Prostate Problems

Prostate Cancer

Prostate cancer is the most common malignancy effecting men. This is recognised as the most important medical problem facing the male population in Europe. The incidence of prostate cancer is 214 per 1,000 men outnumbering lung and bowel cancer. Prostate cancer affects elderly men more often than young men therefore this is a major health concern in developed countries with a great proportion of older men.

What are the risk factors for prostate cancer?

There are well established risk factors for prostate cancer:

Increasing age: As men get older they are at higher risk of developing prostate cancer.

Ethnic origin: Afro-Caribbean men are more likely to develop prostate cancer and also a more aggressive nature of prostate cancer then Caucasian men. There is a lower instance of prostate cancer in men from Southeast Asia. However the migration of Southeast Asian men into western countries does increase the risk of prostate cancer.

Heredity: There is a heredity link to prostate cancer. If one first line relative has prostate cancer the risk is at least double. If two or more first line relatives are affected the risk is increased by 5 -11 fold.

Can patients consider screening for prostate cancer?

There are two major clinical trials which address the question of screening and the benefit of early detection of prostate cancer. This is PLC Trial and European Randomised Study of Screening for prostate cancer ERSPC. Both trials have shown benefit of reduction of the patients who develop a spread of disease and also some improvement in the survival. There are other confirming factors in these trials which might be considered as influencing these results. Moreover long term follow up is necessary to estimate the accuracy of the benefit.

The main questions still remain unanswered which are:

At what age the screening should start

What are the best methods of screening.

The screening methods used in these trails are checking of blood tests (called PSA) and also finger examination of the prostate. There is no mass implementation of population screening for prostate cancer because of the risk of over diagnosis and over treatment, as well as the emotional and psychological influence the diagnosis might have on men particularly as a large proportion of the prostate cancers diagnosed where not of any clinical significance. However prostate cancer screening can be offered for high risk individuals particularly those with a strong family history of prostate cancer and also those men who request voluntary screening. Men who request voluntary screening for prostate cancer and checking of the PSA, should understand the risk of unnecessary treatment and also complications related to the prostate biopsy which may be recommended if the blood results and prostate examination results are abnormal.

How does prostate cancer present?

The prostate cancer can present in a number of ways. It can present with urinary symptoms which are similar to symptoms of benign prostatic enlargement. These symptoms are due to enlargement of the prostate caused by the prostate cancer or coexisting benign enlargement as prostate cancer is diagnosed in elderly men, as men get older many do develop benign prostatic enlargement as well. A large proportion of men do present silently and they are diagnosed by voluntary screening or a small proportion of patients can present with symptoms due to the spread of prostate cancer to bones.

How is prostate cancer diagnosed?

The prostate cancer is diagnosed by finger examination of the prostate which is done through the back passage. The finger examination by a clinician is likely to identify nodules which are harder in consistency when compared with the rest of the prostate. Blood test (prostrate specific antigen – PSA) the measurement of this PSA level has revolutionised the diagnosis of prostate cancer over the last 30 years. PSA is a substance produced by the prostate and its level is very high in semen and the level can increase in the blood in some conditions affecting the prostate. Those conditions include prostate cancer, benign prostatic enlargement, prostatitis and instrumentation of the prostate by any operations. In the context of prostate cancer the PSA level is helpful to diagnosis prostate cancer. The PSA levels are adjusted to the age of men with different levels of cut off. No PSA level is a safe level though as the PSA level goes up the risk of diagnosing prostate cancer goes up. Just because the PSA level is in the normal range of the age related level does not mean a person will not have prostate cancer, because prostate can be diagnosed at PSA levels as low as 0 – 0.5.

When there is abnormality in the finger examination of the prostate or the PSA level is above the age related normal level, your doctor or the urologist may recommend a prostate biopsy. A prostate biopsy is done through an ultrasound scan probe which is inserted through the back passage (anus). 10 - 12 tissue samples are taken from the prostate at different places to cover the whole of the prostate.

Is prostate biopsy able to fully guarantee to diagnose or rule out prostate cancer?
Though 10 – 12 samples are taken from the prostate mapping the whole of the prostate, absence of cancer in these tissue samples does not mean that there is no cancer in the prostate. A small focus of cancer in the prostate may be missed in between the sampled parts of the prostate. However if these 10 – 12 tissue samples are negative one can be fairly assured that there is no significant sized prostate cancer. However the patients will be monitored for any further increase in the PSA or change in the consistency of the prostate by finger examination in due course, if there are any ongoing concerns about the possible presence of prostate cancer.
What are the risks of complications of prostate biopsy?

Following the prostate biopsy done through the back passage, patients can develop the following complications:

  • Presence of blood in the semen (haematospermia) can occur in about 1/3 of the patients who have prostate biopsy
  • 15% of patients can develop the presence of blood in the urine
  • 2-3% of patients can develop bleeding from the rectum
  • 1% of patients can develop prostatitis
  • 0.8% of patients can develop fever exceeding 38.5°C
  • 0.7% of patients can develop infection in the epdidimys and rectal bleeding with a need for surgical intervention
  • 0.2% of patients will develop urinary retention
  • 0.3% will develop other complications requiring hospitalisation

Therefore the prostate biopsy is not without serious and significant complications. The patient needs to think carefully and the clinicians will take all of this into account before offering this investigation with a full discussion to the patients about these risks.

What if my prostate biopsies are negative and I still have a high PSA?

If your prostate biopsies are negative (i.e.: there is no evidence of cancer) and your PSA blood is still abnormal you doctor may suggest to follow up with further blood tests on three to six monthly intervals. If there is any further significant rise in the PSA levels you urologist may recommend further biopsy.

What will happen once I am diagnosed with prostate cancer?

Once a person is diagnosed with prostate cancer further treatment options will depend on the type of cancer (aggressiveness of the cancer) and also extent of cancer spread within or outside of the prostate. The patient age, general levels of fitness and potential life expectancy will be taken into consideration in deciding about radical (aggressive) treatment options to cure the prostate cancer. For example if someone has a life expectancy of less than ten years due to other medical problems or advancing age clinicians may not be keen to offer more aggressive treatment options that have significant side effects and may potentially compromise the quality of life. Since prostate cancer is a slow growing cancer in a majority of the patients it is a difficult decision to make how aggressively one should aim for a curative treatment versus the potential risk of the cancer within the expected lifespan of the patient. If your doctor decides to offer a radical treatment option with your agreement then the options available are radical radiotherapy or radical prostatectomy which means the removal of the prostate.

If the prostate cancer is not aggressive (low risk variety) and if it is confined to the prostate and certain parameters are met in terms of the volume of cancer in the biopsy and also the PSA levels then your doctor may recommend a treatment method called Active Surveillance. In this method if the danger from the cancer is considered to be small, then you may be recommended to have this method of management which entails is serial monitoring of the cancer and intervene with radical curative treatment options if there is any evidence of further progress (spread or increase in the size of the cancer). This serial assessment is made by checking the PSA levels on regular intervals over a three to six months basis and repeating the prostate biopsy once every 18 – 24 months. If there is any change in the nature of the cancer from less aggressive to higher levels of aggressiveness or increase in the volume of cancer you would be recommended to have a radical curative treatment options. The advantage of this option is to avoid overtreatment with high risk treatments in patients with prostate cancer considered to be less risky to progress and cause problems.

Radical surgery (prostatectomy) is complete removal of the prostate and this can be achieved by various methods of operations. This can be done through keyhole surgery (laparoscopy) or open operation or robotic assisted surgery. The advantage of surgery is one can be sure that the whole prostate is removed and confirm if the cancer has been completely removed or not. Once the cancer is completely removed there is no need for further treatment unless there is evidence of microscopic spread of the cancer to other parts of the body. Of course the disadvantages are that this is a major operation and having to remain in hospital for 5 – 10 days. There is a risk of impotence in the order of about 70 -80% and incontinence in the order of about 10% to start with and coming down to 1% by the end of one year. Other complications associated with major surgery around the time of the operation is also possible which may include clotting of blood in the veins or lungs, chest infection, slightly increased risk of heart attack and stroke around the time of any major operations.

Radical radiotherapy involves treating the prostate cancer by application of radiation treatment by two possible methods. One is external beam radiotherapy, in this type of treatment the radiation is passed onto the prostatic area from outside and the treatment would be carried out by a clinician called an oncologist (radiation oncologist who would decide to give the appropriate dose of radiation over a period varying from 5 – 7 weeks for 5 days a week). This would be carried out as day visits to the hospital five days a week. The side effects include radiation sickness where patients can feel weak and unwell during the time of radiation treatment and the side effects due to injury to other organs near the prostate. This could present as irritation of the bladder and also irritation of the lower part of the bowel and at times resulting in the discharge of blood and mucus from the rectum. There are long term risks of developing impotence and incontinence with the radiation treatment as well. Another form of radiotherapy treatment called brachytherapy where radiation needles are implanted into the prostatic tissue which will emit radiation. If a patient has a large prostate which is already causing obstruction the oncologist may insist the full the treatment of the enlarged prostate and relieving the obstruction before considering either methods of radiotherapy.

For further information about treatment for prostate cancer please click the link: http://www.patient.co.uk/health/Cancer-of-the-Prostate.htm