Research student Ms Ophelia Blake has won this year's Royal Irish Academy Biochemistry Science Writing Competition with a paper entitled The Prostate - A Man's Thing. Ms Blake is a PhD candidate studying at University College, Dublin and the Surgical Research Laboratory at the Mater Misericordiae Hospital.
The competition encourages third-level students to write about some aspect of biochemistry research, describing the work in non-technical language.
Originally from Goa, India, Ms Blake has lived in Ireland since secondary school, attending school at Taylor's Hill, Galway. She completed an MSc at Trinity College, Dublin and is working for her doctorate at UCD.
First prize in the competition, co-sponsored by Yamanouchi Ireland Co Ltd and The Irish Times, is a cheque for £300 and the publication in Science Today of the winning paper. The runner-up prize, worth £150, was won by Mr Gearoid Tuohy, a PhD graduate of the Department of Genetics, Trinity College. Mr Tuohy won last year's competition.
Ms Blake's paper is presented below.
The incidence of diseases of the prostate is on the increase in the West. The reason for this is complex and may be due to longer male life expectancy and increased public awareness of the problem. High-profile patients like President Mitterrand of France and Gen Norman Schwarzkopf of the United States have helped to bring the subject out into the open.
In the US, screening has led to a dramatic increase in the detection of prostate cancer. These cancers are being detected at an earlier stage, when they can be treated with a high probability of cure. In Ireland, which has no screening programme, most patients are diagnosed at a late stage. The debate concerning the screening and treatment of prostate cancers remains one of the most controversial subjects in medicine.
Apart from the appearance of high-profile patients, there is another reason why there has been a dramatic increase in prostate disease detection in the United States. A simple blood test has raised hopes that ultimately the rapid detection and identification of prostate disease would be possible.
This test detects a protein in blood which is produced in the prostate gland. If it is elevated in blood, that means the prostate is inflamed and is producing more of this protein than normal. This discovery was made about 10 years ago and people were so sure of its specificity that they called the protein Prostate Specific Antigen (PSA). Like so many certainties, this has proven to be wrong, but the name PSA has persisted.
The gene responsible for producing PSA in the prostate is located on chromosome 19, but the same gene is also present in women. PSA has been detected in tumours unconnected with the prostate. More exciting is the finding that PSA can be produced in some female breast tumours. PSA, which was originally thought to be valuable in male diagnosis, is now under examination in females, in particular for female breast tumours. Initial results indicate that PSA is a good prognostic indicator for these tumours.
In Ireland, prostate cancer is the most common internal cancer in men (skin cancer is the most common cancer) and accounts for 13 per cent of all cancer deaths in the EU. In the latest issue of the National Cancer Registry in Ire- land (1998), cancer of the prostate represents 11 per cent of all cancers, and 16 per cent of the non-skin cancers, in men. Prostate cancer in Ireland is on the increase and about 1,000 new cases are diagnosed annually. Although the statistics for this disease are similar to those of female breast cancer, it receives considerably less publicity or health resources.
Risk factors for developing cancer of the prostate are complex but include family history, increasing age, racial origin and dietary intake. As the cancer of the prostate is a very slow-growing tumour, many men who develop the disease die from other causes. This fact has generated an oft-quoted truism: "Prostate cancer is a disease that older men die with rather than of."
Is it all doom and gloom for men over 50? "No" is probably the correct answer. If men were to seek medical help at the first signs of trouble, for example a change in the "waterworks", the overall picture would be radically improved. There can be few men who have not heard the symptoms of prostate disease. Frequent urination, inability to urinate or a burning sensation when urinating are the symptoms which indicate it is time to seek help. These symptoms are due to an enlarged gland but are coincidentally associated with prostate cancer only if the tumour is large. Most cancers of the prostate are initially too small to cause any symptoms.
Other diseases of the prostate can cause the same symptoms. The problem may turn out to be a bacterial infection of the prostate. This is a painful but treatable problem.
The more common prostate disease is known as Benign Prostatic Hyperplasia (BPH) and has nothing to do with cancer. Over half of men in their 60s and over 90 per cent in their 70s or older will have symptoms resulting from BPH.
They result from the prostate gland naturally enlarging as men grow old. This enlargement is as much a part of ageing as grey hair.
The prostate gland, which is part of the male reproductive system, is doughnut-shaped and is wrapped round the urethra (the tube that empties urine from the bladder). As the prostate enlarges, it constricts the urethra (just like a clamp on a garden hose), thereby impeding the flow of urine. This produces symptoms in most men and treatment is by surgery or drug therapy. Laser, microwave and other advances specifically devised for BPH treatment have demonstrated improved results. Drugs are available to shrink the gland so that pressure is released. The drug manufacturers seek to solve this problem in different ways and are in tough competition with each other. The two main types of drugs used are alpha blockers and 5-alpha reductase blockers.
The cancer, which grows within the prostate gland, is a slow-growing tumour. If detected while still within the confines of the gland, the outlook is good. The urologist is rightly optimistic that a confined tumour can be effectively treated. Modern X-ray, ultrasound and biopsy techniques have improved the ability to diagnose tumours. None of these expensive diagnostic tools are nearly as cost-effective as early detection.
A blood test, which would detect prostate disease and distinguish the type of disease involved, is the aim of all those working on prostate disease. The introduction of the Prostate Specific Antigen (PSA) assay, as an indicator of prostate disease, has had a stimulating effect both on the public and on those responsible for treating the disease. Even as the shortcomings of the test became apparent, more effort was put into improvement. This has led to an explosion of knowledge on how the body reacts to the release of a protein like PSA.
Prostate specific antigen is an enzyme that breaks down protein very readily. The human body takes great precautions to minimise any damage PSA might do. In effect it hides the protein in blood in such a way as to make its detection very difficult. Because research has found ways of finding the hidden protein, PSA is still favoured as an assay to detect prostate disease.
Other blood tests either alone or in combination are being investigated. The assay of "insulin-like growth factor" was found to be a good indicator. Proteins similar to PSA but under separate genetic control are now being evaluated for the diagnosis of prostate disease. Methods of measuring their amounts, their ratios and their absolute production are the subject of much current research.
The discovery of PSA in the female was an enormous stimulant to find out more about this protein. It was discovered that not all women produce it. Those who do, produce it during pregnancy and in breast milk. Where a breast tumour develops, those positive for PSA seem to have a more favourable outcome. At this stage, it is not known whether the PSA produced by breast tumours is identical to that produced in prostate tumours. As this discovery is only recent, much research to verify this is necessary.
There is very little fundamental research on the problem, despite the increasing incidence of prostate disease in Ireland together with the knowledge that over half of men in their 60s will get the disease. Very little research funding has been earmarked for this area.
ALL the major departments of urology in Irish hospitals are doing something to advance knowledge of prostate disease. The role of standardisation in assays is being pursued, the production of standards and new methods of assay, and the role and regulation of apoptosis (the natural mechanism of cell death) in prostate cancer is ongoing.
Investigation into methods that would rapidly separate benign prostatic hyperplasia from cancer of the prostate is being conducted. Research into the development of therapeutic strategies for the treatment of prostate cancer and the treatment of benign prostatic hyperplasia are ongoing in two Irish hospitals. The expression of PSA in females and in female breast cancer and its potential use as a prognostic indicator are being investigated.
Some workers in this field have described prostatic disease as "the male epidemic". Last October the theme for Europe Against Cancer Week was "Men and Cancer". This raised public awareness of prostate cancer, and every effort must be made to encourage men with symptoms to seek medical advice. This is the single most effective action that can be taken. Ideally men above the age of 50, or younger if symptomatic, should have an annual prostate evaluation as part of a health check-up.
Europe Against Cancer Week also raised other issues. Prominent amongst them is the cost of maintaining funding for research into cancer, and the ever-increasing costs of financing a health service. Surely there should be more effort put into the research and management of prostatic disease in Ireland. Is this a chauvinistic view? Hardly, since the author is female, but her husband, father, brother and half her friends are males, and they all deserve the best.