- A 61-year-old reader has benign prostatic hyperplasia, or an enlarged prostate
- As his symptoms are similar to those signalling prostate cancer, he feels worried
- Dr Martin Scurr explains why getting tested every year is not always necessary
I was diagnosed with benign prostatic hyperplasia (BPH) 12 years ago.
I am 61 and would appreciate advice on how often to have tests for prostate cancer, as some of the symptoms are similar.
My GP monitors me yearly with a PSA blood test and I was also being given an annual physical examination of the prostate, though he has suggested this is unnecessary.
– Malcolm Buchan, Cirencester, Glos
More than 40,000 men are diagnosed with prostate cancer every year, and it claims 10,000 lives. This suggests screening and early detection are vital
More than 40,000 men are diagnosed with prostate cancer every year, and it claims 10,000 lives.
This suggests screening and early detection are vital, though in fact this remains a controversial subject, for reasons I will explain later.
BPH occurs when the prostate gland increases in size with age.
This can affect the outflow of urine, resulting in symptoms such as urgency, frequency, hesitancy, poor flow and nocturia (needing to use the loo more than once at night).
These are known as lower urinary tract symptoms, or LUTs.
However, prostate cancer does not typically cause those symptoms. It is mostly silent until it is very advanced and spreading outside the prostate.
The risk factors for prostate cancer are age, family history and being of black ethnic origin.
But having an enlarged prostate does not predispose you to getting prostate cancer, though the two conditions may co-exist.
Though informal screening is common, it is not current policy to carry out routine screening for prostate cancer because the benefit is small at best, and the potential for harm is considerable on account of the problem of overdiagnosis — where a condition is detected that would not otherwise have been clinically significant.
The severity of prostate cancer varies widely, and in most men it grows so slowly that they die of other causes before it becomes advanced.
Treatment for prostate cancer typically involves surgery and radiotherapy and can result in serious complications such as bowel and urinary problems and sexual dysfunction
There is no benefit in detecting a cancer of this slow-growing type, only potential harm from treatment.
This typically involves surgery and radiotherapy and can result in serious complications such as bowel and urinary problems and sexual dysfunction.
You refer to two screening methods: PSA testing and a digital rectal exam (DRE) of the prostate.
Raised levels of PSA, a protein produced by the gland which is associated with prostate cancer, may precede symptoms of cancer by five to ten years.
But the water is muddied by the fact that this protein is also raised by other conditions, including BPH, prostate infections and also following prostate examination, ejaculations or even cycling.
This means that PSA testing is not sufficiently specific. If levels are high, further tests will be needed — typically a biopsy.
But this carries a risk of infection, and around 10 per cent of such biopsies result in a false negative.
Raised levels of PSA, a protein produced by the gland which is associated with prostate cancer, may precede symptoms of cancer by five to ten years
DRE is where the doctor uses their finger to try to identify abnormalities.
However, only 85 per cent of cancers can be assessed this way. Studies of this technique have not shown a reduction in the mortality of prostate cancer.
The following advice to you is drawn from the findings of five large, long-term, randomised trials.
In cases where men have requested screening by PSA tests, regardless of whether or not they have luts, it is best to do so at intervals of two to four years — but there is no need for the digital exam.
Screening should stop at age 69, or earlier if there are other health problems which suggest a life expectancy of less than ten years.
Write to Dr Scurr
To contact Dr Scurr with a health query, write to him at Good Health Daily Mail, 2 Derry Street, London W8 5TT or email [email protected] – including contact details.
Dr Scurr cannot enter into personal correspondence. His replies cannot apply to individual cases and should be taken in a general context. Always consult your own GP with any health worries.
Men in this age group are statistically more likely to die from another cause and the risks of harm from treatment outweigh the benefits.
If at age 65 your PSA level is less than 1, you could stop screening, as you are unlikely ever to develop prostate cancer.
If your PSA level is between 4 and 7 then repeat the test after four weeks, it may subside — but refrain from ejaculation or cycling for 48 hours prior to the blood test.
If the level is above 7 on a second test, you will need a biopsy, and if that reveals cancer cells, decisions on treatment will have to be made once further tests have determined whether the tumour has spread.
The opinion of the pathologist about the cells seen under the microscope (‘the Gleason score’) will also influence treatment decisions — this is the best barometer we have for judging how aggressive the cancer is.
I take amlodipine daily and my last blood pressure check was normal.
On a recent holiday, temperatures were over 35c and my calves, ankles and feet swelled up and stayed that way for 14 days until I returned.
Can you advise on the cause and any preventive measures?
– Gary Hemmett, Broadstairs, Kent
Gary Hemmett from Kent suffers from hypertension, for which he takes the drug amlodipine
The swelling you experienced — known as oedema — is a common side-effect of amlodipine, the drug you are taking for hypertension.
This is a calcium channel blocker, which works to lower blood pressure by relaxing and widening blood vessels.
It’s not fully understood why this can result in fluid retention but at least 5 per cent of those taking amlodipine experience this.
However, it is not a reason to discontinue the tablets, nor does it interfere with the blood pressure control they give you.
I would suggest the heat was a second factor in the developing of your oedema.
Some ankle swelling is not uncommon in hot weather — a sign that the blood vessels have dilated to allow increased blood flow to the legs, which helps the body cool down.
The increased blood flow means there is extra tissue fluid leaking through the walls of the capillaries (tiny blood vessels).
Amlodipine is a calcium channel blocker, which works to lower blood pressure by relaxing and widening blood vessels
Normally this fluid is drained by the lymphatic channels, but when this drainage system is overwhelmed, it can lead to swelling. In your case, this was greatly increased by the effect of the amlodipine.
There are two options for future prevention. The first is to wear compression stockings on holiday — pharmacists are trained to fit these.
However you may find these unappealing and uncomfortable.
An alternative is the prescription of a diuretic.
These are often used to treat hypertension and may work well with the amlodipine while also helping to minimise fluid retention.
These would need to be taken only while in a hot environment — but it is something you must discuss with your doctor.