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Programme 6.Ìý ÌýProstate
RADIO 4
THURSDAY 06/09/07 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
CHRIS PARKER
PRODUCER:
BETH EASTWOOD
NOT CHECKED AS BROADCAST
MYERS
Well just for the record the prostate is a gland in the male. It lies between the bladder and the rectum, it's wrapped around the urethra, and its job is to make some of the fluid which carries sperm. Now the only reason you might need to know all this is to understand what happens when it goes wrong. After the age of 50 the prostate tends to get bigger, as it presses on the bladder you might find yourself having to pass water more frequently, notably at night. The benign or naturally enlarged prostate can become a problem and there are treatments. But what's more of a health concern is if the prostate becomes malignant - it gets bigger because it's full of cancer. Any diagnosis of cancer is bound to be worrying but for most men prostate cancer is slow growing and it's not life threatening, it may not even need treatment beyond regular monitoring. If it's more aggressive then it can be removed by surgery or radiotherapy, though you may then be worried about side effects.
Well whatever your concerns today we have a top medical expert here to help, here's Dr Chris Parker from the Institute of Cancer Research and from the Royal Marsden Hospital. And we have got a lot of men on the line. The first caller is Geoffrey Bailey, he's in Taunton in Somerset and he's getting up to pee a lot, is that right?
BAILEY
Well what puzzles me is that I don't during the day - I can go out and not think about it all day and come back and just be normal, there's a good flow but at night I always nowadays - I'm 84 - I wake up and need to go and I don't want to tell it not to bother because it keeps you awake, so I go and it's probably just a dribble and that seems very odd.
MYERS
Well is it odd, do you think Chris, in this case, a man of a good age - 84?
PARKER
Hello Geoffrey. It's not odd at all. As men get older their prostates gradually enlarge, it's part and parcel of the ageing process, and as our prostates get bigger so it becomes harder to pass urine. The tube, the urethra, which carries urine from the bladder is compressed by the enlarged prostate and it means it's harder to empty your bladder completely and you'll find you have to pass urine more often. And for reasons which we don't understand this particularly happens at night.
MYERS
So should Geoffrey be doing any thing about this, it's very distressing to be up and down all night and then you're exhausted the next day, is there any treatment for this enlargement - this natural enlargement - as you've described it Chris?
PARKER
Yes absolutely. So if you were to go along to your GP I expect that he would do a digital rectal examination, that is to say he would feel your prostate through your back passage and he would most likely confirm the impression that your prostate is enlarged and at that point he'd be able to give you medication. And there's medical available now that's very effective indeed at helping you to empty your bladder more fully so that you don't have to pass urine so often and so that you might have a less interrupted night's sleep.
MYERS
Geoffrey, I hope that's helpful, I hope you take that advice from a top doctor. We'd like to move to another call though, if we may now, because Mr Mee is in Leicester and is worrying about when benign - this natural enlargement of the prostate - might become something a little bit more serious, what's your particular concern Mr Mee?
MEE
Well I have a family history of cancer - my father had cancer, my mother had cancer, my father's sister and my father's sister's daughter had cancer. So obviously it's something which is worrying on my mind. I'm living with an enlarged prostate quite comfortably but is there any way I can find out if it - or will I know if it turns cancerous?
MYERS
Over to you Chris.
PARKER
Well the first thing to say Mr Mee is that benign enlargement, as you've described, is completely different from prostate cancer and there's no connection between the two. So the fact that you've got benign enlargement of your prostate gland doesn't make you anymore likely to have prostate cancer than the next man and by the same token it doesn't make you any less likely either. And so if we look at the average man in the UK he has a 3% - a 3 in a 100 - chance of dying from prostate cancer. And the things that we know which influence that risk are ethnic origin - so black men have a higher risk than 3% - and family history. So if you have a family history of prostate cancer, if you have close male relatives who've died from prostate cancer, then your risk of dying of prostate cancer will be a little bit higher than 3%.
MYERS
But if Mr Mee is now worried because I think he mentioned members of the family, although of course the female members of the family don't really count in this, what should he do, is there something that he should keep an eye on what he already knows is an enlarged prostate and if he is - you said no more or less likely but still there's a possibility therefore of developing cancer - how would he know, given that he's already got an enlarged prostate?
PARKER
From what he was saying I was under the impression he had a family history of cancer and not specifically prostate cancer, so I don't think that's relevant, so I would regard him on the available information as having a 3% risk of dying from prostate cancer. And if he wants to take that further I would advise him to go to his GP, once again the GP would do a digital rectal examination, this time looking for nodules on the prostate that might suggest the presence of a prostate cancer. And the GP would almost certainly discuss with him whether or not to have a PSA blood test. So PSA stands for prostate specific antigen and the level of PSA in the blood is a marker of some sort as to whether there's any problem within the prostate.
MYERS
Well now you've pre-empted I think the call from Peter Noake, who's on the line in Lancaster, and is interested in these two different tests that you've started to talk about Chris - the direct rectal examination and the PSA. What's your particular concern or question please Peter?
NOAKE
Hello. Well my particular question I'm sure you can put me right on the facts of this, is given what I understand to be the prevalence of prostate cancer in men I wonder why it's not a routine procedure to do PSA tests, in my experience of having PSA tests is going to the GP one has to insist upon it. And the second part of my question is really about whether the PSA test is in fact a reliable indicator or whether the DRE is in fact a more reliable indicator because as I understand it if the cancer is caught in the very early stages it is something which is much easier obviously to deal with.
PARKER
Yes hello there Peter. Perhaps I'll address the point about the reliability of the PSA first. I'm sure you're aware that PSA testing is a highly controversial area and that opinion is divided on the matter. But we have important new information which tells us that PSA is not as reliable as we thought it was...
NOAKE
It's something I have heard yes.
PARKER
So we've known for 10 or 15 years that if you take men who have a high PSA level and if you then biopsy their prostate - if you take a sample of prostate tissue from their prostate - then you'll find that around about a third of them, 30% or a bit more, will have prostate cancer. Now that's obviously a very high proportion and it's that information which has encouraged people to do PSA testing and if their PSA is high then to go and have a biopsy. Now the new information that's emerged only in the last year is that if you take men with a normal PSA level and you biopsy their prostates then about 20-25% of them will have prostate cancer too. So the PSA level is a very poor indicator of who's got prostate cancer and who hasn't.
MYERS
Does that mean it should now be ruled out, it's just a useless test or does it have a place as part of the other tests, including the digital rectal examination?
PARKER
It's not anywhere near as useful as we thought it was going to be but it's still of some value. So now the factors which influence a man's risk of having prostate cancer are his ethnicity, are his family history, are the results of a digital rectal examination, the PSA level and possibly one or two other things. And so really what I think should be happening now is that men should not be divided into those with a high PSA level and those with a low PSA level and the men with a high level all being biopsied and the men with a low level not being biopsied. Rather what I think should happen is that men should be informed of their individual risk of having prostate cancer based on their PSA level, based on their digital rectal examination, family history, ethnicity. And then the ball's in their court, so to speak, they can then make an educated decision whether to have a biopsy or not. But right now my feeling is that men are rushed through to biopsy. We have the cancer waiting time targets which have been a fantastic innovation as far as improving the treatment of other cancers is concerned but one of the by products is that men with a high PSA level are rushed through to biopsy without having any chance to think about it and I think men should think carefully about the pros and the cons of having a prostate biopsy.
MYERS
Peter, you've asked a very interesting question and I think got a very interesting answer, full of new information and some of which I think Chris will inform guidelines in future, so some of this maybe really quite novel, including for our healthcare professionals, this approach.
PARKER
Yes absolutely. Over the last 10 years it's become standard practice to recommend prostate biopsy for all men with a high PSA and that's very much embedded in medical thought. The new NICE guidelines, which are now out for consultation, say quite clearly that the PSA level on its own should not be used to decide who gets a prostate biopsy and who doesn't.
MYERS
And just a thought, could you not cut to the chase, as it were, quite literally almost, and do biopsies sort of fairly straightforwardly, is there any reason why not to take a sample of tissue, see just what's in there - whether you've got cancer cells or not?
PARKER
Yeah that's a good question. There are clinicians, particularly in America, who've advocated, I think half in jest, biopsying all men when they get to the age of 50. Now the problem with that - well first of all it's an extremely uncomfortable procedure and it can result in bleeding or infection and those infections can be very major. But more importantly if any healthy middle aged man has a prostate biopsy there's a very significant risk that it will discover a harmless prostate cancer, one that was there but never going to cause him any problems. So essentially you're turning fit men into cancer patients. And if I've got a harmless prostate cancer - and there's about a 30 or 40% chance that I have right now - I'd much rather not know about it.
MYERS
This seems to fly in the face of the other evidence that we hear which is that you should find cancers early, treat them aggressively, get rid of them, with your best chance of survival and I think actually Peter was rather making that point, that he wants to know what the story is so that if necessary he can get treatment, that's, you're saying, not the case with prostate?
PARKER
Yes, it's a key point that prostate cancer is different from other cancers, so it's just about the only common cancer which often does not need to be treated. And so around about a half of men in their 50s have got prostate cancer, around about 80% of men in their 80s have got prostate cancer, it's exceptionally common. But remember only 3% of men die from prostate cancer. So it's not that it's nothing to worry about but merely having prostate cancer is not of itself anything to worry about.
MYERS
So die with your cancer not because of it often as not?
PARKER
In the majority of cases that's right.
MYERS
Let me go to the phones again, Mr Strong is waiting very patiently. Has been diagnosed with prostate cancer, leaving with you with questions I think about then treatment. What have you been offered Mr Strong?
STRONG
Well I have a booklet here which mentions active surveillance, radical prostatectomy, radical radiotherapy and obviously the - as you say, as the doctor's just said - active surveillance. I was diagnosed two weeks ago following my second biopsy, the first biopsy was three months before that when I was told there was no cancer but a few abnormal cells and now I've got - what I've been told is that I have low grade minor cancer cells. And I've had the bone scan and the MRI, of which I'm waiting the results of, and I'm going to see the specialist at the hospital next week.
MYERS
So you're in a bit of a state of shock I imagine and no small amount of confusion about the options that are perhaps there.
STRONG
Well to say confusion that's putting it mildly.
MYERS
I can hear that in your voice. Well let's see what Chris has to offer on this.
PARKER
Well Mr Strong I probably can't resolve your confusion but it sounds to me as though you've got most likely low risk localised prostate cancer and that's the commonest type of prostate cancer.
STRONG
Yes only on one side of the prostate apparently.
PARKER
And there are many different ways of tackling this. And I think the most important question that you need to try and focus on in the coming weeks and months is whether to have treatment or not. So prostate cancer, as I said a moment ago, is unlike other cancers, the mere fact that you've got it doesn't necessarily mean it's going to cause you any harm ever. And so it's not inevitably that you're going to need to have treatment. And so you need to try and weigh up the pros and cons in your mind of having treatment or not having treatment. Now for low risk localised prostate cancer if you never have treatment on average we think that fewer than 10% of men will die from their disease, probably fewer than 5% of men will die from their disease. So put another way - you're far more likely to die of something else than you are of prostate cancer. So that's one reason why you might decide not to have treatment for the time being. Another reason why you might decide not to have treatment for the time being is treatment has side effects and if you're unlucky, if you get the side effects from treatment, then you may have to live with them for the rest of your life.
MYERS
You mention there's no reason to hurry, are you talking to spend weeks, months, perhaps even years weighing these things up, because people like to get on with making decisions don't they, that's the problem?
PARKER
Yes, I mean I can't - obviously can't advise you what treatment to have ...
STRONG
No I appreciate that.
PARKER
... but what I can do advise you to do is don't hurry. So you've got weeks, you've got months, but unlike other cancers there is no hurry to treat low risk localised prostate cancer. So if I were you I'd try and get all the information that I want to have, I would talk to my family, talk to my GP, talk to my specialist nurse - they're a very useful source of information.
MYERS
Thank you for raising that and for telling us your story.
STRONG
Could I just add very finally?
MYERS
Go ahead yes.
STRONG
I hear what the doctor says about the PSA checks but I really do emphasise that I think everybody - every man at the age of 50 should have a PSA check and obviously the physical examination because it's all very well saying there is a low percentage where they throw up any sign of cancer but by god when it does throw it hits you and I think every man should have a PSA check and a physical examination at 50.
MYERS
Well I hear that point but I think Chris might want to come back on that ...
STRONG
I've no doubt he will.
MYERS
... from his expertise obviously has a different take on this. I mean there is no really role for screening for prostate cancer in your view is there Chris?
PARKER
There's no proven role. I can understand the way you feel having just been diagnosed with prostate cancer and it's quite possible that a policy of regular PSA testing might reduce men's risk of dying from prostate cancer. We don't know that but it's possible. So if there's a 3% risk of dying of prostate cancer without PSA screening, maybe that might go down to 2% if screening works. But - there's an important but - what Mr Strong actually said was he was worried about the effect of being diagnosed with prostate cancer. Now if you never had a PSA test your chance of being diagnosed with prostate cancer are around about 6% but if you have regular PSA testing your chances of being diagnosed with prostate cancer are about 20 or 25%. So the one thing PSA testing does do is it massively increases the chances that a man will have to deal with the sort of problem Mr Strong is now faced with.
MYERS
Thank you for that. We'll go to Robert now, Robert Jennison's in Yorkshire, and he wants to raise the question of treatment and side effects, in particular, of surgery, I don't know whether this is something you've had or are contemplating having Robert, what's the story?
JENNISON
No, good afternoon, no fortunately not but it's something that I've heard about in previous programmes and read about in newspapers and so on that some men who, for example, as a result of prostate cancer or prostate problems have to have the prostate removed, they then wind up with subsequent problems like impotence and incontinence, especially in a urinary way, and I wondered if maybe techniques have improved and that now there's not quite so much to worry about in that area.
MYERS
Chris?
PARKER
Good afternoon Robert. So surgery is a standard treatment for localised prostate cancer and as you say the radical prostatectomy, as it's called, does have side effects. And incontinence of urine is one of them and the chances of that are actually fairly small now, so less than 1 in 20. On the other hand the chances of impotence is actually quite high after surgery, affecting at least one half of men. What we do know is that the risk of side effects from surgery do vary according to your surgeon and so the more skilled more experienced surgeons do have lower rates of side rates than those who are just learning the technique.
MYERS
Find yourself a very good surgeon that's for sure.
JENNISON
Just one thing Barbara, you actually echoed something that I was told at my annual MOT check up last year and you said it just a few minutes ago on the programme where a doctor who examined at that time, not my regular doctor, said you tend to die with cancer of the prostate not of it.
MYERS
That is somewhat reassuring I think isn't it. Okay thanks for your call Robert. We were talking there about the side effects and the risk of impotence following surgery and it's quite a high risk - I think you said 50%. I don't want to tie this in directly but I have got an e-mail that's just come through from someone who is talking about his sex life and wondering whether more ejaculations are going to mean that you're less likely to get prostate cancer - so is there any connection between your sex life and the development of prostate cancer, any at all?
PARKER
There's almost certainly some connection because it's certainly believed that eunuchs don't get prostate cancer. Now whether the frequency of ejaculation affects your risk is really not known, there's no good evidence one way or the other. I mean sometimes I do get asked by men or by their partners whether sexual activity might be detrimental as far as prostate cancer is concerned and there's no evidence that's the case at all.
MYERS
A question from Geoffrey Brooks in Colwyn Bay. Geoffrey.
BROOKS
Good afternoon. I was diagnosed by accident in 1996 with prostate cancer. I went to the doctor's with a chest infection which the doctor cured and he said that at my age - which was 60 at the time - he was going to check me out for prostate problems, of which I didn't think I had any. Various tests followed over the next few months until December when I had a biopsy and it turned out to be prostate cancer. I had 33 sessions of radiotherapy at Clatterbridge Hospital, since when my PSA has varied between 0.3 and 1.1, is there any chance that this is likely to go any worse after 10 years, nearly 11?
PARKER
I can reassure you Geoffrey that's - Godfrey - it's extremely unlikely. So although I was critical about PSA testing in healthy men, PSA comes into its own in following up men like you, who've had treatment for prostate cancer. And the fact that your PSA is so low 10 or 11 years after treatment for prostate cancer is almost a guarantee that you're not going to have problems from prostate cancer in the future.
MYERS
Why, just for interest, people might be wondering why is it so useful after you've had treatment for cancer and not as helpful as it might be in a diagnostic before you have treatment?
PARKER
Yes. In untreated men the PSA level depends to a very large extent on how big or how small your prostate happens to be. If you've got a big prostate your PSA level will be higher. But after you've had treatment for prostate cancer the normal prostate doesn't produce PSA, so any PSA that you've got left is likely to be coming from your cancer, so it's much more useful after treatment.
MYERS
Thank you very much, some reassurance there for Geoffrey. Quickly to David in London, David's got a question for us which is?
DAVID
Hello, good afternoon. I've heard an awful lot about the difficulty of diagnosing cancers - prostate cancers, things like that - and how awful the treatment seems to be but what about these more whole food ways of dealing - of preventing the disease coming on? We hear a lot about lycopenes, I think that's the word, and eating all fresh vegetables - things like that - do they actually have much effect?
MYERS
This is the tomato diet isn't it?
DAVID
Yes, yes I believe it is.
PARKER
The short answer David is we don't know. I happen to think the diet and lifestyle are probably very important. We do know, for example, that men who live in the Far East are 18 times less likely to die from prostate cancer than we are in the West. And we also know that when they emigrate to America then their risk of dying of prostate cancer goes up. So there must be something about the Western lifestyle which increases our risk of dying of prostate cancer. And short of emigrating to Japan what can you do? I happen to think that probably the most useful thing that we can do is eat less and exercise more, which might not be the advice you want to hear but that would be my view.
MYERS
And that seems to be good advice that we always come to in this programme and there we must end our programme. But thank you very much for that call and thanks to our expert today Dr Chris Parker. Thanks indeed to everyone who's phoned, e-mailed and listened both today and throughout this the summer series, I hope you found some of the answers to your questions. If you want to speak someone else you can call our free and confidential helpline, that's 0800 044 044. And if you want further resources they're listed on our website, go to bbc.co.uk/radio4 where you can listen again to this and to previous editions of Check Up. You can also leave us a message, in particular if there's a topic that you would like us to cover in the next series which starts in November. Until then take care, goodbye.
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