Year : 2006 | Volume
: 22 | Issue : 1 | Page : 32--34
Analysis of prostate cancer in Tamil Nadu and Pondicherry: Are we missing the boat?
A Mukherjee, S Kumar, NS Kekre, G Gopalakrishnan
Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India
Department of Urology, Christian Medical College, Vellore - 632 004, Tamilnadu
Objectives: Why is it that we do not see enough early prostate cancer in our urological practice? Is it really uncommon, or is it that we are not convinced about the need for its aggressive management? This study intended to look at the opinion and patterns of practice among urologists in Tamil Nadu and Pondicherry, with regards to early prostate cancer. Materials and Methods: A questionnaire was sent to 63 urologists of these states to assess their opinion and practice, regarding the detection and treatment of early prostate cancer. Simultaneously, we retrospectively assessed the cases of carcinoma of the prostate seen at our hospital between January 2001 and September 2003. In these patients, we looked for evidence to see if they could have had localized disease and could have been further evaluated for curative therapy. Results: Though 69% of urologists believed in early prostate cancer detection, only 48% attempted early detection and 41% offered these patients, curative therapy. The most common reason for this was the opinion of urologists that, «DQ»we do not see early prostate cancer in our practice«DQ». An analysis of 153 of our patients revealed that at least 26 of them could have been further evaluated towards curative therapy. Conclusions:One may not believe in the virtue of treating early prostate cancer. If however we are convinced about its usefulness, we are overlooking many cases who could have been offered curative therapy.
|How to cite this article:|
Mukherjee A, Kumar S, Kekre N S, Gopalakrishnan G. Analysis of prostate cancer in Tamil Nadu and Pondicherry: Are we missing the boat?.Indian J Urol 2006;22:32-34
|How to cite this URL:|
Mukherjee A, Kumar S, Kekre N S, Gopalakrishnan G. Analysis of prostate cancer in Tamil Nadu and Pondicherry: Are we missing the boat?. Indian J Urol [serial online] 2006 [cited 2020 Nov 24 ];22:32-34
Available from: https://www.indianjurol.com/text.asp?2006/22/1/32/24650
Surgical management of prostate cancer forms a major part of urological practice in the United States of America, today. The infrequent detection of prostate cancer amenable to surgical cure in our country raises two possibilities. Is prostate cancer really significantly less common in our country than in the USA, or is it the result of lack of enthusiasm in detecting early prostate cancer? While the prevalence of histological carcinoma of the prostate has never been studied in the Indian population, studies in low clinical prevalence areas like Japan seem to suggest that, prevalence of histological carcinoma prostate may not be significantly different in different races. The aim of this study was to evaluate the use of Prostate specific antigen (PSA) in the early detection of carcinoma prostate by urologists of Tamil Nadu and Pondicherry. We also planned a retrospective review of the spectrum of cases of carcinoma of the prostate seen at our hospital, to assess if we were overlooking possible curable cases.
Materials and Methods
This study was performed in two parts. We conducted an e-mail and telephonic interview of urologists in Tamil Nadu and Pondicherry, wherein we asked them four simple questions:
1. Do you routinely test for PSA levels before starting a patient on medical management for benign prostatic hyperplasia (BPH)?
2. Do you believe in early detection of prostate cancer?
3. If yes, do you attempt early detection?
4. How would you manage a patient with a diagnosis of a significant localized prostate cancer?
The urologists questioned, were contacted using the phone numbers or e-mail addresses available in the directory of south zone of Urological Society of India. We attemped to contact all urologists listed therein, but were able to get a reply from some members only.
As a second part of this study, we retrospectively analysed the data on all patients with biopsy- proven prostate cancer seen at our hospital between Jan 2001 and Sept 2003. In these patients we looked at the mode of detection, the distribution of Gleason's grade, PSA levels and evidence of metastasis. These data were analysed to look for patients who could be having significant localized disease and could have been further worked up for a curative therapy.
Of 63 urologists to whom the questionnaires were sent, we were able to get a response only from 42. While 48% routinely asked for a PSA report before initiating medical management, 38% did not, while 14% did so, selectively. Sixty nine percent of these urologists believed in attempting early detection of prostate cancer, while 31% did not. A fair number of urologists who did not believe in early detection, reasoned that early prostate cancer cases did not exist in their clinical practice. However, in spite of being convinced about the utility of early detection of prostate cancer, only 48% of the urologists actually attempted early detection. The reasons for that being lack of facilities for trans rectal ultrasound (TRUS) guided biopsy, or inability to provide curative therapy in case of early detection. Even more surprising was the management recommended in significant localized prostate cancer. Only 55% of the urologists would offer or refer for curative therapy- 41% preferred radical prostatectomy, while 14% would offer their patients, radiotherapy. These figures represented the opinion of the urologists and not necessarily their practice. A lack of early prostate cancer detected in their clinical practice meant that some urologists were not actually referring patients for curative therapy. Thirty eight percent would offer hormonal therapy for early prostate cancer, while 7% would prefer to follow up their patients.
Our patients- We had a total of 153 patients with an age range of 44-95 years (mean-66.6 years). Of these, 105 patients were less than 70 years of age. Evaluation for suspicious digital rectal examination (DRE), raised PSA or metastasis evaluation resulted in the diagnosis in 126 patients. Twelve patients were diagnosed to have prostate cancer following transurethral resection of prostate (TURP), while 15 patients presented with slides made elsewhere, showing malignancy. Of the 153 patients, 149 had a Gleason score reported in their biopsy reports, 136 had PSA done before biopsy, while 104 had bone scans following diagnosis. Seventy six patients had sufficiently advanced local disease to undergo finger-guided transrectal trucut biopsy. Thirty four patients underwent TRUS guided biopsy, 15 presented with slides made elsewhere, while 28 patients were diagnosed after TURP. Of these 28 patients, carcinoma was clinically suspected in 16 patients before TURP and surgery was offered to them for bothersome lower urinary tract symptoms or acute urinary retention. Twelve patients were incidentally detected to have prostatic malignancy in the TURP chips. The distribution of Gleason score and PSA in terms of patient numbers is shown in [Table 1]. The distribution of PSA and bone scan findings is shown in [Table 2]. Percentage of patients with Gleason score 2-6, 7 and 8-10 who had bone secondaries was 42%, 60% and 70%, respectively. In eleven of the 12 patients with carcinoma detected on TURP, the Gleason score was less than or equal to seven.
The basic dilemma in radical therapy of cancer of the prostate today, is aptly summed up in the often quoted words of Whitmore, 'Is cure necessary in those in whom it may be possible and is cure possible in those in whom it is necessary?" While one may not be convinced about the benefits of radical therapy for early prostate cancer in most cases, if we are convinced that it works, it is wrong to assume that early prostate cancer does not exist in our practice. If we were to consider patients of less than 70 years with a PSA of less than 10 and no secondaries on bone scan as eligible for further workup for curative therapy, there were 15 such patients in our study. Another 5 patients had PSA between 10-20 ng/dl. Four other patients with a PSA of less than 20 had bone scans, not definitive of secondaries. They could have had further workup for confirmation. A further 11 patients with Gleason score less than or equal to 7 detected incidentally on TURP, could have been evaluated for curative surgery. Thus even without a policy of actively searching for localized prostate cancer, at least 26 (15+11) of the 153 (16.3%) appeared to have low grade and low volume disease. Co-morbidities are likely to further reduce the number eligible for surgery. A retrospective study like this is likely to have overlooked some other factors which could have influenced our decision for surgery. However it does prove one fact- we can find early prostate cancer in our population, if we look for it. The early results of the Scandinavian Prostate Cancer Study Group by Holmberg et al show an improvement in disease specific survival of 2% at five years and 6.6% at eight years, following radical prostatectomy. Interestingly 77.8% of these patients were stage T2 and were not detected by screening. With a risk of metastasis reduced by 14% at eight years, the reduction in disease specific mortality is likely to become more significant on further follow up.
Prostate cancer is presently the most studied urological malignancy. The uncertainty in the minds of the general urologist in our country is well seen in the response to the questionnaire. If however we are convinced at some point of time that radical prostatectomy does work, we will find adequate cases if we are on the look out for it.
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|2||Holmberg L, Bill-Axelson A, Helgesen F, Salo JO, Folmerz P, Haggman M, et al . A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med 2002;347:781-9.|