Dr Ademola Oyekan consultant radiation and clinical oncologist at the Lagos State University (LASUTH) speaks with Gboyega Alaka on Prostate cancer, why it is rampant among people of black race, plus the difference with prostate enlargement and urinary tract infection.
What exactly is prostate cancer?
Prostate cancer is cancer arising from the prostate. The prostate gland is a gland in the urinogenital system. It is a gland responsible for producing some parts of the things that form the semen. The gland lies beneath the bladder and the urethra – that is the pipe that takes urine. The urethra moves through it to come out on penis. So urine moves from the bladder, through the urethra. So the cancer that arises from there is called prostate cancer.
We also hear of prostate enlargement. Is it the same as prostate cancer or they are different?
The prostate gland is a tissue; it is a fibromuscular gland; that means it has about two or three components – the fibros component, the muscular component and the epithelia component. The epithelia component forms at the periphery of the prostate. Now there are different zones and different lobes inside the prostate. Observe that the prostate enlargement occurs in the fibro muscular part. As we grow older, from the age of maturity, the prostate gland enlarges every decade. For different people, depending on their family history, the increase varies. When the prostate enlargement is occurring, especially in that fibromuscular area, it enlarges to such a point where it will be causing cessation of urine, where the person will have to wait a while for his urine to flow. That is benign prostate enlargement. Almost every male grow up to have it. However, prostate cancer occurs in the periphery of the prostate gland. Most times, it does not cause enlargement but it can cause some nodular thickening of the prostate. So for a number of people, when they have benign enlargement and are going through difficulty in urinating or frequency of urination, they may decide to go for prostate surgeries; and at this point, they may find some traces of cancer in it. That means it is possible for somebody to have both benign prostate enlargement and prostate cancer. However, somebody may have prostate cancer without a benign prostate enlargement, and that is the one that is most dangerous, because most patients don’t have symptoms until it is very advanced.
Is it possible to reverse the enlargement, such that the person can begin to urinate freely?
Yes, there are drugs that can be used to make the size of the prostate gland smaller.
Are the drugs dangerous or have negative impact on the sexual capability of the patient?
No, the drugs will not affect the libido, but the presence of that enlargement itself could be impinging on the nerves around the prostate gland and could cause eventual problem with libido, that is erection or ejaculation as the case may be. Bear in mind, however, that at some point, the drugs may begin to fail.
There have been talks about exercise playing a role in reversing prostate enlargement; what’s your take on this?
I don’t think there is any concrete evidence regarding that. What happens is that exercises can make you burn some fat and maintain a normal BMI. When you do that, some parts of your body may be shrinking. But this thing is not 1+1. It may happen, it may not happen; and that’s why I say it is inconclusive. There is no conclusive evidence but there may be a role theoretically.
Another way to reduce prostate enlargement is to undergo surgery, whereby they try to bore a hole through the urethra. That surgery is called TURP – Transurethra Resection of the Prostate. TURP is another way and it is more long-lasting, more durable compared to use of drugs.
Let’s talk about Urinary Tract Infection; what role does it play in passing urine? Can one have it without having prostate enlargement? A lot of people have urinary tract infection and think they have prostate enlargement or prostate cancer.
Urinary tract infection is an infection that occurs as a result of external factors, maybe infection that you pick in the toilet, but it’s not very common with men. It’s more common with women because they have a shorter urethra. What men have is more of STI translating to urinary tract infection, which they pick from their women or sexual partners. Of course if somebody has the habit of storing urine, he can develop urinary tract infection. If you have a habit of waiting too long before going to empty your bladder when you are pressed, you run a higher risk of developing urinary tract infection, although it is treatable.
Now, does that increases the risk of prostate cancer? I’d say yes – because of chronic inflammation. And it’s not just prostate cancer, but risk of other diseases, because it’s like a part of the body is getting injured and healing, and cells are being formed and destroyed. When this process keeps going back and forth, anything can happen.
Now, what are the causes of prostate cancer?
Prostate cancer does not have a cause that we can lay our hands on as we speak, but we can say there are things that increases the risk. One is increasing age. As you grow older, you have a risk of having prostate cancer. Among the whites, they have a higher life expectancy – about 70; but for us black, it is lower – about 68/69. So the age for prostate cancer in most backs, especially in Nigeria, is 68. We have seen prostate cancer in younger persons, but what we have observed is that the younger a person is, the more aggressive the disease is likely to be.
Any reasons for that?
Well, cancers generally are usually more aggressive as outliers; that is when found in the age you are not supposed to see them. If you see a person in his 40s having prostate cancer, by the time you diagnose it, it may even have reached an advanced stage. Whereas you can see a 75/78 year old man, who doesn’t even know he has cancer. Most times, you just detect it by incidence. And you may even realise that it is still localised and there is no problem. But basically, increasing age increases the risks. If there is a family history in first degree relatives, maybe a brother with prostate cancer, such a person has a high risk of developing prostate cancer.
Another thing is race. Prostate cancer is commoner in blacks. It has been established that black people have a higher level of testosterone, and this cancer feeds on that hormone. So it is more aggressive when you find it in a black man than white men, and more common. And there are some genetic or hereditary factors; there are some genes that when somebody has a mutation (when a gene has been altered), it increases the risk. And one of the major gene that evolves is the Human Prostate Cancer Gene HPC1. The other is BRCA2 (Breast Cancer Antigen 2). Those are some genetic factors that have been implicated. There are others, but we’ll leave it at this two for this discussion.
The other thing is diet. When you consume foods that are high in animal fat and are low in vegetable, there is a higher risk.
What about alcohol and cigarette?
Well that of alcohol is not convincing, no conclusive evidence; however, smoking increases the risk. So also obesity.
Is it treatable?
Yes it is treatable, but it can also reoccur. So if it’s detected early, the options are to do surgery or radiotherapy. Sometimes, we can also do what we call Watchful Waiting. This is for people who have a life expectancy that is less than ten years. Let’s say you have a 90-year-old male patient that has prostate cancer who may be looking frail and also have other diseases that can kill him faster. So you may want to watch and only manage the symptoms. That is watchful waiting or observation.
Another way to go about it is Active Surveillance, where somebody has prostate cancer that is early, but you feel that because of the type, you may just keep checking from time to time: checking his PSA, doing scans for him and biopsies, to know if the prostate cancer is becoming advanced. So by the time you notice a change – because somebody can have prostate cancer that can remain at the same level for four years and you have to be monitoring it; then you swing into action to treat. But primarily, to eradicate it in the early stage is to do surgery. Surgery involves the removal of the prostate and the surrounding structure- the seminal vessels.
Does that take away the sexual power of the man?
It is not supposed to, but part of the complication is that it could affect the libido of the person and ejaculation. So many a times, a lot of men run away from surgery. So even though a cancer can be treated and cured by surgery, patients prefer to evade it because of that complication. But according to our ethics, it is important for us to enlighten our patients about the complications associated with every procedure before we carry it out; so that they can take informed decision and we will not be held liable. Also we need to get consent.
Is it automatic that the procedure would lead to loss of sexual ability?
No it is not automatic, but the risk is there, about 20 to 30 percent.
What is the rate of recovery from prostate cancer?
In the US and advanced countries where they have a more advanced approach to health, they have a system that works where the patients who are on insurance go for screening. We don’t have that system here. Here, people pay out of pocket, so it may be out of sheer will. Over there, they do it out of compulsion, because if they don’t do it, the insurance company can sue them. And if they present at an advanced stage, the insurance company can refuse to pay because the patient was reckless. Here we have a lot of advanced cases, where patients present when it is already at advanced stage. They may have been having the symptoms for years but only present when it has become unbearable. Sometimes, some people present to the hospital but the clinicians may not be properly trained to interpret the symptoms, and may end up playing it down, thereby making the patient miss that early diagnoses. So there, they are able to treat at early stage and patients recover better.
The other advantage is that among the white, the disease is far less aggressive compared to blacks; remember what I said about the testosterone concentration among blacks being higher. So most times when we pick it, it is usually at advanced stage.
