Bring together a group of urology specialists, who have chosen to combine skills and resources. Integrate them into a structure, C.Ur.E. – European Urological Centre, which manages to combine professional excellence, therapeutic innovation and sustainability, bringing together experts in robotic surgery, laser, andrology and urogynecology. And then try to see how much and how this sustainable and transparent advanced medicine approach can offer specific answers for the prevention of prostate cancer.
The network, which boasts numerous collaborations with universities, is active in Emilia-Romagna, Lazio, Lombardy, Veneto, Puglia, Abruzzo, Campania, Tuscany, Calabria, Sicily, Sardinia. Returning to what has been achieved with the “Modena” model, here is the opinion of Giovanni Ferrari, president of the President of the European Urological Center (CUrE), who has continued what has been achieved in the Emilian city.
A particular idea
The work to prevent this form of cancer starts a long time ago.
“It was born in 1989, when my father, Professor Paolo Ferrari, started the first process of early diagnosis of prostate cancer in Italy. As a general surgeon he realized that prevention programs already existed for women (breasts, uterus), while for men there was nothing. In agreement with the mayors of the Modena municipalities we began free visits for citizens over 50, invited to come with a PSA and urine test. From 1989 to 2008, 70 thousand patients were seen.”
explains Ferrari.
Let’s be clear. Compared to today the situation was extremely different. Only in 1993 Fritz Schroder, now the leading European expert on the topic, initiated a protocol published in 2014 in the Lancet, which demonstrated how screening reduces mortality. It took time because prostate cancer progresses slowly: it took 20 years to collect solid data. But now the Modena model shows the value of the initiative.
“In the 70 thousand patients seen we published an analysis showing that out of 619 men, 269 (43.5%) had adenocarcinoma; of these, 182 (67.5%) were organ-confined, while 87 were already locally advanced or metastatic. On the epidemiological front, in Modena the incidence went from 34.7 cases per 100,000 inhabitants (1988-90) to 78 cases (2008). instead, it fell from 44.5% (63 deaths out of 141 new cases/year) to 17.2% (155 deaths out of 899 new cases/year) in 2011-12: -27.3%. Comparing with Reggio Emilia and Parma, which had not adopted any screening, in 2011-12 there were 541 new cases with 129 deaths (23.8%). In Modena, therefore, fewer people died thanks to screening”
Ferrari says.
How much is screening worth?
The story tells of an undoubtedly important result. From the idea of a single urologist and the strength of a few volunteers, it was demonstrated that the culture “against” PSA and screening has been overcome.
“Today there is a lot of scientific evidence: screening has a crucial role in early diagnosis and in reducing mortality”
takes over Ferrari.
“The combination of PSA and rectal examination remains the winning combination, also because we must not forget that in 10% of patients with prostate cancer the PSA is normal. The rectal examination, although feared by men, is actually harmless if performed delicately: the doctor must be attentive and the patient put at ease”.
To remember how important it is to arrive early and above all to make men reflect on the need for prevention, the Italian Society of Urology has relaunched the theme with campaigns such as Movember, dedicated to male prevention. The idea is to set up free clinics with dedicated slots, where men between 50 and 75 can book, bring PSA and urine tests, have the visit and have a clear path. If there is a suspicion, the patient is guided to diagnosis and therapy; if everything is negative, a periodic check is scheduled.
“Diagnosing early means recovering in a high percentage and reducing the side effects of more aggressive therapies, such as incontinence and erection problems.”
More awareness
For the male, therefore, awareness is fundamental. And we need to focus on knowledge, otherwise we tend to avoid urological visits because they are considered “uncomfortable”. But cultural awareness helps overcome this resistance.
“The prevention of prostate cancer has the same right as screening for the breast, colon and female genital system. All men between 50 and 75 years of age, especially if they have a family history of prostate or breast cancer, must undergo a PSA, urine test and physical examination. Today, thanks to evidence and new technologies, if the tumor is caught in time it is not lethal”
concludes the expert.
Who is at risk
The risk of developing prostate cancer increases with age and depends on a combination of non-modifiable (age, ethnicity, family history, genetic predisposition) and modifiable/environmental factors (nutrition, obesity, professional exposures).
The guidelines of the European EAU and American AUA scientific societies explicitly indicate high-risk groups for which it may be appropriate to start screening earlier (for example men with family history or with known germline mutations).
More specifically, the risk increases significantly after the age of 50 and even more so after the age of 65. Family history matters a lot: having first-degree relatives (father, brother) with prostate cancer increases the risk, which is even greater if more relatives are affected or the disease appeared at a young age. Finally there are inherited germline mutations: some pathogenic variants in DNA repair genes and others (e.g. BRCA2, BRCA1 to a lesser extent, CHEK2, ATM, PALB2) increase the likelihood of developing prostate cancer and are often associated with more aggressive phenotypes. All this, without forgetting that a diet rich in saturated fats, obesity and a sedentary lifestyle can contribute to increased risk or a worse prognosis, even if the data are less clear-cut than genetic factors.
