Prostate Cancer Community Awareness
Anthony J Costello, F.R.A.C.S., M.D.
Professor of Urology, The Royal Melbourne Hospital
Department of Surgery, University of Melbourne
Board, Prostate Cancer Foundation of Australia
Prostate cancer is the number one male cancer in Australia. It is the second commonest cancer death in men in this country. In the year 2000 there were approximately 2,700 deaths from prostate cancer and 12,000 cases of prostate cancer were diagnosed. This means that prostate cancer is equivalent in incidence and mortality to breast cancer. It is astonishing that there is such a low level of awareness of prostate cancer in the Australian community compared with the awareness of breast cancer and such a difference in attitude to testing for breast cancer compared to prostate cancer testing.
In 2001, approximately 70% of Victorian women and the age group at risk for breast cancer will have appropriate screening mammography. In Australia in the year 2001 only one in ten men will have appropriate prostate cancer testing.
Although there is significant government concern of the overuse of Prostate Specific Antigen (PSA) blood testing it appears that there is very little usage of this blood test, which is commercially available at all pathology laboratories costing $26.00.
We also know that if there is a family history of prostate cancer, that is a first degree relative; father, son or brother with prostate cancer and that diagnosis is made around the age of 60, relatives of that prostate cancer sufferer have a three times increased risk for the development of prostate cancer. Unfortunately there is no equivalent test such as the BRCa1 gene testing done in breast cancer high-risk families.
Prostate cancer is diagnosed generally after a PSA blood test is drawn or an abnormal digital rectal examination is found. After appropriate information given to the patient, most organisations such as the Urological Society of Australasia recommend that men between the age of 50 and 70 who have at least ten-year life expectancy be recommended to have a PSA blood test. PSA blood test whilst not 100% sensitive and 100% specific for prostate cancer diagnosis is the best marker in oncology. It is also relevant that PSA has a 60% better positive predictive value for cancer diagnosis than does mammographic screening.
A man diagnosed with prostate cancer between the age of 50 and 70 with a ten-year life expectancy almost certainly will die from prostate cancer and not with prostate cancer. A man who has a PSA elevation sees his local doctor and is then recommended to do a biopsy on the prostate under transrectal ultrasound guidance. This is a very accurate way of diagnosing prostate cancer which is clinically significant. Transrectal ultrasound guided biopsy has about a 90% accuracy of finding clinically significant prostate cancer.
Once a man has had prostate cancer diagnosed and is suitable for curative therapy there are a number of options for him. The mainstay of treatment for organ confined prostate cancer has been radical retropubic prostatectomy. This operation has been refined significantly over the past ten years. The problem of incontinence, which bedevilled this operation in earlier times, has become much less significant. Most centres where this operation is performed now have incontinence rates around 1 to 2%. This incontinence means a total incontinence where some form of artificial sphincter or urinary diversion would be required for control of urinary flow. Minor incontinence like stress incontinence happens in approximately 20% of men who have radical prostatectomy. This is often managed with pelvic floor exercises and no other therapy.
There have also been significant improvements in radiation therapy for organ confined prostate cancer. Outcomes in terms of cure rates for radiation compared to radical prostatectomy are very similar. The event of intensity modulated radiation therapy and conformal radiation therapy techniques means that scatter of the radiation therapy beam is minimised and the prostate is optimally treated for cure. Morbidity from both radiation therapy and surgery relates mainly to sexual dysfunction. Approximately 70% of men after radical prostatectomy will have difficulty obtaining spontaneous erection without pharmacological help. About 60% of men after external beam radiation therapy will also have sexual dysfunction requiring further management. This sexual dysfunction remains the major morbidity from curative therapy for prostate cancer.
Some men who have other co-morbidities where curative therapy is inappropriate will be assigned to a program of watchful waiting using PSA as a clinical measure for disease progression. In these patients often hormonal therapy using injectable LHRH analogues will provide many years of amelioration of prostate cancer.
In summary at present in Australia only one in ten men will have appropriate prostate cancer testing that is digital rectal examination and PSA blood test annually. Although the Federal Department of Health suggests that PSA testing is overdone in our community, most PSA testing is done for disease monitoring rather than for screening diagnosis.
It would be timely to introduce an education and awareness campaign for men in the Australian community and their partners to understand the problem of prostate cancer in our community and allow men to make an informed choice regarding testing and options for curative therapy.
The Prostate Cancer Foundation of Australia is planning a National Awareness Campaign which will be run in two stages. Information will be sent directly to GP’s early in 2003 and continuing articles will be presented in Medical publications such as Australian Family Physician. The Foundation will also be undertaking a public awareness campaign through mainstream media.
Further information is available through the Prostate Cancer Foundation of Australia at www.prostate.org.au and www.prostatehealth.org.au The booklet “Localised Prostate Cancer – A guide for men and their families” is available free of charge by calling 1-800-220-099.