Prostate Cancer - Diagnosis and Management

Prostate cancer is the most common cancer found in men. It is estimated that the risk of a man being diagnosed with prostate cancer by his 85th birthday is 1 in 5.

Prostate cancer is the second leading cause of cancer death in men, yet it is highly curable if discovered while still confined to the prostate gland. Most prostate cancers grow slowly, usually remain confined within the prostate gland and cause no harm. This type may need minimal or no treatment other than close surveillance. Some prostate cancers, however, are aggressive and can spread quickly, early detection has a much better chance of successful treatment.

Symptoms of Prostate Cancer

Prostate cancer causes no signs or symptoms in its early stages. Symptoms may show once the cancer grows and spreads to other parts of the body. Advanced prostate cancer may lead to trouble voiding, weak or interrupted stream of urine, frequent urination at night, blood in the semen, erectile dysfunction or bony pain.

Prostate cancer incidence increases with age, majority of prostate cancers are diagnosed after the age of 65.

Men whose relatives have had prostate cancer are considered to be at high risk. Having a father or brother with the disease doubles the risk for prostate cancer.

Men with high PSA levels at a young age are at higher risk of developing and dying from prostate cancer. Men in the highest 10% of PSA concentrations at the age of 45-55 will contribute to approximately half of prostate cancer-related deaths occurring before the age of 70-75.

Diagnosis of Prostate Cancer

Prostate cancer screening involves performing a PSA (prostate specific antigen) blood test and a prostate examination by a doctor through the rectum. PSA testing combined with DRE helps identify prostate cancers at their earliest stages.

Whether to test healthy men with no symptoms for prostate cancer is controversial. Medical organizations don't agree on the issue of screening and whether it has significant benefits. Discuss your particular situation and the benefits and risks of screening with your doctor. Together, you can decide whether prostate cancer screening is right for you.

If an abnormality is detected on a DRE or PSA test, your doctor may recommend tests to determine whether you have prostate cancer. These tests may involve a MRI scan of the prostate or a biopsy of the prostate where a thin needle is inserted into the prostate gland to collect tissue for analysis.

When a biopsy confirms the presence of cancer, the pathologist examines a sample of your cancer to determine how much cancer cells differ from the healthy cells. A higher grade indicates a more aggressive cancer that is more likely to spread quickly. The most common scale used to evaluate the grade of prostate cancer cells is called a Gleason score. Scoring combines two numbers and can range from 6 (low risk cancer) to 10 (high risk cancer).

Treatment of Prostate Cancer

Many treatment options are available for prostate cancer. Prostate cancer treatment is tailored to the patient’s needs, taking into account the aggressiveness of cancer, the degree to which the cancer has spread and the general health of the patient.

Possible treatment options include:

Active surveillance

For men diagnosed with a small volume of low risk prostate cancer, treatment may not be necessary right away. Some men may never need treatment if the prostate cancer remains low grade. Instead, doctors may recommend close monitoring of the prostate cancer using regular PSA, MRI scans and sometimes biopsies to monitor progression of prostate cancer. If tests show your cancer is progressing, you may opt for curative prostate cancer treatment such as surgery or radiation.

Radiation therapy

Radiation therapy uses high-energy photons to destroy cancer cells.

This can be delivered from outside of the body (external beam radiotherapy), or using radioactive seeds placed into the prostate gland (brachytherapy).

External beam radiotherapy usually involves a 10-20 minutes session of treatment five days a week for 5-8 weeks. Your doctor may place gold markers within the prostate gland to improve the accuracy of radiotherapy targeting. Your doctor may also inject a special gel between the prostate and the rectum to protect the rectum from being affected by radiation.

Side effects of radiation therapy can include painful urination, frequent urination and urgent urination, as well as rectal symptoms, such as loose stools or pain when passing stools. Erectile dysfunction can also occur.

Hormone therapy

Prostate cancer cells require testosterone (male hormone) to grow. Without testosterone, cancer cells die or grow more slowly. Hormone therapy reduces the levels of testosterone in the body. This can be administered by injections administered every 3 months or permanent surgery to remove the testosterone producing cells in the testicles.

Hormone therapy is used in men with advanced prostate cancer to shrink the cancer and keep it in check. In men with early-stage prostate cancer, hormone therapy may be used before radiation therapy. This can make it more likely that radiation therapy will be successful.

Surgery to remove the prostate – radical prostatectomy

Surgery involves removing the prostate and seminal vesicles and then reconnecting the bladder to the water pipe (urethra). The surgeon may elect to preserve the nerves around the prostate gland in order to preserve erectile function in suitable patients with prostate cancer that is localised within the prostate gland. In patients with more aggressive prostate cancer, the nerves and surrounding tissues around the prostate gland are also removed to ensure complete removal of all cancer cells.

Robotic assisted laparoscopic radical prostatectomy

Two to three robotic arms are inserted into the lower abdomen through several small incisions. The surgeon controls the robotic arms from a console next to the patient. The robotic device allows a more precise and dextrous response to movement of the surgeon's hands. This technology allows reduced pain, less blood loss, less scarring and a quicker return to normal activity for the patient.

PSA Monitoring

Prostate-specific antigen (PSA) is a protein produced by cells of the prostate gland. The PSA test is a blood test that measures the level of PSA in the blood. The doctor takes a blood sample, and the amount of PSA is measured in a laboratory. Because PSA is produced by the body and can be used to detect disease, it is sometimes called a biological marker or a tumour marker.

Trans-rectal Ultrasound-guided biopsy with or without Fusion Biopsy

Ultrasound scans use sound waves that build a picture of the structures inside the body. To scan the prostate gland, a small probe is passed through the anal opening, which takes images of the prostate. This type of scan is used to measure the size and density of the gland.

Prostate Cancer Surveillance

Radical Prostatectomy

Open radical prostatectomy is a surgical procedure to treat prostate cancer and involves the removal of the whole prostate gland, seminal vesicles and the surrounding tissues through an incision in the lower abdomen. Surgery may increase life expectancy by at least 10 years.