...So said the BBC on 19/1/17, commenting on the results of the PROMIS study. This is a major UK research study comparing the effectiveness of standard (trans-rectal) prostate biopsy, template prostate biopsy, and MRI scans in diagnosing prostate cancer. Prostate biopsy can be unpleasant, and can have side effects. MRI detected 93% of aggressive cancers compared to 48% of cancers when the prostate was biopsied "at random". With greater use of MRI scans, up to a quarter of men who currently undergo prostate biopsy might be able to avoid biopsy altogether. This is exciting evidence. Some concern has been expressed about whether a "normal" MRI in this study might miss some cancers that could be significant. But overall this work supports greater use of MRI in the diagnosis and assessment of prostate cancer. This is something that we've been doing in Bournemouth for a couple of years. MRI is available to all men in the diagnosis of prostate cancer, and is used widely in the on-going surveillance of men in whom the prostate cancer is low risk.
This headline was typical of the way in which a preliminary research study was reported. This is exciting work. A light sensitive drug is injected into a patient with prostate cancer, and then fibres that emit a laser light are inserted into the prostate. The light switches on the drug, and the drug kills prostate cancer cells. And it seems to work - at least in some patients. We need new treatments for prostate cancer - treatments that have fewer side effects than current treatments. And this treatment shows some promise. Unfortunately though, the reporting of this preliminary research made it sound as if this is a major, proven advance. It's not. All the patients treated had very low risk prostate cancer - the kind of disease that urologists wild generally watch, rather than treat (known as Active Surveillance). And of those low risk patients, only half were free of cancer at the end of the treatment period, and in nearly one third of patients the disease seemed to get worse. The side effect profile wasn't that impressive either - with one third of patients developing erectile dysfunction. Unfortunately the hype was not supported by the published results. Some promise, yes. But a major new advance? No, it's a long way from that.
Many cancers are linked to obesity - breast, bowel, and kidney cancers for example. It's not entirely clear whether obesity makes developing prostate cancer more likely. But recent evidence from France suggests that once you have prostate cancer it may behave more aggressively if you are obese. It might be that fat cells around the prostate release factors that encourage prostate cancer cells to spread beyond the prostate.
As always though, the situation here is not black and white. Many are aware that omega-3 fats (found in oily fish) are linked to all sorts of health benefits. A couple of studies though have suggested that men who have high levels of omega-3 fats in their blood might actually be more likely to develop prostate cancer. There might be an association here, but an association is not the same as cause and effect. There might also be a difference between men who have high levels of omega-3 from supplements (as opposed to men who are eating fish without additional supplement pills).
So for now, being slim and eating a healthy balanced diet that includes fish, but possibly without additional supplements, is the best we can do to reduce prostate cancer risk.
Exercise is good for you, and being overweight increases your risk of certain types of cancer - so it's good to keep fit and to try to stay slim. But what about the situation when someone already has cancer - could exercise actually be a treatment for cancer? Researchers in Sheffield are looking at this question in men who have been diagnosed with prostate cancer. 50 men who have a diagnosis of prostate cancer confined to the prostate are being split into 2 groups. Half will have supervised exercise sessions and half will be told about the benefits of exercise but will not have direct supervision over their physical activity. The PSA blood test will be monitored to determine the impact of exercise on prostate cancer. Therein lies one of the problems of this study - PSA is an awkward (though useful) test - using it as a marker of cancer progression will be difficult.
Actually there's quite a bit of evidence already that exercise affects prostate cancer. In 2011 the "Brisk Walking Study" from San Francisco showed that men with prostate cancer who walked at least 3 miles per hour for at least 3 hours a week had a better prognosis. It could even be that exercise increases the expression of some genes that are important in combatting prostate cancer.
More data is needed, but what we know for sure, is that exercise is good for you!
Researchers from Loyola University in Chicago have discovered that normal urine in healthy people can contain bacteria. It is a commonly held belief that normal urine is sterile and the presence of bacteria in urine must be an abnormal finding which could contribute to urinary symptoms. Using very careful collection techniques and very sensitive ways of detecting bacteria, these researchers in Chicago have demonstrated that normal urine can contact bacteria. The other side of the coin here is that traditional ways of identifying bacteria in the urine may be insufficiently sensitive to pick up all types of urine infection. We have known for some time that some patients with the typical symptoms of a urine infection can get better with antibiotics even when bacteria cannot be identified. This recent study demonstrates that this may be because there has been bacteria in the urine all along but we have just been unable to find them.
Researchers in the University of Michigan have discovered a biomarker that may help differentiate between aggressive and non-aggressive prostate cancer. The protein known as RUNX2 can change its structure to activate specific genes in prostate cancer cells. One change in the RUNX2 protein known as phosphorylation may be associated with more aggressive forms of prostate cancer.
We have known for a long time that a central dilemma in prostate cancer treatment is trying to work out which men have disease which is a threat to the quality or duration of their life and therefore needs to be treated aggressively, and which men have disease which will run a gentler non-aggressive course and where the side effects and complications of treatment may outweigh the potential harm from the disease itself. Although this recent discovery is many years away from being used clinically it is an exciting development in the on-going search for new ways to differentiate different types of prostate cancer.
The PSA (prostate specific antigen) prostate blood test is much used in Urology to help in the diagnosis of prostate cancer and other urological symptoms in men. It is a controversial test with a number of potential limitations.
There have been a number of attempts to try and improve the accuracy of this test and researchers in Austria, based at the Medical University of Vienna and Vienna General Hospital have combined the PSA test with newer molecular methods to try and improve the accuracy of PSA.
My view is that PSA should always be interpreted in an individual context in combination with an assessment of the patient’s symptoms, findings on examination, and increasingly the use of imaging such as an MRI scan. Research for a replacement for PSA goes on but until then it remains an extremely useful test if it is interpreted appropriately.
On 27th January 2015 the BBC reported a study which linked commonly used medicines, including over the counter remedies for conditions such as insomnia and hay fever, to dementia. All the types of medication in question are drugs that have an “anticholinergic” effect. A number of medicines used by Urologists to treat overactive bladder conditions are of this anticholinergic type.
The study was based on over 3000 people aged over 65 who had no signs of dementia at the start of the study. The study does not mention any specific brands. It is important to emphasise that the investigators are not claiming a definite cause or link and that they only saw an effect in people taking fairly high doses of medications over a prolonged period of time. Representatives from Alzheimer’s Research UK and from the UK’s Alzheimer’s Society noted that the findings were interesting but emphasised that more research was needed and that patients should not stop taking medication which has been prescribed for them by their doctor. It should also be emphasised that there are many other benefits from treating overactive bladder in elderly patients (for example episodes of incontinence can be linked to falls which are in turn associated with fractures). There are alternatives to the medications about which concern has been expressed and I would be more than happy to meet with any patients who wish to discuss alternative means of managing their symptoms.