We are a very complex set of people when it comes to assessing clinical advice from our neighbourhood caregivers. On many occasions I have been invited to other health facilities for surgery only to discover that the person on the table is my neighbour! Over the years I have developed the simple approach of proceeding with the surgery, collect my fees and move on without acknowledging the fact. We want to keep anything health from our neighbours and that has been the warped mentality that is making us pay dearly for medical tourism. I had the ill luck of living in the midst of three septuagenarians where my medical opinions got me worsted. The first was a diabetic with hypertension and kidney failure due to GLOMERULOSCLEROSIS or rather scarring of the filtration unit of the kidney known as the glomerulus. I was as honest as I could be; so I thought, but by the end of it all I was called Prophet Jeremiah.
And here came again my neighbour that was a father figure to me. My biological father took a bow thirteen years ago. I was not privy to his medical condition prior to his being taken abroad. Then we started hearing about tube drains and stuffs like that, as the Americans would say. It gradually dawned on us that this was definitely stage 4 cancer of the prostate with spread to the liver and pelvic bones. One day I ran into a very close relation of his and my advice was simple: at this stage it is best to bring him back home for logistic reasons. The advice was hard on him and a couple days later when I asked him about the old man, his response was very brief: he is getting better. Five days later the old man was dead. He’s been cold towards me since then
In the management of prostatic Cancer, the first decision is whether the patient needs to be treated at all. This would depend on the stage of the disease, the appearance of stained sections of biopsy samples, the level of PSA in the blood, the age and any other health conditions. Usually in the very elderly the cancer is of the low grade type and hardly requires any treatment. The care givers would rather watch and wait. Conventionally there are four stages of the cancer under the TUMOUR, NODES and METASTASES (TNM) classification, designated 1-4. The components of these stages include the size of the tumor, the number of lymph nodes affected and evidence of spread out of the prostate gland. As a rule clinically, in T1 and T2 the tumor is stilled confined to the prostate gland while T3 and T4 cancers have spread beyond the gland. In this instance imaging techniques like Magnetic resonance, CT-Scan and in our environment the good old pelvic x-rays would be needed to make a diagnosis.
The diagnosis of Carcinoma of the prostate is confirmed through biopsy with tissue examination under a microscope known as histology and the virulence of the cancer can be predicted through GLEASON patterns scoring. Basically this involves noting the degree of changes in the cancer tissue compared to the normal prostatic cells and stoma. In this grading, pattern 1 shows what is normally referred to as well differentiated carcinoma in which the cells and the stoma look almost exactly like you have in a normal prostate. This type is usually not very virulent and in a lot of cases the diagnosis is made as incidental finding at post mortem. From this there are variations in the appearance until GLEASON pattern 5. Here the tissue does not have any semblance to the original prostate gland.
They are just sheets of cells with occasional mitotic bodies, which are cells in active state of division. The best description of this pattern is ANAPLASTIC carcinoma and they are very malignant. In clinical practice, pattern 3 is the most common. Most care givers are comfortable with the report of well differentiated, poorly differentiated and anaplastic type from the pathologist. Above all Prostate Specific Antigen level in the blood is also necessary in the decision making process with respect to the treatment option that would be offered to the patient. Not commonly used in this environment is the PROTEIN SPECIFIC MEMBRANE ANTIGEN. This protein is generously expressed in prostate cancer tissue and goes a long with high Gleason score.
In practice, it is commonplace that most men with low risk prostate cancer would be subjected to what is generally referred to as ACTIVE SURVEILLANCE. This simply refers to a situation where the tumour is kept under close observation over a period of time with the intention of intervention for a cure if there is evidence of disease progression. In active surveillance, the tumour is monitored through serial PSA, digital rectal examination and repeated biopsies. The whole essence of this line of management is to avoid overtreatment and perineal side effects of treatment in slow growing tumours that ab initio would never have caused any problems for the person.
Another approach is the concept of WATCHFUL WAITING. Here, no treatment or specific program of monitoring is intended. In reality PALLIATIVE TREATMENT is assumed even if not commenced. Waiting for the symptoms of an advanced disease is mainly discretional when in most cases it’s obvious. Palliative care in general terms, focuses on treating symptoms of the terminally ill and improving the quality of life at that stage. The underlying lesion at this state is not of primary concern to the caregiver. By this time even the very sick are aware that the end of life approaches. Pain can be a nuisance in prostatic cancer with bone metastases. The objective is to kill the pains, make the patient as comfortable as possible while waiting for a final event. Just anything can be thrown in palliative care; from radiation to bisphosphonate which cause apoptosis in osteoclasts to steroids. Other features like weight loss, swelling of the scrotum and the penis should be addressed accordingly.
The need for family support and care should not be neglected at this point. Faith leaders, be they Christians or Muslims could be in an immense position to help in the care of this class of patients. Those with prostatic cancer can remain recumbent until just a few days to their demise due to the nature of the disease especially with the slow growing type. This makes it a little bit challenging for the patient to accept psychotherapy. But whatever be the situation what they cannot reject are occasional visits by priests, pastors and imams.
…..To be concluded next fortnight. Cheers.