THOUGH concerns exist about overdiagnosing and overtreating patients with prostate cancer, consultant Urologist Dr Robert Wan says the cancers that can be cured are those that are detected early.

He admitted in an interview with the Jamaica Observer that there is always a risk one could overdiagnose or overtreat, but that there is also an opposite side to that coin. “If you don’t diagnose early, early cancer doesn’t manifest itself,” Dr Wan said.

“So if a cancer is advance and causes symptoms, such as pain or difficulty with urine, at that point, prostate cancer is usually incurable.

“So the cancers that we can cure are cancers that we find early,” he insisted. “Early means doing the PSA (Prostate- Specific Antigen) and the digital rectal exam, before symptoms occur.”

He explained that prior to the PSA test, men didn’t present until they had developed symptoms and at that point “we usually can’t cure them”.

He told Your Health Your Wealth that since the PSA test, which measures the level of protein produced by cells of the prostate gland in a man’s blood, physicians know that prostate cancer mortality has dropped.

He highlighted that there is an argument as to whether it is the PSA itself or it is just that physicians are getting better at treating prostate cancer.

“So there is always the danger that we could treat men who don’t need to be treated, so there is a burden on us as physicians to really try to single out the ones who really need treatment,” the consultant urologist said, adding that this is done through stratifying patients in terms of risk.

The PSA, combined with the results of a digital rectal exam and the result of a biopsy, which Dr Wan explained would include a report from a pathologist that would include the Gleson grade if the biopsy revealed cancer.

A Gleson grade of six or below, Dr Wan said, is considered to be low grade, meaning that the cancer is not very aggressive; a score of eight and above, the maximum being 10, would indicate a very aggressive cancer, and a Gleson score of seven would be moderate.

“So based on those findings, then one may decide whether this is the kind of cancer which would need treatment or one which maybe we could monitor it, through active surveillance,”

Dr Wan told Your Health Your Wealth. He explained the levels of risk considered, whether it is low, intermediate or high, and that there is a combination of factors, both favourable and unfavourable, that are considered before physicians decide to treat or monitor these cancers.

“It is kind of difficult to find somebody with a cancer and say ‘we are not going to treat you, what we are going to do is watch it’, but it can be done like that nowadays,” he said. “We find a cancer, we don’t necessarily say you have to take it out right away, but there are times that we do.

“If there is an aggressive cancer, we would strongly advise that this person gets treated, if it is a cancer that is not aggressive then one of our options, and it is a viable option, we say ‘I think we can watch this thing, we are going to do the PSA every several months, we are going to do the digital rectal exam every year, we are going to repeat your prostate biopsy in a year’s time’,” Dr Wan continued. In a year, he said, they would then look to see if there are signs of progression, for example if the PSA increases.

“But we now know there are men that have been watched for 10 years and they are doing quite good. But we also know that there are some men, if you leave them alone, they are going to end up with a very bad situation,” the urologist shared. Whether the patient is being treated or undergoing active surveillance, Dr Wan said lifestyle changes are always recommended. These include reduction in their intake of animal fat, sweets and refined carbohydrates while increasing their intake of vegetables and fruits. It is also recommended that these men exercise, do not smoke and avoid obesity.

He told Your Health Your Wealth that by stratifying patients based on risk, that is treating those who are considered intermediate and high risk and using active surveillance to monitor those that are considered low risk, it lowers the chance of physicians overtreating the population. In the meantime, scientists are trying to find other tests which would single out people who are going to be in the high-risk group, versus people who physicians could really monitor, Dr Wan said.

However, at present, Dr Wan shared that there are no commercially available tests which would tell physicians, for sure, that one patient has to be treated while another patient can be left alone. So for now, physicians use the tools available to stratify patients and make “reasonable decisions”.