Risk Prostate cancer is important because of the total number of men nationally and worldwide that are affected. Prostate cancer affects 40 000 men in the UK every year. It is estimated that 250 000 men in the UK live with prostate cancer but sadly 10 000 of them will die of the disease each year. It is most common in older men with the majority of newly diagnosed men in their 70s to 80s. It is rare for men to have prostate cancer under the age of 50.
There are strong familial links in prostate cancer with men being two and a half times more likely to get prostate cancer if their brother has prostate cancer. Black Caribbean or black African men have three times greater risk that white men.
Symptoms The common symptoms of prostatic enlargement are reduced urine flow, increased number of day and night voids, urgency, hesitancy at the start and a persistent dribble towards the end of urine flow. However, these symptoms merely indicate an increase in prostate size and not of the nature of this enlargement and are therefore a poor indicator for the presence of cancer.
PSA - the prostate blood test. Prostate cancer is more specifically assessed with a digital rectal examination (DRE) and a blood test called prostate specific antigen or PSA. This is specific to prostate problems but not to prostate cancer. Frustratingly the PSA cannot prove that a man does or does not have prostate cancer. It is therefore best thought of as a test to help identify those patients at higher risk of having prostate cancer. Overall, the higher the PSA then the higher the risk.
There is no prostate cancer screening programme in the UK but all men are entitled to a PSA blood test from their GP on request. Men of good health should be encouraged to have their PSA checked in their 50s as they have the most to gain from early detection.
Diagnosis Men with an abnormal DRE or a raised PSA are offered a transrectal ultrasound guided prostate biopsy taking pieces from both sides of the prostate and inspecting the pieces for prostate cancer under a microscope. During the biopsy an ultrasound probe is inserted into the rectum recording the size and appearance of the prostate. Local anaesthetic is injected around the prostate making it more comfortable. A biopsy needle is then placed, under ultrasound guidance, into the prostate taking several pieces. The pathologist assesses the cell appearance, aggressiveness (Gleason grade) and disease volume.
Once cancer is confirmed CT, MRI or bone scans may be necessary. These look for the local extent of the disease, any lymph node enlargement and distant bony spread. Armed with this information the patient and surgeon can opt for the best individualized treatment. There are several choices including surgery, active surveillance, radiotherapy, brachytherapy, HIFU and hormonal manipulation. This choice at first seems very encouraging. However many patients find choice confusing and the decision making difficult.
Management Once prostate cancer is diagnosed on prostate biopsy and the appropriate scans performed, a discussion about treatment options is needed. This is a difficult conversation, mainly because there are several options available. At first this sounds very encouraging, but often puts the emphasis of decision making onto the patients. The options depend on the grade or aggressiveness of the disease and on the stage or extent of the disease. In concept, localized disease can be cured with treatments to the prostate itself and spread disease is not curative but it can be controlled.
Treatment choices are influenced by side effects, the most important of which are decreased urinary continence and erectile dysfunction. Therefore, when choosing a treatment we are governed by the patients’ disease, symptoms, lifestyle and aspirations.
Localized prostate cancer
Active Surveillance Cancer confined to the prostate has many treatment options. The first is active surveillance (AS). This is offered to men with the less aggressive disease, who either have other medical conditions or want to avoid the complications of aggressive treatments. In these cases we accept the indolent slow growing natural history of early non-aggressive disease. These cancers may not shorten life or affect health over the next 15 to 20 years. However it is not ignoring the disease and men on AS are monitored with regular Prostate Specific Antigen (PSA) blood tests and are encouraged to have a repeat biopsy after 18 months to look for any increase in the grade, stage or volume of the disease. If these are observed then possible curative options are offered.
Surgery Radical prostatectomy involves removing the whole prostate gland and stitching the bladder to the urethra. This may be performed as open, laparoscopic (key hole) or robot assisted laparoscopic surgery. The two laparoscopic methods are the commonest and although technically difficult come with the advantage of a faster recovery and arguably better outcomes.
Radiotherapy This may be given as external beam radiotherapy (EBRT) for 5 days a week for approximately 7 weeks or as brachytherapy, involving radioactive seeds being injected into the prostate under general anaesthetic.
HIFU High intensity focused ultra sound treatment of the prostate involves a probe inserted into the rectum with cell death caused by thermal damage. This technique is still in its infancy and should be performed within trial conditions.
Advanced disease A widespread disease is better treated with a far reaching treatment. Therefore hormonal manipulation is used in spread prostate cancer. This stops the production of testosterone, the male hormone, and so stops the growth of a male gland, the prostate. These treatments are most commonly provided using 3 monthly injections or a variety of tablets to shrink the prostate cancer where ever it is.
Radiotherapy may also be used in this setting for the treatment of areas of specific painful bony spread.
Chemotherapy This is not curative but may give a survival advantage in patients with spread disease which is no longer being controlled by hormone manipulation. However, because of some of the side effects, it is best used in fitter men. The diagnosis and treatment of prostate cancer is a very involved process for the patient and his doctor. It is important that the patient is well supported through this difficult time and much of the success of this relies on the rapport between patient and doctor so that the best informed decision is made.