Question 1

What operation is ideal for prostate cancer in a 74-year-old man?

Dr. Anurag Puri · Accepted Answer

Age is not the only barrier. If the patient has a lower metabolic age, is fit and mobile, has a life expectancy of more than 10 years and no comorbidities, and the disease is limited to the prostate, robotic surgery can still be offered. If the patient is frail, has difficulty looking after himself and does not have a long life expectancy, treatment is tapered to his needs: if there is a problem evacuating urine, we open up the urinary passage and add hormone ablation.

Question 2

Which PSA test is more specific for diagnosis: total PSA or free PSA?

Dr. Anurag Puri · Accepted Answer

PSA has to be interpreted with caution. The total PSA report comes first, and a single PSA report should not guide the decision to biopsy. If there is doubt, repeat the PSA two to three weeks after the first test; if both total PSA readings are high, proceed to biopsy. When total PSA is between 4 and 10 and doubt remains, order a free PSA test. A free PSA below 10% of total PSA points towards malignancy; a free PSA above 25% of total PSA means a lower chance of malignancy. Treatment can then be guided accordingly.

Question 3

Who should perform an ultrasound-guided prostate biopsy: a urologist or an interventional radiologist?

Dr. Anurag Puri · Accepted Answer

Both can perform it, but a urologist is better equipped to manage complications if they occur, such as bleeding in the urine or from the rectum.

Question 4

Is there a specific disease stage for which robotic treatment is used?

Dr. Anurag Puri · Accepted Answer

Robotic surgery is used for low and intermediate risk disease. It can be done for high-risk disease: if the lymph nodes are positive, we do not do a radical surgery, but if the lymph nodes are not positive, we can do robotic surgery along with an extended lymph node dissection.

Question 5

Should a PSA test be sent for all patients with BPH?

Dr. Anurag Puri · Accepted Answer

It is not mandatory as routine screening, but a baseline PSA is checked before starting a 5-alpha reductase inhibitor such as dutasteride, which is commonly prescribed for BPH, because these drugs lower the PSA value.

Question 6

At what stage or severity should I refer a prostate cancer patient through Jivo?

Dr. Anurag Puri · Accepted Answer

All stages of prostate cancer require treatment. The earlier the patient presents, ideally at an early stage when he is asymptomatic and detected incidentally, the better the results, prognosis, life expectancy and cure rates. Even if he has symptoms and complications from the prostate cancer, he should still be sent: every stage of prostate cancer requires some form of treatment.

Question 7

A man in his early fifties has histologically confirmed adenocarcinoma of the prostate staged T4 N0 M0, with no metastatic disease on local imaging. He has been started on Zoladex and is due to travel to India for radiotherapy. What is the general outcome for a patient like this?

Dr. Anurag Puri · Accepted Answer

Among all cancers in the body, prostate cancer is one of the slowest growing. Fortunately, this patient has no metastasis, but that would have to be reconfirmed when he comes to India, because PET scan facilities are very limited there. The PSMA PET scan is the newest modality and is very specific for prostate cancer metastasis. With a very high PSA and T4 disease, there might be foci of spread. If metastasis is present, the prognosis changes a lot; if it is not, he might have a very good life expectancy in spite of the disease.

Question 8

What is the benefit of alfuzosin in the symptomatic management of BPH, and is there a newer drug you recommend?

Dr. Anurag Puri · Accepted Answer

Alfuzosin is a commonly used drug for BPH and relieves the urinary symptoms. Newer drugs such as silodosin are more selective for the prostate, and we prescribe either. Alfuzosin is more commonly given to a younger, sexually active man, whereas silodosin is given to an older patient because of its sexual side effects.

Question 9

Is it true that there is no treatment for prostate cancer above the age of 80?

Dr. Anurag Puri · Accepted Answer

It is not the case that there is no treatment. About 80 percent of men aged 80 to 90, and 90 percent of men over 90, harbour some focus of prostate cancer on autopsy, but they die of other causes and it does not present as a disease in them. Treatment is therefore sometimes avoided when the patient is asymptomatic and the disease is low risk, because such men are more likely to die of other causes.

Question 10

Pooled prevalence data suggest that sexual performance weakens with age because of atherosclerotic and degenerative changes in the penile vessels. Is there a better urological explanation?

Dr. Anurag Puri · Accepted Answer

That is usually the case: atherosclerosis in the blood vessels reduces the blood supply to the penis, and that is usually the cause of the decline in performance.

Question 11

What are the principles of prostate cancer management, are there curative options beyond medical and surgical intervention, what are the survival rates, and what is the prognosis of advanced disease?

Dr. Anurag Puri · Accepted Answer

The principles of management depend on the staging and on the patient's disease parameters: PSA level, Gleason score and clinical stage. Survival rates change with the stage of the disease. Early or low-risk disease has a 100 percent cure rate and a very good prognosis, and even in metastatic patients, with appropriate treatment, life expectancy is much longer than in other stage four cancers. Glutathione has been studied for its antioxidant properties in prostate cancer and other cancers, but it is not a standard of treatment at present.

Question 12

What does it take to have a kidney transplant, and if a different genetic makeup leads to failure after transplant, what can be done to restore the kidney?

Dr. Anurag Puri · Accepted Answer

Kidney transplant is usually the treatment of choice for patients with renal failure, and results are best when the transplant is done with a related donor who is a genetic match. Even if there is no genetic match, or the blood groups are different, plasmapheresis can be used: it is an advanced form of desensitisation that removes the recipient's antibodies against the donor's blood group or tissue antigens.

Question 13

I hear that many patients who have a prostate operation die. Is that right?

Dr. Anurag Puri · Accepted Answer

This is a totally misplaced notion; we do these operations day in and day out. The majority of prostate operations are done for the benign causes of BPH. These patients are very happy and go back with little morbidity, because it is an endoscopic procedure nowadays. Even for prostate cancer, with the advent of robotic surgery, a hospital stay of just three days is needed for such a big surgery, and the patient is fit to fly to his country within two to three weeks, without the catheter.

Question 14

Can a combination of finasteride and tamsulosin eradicate BPH?

Dr. Anurag Puri · Accepted Answer

This treatment is for symptomatic relief, not for eradication. In benign prostatic hyperplasia, tamsulosin relaxes the prostate to increase urinary flow, and finasteride can decrease the size of the prostate. These drugs do not eradicate BPH; they treat the patient symptomatically.

Question 15

How do you decide between chemotherapy, radiotherapy, hormone therapy and prostatectomy?

Dr. Anurag Puri · Accepted Answer

If the disease is limited to the prostate, without spread outside it, to the lymph nodes or to bone, the intent of treatment is curative: robotic radical prostatectomy or radiotherapy. If the disease is locally advanced, spreading somewhat outside the prostate but not through the body or the lymph nodes, we can again opt for robotic radical prostatectomy, or radiotherapy along with androgen deprivation therapy, in the form of bicalutamide or other androgen-depriving agents. If the disease has spread to surrounding organs and is not amenable to surgical resection, treatment is less aggressive: radiotherapy along with hormone deprivation. Where the disease has spread to the bones, the intent is not curative but suppressive, by hormonal suppression: either surgical orchidectomy, removing both testes, or hormone-depleting injections given monthly or three-monthly. The last category is hormone-resistant disease, which no longer responds to hormone deprivation; here we add chemotherapy such as docetaxel or oral agents such as abiraterone and enzalutamide.

Question 16

What can be done to prevent prostate cancer?

Dr. Anurag Puri · Accepted Answer

It is very hard to prevent prostate cancer. The prevalence, incidence and mortality of prostate cancer in the African continent are higher than in the Asian population. When a patient has relatives who have been diagnosed with prostate cancer, screening should be more aggressive: in the African population, an annual PSA test from the age of 45 onwards, together with an annual digital rectal examination by a doctor. This may not prevent the incidence, but it allows early detection and prevents mortality.

Question 17

As a clinical dietician, I see nutrition as critical to the outcome of prostate cancer. Are dieticians involved in treatment, and are patients referred to them?

Dr. Anurag Puri · Accepted Answer

Dietary factors have been proposed, although it has not been fully proven that diet plays a major role in prostate cancer. Some nutritional factors have been suggested as protective: reduced fat intake may reduce the chances of prostate cancer, and lycopene, found in tomatoes, has been promoted as protective. Vitamin E and selenium were tested in a large randomised trial and did not protect; vitamin E supplements slightly increased the risk. I agree there has been less emphasis on this in our daily conversations with patients, and it can be promoted, although there are no randomised controlled studies proving these protective effects.

Question 18

How common is hydrocele in prostate cancer, and how can it be managed in patients still undergoing therapy?

Dr. Anurag Puri · Accepted Answer

Hydrocele is very uncommon in prostate cancer. It can occur because of malignancy near the testis or distant spread. While treatment is ongoing, and unless the hydrocele is very big, manage it conservatively rather than with major surgery. Correct it only when it becomes very big and needs symptomatic relief.

Question 19

Is there a role for prophylactic prostatectomy to prevent prostate cancer?

Dr. Anurag Puri · Accepted Answer

No, this has not been proven. Prophylactic surgery has been done for some cancers, such as prophylactic mastectomy for breast cancer, but not for prostate cancer. The approach is more aggressive screening of first-degree male relatives of prostate cancer patients, and treating prostate cancer accordingly if it is found.

Question 20

At what stage should a patient with prostate cancer not be referred to India, or should every patient be referred after assessment?

Dr. Anurag Puri · Accepted Answer

Rather than asking who should be referred, it is better to ask who should not be. All stages of prostate cancer require treatment, even if the patient is frail. If you can offer the treatment for that stage of cancer in your country, it is best to do that. Where the modalities of assessment and treatment, such as PET scans, radiotherapy and robotic surgery, are lacking and you cannot offer 100% of the treatment, the patient should be referred. If the patient is very frail and unfit to travel or for any major procedure, you may avoid sending him.

Question 21

Why do older men experience urinary incontinence, and why do prostates enlarge with age?

Dr. Anurag Puri · Accepted Answer

Prostate enlargement occurs with age, and it can be genetic as well. Prostate size does not decide the treatment; symptoms do. Even if the prostate is 100 grams, growing outward and non-cancerous, it does not require treatment. But if a prostate of even 22 grams is growing inward, blocking the urine and causing symptoms, it requires treatment. Prostate size increases with age, so age is a very big factor in prostate enlargement.

Question 22

I have a cancer patient who is very weak and frail and unable to take chemotherapy, and he is currently on no medication. What should we do?

Dr. Anurag Puri · Accepted Answer

In prostate cancer, chemotherapy is not the first modality of treatment; it is the last. First and foremost is hormone ablation: if that has not been offered, consider either hormone-ablating injections or orchidectomy. Chemotherapy has its own side effects, and he could become worse than he is now. The first step is to stage the disease and check whether the initial treatments have been offered, rather than going straight to chemotherapy.

Question 23

Is there a role for HIFU (high-intensity focused ultrasound) in prostate cancer?

Dr. Anurag Puri · Accepted Answer

HIFU is a newer modality for patients who are unfit for major surgery and can be offered to them, but it is not the standard of care and it is not widely used.

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