It is a difficult and complex area and there are many popular misconceptions in the community. These are often driven by apparently contradictory positions taken by various bodies, especially about screening (PSA testing) and treatment.
What is Prostate Cancer?
The prostate is an organ which sits just below the bladder and in front of the rectum. It produces enzymes which are essential to the survival of sperm and therefore vital for reproduction. The urethra, which is the tube that carries urine from the bladder through the penis, traverses the prostate and is therefore prone to blockage from conditions that affect the prostate. Prostate Cancer is the most common Cancer affecting men. Approximately 20,000 men will be diagnosed with the cancer annually and over 3000 men will die of it each year. Prostate cancer can run strongly in families. Some families with a strong history of Prostate Cancer also have a strong family history of Breast Cancer in female members. Patients who have more than 3 first degree relatives with Prostate Cancer may have hereditary Prostate Cancer that may be related to certain genes (BRCA 1 and BRCA 2). Patients with such strong family histories may have 20 times higher risk than the general population of developing Prostate Cancer.
How do we identify people who may have Prostate Cancer?
Throughout the western world, there is an ongoing debate on whether to screen for Prostate Cancer and at what age and how. If screening is undertaken, it is recommended to start at 50 years of age. If there is a family history of prostate cancer we recommend that screening begins at 45. Recent studies would also indicate that a baseline PSA at the age of 40 may be an indicator of your long term risk of prostate Cancer, and therefore should be a guide as to how often a PSA should be checked. This can be discussed in more detail with your Urologist.
One of the difficulties in treating Prostate Cancer is that if we wait for symptoms to develop, the cancer is often incurable. Therefore, we try to make the diagnosis of the cancer before men have any symptoms. We can generally find the cancer 5- 10 years before it would cause any symptoms and therefore have a much better chance of cure.
Currently there are two techniques used to try and find an early Prostate Cancer. These are Prostate Specific Antigen measurement and Digital Rectal Examination.
Prostate Specific Antigen (PSA)
Prostate Specific Antigen (PSA) is a protein produced only by cells in the prostate. PSA is prostate specific and not cancer specific and therefore a can indicate a ‘problem’ in the prostate. A high PSA reading does not always mean cancer. The other very important tool for finding early Prostate Cancer is a digital rectal examination, which is done by your doctor or sometimes by your specialist. This allows him/her to feel for abnormality in the actual palpation of the prostate gland itself.
Digital examination of the prostate
The digital examination of the prostate may sometimes identify prostate cancers that maybe missed by PSA alone and is therefore a vital part of screening for Prostate Cancer. Prostate cells (either benign or malignant) can cause the PSA level to rise with any prostatic disease, with age and also with an enlargement of the prostate. In the absence of any other cause for an elevated or rising PSA, then prostate cancer needs exclusion.
How is Prostate Cancer diagnosed and what is Transperineal Biopsy?
If you are at risk of having early prostate cancer then we will discuss the situation and probably recommend that you have a Transperineal Biopsy of your prostate. This technique involves coming into Day surgery. Traditionally, Transrectal Ultrasound Guided Biopsy was used. This procedure has an increased risk of infection or septicaemia as biopsies are taken straight through the bowel wall. For this reason, we have moved away from the traditional method and are now offering a safer approach.
A Transperineal biopsy involves having a probe inserted into the rectum and a grid positioned between the scrotum and anus (perineum). Using the grid, very fine needles are passed through and a number of biopsies are taken (12-18). These are sent to a pathologist for examination. The biopsy can find out whether any of your prostate cells have become cancerous. Your doctor will contact you by phone to discuss the results with you when they become available. This can take up to 3 days. This procedure requires a general anaesthetic and you will only be required to attend as a day case.
After your procedure
- Infection – less cases are reported using this form of biopsy
- Blood in the urine (this is normal and needs to be monitored. Increase and maintain an adequate fluid intake). This can last up to 2 weeks sometimes longer.
- Blood in the semen. This is normal and can persist for up to 4 weeks.
- Difficulty passing urine. This is normal, providing you don’t have a urinary tract infection, and will resolve. In some patients, medications can be given to alleviate this.
- Erectile dysfunction (this occurs in less than 3% of patients and does resolve).
A Transperineal biopsy samples a small amount of prostatic tissue from various areas of the prostate and therefore occasionally miss a tumour. It is often the case then should a biopsy not reveal any cancer we would recommend to continue PSA checks and Digital Rectal Examinations.
How do we decide which cancers to treat?
The treatment of early prostate cancer depends on the type and extent of the cancer itself and of the patient himself taken as a whole.
Although PSA alone is not a good tool for diagnosing prostate cancer when the cancer has been diagnosed it becomes very useful. The higher the PSA level at the diagnosis the more likely the cancer is to be extensive i.e. it can help predict the local and distant extent of the disease. The rate of rise of PSA is also a very useful predictor of long term outcome.
Rectal examination findings
Unfortunately no-one has replaced the educated finger in determining the local extent of the cancer.
The Gleason score
This is a graduated scale that places the microscopic appearance or pattern of the cancer in reliably reproducible fashion. Although nearly all prostate cancer is of the same basic type, the degree of de-differentiation i.e. how far the cancer cell has changed from normal tissue from which it arose, determines the way the cancer is likely to behave in the future. The pathologist looks at this under the microscope and gives the two commonest patterns a score out of 5 and adds them together to give a score out of 10. The higher the score the more aggressive the cancer is likely to behave. A Gleason score of 6 out of 10 is called moderately differentiated carcinoma of the prostate and that is probably the most common cancer that is seen (it is very rare nowadays to have any Gleason scores less than 6 out of 10 reported). A Gleason score 7 out of 10 is called a moderately to poorly differentiated carcinoma of the prostate and is more likely to behave in an aggressive fashion when compared to Gleason score 6 and so on.
A new grading scheme for prostate cancer is being introduced by the World Health Organisation. The Epstein Grade will probably replace the Gleeson score. Gleason 6 will become grade 1, Gleason 10 will be Grade five and grade in between.
For some patients, we recommend further scans, including Nuclear Bone Scans, CT Scans and occasionally PET or MRI scans to see if there is any evidence of spread of the tumour. Magnetic Resonance Imaging (MRI) scanning is used to help diagnose and to stage prostate cancer. Newer, high powered scanners can help to pinpoint areas in the prostate that may contain high risk cancers. They can also reassure us that we have not missed a significant cancer on biopsy. For example, a man with a high PSA and a negative biopsy or a man with early lowish disease on his biopsy, who may be a candidate for active surveillance. PSMA PET scan: This is a very new scan that looks at antigens on prostate cell membranes. It is very good at picking up disease that has spread outside the prostate e.g. to bone or lymph nodes. We are using the PSMA PET scan more frequently, usually after definitive treatment, to check for spread.
What is watchful waiting?
A large percentage of early prostate cancer has a long and natural life i.e. they may outlive the patient. The decision to watch the cancer depends on the PSA level, the Gleason score, and the local extent of the cancer and of course the individual’s life expectancy if he didn’t have prostate cancer. For example, a 69 year old man with a small amount of Gleason 6 prostate cancer and PSA level under 10 may well be more likely to die of something else other than prostate cancer.
Watching does not mean just forgetting – it means regular monitoring with PSA blood test.
What are the treatment options for prostate cancer?
Multiple techniques have been described for the treatment of localized prostate cancer, however, there are only two types of treatment that are recognized to be effective incurring early prostate cancer. They are radiation therapy and surgery. Other treatments come and go and usually involve an energy source trying to kill the cancer and the normal prostate. There are a number of these treatments around at the moment but none of them are recognized as being effective and are not available in teaching hospitals except in the clinical trial situation under strict academic control.
At North Eastern Urology (NEU), we offer all surgical options for prostate cancer including open surgery, pure laparoscopic surgery or robotically assisted laparoscopic surgery. Please see our section on surgical options for prostate cancer for further details.
What are the surgical options and what are the differences?
Surgery involves the complete removal of the prostate, and the adjacent seminal vesicles. Prostate cancer is usually multifocal, which means that there are often multiple areas of cancer within the prostate even if they have not been picked up on the Transperineal Biopsy. It is therefore necessary to remove the whole prostate in cases of prostate cancer. In some instances, at the time of surgery, a lymph node dissection is also performed i.e. take out the lymph nodes draining the lymph fluid from the prostate. Prostate cancer may spread to these sites, however, this procedure is not without its risks and therefore not routinely performed on everyone. Surgery is suitable for fit patients with localized prostate cancer. People with high grade cancer or more extensive cancer may be recommended to have a node dissection done at the same time to assess the extent of the spread and possibly improve the outcome.
Surgery can be done by a number of techniques but the two techniques that we use are open surgery or laparoscopic surgery. Open surgery involves an incision in the abdomen below the umbilicus. Laparoscopy is “key- hole surgery” which involves using telescopic instruments to operate on the prostate and this can be done with or without the help of a robot.
There is a great debate as to which technique offers a superior outcome, however, one thing is generally agreed upon by all- best long term results are obtained by surgeons who do many of these operations using the technique they are most comfortable with. At NEU, we are fortunate to have high volume surgeons in both the open and laparoscopic techniques.
There is no difference in the cancer outcomes between any of the surgical techniques. Key-hole surgery usually allows a shorter stay in the hospital and a quicker return to physical work. There are also several studies to indicate that there is significantly less bleeding using the key-hole techniques. In a recent study comparing all the techniques, open surgery was shown to decrease the likelihood of patient requiring subsequent surgery or incontinence surgery however proponents of keyhole surgery feel that these figures may be skewed by the fact that they include the learning curve for keyhole techniques. Open surgery usually allows for a return to physical activities such as tennis and golf at about 6 weeks and keyhole surgery about 3-4 weeks.
What are some of the potential complications of surgery?
Early complications relate to intra-operative events and anaesthetic complications. The most serious intra-operative complications is damaging the rectum at the time of surgery. This is a very rare event in our practice. There is certainly more bleeding in open surgical approaches than the laparoscopic procedures, but serious bleeding is very rare, so that we rarely need to transfuse our open surgery patients. Other rare complications include damage to the ureters. In key-hole techniques, there may be issues associated with excessive gas absorption as carbon dioxide is used to create a working space. Patients are closely monitored by our anesthetists regarding this and are treated accordingly.
Then there are the complications from the anaesthetic and of any surgery such as DVT (which is a clot in the leg), heart attacks, chest infections etc. Again, in carefully selected patients, these are rare complications.
Late complications are the major concerns with radical prostatectomy, and the two that people worry about are incontinence of urine and impotence.
Incontinence of urine occurs to some extent in the hands of all surgeons. It can vary between just wearing a pad “incase”, through to being terrifyingly wet and requiring reconstructive surgery. The open surgery results suggest a pad rate of approximately 1 in 20 patients i.e. 1 in 20 patients that require a pad and about 1 in 200 risk of having serious incontinence that requires a sling or other reconstructive surgery. Impotence is a major problem no matter how the surgery is done. There is no treatment that doesn’t have some impact on the nerves that cause an erection as they run right between the rectum and the prostate. In open surgical series we have an impotence rate of approximately 50% for all patients. Some of the published series by robotic surgeons suggest post-operative potency rates as high as 90% (Menon et al), however, more realistic studies and our own figures would indicate that these figures are similar to open surgical series. Regardless of technique, it often takes 18-24 months for spontaneous erectile function to return. The better quality of the erections a patient is having prior to the surgery, the more likely that they are to maintain spontaneous erections afterwards with appropriate nerve sparing surgery. Most of the men who are impotent can be returned to reasonable sexual function with the help of either oral or injectable treatments.
Bladder neck contracture is another possible complication which may occur sometime post operatively. This may occur in up to 5% of cases and may require surgical treatment. Patients may notice deterioration in their stream.
How Radiotherapy and Brachytherapy given and what is are the risks?
This can be delivered in two ways. The commonest is external beam radiation therapy. The second is Brachytherapy and involves implantation of radio-active seeds into the prostate. Both treatments aim to kill the cancer cells by delivering a very high dose of radiation to the prostate with a rapid drop off in radiation to the surrounding structures. The type of radiotherapy used depends on the local extent and grade of the tumor, but usually brachytherapy is the best for localized better differentiated cancers and external beam radiotherapy for the more high-grade end of the spectrum.
External beam radiotherapy is usually given as an out-patient over approximately 7-8 weeks. It involves attending the Radiotherapy center for a relatively short period every day of the week and the total number of treatments is usually more than 40. Just prior to treatment we usually place gold seeds around the prostate so that it can be more accurately localized during the therapy. This involves usually an anaesthetic very similar to the biopsy itself.
External beam radiation therapy has potential complications. Most people get through the treatment itself without too much trouble apart from tiredness, which usually takes a month to settle afterwards also some bowel upset, which again may take a few weeks to settle after treatment finishes. In some patients bowel upset never settles. Less often patients have bladder difficulties, rather similar to the bowel problems. The commonest complication is impotence, which usually does not occur immediately, but comes on over one or two years after radiotherapy. Another rare event is the development of a second cancer usually occurring in the pelvis as a result of the high dose radiation. These cancers usually occur 10 or more years down the track and is often a reason to avoid radiotherapy in younger patients. In some cases of more aggressive prostate cancer (higher PSA and higher gleason score), radiotherapy is given in combination with hormonal therapy. Hormonal therapy inhibits the effects of testosterone on cells and this has been shown to make the radiotherapy more effective in certain instances where the prostate cancer has progressed beyond the prostate to other parts of the body.
Brachytherapy can be given either with radio-active seeds permanently implanted into the prostate itself (low dose rate –LDR) or a temporary radioactive source placed into the prostate (High Dose Rate HDR). In this practice the only brachytherapy we use is the permanent seed implantation technique (“LDR”). This again involves two trips to the hospital- usually a planning ultrasound to accurately measure the size of the prostate and then a second trip to have the seeds implanted. Complications can also arise with brachytherapy. The early complication is difficulty voiding and that can vary from minor to significant and about 4% of men will have significant trouble voiding for 6 months or so after the implantation of the seeds. It is therefore usually the case that we avoid this type of treatment in men who are having difficulty with their passing of urine. Patients are started on some medications after seed implantation to help with the passing of urine. This is usually a short term measure. Late complications are similar to external beam radiation therapy but less common. The most common is narrowing of the urethra, which may require surgery to be repaired.
What is the risk of prostate cancer recurrence post-surgery?
The likelihood of cancer recurrence after surgery is dependent on factors such as stage of the tumour, the grade of tumour and whether or not the margins are involved with the tumour. Patients are followed with PSA and in some instances extra treatment with the radiotherapy or hormonal therapy may be considered.
What are Multi-disciplinary meetings and do you have them?
The management strategies for patients with prostate cancer are not always straightforward and may sometimes require input from medical disciplines outside urology. At NEU, we have fortnightly Multi- disciplinary meetings in our rooms and have specialist medical oncologists, radiation oncologists and other urologists present. Also, through our association with Austin Health, our Urologists also attend their weekly Multidisciplinary meetings. This ensures that all our patients have access to all the latest therapies and clinical trials being run as well as the collective opinion of a team of specialists dedicated to the management of prostate cancer.