Prostate Cancer

How common is prostate cancer?

  • Prostate cancer is the most common solid organ tumour affecting Australian males
  • It is the second commonest cause of cancer death
  • Life time risk prostate cancer: 1/6 (approx. 17%)

What are the risks for developing prostate cancer?

  • Family history of prostate cancer is by far and away the strongest risk factor for developing prostate cancer. The risk increases with: the closeness of the relative (e.g. highest with father or brother), the younger the age at diagnosis and the number of relatives affected.
  • Numerous other potential risk factors are discussed in the literature, however the evidence for these in general are relatively weak.

What is the prostate?

  • The prostate is a small chestnut sized gland within the male pelvis.  It sits beneath the bladder and rests on the pelvic floor muscles. It is part of the male reproductive tract and normally contributes fluid to the ejaculate

How is Prostate Cancer detected?

  • PSA elevation:
    • Most Prostate Cancers these days are detected due to an elevated PSA blood test (see below for details on PSA).  Most men will not have symptoms attributable to their prostate cancer.
  • Urinary symptoms.
    • slow flow, dribble, blood in the urine, frequency, urgency. However, most of these symptoms may simply be due to a benign (non cancerous) enlargement of the prostate (BPH).
  • Abnormal rectal examination findings
    • Some prostate cancers will be palpable on rectal examination of the prostate, so a DRE (digital rectal examination) should always be used in conjunction with a PSA test
  • Metastatic symptoms:
    • A minority of men will have symptoms due to spread of prostate cancer beyond the prostate. These may include: bony pain, loss of weight, neurological symptoms (leg weakness, loss of bladder and/or bowel function)

What is a PSA blood test?

  • PSA (Prostate Specific Antigen) is an enzyme secreted by normal prostate cells. It is present in low levels in the blood of all men
  • It is used as a tumor marker to aid in the early detection of prostate cancer. However, although it is specifically produced by the prostate, it can be elevated by other conditions other than Prostate Cancer. These include: urinary tract infections, BPH (benign enlargement of the prostate), prostate infections (prostatitis), urological procedures on the prostate/urethra, urinary retention

What is a normal PSA level?

  • There is no absolute normal level of PSA. However, the higher the value of the PSA, the greater the likelihood of harboring Prostate Cancer. Some aggressive types of Prostate Cancer may not produce PSA and so may have surprisingly low levels of PSA in the blood.
  • The acceptable ranges of PSA increase with age. The below are guides for age specific normal ranges.
    • Age 40 – 49: normal PSA <2.5
    • Age 50 – 59: normal PSA <3.5
    • Age 60 – 69: normal PSA <4.5
    • Age 70 – 79: normal PSA <6.5

How is Prostate Cancer diagnosed?

  • A prostate biopsy is the main way in which Prostate Cancer is diagnosed
  • The 2 types of prostate biopsies are:
    • Trans Rectal Ultrasound Guided (TRUS) Biopsy
    • Trans Perineal Guided (TP) Biopsy
    • For details of both TP & TRUS biopsy techniques including pros & cons see Urological Procedures explained
  • Both techniques will be performed under sedation or a general anaesthetic
  • An ultrasound probe is inserted in the rectum to take images of the prostate and measurements of size.
  • Multiple (12-20+) biopsies are taken with a small needle gun device. The biopsies are the size of a small match stick.
  • The biopsies will be sent to a Pathologist to check under  microscope for the presence of prostate cancer.

If prostate cancer is detected, what other tests may be needed?

  • For intermediate and high risk prostate cancer, staging scan including a: Bone scan, CT scan and sometimes a prostate MRI may be ordered.
  • These X-rays are to exclude any spread of prostate cancer beyond the prostate (metastasis)
  • The MRI scan can also be useful for providing information as to wether the nerves involved in erection, around the prostate can be spared during surgery if this treatment option is chosen

What are the treatment option for Prostate Cancer?

  • There are numerous options for treatment including surgery, radiotherapy, active surveillance and hormonal therapy.
  • The treatment option appropriate will be influenced by:
    • Prostate Cancer factors such as:
      • Gleason grade
      • Volume of cancer detected
      • PSA level
      • Staging scans/ presence of metastasis
    • Patient factors including:
      • Age
      • Estimated life expectancy
      • Co-morbid diseases
      • Quality of life factors: continence, erectile function

What are the treatment options for localised prostate cancer (non metastatic)?

  • Radical Prostatectomy (surgical removal of the entire prostate):
    • For details see Urological Procedures explained
      • Open
      • Laparoscopic (key hole)
      • Robotic Assisted (robotic assisted key hole)
  • Radical Radiotherapy:
    • External beam radiotherapy
    • Seed (Low dose Rate) brachytherapy
      • An option for low risk localised prostate cancer
    • HDR (High dose rate) brachytherapy
  • Active Surveillance:
    • A potential option for well selected patients with low volume, low risk prostate cancer
    • Generally men with small volume Gleason 6 prostate cancer
    • Aims to avoid potential overtreatment of low risk prostate cancer where the benefit of treatment may be outweighed by the potential side effects (incontinence & impotence)
    • Involves close monitoring with regular prostate examinations, PSA tests and repeat prostate biopsies
    • Before commencing Active Surveillance, you will have a repeat biopsy taking more cores to ensure that a higher grade or greater volume cancer has not been missed
  • Watchful waiting:
    • Is a process of monitoring prostate cancer in older men often with many co-morbidities who may not benefit from surgery or radiotherapy due to their life expectancy.
    • Involves monitoring of PSA, urinary symptoms and x-rays looking for metastasis
    • Hormonal therapy (ADT – androgen deprivation therapy) in the form of tablets and injections may be used to control and slow the growth of the prostate cancer if metastasis are found or the PSA is rapidly rising