Prostate cancer is the commonest male cancer in UK, approximately 41,000 new cases per year are diagnosed. Men have a 1 in 6 lifetime risk of developing prostate cancer. It accounts to around 10000 death. However, early diagnosis and treatment could result in cure as early treatment of clinically significant prostate cancer has a very high cure rate.
There are three well-established risk factors for prostate cancer:
- increasing age: the older men get, the more likely a cancer might develop in the prostate.
- Ethnic origin: Afro-Caribbean men are at higher risk than Caucasians and men from the Far East have a lower risk for cancer.
- Family history (genetic/heredity): risk is increased if a father, brother or paternal uncle has prostate cancer.
However, there are some other factors which may impact risk of developing prostate cancer, which are not well understood.
Symptoms of prostate cancer
There are usually no symptoms associated with prostate cancer that is confined to the prostate, especially when the disease first starts. It can be present for a long time before a man can be aware of it.
Some of the symptoms associated with prostate cancer (specially as it advances are :
- frequency day and night (nocturia)
- weak urine flow that stops and starts
- discomfort whilst passing urine
- inability to urinate (\”urinary retention\”)
- inability to get an erection (impotence)
- blood in the urine (haematuria)
- In advance stage: persistent pain in the back, thighs and pelvis as well as weight loss.
It is important to note that these symptoms usually occur due to non-cancerous conditions of prostate such as urinary infection, benign prostate enlargement. Therefore, although these symptoms need investigation, one should not be alarmed about diagnosis of prostate cancer with these symptoms.
Diagnostic tests used for detection of prostate cancer
Although the only sure way of diagnose prostate cancer is biopsy, there are other tests that can performed first, to avoid unnecessary invasive biopsies. These include:
- PSA (total, Free/Total ratio)
- Examination of prostate.
- PSA (total, F/total ratio)
- PSA density (PSA/prostate volume)
- PCA3 score
- Gadolinium enhance MRI
Prostate biopsies are the only way to be certain of prostate cancer diagnosis. Although this is an invasive test, with the MRI guided targeted transperineal biopsies, the side effects of this procedure has reduced and its accuracy has increased.
Treatment of prostate cancer
Prostate cancer generally grows slowly and some form of this disease do not need immediate treatment. However, the highest chance of being cured from prostate cancer is when it is confined to the prostate.
There are numerous treatment options available for prostate cancer which can be confusing. However, not all of these options will be suitable for an individual patient. Furthermore, some of the new treatments are experimental and do not have long term data. It is worth emphasising that depending on individual’s situation (both in general and more specifically with regards to his cancer), some of the available options may not be advisable.
Some of the available options are:
- active monitoring
- radical prostatectomy (best done robotically)
- radical radiotherapy (external beam)
- Experimental techniques (cryotherapy, high intensity focused ultrasound (HIFU))
- hormone therapy
Not all patients with prostate cancer need immediate treatment. This is because some types of prostate cancer have a very small chance of progressing to become life threatening in the short to medium and sometimes long-term. Therefore, some patients with prostate cancer can be safely monitored. Some patients with low grade and low volume cancer are most suitable for this form of treatment.
It is worth noting that active surveillance is not the same as “doing nothing”. The patients are on active surveillance are regularly monitored and at the first sign of disease progression.
Active monitoring involves regularly measuring the PSA and prostate examinations regularly. There are also regular MRI and repeat prostate biopsies to monitor the situation carefully.
Robotic radical prostatectomy
Robotic prostatectomy, which is now thought to be the gold standard for patients having surgery for prostate cancer, has revolutionised the surgical removal of the prostate as a treatment for cancer. Mr Khoubehi at London Urology Specialists, was one of the first surgeons to take up this technique in UK and has been doing the procedure since 2007. He is a high-volume surgeon which achieves results regarding all out parameters (negative margin, impotence and incontinence) comparable to the nest published series.
It is worth noting that the surgeon and not the robot performs the operation. The surgeon is seated at the operating theatre and controls the movements of the robot. By using the robot, surgeon is able to carry out precise and controlled movements using tiny robotic instruments. These instruments have a 360º range of movement and can be manipulated intricately because of the powerful 10x magnification and 3D view that the surgeon has at the console. They dissect the delicate structures, eliminating the tremor associated with traditional laparoscopy.
What does surgery involve:
The surgery involves removing the whole of the prostate and the seminal vesicles which are attached to the prostate. Depending on the nature of the cancer (its grade and stage), the pelvic lymph nodes are also sometimes removed.
Robotic radical prostatectomy is not only an excellent treatment for localised prostate cancer but it is also proving to be very good treatment for disease that has breached the prostate capsule (locally advanced), usually as part of multi-modality treatment.
Surgery carry certain advantages our other treatment option:
- Due to complete removal, the prostate can be examined fully giving a more accurate information about stage and grade of the disease, thus an accurate prediction can be made of the likely outcome.
- Post-surgery, within weeks the PSA level should fall to un-recordable levels, giving a degree of certainty about the effectiveness of treatment.
- As PSA should be undetectable following surgery, the follow-up is made easier with regular PSA tests. In unfortunate situations, when the disease recurs, this is picked up very early.
- With the robotic technique, the hospital stay is usually short (1-2 days).
- If the disease recurs, or as part of multi-modality treatment, other treatments such as radiotherapy can be given.
- By removing the prostate, urinary problems due to an enlarged prostate (slow flow etc) will usually also be relieved.
- Studies have suggested that surgery offers an excellent cure rate in long term and many urologists believe surgery is the best treatment option for prostate cancer in appropriate patients.
Radiotherapy can be used for treatment of prostate cancer by using high energy x-rays. The main methods used are: external beam radiotherapy (EBRT) and Brachytherapy (low dose). Recently, Cyberknife which is a new method of delivering radiotherapy has also been used for treating prostate cancer. Radiation can cause changes to prostate that may preclude surgery in future should the disease recur.
External bean radiotherapy
The prostate is treated with High-energy beams of X-rays are aimed from outside the body at the prostate gland and the immediate surrounding tissues. This is done while patient lies in the radiotherapy machine. The treatment takes place every day for a period of about 6 weeks. EBRT is usually accompanied is usually accompanied by hormonal treatment that block the effect of and/or production of male hormone testosterone.
EBRT is generally thought to be less suitable for younger, fit men who have organ confined disease. EBRT is usually given to patients who are less fit, older or have advanced disease.
Low-dose brachytherapy is an alternative way of delivering radiotherapy to the prostate. Radioactive seeds are systematically place permanently into the prostate gland under a general anaesthetic. The procedure is done either in one or two stage. Usually patients stay in hospital one night.
Brachytherapy is best used for patients with Gleason score less than 7 and low PSA. It is not used for large prostate or patients with severe urinary symptoms.