Medical Matters: Keeping aggressive treatment for those with aggressive cancer

Billy Connolly is one of my favourite comedians. The Big Yin, as he is known in his native Scotland, shared some bad news about his health last week.

In an unfortunate double whammy, he has been diagnosed with Parkinson’s disease and has had surgery for prostate cancer.

A spokeswoman for the 70-year- old comedian and actor said: “Billy Connolly recently underwent minor surgery in America after being diagnosed with the very early stages of prostate cancer. The operation was a total success.”

So at least the cancer was caught early; the survival rate for men aged over 70 diagnosed at an early stage in the disease process is over 85 per cent.

PSA test
Almost certainly Connolly had a blood test for prostate specific antigen (PSA) as part of his assessment.

This is the test that has attracted a measure of controversy after the US Preventive Services Taskforce (USPSTF) ruled last year that the routine use of the test as a screening mechanism did more harm than good.

Its decision came among concerns that some men, after routine screening using PSA, were being treated for a form of the cancer that was unlikely to shorten their lives.

Post-mortem studies show the presence of prostate cancer in older men who have died from other causes, illustrating the usually slow - growing nature of the disease.

But as always in medicine there are exceptions to the rule.

A minority of men get a more aggressive form of prostate cancer and the detection of the disease in your 50s poses a different set of challenges than a prostate cancer diagnosis in a man in his 80s.

Urologists, the specialists who treat prostate cancer, feel a more nuanced approach to that adopted by the USPSTF is needed.

David Bouchier-Hayes, consultant urologist at the Galway Clinic, says PSA has been a helpful tool in the early diagnosis of prostate cancer but that it is "far from perfect".

“The concern is that some men with the disease may have been over-treated; we are not sure if this is true or not.

“But we have realised as a group of physicians that there are men with prostate cancer who won’t have problems, while some will.”

Way forward
The way forward, he feels, is to decouple the diagnosis of prostate cancer from its treatment.

A series of consensus statements on PSA testing emerged from last month’s World Congress on Prostate Cancer in Melbourne, including this one dealing specifically with the need to decouple diagnosis from intervention:

“Although screening is essential to diagnose high-risk cases within the window of curability, it is clear that many men with low-risk prostate cancer do not need aggressive treatment.

“Active surveillance protocols have been developed and have been shown to be a reasonable and safe option for many men with low-volume, low-risk prostate cancer .

“While it is accepted that active surveillance does not address the issue of over-diagnosis, it does provide a vehicle to avoid excessive intervention.”

The 14-member expert group also suggested that PSA testing in men in their 40s could be useful in predicting their future risk of cancer; in particular, men with a low level of PSA (less than O.6 ng/ml) do not need further testing until they reach 60.

What are the treatment options once a diagnosis of prostate cancer has been made? Radiotherapy, surgery, watchful waiting and active surveillance make up the broad menu.

Bouchier-Hayes expertise is in robotic surgery using the Da Vinci system. The Galway Clinic is one of just two private hospitals in the State offering the potential advantages of this minimally invasive approach.

An analysis of the first 125 cases operated on robotically by Bouchier - Hayes and his colleague PJ O’Malley found that 72 per cent of patients remained potent after the operation while some 85 per cent were fully continent three months later.

Meanwhile, this column wishes Billy Connolly a full recovery.

mhouston@irishtimes.com
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