Various conditions affect the prostate including the most common male cancer, as Lea Taylor reports
The prostate is a small gland about the size of a walnut. It is situated around the urethra immediately below the bladder outlet. Its function is to provide the necessary fluid to transport sperm during ejaculation.
The three most common prostate conditions are benign prostatic hyperplasia (BPH), prostatitis and prostate cancer. BPH is the enlargement of the prostate resulting in problems with urination. BPH is not cancer and does not increase the chances of developing prostate cancer. The likelihood of developing BPH increases with age. In fact, BPH is so common that it has been said that all men will have an enlarged prostate if they live long enough. A small amount of prostate enlargement is present in many men aged over 40, and more than 90% of men aged over 80.
Less than half of all men with BPH have symptoms of the condition, which include:
• Slowed, weak or delayed start of the urinary stream.
• Dribbling after urinating.
• Straining to urinate.
• Strong and sudden urge to urinate.
• Incomplete emptying of the bladder.
• Needing to urinate more than twice during the night.
• Incontinence.
• Pain during urination.
• Haematuria (blood in urine).
There are a number of tests which can be carried out to test for BPH:
• Prostate specific antigen (PSA) test.
• A digital rectal exam (DRE) can be carried out where the GP inserts a finger into the rectum to feel the size and shape of the prostate gland.
• Pressure flow in the bladder can be measured during urination.
• A form of x-ray called intravenous pyleogram (IVP) can show blockages.
• Urine sample can detect infection.
• Cystourethogram, a form of x-ray, can be performed during urination.
• Cystoscopy, where a small camera is inserted via the penis to visualise the bladder and prostate.
• Needle biopsy and ultrasound, known as a transrectal ultrasound (TRUS), can allow samples of abnormal areas to be taken.
The diagnostic blood test, PSA, is probably the most commonly used method of identifying prostate disorders, including cancer. PSA levels, however, do increase with age and some men naturally have high PSA levels and still have perfectly healthy prostates.
High levels of PSA indicate cancer in only about a third of all cases. Due to this lack of specificity, PSA testing is often carried out in combination with a DRE. These procedures are contributing more to the frequent diagnosis of the disease. In view of this, it is not uncommon for an underwriter to request a PSA test for males over 50, if the GP is unable to provide such information.
Medication to lower hormone levels can be given for BPH, this reduces the size of the prostate gland allowing increased urine flow and reducing symptoms. Other medication (Alpha 1 blockers) can be used to relax the bladder muscles allowing easier urination. Two thirds of men treated in this way report an improvement in symptoms. Antibiotics may be prescribed if the prostate is inflamed, known as prostatitis, which may accompany BPH. Relief is normally noted after the course of antibiotics. Surgery is more commonly recommended for incontinence, recurrent urine infections, haematuria and urinary retention.
Surgery
The type of surgery required varies depending on the severity of the symptoms:
• Transurethral resection of the prostate (TURP) is the most common surgical treatment for BPH. The process involves a scope inserted via the penis and the prostate is removed piece by piece.
• Transurethral incision of the prostate (TUIP) is similar to TURP but is usually performed on men who have a relatively small prostate.
• Open prostatectomy is the removal of the prostate by insertion via the abdomen. This is a lengthy procedure and normally endures a five to ten day hospital stay.
Most men find symptoms improve after surgery, however possible complications include impotence, urinary incontinence and infertility.
Prostatitis is inflammation of the prostate and is usually caused by infection. Acute prostatitis develops suddenly and is usually caused by a bacterial infection, however some sexually transmitted infections (STIs) can also cause acute prostatitis, typically seen in men younger than 35. In men older than 35, E.coli and other common bacteria are more often the cause of prostatitis.
Symptoms of prostatitis include chills, fever, low abdomen and genital pain, and burning during urination. Treatment is normally in the form of antibiotics and symptoms usually resolve after completion of treatment. Other advice given is modification of diet and practicing safe sexual behaviour for infections associated with STIs.
Chronic prostatitis develops gradually and continues for a prolonged period. This condition is diagnosed in five out of every 1,000 outpatient visits with an estimation of as many as 35% of men older than 50 suffering from this condition. Increased risk is associated with men over 30.
Symptoms are similar to acute prostatitis, however are recurrent and less severe. Various treatments are available for chronic prostatitis including a combination of medication, surgery and lifestyle changes. An extensive course of antibiotics is commonly used, however in some cases where the antibiotics are unable to penetrate the prostate tissue, a TURP may be necessary. This procedure, however is usually only performed on older men due to the potential risks of sterility, impotence and incontinence.
Family link
Prostate cancer is the most common cancer in males in the UK, with over 30,100 new cases each year. The lifetime risk for being diagnosed with prostate cancer is one in 14. This cancer is rarely found in men under the age of 50, however the risk of developing it increases if a first degree relative (father/brother) was diagnosed at a young age. In a small number of cases, prostate cancer runs in families due to a faulty BRAC2 gene. Prostate cancer is more common in African men.
Symptoms are similar to BPH with possible symptoms of bone pain/tenderness in the spine, pelvis and hips. This is due to spread into the blood stream resulting in the disease spreading into the bones, in particular the pelvic region. With the introduction of PSA testing, most prostate cancers are now being identified before they cause symptoms.
Tests include:
• PSA test, although elevated PSA levels can also indicate BPH.
• DRE
• Prostate biopsy in the form of a TRUS.
• CT/bone scans and chest x-rays may be performed to rule out metastasis (spread of the cancer to other parts of the body).
Treatment varies depending on the staging and grading of the tumour, with options including surgery, radiotherapy, hormonal treatment and /or chemotherapy. Removal of the prostate is normally successful where the tumour is confined to the prostate. Where the cancer has spread outside the prostate gland, then chemotherapy is sometimes used to improve the quality of life, if hormonal treatment is not effective.
Radiotherapy is used to eliminate cancer cells and is performed instead of surgery. If the cancer is more locally advanced then radiotherapy can also be used to reduce the size and help relieve symptoms.
Staging and grading provides differentiation of cancers, with the Gleason score being the most commonly used for prostate cancer. The higher the Gleason score the less differentiated the tumour, with an increased probability of spread, nodal involvement and subsequent metastates.
Staging is a way of summing up information from biopsies, scans, Gleason scores and other diagnostic tools. The staging ranges from stage one to four with prognosis being progressively worse at each stage. In addition, biopsies can also identify an atypical result known as Prostatic Intraepithelial Neoplasia (PIN).
Two types of PIN exist: low grade, which is not associated with prostate cancer; and high grade, which is a pre-cancerous condition with an increased threat towards prostate cancer. Close monitoring is recommended with regular follow up biopsies.
Lea Taylor is life and distribution underwriter at Scottish Equitable Protect
Underwriting implications
BPH will not usually attract a rating for life cover assuming it has been investigated fully and no residuals are present, e.g. abnormal urinalysis or renal impairment. However, if the applicant is under age 50, an insurer would need to see a general practioner's report (GPR), requesting results of investigations, details of any treatment and PSA levels.
For critical illness (CI) cover, insurers are more cautious, therefore a GPR would always be requested. Any abnormalities or residuals would be rated accordingly, and if there are any pending investigations then the decision would be postponed until fully investigated and exact diagnosis was made.
In all instances, a GPR is requested for disclosure of prostatitis to fully establish the type and cause. For a past history of this condition or current mild symptoms with normal urinalysis, standard rates for all benefits would be offered, however if there are any abnormalities or residuals these would be rated separately.
In addition, for income protection (IP), excluding the prostate gland for shorter deferred periods would be considered depending on the severity of the condition.
A GPR and questionnaire is always required to establish the grading and staging of the tumour and any ongoing symptoms. As with most cancers, for life cover, per mille ratings (rating per thousand pound sum assured) are normally applied, however such cases can only be considered after completion of all treatment and surgery. CI cover is normally declined. IP can be considered with a minimum deferred period of 13 weeks.
Our guidelines allow us to offer terms for PIN cases also, with PIN 1 being considered at standard rates for Life cover. With regard to CI cover an exclusion for cancer of the prostate for all PIN cases is appropriate, however if a client has been diagnosed with PIN2/3 and only has one set of biopsy results, then the underwriter would postpone a decision until further investigations/biopsies have been carried out.
PIN 1 cases for IP are acceptable at standard rates with a minimum deferred period of 13 weeks, however all other cases are as per the tumour guidelines above.
Additional Information:
www.nlm.nih.gov/medlineplus/encyclopedia.html
www.cancerresearchuk
www.prostatedisorders.co.uk
www.prostatecancerscreening.co.uk
Davidson Practices and Principles of Medicine (19th edition)
