BRCA2 gene mutations and prostate cancer – role of prophylactic radical prostatectomy

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The presence of BRCA gene mutations in a person increases the risk for developing cancer. This has received much publicity after movie star Angelina Jolie announced that she had a prophylactic mastectomy to avoid breast cancer.

Results from trials have shown that a man with a BRCA2 mutation has an 8.6-fold increased risk of developing prostate cancer, and with a BRCA1 mutation has a 3.4-fold increased risk. ICR researchers  recently reported that prostate cancer in men with the BRCA2 mutation is more aggressive and more likely to be fatal (J Clin Oncol2013;31:1748-1757).

A first man has undergone prophylactic radical prostatectomy to prevent prostate cancer, after finding that out that he carries the BRCA2 gene mutation. He underwent prostate biopsy which is the standard way of diagnosing prostate cancer before undergoing radical prostatectomy surgery to remove his prostate.

Currently, there is no adequate data to support a man with a normal prostate undergoing prophylactic radical prostatectomy because he carries the BRCA genes. However, initial research does suggest that men with BRCA genes may develop more aggressive cancer should they eventually have prostate cancer.

Robotic radical prostatectomy for prostate cancer – 10 years on

da Vinci Robotic prostatectomy

Robotic radical prostatectomy has been the most common method of treatment for early prostate cancer. In the last decade, surgical treatment of prostate cancer has evolved from open retropubic radical prostatectomy to minimally invasive radical prostatectomy.

Laparoscopic radical prostatectomy has a step learning curve but in the hands of an experienced surgeon, the results as just as good as robotic prostatectomy. Robotic prostatectomy on the other hand, has a shorter learning curve. However, there is the inherent capital cost burden of the purchase of a robotic system.

The following review article by Skarecky reviews the technical aspects of the evolution of radical prostatectomy surgery in the last 10 years. It gives a very detailed account of a technique adopted by one of the pioneer centers for robotic prostatectomy surgery.

Robotic-Assisted Radical Prostatectomy after the First Decade: Surgical Evolution or New Paradigm

Department of Urology, University of California, Irvine, CA 92697,  USA

We look forward to the next 10 years of rapid development in the treatment of early prostate cancer and the possible emergence of robotic radical prostatectomy being the standard of care for this disease.

In Singapore, there are 3 centers in restructured hospitals and Mount Elizabeth Hospital (Orchard and Novena) in private practice offering robotic radical prostatectomy. The newly opened Mt Elizabeth Hospital houses the newer 4 arm da Vinci robotic system.

 

New prostate cancer screening guidelines from American Urological Association

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The American Urological Association (AUA) during the May 2013 AUA Annual Meeting issued guidelines on screening of prostate cancer. Men aged 55 to 69 years who are considering prostate cancer screening should talk with their doctors about the benefits and harms of testing and proceed based on their personal values and preferences. The new guideline updates the Association’s 2009 Best Practice Statement on Prostate Specific Antigen (PSA).

This contrasts with the statement from the U.S. Preventive Services Task Force issued by USPSTF Co-Chair Michael LeFevre, M.D., M.S.P.H. in May 22, 2012 which quoted: “Prostate cancer is a serious health problem that affects thousands of men and their families. But before getting a PSA test, all men deserve to know what the science tells us about PSA screening: there is a very small potential benefit and significant potential harms. We encourage clinicians to consider this evidence and not screen their patients with a PSA test unless the individual being screened understands what is known about PSA screening and makes the personal decision that even a small possibility of benefit outweighs the known risk of harms.”

It is clear is that prostate cancer screening is NOT recommended for men below 40 years old. Routine screening in men between 41 and 54 years old with average risks is also not recommended. The guidelines also state that, to reduce the harms of screening, a routine screening interval of 2 years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of 2 years preserve the majority of the benefits and reduce overdiagnosis and false positives. Finally, routine PSA screening is not recommended in men over age 70 or any man with less than a 10- to 15-year life expectancy.

What should we recommend to our patients? Should we continue doing PSA testing? Should we underestimate the seriousness of prostate cancer which is the 3rd most common cancer in Singapore and seen much fatality every year?

The general public and patients with prostate diseases are confused on these very differing opinions from very renouned professional bodies. Our centre are with the opinion that prostate cancer remains an important disease in some individuals that will require treatment. We are challenged in identifying this group of individuals as the currently available tests such as PSA does not have a high specificity for prostate cancer.

Introduction

Dr Ho Siew Hong

Dr Ho Siew Hong, Consultant Urologist
S H Ho Urology & Laparoscopy Centre

Urology is a surgical discipline that deals with diseases of the kidney, ureter, bladder and urethra. It also covers problems with the male genital system such as the prostate and testicle.

The field of urology has seen much developement in the last 50 years. The major mile stones include introduction of endoscopy surgery, minimally invasive surgery or laparoscopy, shock wave therapy for stones, kidney transplantation and robotic assisted surgery. Developement of medications in the areas of treatment for benign prostate enlargement and urological cancers has been rapid.

Our centre, S H Ho Urology and Laparoscopy Centre attempts to keep abreast with the newest developement in the field of urology. We will review the latest medicines and surgical methods in order to provide our opinion on the suitability of these new treatments for our patients.

We will also share our thoughts on the treament guidelines and recommendations for management of urological conditions.