Early diagnosis increases the chances of curing cancer
Promoting cancer early diagnosis; Prostate cancer is the second most common in Brazil among men and also the second that kills the most. Early diagnosis is essential for this type of tumor, as it increases the chances of cure by up to 90%, especially among those who have risk factors, such as obesity and a family history of the disease.
In general, digital rectal examinations and PSA should be performed periodically after the age of 50. But many men avoid this checkup due to embarrassment.
In this episode of DrauzioCast, dr. Drauzio talks with Dr. Leonardo Seligra Lopes, urologist and specialist in andrology and human reproduction on the stigmas linked to prostate cancer, the importance of screening and the diversity of treatments for the disease.
Prostate cancer is the second most common type of cancer in men, behind only non-melanoma skin cancer.
It is also the second that kills the most. But it didn’t have to be that way. Most patients achieve a good outcome when the disease is detected and treated early. This is why tracking is so important. The recommendation is to start examinations for the early diagnosis of prostate cancer from the age of 50. But this indication may be a little different for people who have a higher risk of developing the disease. We’ll see what they are.
Promoting cancer early diagnosis; Many men are reluctant to do the necessary follow-up because of embarrassment and, oddly enough, it’s an embarrassment because of the rectal exam, which is a big nonsense, isn’t it? Don’t be ashamed to take care of yourself and preserve your health.
Dr. Leonardo Seligra Lopes is going to talk to us about this topic. He is a urologist, specialist in andrology and human reproduction, and Leonardo is also director of communication for the Brazilian Society of Urology in São Paulo. Welcome Leonardo.
Doctor Leonardo Seligra Lopes – Thank you, Drauzio. Thanks for the invitation.
It’s a really important topic, very relevant, you know, for men’s health as a whole and let’s see if we can provide all the necessary information possible.
So let’s start, Leonardo, talking about risk factors. Who has the highest risk of developing prostate cancer?
Well, prostate cancer is a disease that affects individuals as they age. So, men, as age goes by, begin to have a greater risk of developing prostate cancer, more or less from the age of 50. Other than that, we have to worry about some specific populations, you know. We don’t really know why, but Afro-descendants have an increased risk factor for developing prostate cancer and so do patients, individuals who are obese.
Promoting cancer early diagnosis; So, obesity also plays an important role in the development of prostate cancer. Now, whoever had a family member with prostate cancer, right, so, a much more evident first degree, has an increased risk of up to two times or, if he had more than one family member, he may increase the risk of developing it by more than five times prostate cancer. So, these are the main risk factors that we have to be aware of.
So, let’s take a person, a man who reached 50 years old, he doesn’t have any case in the family, he’s white, he’s going to start taking the exams at 50 years old, right?
How often, Leonardo, does he have to do it?
This is a rather big discussion, right, first, what would be the exams and what is the frequency. The recommendation, which today the Brazilian Society of Urology has considered, is that this be evaluated a lot in relation to the risk factors, right, so, this population that has the risk factor present, including, we recommend that you go earlier, right, seek care for early screening from the age of 45, and the frequency will depend a lot on this issue of risk factors. So, for those who have a risk factor, it is very important to have a follow-up once a year, but when the exams show a low probability of developing prostate cancer, we can wait until, eventually, that follow-up is done every one or two years, not necessarily every year, depending on this initial assessment of the exams.
Promoting cancer early diagnosis: And those patients who have several cases in the family? He has a father, a grandfather, an uncle with prostate cancer and he wants to know: “Is 45 years old okay or should I start even earlier”?
This is also very important information, right?
Today we already understand the relationship of genetic inheritance, right? We have been studying some important genetic markers related to this familial relationship of prostate cancer and there are some possible tests that can be performed, genetic blood tests, to identify risk factors. Even the gene related to breast cancer, you know, BRCA, has already been meant as an increased risk factor for prostate cancer. So, eventually, this population that has this gene present, sometimes, we even recommend an earlier start.
And what are the routine exams?
A person appears in his office and says: “look, I turned 50 now, I want to start doing the controls”. What are the exams?
Initially, right, in medicine, we need to do what we call a physical exam, you know, and this physical exam, in the case of the prostate, is the rectal exam, which you mentioned, right, the prostate exam. The bad part is that, in the rectal examination to identify any changes in the prostate, and what do we look for?
Look for any nodulation, any hardening of the prostate, an enlarged prostate. But in this digital rectal examination, we cannot feel the entire prostate, so we associate a blood test, you know, which is called a PSA test and, in the alteration of one or the other, we follow up the follow-up of these patients. Promoting cancer early diagnosis.
Today, we even have a conduct, which is not yet fully validated, you know, because of costs, that we also start doing a magnetic resonance imaging of the prostate, when we identify either the touch or the altered PSA, to to be able to take the next step, then, that is in the suspicion of a disease, doing a prostate biopsy that would give, then, yes, the definitive diagnosis of cancer.
And why is it so important to make this early diagnosis?
This is the main message, right, Drauzio, because prostate cancer is a tumor that we call silent, right? Initially, it does not bring any symptoms to the patient, so it is the bad part of the issue related to prostate cancer. But when we manage to make an early diagnosis, we give a chance of curing cancer more than 90% of the time, right? So, indicating the appropriate treatment for each type of patient, we have a very high chance of cure and that is why this early diagnosis is important, which, unfortunately, does not give symptoms and that is why tracking is so important.
When you find a high PSA, people in general get scared, right, they think they have prostate cancer. It explains this issue of high PSA or normal PSA.
Promoting cancer early diagnosis; It is important for us to remember, right, that the PSA, this blood test, is related to any alteration in the prostate. So, the prostate is a solid organ, which can happen to have an infection, inflammation, in addition to the benign enlargement of the prostate itself, right? I usually say that all of us men, if we survived more than 100 years, we would all have an enlarged prostate, and this is not necessarily related to a malignant disease. So, the alteration of the PSA blood test can indicate both this inflammation or an infection, which we call prostatitis, as well as a benign enlargement of the prostate, benign prostatic hyperplasia, or prostate cancer, and that is why the we end up having to use the MRI and then the biopsy to give this diagnosis for sure.
You have a discussion in urology that PSA may lead to many unnecessary biopsies, right?
You go there, do a PSA, it’s elevated, biopsy the prostate and there was no important alteration that was considered malignant, right? How do you see this discussion?
This is a very relevant discussion, right? Because this has an impact not only on the patient himself, you know, in relation to being subjected to procedures that could sometimes be avoided, but also very much related to the cost of health care as a whole, right? We have to understand that someone pays the bill when we indicate some kind of treatment or some kind of exam.
Promoting cancer early diagnosis: What we have to take into account is that the use of PSA was a watershed in prostate cancer. When we started using PSA, we were able to reduce the number of diagnoses in very advanced cases, with metastasis, with advanced disease, and that was very important. But at the same time, we increased the number of diagnoses.
I think that we have to do, as recommended by both the Brazilian Society of Urology and international urological societies, is that this screening is very focused on this risk population, identify well that patient who can also, despite not being in the risk factor present risk, having a possible risk, so those individuals between 50 and 70 years old, also talk and discuss the issue of risk and benefit well, right?
And in this scenario, the patient participates in this decision, knowing the benefit he may have or the risks he has in relation to having a biopsy or not, having an MRI or not.
So, I don’t think we can demonize tracking that much. I think tracking, it doesn’t have to be in bulk. Timely tracking is important, but so is targeted tracking. So, I think we still can’t demonize not doing the exams as much as some societies advocate.
Leonardo, there are many men who say: “oh, no, I don’t take the test because I don’t feel anything”. And we know that early prostate cancer has a silent evolution, the person doesn’t really feel anything, right? When the symptoms start to appear, it’s because the disease is more advanced, right? In that case, what kind of symptoms should attract the attention of young people? Promoting cancer early diagnosis.
Undoubtedly, the main symptoms are related to urinary symptoms, you know, to the way the individual is able to urinate: the jet becomes weaker or there is some kind of discomfort or pain when urinating; eventually, the presence of blood in the urine or blood even in the ejaculate, in the sperm, is also a possible sign of advanced disease.
But they can also be related to prostate enlargement, you know, that’s why it’s important to seek care soon to make this differential diagnosis, which we call.
Even more advanced diseases can give symptoms related to other situations, such as bone pain, for example, because of metastasis of the disease outside the prostate organ.
So, these are important signs and the main factor that we have to take into account is that, when we diagnose these patients with symptoms, the vast majority of them are already in a more advanced situation, which makes treatment difficult and reduces the chances of cure.
I mean, it’s very important that you take into account some preventive exams, even if you don’t feel anything at all because it could happen that, when you feel it, the disease is already at an advanced stage that is no longer curable, right?
And talk a little now about prostatic hyperplasia, which is the benign enlargement of the prostate, you know, that happens to men as they age. Many people, when they see that the prostate is enlarged, already think they have prostate cancer, Promoting cancer early diagnosis.
And it’s very important to differentiate this, right?
Usually close to 20, 30 years old, our prostate is similar in size to a walnut, it is very small, it weighs something close to 20 g. And, like I said, if we all lived to be over 100 years old, we’d all have it enlarged and some urinary symptoms. The prostate, as it is located between the bladder and the channel through which we urinate, every time it enlarges, there is a risk of starting to have these urinary symptoms: difficulty urinating, urinating several times at night, getting up several times at night to urinating or even a burning sensation, bleeding in the urine and these symptoms are related to this prostate enlargement, which in most cases is benign. So, just an enlarged prostate does not mean you have cancer. That is why, again, the importance of carrying out this follow-up with the doctor in order to be able to differentiate well and, if any risk of malignant disease appears, to be detected early.
We have several ways of treating prostate cancer.
In the initial cases, which is what we try to diagnose with preventive exams, we have surgery, radiotherapy, in other words, other treatments. Let’s start talking about the surgery.
Well, the surgery, it is a treatment where we are aiming to cure the patient, right? Every time we propose a surgical treatment, we understand that this disease is at a very early stage and that we have a great chance of curing the patient. The surgery will completely remove the prostate, right, and as it is between the organs I mentioned, the bladder and the urine channel, when we remove the prostate and, together there, the tissues that are beside it, the we have to do what we talk about reconnection, anastomosis between the bladder and the urethra, to restore the normal function of urination of urine. In general, it is a surgery that can be done in several ways, you know, or nowadays more modern, you know, with technology by laparoscopy or by a robot-assisted laparoscopy, you know, which is robotic surgery, and which has results very good cure rates, there, as I said, close to 95%, in cases where the cancer is early.
Many people think that robotic surgery, because it is more technological, has better results than laparoscopic surgery or the same surgery that we call open surgery, isn’t it, in which you open the cavity and expose the prostate.
It explains which is the best of the three methods.
This scenario for us is still very new, right? Robotic surgery is still very new compared to traditional treatments, right? Because a good surgery, well done, as you said, in the open, it will bring these results, as we say, functional results, right? When we treat a prostate cancer patient, we have three objectives, right? We aim to treat him oncologically, have a good oncological surgery, and also treat the functional results, which are related to urinary continence and sexual potency. So, a well-done open surgery has great results, as well as a laparoscopic surgery. The benefit of robotic surgery, today, it is starting to be evaluated due to better visualization, you know, and perhaps a little better detail on this issue of functional results, in relation to urinary continence, in relation to sexual potency. But even today, it is not well established that robotic surgery is much better. So, whoever is going to be treated with an open or laparoscopic surgery is being treated very well and there is no difference in relation to the oncological part.
What about radiotherapy? We have several ways to irradiate the prostate in these initial cases, right, Leonardo?
Radiotherapy is also an option, you know, especially for those patients who, for some reason, cannot undergo a surgical procedure, you know, because of a more serious health problem or even eventually a patient who refuses to undergo surgery. Radiotherapy is a treatment option with cure rates also close to 90%, but if diagnosed early. More modern radiotherapies even have fewer side effects than radiotherapy in the past. So, a lot of people are also confused because of having undergone radiotherapy something like 20 years ago. Symptoms related to radiotherapy treatment are now much smaller, right? But we have to remember that in radiotherapy we do not remove the prostate as a whole, so there is a slightly higher risk of having a problem again after radiotherapy, but it is an option for initial cases and, yes, they should The various existing methods will be discussed there.
I think the advantage is you, when you have the surgery, if you have to burn a recurrence at the site, if the disease returns at the site, you can have radiotherapy and, in the case of irradiation, you will no longer be able to have surgery. Because?
In fact, what we know is that, when prostate cancer starts to get more advanced, sometimes we have this option of combining treatments, you know, having surgery with radiotherapy.
When we are going to perform surgery after a case of a patient who underwent radiotherapy, the surgery becomes much more difficult, it becomes much more complex, the chances of complications related to bleeding increase, to the difficulty of functional issues, as I said , huh? A patient who undergoes radiotherapy and undergoes surgery is more likely to have incontinence, more likely to have impotence. So, it is always preferable, you know, to perform surgery on patients who have not undergone radiotherapy and, even so, if there is a complementary treatment to be performed, we can use treatments such as hormonal blockade, you know, and still avoid, thus, complications surgical procedures in post-radiotherapy cases.
And he talks a little now about the consequences of surgery, radiotherapy and what scares men the most, which is sexual impotence, in addition to urinary incontinence, of course.
Yes, this functional issue of treatment sequelae, it exists for both types of treatment.
Both radiotherapy and surgery can cause sequelae of both impotence and incontinence.
Urinary incontinence, it happens to a lesser extent, you know, less than 10% of patients will have a complaint of urine loss and less than 3% will have a complaint of severe urine loss, right? But the good news is that even these patients, you know, they can recover after up to a year after the surgery. And, if necessary, there are adequate treatments to correct this urinary loss and we can improve the quality of life of these patients afterwards.
Promoting cancer early diagnosis; Impotence is a slightly more complex case because it will happen to a larger portion of men, so it can happen up to 80% of the time after surgery, and this is what men are most concerned about.
But it is important to say that, when we treat the patient at an early stage, we can also reduce this risk of impotence to less than 20%. Of course, it depends on how the patient’s sexual function was before the surgery, but in initial cases, in general, we manage to better preserve the nerves, you know, during the surgery and improve this quality of sexual potency.
But also good news is that, after we operate, we have the possibility of treating this patient’s impotence in different ways,
whether with medication or even surgery, and this can also be an improvement in the quality of life as a all after treatment. So, as I said at the beginning, our objective, both oncological and functional, the patient needs to understand that we are also concerned about this and that, throughout the treatment, we will pay attention to everything.
Leonardo, I had a patient who underwent prostate surgery and he started having a lot of difficulty getting an erection. A prosthesis was placed and he, who was a man in his late 60s, was so satisfied with the result that he said: “if I had known it was like this, I would have had this prosthesis fitted at age 25”. Are the results that good?
Yes, the satisfaction rates with penile prostheses are really very high, not least because what happens a lot in relation to sexual complaints has much more problems with the psychological part than with the physical part itself, you know, and these taboos related to the good -being of sexual intercourse, they are gradually being broken. So, really, the patient that we implant the prosthesis, and that’s most of them, is very satisfied, mainly because it allows him to have a quality of life. So yeah, that’s how it is.
Promoting cancer early diagnosis: Of course we have the surgical risks, right, of a prosthesis implant, this should be discussed with the patients, but most of them are really satisfied.
And for us to close, we are talking here about early diagnosis of prostate cancer, right, people who have to receive this diagnosis as early as possible, which is to be able to be treated with excellent results, right? And prevention really, for those who… “oh, I want to reduce the risk of one day having prostate cancer”. How can he do? What measures should he take?
Perfect, right? In the scenario of prostate cancer, unfortunately, we don’t have many preventive events because, when we talk about risk factors – being a man, being black or having a family member with prostate cancer – these are things that we cannot avoid. Perhaps the only thing we can avoid is related to obesity, to a healthy lifestyle as a whole. So, weight control, healthy eating, understanding that chronic diseases as a whole cause stress, right? We saw there, in the pandemic scenario, how important it is to have controlled diabetes, controlled pressure, controlled cholesterol, so, all this is where we manage to try to promote quality of life and prevent diseases, as in the case of prostate cancer. So, it’s quality of life, healthy habits, diet and exercise.
Leonardo, thank you very much for so many answers and with all this clarification regarding prostate cancer.
I would like to thank you, right, here, for the invitation to participate in the podcast and once again tell the population not to be afraid, right, not to be prejudiced and to be concerned about your health, both in terms of general care and quality of life , but also with early detection. It was a pleasure to participate with you here. Thanks. Promoting cancer early diagnosis. Tips for Prostate Health