Prostate Cancer

Prostate cancer is still one of the most commonly diagnosed cancers in men, with more men dying from it that women from breast cancer.  Diagnosing early prostate cancer remains challenging although recent advances including MRI and fusion transperineal biopsies are now available in addition to routine PSA testing.

There also have been significant advances in treatments for prostate cancer including newer chemotherapy agents, advances in radiotherapy techniques as well as the availability of robotic surgery in Newcastle.

Elevated PSA & Prostate Cancer

Prostate cancer is difficult to diagnose at an early stage when it is more likely to be treatable as there are no warning signs beforehand.  Often the local doctor will organise a yearly PSA blood test after the age of 50.  If it is elevated, usually a referral to a urologist is made for a discussion regarding further testing.

The PSA measures the risk of prostate cancer, but unfortunately does not diagnose it, as there are other reasons that the PSA may rise. If the PSA is elevated, it means that the risk of having prostate cancer is higher than the general population.  However, a biopsy of the prostate is required to confirm whether prostate cancer is present.

Assessment

A uroflow and residual is usually booked at the same time of the initial appointment.  This measures how quickly the urine flows and whether the bladder is emptying completely. A digital rectal examination will be performed to feel for any obvious abnormality of the prostate.

A biopsy of the prostate is offered through the perineum (skin behind the scrotum) or the rectum under the guidance of an ultrasound probe in the rectum.  It is normal to have blood in the urine for around a fortnight and blood in the ejaculate for up to 3 months.  For the transrectal biopsies, there is also a risk of bleeding from the bowel and a small risk of a severe urine infection after the procedure.

Prior to the biopsy, there is also the option of an MRI.  This is the only imaging modality that looks at the internal architecture of the prostate in detail to outline any suspicious areas.  It will help so that a targeted biopsy of the suspicious area can be performed.

Prostate Cancer Treatment Options

The treatment options for prostate cancer are very variable, depending on individual circumstances. Prostate cancer is generally a very slow growing cancer and curative treatment with either surgery or radiotherapy is only offered if there is an anticipated good life expectancy. The various treatment options are listed below and discussed in broad terms only. Obviously, the relevant options for your particular case will be outlined with your surgeon with the opportunity to ask specific questions.

Active Surveillance

This is suitable for low-grade, low-volume disease. This type of cancer has a very low chance of progression so watching it very closely is a valid option, particularly as the side effects of curative treatment may be worse than the disease being treated. Generally, this involves close monitoring of the PSA and repeat biopsies every 1-2 years.  There is a wide window of opportunity to offer curative treatment if the disease becomes more aggressive over the period of observation.

Surgery (Radical Prostatectomy)

A radical prostatectomy is the operation to remove the entire prostate and attached seminal vesicles. The bladder is then joined to the pelvic floor over a catheter. The associated lymph nodes may also be removed in high risk disease.

This can be performed as a traditional open procedure or with a robotic assisted laparoscopic approach. There is no clear scientifically proven benefit in oncological or functional outcomes of either approach after 3 months, although anecdotally there is less blood loss and pain with the robotic approach.

Patient information sheet on open and robotic radical prostatectomy

The main long-term risks associated with the operation is stress urinary incontinence because the pelvic floor is the sphincter mechanism that holds urine in, as well as erectile dysfunction because the penis lies beneath the pelvic floor with autonomic nerves passing through the pelvic floor to supply the penis. The major determinants of recovery are pre-operative function and age.

Pelvic floor exercises are important to learn prior to the operation and are an imperative part of rehabilitation afterwards. It is also important to stay healthy and keep slim.

A viagra-like agent will usually be started after the operation. While it is unusual to obtain an erection in the first few months after the operation, it is an important part of regaining erections later as these medications increase the blood flow to the penis.

PSA monitoring is performed routinely after the operation. Ideally the PSA is undetectable after a radical prostatectomy but ensuring it does not rise after a low reading is also important.

Radiotherapy

Prostate cancer is very sensitive to radiotherapy. It has equivalent cancer cure rates and long-term functional outcomes to surgery. Radiotherapy still carries the risk of stress incontinence and erectile dysfunction in the same way that surgery does due to the location of the prostate although the side effect profile is slightly different as this is a different treatment modality. Usually external radiotherapy beams are focussed onto the prostate 5 days a week for 4-8 weeks.

There have been recent improvements to radiotherapy including insertion of gold seeds (fiducial markers) which outline the location of the prostate prior to each fraction of radiotherapy administered as the prostate is a mobile pelvic organ. A hydrogel (SpaceOAR) may be inserted at the same time which separates the rectum from the prostate, thereby limiting the toxicity to the nearby rectum. The water-based gel dissolves in around 6 months after the radiotherapy course has been completed.

At almost all times, available clinical trials will be offered if appropriate and the surgeons at Lake Macquarie Urology are active in recruiting patients and work closely with their radiotherapy counterparts.

Radiotherapy is available publicly through the Calvary Mater Hospital or privately through Genesis, co-located with Lake Macquarie Private Hospital.

Watchful waiting & androgen deprivation therapy

In cases of advancing age and other more urgent medical problems, watchful waiting may be advised. This is particularly the case if life expectancy is less than 10 years. In this situation, the cancer is observed only. If the PSA rises and there are symptoms of disease progression, medical castration is offered with a regular injection usually administered by a GP. This injection blocks the production of testosterone which feeds the cancer.

Chemotherapy

There are a lot of new chemotherapy agents available for prostate cancer that were not present 5-10 years ago. Even in advanced disease, the prognosis may still be reasonable. Currently, many of the newer chemotherapy agents are available on a clinical trial with an appropriate referral to a medical oncologist.