The Sussex Urology Tumour Group guidelines on prostate cancer will benefit both GPs and patients, says Dr Rob Wicks
The Sussex Urology Tumour Group has recently published guidelines for the detection and management of prostate cancer in primary care, which make interesting reading (Figure 1).
Cancer of the prostate is the third most common cause of cancer death in men, and it is therefore important to manage it correctly in general practice. Until now I have routinely offered a prostate specific antigen (PSA) test to men who are concerned, and in those with symptoms have often done an ultrasound and intravenous pyelogram (IVP) as well.
However, it appears that although men with an abnormal digital rectal examination (DRE) or PSA should indeed be referred to a urologist as possible prostate cancer, many men with an abnormal PSA will have no malignant disease. These men are likely to suffer at the hands of surgeons and experience a good deal of stress.
This situation is particularly well illustrated by my patient Mr A who presented in January 1994. He is a pleasant, although anxious, 71 year old who had been well until a myocardial infarction 4 years previously.
In common with many men in their 70s, he presented with a minor degree of urgency, which was beginning to trouble him at night. DRE was unremarkable, revealing a benign-feeling prostate, and his MSU was negative. He had heard about the PSA test, and I accordingly did one, fully expecting it to be normal.
The PSA was raised at 14.6ng/ml (upper range of normal in this age group is 6.5). I referred the patient to the local urologist who, in view of the raised PSA, did a cystoscopy and transurethral resection of the prostate (TURP). This revealed a normal bladderand a normal, benign prostatic hypertrophy (BPH).
Subsequently his PSA dropped to 6.5 but rose again by June 1996 and he underwent transrectal biopsy, which also showed BPH. He has been followed up yearly since then, and his PSA has carried on rising. Finally, in February of this year it rose to 45.9. He has undergone a further prostatic biopsy, and the results are awaited.
The reason for using this illustration is that it shows quite nicely what the Sussex Urology Tumour Group are saying, i.e. that screening for prostate cancer is unlikely to be useful and shows up only 1.7% of the cancers in men aged 55–70 years. Furthermore it is far from proven that early intervention makes any difference to long-term survival. There is also considerable scope for damage, both from the biopsies, causing bleeding and subsequent prostatic infection, and from radiotherapy.
Mr A has been in and out of the surgery over the past 6 years, worried to death that he has prostate cancer. Had the guidelines been available when he presented, I could have counselled him as suggested and handed out the leaflet about PSA testing. At least then he could have made an informed choice, and I could have saved him two general anaesthetics, two biopsies and numerous blood tests!
The section on treatment for localised prostate cancer is also informative. The three possible treatments are: watchful waiting with monitoring; radical prostatectomy; and radical radiotherapy. The complications of the last two are considerable, and include incontinence, impotence and death. It must be remembered that most of these patients are well and their long-term survival is probably not affected by radical surgery.
The guidelines certainly highlight the value of a PSA test and its place in the management of prostate cancer. The concise format, comprising small nuggets of information, certainly contains everything one needs in dealing with this patient group.
- In view of the recent directive on suspected cancer referrals, these guidelines will be reviewed in December 2000.
|Front of the Sussex Urology Tumour Group ‘Guidelines for the Detection and Management of Prostate Cancer in Primary Care’*|
|Reverse of the Sussex Urology Tumour Group ‘Guidelines for the Detection and Management of Prostate Cancer in Primary Care’*|
|* Reproduced by kind permission of the Sussex Urology Tumour Group|