Prostate Cancer

Prostate cancer may be diagnosed due to symptoms, or as a result of regular tests and check-ups.

Anyone with suspected prostate cancer should have three specific tests.

• Prostate-specific antigen (PSA) measurement:
  • Normally, only a tiny proportion of PSA is absorbed into the bloodstream. However, in men with prostate cancer, PSA leaks into nearby blood vessels.
  • A healthy PSA reading is usually less than 4ng/ml.
  • In men over 70, 6.5ng/ml is acceptable.
  • High PSA may also indicate benign prostatic hyperplasia (BPH). Comparing the ratio of 'free' (meaning not bound to a protein) to 'total' PSA is one way to tell the difference.

• Digital rectal examination (DRE):
  • The most useful clinical assessment. The doctor checks the consistency and size of your prostate through the rectum wall by inserting a finger into your anus.

• Trans-rectal ultrasound (TRUS) and biopsy:
  If a PSA test or DRE raises concern, your doctor may recommend a TRUS and biopsy.
  • TRUS uses an ultrasound probe in the rectum to create a visual image of the area.
  • Biopsies are taken using a needle, under local anaesthetic. It normally does not cause too much discomfort and there is no need for any hospital stay.
  • There can be some blood in the urine afterwards but this usually settles without any problems.

A pathologist will study the biopsy results. If cancer is present, it is given a “Gleason Score”. This is a number that describes the cancer's aggressiveness, ranging from 1 to 10, with 1 being the least aggressive.

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Patients with prostate cancer have access to several treatment options, and some promising new therapies. The right treatment depends on the exact type and aggressiveness of the cancer. A urologist will discuss your options before making a decision.

What are the options for localised prostate cancer?

Watchful waiting

This option is appropriate for:

• Small and less aggressive cancers.
• Older men (over 70 years old).
• Men with health issues, such as angina or chronic obstructed pulmonary disease.

Careful follow-up with regular DRE and PSA monitoring is essential. However, the patient needs to be offered counselling and active treatment if the cancer progresses.

Radical prostatectomy:

• Removes the whole of the prostate, greatly reducing the risk of recurrence.
• Requires general anaesthetic and involves an incision in the lower abdomen. Laparoscopic (or 'keyhole'), or robotic surgery reduces the risk of bleeding and shortens the hospital stay.
• A catheter will be left in place for 2 weeks while the urethra and bladder heal.
• Every man will be infertile afterwards and erectile dysfunction can be a problem.
• Stress incontinence is seen in a few men (2-3%), but it improves over time with physiotherapy or medication.

External beam radiotherapy (EBRT)

• Suits patients with medical conditions that make surgery high-risk.
• Treatment takes place over 6 weeks as an outpatient.
• A beam of radiation destroys the cancer cells in the prostate and lymph nodes.
• Side effects are minimal, but inflammation of the rectum, rectal bleeding and blood in the urine can occur. There is also a small risk of incontinence (1-3%).
• EBRT can offer a 15-year overall survival. However, if recurrence occurs then the cancer cannot usually be treated with surgery.

Brachytherapy

• Involves deploying radioactive 'seeds' directly into the prostate via 15 to 20 needles.
• Most suitable for men with smaller, lower-risk cancers and for those who have small or medium-sized prostates.
• The field of radiation is calculated to avoid damage to the urethra and the rectum.
• A catheter is normally left in place for 12 hours after the operation.
• Main problem is swelling of the prostate, which can cause worsening of lower urinary tract symptoms for some time. Therefore this procedure should be used with caution in patients with existing bladder outflow obstruction.
• Outcomes are comparable to those of radical prostatectomy and EBRT.

• Relatively rare procedure involving 8 to 10 needles inserted into the prostate via the perineum, under general anaesthesia.
• Liquid nitrogen is then circulated along the needles to create an 'ice-ball'. The urethra is protected by running warm water, via a catheter, into the bladder.
• There have been reports of significant complications with cryotherapy, including pain, urinary retention and erectile dysfunction.
• There is also the risk of the creation of a passage between the urethra and the rectum, which could necessitate an operation to correct it.
• Survival rates similar to those of radical prostatectomies have been reported, but there have been no long-term trials to compare cryotherapy with established treatments yet.

What are the options for locally advanced prostate cancer?

With locally advanced prostate cancer, the cancerous cells have spread to the seminal vesicles or the bladder, but not to the lymph nodes or bones. The PSA is normally more than 10ng/ml. In this case, surgery is often avoided, and radiotherapy and hormone therapy are preferred.

Treatment of locally advanced disease is unlikely to cure the cancer. The aims are to slow progression of the cancer and to improve quality of life.

External beam radiotherapy (EBRT)

• As above.

Hormonal therapy (or androgen ablation)

• Often used on its own in older men with pre-existing colorectal disease. Can be used in combination with EBRT.
• Medications block testosterone production, a hormone linked to prostate cancer growth.
• Up to 80% of men with prostate cancer respond to treatment.
• The main side effects are a reduction in sex drive and impotence, which is reversible when treatment is stopped. Treatment can also cause hot flushes.
• Reduces the size of the cancer and slows progression, but does not offer a cure.
• Side-effects of anti-androgen tablets include breast enlargement and soreness.

What are the options for metastatic prostate cancer?

Metastatic prostate cancer is where the cancer has spread to other parts of the body.

The PSA level will often be highly elevated and scans will show how the cancer has spread. Lymph nodes may also be enlarged.

This form of prostate cancer has the worst outlook: about 70% of men with metastatic cancer will die within 5 years. Fortunately, there are options that can delay the progression for several years.

Orchidectomy

• The surgical removal of both testicles to stop testosterone production.
• It is a permanent, irreversible procedure and patients will be infertile afterwards.
• Prosthetic testes can be inserted for a more cosmetic appearance.
• The main side effects are hot flushes, loss of libido and impotence.
• About 80% of men will respond to this treatment and disease progression will be slowed for around 18 months.

LHRH analogues

• Commonly given as a 3-monthly injection into the abdomen, these agents act by blocking the release of hormones that stimulate the production of testosterone.
• The main side effects are a reduction in sex drive and impotence, which is reversible when treatment is stopped; they can also cause hot flushes.
• About 80% of men will respond to this treatment and its benefits last around 18 to 36 months.

LHRH analogues and anti-androgens in combination

• Completely blocks testosterone production.
• Unclear whether this significantly delays disease progression or overall survival. The side effects include impotence, hot flushes and stomach upsets.
• Probably best suited to younger, relatively fit men with advanced prostate cancer.

What happens if the PSA starts to rise?

All men with prostate cancer have regular PSA checks. After radical prostatectomy the PSA should remain at zero if all of the cancer has been removed. With locally advanced and metastatic disease treated with hormones, the PSA should initially fall to very low levels. However, the cancers eventually become insensitive to hormone therapy and the PSA begins to rise.

This PSA rise often brings clinical symptoms, especially bone pain. Quite often a bone scan will need to be repeated to see whether there has been any spread of the cancer. If the PSA does rise there are other therapeutic options, but none of them will offer a cure. Options include:

• Modifying existing hormonal therapy
• Chemotherapy
• Oestrogens (a female hormone believed to damage prostate cancer cells)
• Biphosphates
• Palliative radiotherapy

Need more information?

If you're worried about prostate cancer symptoms and treatment, speak to your GP.

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