In Italy it has about 37,000 new diagnoses every year. We are talking about prostate cancer, the most common form of cancer in the male population, precisely 19% of all male cancers. For this reason it is important to make the population aware of the importance of correct information, primary prevention and early diagnosis. On the occasion of Father’s Day, ForlìToday has chosen to celebrate the anniversary of March 19 with a specific study with Dr. Roberta Gunellihead of the Urology Unit of the “Morgagni-Pierantoni” hospital in Forlì and president of the Italian Urologists Association (Auro).
Who knows how many times he has heard “Doctor I have a prostate”. At what age do the symptoms usually appear?
“When we talk about the prostate we are talking about an organ of the male body that we find below the bladder and that surrounds the urethra, the tube that carries urine out of the bladder, over the years the prostate can cause different types of disease and each age group presents specific problems.In young people, starting from 25-30 years, we can have prostatitis, they are forms of inflammation that can be caused by germs, generally of intestinal origin, or be secondary to inappropriate lifestyles (excessive sedentary lifestyle and wrong eating habits).Going on over the years, however, the disorders linked to the increase in the size of the prostate, prostatic hypertrophy, which can obstruct the urine output from the bladder, prevail and, generally starting from 50 years, prostate cancer can develop.”
What are the main annoyances?
“The first thing I would like to say is that prostate cancer, in its initial stages, does not cause symptoms, so much so that the diagnosis is often made in the context of periodic check-ups which are recommended starting from the age of 50, while for prostatitis and for the increase in the size of the prostate we can have two types of symptoms: symptoms of an irritative type and symptoms of an obstructive type.
Can you go into detail?
“I’m simplifying the “technical” language. When we talk about irritative symptoms we are referring to the increased frequency of urination both during the day and night hours and urination can be accompanied by urgency, forcing the patient to run to the bathroom to avoid episodes of urinary incontinence.In the case of acute prostatitis, there will also be pain during urination and sometimes even high fever.The obstructive symptoms are instead linked to the obstruction, caused by an increase in prostate volume or stiffness of the prostate tissue at the level of the bladder neck, which reduces the flow of urine out of the bladder.The difficulty in emptying the bladder can worsen over time producing a progressive increase in the residual urine after urination until reaching a state of “block” of urination (acute retention of ‘urine), much feared by prostate patients due to the need to place a bladder catheter”.
Is it true that the prostate is the site of the main tumor affecting males?
“Yes, in Italy prostate cancer is the most common tumor in the male population and represents 18.5 percent of all tumors diagnosed in men: estimates for the year 2020 speak of 36,074 new cases per year national level. Survival 5 and 10 years after diagnosis is very high in Italy (91.4% and 90.0%, respectively). However, given the high number of new cases, overall mortality remains consistent (7,196 deaths in 2015)” .
What are the values to check to check the health of the prostate and prevent diseases?
“There is a laboratory test. It is the PSA which is specific for the prostate, being produced only by prostate tissue, but which is not specific for prostate cancer. In fact, it increases both during prostatitis as well as in prostate cancer, but it has been seen how a correct use of this test is important for early detection of the oncological disease.Moreover, the indiscriminate execution of the PSA has led in recent years to an overdiagnosis of prostate tumors, i.e. to the diagnosis of numerous tumors potentially meaningless clinical, but certainly not devoid of psychological and therapeutic implications.Therefore, the PSA test should always be prescribed by the specialist and be considered as a datum to be integrated in the context of a specialist visit which can highlight the possible correlation of the increase in Psa with a prostatic inflammatory state or detecting a change in the normal consistency (reduced in pr ostatitis and increased in suspected carcinoma). These considerations have led in recent years to try to use it selectively, in particular on the basis of age and in the categories of men exposed to the greatest risk of developing a high-grade disease”.
At what age should these tests be done?
“A first check-up for the early diagnosis of prostate cancer is recommended at 50 years of age, even if, in the case of a family history of prostate cancer, the first check-up is anticipated at 45 years of age”.
What happens with high Psa values?
“As I specified, an increase in Psa values does not in itself represent a diagnosis of prostate cancer, but must be “interpreted” by the specialist who will decide what type of diagnostic procedure will be undertaken. In order not to create a state of doubt or apprehension unjustified we always advise not to perform the PSA test in the course of suspected prostatitis, knowing how in this situation the absolute value of the PSA increases”.
What has changed in recent years in the therapeutic approach to prostate problems?
“It is important to underline how prostate cancer is classified on the basis of grade, which indicates the aggressiveness of the disease, and stage, which indicates its diffusion and PSA. Consequently, the correlation of these parameters allows us to divide patients in three different risk classes: low, intermediate and high. This is extremely important since in the low risk class, also in order to avoid unjustified side effects of the therapy, active surveillance is now feasible. Active surveillance is a program structured for surveillance only.This is a monitoring which provides for the evaluation of the PSA every 3-6 months, the digital-rectal exploration every 6-12 months and as a rule involves the use of additional biopsies, with the possibility of intervening in case of clinical worsening of the tumor”.
Obviously different therapies depending on the case. What are the treatments in case of cancer?
For low-risk developmental forms, when the patient does not accept therapy with active surveillance, and in medium-high-risk patients with localized prostate disease, two therapies are now considered optimal: surgery (radical prostatectomy) and radiotherapy. Nowadays, the improvement of surgical techniques has made it possible to considerably reduce the complications of the operation (such as erectile dysfunction and urinary incontinence). In any case, the intervention proposal must always be motivated by the specialist and well accepted by the patient. Radical prostatectomy today can be performed with the traditional technique (open) but also with the laparoscopic technique or with the aid of the robot.
What can you tell us about radiotherapy?
“As far as external beam radiotherapy is concerned, the most modern radiotherapy techniques (conformal and modulated intensity) allow a limited dose distribution to the target volume (the prostate and seminal vesicles) with consequent sparing of the surrounding healthy tissues. This has allowed to enhance the effect of radiation on the organ to be hit, significantly reducing the side effects on other healthy organs”.
What are the timelines in terms of rehabilitation?
“Thanks to the advantages given by the laparoscopic and robotic technique, the recovery times of urinary continence have been significantly reduced, some patients are already continent when the catheter positioned during the operation is removed and for the others the recoveries are very rapid and at a year the percentage of incontinence is extremely low.As regards sexual rehabilitation there is no uniformity in the indications given by the various guidelines, not everyone recommends pharmacological rehabilitation, however thanks to nerve-sparing techniques which aim to preserve the integrity of the nerves involved in the erection, the results one year after the operation are encouraging and there is always the possibility, in case of failed spontaneous recovery of erections, to use the available drugs with good results”.
How many cases are ascertained annually in our area?
“For our territory we are currently at estimated average values of 140 new cases per year per 100,000 inhabitants”.
Have there been increases since the pandemic?
“Since 2003, the incidence has decreased slightly (-1.4%/year), similarly to what happens for mortality, however, since the beginning of the Covid19 pandemic, it is believed that a diagnosis of prostate cancer out of two has been lost with heavy repercussions on the increase in new cases in more advanced stages of the disease in the coming years.In particular, in 2020-2021 there was a drop in accesses for screening, follow-up and therapeutic pathways due to fear of risk of contagion and for the conversion of departments in the acute phase of the pandemic”.
Prostate problems also highlight sexual discomfort in the couple, is shyness the main taboo to dispel? And can the partner play an important role in this case?
It is common to see the (male) patient arriving at the clinic who starts by talking about the prostate, but who, thanks to this “Trojan horse”, goes on to propose problems related to sexuality and often it is couples who present themselves and the “complicity” between partners becomes a trump card, allowing you to act both on the themes of the relationship, frequently more psychological than physical, but being able to more easily use any pharmacological support.
What advice would you like to give to our readers?
“I would like to tell everyone what I like to repeat to patients: “medicine can do a lot for you, but you yourselves must be the most valid starting platform for a peaceful life“. An adequate lifestyle that includes healthy eating and regular physical activity, combined with attention to the messages that your body sends through symptoms, in our case urination difficulty or erection difficulty, can avoid or at least make it less important prostate-related diseases clinically. These “simple” indications are summarized in the current definition of health given by the World Health Organization. And that is “health, a state of complete physical, mental and social well-being and not merely the absence of disease“. Good health to all”.