Sometimes, and particularly in a country such as ours with no organized screening programme, prostate cancer is detected late. These cancers may present with blood in the urine, pain, kidney 
failure and in very advanced cases may spread to other organs or to the bones in the back, even causing paralysis.
How does the urologist decide that the cancer has spread?
The urologist will request special scans of the abdomen and pelvis such as an MRI which will show whether the cancer has spread outside the prostate. He will also request simple x-rays of the bones of the spine which may show spread. Depending on the clinical examination and PSA value at initial evaluation, he may request a bone scan (this is a nuclear scan of the bones). An MRI scan of the back may show spread to the back or compression of the spine.
What are our options for treating cancer which has spread beyond the prostate?
If the cancer has metastasized, meaning it has spread beyond the prostate, the primary treatment option is hormonal manipulation. This is achieved by lowering the patient’s testosterone. Testosterone is to prostate cancer what gasoline is to a fire – it in a sense, acts as fuel. Therefore, lowering the testosterone is usually accompanied by a shrinking of the cancer. We can lower the testosterone through injections, given every few months or by removing either the entire testicle or the part which produces testosterone – this is called an orchidectomy. An orchidectomy is done under local anaesthesia and is completed in less than an hour. Both testicles are removed during the procedure but as an alternative the testicles may be opened up, the testosterone producing insides removed, and the outer covering sewn up – this is called a subcapsular orchidectomy and gives a more natural feel. When the testosterone is low enough, men may experience hot flushes, erectile dysfunction and gradual bone loss.
What about the injections?
These injections are given every 30 to 90 days and lower testosterone by acting on the brain. Their effect is the same as an orchidectomy. They may be accompanied by pills which also block testosterone at the cellular level. Unfortunately these injections are very costly – one injection averages US$400 to US$700 in Trinidad and Tobago. Because of the cost and the associated side effects of treatment, a strategy has evolved whereby the injections are stopped when the PSA drops to a low level and restarted only when it rises again – this is called intermittent androgen deprivation and gives the patient an “off period” from the drug.
Can the patient’s cancer progress even when on hormonal treatment?
The answer is yes. Even if the patient reaches very low levels of testosterone the cancer may eventually start to grow again. This happens for a number of reasons one of which is the continuous mutations seen in cancers. This growth even in the face of low testosterone is called castrate resistance and typically occurs after several years although it can occur within months of starting treatment. A number of options will be discussed once the patient reaches this stage, including chemotherapy.
What other problems can an advanced cancer cause?
Sometimes the cancer can block the bladder outlet and cause what is commonly referred to as stoppage of water. The tumour may grow into the bladder and block the outlets coming from one or both kidneys, leading to swelling of the kidneys and kidney failure. One feared complication is spinal cord compression caused by spread of tumour to the spine – any leg weakness in a prostate cancer patient should be reported immediately and treated with the utmost urgency.
Palliative care
Sometimes patients reach a stage where all options are exhausted and there is nothing else we can do. These patients should be treated with dignity and understanding. Palliative care should meet the patient’s physical and spiritual needs. Particular emphasis should be placed on adequate pain control.
This has brought an end to the series on prostate cancer. If you have any questions or ideas for future topics, please email at satyendrapersaud@yahoo.com
