Prostate Cancer

Prostate cancer is described as ‘early’, ‘locally advanced’ or ‘late’. It starts with changes in the cells of the prostate.

The cells form a lump which may eventually be felt in a physical examination.

Prostate cancer does not usually cause any symptoms until the cancer has grown large enough to put pressure on the tube that carries urine from the bladder out of the penis (urethra).

Symptoms of prostate cancer can include:

  • needing to pee more frequently, often during the night
  • needing to rush to the toilet
  • difficulty in starting to pee (hesitancy)
  • straining or taking a long time while peeing
  • weak flow
  • feeling that your bladder has not emptied fully
  • blood in urine or blood in semen

These symptoms do not always mean you have prostate cancer. Many men’s prostates get larger as they get older because of a non-cancerous condition called prostate enlargement.

Signs that the cancer may have spread include bone and back pain, a loss of appetite, pain in the testicles and unexplained weight loss.

Unfortunately, it is only when it has advanced that most men will get symptoms which lead them to see a doctor. So about half of the men diagnosed with prostate cancer will already have it in an advanced or late stage. However, even when prostate cancer has reached this stage it may still be possible to slow down its growth.

Signs that the cancer may have spread include bone and back pain, a loss of appetite, pain in the testicles and unexplained weight loss.

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Diagnostic Tests

Additional tests

Biopsies can be taken to determine whether the lump is cancerous. These are examined by a pathologist who will report the grade of cancer present in the cells.

Prostate biopsies are taken under ultrasound guidance and sent to a histology laboratory for examination under a microscope. These are taken via the rectum and local anaesthetic is used. The tissue is examined for evidence of cancer, infection and/or inflammation.

Prostate biopsies are taken through the perineum using a template to guide the position of the samples taken. This can be done under general or local anaesthetic. The samples are then sent to a histology laboratory for examination under a microscope. The tissue is examined for evidence of cancer or inflammation. The benefits of transperoneal biopsies over TRUS & biopsy is a reduced rate of missing cancer, reduced rate of infection and bleeding tends to be minimal. This test is always done in conjunction with MRI imaging.

The results of all of the above tests take between 3 days and 2 weeks to be available and will be explained to you once they are available.

If prostate cancer is diagnosed a bone scan is sometimes needed to check for metastases (spread of cancer to the bones) but this will be discussed with you by your urologist.

Prostate Specific Antigen (PSA) test 
A small sample of blood is taken from a vein in your arm and sent to the laboratory to measure the level of PSA. PSA is a protein made in the prostate that leaks into your bloodstream. The PSA level rises as men get older.
There are various reasons for a raised PSA level. A high PSA does not necessarily mean cancer is present nor does a lower level always mean it is absent. It is generally felt that the PSA test is not accurate enough to be used to screen every man.

You may also have a blood test to check your kidney function as some prostate problems may affect the way the kidneys work. A blood test to check your white cell count may be used if infection is suspected.

You will be asked to lie on your left side on the examination couch with your knees drawn up towards your chin. The doctor or nurse will then use a lubricated and gloved finger to feel your prostate via the rectum (back passage). The prostate can be felt through the rectal wall and will be examined for approximate size and consistency. A DRE should not be painful but may be uncomfortable and embarrassing.
There is some controversy over whether a DRE will affect the PSA reading and therefore your blood tests may be taken prior to the examination.

For this test you will be asked to fill your bladder and then pass urine into a special machine which measures the strength of your flow. If your flow is slow it may mean that your prostate is pressing on the urethra and causing an obstruction.
A bladder ultrasound is used following the flow test to check whether you have emptied your bladder completely.

A TRUS is an ultrasound scan of the prostate performed via the rectum. The prostate can be seen clearly through the rectal wall. TRUS images are useful in that they show the shape and consistency of the prostate. Measurements can be taken to calculate the size of the prostate.
You will be asked to lie on a couch on your left side with your knees drawn up towards your chin. The ultrasound probe is lubricated prior to insertion to prevent discomfort. The results of the ultrasound can be explained to you immediately following the test.

If any of the above tests suggest you may be at risk of having prostate cancer the following tests may also be performed.

Prostate biopsies are taken under ultrasound guidance and sent to a histology laboratory for examination under a microscope.

Non-Invasive Tests

The PCA3 assay is a genetic diagnostic test and can be used in conjunction with traditional tests to diagnose prostate cancer. PCA3 is highly prostate cancer specific. It uses urine to measure the PCA3 and PSA messenger RNA and these are then used to calculate the PCA3 score. The PCA3 score is not affected by the prostate volume. It is however not a definitive test and should be reviewed in conjunction with other tests. Although not frequently used, the BUA can offer this test if requested.

Prostate biopsies are taken through the perineum using a template to guide the position of the samples taken. This can be done under general or local anaesthetic. The samples are then sent to a histology laboratory for examination under a microscope. The tissue is examined for evidence of cancer or inflammation. The benefits of transperoneal biopsies over TRUS & biopsy is a reduced rate of missing cancer, reduced rate of infection and bleeding tends to be minimal. This test is always done in conjunction with MRI imaging.

The results of all of the above tests take between 3 days and 2 weeks to be available and will be explained to you once they are available.

If prostate cancer is diagnosed a bone scan is sometimes needed to check for metastases (spread of cancer to the bones) but this will be discussed with you by your urologist.

A TRUS is an ultrasound scan of the prostate performed via the rectum. The prostate can be seen clearly through the rectal wall. TRUS images are useful in that they show the shape and consistency of the prostate. Measurements can be taken to calculate the size of the prostate.
You will be asked to lie on a couch on your left side with your knees drawn up towards your chin. The ultrasound probe is lubricated prior to insertion to prevent discomfort. The results of the ultrasound can be explained to you immediately following the test.

If any of the above tests suggest you may be at risk of having prostate cancer the following tests may also be performed.

For this test you will be asked to fill your bladder and then pass urine into a special machine which measures the strength of your flow. If your flow is slow it may mean that your prostate is pressing on the urethra and causing an obstruction.
A bladder ultrasound is used following the flow test to check whether you have emptied your bladder completely.

Treatment Options for Early Prostate Cancer

You may be offered active surveillance if your prostate cancer is localised, deemed to be of a low risk and it is felt that you are unlikely to benefit from treatment. Generally the prostate cancer should be of a low grade (Gleason score 6 or less, sometimes expressed as Gleason score of 3+3) and your PSA stable and under 10 micrograms per liter. Active surveillance has been shown to be a safe strategy over a 10 year period but has not been formally tested against the standard therapies of radical surgery and radical radiotherapy.

Active surveillance is based on the notion that most men, with time, will get prostate cancer but few men will die of it (3%). It is assumed, again quite logically, that men who are destined to die will undergo progression of their disease that can be detected and more importantly can be treated at a time before the disease has spread beyond the prostate.

It therefore involves a high level of precision at the time of diagnosis. This usually involves MRI scans of the prostate and often prostate mapping so that we can have a 95% certainty that the disease we think we are treating is indeed the disease that exists within the prostate. Once the baseline is established active surveillance is what it says. At regular intervals the PSA is checked. MRI can be done every 12 – 24 months. Many programmes include a re-biopsy at 24 months. This probably less important if mapping has been done at the outset.

PSA density may also be used to determine your suitability for active surveillance. This is calculated by dividing your PSA level by the volume of your prostate. Generally men with larger prostates have a higher PSA level. You will usually need a PSA density of less than 0.15 to be eligible for active surveillance.

Many men on active surveillance choose to optimise their weight, increase their exercise and sometimes change their diet. There is some evidence that some or all of these lifestyle changes do result in slower progression of prostate cancer. We can help with all these aspects of care.

Advantages:

  • As there is no physical treatment, there are no physical side-effects
  • It will not interfere as much with your everyday life as physical treatment

Disadvantages:

  • Some men may become anxious or worry about the cancer changing
  • You will need to have more biopsies
  • You will need to be seen fairly regularly

Radical prostatectomy is the removal of the whole prostate. This can be done in one of three ways:

  • Robotic (da Vinci) Prostatectomy
  • Laparoscopic Prostatectomy
  • Open Prostatectomy

Radical Prostatectomy is generally recommended for men with a life expectancy of 10 years or more and who are fit enough to cope with a major operation. Your decision may depend on how the side-effects of each treatment may affect your quality of life.
Unfortunately in 3 out of 10 men having a radical prostatectomy the cancer will already have spread to surrounding tissue, making the operation ineffective. In these men the PSA will rise at some time after radical prostatectomy. You will then need to undergo further treatment, usually by radiotherapy. Your PSA should fall to a very low level following the operation. As long as it does not rise, it is generally considered that you are free of the cancer.

Robotic Radical prostatectomy is performed using the da Vinci robot. The whole prostate can be removed through a number of small incisions, meaning that healing time is quicker, post-operative pain is reduced and there is less risk of infection. The view of the surgical field by means of the 3D stereoscopic display means that the surgeon has a much clearer view of the nerves and blood vessels surrounding the prostate which may help to minimize blood loss and reduce the risk of damaging the nerves responsible for continence and erectile function.

Laparoscopic Prostatectomy is performed through a number of small incisions using special instruments and a laparoscope to visualize the prostate and surrounding tissue. Laparoscopic surgery offers the benefits of reduced bleeding, less soft tissue damage and shorter recovery period as compared to open prostatectomy.
However, laparoscopic surgery should only be done by a specially trained and skilled surgeon to get the best results.

Open Prostatectomy is the traditional form of removing the prostate through one midline incision.

Side Effects of Radical Prostatectomy

The side effects for all three forms of treatment are similar; however the percentage of risk is much lower in robotic prostatectomy as compared to open prostatectomy.

  • Some risk of long term urinary incontinence
  • Some difficulty in achieving erections, but this is usually treatable
  • Most men will be infertile due to the absence of ejaculatory fluid
  • Risk of urethral stricture (scar tissue)
  • Small risk of infection following surgery
  • Small risk of bleeding requiring a blood transfusion

HIFU stands for High Intensity Focused Ultrasound which is a new technique for treating prostate cancer. Ultrasound has been used for medical imaging (such as ante-natal scans) for decades, but recently the technology has been developed so that it can be used for treatment as well as diagnosis.

In HIFU, an ultrasound beam is focused onto a small area of diseased prostate, in much the same way that you can focus the energy of the sun with a magnifying glass; the diseased area is then heated to 80-90°C and destroyed. The heat is carefully targeted to avoid damaging the surrounding tissue. In particular, the nerves that control erectile function are spared.

Either the entire prostate gland can be treated or only the areas that have cancer (hemi-ablation or focal therapy). It is possible to perform HIFU for recurrent prostate cancer following other forms of treatment, for example radiotherapy and brachytherapy.

It is possible to give Radical Radiotherapy in three ways:

External beam radiation – high-energy x-ray beams are aimed at the prostate from outside the body.
Conformal Radiotherapy – is a modification of external beam radiotherapy but is a more targeted approach. It tries to minimise the radiation to the surrounding areas.

Brachytherapy – is the use of radioactive implants which are placed in the prostate. There are two types of brachytherapy that can be used for different stages of prostate cancer.

Who are these Treatments Suitable For?

As with surgery, radical radiotherapy is recommended for those men with a life expectancy of 10 years or more. It is a good option for men whose cancer is at the stage where it can be treated radically but who are not fit enough to have an operation. It also provides a radical option for men who do not want to undergo surgery.
Radiotherapy carries its own risks and side-effects which you must consider before making this choice.

Some doctors like to administer a hormone drug before starting radical radiotherapy

Cryotherapy (or cryo-ablation) is the controlled freezing of the prostate gland in order to destroy cancerous cells. It works by rapidly freezing and thawing cells. This causes damage to the cell and makes it difficult for the cell to survive.

Who are the Most Suitable Candidates for Cryotherapy?
Cryotherapy may be offered to patients who are seeking minimally invasive treatment for prostate cancer instead of surgery or those who prefer not to have radiotherapy. The cancer needs to be confined to the prostate. Your urologist will have a list of criteria for choosing suitable patients. Cryotherapy is one of the few options if you have developed a recurrence following radiotherapy.
In general men with smaller prostates are better candidates but those with larger prostates can undergo hormone therapy to decrease the size of the prostate prior to cryotherapy.

Read about an exciting trial that we do in Bristol to improve the outcomes of prostate surgery. We are one of 4 centres involved in the UK.

You may also have a blood test to check your kidney function as some prostate problems may affect the way the kidneys work