Imaging Prostate Cancer
Posted: Nov 01, 2018
POSTED: August 28, 2017
Dr. Vedang Murthy is a Professor in the Department of Radiation Oncology at Tata Memorial Centre in Mumbai, India.
Prostatepedia spoke with him about prostate cancer in India.
Dr. Murthy: When I was growing up in India, kids either became doctors or engineers. Because I did not enjoy mathematics and physics, I made the obvious choice and became a doctor! I think practicing in India has been most rewarding. There is a certain respect that doctors get here that is quite unique. Patients, even the educated ones and those who are aware of the options available, put everything in your hands, almost without question. To justify that faith imposed on doctors, I think we need to make correct and balanced decisions. That’s a very responsible position to be in.
Dr. Murthy: Certainly. Often that’s the difference in choosing reasonably difficult—or even obvious—treatment options for patients. They say: “Doc, you should make decisions as if I’m your father,” or they ask for that kind of a personal relationship.
I have not experienced this often in the West.
Dr. Murthy: Once I finished my training—my MD in radiation oncology—I worked at the Royal Marsden Hospital in Sutton, United Kingdom, for about four and a half years. I worked with experts like Professors Alan Horwich and David Dearnaley, who really helped to hone my skills and knowledge. That is where I learned the tricks of the trade and developed some understanding of urological cancers. When I returned to India in 2008, I continued treating urological cancer, along with head and neck cancers, for the next 10 years.
Dr. Murthy: Screening is absolutely not there for prostate cancer in any form currently. In fact, screening is not even there in a formal way for common cancers like cervical, colon, or breast cancer, which are very common in the West. Prostate cancer really comes down the line in terms of prevalence in India, so screening is not there.
Because of this, most of the patients present to us in advanced stages. In fact, I would say about 60-70% of all patients present with metastatic disease, which is quite high. Of the remaining 30-40%, a majority have advanced cancer.
Dr. Murthy: It is not the biggest or the primary issue. The main issue is the advanced nature of the disease. There is actually a difference in geography. In larger metropolitan cities, the incidence has increased in the last couple of decades. For example, in cities like Delhi, Bangalore, and Chennai, prostate cancer is the second or third most common cancer in men, whereas overall, it is about seventh or eighth.
Because of changing lifestyles, food habits, and migration from rural to urban populations, incidence is on the rise in urban areas. When we look at the data for incidence, we talk in terms of cases per 100,000 people. On average, if you look at the total population of 1.3 billion people in India, that means about 60,000 new cancers every year, which is the same or higher than any large European country like Germany, France, or the United Kingdom, which average around 50,000 new cases per year.
Dr. Murthy: We don’t know. I think that the data is not robust enough to give us that information by region.
Clearly, the larger, metropolitan cities have an increased incidence of disease due to lifestyle-related issues.
Dr. Murthy: A screening program must be initiated at the national level, not at the hospital or city level. At the national level, prostate cancer is just not ranked with the big killers like cervical, breast, lung, or oral cancers. These are the big healthcare issues that the policymakers have to contend with first. This is the main reason screening is not discussed right now.
There is talk among the urologists—among us treating prostate cancer— that we need some kind of targeted, symptom-based screening. But there are no defined, high-risk populations as you see in the West, such as African-Americans or genetic-based risks. I think the urologists and general physicians have to be more aware of doing a PSA than they are currently in older men with urinary symptoms.
Once a man is diagnosed, are there any kinds of support systems in place for him? I know in the United States there is a whole system of support groups and nonprofits that offer services. Is there anything similar in India?
Dr. Murthy: There are no such support groups that I’m aware of. However, patients have a lot of family and societal support. Of course, there are nongovernmental organizations doing a lot of work but not specific to prostate cancer.
Dr. Murthy: I don’t think prostate cancer is spoken about generally in the community. Though there exists social stigma attached to breast cancer, or any male or female cancers of the genitalia, I suspect most of the population might be unaware that the prostate even exists! Because of this, I don’t think there is any such stigma associated with it, just a pure lack of awareness.
Dr. Murthy: In general, I would say 80% of the population pays out-of pocket expenses. Even if they go to a state-funded institution where a lot of the treatment is subsidized, the cost of the drug is often not. Radiotherapy and surgery might be completely subsidized, but the cost of drugs is often just reduced and the patient pays the rest.
A number of state governments have begun to fund cancer patients. Many receive government help in the form of a fixed purse like a state-funded insurance. There is very little medical insurance as such in the community. In cities, some people are covered by their employer’s corporate insurance, but that’s a minority.
Dr. Murthy: Late presentation is the biggest problem we currently face. We need symptom-based screening, particularly in the cities where incidence is higher. As anywhere else in the world, patients see urologists or general physicians in the first instance.
But the urologists here tend to perform orchiectomy without other treatments, which can do a lot of harm, especially if the patient has nonmetastatic prostate cancer. Orchiectomy is a very good treatment for metastatic disease, but people tend to underestimate the side effects of androgen deprivation therapy. This must change.
Similarly, transurethral resection of the prostate (TURP) is a very common procedure. Urologists often perform a TURP, remove the obstructing tissues, and then the patient feels better. It can have a lot of negative impact on future treatment like radiotherapy or even prostatectomy. In the next 15-20 years, we face a looming epidemic due to lifestyle changes. I think what happened in the West is going to happen here, especially in the larger cities. Indians face the burden of traveling long distances for treatment. If they want state-of-the-art treatment, they seek larger centers. For example, they come to Mumbai from far-flung areas. If they have, for example, radiotherapy for six to eight weeks, that is a large expense. And while receiving treatment, they often spend several times more on lodging than on the treatment itself.
We have begun to address this by introducing or developing hypofractionation schedules, which are much shorter. They have a much shorter treatment course: five to seven days rather than five to seven weeks. This reduces the burden of travel and out-of-pocket expenses as well as the burden on the hospital. Seven days versus seven weeks of treatment on the machine means a rapid turnover.
Dr. Murthy: The first advice would be not to panic—there is absolutely no need. Men who are diagnosed with prostate cancer need to seek treatment at a reasonably good center, either at a private organization or a state-funded hospital. There are a number of cancer centers—even the state-funded ones—that have pretty good state-of-the-art equipment and expertise with world-class care. There is no doubt about that. But patients have to show up, and in time, to benefit.
Lots of effective treatments are available, so it’s unlike other types of cancers such as lung, pancreatic, or certain brain tumors where survival is limited and treatment lasts for a few difficult months. Even if it has spread and prostate cancer is diagnosed as metastatic, with the number of effective treatment options, these men live a long and reasonably good quality of life. That’s important to remember.
One of the accepted treatments for metastatic prostate cancer, which many men choose, is removal of the testes or an orchiectomy, which is effective and quite inexpensive as compared to lifelong hormonal injections. People should not be afraid or think of removal of testes as feminization—that is a common misconception. Of course, orchiectomy has side effects due to a lack of testosterone, but it is effective.
Depending on the stage and type, nonmetastatic prostate cancer—if it has not spread outside the prostate—is pretty much curable with radiotherapy, surgery, or a combination of these. Even metastatic cancer can be controlled for several years. A number of life-prolonging agents have recently become available, when just five years back, they were prohibitively expensive. They are still expensive, but the price is rapidly coming down, so we have gained access to some of these drugs at a reasonable cost now.
Many patients have bone pain, which is how prostate cancer spreads. Bone pain can be controlled effectively. Palliative radiotherapy is a very effective option. I have seen a lot of patients worry about taking painkillers because they’ve been told painkillers are addictive, but they miss the point. If you have cancer pain, you need to take the painkillers. That’s what they’re for. This is the kind of misconception we must clear up.