Prostate cancer: the silent killer that still lurks in the dark

Prostate cancer survivor Stephen Zammit has spoken out to raise awareness about the condition that has now haunted him for over a year. 

“Undergoing tests at least once a year should become part of the routine for men over 45,” he advises, having himself only discovered his condition due to a routine blood test during his yearly check-up as a diabetes sufferer.

“It’s a silent killer,” he said, having never experienced any symptoms besides some difficulty urinating: easy to ignore something altogether innocuous.

“Even after my doctor alerted me to the irregularity, I took it lightly given the lack of what I assumed would be obvious symptoms,” he said. Had it not been for his wife Natalie’s concerns he probably never would have sought further specific tests.

“Unlike breast cancer, it is not a cancer that is detectable through a lump or unusual patch of skin at its early stages,” he said, saying that public investment should be dedicated to raising awareness about the importance of taking regular tests and prevent the cancer spreading to a point where it becomes incurable.

Zammit also rues the lack of support groups for those diagnosed with cancer to help them face the illness, and to give guidance over operations or treatment.

“Any doctor will tell you that the first two years after the operation are critical,” he said. “Testing happens frequently, and waiting for the results is like re-living the trauma all over again, so men need all the help they can get at this stage.”

Zammit’s father was also recently diagnosed with prostate cancer.

“My appeal to men to go for the tests out of their own initiative, particularly if they had a family history of the illness. Although there is no concrete evidence of it being genetically linked, being vigilant in such cases can only help.”

Zammit’s story 

Zammit’s blood test results had shown elevated levels of Prostate Specific Antigen (PSA), a protein produced by the prostate gland and normally present the body in small quantities.

The health parliamentary secretariat explained in fact that the screening test in question is very sensitive for the detection of prostate cancer, however an elevated PSA does not necessarily mean that there is cancer.

“The presence of tumours or cancerous cells often results in excessive amounts of the protein being released, but a number of benign conditions, including inflammations, can also cause a man’s PSA level to rise,” it said.

Zammit says it his wife Nathalie, his rock, who sparked the journey for a timely recovery thanks her insistence to see a specialist in the early stages. 

“The doctor had initially recommended a course of antibiotics due to a prostate infection that had developed, irrespective of the tumour. Once the infection had healed, I underwent the biopsy that changed my life.

“Once I heard the result, the word ‘cancer’ kept resounding in my head. I became concerned about those I would be leaving behind, things that could remain unresolved, like home loans and life insurance,” he said, adding that the experience had forced him to re-assess his life.

For Zammit the battle was, to a certain extent, more of a mental one.

“It’s the awareness of it and the events until the moment I was given the all clear that really get to you,” he said, adding that although the surgery tends to be somewhat painful, men with cancer need emotional and mental support above everything else.

Which is why Zammit remains indebted to the Puttinu Cares Foundation, which helped him spend quite some time in London to undergo the necessary operation, something he might not have been able to afford without their assistance.

“Besides the obvious financial burden this foundation had lifted, given that they offer free accommodation to patients and relatives, the residence we were in was like a soothing balm,” he said, adding that every effort was made to make patients feel at home and cared for.

“Given the nature of my tumour and my age when it was detected, my best option was a kind of surgery known as robotic prostatectomy, which completely removes the gland and which isn’t available local.”.

Relatively young at the time of the diagnosis, it was more likely that the tumour could rear its ugly head again over time with the option of radiotherapy, which is offered locally. “Although the surgery I underwent doesn’t necessarily guarantee the tumour will not return, the risk of recurrence is much lower like this.”

The route to the operation was not straightforward, but something of a saga until the operation to surgically remove the tumour was actually decided upon.  

“When we travelled to London for the surgery in October 2014, the surgery had to be put on hold because of multiple scars I have from previous hernia operations,” he said.

Further tests to explore alternative therapies had revealed that he did not have just a 1mm tumour anymore, but that he now had at least five tumours, with the largest measuring some 12mm. “This ultimately decided my fate and made it paramount to carry on with the surgery despite the risks,” he said adding that he had returned to London for the procedure in January this year.

Prostate cancer and screening in Malta 

According to data forwarded by the health parliamentary secretariat, an average of 190 cases of prostate cancer were reported every year, over the last five years, with incidence peaking in 60-70 year olds.

The same data also reveals that Malta has a comparatively good five-year relative survival rate of 84.9%, which is above the 83.4% EU average.

One might logically conclude that one of the best ways to improve this rating is to introduce a system of nation-wide screening, such as is in place for breast cancer. Every year, women of a certain age cohort are invited for a breast cancer-screening test, with the process being provided for by the state. However, as the parliamentary secretariat pointed out, the situation isn’t so cut and dry.

“There is a lack of evidence to support or disregard widely adopted programmes for early detection of prostate cancer aimed at all men in a given population, with the correlation of prostate screening with a reduction in mortality being largely inconsistent across studies. Furthermore, the screening itself could have some consequences,” it said pointing out that there has been a long-standing controversy on the PSA tests.

Over-screening could lead to over-treatment, and that the common treatments could have unwanted and permanent side-effects in men, including incontinence and impotence for surgical treatment, and irritation of the rectum and bladder following radiotherapy.

The secretariat adds that a free/total PSA ratio is another blood test that can ultimately help ‘fine-tune’ the simple PSA test.

PSA comes in two forms – free and attached – and cancer tends to produce more of the attached form. As a result, measuring free vs. attached PSA may help determine whether a biopsy is warranted.

“If the ratio is abnormally low, then there is an increased probability that the elevated PSA is coming from cancer rather than a benign disease.”

Urologists will also perform a digital rectal examination to perhaps detect an abnormal feel to the posterior surface of the gland. It added that over the last year, MRI scans of the prostate were being done which are very good at detecting the more aggressive type of prostate cancers.