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
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