Lifting the kilt on prostate cancer

Prostate cancer is sitting comfortably in first place in terms of numbers of men diagnosed with cancer in Australia. Despite men being told for years that you die with it, not from it, the evidence begs to differ.

It is estimated that 18,110 new cases of prostate cancer will be diagnosed in Australia in 2021 and that over 3000 men will die as a direct result.

To put this into perspective, one in six men will be diagnosed with prostate cancer by the age of 85 - perhaps more revealing is that 63% of cases are diagnosed in men over 65 years of age - meaning that 37% of cases are in men under 65.

On a lighter note, it’s nice to recognise that largely, when diagnosed early (which is happening more and more), prostate cancer is not a death sentence. The surgical techniques now are better than ever; imaging and diagnostics are better and more accessible, and the work our radiation and medical oncologists are doing with new medications and techniques is certainly prolonging life. For the record, the five-year survival rate for prostate cancer is 95% which is, with all things considered, very promising.

In terms of the actual cancer, it can be described in a number of ways. Early (localised) prostate cancer refers to cancer cells that have grown, but do not appear to have spread beyond the prostate; this is the preferred diagnosis.

There are two stages of advanced prostate cancer: locally advanced prostate cancer where the cancer has spread outside the prostate to nearby parts of the body or glands close to the prostate, and metastatic prostate cancer where the cancer has spread to distant parts of the body. The best course of management will depend largely on this description and would be discussed with your urologist in the first instance.

To understand prostate cancer, it’s worth first refreshing our knowledge of the prostate.

The prostate is a walnut-sized gland located between the bladder and the penis, and it sits just in front of the rectum. The urethra, which links the bladder to the penis and outside world, runs through the center of the prostate (which is why when there is something happening with the prostate it can affect one's ability to urinate normally/comfortably).

The prostate is involved in the secretion of fluid that nourishes and protects sperm; during ejaculation, the prostate squeezes this fluid into the urethra, and it is expelled with sperm as semen. Screening is largely a tried and tested process today with a prostate specific antigen (PSA) blood test being the most likely starting point.

What is PSA?

PSA is a test for protein produced by normal, as well as cancerous cells, of the prostate gland. But this alone is not enough to make a diagnosis on. If  your GP feels the PSA pathology results are not as expected, they will then refer you to a urologist who will do  further investigation to guide future management and shed light on what is actually happening. The other pathology your GP might look at, is the free PSA or free-to-total test prostate health index (PHI), as this might help them better understand what is happening.

As for a prostate cancer diagnosis, this would generally be made by the urologist after conducting a number of tests. This is not a prescriptive list, but rather a few options that they might look at to gather the required information to make an overall diagnosis. This could include:

●      A digital rectal exam - where the urologist feels the prostate for lumps and bumps. This would generally be done before any biopsy was done and might provide some insight as to what was happening for the doctor.

●      An MRI - which is a scan that uses a powerful magnet and radio waves to build up detailed pictures of the inside of the body. The urologist may suggest an MRI to help determine if a biopsy is needed. It can also provide insight as to whether the cancer has spread from the prostate to nearby areas. Finally, it can help guide a biopsy needle.

●      A biopsy – during a biopsy, small samples are taken from the prostate using a special needle. The samples are then sent to a laboratory where the pathologist checks them for cancerous cells. There are two main types of prostate biopsy: a transperineal (TPUS) biopsy (needle is inserted through the skin between the anus and the scrotum) or a transrectal (TRUS) biopsy (needle is inserted through the rectum). The TRUS biopsy is more common today.

Further tests might include; having a bone scan to determine whether the prostate cancer has spread to the bones, a CT scan which may show whether cancer has spread to lymph nodes, and a PET scan to help detect cancer that has spread or come back.

When specifically discussing prostate cancer, the PET scan usually uses gallium to show

prostate-specific membrane antigen (PSMA) - thus this scan is often referred to as a PSMA PET scan and provides the best suggestion as to the nature and progress of the cancer.

When the result of the above is suggestive of prostate cancer there are a few options. Some of these options will be governed by both the grading (as per the biopsy), the scans listed above and also the nature of the cancer (seemingly localised or metastatic).

Treatment methods may include:
 

Stage	Management of treatment options
Localised or early	●      active surveillance ●      surgery or radiation therapy or both ●      watchful waiting
Locally advanced	●      surgery or radiation therapy or both ●      androgen deprivation therapy (ADT) may also be suggested.
Advanced or metastatic (at diagnosis)	●      usually androgen deprivation therapy (ADT) ●      sometimes chemotherapy or radiation therapy ●      watchful waiting may be an option ●      newer treatments as part of a clinical trial

 

As you can tell, there are many ways forward with a diagnosis of prostate cancer and it can be confusing to know which is your best way forward.

We are lucky here in Australia to have a wonderful team of experts; urologists, medical oncologists, radiation oncologists as well as GPs, prostate nurses and a range of wonderful patient support organisations, all of which can provide information to help patients make an informed decision.

Some of these support organisations include; The Prostate Cancer Foundation of Australia (PCFA), Movember and their True North project, Mens’ Health Downunder, Cancer Council, Beyond Blue, Healthy Male, Mens’ Shed, Australia Mens’ Health Forum and more. These organisations are readily available and are a great source of support and information for patients and their partners.

Please don’t hesitate to get in touch if prostate cancer has touched your life or the life of a loved one.