The Emperor of Men’s Maladies

By Shobha John

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In 2008, when Raj Kunwar Gupta, 58, a Ghaziabad bank official, had problems urinating, he went for a medical check-up. It found an obstruction in the urine flow, but Gupta ignored it and continued to lead a normal life. However, in 2010, the prostate had enlarged and a Ghaziabad urologist gave him medicines and recommended a biopsy. Gupta ignored it for another six months, till he did a PSA (Prostate-Specific Antigen) test for likely prostate cancer.

It was more than 5.84 ng/ml (nanograms per ml), showing a 22-30 percent increased risk of prostate cancer. The doctor, then, put his foot down and insisted on a biopsy. Gupta did and found it malignant. After consultations with numerous doctors in Delhi, Gupta finally got his prostate removed via robotic surgery in May 2012. Today, his PSA level is .009 ng/ml. Gupta says: “I was lucky my cancer was detected in the initial stages. If I had enough knowledge of this disease, I would never have been so lax.”

LOW AWARENESS

And that is the biggest hurdle for prostate cancer in India—lack of awareness and funding. Even as life expectancy has increased, prostate cancer incidence has also grown by 1 percent every year. Dr Ashish Sabharwal, chief consultant urologist and robotic prostate surgeon, Fortis Hospitals, says: “Unlike other cancers which are well-publicized, few in India know that prostate cancer is the most common malignancy among men and the second leading cause of cancer deaths after lung cancer. Prostate cancer should get as much prominence as breast cancer gets. Ten years back, I hardly saw prostate cancer patients; today, I see one a week.

Almost 80 percent of patients come in an advanced stage of cancer. That’s sad because if caught early, prostate cancer is 95 percent curable.” It is believed that of the 8.2 million deaths due to cancer worldwide, one-sixth are due to the prostate, with 70 percent being diagnosed in men over 65 years.

As prostate cancer is asymptomatic, only regular screening will catch it. This is a must after 55 years. In case the doctor suspects anything, a biopsy may be needed.

Lifestyle with regular exercises can go a long way in preventing prostate cancer

The prostate is a walnut-sized exocrine gland (secretions end up outside the body), which is directly under the bladder. Besides producing a fluid that forms part of semen and which protects the sperm, the prostate gland also plays a role in urine control. Though the incidence of prostate cancer is highest in developed countries and among Africans, it is also rising in South and East Asia. As prostate cancer is asymptomatic, only regular annual screening will catch the disease. This is a must after 55 years and involves a rectal exam and a PSA test. In case the doctor suspects anything, a biopsy of the prostate may be needed.

PSA, incidentally, is a protein produced by the cells of the prostate gland. Its level increases with cancer. The two commonest prostate problems are enlarged prostate and cancer. The prostate gland usually starts to enlarge after a man reaches 40 years. While the size of a normal prostate, says Sabharwal, is 20 gms, it can increase in size due to a tumor inside and cause problems in urine flow (see box). While a PSA of less than 4 ng/ml is considered normal, anything over it should be investigated. It could be due to an infection, enlargement or cancer, say doctors. Though prostate cancer usually grows slowly and initially remains confined to the prostate gland, some types of cancer are aggressive and can spread quickly. If the PSA levels are rising fast, it could be an indication of aggressive cancer.

LIFESTYLE CHANGES

So what are the factors that predispose one to prostate cancer? It is a diet rich in fatty foods and red meat, sedentary lifestyle, obesity and genetic disposition. It is also seen among patients with a higher socio-economic status and those doing night shifts. Therefore, to reduce the risks, one should eat less processed red meat and more leafy vegetables, stop smoking, avoid sugar and starch as they spark inflammation, exercise, eat fish and have a body-mass index of less than 30. Strangely, it is believed that frequent ejaculation also leads to lesser chances of this cancer. “And while more testosterone does not cause prostate cancer, it is believed that once you have a malignancy, high testosterone can make it more aggressive,” says Sabharwal. Experts say one of the best options for prostate cancer is robotic surgery.

The reason for this is that the nerves for erection and ejaculation are close to the prostate and manual surgery could damage these. “This could lead to impotence and erectile dysfunction. In addition, it can lead to a long hospital stay of 5-10 days, blood loss of up to two liters and multiple blood transfusions and infection,” says Sabharwal. However, it is important to weigh other options than surgery, such as radiotherapy, brachytherapy (internal radiotherapy, where small radioactive metal seeds are placed within the tumour) and ultrasound treatment. It is important to know that there could be some complications while removing the prostate—slight incontinence, or erectile dysfunction. Robotic surgery is done through the da Vinci System, where surgeons operate through a few small incisions in the stomach. The da Vinci System has a magnified 3D vision system and special instruments (up to four ports) that bend and rotate.

The doctor operates this through a console and uses hand movements to manoeuvre the tiny instruments inside the body. This allows malignant tissue to be removed precisely, so that healthy prostate tissue is not damaged.

(From left to right) Dr Ben Shapaya, Dr Ashish Sabharwal and Johnson Shapaya, Ben’s 70-year-old father, who had prostate cancer. Ben, a doctor from Kenya, got his father to India for surgery and two days after the procedure, Johnson recovered fully and flew back to Kenya

DON’T DELAY

Gupta, who underwent this surgery, says that he was hospitalized for just five days. “I was advised to do exercises and while urine leakage continued for a few days, I am fine now and have resumed my normal lifestyle.” He advises other patients to immediately go to a doctor if there are any urinary problems as lack of information can delay vital medical intervention. “The government should disseminate information on prostate problems so that it reaches a wider audience,” he says.

South African president Nelson Mandela and American actor and filmmaker Robert de Niro also had prostate cancer

At an individual level, doctors and private hospitals are doing their bit to raise prostate awareness. Sabharwal, for example, has started the Blue Ribbon Prostate Clinic, an initiative on Facebook, to raise awareness about prostate cancer. Blue Ribbon, incidentally, is the international symbol of prostate cancer awareness, quite like pink ribbon is for breast cancer awareness. In September, Dr David B Samadi, chairman of urology and chief of robotic surgery at Lenox Hill Hospital, New York, issued a unique challenge to women worldwide—the #SamadiChallenge.

Just as cervical cancer and breast cancer screenings and awareness have gone up with women going in for pap smears and mammograms respectively, Samadi thinks that their proactive approach could encourage the men in their lives too.