William Aiken

In general, prostate cancer is a slow growing tumour and will not usually cause death until 10 to 15 years after initial diagnosis at an early stage.

Based on this important observation and the fact that the average life expectancy for men in Jamaica is roughly 72 years, it is not likely that men older than 70 years would benefit from tests such as the prostate specific antigen (PSA) blood test designed for the early detection of prostate cancer. These men would most likely die from other causes. Therefore, looking for and treating prostate cancer in these men would be meddlesome at best and at worst could result in a compromised quality of life and indeed death.

Younger men

Following the same argument, relatively younger men, that is, men 40 to 60 years, are the ones most likely to die of prostate cancer if it is not detected early and curative treatment offered. It should, therefore, now be understood why the focus is on these men when promoting early detection of prostate cancer as they are the ones most likely to benefit from screening with PSA and the digital rectal examination (DRE).

To complicate matters somewhat, among medical scientists, it is still being debated whether screening for prostate cancer is actually of benefit to patients in terms of increasing their length of survival. Of the 12 major North American medical associations, three recommend screening for prostate cancer, three are equivocal and six outrightly discourage prostate cancer screening.

The current joint position of the Jamaica Urological Society and the Jamaica Cancer Society is that early detection of prostate cancer utilising PSA and the DRE should be encouraged in men aged 40 to 70 years. The outcome of an ongoing study of high scientific rigour that will unequivocally answer this vexing question regarding prostate cancer screening is eagerly awaited. In the meantime, the available evidence seems to be in favour of early detection of prostate cancer.

Possible litigation

Any decision regarding detecting early prostate cancer or treating it should bear the above considerations in mind. Once the decision to screen for prostate cancer is made, the next step is to have both tests performed - the DRE and the PSA. Many doctors continue to do the PSA test alone thereby exposing their patients to inadequate detection and themselves to possible litigation.

The recommended screening interval remains one year, although there is evidence that it may be increased in select patients with a very low initial PSA and no strong family history. If either the PSA or DRE is abnormal, an ultrasound-guided biopsy is performed in which prostatic tissue is obtained via the rectum and sent to be evaluated by a pathologist to determine whether cancer is present or not.

Biopsy of the prostate is a straightforward procedure but may infrequently be complicated by serious infection or troublesome bleeding. Observing some blood in the urine and the semen is not unusual after having a prostate biopsy. The biopsy report invariably assigns a grade if cancer is present. This gives an indication of the likely degree of aggressiveness of the cancer.

If the report returns positive for cancer, the patient's PSA level, findings on rectal examination and the grade of the cancer are all reviewed and used to determine the likely stage or extent of spread of the cancer and the need for further tests such a bone scans and CT scans.

Options for cure (primarily radical surgery or radiotherapy) are discussed with the patient if the disease is assessed as being early and the patient has a 10 year life expectancy.

Dr. William Aiken is the head of Urology at the University Hospital of the West Indies and president of the Jamaica Urological Society; email: yourhealth@gleanerjm.com.