Diagnosing prostate cancer
It seems that most people today know someone who has suffered from cancer. With November being Movember, with the aim of raising awareness around cancer, Moneybags journalist Jessica Anne Wood finds out more about prostate cancer.
What is prostate cancer?
Dr Philippa Peil, chief medical officer at Liberty, notes that prostate cancer is not as aggressive as other cancers, and it occurs mostly in “older men over the age of 65 who are more likely to die of other causes.”
She explains: “The prostate is a gland found only in men and is situated immediately below the bladder and in front of the bowel. It produces fluid that protects and enriches sperm. Cancer occurs when some of the cells in the prostate reproduce far more rapidly than normal, resulting in a malignant tumour. If left untreated, the prostate cancer may eventually spread into other parts of the body such as the lymph nodes and bones. At this stage the cancer is more difficult to treat and chances of surviving decrease.”
Dr Greg Boustead, specialist urologist and robotic surgeon, points out that the number of cases of prostate cancer in the private sector in South Africa that appear in advanced stages is about 15-20%, possibly lower. However, in the state sector this number increases.
The prostate is not a vital organ, however, it is necessary for reproduction. If a man is diagnosed with prostate cancer and surgery is required, the man will be sterile.
Screening and testing
Dr Noluthando Nematswerani, head of centre for clinical excellence at Discovery Health Medical Scheme, points out that with the medical scheme’s screening benefit there is no age cut off. However, she reveals that most recommendations suggest regular screening from the age of 50 for men at average risk and, 40 for those at a higher risk. However, screening for prostate cancer is an individual decision taken between a patient and their doctor.
Boustead emphasises that when it comes to screening a differentiation needs to be made between national screening and targeted screening in selected populations. “There are very few countries in the world that have national screening programmes for prostate cancer because they are very expensive and there is a lot of controversy.”
A targeted screening programme will rather focus on a targeted age group or population group, and every person within that group is invited for testing. There are a number of ways to choose the target group. “If you have a family history, if you are of certain ethnic groups, like Afro-Caribbeans, we know they get prostate cancer earlier and more aggressively, so those groups you should probably start a little earlier, probably about the age of 45.”
Despite these guidelines, if you are concerned, Boustead notes that you can visit your GP for a check-up, where a range of blood tests are usually conducted, including a PSA.
Peil states that not all men with prostate cancer will have raised PSA levels, as other factors could interfere with the test results. For example obese men have a naturally lower level of PSA. The best form of testing for early detection would be a PSA blood test, together with a digital rectal exam. “However, both tests may result in false positives and negatives.”
At risk of cancer
There are a number of risk factors that may lead to or indicate an increased chance of developing prostate cancer, including:
- Sedentary or inactive lifestyle
- Family history of prostate cancer. Dr Bobby Ramasia, principal executive officer at Bonitas says: “For men younger than age 55 years at higher risk (e.g. positive family history or African American race), decisions regarding prostate cancer screening should be individualised.”
- Bad eating habits
- BRCA 1 and 2 genes
- Black men are more likely to develop prostate cancer compared to white men.
Boustead is the doctor responsible for bringing the UroNav to South Africa. It is not the only MRI ultra sound fusion device on the market, however, as far as Boustead is aware the UroNav is the first system of its kind in South Africa.
“Several fusion biopsy systems are available on the international market, of which UroNav is one. The UroNav Fusion Biopsy System fuses pre-biopsy MR images of the prostate with ultrasound-guided biopsy images in real time, for improved, targeted biopsies of suspicious prostate lesions,” points out Ramasia.
Boustead explains that several trials have already been carried out on patients from Johannesburg, Cape Town and Durban.
According to Boustead, the cost of a single unit is about R2.5 million, which means that the cost of testing (at least initially) will most likely be higher. But there are trade-offs. While the cost may be higher, the UroNav allows for more accurate biopsies. At present Boustead says that medical aids may not initially cover the use of the technology, but they will cover the cost of the actually biopsy.
However, Ramasia says that the accuracy of devices such as the UroNav is not yet certain. “It is currently unclear whether MRI-TRUS fusion-guided biopsy consistently detects clinically significant cancer at a higher rate than the reference standard and if the use of this technology is warranted. Bonitas has not yet reviewed this technology and there is no funding policy currently in place.”
Nematswerani says the UroNav has not been approved by Discovery Health Medical Scheme as it needs to be evaluated, but this will only be finalised once all the necessary information has been received from the supplier.
Boustead notes that over the last 20 years, if you had an elevated PSA, or an age related PSA, your doctor would offer you a biopsy, or a trans-rectal ultra sound guided biopsy. They were carried out under an essentially blind technique, you could see the prostate with the ultra sound and had a rough template, but you could not see the tumour in the prostate.
“Unlike breast cancer, for example, you have a mammogram, you see a lesion and you have a targeted biopsy. In most areas of solid oncology you have images, so it’s imaged guided biopsy. In the last four or five years we have seen more utilisation of MRI scans, so we have moved into an era of image guided biopsies [for prostate cancer],” reveals Boustead.
Today, when a high PSA is detected, and other causes such as infection have been excluded, an MRI scan is carried out. “MRI has got the ability to see about 95-97% of clinically significant cancers, and then you can take that information and you can go and do an image guided biopsy,” explains Boustead.
This is where the UroNav comes into play. You import the MRI images and you can conduct a real-time ultra sound when doing the biopsy. The UroNav takes the information from the MRI images and fuses it with the ultra sound image, providing a 3D reconstruction of the prostate.
Boustead elaborates: “It targets your regions of interest, and obviously your radiologist will mark them out before, and then when you do your ultra sound, it has the ability then to show you in real time where these areas are that you want to biopsy.”
With the pre-biopsy MRI, the first step is to determine the stage and location of the cancer. Once this has been ascertained, it is a question of finding the most appropriate treatment. “This will depend on the individual patient, how old they are, what their sexual function is like, their urinary function, the size of their prostate,” clarifies Boustead.
Surgery and chemotherapy are not always necessary, but this is determined on a case-by-case basis. When surgery is required, Boustead explains that the entire prostate is removed. “The prostate is not a vital organ, it’s vital for procreation, but your testosterone comes from your testicles, you still have your testosterone, you still have your libido. Obviously if you damage the erectile nerve you can have erectile dysfunction, and then there is risk of stress incognisance post-surgery and those things are all better with robotic surgery. You can deliver the treatment much more accurately and you can preserve those.”
If the patient is younger, Boustead notes that the doctor will often do semen preservation.
The cost of treatment
Nematswerani offers the following breakdown of costs for the various types of screening and procedures used for diagnosing and treating prostate cancer. (These prices are an estimate and may vary depending on the service provider etc.)
- Screening PSA – the average cost is R173
- Radiation therapy – can cost between R65 000 and R125 000
- Brachytherapy – R90 000 – R118 000
- Robotic surgery – R165 000
- Open surgery – R87 000
- Laparoscopic surgery – R150 000
- Chemotherapy – R55 000 – R75 000 for anticancer drugs
- R15 000 – R20 000 for hormonal therapy
- High cost chemotherapy such as Jevtana – over R30 000 per treatment and members can have between four and eight treatments.
What costs and procedures will your medical aid cover?
With Bonitas medical scheme, the PSA test for prostate cancer screening is funded from your risk benefit as part of the enhanced preventative care benefit on the BonComprehensive option (Bonitas’ top option). This is for men from 55 to 65 years of age. For all other options, screening PSA tests can be funded from the savings benefit, reveals Ramasia.
Discovery Health Medical Scheme will cover an annual prostate screening in line with recommendations. The only factor looked at here is the age of the member, as a higher risk patient may be required to start screening from a younger age.
“The prostate screening benefit right now includes the prostate specific antigen, a blood test that is covered from the screening benefit, a normal consult obviously pays from normal day-to-day benefits. From a specific screening point of view we are looking at the PSA,” says Nematswerani.
She adds: “Once a patient has been confirmed to have prostate cancer, they need to enrol on our oncology benefit, so then all the related costs for the management of that cancer will be covered under the oncology benefit, this includes the chemo, if they need to do surgery, so everything is covered.”
Peil adds: “Suffering a critical illness such as prostate cancer could have a severe impact on your lifestyle. Taking cover such as lifestyle protection cover can assist financially with these lifestyle adjustment expenses associated with suffering an illness.”