Guest Speaker: Dr Alan Stapleton  M.B., C.H.B., F.R.A.C.S.

"What turns prostate cancer cells on?"

Once again, at our Nov 2003 meeting, Alan gave an excellent and information-packed talk to the group for over 2 hours! Here are some of his key points.

Dr Alan Stapelton

- Urologists are getting busier in SA. There is 1 Urologist to 80,000 people in SA compared to approximately 1 per 40,000 in the US.

- Prostate cancer, like breast cancer, is hormone driven, however breast cancer occurs about a decade earlier than prostate cancer.

- Another key trigger for prostate cancer is age. Prostate cancer will occur in everyone if you live long enough (the only way to prevent it is castration before puberty!). Prostate cancer is a 'part of life'. 4 out of 5 men by 80 years of age will have some cancer cells in the prostate. However, not all these men need treatment.

- Should we be screening for prostate cancer? Current Cancer Council and Australian Urological Society guidelines would suggest that screening all men is not appropriate. However, whilst PSA screening is not recommended, PSA Information is very important. All men should be aware of the test and should decide with their doctors whether this test is for them. The key is making an informed decision.

- Diagnosis of prostate cancer usually happens with a digital rectal examination (DRE) and a PSA test. Then there is a Trans Rectal Ultra-Sound (TRUS) and a tissue biopsy which involves taking about 8-10 samples (this used to be 6). This tissue sample gives you your grade or Gleason score. Then there is usually a bone scan, an MRI and a CT scan undertaken to see if the tumour is confined to the prostate which gives a picture of your stage. Stage and Grade are very important in determining your treatment options.

- The highest PSA result I have ever seen was a man with metastatic prostate cancer who had a PSA of 32,000. The secondary cancers were also producing PSA which led to the extremely high result.

- PSA tests give you an average predictive value, but on an individual basis they are not as accurate as other cancer tests. You can have a low PSA and have advanced prostate cancer, alternatively you can have a high PSA due to an infection rather than due to prostate cancer. PSA is a good guide and good for looking at trends.

- PSA cut off points - A PSA less than 10 is usually viewed as low, between 10 and 20 is viewed as intermediate and above 20 is described as high. 'Normal' PSA cut off's are approximately 2.4 for men aged 40-50 yrs, 3.5 for men aged 50-60 yrs, 4.5 for 60-70yrs and 6.5 for men aged 70-80 yrs.

- There is now a new product to help ease the pain of biopsy. An anaesthetic spray (similar to that used in ENT) and an injection of local anaesthetic are now used.

- Family History:- 1 in 10 patients will have a family history of prostate cancer, for 9 out of 10 men the diagnosis will occur 'out of the blue'. For those with a family history, sons of men aged less than 70 years at diagnosis will have twice the risk of developing prostate cancer than other men their age. For sons who have two first -degree relatives with prostate cancer (ie a father and an uncle) this risk doubles to 4 times Those who do develop prostate cancer due to a family history usually develop it 10 years earlier than their fathers and have a higher Gleason score

- Q: Can prostate cancer be passed on by the mother?. A: there is no evidence for it at this stage.

- Genes. There is still a way to go before we understand exactly how genes work in prostate cancer. We have mapped the human genome, but to know the gene is one thing, to understand how it will be expressed is another, we really need to find out what turns these genes on.

- There are other risk factors for prostate cancer such as comorbidities (other illnesses), smoking, alcohol, diet, BMI, and activity levels to name a few.

- Q: What PSA level should people worry about if they are on watchful waiting?  A: This is different for each person. It depends on your PSA and DRE results, your Gleason score and the presence of other risk factors such as age and comorbidities etc.

- All treatments have side effects and risks. The big three side effects in prostate cancer are gastro-intestinal problems, incontinence and sexual dysfunction. Surgery has a risk of 1 in 500 deaths in 28 days, radiotherapy risks are higher but the population receiving radiotherapy is usually older. We always need to weigh up the risks and benefits of treatment.

- Q: What about alternative therapies?  A: We don't know if they work. They might help or, in some cases, they may be harmful. We all want to feel in control of our health. I usually say to my patients "just try to keep some money in your pocket for other things".

- Chemotherapy has traditionally not worked so well in prostate cancer as the cancer is slow growing and most chemotherapy drugs are aimed at stopping the growth of fast growing cells. There is a new chemotherapy drug being trialled at the RGH called Atrasenton. This drug stunts the nutrition to the cancer.

- Outcomes for prostate cancer remain very good. In most cases prostate cancer may be best viewed as a chronic illness.

- An individualised management plan is important. Everyone is different. Seek other medical opinions until you find a specialist you are happy with.

- At the conclusion of Dr.Stapleton's lecture, Gerry thanked him or his excellent & informative talk and presented him with a bottle of Peter Lehman's finest red.

from notes taken by Melissa