First reported case of preventative prostatectomy

Jennifer Mamby-Alexander, Contributor

Hot on the heels of the media coverage of Hollywood actress Angelina Jolie's preventative mastectomies, because of a BRCA gene mutation, a 53-year-old business man from London, England, who is married with children, and who it is reported to have family members with prostate and ovarian cancer, requested to have his prostate removed after discovering that he was carrying the BRCA2 gene mutation.

Previous studies have shown that a man with the BRCA2 gene mutation has an 8.6 fold increased risk of developing aggressive prostate cancer. Again, like breast cancer, the normal population of men at risk for developing prostate cancer does not carry the BRCA mutant gene.

Initially, it is said his doctor, the director of the Prostate Cancer Centre in London, was reluctant to perform the surgery because there were no clinical indications that there was a problem, either from his physical examination, normal prostatic specific antigen test (PSA) or from his negative magnetic resonance imaging (MRI) scan. A subsequent biopsy confirmed that he had microscopic prostate cancer changes.

'WATCHFUL WAITING'

What is important is that men with normal digital rectal examinations, normal serum PSA levels and other normal tests are usually not sent for biopsies. What is even more important is that men with early prostate cancer are otherwise classified to be low risk from dying from the disease, and are sometimes given the choice of 'watchful waiting' to see if the disease develops, but in this case the presence of the BRCA mutation prompted immediate surgery to remove the gland.

The controversy of 'watchful waiting' for men with early prostate cancer, rather than surgery, results from the fact that removal of the prostate gland, even for small-volume disease, is not without harm to other systems, like dribbling of urine and erectile dysfunction, which may last from months to years.

Dribbling of urine is a nuisance that requires a man to wear an incontinent pad for the duration of time dribbling occurs and no man even wants to think about erectile dysfunction or infertility.

An alternative to a prostatectomy is radiation therapy, but these complications may also occur after radiation therapy. All of this makes removal of normal glands a tougher decision for men even with the BRCA mutant gene.

Also, in this particular case, this man had actual evidence of prostate cancer and does not compare to a woman who removes her breasts without any evidence of cancer but with a heightened risk of developing the disease.

Dr Marc Garnick from Beth Israel Deaconess Medical Centre in Boston, United States, commented that the issue of performing so-called prophylactic prostatectomy, because the man is a carrier of the BRCA mutant gene, raises many complexities.

He is reported to have said, "The real unanswered question relates to whether intervention, if applied to this group of men with aggressive cancers, either with or without BRCA mutations, will ultimately have a positive impact on the course of the disease.

Currently, a man's decision to undergo a prophylactic radical prostatectomy because he is carrying the BRCA gene is based predominantly on emotions, not data. Only appropriate clinical research will answer this question."

My first comment on this issue is that these are personal choices. My second comment is that although prostate and breast cancer are the number-one cancers in countries like Jamaica, more persons are still dying from cardiovascular disease (heart disease and strokes), so after removal of normal breasts and prostate glands because of the fear factor of cancer, how do we address the other diseases that are left?

Persons who have many family members with diabetes and heart disease are not at this time in a position to remove normal organs to prevent the development of these illnesses. Where do you start and when do you stop? Is it the aim for us to see tombstones with the captions 'Here Lies John Doe Who Died from Nothing?'

Lifestyle changes are still very important because they have an impact on all body systems so when a disease develops, and I say when, because it will, our bodies will be in better shape to fight and survive these diseases.

Take another look at the low cancer rates in Okinawa, Japan because of healthy lifestyles. It would be interesting to see if any Okinawans have the BRCA mutant gene.

Dr Jennifer Mamby Alexander MD, a cytopathologist and author of 'A Practical Guide to Coping with Cancer', is a 24-year survivor of stage 4 breast cancer