Prostate Cancer

  • Is the most commonly diagnosed cancer in men
  • Not all diagnosed cancers need to be treated
    • Many are managed with active surveillance or with watchful waiting (explained below)
  • Has attracted a lot of media attention, in particular, PSA testing
    • Your surgeon will be able to help you navigate through this and give you an understanding of its details
Prostate Cancer
Risk Factors
  • Age
  • Family History
    • Prostate cancer
    • Breast or ovarian cancer
How is prostate cancer diagnosed?

History

  • Family history is most important here

Examination

  • Digital Rectal Exam (DRE)
    • This is where the prostate gland is felt by your Surgeon
    • Involves the gentle placement of a gloved and lubricated finger into the back passage for a few seconds
    • Checking for the size of the prostate and any hard lumps to suggest a cancer

PSA testing

  • Its interpretation can be complex and is not a ‘perfect’ test
  • Is definitely very helpful in the diagnosis of prostate cancer and forms a very important and necessary ‘piece of the puzzle’ when it comes to the investigation (and management) of prostate cancer
  • Your Urologist can help you understand its role in your specific situation

MRI scan

  • Is also another important ‘piece of the puzzle’
  • Is also an imperfect test but is a very useful and an important test in both planning your biopsy and, if required, treatment of the prostate cancer

Biopsy

  • Is done under an anaesthetic (usually general, sometimes local) as a day procedure
  • Involves the obtaining of small samples of prostate tissue using a needle that is passed through the skin of the perineum under ultrasound guidance
  • The samples of prostate tissue will be examined under the microscope by a pathologist who will report if there is a prostate cancer present or not
What Type of Cancer is it?

This information is largely obtained from the biopsy. The majority (>90%) of prostate cancer will be an adenocarcinoma (this is the type of cancer).

The pathologist will give an ISUP grade (range: 1-5). This is a measure of the cancers potential to spread to other sites in the body (become metastatic) or spread beyond the prostate into adjacent structures. The ISUP grading system has replaced the old grading system for prostate cancer (gleason score): they are nevertheless closely related. In fact, the ISUP grade is based on the gleason score (see table below for how the two systems are related). ISUP 1 prostate cancer is least concerning while ISUP 5 prostate cancer has the greatest potential to metastasise.

ISUP Grade Gleason Score

1

3+3=6

2

3+4=7

3

4+3=7

4

4+4=8

5

9 or 10

Stage of Cancer: How Far Has it Gone?

Just like all other cancers, the answer to the question is based on the international TNM classification system. The key questions for prostate cancer include:

  • Has the cancer spread into the organs adjacent to the prostate? Eg into the bladder, rectum or pelvic wall?
  • Has the cancer spread to the lymph nodes?
  • Has the cancer spread to other organs of the body?

This information will largely be obtained from the PSA level, ISUP grade and scans that are done prior to your treatment. Not everyone diagnosed with a prostate cancer will need staging scans (CT, bone scan or PET scan) prior to treatment

Does My Cancer Need To Be Treated?

This question is particularly relevant to prostate cancer. It may even seem like a strange question to ask when it comes to a cancer! Sometimes the answer to this question is straightforward whereas other times it can be quite complex.

The reason this question is asked is because some prostate cancers are very mild in nature and in fact would not be expected to cause you any issues if left alone! Hence, the decision around whether to treat or not to treat can be a complex one and will depend on many factors including:

  • age
  • medical and surgical history
  • rectal examination, PSA (and its change with time) & MRI finding
  • biopsy result (ISUP grade and volume of cancer on biopsy)
  • staging scans

The treatment plan for the prostate cancer will therefore be quite individualised and tailored to not only the factors here stated but also to your own personal preference. The decision around treatment will probably be made after multiple consultations where the advantages and disadvantages of each approach will be discussed.

What are my Treatment Options?

The treatment for prostate cancer can be complex. It may include only one treatment modality or may include a combination of treatments over time. Prostate cancer treatment is delivered in a multidisciplinary team setting and while your Urologist will usually be the first to be involved, you may require input from a Radiation Oncologist and/or a Medical Oncologist. Below is a summary of the individual approaches to the treatment of prostate cancer, but as stated, it should be remembered that you may require a combination of these approaches over time. Your Surgeon will help guide you through this complexity.

  • Active Surveillance
    • Appropriate for men who have a low grade prostate cancer that may never cause long-term harm
    • Aim of this approach: to avoid the side effects of the treatment of prostate cancer while not missing the window of opportunity for a cancer cure if definitive treatment is eventually required
    • Involves regular and close surveillance of the prostate cancer using PSA checks, repeat MRI scans and prostate biopsies
  • Active treatment
    • Surgery: Radical Prostatectomy
      • Removal of the prostate gland (with the seminal vesicles) and the cancer it contains
      • Usually done robotically with a one to two night hospital stay
    • Radiotherapy
      • The delivery of high dose x-rays to the prostate
      • Usually done as a daily treatment over the space of a month together with hormone therapy (see below)
      • Other options of delivery include brachytherapy (low dose and high dose)
    • Systemic treatment – usually for men with prostate cancer that has spread to the lymph nodes or other organs of the body
      • Androgen Deprivation Therapy (ADT)
        • Sometimes referred to as hormone treatment
        • Stops the bodies production of testosterone or sometimes blocks the effects of testosterone
        • Causes a male ‘menopause’ and while this slows the growth of the prostate cancer it is also the cause of its side effects (hot flushes, reduced libido, erectile dysfunction, reduced muscle mass etc)
      • Chemotherapy
        • Delivered by a Medical Oncologist and has been shown to improve long term survival with metastatic prostate cancer
      • Watchful waiting
        • This is the approach used in men who have a known prostate cancer but in whom treatment is likely to cause more harm than good
        • The aim of this approach is symptom control and not cancer cure
        • The time when treatment (usually in the form of hormone treatment) is instituted is if (or when) the cancer causes symptoms or begins to spread to other parts of the body.
        • There are other scenarios in which this approach will be preferred and your Urologist will be able to discuss the details of this with you if it is required for yourself.
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