A Urologist Addresses the More Controversial Aspects of Prostate Cancer Screening

WORDS PROFESSOR DATO’ SETIA DR TAN HUI MENG

FEATURED EXPERT
PROFESSOR DATO’ SETIA DR TAN HUI MENG
Consultant Urologist
Subang Jaya Medical Centre (SJMC)

Prostate cancer is the third most common cancer among the male population in Malaysia after colorectal and lung cancer.

However, despite these staggering numbers, compared to breast cancer, prostate cancer screening appears to be a very controversial topic in medicine.

THE UNCERTAINTIES SURROUNDING PROSTATE CANCER

To date, most health professionals and the public at large are still lost and uncertain on how to go about preventive measures and the treatment of prostate cancer.

Sometimes, early prostate cancers are localized and contained within the prostate. The cancer grows very slowly and may not cause problems for years or may not even become advanced cancer. In cases like these, patients do not need to be treated.

THE RECOMMENDATION FOR PROSTATE CANCER SCREENING

In the United States, the Preventive Services Taskforce (USPSTF) gave a Grade C recommendation on screening for prostate cancer, which means individuals do not necessarily need to screen for prostate cancer unless they have concerns, and they should discuss their concerns with their physicians.

This recommendation came about to reduce the overdiagnosis and overtreatment of prostate cancers.

This decision, however, has resulted in an increasing trend of prostate cancer mortality and morbidity, causing much suffering and compromising the quality of life for patients.

THE CHALLENGE THAT WE FACE TODAY

The challenge today is to come up with a strategy to screen the right population and find lethal prostate cancers.

Equally important, we will also need new treatments that are less invasive and cause less morbidity in individuals.

IMPROVING SCREENING ACCURACY WITH mpMRI SCREENING

For more than 30 years, the medical profession did not make headway with regard to the diagnosis and management of prostate, other than developing robotic techniques and better radiotherapy to remove the tumours.

The Problem with the ‘Old System’

The diagnosis using systematic non-targeted transrectal ultrasound scan (TRUS) guided biopsy is highly inaccurate as it has high false negative rate. This is dangerous as it misses at least 50% of cancer.

The Development of mpMRI and Its Advantages

The transformative advancement in the diagnosis and treatment of prostate cancer was the development of multiparametric MRI (mpMRI) of the prostate.

Using mpMRI as a triage can spare significant number of men from undergoing unnecessary prostatic biopsies and avoiding both physical and psychological trauma and morbidity, especially if TRUS biopsies are performed.

Many studies have confirmed that mpMRI is highly reliable in identifying more than 90% of men with clinically significant and lethal prostate cancer.

This method was reported to be much more sensitive (93%) in detecting prostate cancers compared to TRUS biopsies (48%).

MpMRI as a triage also detects much fewer clinically unimportant prostate cancer (54% fewer) compared to using the traditional TRUS biopsy.

In other words, mpMRI reduces overdiagnosis of clinically unimportant prostate cancer and improves the detection of clinically significant and deadly prostate cancer.

HENCE, TO SCREEN OR NOT TO SCREEN?

Many screening studies have shown that for men diagnosed with prostate cancers, whether they are treated or not, their survival outcome is generally over 10 years or so.

This shows that a majority of the men with prostate cancer detected by screening do not benefit from treatment.

Instead, they suffer the consequences of treatment, like losing potency and experiencing urinary or rectal symptoms with occasional incontinence!

However, long-term studies show the benefits of screening are observed after consistent follow-ups for 12 years or more.

The Goteborg Randomised Cancer Prostate Screening Trial, done in Sweden, revealed that for men who have undergone over 14 years of follow-up and completed the screening, there was a 66% decrease in advanced prostate cancer in the screened population compared to the population of men who were randomized to the non-screening arm.

Therefore, one can conclude that men who have serial PSA screening and then treated if prostate cancer is detected have a 66% less chance of developing advanced prostate cancer—which often results in very painful bone metastases.

There was also a 56% lower mortality rate in the screened population.

Extrapolating from this result, in the Swedish population, PSA screening can save 5,700 out of 1 million screened men from dying of prostate cancer.

THE BEST WAY FORWARD

In summary, prostate cancer is still a significant life-threatening disease.

Early detection and early prediction of the disease are crucial, whereas screening in men with long life expectancies is beneficial.

Overdiagnosis and overtreatment issues can be addressed with targeted screening and biopsy only for at-risk patients. This aims for early detection & diagnosis of localized lethal prostate cancer, which is fully curable.

If diagnosed with non-lethal prostate cancer (especially low-grade cancer), individuals only require good active surveillance with a follow-up mpMRI. They should also repeat a biopsy of the prostate if necessary.

It is crucial for those with intermediate-grade prostate cancer (ISUP 2) or large volume low-grade prostate cancer (> 6mm core cancer tissue) to receive careful active surveillance paired with good clinical judgement and a follow-up mpMRI as well.

Men with localized lethal prostate cancer will need ablative treatment with surgery, radiotherapy or occasionally brachytherapy. Counselling for adverse events like erectile dysfunction and occasional urinary incontinence following ablative treatments should also be given.

MpMRI has greatly improved the diagnosis of clinically important prostate cancer, and better genomics will help predict the prognosis of the disease. Transperineal mpMRI – ultrasound fusion prostatic biopsy is the way forward. Focal therapy like HIFU, irreversible electrophoresis or targeted ablation will probably play an increasing role, especially for patients with favourable intermediate-risk or low-grade large-volume prostate cancer.

How Breast Ultrasound & Mammogram May Save Your Life

WORDS LIM TECK CHOON

FEATURED EXPERT
DR WINNIE NG NYEK PING
Consultant Clinical Oncologist
Subang Jaya Medical Centre
NO FAMILY HISTORY OF BREAST CANCER = NO PROBLEM? WELL, THINK AGAIN!

“Even if one has no known family history of cancer, external factors such as environmental exposures, prolonged exposure to female hormones and lifestyle features may contribute to an increased relative risk of breast cancer,” says Dr Winnie Ng, a consultant clinical oncologist.

“Aside from genetics, there are numerous underlying possible causes of breast cancer,” says Dr Ng
  • Alcohol intake
  • Smoking
  • Prolonged exposure to female reproductive hormones such as oestrogen, such as in women that reach menstruation at early age, women that have never been pregnant, women on oral contraceptive pills, women that experience menopause late, and woman that have their first full-term pregnancy at a later age
  • Postmenopausal women on hormone replacement therapy
  • Obesity

Therefore, even if you have no family history of breast cancer, Dr Ng recommends that still going for breast cancer screening.

“The easiest method of screening is by self-examination of the breast,” she adds.

How to perform a breast self-examination. Click on this image to view a larger version.
AS WE STILL DON’T HAVE A CURE FOR BREAST CANCER, SCREENING REMAINS THE MOST PRACTICAL SOLUTION TO DETECT BREAST CANCER EARLY

Dr Ng recommends that:

  • Women below 40 should undergo a breast ultrasound.
  • Women above 40 are advised to go for a mammogram.

You should consult your doctor about your risk factors and how often you should go for breast cancer screening.

“A breast cancer diagnosis is not a death sentence. Self-tests and regular screenings can save lives,” says Dr Winnie Ng.

What Every Parent Should Know about Congenital Heart Defects in Children

WORDS DR CHOO KOK KUAN

FEATURED EXPERT
DR CHOO KOK KUAN
Consultant Paediatrician and Paediatric Cardiologist
Subang Jaya Medical Centre

The most common heart disease among children is known as congenital heart defects.

This condition occurs when the heart or the blood vessels near the heart do not develop normally before birth.

HOW COMMON IS THIS CONDITION?

According to our Ministry of Health, the incidence of congenital heart defects among children is about 8 to 10 per 1,000 live births.

With an average of 500,000 deliveries in Malaysia each year, the number of children born with congenital heart defects is about 5,000 a year, of which two-thirds will require surgical intervention.

THE CAUSES & RISK FACTORS

Most congenital heart defects have no known cause.

They may sometimes run in families.

Some congenital heart defects may be associated with genetic disorders, such as Down syndrome, Turner syndrome, Williams syndrome, etc.

Some children have a higher risk of developing congenital heart defects if the mother has diabetes or rubella, or has taken certain medications such as anti-epileptic drugs, during pregnancy.

DETECTION OF CONGENITAL HEART DEFECTS

Sometimes a heart defect can be diagnosed before a baby is born.

However, defects are usually identified days or even months after birth, when symptoms become obvious.

Less serious congenital heart defects may not show any noticeable signs or symptoms, so they may only be diagnosed later in childhood.

It is also possible to have a heart defect and show no symptoms at all.

POSSIBLE SIGNS THAT A BABY OR YOUNG CHILD MAY HAVE CONGENITAL HEART DEFECTS
  • Rapid breathing
  • Bluish discolouration commonly noticed around the lips, fingernails, palms of the hands, and soles of the feet
  • Shortness of breath during feeding, leading to poor weight gain
  • Poor growth
  • Recurrent lung infection
WILL A CHILD WITH CONGENITAL HEART DEFECTS BE OKAY?

As a result of medical advancements, the outlook for congenital heart diseases is increasingly positive.

Most children with this condition reach their adulthood.

In fact, children with simple conditions may lead completely normal lives, while those with more complex conditions usually face more challenges that can nevertheless be addressed with the right measures in place.

6 THINGS THAT EVERY PARENT OF CHILDREN WITH CONGENITAL HEART DEFECTS SHOULD KNOW AND DO
  1. Heart medications can be very strong and dangerous if not given correctly. Parents must understand how much medicine to give and how to give it. If the child takes a blood thinner, parents must have clear instructions on how to give this medicine safely.
  2. Ensure the child eats well and receives adequate nutrition. They often tire when eating, so they eat less and may not get enough calories.
  3. Prevention of infections is crucial. Although an infection in the heart (endocarditis) is uncommon, children with heart defects have a greater risk of developing this. Good dental hygiene goes a long way toward preventing endocarditis by reducing the risk of tooth or gum infection. Parents can get more information from cardiologist about the latest guidelines on antimicrobial prophylaxis against infective endocarditis. These children must also get all the recommended vaccinations.
  4. Most children with a congenital heart defect can be physically active without restrictions. In fact, children are encouraged to be physically active to keep their hearts fit and to avoid obesity, unless they have a few specific heart conditions.
  5. Emotional support will help children who may have self-esteem issues because of how they look. They may have scars from surgery, and they may be smaller, or have limits on how active they can be.
  6. As children transition to adulthood, parents can gradually teach them about their heart defect and guide them in how to care for their own health without being overly protective.