QUESTIONS FROM READERS:PROSTATE CANCER

Q:My husband, who is 63, was told several months ago that he had prostate cancer. I am giving my husband various homeopathic remedies. We have been vegetarian for 10 years, so we have boosted our fruit and vegetables, raw and juiced, and we have f

As a remedial yoga teacher, I have encouraged my husband to return to yoga daily, to tone the muscles and bladder and also prepare the body for surgery, if it is essential, and also to undertake regular relaxation and meditation.

All these suggestions I have acquired over the years from you, the Bristol Cancer Help Centre and various other sources.

I have a distrust of surgery and, failing any advice from the hospital, we are using anything that might possibly help. I was therefore interested in your article (WDDTY vol 4 no 10) on the low incidence of prostate cancer in Japan due to the consumption of soya products. Where do we go from here? E C, Isle of Wight…..

A:We’re sorry to hear of your troubles. The commonest form of cancer for men over 40 concerns the prostate, the gland which lies just below the base of the bladder, which produces some of the seminal fluid. Because it is so close to the bladder and urethra, problems in this area invariably cause problems in urination.

Although the incidence of prostate cancer hasn’t really gone up, aggressive treatment like radiation and surgery have by a whopping 36 per cent.

Researchers from the Center for Evaluative Clinical Sciences, Hanover, New Hampshire, writing in The Lancet (29 January 1993), examined nine cancer registries throughout America, plus data compiled by the National Center for Health Statistics. Their results, titled the SEER programme (Surveillance, Epidemiology and End Results) found only a modest increase in prostate cancer incidence between 1983 and 1989 (attributed mainly to increased attempts at detection of early stage disease). There was no increase in the types of cancer that spread and can be fatal. Nevertheless, the study found that the rates of prostatectomy (surgical removal of the prostate gland) increased by nearly 35 per cent per year, and varied greatly from area to area.

Nevertheless, as this and other studies show, all this aggressive cutting doesn’t seem to make the slightest bit of difference to survival rates.

This and another recent study in the medical press add to the other substantial evidence proving that conservative treatment of early prostate cancer that is, maintaining a watchful wait and see attitude, and using other forms of therapy, such as hormonal treatment, rather than rushing into surgery could be the best course, particularly in older men. This is largely because prostate cancer can be, in the main, a slow growing form of cancer. Furthermore, according to autopsy studies (The Lancet, 13 February 1993), a third of men in the European Community have prostate cancer, but only 1 per cent will die from it.

As the SEER study put it: “Increasing use of radical prostatectomy in men over 70 is especially troubling, since these patients are relatively unlikely to die of their prostate cancer before other causes take their lives.”

In another recently published American study, Dr Gerald Chodak and his colleagues at the Prostate and Urology Center, University of Chicago Hospitals in Chicago also concluded that a policy of “watchful waiting”, and the use of conservative treatment (delayed hormone therapy to shrink the cancer), rather than aggressive intervention such as surgery and radiation, may be the best option for men with early stage prostate cancer, especially if their life expectancy, because of their age, is 10 years or less (New Eng J Med, 27 January 1994).

These two latest studies echo the results of an earlier decade long follow up of men with early prostate cancer, showing that after 10 years only 8.6 per cent of the patients had died from prostate cancer. Furthermore, the survival rate of 86.8 per cent was nearly identical in a group who would have been considered perfect candidates for radical prostatectomy.

This study underscores the fact that most prostate cancer doesn’t spread. During the decade of observations, tumours had only undergone local growth and hadn’t spread to other organs in two third of the patients. In these patients, hormonal treatment was usually successful (JAMA, 22/29 April 1992).

Another study (JAMA, 1993; 270: 948-54) concluded that among men over 70, radical prostatectomy not only isn’t better than watchful waiting but can be downright harmful. In men over 75, the 30 day postoperative mortality rate after the operation is nearly 2 per cent.

Indeed, some studies show that survival rates are actually higher in groups with watchful waiting, as compared with groups undergoing surgery.

The reason for the sudden burgeoning of radical prostatectomies has to do with the introduction of the “nerve sparing” technique, a method supposedly able to preserve sexual potency. In this operation, both the inner gland and the capsule of the prostate gland is removed. However, nearly 100 per cent of the nerves are spared, supposedly to maintain sexual potency.

Several studies have reported excellent survival rates with this technique (National Cancer Institute Monogr 1988; 7: 117-26). Mr Reginald Lloyd Davies, senior consultant urologist of St. Thomas’ Hospital in London, says that 80 per cent of patients can expect a five to 10 year survival rate.

However, as Mr Lloyd-Davies points out, half of all patients still lose potency and something in the order of 5 per cent become incontinent. The other downside is that it is major abdominal surgery, performed above the pubic bone, and so must be done by an experienced surgeon.

But the most important point, he says, is that radical surgery is indicated in only a very small number of cases: for those with a very early cancer (stage 1), confined to the gland itself and not the capsule containing it or any lymph nodes. It is also only effective if the margins around the gland are free from cancer. “The number of patients suitable for this is very small,” he says.

If your husband were in his 70s, and had early cancer, the decision would be easy: to elect for watchful waiting. However, since he is 63, much depends on which stage the cancer is at and whether he meets the criteria for surgery. For those with a substantially longer age related survival rate than 10 years, the “watchful waiting” approach supposedly is associated with a higher probability of living with cancer that spreads, or dying from prostate cancer, according to the Chicago study mentioned above.

However, the study does admit that conservative management can be a reasonable choice for men of all ages with stage 1 or 2 disease. It also admits that the benefit of aggressive treatment even for grade 3 cancer (as against conservative management) is “less clear” and that new strategies for this stage of cancer are needed. This is as good as admitting that surgery for all patients may not be doing any good.

Aside from the fact that prostate surgery doesn’t seem to improve survival, the SEER study also questions the wisdom of radical intervention and screening which simply brings to light many cancers which would otherwise remain dormant and harmless if left undetected.

Another operation that may be done is the transurethral resection (TUR), in which an instrument inserted through the urethra removes the prostate piece by piece, without having to do an incision through the abdomen. However, this operation should only be done to relieve an obstruction, in cases where an enlarged prostate is causing difficulty. It won’t cure the cancer.

One major concern is that TUR prostate operations can cause major changes in the cardiovascular system. A study at the Department of Urology in Middlesex Hospital in London discovered important “hemodynamic disturbances” during the operation. These included a reduction by half in cardiac output and also rapid central cooling, both of which could bring on cardiac arrest for an estimated 2.5 per cent of patents. The risk is thought to have something to do with the irrigation fluids used in the bladder during the operation (The British Medical Journal, 14 March 1992).

If done properly, says Mr Lloyd-Davies, TUR shouldn’t cause impotence because the nerves are left alone. However, in practice, many patients do suffer from impotence afterward, and in 3 per cent of cases, the operation may have to be repeated, according to Dr Ruth Lever, writing in A Guide to Common Illnesses (Penguin, 1990). Two per cent of patients develop a narrowing in the neck of the bladder a year after the operation, and in some cases a patient is unable to pass urine afterward because the bladder muscles have become slack.

Another more frequent side effect is a phenomenon called retrograde ejaculation. As Dr Lever explains, because one of the bands of muscle controlling the bladder is destroyed in the surgery, any ejaculate passes up into the bladder rather than down the urethra. Consequently, if the patient isn’t impotent, he will probably be sterile after the operation.

Before you consent to surgery, return to your doctor and grill him about the kind and stage of cancer your husband has. If your situation doesn’t fit the stringent criteria listed by Mr Lloyd-Davies, discuss with him the possibility of resisting surgery and instead having radiation or the least invasive treatment of all, which is hormonal therapy the conventional method of choice for cancer that has spread (see next question below).

One final suggestion. You are to be applauded for aggressively pursuing any and all possible approaches, since conventional medicine certainly doesn’t have the final answer on cancer cure. (See WDDTY vol 4 no 7 for the latest evidence of nutritional therapy).

However, if you do elect to use alternative medicine we urge you to work under the care of a doctor highly experienced in alternative cancer therapy so that you don’t fall prey to many of the unproven treatments being peddled about, which can be as dangerous as inappropriate surgery.