostheses. Complications are real and devastating but shouldn¹t be blown out of proportion. We are dealing with a life-threatening condition and, if removing nerves is essential for cure, then we have to do so, and the patient has to accept this.  However, there are many things that can be done to normalise the patient afterwards.  Dr Wood sees radical prostatectomy as being viewed in three tiers:  clearance of the cancer, continence, and normal erections.  It is ideal if we can achieve all three, but this is difficult to attain.  Younger men in their late 40s are more likely to regain continence and erectile function rather than men in their 70s, regardless of where the nerve bundle goes. Patients should know that there is no ejaculation after prostatectomy.  Brachytherapy patients with erectile problems can be treated very effectively by Viagra-like drugs. Brachytherapy can spare nerves physically in a certain number of cases because they can actually see nerve bundles on the ultrasound.</div> <bR> <div> Robotic surgery is an exciting development in being minimally invasive. The advantage of all such surgery is in not giving a painful wound with major muscle disruption. The patient still gets a catheter, and there is no information that impotence or incontinence rates are different, Robotics gives better vision, but foregoes tactile information.  But robotic and laparoscopy surgeons will say that you don¹t need to touch if you can see.</div> <bR> <div> What happens if PSA progresses after a radical prostatectomy or brachytherapy?  The progress is the same but management is different.  If PSA progresses after a prostatectomy, the patient will wonder why it shouldn't be zero.  However, other organs produce a PSA-like substance. If the PSA level rises, there is a source of Prostate cells somewhere and this usually means metastases. If there is a nodule where the Prostate was located, EBRT may be used, so long as there are no metastases elsewhere.  It is usual to wait till the patient has regained continence. If there is a relapse with metastases, systematic hormone therapy is used to suppress growth and put the patient into remission. Radiation oncologists regard three successive PSA rises as indication of failure.  30% of cases may have one or two rises, which is not an indication of recurrence.  It is usual to delay for up to six months, during which time most levels go down. If the doctor feels that something is happening, it is difficult to know if the recurrence is local or metastatic in deciding on localised therapy.  In the USA some surgeons have done a radical prostatectomy after brachytherapy. However, Dr Wood would dissuade patients form choosing a radical prostatectomy on the grounds that if it fails he can have EBRT, because if PSA does progress it may be at a metastatic site.</div> <bR> <div> The presentation concluded by giving a number of useful website addresses.</div> <bR> <div> The tape is available on loan for one month only from our Lending Library.</div> <bR> <bR> <div> <B>3.        INFORMATION  UPDATE</B></div> <bR> <bR> <div> a.    Publications Received</div> <bR> <div> Dr Peter Scardino's Prostate Book:  the Complete Guide to Overcoming Prostate Cancer, Prostatitis, and BPH.</div> <bR> <div> This book was released in April of this year and is a thorough, professional and readable book on all matters relating to the Prostate.  Dr Scardino is one of the leading Urologists in the USA and he brings a wealth of knowledge and experience to this work.  Many thanks to Mark Tweeddale for drawing it to our attention. It is available on loan for one month only from our Lending Library.</div> <bR> <div> Checkmate, The Newsletter of Torbay Prostate Support Association.  Issue8.</div> <bR> <div> This issue includes items on:  clinical trials, help with bladder problems,  Impotence, relaxation and visualisation, active surveillance, and tips from readers. It is also available on loan for one month only from our Lending Library.</div> <bR> <div> b.   Treatment Issues</div> <bR> <div> Information from Pam Sandoe, who has checked out professional medical advice, confirms that genetic, serum, urine and semen tests for Prostate Cancer are, for the time being, not validated or in clinical practice.  PSA and DRE are still the recognised diagnostic tests.</div> <bR> <bR> <div> <B>YOUR CONTACT NUMBERS</B></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="2" CELLSPACING="1" WIDTH="664" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 116 WIDTH="357"><div> <U>Program Co-ordinator</U> </div> <bR> <div> Dr Peter Moore </div> <div> Northern Beaches Palliative Care<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> 9997 3555 </div> </tD> <tD VALIGN=TOP WIDTH="296"><div> <U>Group Leader</U></div> <bR> <div> John Conroy<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> 9918 9358<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <div> <A HREF="mailto:conroyjs@bigpond.com" TARGET="_top" TITLE="mailto:conroyjs@bigpond.com"><U><U>conroyjs@bigpond.com</U></U></A></div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 89 ><NOBR><div> <U>NSW Cancer Council Cancer Support Helpline</U></div> <bR> <div> 13 11 20<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div> <U>Prostate Cancer Foundation of Australia</U></div> <bR> <div> 1800 220 099</div> </NOBR></tD> </tR> </TABLE></div> <bR> </td> </tr></table></body>