Men's Health - Q4 - 2019 by Mediaplanet UK&IE

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PROF RICHARD HINDLEY AND PROF AMR EMARA Innovations in treatment for BPH » p4-5

PROF AMIT BAHL New hydrogel can reduce side effects of radiotherapy in prostate cancer » p8-9

DR STEVE ALLEN Don’t avoid your diagnosis, go for a PSA test » p14

Men’s Health

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1. Hamstra DA, Mariados N, Sylvester J, et al. Continued benefit to rectal separation for prostate radiation therapy: Final results of a phase III trial. Int J Radial Oncol Biol Phys. 2017 Apr1; 97(5): 976-85. 2. Hamstra DA, Mariados N, Sylvester J, et al. Sexual quality of life following prostate intensity modulated radiation therapy (IMRT) with a rectal/ prostate spacer: Secondary analysis of a phase 3 trial. Pract Radiat Oncol. 2018 Jan - Feb;8(1):e7-e15. CAUTION: The law restricts these devices to sale by or on the order of a physician. All the images are the property of Boston Scientific. All trademarks are the property of their respective owners. © 2019 Boston Scientific Corporation or its affiliates. All rights reserved. URO-664709-AA AUG 2019 CONTENT IS PROVIDED BY BOSTON SCIENTIFIC. BOSTON SCIENTIFIC IS DEDICATED TO TRANSFORMING LIVES THROUGH INNOVATIVE MEDICAL SOLUTIONS THAT IMPROVE THE HEALTH OF PATIENTS AROUND THE WORLD.

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What is the prostate? The prostate is a walnut sized gland found in men. It lies between the penis and bladder, and wraps around the urethra (the tube that passes urine out of the body). Normal Prostate

Enlarged Prostate

Bladder

Prostate Urethra

An enlarged prostate is a benign, non-cancerous growth of this gland. By increasing in size, it puts pressure on the bladder and makes it difficult to urinate.

Who gets BPE/BPH? Only men get BPE/BPH. An enlarged prostate is associated with ageing. Around 40% of men over 60 have lower urinary tract symptoms (in the bladder and urethra) due to an enlarged prostate.

1. How inaction can be detrimental As men get older it is sad that he who is master of his destiny often becomes servant to his bladder. When it comes to seeking advice, it is often men who prefer to put things off. But the ‘wait and see’ approach can often be detrimental to their quality of life. After all, men, but also women, are predisposed to urinary tract problems – especially as they get older.

s of the age of 50, more men suffer from increased urinary frequency, which may disturb sleep and generally interfere with quality of life. It is therefore perhaps no surprise that with an ageing population, an increase in diseases affecting function of the bladder and male erectile function, such as diabetes and obesity, occur. Men tend to make light of the situation and while this can be all well and good for raising the spirits there is very much an attitude of ‘it won’t happen to me’. And certainly, although it is common, avoiding difficulty, increased urinary frequency, erectile dysfunction or more sinister findings, such as finding blood in your urine, are topics that men might find hard to open up about. It is important for them to speak up and realise that some conditions such as prostate cancer can develop silently. A lot of information on urological issues can be found on the internet. Some of this information comes from trusted authorities, like hospitals, but quite a lot of it comes from unreliable and biased

sources. It is important to look for a dependable source of patient information on the internet like EAU Patient Information (www.patients. uroweb.org), enabling patients and their family to educate themselves more easily.

urological health. This means that, often, a male patient will only present when accompanied by their partner – in many cases one fed up of being woken in the night by frequent bathroom visits! The urologist is to me exactly like the gynaecologists’

Men tend to make light of the situation. To that end, as healthcare professionals, we are perhaps guilty of using jargon that can mystify our patients slightly. There is so much information out there that urological health can seem very confusing to someone unaware of typical symptoms or treatments. It is a urologist’s job to advise and guide patients and facilitate a patient’s struggles to find recent and up-todate material. If men and their families are wellinformed, they can better face the reality of these problems. I believe this could empower them to take more ownership of their medical care and facilitate their decisions. Women tend to have more open and frank conversations about

role for women, dealing with all aspects of urinary abnormalities for both men and women. Men need to accept that there is a strong likelihood that they – or someone they know – will suffer a urological condition at some stage of their lives. Having knowledgeable resources or the ability to ask a healthcare professional, are important tools that more men should access. However, only by talking more openly about these conditions and spreading this information can we really equip the people who might need it the most. TYPED BY JEN TIDMAN, RESEARCH SECRETARY

Why does it happen? The cause of an enlarged prostate is unknown. One theory is that an increase in prostate cells is linked to changing levels of hormones in older men. Testosterone levels reduce with age and men subsequently have a higher percentage of oestrogen in their body, encouraging prostate growth. 2 HEALTHAWARENESS.CO.UK

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Symptoms of BPE/BPH 1. Having to push or strain to start urination 2. Finding it difficult to postpone urination

2. Why more men need to know what BPE is Do you know what benign prostatic Enlargement (BPE) is? If not, you are not alone. A survey was recently conducted in the United Kingdom, France and Germany, which found that, out of the 1,002 male respondents in the UK aged 50 and above, 37.5% did not know what BPE is. France reported 33%, while in Germany 45% of men were unfamiliar with BPE. (See figure 1.)

PE, also known as benign prostatic hyperplasia (BPH), is a non-cancerous increase in the size of the prostate gland. The symptoms include frequent urination (including at night), difficulty in urinating and/or a weak stream of urine, and pain while urinating. You need to know what your prostate is The results of the survey also showed that 75% of men above the age of 50, did not know what the prostate’s main function is. The prostate is a gland vital to men’s sexual health as it produces prostatic fluid that nourishes and protects the sperm. During ejaculation, the prostate squeezes this fluid into the urethra which is then expelled with sperm as semen. (See figure 2.) It’s time to talk about urological health

Having an enlarged prostate does not only affect the men who suffer from it, but their partners as well.

75% of men above the age of 50, did not know what the prostate’s main function is. In the past, it was considered taboo to talk about urological and sexual health issues, but times have changed. Campaigns such as Urology Week encourage open discussions among patients, their partners and/or family, and their urologists. Urolog y Week is an annual initiative of the EAU where national u rolog ic a l soc iet ies, u rolog y practitioners, urolog y nurses and patients organise diverse activities to spread the word on the importance of urological health. Urology Week was hosted this year from 23rd to 27th September, and aimed to increase awareness of BPE: Wh at t he c ond it ion is, sy mptoms to look for, its treatability despite its prevalence, and the importance of consulting a urologist. Urologists and other healthcare providers all over Europe prepared a

wide range of activities for Urology Week 2019, including television and radio press conferences, marathons, open days at clinics and many others.

Read more at healthawareness.co.uk

Urology Week 2020 Interested in supporting Urology Week in 2020? Visit the website www.urologyweek.org for inspiration and information. And always remember, BPE is treatable and your urologist can help.

3. H aving a sensation of not emptying your bladder completely after you finish urinating

Treating BPE/BPH 1. For mild to moderate symptoms, a policy of ‘watchful waiting’ is typically implemented. This includes annual check-ups with blood and urine tests. 2. Lifestyle changes, which might include: - Drinking less in the evenings - Cutting down on caffeine and alcohol

3. If your quality of life is affected greatly by BPH, recommended options include: - Medication that can make it easier to pee and reduce the size of the prostate - Surgery, typically as a final resort, to remove parts of the prostate that cause blockage - For very large prostates, the entire prostate may be removed Sources: 1. EAU Patient Information, patients.uroweb.org 2. https://www.theurologyfoundation.org/images/2018_ Bitesize_Guides/181120_-_Bitesize_Guide_to_ Enlarged_Prostate.pdf

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Understanding Rezum: Just one of the new treatments for BPH

AMR EMARA Consultant Urologist, Hampshire Hospitals NHS Trust

New techniques to treat benign prostatic hyperplasia (BPH) are being hailed as minimally invasive. But what do they entail? Two consultant urologists explain.

ecently in the UK, new, less invasive treatments have been approved to treat an enlarged prostate, known as BPH. While a TURP (transurethral resection of the prostate) procedure is the most recognised option, it does carry risks, including erectile dysfunction (around 5-10%) and retrog rade ejaculation (when semen enters the bladder instead of emerging through the penis during orgasm), which occurs in the majority of cases after a TURP. Using water vapour to shrink the enlarged prostate gland The Rezum procedure involves delivering steam into the prostate gland, which destroys tissue and shrinks the gland over the following weeks. This is particularly useful in the longer term because the prostate does continue to grow with ageing. Rezum was given NICE approval in August 2018. Since then, Professor H i nd ley ha s beg u n t ra i n i ng surgeons across the UK and Europe in delivering the treatment. He explains: “When I first heard about Rezum, and with my previous experience of similar procedures, it seemed like it had great potential and was complimentary to the other

4 HEALTHAWARENESS.CO.UK

minimally invasive options. Here in the UK, we have traditionally been very loyal to TURP because it is a very good treatment, however, we are now developing a portfolio of minimally invasive treatments as we understand that the TURP procedure isn’t for everyone, especially those who still have an active sex life.” Professor Hindley first carried out the procedure in March 2017, and it is now available in many more centres as more surgeons are trained. “With a treatment time of roughly 15–20 minutes, my hope is that this procedure could transform NHS waiting lists as well as reducing medication, as there are fewer side effects.” Patient feedback is overwhelmingly positive While medication and surgery (TURP, usually) are the two most common options for BPH sufferers, Prof Hindley hopes that minimally invasive treatments such as Rezum could fill a gap. “The feedback we get is very positive” says Mr Hindley. “I get men telling me that they have been waiting years for a treatment like this.” The technique is now rolling out

RICHARD HINDLEY Urology Clinical Lead, Hampshire Hospitals Trust

Men typically, don’t like to talk about their concerns to avoid big operations, but this new treatment is really opening up the conversation. across the NHS. Mr Amr Emara, another consultant urologist also at Hampshire Hospitals, who was also an early adopter of this procedure, says men are now much happier knowing they have several options when diagnosed with BPH. “Men, typically, don’t like to talk about their concerns to avoid big operations, but this new treatment is really opening up the conversation. I find many men have already done their homework and asked for a referral for the procedure. My job then is to make sure that they are suitable.” Are minimally invasive treatments suitable for everyone? While there are other minimally

invasive treatments that can be offered with BPH, they are not suitable for everyone. Mr Emara says: “There are some cases where the prostate may be bigger than the range we recommend for Rezum (up to 90 cc), which may require a longer recovery period, but the feedback we have had is that men would much prefer a day procedure with symptoms improvement that develop over a period of time, rather than a surgical procedure with an immediate outcome that carries more risk.” Most common side effects are the short-term, catheter related discomfort, and blood in urine in the early post-operative period. “We have had no new cases of erection problems or urinary leakage after Rezum in all the cases we have

treated so far, and this is a better profile of side-effects than with current medication,” explains Professor Hindley. Generally, these are tolerated quite well, as long as they are explained in advance said Mr Emara. “I find that, if men know what to expect, then they usually run a smooth post-operative recovery.” I tend to describe the outcome of Rezum as shrinking the prostate gland and making it 10 years younger without having to take daily medication.” “ We d o n e e d m o r e d a t a , particularly around the issue of whether, in the future, younger, sexually active men should be offered a minimally invasive intervention instead of medication. We suspect this may be better for men but we need to better understand the costeffectiveness of this strategy. A study investigating this issue is soon to be underway in France. We are keen for something similar in the UK,” says Professor Hindley.

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Our treatment: Why we tried Rezum Rezum is slowly becoming more popular as a treatment for benign prostatic hyperplasia (BPH) after its NICE approval last year. So, what did these two men think of the treatment?

rou nd f ive ye a r s a go, 69-year old Nick Pyne from Wiltshire started to get up more frequently in the night. “I was waking up three to four times to go to the toilet and sometimes I found it very difficult to empty my bladder,” he says. Nick decided to have a PSA check with his GP, and, while this came back as slightly elevated, it wasn’t enormously high. Nick was therefore relieved when further tests showed that his enlarged prostate was benign. However, the standard procedure for the treatment of BPH wasn’t quite the outcome Nick had hoped for. He s ays: “I d id n’t l i ke t he potential risks associated with the TURP procedure, such as erectile dysfunction and incontinence;

the risks of down sides were worrying.” He decided to continue mon itor i ng h is prostate a nd became a familiar face at the urology unit in Bath. But, over time, Nick found it difficult to plan long journeys of more than an hour away in case he had to use the toilet. A family member told him of a new procedure, a Urolift, but due to the size of his prostate the consultant offered Rezum, a new, pioneering treatment at Basingstoke hospital; he had the treatment in spring 2018. “It was the best thing I’ve ever done.” he says. “Once I heard about the procedure I was quite relaxed about it and thought it was quite logical really. I turned up at the

I didn’t like the potential risks associated with the TURP procedure, such as erectile dysfunction and incontinence; the risks of down sides were worrying.

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hospital in the morning, had the procedure in the day unit and the treatment only took 15 minutes. My wife drove me home two hours later. A week later, the catheter ca me out a nd I i m med iately started to notice improvements Now, sometimes I don’t even need to get up in the night. I would definitely repeat the procedure again if I needed to.” First in and last out S i x t y- e i g ht-ye a r- o l d Je f f r e y Clement from Wales had been suffering from disturbed sleep and a slow flow for over a decade, for which his GP prescribed two types of medication. “I’d be t he first one in t he loo and the last one out,” says Jeffrey. “It was obvious that I had a problem, and was a bit emba r ra s si ng. E s p e c ia l ly on a golf trip with my friends, it was taking the enjoyment from going away. “ We a l s o h ave fou r you n g grandchildren who live about a three hour drive away. Planning these visits necessitated numerous toilet breaks.” With the condition fur ther exacerbated by alcohol, BPH began

NICK PYNE BPH Patient

JEFFREY CLEMENT BPH Patient

I’d be the first one in the loo and the last one out...It was obvious that I had a problem, and a bit embrarrassing. to take its toll on Jeffrey’s social life, and so the Welsh NHS offered him a TURP procedure. His fat her hav ing had t he s a me pro c e du re, Jef f rey de c ide d he w a s n’t prep a re d to ta ke t he r isk s. There was also a waiting list of around eight months. After reading an article in the paper, Jeffrey discovered Rezum and had the treatment in summer 2019. He suffered some discomfort, but is very happy with the results. He says: “I had a very slow flow about two weeks after the catheter was out and realised it was the ablated tissue that was yet to pass. After a quick visit to the hospital I was given equipment to selfcatheterise and then once it had passed I found I was having much improved results.” Jeffrey now fully enjoys his

golf trips and finds himself a less frequent visitor to the toilet in the night. “In fact, I’ve just returned from a week’s golfing in Portugal and I had a brilliant time.” I’m now first in to the toilet and first out “I now look forward to the trips to s e e my g r a ndch i ld ren a s the journeys have become less arduous. “Rezum has g reat ly improved the quality of my life and I am no longer reliant on taking medication. I would recommend t h is procedu re to a nyone suffering symptoms like I was experiencing.”

Read more at healthawareness.co.uk

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Why some men are opting to put off prostate cancer surgery Thousands of British men are now choosing to have their prostate cancer monitored instead of having surgery or radiotherapy. It is an important decision that must be carefully considered.

very year, around 47,000 British men will find out they have prostate cancer. Those with an aggressive form of the disease will need rapid treatment in the form of surgery, radiotherapy or sometimes chemotherapy. However, if it is classed as being ‘low risk’ or slow-growing and looks likely to stay that way for some time, then it is often possible to have no treatment at all - an approach known as active surveillance (AS). For a man who just been told that he has a type of cancer that kills 11,000 men every year, the idea of having no active treatment for it can be a difficult one to get his head around. But sometimes, doing nothing is the safest option. Active surveillance is an alternative to active treatment, which involves regularly monitoring low-risk or slow-growing prostate cancer instead of undergoing radical treatment such as surgery or radiotherapy. It allows some men to avoid, or delay, the start of treatments that can carry side effects such as incontinence, sexual and bowel dysfunction – all of which can have a long-term impact on their quality of life.

Researching the potential for active surveillance Up until relatively recently, it was thought there wasn’t enough evidence for doctors to recommend it. That’s why the Movember Foundation invested in researching active surveillance through the GAP3 project. The aim is to create the world’s largest centralised database of men with prostate cancer on active surveillance. It includes clinical, MRI and genomics data from over 15,100 men in 12 countries who have chosen active surveillance. It will allow clinicians to better identify men who are suitable for active surveillance and more accurately determine when a man’s cancer has progressed to the point that he needs active treatment.

Data suggest more UK men are opting out of surgery There are signs that the trend towards AS in the UK is rising. Earlier this year, the National Prostate Cancer Audit Annual Report showed that the proportion of low-risk men who opted for radical treatment in 2016-17 fell from 8% to 4% in one year. T h i s i s g o o d n e w s b e c au s e t he p r o ble m o f m e n b e i n g overtreated has been one of the challenges we face in treating prostate cancer. But, just because it’s the right path for some men, doesn’t make it an easy decision. C ho o s i n g whet her to h ave treatment or not can be ver y tough. It’s vital that men get t h e i n fo r m at io n t h e y n e e d and understand the risks involved so that they can make an informed decision about their ow n t re at ment a nd no m a n i s left reg retting t hat choice later down the line.

PAUL VILLANTI Executive Director, Programmes, Movember Foundation

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Risk-based management of early prostate cancer

PROFESSOR ROGER KIRBY Editor-in-Chief, Trends in Urology and Men’s Health

The need for treatment following a diagnosis of prostate cancer should take into consideration, not only the stage and grade of the disease, but also patient preferences.

n low-risk cases (PSA <10ng/ ml and Gleason score ≤6), the majority of men are now advised to undergo a period of active surveillance in order to determine whether or not intervention by surgery or radiotherapy is required. The recently revised NICE guidelines1 on the diagnosis and management of prostate cancer have proposed PSA measurement and accompanying digital rectal examination every four months, with reassessment at 12 months using a multiparametric MRI, followed by a repeat biopsy. In the absence of evidence of progression, follow up should continue with regular PSA determinations either in primary or secondary care. If cancer progression becomes apparent, then the need for more definitive treatment will need to be discussed. Evidence currently shows that patients treated by surgery or radiotherapy, after an initial period of active surveillance, do not seem to have worse outcomes than those that were treated at the time of the original diagnosis. In intermediate-risk cases (PSA 10 –20ng/ml, or Gleason score 7), following an initial discussion about active surveillance, most urologists advise definitive treatment to prevent the development of local complications and/or metastatic spread. Eliminating early prostate cancer by removing the gland The most reliable way of permanently eliminating early prostate cancer is to remove the gland before the cancer has spread. This is most commonly achieved by keyhole surgery, with or without robotic assistance. With careful technique and an experienced surgeon, the risk of more than temporary stress urinary incontinence is 2–5%. The chances of erectile dysfunction (ED), however, are considerably greater. This risk needs to be discussed with patients.

The recent vogue for active surveillance will reduce the potential for ‘overtreatment’ of low-risk cancers. ED can be managed reasonably effectively with regular phosphodiesterase 5 inhibitor therapy and/or prostaglandin injections. Radiotherapy treatment Alternatively, the patient can be © NATTAKORN MANEERAT offered treatment by radiotherapy, using either external beam radiation, usually preceded by at least three months’ androgen blockade, or brachytherapy. Other newer ‘focal’ therapies, which target the tumour rather than the entire prostate, such as high-intensity focused ultrasound (HIFU), are still regarded as experimental and should only be employed within the context of a clinical trial. Active surveillance is not advised for high risk cancer In high-risk patients (PSA >20ng/ml or Gleason score 8–10) with localised disease, active surveillance is not advised. Instead, surgery or radiotherapy, plus hormone treatment is recommended. The c hoic e b et we en t he s e options will depend on patient preference and on the local extent of the tumour. If, for example, there is evidence of bulky local disease and/or seminal vesicle involvement, the decision should be more likely to include radiotherapy. If it looks as though the tumour can be removed in its entirety, with negative surgical margins, then radical prostatectomy may be possible. However, patients in this category should be informed that subsequent ‘multimodality’ treatment with radiotherapy and hormone treatment may often be required. The patient must be actively involved in treatment decisions

1: N ational Institute for Health and Care Excellence (NICE). Prostate cancer: diagnosis and management (NG131), May 2019 (https://www.nice.org.uk/guidance/ng131; accessed 22 July 2019).

The diagnosis and management of early prostate cancer continues to generate much discussion and controversy. Recently, several studies have reported superior outcomes for surgery as opposed to either radiotherapy or ‘watchful waiting’. However, every treatment option carries the risk of side-effects, which need to be carefully explained to both the patient and his partner. The recent vogue for active surveillance, which features prominently in the recently updated NICE guidelines, will reduce the potential for ‘overtreatment’ of low-risk cancers that are destined never to affect the patient within their natural lifespan. Anxieties persist that current methods of initial diagnosis and staging, and subsequent identification of disease progression, are still suboptimal. The use of genomic markers may prove useful refinements by providing prognostic information. These include the ProlarisTM or Oncotype DxTM tests, which identify and quantify markers of cell cycle progression. Current extensive research seems likely to identify other clinically useful biomarkers, as well as alternative treatment options, which cause less morbidity. Sign up to receive content at trendsinmenshealth.com

About Trends Trends in Urology and Men’s Health covers subjects that particularly affect men. These subjects include cardiovascular disease, urological, sexual and mental health issues. The journal publishes six times a year and includes concise, evidence-based, educational and practical articles aimed at urologists, GPs and specialist nurses. MEDIAPLANET

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Prostate cancer: Stats and facts

Who gets it? It is most common among men over 50 years old, especially those with a close-family history of prostate cancer.

Signs and symptoms 1. A need to urinate frequently, especially at night 2. D ifficulty starting urination or holding back urine 3. W eak or interrupted flow of urine 4. P ainful or burning urination

5. Difficulty in having an erection 6. Painful ejaculation 7. Blood in urine or semen 8. Frequent pain or stiffness in the lower back, hips, or upper thighs

Why does it happen? It is unclear why cells become cancerous. Several factors make prostate cancer more likely to occur: 1. Increasing age 2. Being of African-Caribbean

or African descent

Treating prostate cancer Treatment will depend on a number of factors: the extent and aggressiveness of the cancer, your age, and your general health. If your cancer is small and low-risk, your doctor may advise a policy of ‘watchful waiting’ or ‘active surveillance’. This simply means monitoring your symptoms and having regular check-ups to see if the cancer has spread. If the cancer is in its early stages, or has just started to spread outside the prostate, you may be treated with one or more of the following:

3. Family history of prostate cancer 4. Being overweight 1. Surgery - removal of the whole prostate (radical prostatectomy) or parts of it 2. Radiotherapy – radiation is used to kill the cancer cells 3. Brachytherapy (another kind of radiotherapy) – small, radioactive seeds are inserted into the prostate to target the cancer

5. Men who are black, and

men who have a family history (a brother or father with prostate cancer), are 2.5x more likely to get prostate cancer

6. If you’re 50, you should be talking to

your doctor about PSA testing. If you’re black, you need to start that conversation at 45, and if you have a brother or father with prostate cancer in their history, do it at 45

4. Cryotherapy (or freezing therapy) – a substance is injected into the prostate to freeze and kill cancer cells 5. Hormone therapy

Early detection is key Side effects Depending on the treatment you undergo, you may experience some of the following:

1. Incontinence (involuntary leakage of urine) 2. E rectile dysfunction (difficulty achieving or maintaining an erection) 3. W eight gain due to hormone therapy 4. Depression

If detected early:

98%

chance of survival beyond 5 years.

If detected late:

26%

chance of survival beyond 5 years.

Sources: h ttps://uk.movember.com/mens-health/prostate-cancer#the-facts https://www.theurologyfoundation.org/images/2018_Bitesize_Guides/181120_-_Bitesize_Guide_to_Prostate_Cancer.pdf

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PROFESSOR AMIT BAHL Consultant Clinical Oncologist and Clinical Director, The Bristol Haematology and Oncology Centre

New advancements in prostate cancer mean that men who underwent radiotherapy in a randomised clinical study reported fewer bowel, urinary and sexual side effects at median three year follow-up compared to control patients thanks to a new hydrogel spacing technology.2

rostate cancer is currently one of the most common cancers in the UK; more than 40,000 cases are diagnosed each year.1 Typical treatment plans include a high dose of radiotherapy that aims to effectively kill cancer c el l s s o t hey c a n not s pre ad any further. Due to the prostate being close to other organs and tissues, such as the rectum, there is a risk of

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long-term damage and side effects such as rectal pain, bowel and urinary leakage and sometimes erectile dysfunction. New gel solution can reduce side effects of radiotherapy S p ac e OA R Hyd rogel, a N IC E approved water-based hydrogel spacing device, available across the UK via private and co-pay providers

has recently been adopted by NHS England’s Innovation Programme. Inserted via a fine needle into the space between the prostate and rectum, under anaesthetic, the gel fills the cavity between the prostate and rectum, creating about one centimetre of space. This allows the oncologist to deliver radiation to the prostate and reduce exposure to surrounding healthy tissues. The only prostate-rectum spacing

device to be supported by a 222patient randomised control trial and over 50,000 implants worldwide, this has had very positive patient outcomes.2,3 Professor Amit Bahl, Consultant Clinical Oncologist and Clinical Director based at The Bristol Haematology and Oncology Centre, was the first to use this new technology when it became available on the NHS Innovation Technology P rog r a m me (I T P) e a rl ier i n the spring. Professor Bahl says: “When looking at treatment options, the risks of these procedures are low but it’s understandable that patients are worried about them when they include terms such as ‘rectal toxicity’. Together with worries over erectile dysfunction or urinary incontinence, it can make the choice between radiotherapy and surgery quite tough. “Now, I a m able to s ay to patients that I can perform a small procedure that will reduce these side effects and minimise radiation exposure to healthy organs and tissues, I haven’t had anyone turn it down yet.”

A 15-20-minute treatment under anaesthetic The treatment itself is minimally invasive and takes around 15-20 minutes as a day procedure, under genera l or loca l a naest het ic, depending on the patient. P rofe s sor B a h l ex pla i n s: “Essentially, it is a fine needle t h roug h t he p er i neu m, i nto the peri-rectal fat. The idea is to dispense the gel between the posterior part of the prostate and the anterior part of the rectum, where the prostate touches the rectum. The gel then forms a soft spacer to separate these tissues. Once the patient has undergone radiotherapy, the gel is broken down by the body and naturally absorbed in about six months.” Spacer means radiotherapy clinicians can be more accurate This technique g ives about a centimetre of additional space for the clinician to see a clearer margin between the organs during radiotherapy. “The prostate moves when a patient breathes,” adds Professor

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Supported by Boston Scientific Bahl, “And, despite all technical advances, without that additional gap, we just can’t be as accurate. What this means is that essentially the outcomes are the same but the long-term side effects are much better.” That was certainly the case for 71-year old Alan Clarke, who was the first patient to have the hydrogel treatment at Bristol earlier this year. Alan was first diagnosed with prostate cancer back in 2010. He says: “It came about after a random check on my PSA level; my GP sent me for a biopsy as my results were borderline and it turned out that there were cancer cells within my prostate. I had to have 37 doses of radiotherapy, five days a week for seven weeks. “It was a complete surprise for me as I had never expected to be told I would have cancer.” Men should talk more about prostate cancer For ex-motor mechanic, Alan, this was his first experience of prostate cancer. “A lot of men don’t talk about prostate cancer, and they should. This was the first I had really heard about it, but I would end up going to work in the morning and back to the hospital in the afternoon for my treatment. I just got on with it and didn’t

Now, I can perform a small procedure that will reduce radiation exposure to the rectum and minimise long-term side effects for my patients. I haven’t had anyone turn it down yet. really ask questions.” L u c k i l y, A l a n’s t r e at m e nt worked. Over the past nine years, he has had regular check-ups, but earlier this year, his PSA results showed that something was wrong. Alan says: “When I heard that the cancer had come back, I knew that there would be complications because of my previous treatment. I had a big holiday to Australia c om i n g up t o c e le b r at e my s t e p - d a u g h t e r ’s a n d g r e a tgranddaughter’s birthdays, so I just hoped I would be able to go.” Day surgery allowed me to continue my travel plans Alan met Professor Bahl at The Bristol Haematology and Oncology Centre and was told about the gel. A lan was deemed a good patient to receive the spacer as he was more likely to receive potential side effects due to his previous treatment.

On t he day, Professor Ba h l s i mpl y m i xe d t wo s y r i n g e s together, inserted the needle into the space – where the gel sets – within seconds. Alan was allowed home later that day and, after one dose of high-intensity radiotherapy, he was allowed to travel the next month. “We have always been big on travel in my family, so I’m very glad the treatment allowed me to continue with my plans so quickly with no real side effects. I’ve now got a cruise booked to Canada in October and can’t wa it to see what it ’s l i ke i n the autumn.” Spacer gel being rolled out across NHS England Now the spacer gel is available in several hospitals across England, and is covered by all major private insurance providers, but Professor Bahl is hoping it will be made available more widely in the future.

Professor Bahl says: “We are very grateful that the NHS ITP programme is embracing new technologies and that hospitals across the UK will benefit. Equally, I would say to patients that, if it is not being offered in your local hospital then there is the option of discussing with your clinical oncologist regarding other avenues for availing this treatment.” The ITP programme aims to approve a reimbursement for all men considered eligible to have the new spacer gel inserted. In studies, its use has been shown to reduce life-changing side effects, such as rectal complications, by 75% compared to control patients at a median of three years of follow-up.1 Alan highly recommends the treatment. He says: “I had anaesthetic so, in terms of the waist down, I was numb. A little uncomfortable over the next few days but that was to be expected. Now, my life is back to normal; I go on lon g h au l f l i g ht s, shoppi n g trips with the wife and do the gardening. If you’re considering radiotherapy, I would say, ‘go for it.’” WRITTEN BY: GINA CLARKE

Results from case studies are not necessarily predictive of results in other cases. Results in other cases may vary. There are risks associated with all medical procedures. Please talk with your doctor about the risks and benefits associated with SpaceOAR Hydrogel. Potential complications associated with SpaceOAR Hydrogel include, but are not limited to: inflammatory reactions, infection, bleeding, and pain or discomfort from the injection. CAUTION: The law restricts these devices to sale by or on the order of a physician. Indications, contraindications, warnings and instructions for use can be found in the product labelling supplied with each device. Information for use only in countries with applicable health authority registrations. This material not intended for use in France. 1: NHS. 2018. Prostate Problems. [ONLINE] Available at: https://www.nhs.uk/conditions/prostate-problems/. [Accessed 9 September 2019]. 2: Hamstra DA, Mariados N, Sylvester J, et al. Continued benefit to rectal separation for prostate radiation therapy: Final results of a phase III trial. Int J Radiat Oncol Biol Phys. 2017 Apr 1;97(5):976-85. 3: Data on file with Boston Scientific.

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SpaceOAR hydrogel is clinically proven, minimally invasive spacer designed to minimise urinary, sexual, bowel side-effects and protect quality of life for prostate cancer patients undergoing radiation therapy.

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The discussion of erectile problems is still taboo While there might not be an underlying cardiovascular cause identified, the risk factors associated with erectile dysfunction include smoking, alcohol, obesity, high blood pressure, high cholesterol levels, reduced levels of exercise and depression.

t can be difficult, more than difficult for some, to go to your GP and talk about a problem with your sexual function. But, stigma and embarrassment aside, a number of us may not necessarily know which parts of the body ‘urology’ specifically refers to, with the UK lagging behind the rest of Europe on patient education. That’s according to Consultant Urological Surgeon, Mr Duncan Summerton, from The University Hospitals of Leicester NHS Trust.

making up a large percentage of the complaints dealt with by GPs in the UK. However, it appears to be the most difficult to talk about, with men’s partners often playing a big part in encouraging their other halves to talk to their GP. A visit to the GP is important, as erectile dysfunction can be an indicator of more serious underlying cardiovascular problems.

What does ‘urology’ actually refer to?

The arteries that supply blood to the penis are roughly the same diameter of those that supply the heart, so, an issue with erectile dysfunction may suggest the patient needs to be investigated more fully from a general and cardiac viewpoint. “Around 6% of men who complain of ED will have some form of cardiovascular episode (twice the rate of those men who don’t suffer from ED) within three years, so it’s really important that men from middle-age upwards do talk about it with their GP. “Once someone presents with erectile dysfunction, invariably they’ll have a full health screening to ensure that there isn’t anything more serious at play.” With the links to other potent ia l underly ing issues with the heart, slightly older men may have a reason to finally take t h at j u mp. Ye t , M r

“Essentially, we’re talking about the urinary tract, comprising of the kidneys, the bladder, the prostate, urethra, testes and the penis.” Urology also covers non-cancerous as well as cancer of these organs. Erectile dysfunction (ED) is just one of a number of many medical complaints that fall under the tag of being a urological issue, with bladder and prostate problems also

Erectile dysfunction may be a sign of poor cardiovascular health

Summerton believes all sufferers would benefit from more public f i g u re s t a l k i n g ab out t hei r erectile issues. “Prostate cancer had the likes of Stephen Fry and Bill Turnbull act as role models in talking about their illness, yet erectile dysfunction still carries that stigma.” I n d e e d , u n t i l r e c e n t l y, ver y few men had spoken publicly. Now though, England cricket legend, Ian Botham, has gone on record, describing how much treatment for his erectile dysf unction has helped him, saying it was the “best health decision he’d ever made.” So, the message is clear. Going and seeing your GP could both open up a range of options and may even save your life. WRITTEN BY: JAMES ALDER

DUNCAN J SUMMERTON Consultant Urological Surgeon, University Hospitals of Leicester NHS Trust Honorary Associate Professor, University of Leicester President, British Association of Urological Surgeons

One patient reveals how erectile dysfunction caused by an underlying condition made his life a misery — and how an implant procedure gave him back his confidence... and his sex life.

ic h ael Mo ore w a s a married man of 28 when he began experiencing issues with erectile dysfunction ( E D) , w h i c h s h a t t e r e d h i s confidence and affected his mental health. “I began feeling extremely depressed,” he remembers. When Michael finally went to see his doctor (“It took me six months to find the courage”), he was given various treatments, but none of them worked. This went on for more than 20 years. Michael's erectile dysfunction wasn't psychological, however. It was being caused by an underlying neurological condition, which he discovered when he was finally diagnosed with multiple sclerosis in 2015/2016. MS was the cause of my erectile dysfunction By the time he was referred to Mr Vaibhav Modgil, Consultant Urological Surgeon and Andrologist — a specialist in male sexual and reproductive health — Michael admits he was in a dark place psychologically. “I wanted to get back some control,” he says. “And I wanted normality again for myself and my wife.” “It's far more common than people think, and doesn't just affect older men,” says Mr Modgil. “The vast majority of cases I see in my clinic are organic, rather than purely psychological; although

10 HEALTHAWARENESS.CO.UK

It’s far more common than people think, and doesn’t just affect older men. there is no doubt psychogenic ED is more common among younger men, it can be linked to diabetes, conditions affecting the nerves and even sleep-rated issues, for instance. Cancer treatments such as pelvic surgery, chemotherapy a n d r a d i o t h e r ap y, c a n a l s o cause ED.” Treatment options for erectile dysfunction First-line therapy tends to be tablet treatment. “If patients don't respond to tablets, injections into the penis and topical treatments are available to produce erections,” says Mr Modgil. “While these might work for some people, others don't want to inject into their penis, as it kills spontaneity.” Vacuum pump devices designed to engorge the penis are also available; but, again, these are neither discreet nor spontaneous enough for some patients. If these solutions don't work, and all other options have been exhausted, penile implant surgery MEDIAPLANET

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Penile prosthesis:

What are they and who can get one?

CLARE AKERS Clinical Nurse Practitioner University College London Hospital, NHS Foundation Trust

MICHAEL MOORE

Patient

VAIBHAV MODGIL Consultant Urological Surgeon

I have to bust myths to help patients understand their options

and Andrologist

— a procedure that is available on the NHS in specialised centres — may be a consideration. “There are two types of penile implants,” says Mr Modgil. “With t he s em i-r i g id or m a l le able implant, two malleable rods are placed within the penis that can be pulled up into the erect position. “Then there's the inf latable penile implant, which involves fitting two cylinders into the body of the penis. A pump sits within the scrotum and a reservoir sits within the abdomen. When the patient squeezes the pump in the scrotum, fluid leaves the reservoir and makes its way to the cylinders to prov ide a n ere c t ion. Th i s results in an on-demand erection, when the patient wants, for as long as they want. No part of the device is externally visible with what is usually a very small scar either above or below the base of the penis.” Return to positive self-worth and body image Michael, now in his early fifties, chose this option and underwent surgery in March. In the vast majority of cases, patients are able to return home a day later. More recently, the team at Manchester Royal Infirmar y have started performing ‘day-case’ procedures for selected patients, allowing them to return home the same day as their surgery. “However, people MEDIAPLANET

should understand that this, like any operation, is a significant undertaking,” says Mr Modgil. “The operation must be carried out at a specialist centre under the care of an experienced team. It’s also the point of no return, because surgery eviscerates erectile tissue in the penis — so the only way a patient will get an erection afterwards is with an implantable device. “It’s a last resort option for most patients, but it works incredibly well.” Its availability is not well-known, however. In fact, Mr Modgil often speaks to healthcare professionals, and even GPs, who are unaware of this type of surgery. M ic h ae l ’s b e e n i mp r e s s e d with the results of the surgery, from both a physical and mental standpoint. “My sex life hasn’t been this good since I was 18! Psychologically, it’s boosted me, too, changing my overall mental health. In fact, the procedure has done more than cure my ED. It has also had a positive effect on my

rectile dysfunction is still an embarrassing issue for men, but one that is increasingly common. While there are many treatments to try first, for some men, the only alternative will be a surgical procedure such as a penile prosthesis. Clinical nurse practitioner, Clare Akers, advises men on the various treatment options available for erectile dysfunction, no matter their age. It’s something she feels both the medical profession and the media have a role in making less taboo. She says: “All too often, a patient will come to us with erectile dysfunction. This could have developed after surgery for prostate cancer, for example, or by having diabetes. The sad thing is they believe that they’re not entitled to surgical help because they are too old or not in a relationship. But there isn’t an age limit and you don’t have to be in a relationship to have a penile prosthesis.

feelings of selfworth and body image.” “Let’s be honest,” says Michael. “Erectile d y s f u nc t ion i s n’t a n easy subject for men to talk about with anyone — let alone admit to in the pages of a national newspaper. “Even though ED was a result of my MS, it doesn’t make it any easier that my friends and family will know about it! That said, there must be hundreds of men who have felt the way I was feeling for years. So, if there’s anything I can do to change that, I will.” WRITTEN BY: TONY GREENWAY

Clare finds it important to be truthful to the men who come to see her, often having heard rumours of a ‘bionic penis’ but not sure of the mechanics. Her role as a clinical nurse practitioner is to make sure that all other medical treatments and options have been exhausted, and t hen to ex plain t he alternatives if they are fit enough for surgery. It is essential that the men understand that a penile prosthesis is irreversible and, like w it h a ny surgery, carries

some risks, all of which she explains carefully to ensure men remain fully informed. She says the main difference between the two types of penile prosthesis available is that one maintains an erection at all times (malleable prosthesis), which can be concealed, “I often describe it as ‘bendy rods’ that are inserted into the penis. Whereas, the other type consists of a mechanical device (inflatable prosthesis) that is fitted into the penis, scrotum and pelvis, which can be inflated and deflated through a pump in the scrotum.” The inflatable penile prosthesis is not detectable from the outside, whereas the malleable one looks less concealable, and yet after surgery men can return to a normal life with sensation and orgasmic function. Making men feel whole again Clare often finds men are worried about the possibility of embarrassment, such as walking through an airport scanner or not being able to continue their hobbies, but that’s not the case. She says: “There is often discomfort from the procedure in the first four to six weeks and then, if they have the inflatable penile prosthesis, they must be taught how to inflate and deflate the device, but, within three months, men should be able to return to normal activity and regain their sex life. WRITTEN BY GINA CLARKE

I lost any kind of sex life from my late twenties through to my early fifties. HEALTHAWARENESS.CO.UK

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Features of a penile implant

The doctor’s story... MR ASIF MUNEER Consultant Urological Surgeon and Andrologist, University College London Hospital

n estimated 7,000 men in the UK are currently eligible for a penile prosthesis (also referred to as a penile implant) for erectile dysfunction that has not responded to pharmacological treatments, yet fewer than 10% go on to have the surgery, despite the high success rates. Case study For Christopher, an aggressive form of prostate cancer in his m id- 5 0 s, lef t h i m w it h t he embarrassing side effect of erectile dysfunction after his prostate was surgically removed. Not only was it highly embarrassing for the father of four, but it was something that deeply affected his previously loving relationship with his wife. Common side effect of prostate cancer Source: AMS Penile Prosthesis Product Line Instructions for Use. American Medical Systems. 2012

“The majority of men I treat will

have had a similar experience to Christopher; it is an incredibly common side effect as the nerves and blood vessels run close to the prostate gland in a complex network,” explains Mr Asif Muneer, Consultant Urological Surgeon and Andrologist from the department of Urology and NIHR Biolmedical Research Centre, University College London Hospital. Returning full sexual function Erectile dysfunction may improve following a clinical assessment and first line treatments, such as lifestyle changes, oral tablets, or injections given by patients into the penis. But, if required, a penile prosthesis returns full erectile function in almost 100% of patients six weeks after surgery. “It’s a relatively uncomplicated operation in high volume centres such as ours,” says Mr Muneer. “Patients are often surprised that such a lot of ‘equipment and

components’ can be placed through a small incision in the scrotum. I often hear: “I didn’t realise it was so easy.” Most of our patients are discharged the next day and report over 90% satisfaction rates once the device is used.” Of course, there is a degree of ‘teaching’ the patient to use the mechanism, but, after two weeks, by which time the swelling subsides, a patient can practise inflating and deflating the implant. Six weeks later they will be able to have full, penetrative intercourse. Erectile dysfunction can have a serious impact on mental health It is important not to underestimate the psychological impact that erectile dysfunction can have on a man, as recognised by the World Health Organization, which states that sexual health is fundamental to the physical and emotional well-being of humans.

we help people affecteD by erectile Dysfunction (eD) finD their best treatment solution if you have eD or know someone with eD, eDtreatments.com is there to help.

12 HEALTHAWARENESS.CO.UK

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...and his patient’s journey JOHN GOODRIDGE Sexually active pensioner

Sources: 1: Gandaglia G, Briganti A, Jackson G, et al. A systematic review of the association between erectile dysfunction and cardiovascular disease. Eur Urol. 2014 May;65(5):968-78. 2: Jackson G, Rosen RC, et al. The second Princeton consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. J Sex Med. 2006 Jan;3(1):28–36.

A penile prosthesis returns full erectile function in almost 100% of patients six weeks after surgery. Alongside the psychological aspect, is the issue of age and the worry that older men need to ‘put up with it’. “Within my work, there is no discrimination regarding age. I have treated men from their early 20s to a man in his 90s. It really makes no difference to us, as long as they fulfil the criteria and we can make a difference to their lives,” says Mr Muneer. With an ageing population and the treatment of more aggressive cancers, particularly those from childhood, Mr Muneer has seen an increase in younger men affected by erectile dysfunction following cancer treatment, such as Gary.

Gary’s cancer left him with erectile dysfunction “Gary was a young man in his late 30s who had been treated for a particularly aggressive, rare pelvic tumour. Unfortunately, he developed erectile dysfunction as a side-effect of the treatment. But, following his operation, his relationship with his wife was transformed. They’re both incredibly happy.” These cases will only add to the testimony as to what the device can do. And, with a low complication rate following the operation (the mechanical device often lasts over a decade before a replacement may be

needed), Mr Muneer is certain that there will be a growing demand for penile implants in the future. He says, “I think a lot of people simply don’t know that this treatment exists. For anyone currently suffering with erectile dysfunction and who has exhausted pharmacological treatment options, I would simply say, ‘ask for additional help’, because these solutions are out there and with such a great satisfaction rate, I see this becoming a much more well known and popular operation over the next few years.” WRITTEN BY: GINA CLARKE

Read more at healthawareness.co.uk

t 77 years old, I count myself very lucky to be here. I’ve survived cancer four times in total but, when I had my prostate removed in 2010, following a diagnosis of prostate cancer, I suffered a common side effect – erectile dysfunction. While prostate problems are incredibly common, the side effects are not so well known. I developed urinary incontinence after the operation, but that soon passed. However, I found the side effect of erectile dysfunction harder to ignore. As a red-blooded male I was determined to find a way to return my libido and, despite my initial embarrassment, I was determined to keep going back to my doctor until we found a treatment that worked. Over the next three years, I found myself searching for the right treatment. I became depressed and confused mainly because, although these conditions are well known, they are rarely talked about. Men like to joke but it is women who are far more practical at getting themselves help. While it wasn’t something I felt I could talk about openly, privately, I was doing a lot of research. I rejected the idea of injections for a few years just because it seemed

like the idea of an injection in such a sensitive area was a big deal for me mentally. So, after tablets, pumps and – finally – injections failed me, I booked an appointment with my GP in 2013 to hear more about penile implants, delighted that they were available on the NHS. This led me to the excellent care of the urology department who explained more about the minor operation and that, after two days in hospital and six weeks’ rest, I would have a fully functioning sex life. The past five years have been nothing short of wonderful. I was given a lesson on how to work the implant, which is very simple, and it has been a breakthrough both for myself and my partner, who has supported me through those difficult years. My life now is as active as ever. The implant is incredibly small and very easy to use. I would recommend the treatment to anyone. WRITTEN BY: GINA CLARKE To find out more, email us at

cancertestingsouth@ btconnect.com

DiD you know? Erectile dysfunction is estimated to affect 25 to 35 million men over the age of 18 in Europe.1 • Take the online ED quiz and get the results by email • Learn more about treatment options available • Find out how people managed to treat ED • For those who want to know more about penile implants, a new feature is coming soon to find an implanting physician nearby

1. Causanilles, A., Cantillano, D. R., Emke, E., Bade, R., Baz-Lomba, J. A., Castiglioni, S., Kinyua, J. (2018). Comparison of phosphodiesterase type V inhibitors use in eight European cities through analysis of urban wastewater. Environment international, 115, 279-284.

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How can a shed be good for your health?

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Originating in Australia, the Men’s Sheds movement is building momentum in the UK; where over 500 groups are changing the lives of an estimated 11,000 men through improving their health.

en’s Sheds (or Sheds) are similar to garden sheds – a place to pursue practical interests at leisure, to practice skills and enjoy making and mending. The difference is that garden sheds, and their activities, are often solitary in nature while Men’s Sheds are the opposite. They’re about social c on ne c t ion s a nd f r iend sh ip bu i ld i ng, sha r i ng sk i l l s a nd knowledge, and of course a lot of laughter and tea. Sheds are whatever t he members (or Shedders as they’re a f fe c t ion ately k now n) w a nt them to be. Although labelled sheds, they often aren’t sheds at all. They can be empty offices, por table cabins, warehouses, garages, and in at least one case, a disused mortuary. M a ny S h e d s g e t i nvo l ve d in com munit y projects too – restoring village features, helping maintain parks and green spaces, and building things for schools, libraries and individuals in need. Act iv it ies in Sheds var y greatly, but you can usually find woodwork ing, metalwork ing, repairing and restoring, electronics, model buildings or even car building in a typical Shed. Sheds typically attract older men, but many have younger members and women too. Whatever the activity, the essence of a Shed is not a building, but the connections a nd relat ion sh ips bet ween its members.

How are Sheds good for your health? A recent focus on the impact of loneliness has emphasised how it can affect both mental and physical health: increasing the risks of dementia, heart disease a nd depres sion. It ha s b e en estimated that loneliness and poor social connections can be as bad as smoking 15 cigarettes a day and is more detrimental to health than obesity. The UK Men’s Sheds Association, a support and advice charity for Men’s Sheds in the UK, conducted a survey with over 500 Shedders to capture health benefits men e x p r e s s e d t h e y ’d b e n e f i t e d through joining a Men’s Shed. The results highlighted men felt they had gained new friendships and increased their happiness, whilst reducing feelings of anxiety and depression. James, from Forest of Dean

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Men’s Shed, says “I have made new friends and learnt some great things, it’s probably saved my life, or at least my sanity.” Megan’s dad is a shedder in Biggin Hill, she says “My Dad suffered a stroke 2 years ago now, and this is where the Men’s Shed stepped in. The Shed is a safe, social place for my dad to go to - he loves going twice a week. It takes the pressure off my mum and has been so beneficial to his health and wellbeing. It’s keeping him busy and healthy.” A long w it h posit ives for individuals and their families, com mun it ies benefit from their activities to an estimated volunteering value of £10.5 million. Many Men’s Sheds support their local community, repairing items for individuals, and supporting other groups in a variety of ways, from making play equipment for local pre-schools to planters for care homes. As well as the boost for local communities, 88 per cent of Shedders say they feel more connected to their community t h roug h b ei n g pa r t of t hei r local Shed. WRITTEN BY: LAURA WINKLEY

In the UK there are now over 500 open Sheds, with an estimated 140 in development. To get involved with, or support your nearest Men’s Shed visit www.findashed.org.uk. Alternatively contact UK Men’s Sheds on 0300 772 9626 or email admin@ukmsa.org.uk. If you’d like to learn more about Men’s Sheds, or see how you can set one up in your local community, visit www.menssheds.org.uk.

My prostate cancer journey, 12 years down the line… DR STEVE ALLEN Prostate Cancer Spokesperson

PSA test is still the best diagnostic test for discovering if you have prostate cancer. Don’t avoid or delay your diagnosis like I did. You may regret it.

am a retired doctor; I worked as one of the senior anaesthetists with the urology department in my local hospital for around 25 years. Because I thought I knew better, I put off seeking treatment for my con siderable u r i na r y symptoms - I simply thought I didn’t have cancer. It came as a shock to find out that I did indeed have cancer. One of my biggest emotions at the time of diagnosis was actually guilt - I felt guilty that I had left things too late and had not considered the potential consequences of a late diagnosis on my family. The treatments available then were nowhere near as good as today and I have ended up with life-changing consequences.

I shouldn’t have left it so long before I got checked I was diagnosed with prostate cancer (PCa) when I was 59. Because I had left it so long, my treatment options were limited to a choice between ‘watch and wait’, external beam radiotherapy or radical surgery. I chose the latter. Post-surgery, I became totally i nc ont i nent of u r i ne, a lb eit currently well controlled after implantation of an AUS (artificial urinary sphincter). I also became completely impotent and it took 18 months before I was able to achieve any form of spontaneous erection – aided by a maximum dose of meds. Today, we have vastly improved tools to investigate PCa, but the foundation stone remains the PSA test. It is highly sensitive: ac c u r ately a nd c on s i s tent ly measuring a very wide range of PSA levels. It is specific: it only measures

I felt guilty that I had left things too late and had not considered the potential consequences of a late diagnosis on my family. PSA and results are not skewed by the presence of other substances. But it is not selective: it cannot distinguish between PSA produced by cancerous or non-cancerous cells. It is a good indication of prostate health but not diagnostic for prostate cancer. However, it is the best that we have at present and, in combination w it h i mproved i nvest igat ive techniques, can achieve early diagnosis of localised disease, earlier and less invasive treatment, fewer long-term side effects from treatment and, ultimately, a better outcome and quality of life.

New evidence suggests PSA could offer earlier warning signals There is also now emerging evidence that a PSA at the upper end of normal in mid-life may well indicate an increased risk of developing an aggressive PCa later. If I had realised the significance of this all those years ago, I would certainly have sought treatment earlier. The arg uments for and against a National Screening Programme continue. Opinions on PSA screening are beginning to change. A new NICE (National Institute for Health and Care Excellence) guideline for treatment of PCa was published in 2019 but sadly PSA screening was not part of its remit... The need for formal guidance has never been more urgent.

My personal view? The need to raise awareness of PCa has never b e en s t ron ger. Newer t reat ment reg i mes have a much lower incidence of side effects but are only appropriate in early stage disease: i.e. when contained within the prostate capsule and, even better, if only present on one side of the prostate. To me it is a no-brainer. PCa needs to be diagnosed as early as possible. Obviously, this can only be achieved if men are aware of the disease.

Many men are discovering their diagnosis later than is ideal The latest figures from the National Prostate Cancer Audit show that, at the time of initial diagnosis, one in six men (17%) already have distant spread of their disease. The cancer is confined within the prostate itself only in just under 50% of men diagnosed. We have to do better than this! Sadly, also, far too many GPs still have opinions based on old knowledge or f lawed data and inaccurate sound bites. We still hear of men who have been given poor advice, men who are being ref used appropr iate requests for a PSA test and men who are diagnosed too late when secondary spread has already occurred. There is a lot of work still to be done. Source: https://www.npca.org.uk/content/uploads/2019/02/NPCA-Annual-Report-2018.pdf

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Could exercise beat advanced prostate cancer? DR MARK BUZZA Global Director of Biomedical Research, Movember

Regular workouts can help men with early prostate cancer live better, for longer but could it also help patients with advanced disease?

tay ing physica l ly act ive might be the last thing on you r m i nd when you’re exhausted from dealing with cancer - but exercise make a huge difference before, during and after treatment. Continuing to be physically ac t ive t h roughout t reat ment has been proven to help prevent a decline in cardiorespiratory and muscle fitness. It also helps p at ie nt s c o p e w it h c a n c e rrelated fatigue, improves their overall wellbeing and reduces the likelihood of dying from the disease that claims the lives of 11,000 men in the UK every year.

New exercise guidelines for cancer patients L a s t mont h (O c tob er 2 01 9), a t horough rev iew of t he available evidence, conducted by an international group of 40 experts led by the University of British Columbia, resulted in the development of new guidelines for preventing, managing and recovering from cancer. The up date d i nter nat iona l recommendations now advise that taking part in exercise helps improve survival after a diagnosis of breast, colon and/or prostate cancer. This is good news for patients as it gives us a real opportunity to continue integrating exercise medicine within cancer care.

We need better understanding of how exercise affects those with advanced cancer However, we still don’t yet know enough about the benefits of MEDIAPLANET

Taking part in exercise helps improve survival after a diagnosis of breast, colon and/or prostate cancer. exercise for men with advanced disease. This is a gap in our knowledge and an important question that needs to be studied. Th at ’s why Movemb er h a s initiated the INTERVAL GAP4 trial, the first randomised, controlled trial in the world, which is aiming to prove whether high-intensity aerobic exercise combined with resistance training could extend the lives of men with metastatic prostate cancer. Over 20 research teams from eight countries, including the UK, US, Canada, Australia and Germany, are working together to recruit 866 men to test whether exercise could be prescribed as a medicine alongside standard treatments such as chemotherapy, radiotherapy or hormone therapy. Half of the men who sign up are assigned to the active (or supervised exercise) arm, while the other half are put on a control arm. Every man participating in the study is given reg ular c h e c k- u p s (a l o n g s i d e t h e i r normal treatment).

their disease and they will follow it for two years. The programme includes two 75-minute sessions of mixed resistance and aerobic exercise and one 30-minute session of aerobic exercise each week for the duration of the trial. A 2016 pilot study led by Professor Rob Newton from Edith Cowan University in Western Australia, published in the medical journal the British Medical Journal Open, demonst rated t hat t h is t y pe of exercise has the potential to be a powerful tool to delay the progression of advanced prostate cancer. It’s an ambitious project and there is a long way to go, but we hope it could lead to a revolution in the way we tackle advanced prostate cancer. The men who join GAP4 are not only benefitting from the exercise programmes but by tracking their progress, they are also helping us get a better understanding of how best to treat the disease and improve the lives of all men living with prostate cancer.

Trialing a two-year, tailored exercise plan aimed to delay prostate cancer progression Men on the supervised exercise arm are given a detailed training plan – designed to increase their strength, fitness and flexibility. The plan is specifically tailored to them and

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Promoting prostate health awareness

“Having been born in “The Butts” in Warwick (the longbow training area for the Castle in medieval times), I couldn’t have been luckier or more proud to actually carry the Olympic Torch through the grounds of the Castle!!”

GRAHAM FULFORD Co-Founder, Graham Fulford Charitable Trust

Losing two close friends to this awful disease, and realising we had no knowledge of it, encouraged us to raise awareness of prostate cancer so others might make it in time.

y w i fe, S ue, a nd I started a charity in 2004 following the, sadly too late, prostate cancer diagnosis of a close friend and a close relative. Both were in their late 50s and sadly neither of them survived. It was a shock to have two loved ones diagnosed virtually at the same time and, with no knowledge of this insidious disease, we decided to try to make a difference by l au nc h i n g a n aw a rene s s campaign with the emphasis on early diagnosis.

PSA tests are the best tool in our armory right now In 2 0 05, we had a major breakt hrough when we were introduced to consultant urologist, Mr David Baxter-Smith who, at our first meeting, when asked. ‘How do we help find prostate cancers?’ replied: ‘PSA testing. It’s far from per fect but t here’s cur rent ly nothing else.’ Fourteen years later, with his help and working with groups including prostate cancer support groups, Lions Clubs, Rotarians, Masonic lodges and others, we’ve helped carry out over 140,000 tests on over 100,000 men from over 69,500 different postcodes around the UK. We’ve helped find 1,820 cancers on the results so far. We a re f u l ly aw a re of t he limitations of the PSA test, but until a more focused test is available, we feel we should make the most of it.

Alerting those most at risk with possible tre atme nt options We operate a ‘green; amber and red’ alert system. The rule of thumb statistics show that, for every 100 tests we carry out, 90 will be green, four will be amber and six will be red. Of the reds, around one in four turns out to be prostate cancer. Those patients presenting red results will be sent a letter with information on the importance of

MRI scanning before biopsy. It will also include a summary of the three leading treatment options that our 1,820 cancer finds have revealed as most appropriate next steps: • ‘A c t i ve s u r ve i l l a n c e ’ i s considered most appropriate for non aggressive cancer and has been apt for 21% of patients • 26% opt for surgery • and 33% elect for radiotherapy. We send a copy of the Space OAR leaflet to all these men on the basis that, for every 100 red letters, eight will end up having radiotherapy, and we feel they should be aware of the benefits of this breakthrough technology.

Companies are supporting e m p l oy e e s b y o f f e r i n g PSA tests We’re doi ng more a nd more in-house, corporate testing as employers become more a nd more aware of the importance of looking after their workers’ welfare and are happy to travel the length and breadth of the country with our Awareness and Testing Programme. We have a launch seminar on 28th November to introduce our new Online Registration and Result Retrieval System, which will enable us to carry out even more events and tests in 2020.

Info box For full details about the charity, how to hold an event and upcoming events in your area please visit us at

www.psatests.org.uk Read more at healthawareness.co.uk HEALTHAWARENESS.CO.UK

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