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
- Transrectal Ultrasound-Guided Biopsy (TRUS)
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:
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- 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:
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-
- Bilateral orchidectomy is the gold standard hormonal treatment
- LHRH agonists cause chemical castration (e.g. goserelin)
- Androgen receptor blockers (e.g. bicalutamide)
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- 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