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Five-minute Practitioner: February 2009

Only got five minutes? Then just read these key points on: prostate cancer, testicular lumps and angina

Only got five minutes? Then just read these key points on: prostate cancer, testicular lumps and angina

Prostate cancer
Prostate cancer is the most common cancer in men with more than 35,000 new cases diagnosed annually and almost 10, 000 deaths from the disease.

In general, the earlier prostate cancer is detected, the better the outlook for the patient in terms of cure or arresting cancer progression.

PSA measurement is currently the most effective single screening test for early detection of prostate cancer. Approximately 25% of men with PSA levels above the normal range (?4 ng/ml) have prostate cancer, and the risk increases to more than 60% in men with PSA levels above 10 ng/ml.

The PCA3 is an adjunct to the PSA measurement. A PCA3 value of >35 indicates an increased risk that the prostate harbours a malignancy. This marker may also be useful in differentiating men with clinically significant tumours from those with low-risk cancers which can be managed conservatively.

Transrectal ultrasonography is used to image the prostate gland and direct the biopsy needle. A total of 8-14 biopsies are taken from different regions under local anaesthesia and with antibiotic cover. Histological analysis provides a Gleason score for each core. The higher the Gleason score, the greater the risk of prostate cancer progression and metastasis.

MRI is widely used to stage prostate cancer locally and to diagnose or exclude lymph node metastases. Radionuclide bone scanning is usually performed as a baseline assessment at the time of the initial diagnosis of prostate cancer with bone metastases showing up as ‘hot spots' affecting the vertebrae, pelvis or long bones.

The aim of active treatment in patients with localised prostate cancer is usually cure – whether eliminating the tumour or preventing death from prostate cancer (as opposed to death with prostate cancer).

Testicular lumps
Testicular cancer rarely occurs before puberty and is most common in men aged 15-44 years. Around 90% of cases affect men under the age of 55.

The most common symptom of testicular cancer is a painless enlargement of the testis. Enlargement is usually gradual, and a sensation of heaviness is not unusual. Pain is not always an associated symptom although 30 - 40% of patients with testicular cancer give a history of a dull ache and around 10% present with acute pain.

Physical examination should also include palpation of the abdomen, examination of the neck for enlarged lymph nodes, examination of the chest for any gynaecomastia and auscultation for lung metastases. Around 1 to 3% of testicular tumours are bilateral occurring either simultaneously or successively.

Any solid, firm, intratesticular mass must be considered as cancer until proven otherwise. In around 25% of patients an incorrect diagnosis is made at initial examination. Epididymo-orchitis, epididymitis and hydrocoele are commonly mistaken diagnoses in cases of testicular cancer.

All patients with suspected testicular cancer should be investigated for the presence of tumour markers before referral. However, if a patient has a normal result this does not rule out cancer. These markers have an important role in diagnosis and tumour staging and also in monitoring treatment response.

Angina

Enhanced external counter pulsation (EECP) is an alternative means of managing coronary disease. This therapy provides augmentation of diastolic flow, through sequential inflation and after-load reduction by simultaneous deflation, from a series of three cuffs applied to calves, lower thigh, upper thigh and buttocks.

EECP is used predominantly in patients with severe angina, who are at high risk and are not suitable for revascularisation. It provides a therapeutic and supportive approach to managing such patients regardless of age and comorbidity including those with stable heart failure.

Treatment is carried out daily on an outpatient basis for a total of 35 hours over three to seven weeks. RCTs have shown improved symptoms and exercise time to onset of ischaemia. Improved quality of life scores have been reported two years after therapy.

EECP provides a safe, well tolerated and therapeutic treatment for these patients. It improves fitness through passive lower body exercise and often an improvement in wellbeing which may relate to an effect of therapy delivered to the entire circulation. Other benefits include the potential to reduce erectile dysfunction.

Provision of EECP should be considered as part of a dedicated service for refractory angina. This service should ideally offer a careful diagnostic assessment and a multidisciplinary approach, including psychological support and rehabilitation and in those with a continuing burden of symptoms the freedom to choose between a psychological approach with CBT, EECP therapy and palliative treatments.

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