In Black America; Prostate Cancer with Dr. John Tuttle

heart. From the Longhorn Radio Network, the University of Texas at Austin, this is In Black America. There's a couple of support groups. I conduct a support group myself that meets every other month. And then there is another support group in the city of Lexington.

So the American Cancer Association would be able to help people locate different support groups that are available. And they do help. It's important to inform the public of what the impact of this problem is, what early detection, the importance of it. And after the diagnosis is made to offer, these are the various different treatment options available because among the urologists in the United States, once the diagnosis has been made, there is no uniform recommendation as to how it should or should not be treated. Dr. John Tuttle, MD. Each year in this country, prostate cancer kills an estimated 35,000 men. But African-American men suffer twice the rate of prostate cancer and twice as likely to die from the disease than white men according to the American Cancer Society. Because prostate cancer is a silent disease, the American Cancer Society recommends that all men over the age of 40 undergo an examination and a blood test to determine abnormalities in the prostate as part of their regular medical examination.

While there are no known ways to prevent prostate cancer, early detection and treatment are the keys to surviving the disease. I'm John L. Hansen, Jr. and welcome to another edition of In Black America. This week, prostate cancer, the silent disease with Dr. John Tuttle, MD, in Black America. The traditional way of treating local disease, that's prostate cancer that's been detected early, still within the inside, the confines of the prostate. So if one can eradicate the cancer sales in the prostate, one should be able to cure the patient of the prostate cancer. And that's attempts have been performed through the years to achieve this goal through a radiation or through surgery where one actually removes the entire prostate plant. That is not the same as the TUR prostate, where a channel is created through the prostate, that is not the same as laser prostate surgery.

This is an actual operation to remove the entire prostate plant. Now, as an alternative to that, people are beginning at the research level to look at freezing the prostate, trying to kill the prostate sales without having to undergo the major radical operation or have the side effects of the radiation. African American males have the highest incidence of prostate cancer of any racial or ethnic group in this country. The reason for this disparity are still shrouded in mystery. Risk factors for the disease may include a diet high in fat, although the link has not been scientifically proven. Some believe that prostate cancer runs in families, much like diabetes. Some researchers attribute the higher prostate cancer rate among African Americans to economic factors rather than race, per se. Pointing out that there is also a strong correlation between prostate cancer and poverty. Although those with prostate cancer may not notice any symptoms and enlargement of the prostate and inability to urinate or freaking urination, pain or burning sensation during urination, blood and urine or lower back pain may accompany the disease.

I recently spoke with Dr. John Tello, a urologist in Lexington, Kentucky. A man's prostate gland fits beneath the urinary bladder. The gland actually surrounds the tube that leads the bladder that tube is called the urethra and the prostate gland surrounds the tube. When men become older, the ligament changes can occur in this gland and that's prostate cancer. What is the scope and magnitude of prostate cancer in this country?

Well, prostate cancer is the most likely cancer to be diagnosed in a man in the United States today. One out of every 10 American men, sometime in their lifetime, will be diagnosed just having clinically significant prostate cancer. It will be diagnosed this year, about 135,000 cases. Has the rate of death due to the disease changed over time? Well, the rate of death at about 3% if you look at men and compare the death from all cancers. The diagnosis is the most frequently made diagnosis of malignancy in men. But the death rates from this cancer are behind lung and colon and some of the other more progressive and aggressive malignancy. There will be 35,000 men estimated in 1993 from cancer of the prostate.

Is the rise in cancer due to modern lifestyle changes or is it due to the fact that the baby boomers affect on the population ratio to men over 40? Well, it's due to several factors. I think one of the most important factors is the fact that there's a lot of public awareness for the past four years. National prostate cancer awareness week has directed attention toward early diagnosis and actual diagnosis of prostate cancer. There's been a lot of educational programs at the public level, also at the physician level and as a result of that, there's just an intensified interest in diagnosing prostate cancer today. So when you have a disease entity and you look for it more closely, you're going to probably find it. And so I believe part of the reason that the numbers of prostate cancer, the incidence of increasing, is the fact that we as professionals and the folks as patients, the lay population are more aware, more sensitive to this and are exploring the possibility of prostate cancer more than they ever have before. Historically, men are somewhat reluctant to visit a physician.

Well, that's quite true. I think, you know, for one reason is that they go through life, they get to be 40, 45, 50 and have maybe seen a physician for a life insurance physical at the most. They've been healthy. They're not key to go for wellness examinations and checks, whereas females come along, they have babies, they go to their physician, they get into the routine of maintenance examinations, preventive medicine and they start that a lot earlier. The child bearing has something to do with that, I believe, and men are a lot more reluctant to come in for screening and prevention. I guess the attitude is if it doesn't hurt, you know, why I try to fix something, you know. Are there any ethnic groups affected more than others?

Yes, sir. In the United States, the black population, Afro-Americans are more likely to be diagnosed and to have prostate cancer than any other race. The chances of Afro-American is one out of every nine will be diagnosed as clinically significant, as having clinically significant prostate cancer. Whereas Caucasians in America, one out of 11 will be diagnosed as having prostate cancer. So there is ethnic differences. We don't understand the reasons for that, but they're definite. And because of those ethnic differences, we recommend different screening depending on ethnic background, actually. Living in Lexington, Kentucky, are you finding African-Americans, particularly in your area, coming in for those screenings? Well, I will say in general, the people who are coming in for screening, it's more and more.

Four or five years ago, it was rare to have a patient come in and say, yes, I had an examination last year and I had the PSA blood test performed and I actually know what my PSA blood test was last year. So four years ago, that would be extremely rare to hear. Today, it's a common occurrence. I feel that the prostate cancer awareness week has had a major impact on getting people in for screening. But like other disease dysfunctions, I do believe that the Afro-American population is lingering a little behind in screening compared to the other populations that we see and deal. At the same time, I know I participate with prostate cancer awareness week and we have in Lexington, Kentucky, a typical American ethnic type of a blend. And I see as many Afro-American people coming percentage wise as I do white people.

So I feel that the messages are getting out there and we are screening more and more each year and that's been growing for the last four years. Are there any genes that may have a possible effect on the development of the cancer? Well, there's things that's been implied as associated with etiology or cause of prostate cancer. Nothing absolute, nothing specific, no viruses have been really identified that can be tagged as this is the virus that causes this. There's been reports showing that diet might have a factor and if one eats a lot of fat or lipids or red animal meat, that's been associated with prostate cancer. But that's not really proven, those are some small reports that imply that that might be at the basis. There's some factors, oriental, gentlemen are less likely to get prostate cancer than American men who are born and raised in the United States.

However, if you take an oriental individual and you move him from the far east and you bring him to the United States and he lives there after a certain number of years, his chances of prostate cancer development increases. So one can say there's more involved than the genetics, there's environment playing a role here. And so the change in that diet and habits and perhaps exercise programs have been implied from reports such as someone I just mentioned to you. You mentioned in the other statement the PSA test, because you tell us about that test and what doesn't entail. Well a PSA test is becoming increasingly popular. I'm an early admirer of that test. As a matter of fact, in the Lexington area I've been performing that test really since about 1987 and my colleagues in town were skeptical

of feeling that there's too many false reports, too many reports that say that there may be cancer and maybe not enough reports that actually missed the cancer. But you have to step back, I believe, a step or two and say, well what is it that we have available at our disposal today for early prostate cancer detection? Obviously the goal is to detect it early, then maybe offer a patient cure as opposed to detecting it late and only offering a control because there's a major difference in control and in cure. So a PSA is a blood test and it looks for an enzyme that the prostate gland produces. And if you have prostate cancer, the cell walls, the prostate cancer cell leak this factor and it's just picked up in the circulation.

So when you do a blood test, the PSA will be elevated indicating that there an increase likelihood of prostate cancer. So it's a screening test and the current American Urologic Association recommendations are and these are the rules that I try to live by. If you are when a man reaches the age of 50, he should have a rectal examination, a digital rectal examination to fill the prostate and a PSA blood test performed each year for the rest of his life. On the left, he is an Afro-American and it is an Afro-American since it's more likely to find cancer in Afro-Americans. It is recommended that an Afro-American began the yearly rectal examination and the blood PSA test when he reaches the age of 40. And there are some rules that one needs to apply to that recommendation and one rule is, is that well, you should have an individual who is healthy enough that his life expectancy should be at least 10 years.

And so if you have someone that's really chronically ill and he's 50, then one can modify that recommendation. But for an average person at the age of 50, he should consider that PSA blood test and the digital rectal exam. Are there anything that one can do to prevent prostate cancer? I can go out and say, well, here's a well-done study showing that if you do this or that in your environment change, you will significantly reduce your chances of prostate cancer. The most significant thing that you can do as a patient today with prostate cancer is to follow those guidelines and come once a year for a digital rectal examination by a physician and the yearly PSA.

Those two, combination of those two, that's the best that we have today, the best recommendation we can give patients. This test can be given by a general practitioner? Yes, it can be a nurse practitioner, just a competent person, a physician assistant, a person who feels comfortable with digital rectal exams. The digital rectal exam has been around for years. It has a low impact. I think if you went to the city mall and you had a booth and every man that came by, you just said, come in, let's get a pre-rectal exam, we're doing cancer screening and those have been done. The return of that is exceedingly low as far as prostate cancer detection is concerned to the point where that it would not be cost effective to do that. But any healthcare person that is comfortable and competent to examine a prostate and then the other is just a simple blood test called a PSA. There are a lot of folks in the country who can improve five of those services to patients.

What is the current state of research on prostate cancer? I'm involved with different programs and protocols myself at the present time. One of the newest events that is on the horizon is if one can detect the prostate cancer early, while it's still contained within the prostate gland or if a person has had prior treatments such as a radiation. Now the prostate cancer is coming back. One new approach is called crowd surgery. That is a procedure where one places a probe into the prostate, several probes into the prostate and you actually freeze the prostate gland. And so there's increasing interest and excitement if we're looking at the areas of research and want modality can crowd surgery offer.

The traditional way of treating local disease, that's prostate cancer that's been detected early, still within side the confines of the prostate. So if one can eradicate the cancer sales and the prostate one should be able to cure the patient of the prostate cancer. And that's attempts have been performed through the years to achieve this goal through a radiation or through surgery where one actually removes the entire prostate gland. That is not the same as the TUR prostate where a channel is created through the prostate. It is not the same as laser prostate surgery. This is an actual operation to remove the entire prostate gland. Now as an alternative to that, people are beginning at the research level to look at freezing the prostate, trying to kill the prostate sales without having to undergo the major radical operation or have the side effects of the radiation. So that's one area of excitement in the urology field. The bottom line is not in on how good this is going to be compared to the standard of removing the prostate.

But if it does work out, it certainly saves a lot of patient morbidity and sickness following the surgery and or the radiation. What is the signs of prostate cancer and if left untreated the consequences? When we know the ultimate consequences? Yes. The signs of prostate cancer are confusing to patients and to health care providers. And the reason is when men get to be about 40 years of age, the prostate gland, and again for reasons we do not understand, takes on a second growth. It begins to grow. Now that type of growth is not cancerous. That's not a malignant growth. That is called benign prosthetic hyperplasia. And half of the men, by the time they obtain the age of 60, have problems urinating. Now some of those men have problems urinating because their urine stream is obstructed from the prostate cancer. The majority of them have the urination dysfunction because of the new growth called benign prosthetic hyperplasia.

So the clinician has to separate those out because of the treatments and the recommendation and the impact to the patient is entirely different. However, from a patient's perspective, the symptoms are pretty much the same. The patient may have difficulty initiating a urine stream. He may have to get up several times at night. He may not empty his bladder completely. He may have to strain to urinate. He may have urgency and have to go to the bathroom quickly. He may not get to the bathroom quickly enough before he has an accident. Those symptoms are the same whether it's a malignant process or whether it's a benign process. And so the symptoms do not help the patient and the clinician separate those to diagnose this as a part. Now if the prostate cancer is allowed to continue and go on diagnosed, the patient might develop bleeding. He might develop urinate tract infections.

He might block his entire urinary stream off. Get up one morning needing to urinate. Can't urinate have to go to the emergency room or to his doctor to have a catheter put in. The patient, if it continues, the prostate cancer may grow and block the tubes that come down from the kidneys, the ureters. And he may end up having renal failure because of the cancer growing into the base of the bladder blocking the tubes that drain the left and the right kidney. And the other consequence is that this prostate cancer spreads often very early to the bone marrow. And so he may have pain in the back, pain in the bony areas from the cancer spreading from the prostate gland to the bone marrow. But then at that age of 60, 65, 70, on up, having bone pain is common from arthritic changes. So just the fact that a patient listening to this has bone pain, he shouldn't panic that I have diagnosed him as having prostate cancer.

But that's the evolution of this disease dysfunction. And then eventually it will overpower, over exhaust the patient immune system and then one doctor from this problem. You mentioned in your answer that dealt with research. What are your particular comments on laser surgery? Well, I began about a year, a year and a half ago, performing laser surgery on men who have an obstruction at the prostate. Now this obstruction can be due to that new growth I was referring to, the non-prostate hyperplasia, or patients can have prostate cancer causing blockage and one can perform laser. Laser really means the laser is just a light and you slide a small filament up the urethra and with television cameras you can see where the filament is.

And what you actually do is that you heat the core of the prostate gland and you heat it up to a certain degree and then that heated tissue over the subsequent four or six weeks will dissolve out in the urine. And that will leave behind an open passageway so the patient can urinate again with a hopefully a normal and full urine stream. This is sort of like taking an apple core and coreing the apple. You still have your prostate gland in there and you're just as likely to be diagnosed as having prostate cancer in the future. It does not protect you from that. It's only purpose is to improve urination. The symptoms of obstruction can be improved if one opens the core. And so we have been doing laser for a year and a half here and comparing it to the standard which is to insert an instrument up the urethra and do a trans urethral resection of the prostate.

The TURP, some patients refer to it as the rotor-rooter procedure and we're doing laser and lieu of the TURP because it has advantages that the outpatient procedure one can come and get it go home same day. It does not have to be admitted to the hospital. There's no bleeding with laser prostitutectomy. The patient can return to work the following day and the cost savings is about 50%. It's about half as expensive as our traditional operation. So an outcome performance that competes very well with the TURP prostate. So we feel that there is a future for the laser prostitutectomy. I'm glad you meant is the surgery and the treatment of prostate cancer covered by most insurance? Yes, that's a standard diagnosis and even now today, even in Kentucky, the laser prostitutectomy is covered by insurance.

Is laser surgery used directly to treat prostate enlargement or does it have any other cancer treatment applications? Well, from a urology point of view, it has additional applications. Bladder cancer can be treated by laser. I use laser on most of my bladder cancers and one can actually treat kidney cancers with laser if they're in the tube that's draining the kidney. So it has painless cancer, squamous cell cancer if it's on the surface. I've treated men with painless cancer with laser. And of course, again, the whole key with cancer is the early detection. And if you treat it early enough, you can't save the penis. Otherwise, one has to do surgery if it's invasive into the penis to remove the penis. And so laser has application and other urology areas.

Dr. John Tuddo, MD. If you have a question or comment or suggestions asked to future in black America programs, write us. Views and opinions expressed on this program are not necessarily those of this station or the University of Texas at Austin. Until we have the opportunity again for a production assistant, Rick and Hammond. And in black America's technical producer, David Alvarez, I'm John Johansson, Jr. Please join us again next week. Cassette copies of this program are available and may be purchased by writing in black America cassettes, longhorn radio network, communication building B, UT Austin, Austin, Texas 78712. From the Center for Telecommunication Services, the University of Texas at Austin, this is the Longhorn Radio Network. I'm John L. Hanson, Jr. Join me this week on in black America.

When men get to be about 40 years of age, the prostate plan, and again for reasons we do not understand, takes on a second growth, it begins to grow. Now that type of growth is not cancerous. Prostate cancer with Dr. John Tutto, MD, this week on in black America.