If this patient indeed had prostate cancer stage D-2 as defined by the Jewett staging system, during the first 1–3 weeks of therapy with luteinizing hormone-releasing hormone agonist, there could be an initial increase in testosterone, a condition known as “flare.” Blockade of flare can be accomplished with a number of agents, including flutamide, bicalutamide, nilutamide, diethyl stilbestrol, ketoconazole, and cyproterone acetate. Evidence from the early use of luteinizing hormone-releasing hormone agonists suggested that flare could be serious in nature, with exacerbation of pain, increase in uraemia, development of neurologic sequelae, and possibly death [2
]. The use of luteinizing hormone-releasing hormone analogues in patients with stage D-2 disease is associated with clinical flare in approximately 10% of patients. In addition to bone pain, spinal cord compression, and bladder outlet obstruction, another potentially severe side effect is cardiovascular risk arising from hypercoagulability associated with a rapid increase in tumour burden [3
]. Thompson recommended that androgen blockade should be used in patients with advanced disease, as evidence suggested that with flare blockade, acute complications were extremely uncommon [2
]. When blockade of flare was not used, two deaths were reported from one institution.
We do not know whether this patient manifested tumour flare, as biochemical investigations were not performed subsequent to administration of leuprorelin and whether tumour flare contributed to his demise. Recently, we started prescribing gonadotrophin-releasing hormone antagonist, degarelix to treat advanced hormone-dependent prostate cancer. Degarelix does not induce a testosterone surge or tumour flare; therefore, antandrogen therapy is not required.
Antoniewicz and associates [4
] reviewed 238 patients who were referred to urology service in 2007–2009. Of 238 patients, 155 (65%) individuals received anticoagulant drugs. Haematuria was found predominantly in patients over 65 years; 71% of patients had concomitant diseases: hypertension, coronary heart disease, arrhythmia, and end-stage renal disease. Abnormalities of urinary tract were found in 45 patients (19%). The cost-effectiveness analysis revealed that the cost of detecting a single neoplasm was 3252 Euro. These researchers recommended redefinition of the occurrence of haematuria from the current concept of a manifestation of a serious urological disease to a common result of a long-term anticoagulant therapy.
Spinal cord injury patients may present with advanced cancer, as symptoms may be either minimal or mimicking other inflammatory conditions, which are quite common in this population. In our centre, we had misinterpreted squamous cell carcinoma of urinary bladder as vesical abscess [5
]. Pannek found that more than 60% of the spinal cord injury patients with bladder cancer initially presented with muscle-infiltrating bladder cancer [6
]. Tetraplegic subjects are at risk for developing cardio-pulmonary complications following anaesthesia and major surgery. If urological surgery is performed without anaesthesia, tetraplegic patients are at risk for developing autonomic dysreflexia [7
A retrospective study of all spinal cord injury veterans receiving care at all the Department of Veterans Affairs Medical Centers in United States of America, who subsequently underwent proctectomy for rectal cancer during fiscal years 1993–2002 was carried out by Singh and associates [8
]. Only patients with spinal cord injury due to trauma who met American Spinal Injury Association type A criteria (complete cord injury) were analyzed. Forty percent of spinal cord injury patients had major comorbidities at admission. Postoperative complications occurred in 80% of patients. The complication rate and length of stay for spinal cord injury patients undergoing proctectomy for rectal cancer were higher than those reported for otherwise comparable neutrally intact patients. Singh and associates concluded that spinal cord injury should be considered a risk factor for adverse outcomes in operations for rectal cancer as in other major surgery.
As our patient had two malignancies (melanoma and adenocarcinoma) with hepatic and osteolytic metastases, we prescribed gonadorelin analogue on the assumption that the adenocarcinoma arose from prostate and decided to avoid chemotherapy or surgical procedures including biopsies.
Our patient sustained spinal cord injury at the age of 72 years. Ten years later, he developed haematuria and cancer of prostate was detected. Patel and associates [9
] found a lower prevalence of prostate cancer among veterans with chronic spinal cord injury in comparison with age-matched veterans without spinal cord injury. However, the prostate cancer detected in the patients with spinal cord injury tended to be of a more advanced stage and grade. Scott and associates [10
] postulated that the difference was likely a result of the decreased use of prostate cancer screening in this population. At present, prostate specific antigen levels are not checked during followup of male spinal cord injury patients in the North West Regional Spinal Injuries Centre, Southport, UK.
Middleton and associates from the University of Sydney, Australia, observed that among the first-year survivors, overall 40-year survival rates were 47 and 62% for persons with tetraplegia and paraplegia, respectively [11
]. As spinal cord injury patients live longer, they are at increased risk for developing cancer. Therefore, spinal cord physicians should consider implementing strategies towards prevention and early detection of cancer during followup of these patients.
Several behaviours identified may become targets of prevention strategies to increase longevity, including smoking cessation, stopping binge drinking, avoiding overreliance on psychotropic prescription medications, and promoting daily activities away from home [12
]. Krause and associates [13
] investigated the causes of death in patients who were ≤50 years at the time of traumatic spinal cord injury. In patients surviving ≥10 years, paraplegia was associated with a higher life expectancy compared with tetraplegia, 34 and 25 years (P
= 0.008), respectively, and the leading causes of death were septicemia (n
= 14), ischemic heart disease (n
= 10), neoplasms (n
= 9), cerebrovascular diseases (n
= 5), and other forms of heart diseases (n
= 5). Septicemia, influenza/pneumonia, and suicide were the leading causes of death in tetraplegics, whereas ischemic heart disease, neoplasms, and septicemia were the leading causes of death in paraplegia.
Spinal cord physicians should encourage paraplegic and tetraplegic subjects to participate in cancer screening programmes and provide necessary facilities in spinal units. Implementation of this strategy will require additional resources, for example, admission of a tetraplegic subject in a spinal unit for bowel preparation and sigmoidoscopy or colonoscopy. Therefore, healthcare providers should allocate funding not only for early transfer to a spinal unit for rehabilitation but also for prompt admissions during subsequent years in order to facilitate spinal cord injury patients to undergo investigations for early detection of cancer.
Sadly, in the present setup, some spinal cord injury patients experience delay in diagnosis and treatment of cancer and consequently have poor survival from cancer [14