Prostate Cancer

What is the prostate?

The prostate is a gland in men which sits between the bladder and the urethra (water pipe). It forms part of the male urinary and reproductive tracts. It is essential for normal fertility and produces some of the fluid that makes up semen.

Is cancer of the prostate common?

  • Prostate cancer is the most common solid organ tumour affecting Australian males
  • It is the second most common cause of cancer death
  • Approximately 1 in 6 (17%) Australian men will be diagnosed with prostate cancer but only 1 in 50 (2%) will die from prostate cancer.

What are the risk factors for prostate cancer?

  • Family history of prostate cancer is the biggest risk factor for developing prostate cancer. The risk increases if the family member is:
  • A first degree relative (e.g. highest with father or brother)
  • Younger at the age of diagnosis and if died from prostate cancer
  • One of a number of relatives affected
  • Age
  • Ethnicity/Race (Afro-Caribbean greater than Caucasian, greater than Asian)

There are a number of other possible risk factors, but based on the current research the evidence for these in general is relatively weak

What are the symptoms of prostate cancer?

Most of the time prostate cancer is asymptomatic and is picked up on:
  1. PSA blood test
The majority of prostate cancers are found due to an elevated; PSA blood test.
  1. Abnormal feeling rectal examination
Some prostate cancers can only be detected with a digital rectal examination (DRE), which is used as an adjunct to the PSA Occasionally it may present with:
  1. Urinary symptoms
Such as reduced flow, blood in the urine, frequency during the day and at night, but these would more likely be relate to benign (non cancerous) enlargement of the prostate (BPH).
  1. Symptoms of cancer spread (metastases):
A small proportion of men will present with bony pain, loss of weight and sometimes neurological symptoms such as leg weakness and loss of bladder/bowel function. These are features of advanced disease, which has spread outside the prostate.

What is a PSA blood test?

PSA (Prostate Specific Antigen) is a protein made by normal prostate cells. All men with a prostate produce PSA and some of it goes into the bloodstream where it can be detected. It is used as a tumour marker to help with identifying those at risk of having prostate cancer. Although it is produced only by the prostate, there are a number of causes of an elevated PSA (other than prostate cancer) including:

  • Urinary tract infections or prostatitis
  • Benign prostatic hyperplasia/enlargement
  • Urinary retention
  • Surgical procedures on the prostate/urethra
  • Ejaculation

What is a “normal” PSA level?

There is no definite “normal” level of PSA. Men with low PSAs can harbour prostate cancer, and those with high PSAs may not have prostate cancer. However, the higher the value of the PSA, the greater the risk of having prostate cancer. Some aggressive forms of prostate cancer may be found with low levels of PSA in the blood because they do not produce PSA. The following are age specific guidelines for “normal” ranges of PSA (but these may vary depending on the pathology lab):

Age range Normal PSA level
40-49 < 2.5
50-59 < 3.5
60-69 < 4.5
70-79 < 6.5

How is Prostate Cancer diagnosed?

A needle prostate biopsy is the main way in which prostate cancer is diagnosed (although it may be found during a transurethral resection of a prostate (TURP). An MRI scan is also useful for providing information as to whether there are suspicious areas in the prostate, which can then be targeted during the biopsy. The 2 types of prostate biopsies are:

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 found, are there any further tests?

Depending on the grade and risk of the prostate cancer, staging scans such as a Bone scan, CT scan (may not be required if MRI has already been done) and sometimes a PSMA PET scan may be requested. These are performed in order to exclude any spread of the cancer outside the prostate (metastasis).

How is prostate cancer treated?

There are several options for treatment of prostate cancer including surgery, radiotherapy, active surveillance and hormonal therapy. The choice depends on:
1. Cancer factors such as:
  • Gleason grade (ISUP Grade Group)
  • Volume of cancer on biopsies/MRI
  • PSA level
  • Staging scans/presence of metastases
2. Patient factors including:
  • Age
  • Estimated life expectancy
  • Co-morbidities (other medical conditions)
  • Urinary symptoms and continence
  • Erectile function

What are the treatment options if the prostate cancer is confirmed to be confined to the prostate (non metastatic)?

1. Radical Prostatectomy: surgical removal of the entire prostate
  • This is performed robotically

2. Radical Radiotherapy including:

  • External beam radiotherapy
  • Seed (Low dose Rate) brachytherapy (option for low risk localised prostate cancer)
  • HDR (High dose rate) brachytherapy
3. Active Surveillance:
  • This may be an option for men with low risk disease (low volume, low grade) Eg. those with small volume Gleason 6 (ISUP grade group 1) prostate cancer
  • The goal is to avoid the side effects associated with treatment without compromising survival
  • Patients are reviewed regularly with PSA blood tests, rectal examinations, repeat MRI scans and prostate biopsies
4. Watchful waiting:
  • Applies to men (usually older) who are unsuitable for or would not benefit from radical treatment
  • The goal is to only treat symptoms that are associated with prostate cancer
  • Patients are reviewed with regular PSA blood tests, assessment of symptoms and occasional scans to look for metastases
5. 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 metastases or local symptoms develop or the PSA is rapidly rising

Note – for metastatic prostate cancer other forms of treatment such as chemotherapy, powerful antiandrogens and other new agents can be used. These are usually organised by a medical oncologist.