Dr Vinod Javeri Consultant Urologist / Andrologist 410 Doctor House Opposite Jaslok Hospital

1. AWARENESS OR IGNORANCE “Choice is ours” Dr Vinod Javeri Consultant Urologist / Andrologist 410 Doctor House Opposite Jaslok Hospital Tel: 2351 9179, 9820039428

2. We gather information of Finance sector Real Estate Political Situation Entertainment Spiritual This information is processed analyzed understood and implemented With the aim to Develop & Evolve Awareness or ignoranceIs it difficult to choose?

3. What about Health? How much does one try to know ? • Limited Awareness – Chest Pain, heart attack, heart stops means ... • Rest of the body ? How much do you know your body ? • How many people read health related literature and ask questions to the doctor ? • How many doctors like answering questions? • Medical faculty – lost people’s faith • How can we as doctors get it back ? • Spread Awareness

4. Soul and Body Birth to Death Womb to Fire/Grave Sanskar Owner and Car Factory to Scrap User’s manual Body, a Vehicle

5. CAR Good use and Care Regular maintenance Engine Tune ups Good Fuel and Good Oil Smooth running Serves for a longtime BODY Good Use and care : Good health: Health physical mental social and spiritual well being(WHO definition) Regular diet exercise Health checks screening for diseases awareness. Better quality of life till as long Awareness

6. Bad Oil, bad fuel, improper use, accidents Increased maintenance, more troubles, Small troubles ignored Car breakdown Owner in trouble blames the manufacturer Bad food & drink habits Stress, Anger etc Frequent diseases, admissions to hospital etc. Health Emergencies or last stage diseases - CANCER Starts blaming – GOD, somebody but never himself finally when nobody can be blamed; blames the DOCTOR Neglect

7. Urology

8. Organ foundonly in Males located between Urinary Bladder And Urethra (peeing tube) Prostate

9. What does it do ? • The sperms that are formed in testes are transported through a tube that opens in the prostate. They are released in the form of Semen • It thus, plays a role in Reproductive function • Contributes in the formation of • Semen, Virya, dhatu (20%) • Prostatic Secretions are • important for liquefying the semen • normally within half an hour after • ejaculation Nonliquefying semen can cause infertility

10. What controls it ? The functional control of Prostate, its size and development depends on the male hormone. Name it ? Benign enlargement of prostate Testosterone Beyond the age of 45yrs prostate starts to increase in size. What happens when it grows beyond a certain point? Peeing Problems

11. “When the hair becomes gray and scanty, when specks of earthly matter begin to be deposited in the tunics of the artery, and a white zone is formed at the margin of the cornea, at the same period the prostate gland usually - I might perhaps say invariably - becomes increased in size” - Sir Benjamin Brodie

12. IPSS: International Prostate Symptom Score questionaire Multilingual validation Symptom Score and Quality of Life Score Incomplete evacuation, Frequency Urgency Intermittency Straining and Weak stream Nocturia

13. Men Age 50 years and more After 45 yrs prostate starts growing. Roughly at 50-50% have big prostate, 60-60%, 70-70%, 80-80% Increasing peeing problems Sleepless nights busy days Bathroom MAPPERS Stops going outdoors

14. Symptoms A man walks into his doctor's office and sits down in thewaiting room. While he is waiting his turn to be seen, acasual acquaintance walks in and sits down next to him. The newcomer asks "W w what are yyy you ddd doing here?" The man replies, " I am waiting to see the doctor." "W wwhy dd do yyy you wwant to sss see hhim?" The man replies, "Well, if you must know, I have a prostate problem. “A pp prostate ppp problem, wwhat's ttthat?” "Well, if you must know. I pee like you talk."

15. Definitions • Frequency: urinate again within 2 hours • Nocturia: Number times you get up to urinate after you go to bed • Hesitancy: difficulty in starting urine • Intermittancy: stop and start urine • Urgency: difficulty to control or postpone • Urge incontinence: leak due lack of control • Weak Stream: narrow slow and near • Straining: put pressure with belly to pass urine • Incomplete evacuation: feeling of incomplete emptying of bladder

16. Irritative Frequency Nocturia Urgency Urge Incontinence Obstructive Hesitancy Weak Stream Interruption of stream Narrow and weak stream Feel of incomplete emptying of bladder Types of symptoms

17. Complications Overflow Of Urine Kidney & Bladder damage Bladder stone Sudden retention of Urine Bleeding Infections

18. Seek help earlier than you think you will Treatment started at right time will give better results Stitch in time saves nine

19. Medicines When can we treat With medicines ? Mild to Medium symptoms No complications caused by the disease process In Patients who are Not fit for surgery Two groups of medicines: To reduce spasm of prostate muscles To reduce size of prostate Surgery If - The medications fails to achieve satisfactory goals and peeing problems are persistent or worsening If - Stone in bladder If - Pumped up Bladder If - Back pressure on kidneys has set in Treatment

20. Transurethral Resection of Prostate ( TURP )

21. Cancer Ignorance Awareness

22. American Cancer Society (ACS) Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells without any function. If the spread is not controlled, it can result in death. Cancer

23. Cancer Prostate If you wait… It may be late

24. In USA Prostate Cancer commonest cancer in males -- 33% Bladder Cancer – 6th commonest cancer in males 4% Cancer facts and Figures 2004 American Cancer Society In India Prostate Cancer 3rd commonest Cancer in males of Mumbai Bladder cancer 8th commonest cancer in males of Mumbai Mumbai Cancer Registry FACTS

25. Ca Prostate some more facts…. More than 80% disease come whenthe cancer has already SPREAD Srinivas et al 1995

26. Some more 1 in every 59 male will contract Ca Prostate Asian Pac J Cancer Prev. 2004 Oct-Dec;5(4):401-5.Related Articles, Links Mumbai 4th most populated city in the world with a population of 18 million (1 crore 80 lacs) United Nations 2005 report published on expressindia.com press trust of India How many Cancer prostate are we diagnosing, treating for cure or for palliation ?

27. Tip of an iceberg…. Diagnosed Cases Undiagnosed cases

28. Graph shows Number of deaths by five year age group Total deaths : 583 (4.02% of all, highest being esophageal cancer 9.7%) Deaths caused by prostate cancer1990-1996 data Mumbai Cancer Registry

29. Its there…we are getting it late.. Why are we getting it late ? “I have no problems why should I go to the doctor, he will unnecessarily do some tests and fish money out of me, don’t you know these modern day commercialized doctors”

30. Mumbai Cancer Society 740 patients CaP 1987-1991Survival Information on 602 patients

31. Prostate cancer in comparison with the leading site of Cancer in various PBCR’s Lung Lung Lung Lung Stomach Lung Lung Esophagus Stomach Mouth 3rd 4th 5th Mouth 5th 5th 4th 8th 5th 7th Hypo pharynx

32. Does Cancer Prostate have any symptoms signs or indications? Of all patients with urinary symptoms 20% may have prostate cancer Thus 80% patients who may be having Prostate cancer in its early stage do not have Urinary symptoms or any other symptoms We need to look for it…. HOW?

33. Awareness If aware one cannot be fooled Ignorance invites trouble

34. When early prostate cancer has no symptoms what can be done to avoid being late before the cancer really spreads?

35. Mantra for Early Detection Blood test : PSA ( prostate specific antigen) Examination: Digital Rectal Examination ( feeling the prostate with a finger) Once in a year

36. PSA (Prostate Specific Antigen) • 0 - 4 ng/ml considered normal, if they undergo biopsy 25-30% may have cancer all will be organ confined • 4 – 10ng/ml patients if undergo prostate biopsy more than 70% will have Cancer Of them 70% are likely to have prostate confined disease • 10 – 20ng/ml higher risk of hidden spread to bones more than 50% • 20 – 50ng/ml risk of spread to bones more than 70% • 50ng/ml and > spread to bone and LN more than 80%

37. Digital Rectal Examination Feeling the prostate gland with the finger (digit) Hard or bumpy prostate higher the risk of Cancer Smooth big softer prostate – non cancer enlarged prostate Doctor to whom you go should know what, how to and what to feel on the prostate If not done by a right person there Can be some accidents in the clinic

38. TRUS BIOPSY

39. Grade - Type of Cancer under the microscope Gleason’s Score out of 10 ( e.g. 7 / 10) Stage - How much has it spread in local area or far distant area Bone Scan Diagnosis

40. Radical removal of prostateRadical Prostatectomy

41. After effects of surgery… • Leaking of urine upto 3mon sometimes upto 1 year (waiting increases the risk) • Sexual function: Nerve sparing and non nerve sparing • In experienced and skilled hands the chances of above are less but it depends upon the stage and grade of disease • If you wait, it may be late… • In more than 90% cases leaking stops by 1year • More than 70% cases recover sexual function by the end of year • Viagara helps

42. Recovery time • Eat in the evening or next morning • Walk in 24hrs • Discharge in 5 – 7 days • Tube to drain urine kept for 2 weeks then removed • Complete recovery in 4 weeks … • Start normal routine 6 weeks and beyond • Some may need to manage temporary urine leaking problems • If need be Viagara can be started as early as 8 weeks • No lifting heavy weights for 6months

43. Types External Beam RT Conformal RT Intensity Modulated RT Brachytherapy Can offer curative treatment in selected cases Except for Brachytherapy after effects of RT are more as compared to surgery Brachytherapy expensive and technologically and technically challenging Radiation Therapy

44. Its already late….What do we do? • No curative treatment can be offered • Other Forms of therapy • Hormone therapy • Palliative Radiation therapy • Palliative Surgery • Chemotherapy

45. Hormone therapyMost practiced – Bilateral OrchidectomyRemoval of Testes (both sides)Injections to block testosterone (male hormone) • Is Bilateral Orchidectomy mutilating? • Does anybody disagree? • What after Orchidectomy? • Irreversible • Hormone dependant CaP becomes Hormone refractory independant CaP12-18months • Elderly patients bone pains/spine fractures? CaP metastasis • Pain, neuropathy, disability, morbidity, gradual end of life. • Survival this group of patients:2-3 years

46. Literacy and Prostate Cancer • Wolf et al (Chicago USA) • 197 men • African American, >65yrs, low socioeconomic status, 7th grade or less of literacy • Low health literacy subjects – More than twice likely that PSA levels will be high at the time of diagnosis

47. Awareness • Best way to fight any disease • Prevent if preventable • If not… • Early Detection • Better chance of cure • Hence we should strive to….. • Create & Spread Awareness

49. Thank you