When 60-year-old R.B. Krishnamacharyulu told his doctor in Vijayawada he was bedwetting for the last five years, he'd been immediately advised to have a prostate antigen (PSA) test, a promising blood test that helps detect prostate tumours. Now a week later, the chilling suspicion was confirmed: his PSA was 94.
Both doctor and patient - Krishnamacharyulu is himself a practising ayurvedic physician in Krishna district, Andhra Pradesh -knew what this high reading meant. There was suspicion that two of Krishnamacharyulu's uncles had suffered from prostate cancer, and a grand-uncle had died of it, though it was never confirmed, thanks to poor diagnostic access in those days. So at his late age, Krishnamacharyulu, Pamarru village's friendly neighbourhood `vaid', was five times more vulnerable to this disease than his peers with no afflicted relatives. Did he now have the disease Indian men should fear most?
Prostate cancer is to men what cervical cancer is to women. This year, according to the Indian Cancer Society, 6,600 Indian males will learn they have a malignancy in this walnut-size gland that helps produce semen. Some 4,000 will die, making the disease as one of India's top killer cancers.
Prostate cancer occurs when some of the cells that make up the prostate gland escape from the normal controls on their growth and start to divide, grow and spread in an uncontrolled manner.
At first, the growth of the cancer occurs very slowly and is usually limited within the prostate gland. Later on in the course of the illness, the prostate cancer cells can spread around the body, particularly to the bones where they can cause pain and disability. Estimates show that the cancer may have been growing in some men for up to 10 years before it causes symptoms and is diagnosed. Some men develop sypmtoms whereas others do not. In those that do, the following symptoms are commonly found:
frequent trips to urinate (especially at night) poor urinary stream urgent need to urinate hesitancy whilst urinating lower back pain blood in the urine
There appears to be several forms of prostate cancer. Some men survive for many years with the disease and never develop symptoms. These men may be oblivious to the fact that they have a slow growing form of prostate cancer and may eventually die of other causes. However, other prostate cancers can be more aggressive and can grow quickly. Unfortunately, we can not differentiate between these two forms of the disease using the currently available diagnostic tools.
At some time in their lives, approximately one in 22 Indian males will be struck by prostate cancer. Its incidence, rising 3.5 percent a year, will keep growing as better nutrition and health care extend average male longevity past the 60s.
Would an early demise now deny paternal Krishnamacharyulu at least seven years of the active, service-oriented life he loves so much? Stop him from seeing his darling grand- daughter, only 14 now, get married? Prevent him from enjoying a retirement with his long-dreamt pilgrimage to Kashi and Vaishnodevi? His case is a reminder how critical it is to diagnose prostate cancer early. An ageing population, decreasing trend of deaths due to cardio- vascular and lung diseases have pushed prostate cancer to be the top killer after the tobacco-induced cancers of the lung, oesophagus and larynx.
Men -and the women who love them -need to keep these three facts in mind.
Fact 1: When malignancy is diagnosed and treated while still contained within the gland, cure is likely. Doctors report that thirty-five to 40 percent of such early cancers show no disease progression five years after treatment.
Fact 2: If the cancer is not detected before it spreads to bones, lymph nodes, brain, lungs or other organs -as happens 75 percent of the time - it is usually not curable. However, doctors can help with, besides pain relieving treatment, hormone therapy that inhibits the manufacture of testosterone, which accelerates the cancer's spread.
Fact3: Every man 50 or older (40 and over if prostate cancer runs in the family) should get two tests annually. The first is a digital rectal examination, in which the physician's rubber-gloved finger gently feels the prostate through the rectum for suspicious enlargement, nodes or stiffness. The second is the PSA blood test, involving a simple needle prick.
Developed and widely tested in America in the late 1980s, the PSA test measures how much prostate specific antigen - the enzyme that liquefies semen -leaks from the prostate into the bloodstream. Urologists in Indian metros are increasingly using it to pinpoint prostate cancer.
PSA screening is an extremely valuable tumour marker. While other blood tests can detect tumours, they don't clearly tell where in the body they originate. With the PSA, an examiner knows the problem is prostatic and can gain evidence of malignancy. That's because cancerous cells leak much more of the enzyme into the bloodstream than benign ones do.
In India, studies show that at 50 years, one person in every lakh risks the disease. At 60, the figure rises to 7. At seventy, it jumps to 70. And at 80 years, it shoots to 115. The Indian incidence levels are only an eight of those in America, but prostate cancer in the sub-continent is invariably diagnosed late -at the average age of 65 years, according to Dr Balkrishna Yeole, epidemiologist, statistician-author and deputy director of the Indian Cancer Society.
An American study found that PSA levels begin rising seven to nine years before clinical diagnosis is usually made. There has been no similar study in India, but doctors agree that PSA tests can detect three-fourths of prostate cancers an average of four years before diagnosis would be made without such tests. Also, repeat tests measuring PSA levels over time significantly reduce the number of false readings and, thus, lead to fewer unnecessary biopsies.
The trouble is, most Indian men don't know this critical test exists. And, while a large number of internists and urologists use it, few family doctors or general practitioners include the PSA in routine physical exams of middle-aged and older men. What's more, as it is a diagnostic test and not technically `treatment', Mediclaim will not pay for it. There is no organisation to sponsor its use in mass-screening either. So, to get PSA testing, a man often must ask for it and pay the average Rs 500 cost out of his own pocket.
Wider use can't happen too soon. For that to occur, however, the disease must come out of hiding -as breast cancer has, publicised by globally recognised survivors such as Nancy Reagan. Men, in contrast, often hesitate to tell others they've have prostate cancer, perhaps because treatment sometimes destroys sexual potency. Most middle-aged Indian patients go untreated for prostate cancer, or wait too long to be treated, because of reluctance to talk about it with their physicians.
In America, the disease has at last gained a needed spokesman: Presidential aspirant Robert Dole. ``The PSA detected my prostate cancer early and probably saved my live,'' Dole campaigned after successful treatment last December. ``I want others to have the same chance.'' India unfortunately is yet to see any similar crusade, though the Indian Cancer Society and Cancer Patients' Aid Association are publicising the need for fast action. The Society has five cancer detection centres in Bombay alone, besides a mobile cancer detection unit, and publishes literature on importance of early cancer detection.
Fresh from Bombay's Tata Memorial Hospital after an expensive prostatectomy to surgically remove his prostate gland, Krishnamacharyulu is now urging his vulnerable relatives to learn about the disease. ``I'm telling my brothers never to ignore this dangerous little gland.''
Most Indian middle-aged men, however, think they are too poor - or too busy - to bother with even an annual physical. When he received his PSA report that September morning, Krishnamacharyulu was more than alarmed -he was bewildered. ``I never thought it would happen to me,'' he said with a dry but relieved smile. For him, however, the dangerous bit is over.
One small danger that does lurk, however, is for other casual patients: Surveys show that digital examination misses nearly half of early-stage cancers, especially those in the front part of the gland that the finger can't reach.
Lung, oesophagus and larynx cancers -all tobacco-induced - claim more lives in India than prostate cancer, which however hits back with the maximum number of victims above the age of 80.
In the final reckoning, these are the things Krishnamacharyulu wished he had noted years ago:
Know your prostate. Reddish-brown and averaging 0.7 ounce, the soft-tissued gland nestles in the lower abdomen below the bladder. It encircles a half inch of the delicate urethra that channels urine and, during intercourse, male ejaculate to the penis. The prostate contributes enzymes, proteins, sugars and fats to the seminal fluid to nourish millions of sperm from the testicles and carry them up the vagina into the womb.
Learn how the prostate acts up. Except for occasional urinary-tract infections and prostatitis, both treatable with antibiotics, the tiny gland typically functions without mishap in the youthful years. But as men approach middle age, the prostate begins to grow larger. This occurs in nearly 20 percent of men by age 50, and nearly all men, in varying degrees, beyond that age. Hormonal change is probably responsible, but no one knows for sure.
Pressing against the urethra, the enlarged prostate can slow urination to dribbles, cause burning and infection, and leave a man feeling he has not quite emptied his bladder. Most frequently these symptoms denote a common, noncancerous condition called benign prostatic hypertrophy (BPH). This year, dozens of thousands of Indians will be treated surgically or with drugs for BPH.
Watch for cancer symptoms. Urinary irregularities that flay BPH are also symptoms of prostate cancer. So are blood in the urine, pain on urination or ejaculation, and lower back pain. But frequently, as in Donnie's case, the disease gives no warning. That's why the PSA is critical. It detects 32 percent of tumours that digital examination misses. The digital exam, in turn, catches 21 percent of the malignancies missed by the PSA. So both tests are needed.
Get state-of-the-art diagnosis. When symptoms or tests raise suspicions, see a urologist. A PSA reading of zero to four usually signifies a healthy prostate. But if the PSA is above ten, or if the digital exam reveals an irregularity, examiners typically recommend an ultrasound-guided biopsy. In this procedure, a pencil-thick fibre-optic tube is eased up the rectum to bounce sound waves off the prostate. The biopsy needle, guided by the ultrasound picture toward thick tissue, snips off tiny bits for microscopic study -the sure way to know if there's cancer.
The examiner's skill is critical. As good as the PSA is, it sometimes gives false results. Diagnosis based on a single PSA may wrongly identify BPH as potential cancer, leading to costly, unneeded biopsies that could cause infection. Among India's best hospitals for prostate cancer treatment are Tata Memorial, Jaslok, Sushrusha, Hinduja, Breach Candy (all in Bombay), Kidwai Memorial Institute (Bangalore), Regional Cancer Centre (Trivandrum), Cancer Institute Hospital (Madras), and All-India Institute of Medical Sciences (new Delhi).
Lives can also depend on how the examiner follows up PSA readings in the 4.1-to-ten ``grey zone'' where early, curable cancers are often detected. Some urologists perform a biopsy promptly after such readings. Others do so only if the reading seems high relative to prostate size, or if it rises in follow-up tests. Krishnamacharyulu's urologist, Dr J.N. Kulkarni of Tata Memorial Hospital, advised the removal of his prostate on getting abnormally high readings.
Know your treatment options. The malignancy usually grows slowly, with the tumour taking as long as a decade to swell from the size of a pea to that of a small marble. Unfortunately, doctors cannot distinguish the occasional virulent tumour from the slow-glowing variety. That's why, when cure could mean at least another decade of life, urologists tend to treat aggressively. For men in their mid- 70s and beyond, however, treatment tends to be less aggressive.
The surest, traditional cure for Stages A,B-1 and B-2 prostate cancers - those caught before they've spread -is prostatectomy, followed by radiation therapy. Although fewer than five of 100 patients fail to survive prostatectomy, the others risk impotence and incontinence.
Now a new technique honed in America's Johns Hopkins University makes it possible, in more than half the cases, to save vital penile nerves, reducing the chance of incontinence and preserving potency (with erection and orgasm, but no ejaculation). If the patient wants to father children, ejaculate can be frozen in a sperm bank before surgery.
External beam radiation achieves ten-to 15-year cure rates. Seattle's Northwest Tumor Institute also reports ``excellent'' early results after implanting tiny radioactive pellets with ultrasound-guided needles. In radiation treatments, there are generally few problems of impotence, incontinence or bowel damage. Dr Kulkarni of Tata Memorial says the technique will soon catch up in India too.
Make your own decisions. When confronting a potentially curable prostate cancer, don't leave the treatment decision entirely to your physician. The ``right'' choice can vary with age, the importance of sex in your life and the feelings of your wife. When Krishnamacharyulu realised he had prostate cancer, he almost gave up on his dreams. But as his surgeon said, ``When you stop dreaming, you stop living... moreover, modern medicine is at your service, provided you give it a chance. For reporting late, 75 percent of patients die within ten years of diagnosis.'' So before deciding:
* Read up on prostate disease and discuss treatment options with your doctor.
* Get opinions from one or two surgeons, and from an oncologist specialising in external beam radiation, another in radioactive implants.
* Above all, recognise the value of early detection. Some time, Jaslok hospital saw a prostate cancer case diagnosed as Stage D -advanced well into other organs. The doctors castrated and irradiated him. he lived almost two years, if your can call it living. In the end, he suffered severe bone deterioration and excruciating pain. Death, when it came, must have been merciful.
In that way, Krishnamacharyulu, Pamarru's `vaid', was lucky indeed.
Krishnamacharyulu, his troublesome prostate no longer in him, continues to practice ayurveda in idyllic Pamarru.
In contrast to some other types of cancer, cancer of the prostate can be treated fairly effectively even when it has spread. It is however important to catch the disease at the earliest possible stages as this may increase the number of treatment options available.
Suggested Links:
Basic and Clinical Aspects of Prostate Cancer
Prostate Cancer and Health Resources
