Roland Muntz, Chair of the Association ANAMACAP

“I used to be irresponsible because I didn’t have enough information, so I let a doctor look after my health, just like my accountant looks after my tax returns and my financial advisor looks after my investments … now I fight for citizen’s responsibility in a health democracy”. Roland Muntz was given a radical prostatectomy in 1999. In 2002, he founded ANAMACaP (the French National Association of Prostate Cancer Patients), which he now chairs. He was interviewed by journalist, Nathaly Mermet, on 20 December 2006.

After the virtually immediate recurrence of an aggressive cancer of the prostate for which he had undergone keyhole radical prostatectomy surgery in 1999 when he was 54 years old, Roland Muntz realised how important it was to study and understand his disease, his body, and his health in general. But, health is not an exact science and it is up to each individual to take their charge of their own health provided, of course, they have a minimum amount of information at their disposal.

The birth of ANAMACaP

“If I am the father of ANAMACaP, then Professor Philippe Mangin is its grandfather,” says Roland Muntz. It was in January 2002 that ANAMACaP (the French National Association of Prostate Cancer Patients) really came into being, at the initiative of Roland Muntz encouraged by Prof. Mangin, who at the time chaired the French Urology Association (the Association Française d’Urologie or AFU). “Patients are becoming increasingly powerful”, says Roland Muntz and he goes on to say that “what patients have to say is often controversial because they start out with a complaint about something that wasn’t done, or wasn’t done properly. But what we say is the truth, and it is not affected by conflicts of interest”. ANAMACaP, which is the only national association in France for prostate cancer, has 700 full members and 1200 associate members. But “we should be at least 10,000, because there are 350,000 patients and 50,000 new cases every year”, maintains Roland Muntz. If that were so, “we could really influence decisions relating to our illness". The stated aim of ANAMACaP is to help to define a public health policy that saves lives while stimulating the economy.
Backed up by a scientific board consisting of the “heavyweights” in urology, oncology and radiation therapy, ANAMACaP also acts as an interface between patients and specialists, supported by many other stakeholders. “ANAMACaP is the result of my own personal anxiety, an attempt to establish an effective screening system within the public health policy”, says Muntz, who lives under the constant threat of a recurrence. “I could have been screened for prostate cancer much earlier on, and I might have got rid of it altogether”, he says regretfully. A public figure – both local mayor and chairman of a number of committees – though not necessarily any better informed, Robert Muntz believes it is his duty to speak out on behalf of patients.

Information and prevention

According to Roland Muntz, 75% of the population is unaware of the real risk related to prostate cancer … and therefore does not realise that men face mortal danger! Prostate cancer will kill as soon as the cancer cells spread outside the capsule of the prostate, which can happen via two channels: the lymph – which results in lymphatic metastases – and the blood – which leads to bone metastases. Once this has happened, the mean survival time is no more than two years, and treatments such as hormone therapy and chemotherapy are no longer anything more than palliative, since once it reaches this stage, the disease is incurable.
“Men need to monitor their health, particularly once they are over 45 years of age”, insists Roland Muntz, and “we must obtain a screening system for prostate cancer, similar to that for breast and cervical cancer in women. In the struggle to achieve this, ANAMACaP must enlist the help of urologists and other doctors.
Prostate cancer is a national catastrophe, claiming 10,000 lives each year and “we expect a peak in 2015 when we begin to see cases in the older generation of the grandpa boom”, points out Roland Muntz. Mortality in France has increased by 10% in 10 years, whereas during the same period it has fallen by 25% in the United States.

An organised screening system

It should be remembered that what kills is advanced prostate cancer. What we need to screen for and eradicate is therefore the local cancer, which is still limited to the gland itself. Once cancer has been detected, the patient is conditioned by the people around him who are convinced that prostate cancer is always fatal, although that is not so when the cancer is indolent and localised. Localised prostate cancer that is detected early on can be eradicated by less invasive, and therefore less damaging, methods than radical prostatectomy. Radical prostatectomy is highly aggressive, and often results in impotence and incontinence.
So what is needed is a compromise between the pressure brought to bear on the doctor by his patient, and pressure on the authorities to provide screening. “If we were to carry out a minimum screening programme with the younger population in mind, with a PSA threshold of 2.5 ng/mL, we could detect most advanced cancers”, claims Roland Muntz. Unfortunately, like any screening test, the PSA test is not perfect, and its specificity is debatable, because even at a level of 4 ng/mL, no tumour would be detected by a biopsy in 75% of patients. However, if the raw PSA data were accompanied by other parameters, such as the free PSA, the PSA density, the PSA velocity and a lower cut-off (2.2 ng/mL), both the specificity and the sensitivity of the test would definitely be improved. It is therefore reasonable to suggest that this type of screening programme could save many lives, particularly since there has been a spectacular fall in the mortality rate in all the countries that have a screening policy. It would seem to explain the drop in mortality due to prostate cancer of 25% in the USA, 50% in Austria, and 67% in Quebec.
We should also note in passing that both doctors and their patients still have considerable reservations about digital rectal examinations. “This examination has a specificity level of only 23%, and by the time a nodule is palpated it is often too late”, Muntz points out. To sum up, if we had an organised screening programme consisting of "one PSA test per year reimbursed by national health”, combined with specific tests to distinguish between indolent and aggressive cancer, “we would save 5,000 people a year”, suggests Muntz.

Avoiding excessive treatment

Excessive treatment can be avoided by differentiating between indolent and aggressive forms of prostate cancers. However “the main problem is that our doctors do not distinguish between two very different forms of cancer: indolent and aggressive,” explains Roland Muntz. As a result, the more aggressive treatment of radical prostatectomy is recommended, leading to incontinence and impotence in a large number of cases when it is not justified.
Although an aggressive tumour is life-threatening for a young man, indolent prostate cancer will not kill the patient. “This means that in this context, we need to opt for milder types of treatment that are less aggressive, such as radiation therapy or brachytherapy, Ablathermy, or possibly intermittent hormone therapy – androgen deprivation”, suggests Muntz. In this way we could avoid producing numerous cases of incontinence and impotence as a result of treating indolent cancers with radical prostatectomy.
“The problem today is that since we do not bother to distinguish between these two types of cancer – indolent and aggressive – if we carry out routine screening we will inevitably find prostate cancers, and doctors will make men impotent and incontinent by recommending the aggressive treatment of prostatectomy”, denounces Muntz, who goes on to say, “We are willing to accept over 10,000 deaths a year in France as a result of prostate cancer, but we are not willing to accept 100,000 cases of impotence and incontinence”. The key must therefore lie in distinguishing between indolent and aggressive cancers, in order to diagnose correctly and treat accordingly.

The New Paradigm: a cost-effective approach!

“By saving the lives of 5,000 men a year and increasing their life expectancy by 30 years, we would inject nearly 5 billion euros into the economy”, explains Muntz, based on the Murphy study [Kevin Murphy and Robert Topel, Univ. Chicago, Graduate School of Business, J. Politic. Econ. 2006]. In terms of the national health budget, the PSA screening test would cost 15 euros per year per person, and we could eliminate the prostatectomies that are currently performed as an over-treatment in the case of indolent cancer (one half of cases).
“The French Ablatherm® method, which is both non-invasive and effective, fits in perfectly with the strategy of our new paradigm”, says Muntz, who also points out that it can be used to salvage cases in which radiation therapy has been unsuccessful.

The ANAMACaP campaign

In order to eliminate the invasive treatment of indolent cancer, alternatives such as “Ablatherm, brachytherapy and androgen deprivation could be used”, claims Muntz, who also advocates active monitoring, even if he doesn’t think that “it corresponds to our mentality since we are scared stiff of cancer, even when it is indolent”. A detailed analysis of the tumour is based on specific data, such as the total PSA, the total PSA/free PSA ratio, the density and velocity of PSA, the PAP, the DRE, the volume of the prostate, the Gleason score and the results obtained using imaging techniques.

An indolent cancer is defined as having:
• a PSA score of less than 12
• a PSA-score doubling time of more than 3 years
• and a Gleason score of less than 6.

All the parameters of prostate cancer can be used effectively by algorithms and nomograms to specify the risks involved and help to choose the most effective treatment.

Contact
ANAMACaP Association Nationale des Malades du Cancer de la Prostate
17 bis Avenue Poincaré, 57400 SARREBOURG - France
Phone: 00 33 3 87 03 05 34 Fax. : 00 33 3 87 03 31 60
E-mail: info@anamacap.fr

For further information: www.anamacap.fr