January 2014 Volume 11

Prostate Cancer Screening

Dr. Robert Wan
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Prostate cancer is the leading cause of cancer deaths among Jamaican men. In the USA it is the second leading cause.

Prostate cancer should be distinguished from Benign Prostatic Enlargement which causes many men to have disturbances with their urination. Screening is the detection of disease before it causes symptoms. 

Screening for prostate cancer was done by a Digital Rectal Exam (DRE) for many years. But prior to the 1990s, men who were diagnosed with prostate cancer usually had non curable disease because of the extent of the tumour when it was discovered.

With the introduction of a blood test called the Prostate Specific Antigen Test (PSA) screening for prostate cancer became much more effective and deaths from this disease in the USA have fallen by 40%. However, there is dispute by various bodies about the use of the PSA test because of the danger of over diagnosis and over treatment. This is so because some treatments may have undesired side effects such as erectile dysfunction and urinary incontinence.

Men who are at increased risk for developing prostate cancer include those with a brother or father who have the condition and African Americans.  Screening should be considered at age 40 and discontinued after age 70 depending on the individual's health status.

The two screening tests are a DRE and the PSA Test. The former is still useful and should not be discarded but the latter is much more widely used since it more easily accepted by the public. Teh PSA is a simple blood test and should be less than 4ng/ml. But PSA levels increase with age so a lower value in a 40 year old man would be abnormal and if the rise is too rapid, this would also be abnormal. If either the DRE or PSA is abnormal, then a prostate biopsy is indicated.

Prostate biopsy is done with a rectal ultrasound probe. Antibiotics are necessary to prevent infections and oral painkillers plus local anaesthetic injections are used. General anaesthesia is rarely indicated and it is an in-office procedure usually lasting 15 minutes.

The biopsy involves removing samples of the prostate with a needle guided by real time imaging provided by the ultrasound. Usually 12 samples are taken and sent to a laboratory for microscopic examination. If the PSA level is between 4 and 10ng/ml, the chance of finding a cancer is 30%.

The pathologist will then report what is called the Gleason Grade or score of the tumour. This is very important because a Gleason score of 6 indicates a tumour which is not very aggressive i.e. it will grow and spread slowly whereas, a Gleason score of 8 to 10 indicate tumours which are highly aggressive and dangerous. A Gleason 7 tumour is regarded as being moderately aggressive.

If the biopsy does not show a cancer, continued monitoring may be done. If on the other hand, the biopsy turns out to be positive then treatment should be discussed. For low grade, low volume tumours active surveillance may be an option but surgery or radiation should be considered for high volume, high grade tumours especially in a young man.

Dr Robert Wan attended KC from 1957 to 1963. Upon graduation he was awarded the Caribbean Cement Company Scholarship for Medicine and graduated from the Faculty of Medicine, UWI Mona in 1970. He later attained a post graduate degree in urology in Canada in 1976.

A past president of the Jamaica Urological Society of Jamaica, Dr Wan has membership in the Medical Association of Jamaica, the Caribbean Urology Association, Socite Internationale D'urologie (1994) and the Royal College of Physicians and Surgeons of Canada.  He is also a corresponding and international member of the American Urology Association. An assistant lecturer in the Department of Surgery UWI, he has co-authored several papers on prostate cancer. He currently has a private practice at the Winchester Business Centre in Kingston and is chairman of the Kingston College Choir Committee. 

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