Prostate cancer

The prostate is a gland which lies just below the bladder, in front of the rectum, and wraps around the urethra. Its function is to produce semen. 

Prostate cancer begins when prostate cancer cells start to divide and grow in an uncontrolled fashion first within the prostate and if left untreated, potentially spreading to other organs and parts of the body. The chances of getting prostate cancer increase with age, and although it’s a very common cancer, it’s treatable, and has high cure rates, especially when detected early.

Diagnosis

Many men who are found to have prostate cancer don’t present with any symptoms, but rather have a screening blood test, called a prostate specific antigen (PSA) test, which is higher than normal for age, or is rising faster than expected. 

A screening PSA is usually done on men over 45 years or sometimes younger in men at higher risk for prostate cancer. Men at higher risk may have a brother or father with prostate cancer or carry a BRCA 1 or BRCA 2 gene. Black men also have a higher risk of developing prostate cancer and screening for them can start at 40 years. PSA screening is usually combined with a digital rectal examination (DRE) to feel the prostate for areas of abnormality. 

When symptoms do occur, they are most commonly: more frequent visits to pass urine and/or a weak urine flow. A raised PSA, slow urine flow and frequency passing urine can be caused by other conditions and don’t conclusively indicate prostate cancer. The only way to definitively diagnose it is to take a piece of tissue from the gland, a process called a biopsy. 

Once the urologist has done a biopsy, the tissue is sent to the lab for analysis to see if it contains prostate cancer cells. If a pathologist sees cancer cells in the biopsy specimen, a cancer is diagnosed. They will also give the cancer cells a score (Gleason score) which is a value representing the aggressiveness or grade of the tumour. This score is one of the determining factors used by the oncologist to decide on what treatment is best.  >> pg28

Staging

If a cancer is detected, the next step will be for the oncologist to determine how large the cancer is and if it has spread. This is known as the stage and involves an MRI scan, bone scan or PSMA PET-CT scan. 

An MRI uses magnetic resonance to create pictures of the prostate and surrounding areas, so the doctor can see how big the cancer is, and if it has spread into any surrounding tissue.

A PSMA PET-CT scan uses a special radio-labelled tracer to show if there is any spread of prostate cancer to organs. Your oncologist will use the staging investigations together with the PSA reading and Gleason score to determine what is the most appropriate treatment. 

Treatment

Luckily there are many treatment options, and you and your oncologist will work out together which treatment suits you. Not all options are appropriate for all grades and stages and sometimes a combination of treatments are needed. Some treatments include:

Active surveillance: The cancer isn’t treated immediately, but you’ll undergo regular routine tests to re-check the stage and grade of the tumour. If there is an increase in these, treatment may then be initiated. This option does involve regular scanning and biopsies.

Surgery: An operation to remove the prostate, and sometimes the pelvic lymph nodes.

Radiation: This treatment can be done in two ways. External beam radiotherapy involves aiming high-energy X-rays at the cancer in the prostate and other areas containing cancer cells or is at high risk of containing cancer cells. It’s delivered on a machine called a linear accelerator. 

The second way is brachytherapy, and the most common way that this is done is to implant tiny radioactive seeds into the prostate in theatre. These sources then emit radiation within the prostate, killing the cancer cells. 

Hormone therapy: This treatment either involves having an injection done every few months, or tablets which are taken daily. It will reduce the testosterone levels in the body. Since testosterone causes prostate cancer to grow, this will result in the arrest of tumour growth. This could be given for a few months or indefinitely. Occasionally the same effect can be achieved by removing the testes. 

Chemotherapy: These are medications which are given which can directly kill the cancer cells. 

Survivorship

Follow-up is usually done by the urologist and/or oncologist. After treatment is complete in the case of radiation, brachytherapy or surgery, the response of the cancer is monitored usually by serial PSA readings and regular physical examinations. Occasionally repeat scans or biopsies may be needed. These can also be done while hormone therapy or chemotherapy is ongoing. Side effects of treatment are managed by these doctors.

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