Prostate cancer: the silent threat that took Mr Z’s mobility and could jeopardise yours too

"It has spread and can’t be cured. But I don’t understand. It came out of nowhere?"

THAT night I entered casualty to see a patient who suddenly lost the ability to walk. Unexpectedly, I was directed to Mr Z, a 43-year-old businessman, who warmly greeted me with a strong handshake, a broad smile and an unforgettable zest for life. He lay supine on a stretcher, yet his animated expression starkly contrasted with the stillness of his legs.

Puzzled, I implored further.

Mr Z seemed to have been unfazed by the presentation and reassured me that he will "walk again in no time".

He complained of weight loss over the last few months, associated with recent back pain partially relieved by over-the-counter pain medications. I conducted a thorough examination, concluding with a digital rectal examination. Speechless, I assimilated my clinical findings. The bone-chilling differential glared at me through Mr Z’s kind, enquiring eyes.

"I suspect something serious and this is an emergency," was my best attempt to prepare him for a life-changing diagnosis.

I vividly remember my time in the department of urology as a junior medical officer during my community service at Charlotte Maxeke Hospital in Johannesburg. The hands-on experience over six months at a busy academic hospital allowed me to gain an abundance of clinical experience in independently examining and managing patients specific to the sub-specialty.

Significantly, I discovered that prostate cancer is not uncommon locally, correlating with international statistics as the most common cancer in men following skin cancer. It is not to be underestimated, as it is also the second leading cause of cancer-related death following lung cancer. However, we face a harrowing dilemma: the symptoms are often elusive and non-specific, and this cancer often presents at an advanced stage.

What can we do before it’s too late?

As both a patient and a medical practitioner, one must always maintain a high index of suspicion. Symptoms, when they appear, are largely related to the location and function of the prostate gland. Problems urinating, such as bleeding during urination, incontinence and urinary retention, necessitate further investigation.

Symptoms suggestive of advanced prostate cancer with spread to other parts of the body may include bone pain, especially in the lower back, weight loss, fatigue and a loss of appetite. A sudden loss of the ability to move your legs may be an alarming indicator of spinal cord compression by the tumor, which may be irreversible if not addressed urgently.

Unfortunately, the majority are typically asymptomatic early in the disease course. It is, therefore, crucial to highlight those who are at high-risk for developing prostate cancer. Advanced age (exceeding 50 years of age) and having a parent diagnosed with prostate cancer significantly increases your chances.

Of local importance, those of African descent are at risk for earlier, more aggressive forms of cancer. Genetics almost always play a vital role in cancer progression, reflected by a higher incidence of prostate cancer in those with BRCA2 gene mutations. Environmental influences are key determinants too, with higher incidence rates occurring in those suffering from obesity, with diets high in saturated fat and well-done meats.

Prevention is always better than cure. If you suspect it, get it checked out. Do not hesitate to visit your trusted urologist, even if you feel that something "is not quite right". Screening-tests can also be effectively initiated at the level of a general practitioner to prevent delays in resource-limited settings. The diagnostic process involves a comprehensive history taking and a complete physical examination.

An uncomfortable, but necessary, digital-rectal exam is essential to detect a suspicious prostate gland where it is often described as stone-hard, irregular, asymmetrical and even nodular. These findings are followed by further diagnostic tests: a PSA (prostate-specific-antigen) blood test and a prostate biopsy (an invasive procedure involving taking a piece of the prostate gland to look for cancerous features under the microscope).

Once cancer has been diagnosed, many modalities of treatment are available beyond the scope of this column, including but not limited to surgical resection, chemotherapy and radiation. Further radiological tests, such as CT, PET and bone scans are employed to screen for metastasis: an advanced, irreversible stage of cancer often beyond cure.

Unfortunately, Mr Z presented in the final stage of prostate cancer, with metastasis to the spinal cord and eventually the lungs. He was medically optimised and thoroughly investigated. Although all available treatment modalities, including chemotherapy and radiation, were discussed with him and his family, he declined further treatment and chose a palliative path. He preferred to maximise his time with his family at home.

Mr Z calmly articulated his final decision and smiled as he spoke with me for maybe the last time.

"Thank you for everything that you and your team have done. I will not forget you."

I fought back tears as I shook his hand firmly and wished him everything of the best at his discharge. It is through those defining moments that humanity echoes beyond the devastation of disease; and a respect for patient autonomy allows life to peacefully endure, if for a little longer.

Dr Ishq Pramchand, 27, of Durban, graduated at the Nelson R Mandela School of Medicine at UKZN with Summa Cum Laude and as the Top Achiever of the Class of 2021. He currently serves as a medical officer in surgery in the private and public healthcare sectors. Email [email protected] 

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