Prostate Cancer

Facts

• Most common cancer in men
• Risk increases with age
• Other risk factors include family history, being black, being tall and use of anabolic steroids
• Presentation is similar to BPH but can also include haematuria, erectile dysfunction and general signs of cancer and metastasis (e.g. weight loss, fatigue and bone pain)
• Currently there is no screening program for prostate cancer
• One of the more benign cancers and can be very slow growing (“people die with prostate cancer rather than of prostate cancer”)
• Staged using the TNM system

PSA

• Traditionally done prior to DRE to avoid stimulating release of PSA
• Not very sensitive or specific (positive and negative results are unreliable)
• Most useful in monitoring the progression of the disease and success of treatment

Prostate Examination (During Digital Rectal Examination)

• A benign prostate feels smooth, symmetrical and slightly soft with a maintained central sulcus
• A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular with loss of the central sulcus

Prostate Biopsy

• The definitive method for diagnosing prostate cancer
• Still not particularly sensitive because cancers may be located in areas not biopsied
• Multiple needle biopsies are taken to minimize risk of missing the cancer
• Options:
  • Transrectal Ultrasound-Guided Biopsy (TRUS)
    • Ultrasound inserted into rectum and a needle biopsy taken through rectal wall into prostate under US guidance
    • Usually around 10 biopsys are taken to try and pick up the cancer
  • Transperineal
    • This method allow more biopsys to be taken (around 35)
    • This has a higher sensitivity than TRUS
    • It takes longer than TRUS and reuiqres general anaesthetic

Gleason Grading System

• Specific to prostate cancer
• Helps to determine what treatment is most appropriate
• The higher the grade the worse the prognosis
• Various histological criteria are used to decide on the grade. A very simplistic summary:

• • Grade 1: Well differentiated cancer.
  • Grade 2: Moderately differentiated cancer.
  • Grade 3: Moderately differentiated cancer.
  • Grade 4: Poorly differentiated cancer.
  • Grade 5: Anaplastic (poorly differentiated) cancer.

Management Options

• Watchful waiting in early prostate cancer
• Radiotherapy directed at the prostate
• Brachytherapy
  • Radioactive seeds implanted into the prostate
  • Deliver continuous, targeted radiotherapy to the prostate
• Hormonal treatment (antiandrogen therapy)
  • Prostate tissue grows in response to androgens like testosterone
  • Hormonal therapy aims to block androgens and slow or stop prostate cancer growth
  • Side effects include hot flushes, sexual dysfunction, gynaecomastia, fatigue and osteoporosis
  • Options:

• • 1. Bilateral orchidectomy is the gold standard hormonal treatment
    2. LHRH agonists cause chemical castration (e.g. goserelin)
    3. Androgen receptor blockers (e.g. bicalutamide)

• Surgery in the form of total prostatectomy

Complications of Radical Treatment with Prostatectomy and Radiotherapy

• Erectile dysfunction
• Urinary incontinence
• Radiation induced enteropathy (giving gastrointestinal symptoms like PR bleeding, pain, incontinence etc)
• Urethral strictures