Talking all things prostate cancer

My name is Dr Kieran Hart and I’m a Urologist. I perform robotic prostatectomies for prostate cancer at National Capital Private Hospital. After finishing my urological training in Australia, I moved to the UK in 2016 where I undertook a specialty fellowship in urological cancer surgery at Imperial College in London. I was trained in minimally-invasive laparoscopic prostatectomy, and since returning to Australia in 2017, I’ve performed more than 75 robotic procedures.

September is Prostate Cancer Awareness Month and I am writing this post as a bit of a clinician’s overview for this disease.

Now that you have some background on me, I’ll give you some background on prostate cancer. Unfortunately, it’s more common than you’d think. In the time that it’s taken me to write this article, two men in Australia would’ve been diagnosed with prostate cancer. According to the Cancer Council, more than 18,000 men will be diagnosed this year alone. It is also the third leading cause of cancer death in all men.

Given its prevalence,  there must be a way of screening for this cancer? Well, there is. And it starts with a simple blood test.

The prostate and the prostate alone make up PSA (prostate specific antigen). But, there is a lot of confusion surrounding PSA as a screening test. Testing men from the age of 50 (or younger if they have a family history) has long been the recommendation for many health authorities around the world.  My opinion is that 20 years ago, it wasn’t the most effective screening test. However, in 2021, with the benefit of working out who should be screened (from the previously mentioned studies) and the use of MRI (in helping to determine who should have a biopsy), PSA is a very useful starting point for screening.

Is there still a role to have the prostate examined through the rectum? Yes. Although it’s a less accurate way of detecting prostate cancer, the occasional patient will have a normal PSA but a tumour that you can feel on rectal examination.

Should you get screened?

Well, this is the all-important question. It is paramount that a man understands what’s involved in screening.

I believe that a patient should understand what they are being tested for, that is, before getting that test. A discussion with your GP can help you make this decision. Generally speaking, I recommend patients who are over the age of 50 (and 40 if they have brothers or a father with prostate cancer) to get a PSA screening test if they think they are going to live for another 15 years.

Why 15 years? Those studies I mentioned earlier showed that screened patients didn’t get a benefit in life expectancy for about 10-15 years after screening. It makes sense, as it takes about 10-15 years for someone to die from prostate cancer after being diagnosed. Therefore, once a patient gets to the age of 70 and they have other significant medical issues, then they are unlikely to benefit from screening.

What happens if your test is abnormal?

This is where screening has come forward in leaps and bounds. When I was a trainee, an abnormal test lead to a biopsy. And, the majority of biopsies I did as a registrar were negative (anecdotally about 20% were positive).

Today, patients are fortunate enough to get an MRI, which has turned the number of negative biopsies on its head. I’ve found that only 10-15% of biopsies I do are negative in my practice. Meaning that far fewer men are having unnecessary biopsies. And, given it involves putting a needle either through your rectum or perineum, I would call that a good thing.

If an MRI has suggested a prostate biopsy – what comes next?

There are two ways of performing prostate biopsies - through the rectum or the perineum. Each has pros and cons. I would perform the biopsy that is most likely going to sample the cancer easiest and least likely to cause the patient any harm. Some of the considerations are infection risk, urinary retention risk, location of the tumour on MRI and of course, patient preference. The procedure is done under either sedation or general anaesthetic in a hospital (most patients that I know prefer some form of sedating anaesthetic given that an ultrasound probe has to sit in their rectum for the entirety of the procedure).

If the biopsy result comes back and shows cancer, the first thing I do is tell my patient that there are a multitude of grades for prostate cancer. And even in the highest grade, there is a comparative long-life expectancy.

Prostate cancer is very much like a chronic disease. It takes a long time to cause death. Most prostate cancer diagnoses lead to a scan that checks for the spread of prostate cancer. These can be conventional bone and CT scans through to PET scans using PSMA (a prostate marker) to identify tumours.

Let’s talk about treatment.

Believe it or not, some prostate cancers aren’t worth the hassle of treating. It’s now standard in all major centres across the world to offer “active surveillance” as a treatment for low-grade prostate cancer. This involves watching the PSA, repeating the MRI and biopsy and setting parameters for when treatment should (if ever) begin. This is based on studies that showed that most patients with low-grade prostate cancer did not die from their cancer more than 15 years after diagnosis! Intermediate or high-grade prostate cancers are the types where treatment is often recommended.

When it comes to prostate cancer, treatment can be variable. Surgically removing the prostate (prostatectomy) or giving radiotherapy to the prostate has very similar cancer outcomes. The difference is the recovery for the patient and what potential treatments are available after choosing a specific option.

Surgery has the benefit that an accurate diagnosis of the cancer can be made through pathologically testing, disease recurrence is easy to detect (through PSA monitoring), and, if radiation is required after the procedure, then it can be delivered. What’s great about 2021 is that surgical techniques have come a long way over the last 20 years so recovery for patients just keeps getting better.

Radiotherapy has the benefit of not requiring surgery and the associated risks have similar cancer outcomes to a surgery. Like surgery, radiotherapy has improved in technique over the years so that side effects are becoming less and less. And now, there are different types of radiation treatment too.

Hormone therapy and chemotherapy are used in prostate cancer when there is spread outside the prostate (to try and control its growth). Sometimes, hormone therapy is used in conjunction with radiation treatment.

Talking to your urologist.

Now that you know there are lots of alternate and experimental treatments for prostate cancer, I encourage you to talk to your urologist about these and if they are suitable for you.

I tell my patients that the good thing about prostate cancer (as opposed to other cancers) is that you have the time to choose your treatment, and you get the autonomy of choosing what treatment to go with. There are lots of resources out there, and I encourage patients and their families to explore these before embarking on treatment.