Prostate Cancer

This is not intended to be a full discussion on prostate cancer. The subject is too broad to discuss fully. You will need to discuss prostate cancer more fully with your urologist to be provided with information which applies specifically to yourself. I will however try to give you a brief over view of the subject.

Prostate cancer is extremely common. When doctors examine the prostate glands of 80 year olds who die of a cause other than prostate cancer (for example a heart attack) they find that about 80 out of every 100 will have some prostate cancer. This has clearly not been relevant to them as they have died of something else. In fact in the UK only 3% (3 out of 100) men over the age of 80 actually die of prostate cancer. It is therefore a disease that you more commonly die with rather than of. To put it another way even if you have prostate cancer you are much more likely to die of something else. Never the less we all know someone who has died from prostate cancer, including famous people like Sir Harry Secombe. So what's the difference?

An individuals chance of dying of prostate cancer if it is diagnosed are related to the following :-

1) Age at diagnosis

Most men with prostate cancer are diagnosed in there late 70's or in their 80's. Your chance of dying of something else at this age is high. Although you may need treatment, it is likely to be simple.

2) General medical health

Clearly if you are 60 and have had 4 heart attacks and two strokes then a diagnosis of mild prostate cancer is not nearly so likely to kill you as your poor general medical health.

3) Chance of surviving 15 years

We know from experience that even if you have localised prostate cancer then to benefit from radical (major) treatment you must have a good chance of surviving another 15 years, this is similar to the above point, if you are suffering with severe heart problems then clearly major surgery is likely to be more dangerous than the prostate cancer itself.

4) Grade of the prostate cancer

Prostate cancer is graded for its potency from 2 to 10, where 2 is the mildest and 10 the most severe. In practical terms grades less than 5 are difficult to diagnose. The problem is that if you have for example grade 6 disease we have a good chance of curing you, but similarly you actually have a low chance that the cancer would kill you anyway (unless you are young) but conversely if you have grade 9 or 10 cancer then surgery or radiotherapy is less likely to cure you, but if we do nothing then it is likely that you would die from your cancer.

5) How far the cancer has spread

We have a number of different treatments for prostate cancer. If the cancer has already spread around your body, for example your bones then it is not possible to cure you. We still have treatment for you that may keep the cancer at bay for the rest of your life but you will not be entirely free of prostate cancer at any time.

So, in summary, we try to decide whether you can be cured and need to be, for example a 63 year old man with localised (i.e.. prostate cancer still only in the prostate) grade 8 disease, this sort of patient needs attempted curative treatment, either radiotherapy or surgery. A patient of 83 with grade 6 prostate cancer is unlikely to die and we would watch at first and then provide tablets if needed. Clearly, the difficult decisions lie between these two extremes.

The three possibilities are therefore 1) Cure. 2) Medical treatment designed to hold the cancer at bay. 3) Palliation of the disease.

Cure

There are a number of treatments available to attempt to cure prostate cancer. For the purposes of this explanation we will only discuss those available in Derbyshire (and Nottingham/Leicestershire for that matter).

Radical Prostatectomy

This is an operation which involves removing the prostate gland from its position between the bladder and the water pipe (urethra) the bladder neck is then rejoined to the urethra. This performed through an incision between the pubic bone and the belly button. The patient is in hospital for about 7 days. The main early complication of the procedure is bleeding during the operation which may result in the need for a blood transfusion. The later complications include a risk of long term incontinence (about 1 in 10) resulting in the need to wear a pad in the underwear in case of accidents. In addition the majority of patients are rendered impotent. Although natural erections are impossible for up to 90% of individuals, with assistance, many more will be able to resume normal sexual activity. Finally, up to 1 in 10 people will suffer from recurrent blockages at the join between the bladder and urethra, these often need repeated surgery with some patients needing to pass a catheter (small tube) into their bladder regularly to keep the urethra patent.

Radical Prostatic Radiotherapy

This treatment is provided as an outpatient. You will need to attend the radiotherapy department usually daily (Monday to Friday) for about 6 weeks. The radiotherapy often makes patients feel tired. It also has specific complications just like surgery. Because the prostate is situated next to the bowel one of the more common side effects is diarrhoea which may include blood. This is very often, but not always reversible. Most patients initially keep their erections but by 12 months approximately 50% of patients will be impotent. Again, we can provide help if this is the case. Radiotherapy can also irritate the bladder which is result in more frequent trips to the lavatory, this nearly always improves after the treatment has finished. Long term incontinence is more rare after radiotherapy than surgery. Radiotherapy patients can also have problems with blockages of the urethra.

Brachytherapy, Radioactive Seeds

The procedure of brachytherapy involves implanting seeds which contain radioactive substances deep within the prostate. The first step of the procedure is to produce a computer generated map of the prostate gland so that the seeds can be placed evenly throughout the gland to kill the cancer cells. After the map has been produced the patient has another anaesthetic to place the seeds in the gland. This procedure delivers the radiotherapy directly to the prostate rather than it having to pass through your skin and other organs before reaching the gland. Unfortunately the technique is only suitable to some grades of prostate cancer. It is also only available in a couple of sites in the UK and is a technique still relatively in its infancy. In a highly selected sub group of patients however (i.e. picking those most likely to be cured with which ever treatment is given) it seems to be effective. In America this procedure is more often becoming combined with external beam radiotherapy, as discussed above, to try to increase the dose delivered to the prostate cancer.

Cryotherapy

This is an experimental treatment for prostate cancer. Long term results are not yet available. It involves freezing the prostate gland to kill the prostate cancer cells. It has so far been difficult to limit accurately the limits of the ice ball that is created and therefore there remains a relatively high risk of damage to other organs. The procedure is currently mostly used for prostate cancer that returns after radiotherapy. It is not available in Derby but can be arranged in Leicester.

HIFU

HIFU stands for High Intensity Focused Ultrasound. The treatment consists of aiming ultrasound energy into the prostate cancer from a probe in the rectum (back passage). The treatment is given with an anaesthetic over a single session as a day case. Although only 5 year data is available there is evidence to suggest that it is as effective as surgery or radiotherapy with a much lower number of side effects such as impotence and incontinence. The procedure can be performed with minimal impact to the patient. The energy can be delivered accurately to within 2mm, this means that it is possible to give nerve sparing treatment and hence preserve erections. Similarly if the treatment has pierced the prostate capsule as seen on the CT/MRI scan extra energy can be delivered to this area. The procedure is new but has been approved for use in primary (untreated) prostate cancer and prostate cancer which has come back after radiotherapy by the National Institute of Clinical Excellence in the UK. The treatment is available privately in Derbyshire and work is underway to make it available on the NHS. More information is available here and here.

Holding The Disease At Bay

Prostate cancer has often spread beyond the confines of the gland itself by the time the patient attends his doctor. All is certainly not lost however. Although it is currently impossible to cure anyone with prostate cancer which has spread (there is no effective chemotherapy) there is a lot that doctors can do to halt the further progression of the disease.

Prostate cancer is obviously a cancer of men. The tumour itself grows under the influence of testosterone, the male hormone. Our treatments act to decrease the amount of, or effectiveness of, the testosterone on the body. If testosterone levels drop to very low values the prostate cancer is greatly effected. Most of the cancer dies away leaving only a fraction of the tumour left alive. This remaining cancer will gradually grow. But, because prostate cancer is slow growing this may well never affect your health.

The fact that prostate cancer often grows slowly means that many patients do not need treatment as soon as they are diagnosed. On many occasions we simply keep an eye on patients and only start treatment if the prostate cancer starts to show signs of becoming increasingly aggressive. There are still no definitive scientific studies to show that early treatment makes any difference to the success of treating prostate cancer.

What is PSA?

PSA stands for prostate specific antigen. It is a chemical produced by the prostate which is secreted into sperm. Note that it is NOT prostate cancer specific antigen. By which I mean, although it is produced only by the prostate there are several causes for it being raised other than prostate cancer. Having an enlarged prostate (more and more common as men age) or having an infection in the urine or prostate can all increase the level of the blood test.

How can my doctor tell which is the cause of the raised PSA?

The management of this depends on your age and health, if you are a 50 year old man, who is healthy and has an elevated PSA it is extremely likely that your urologist will biopsy your prostate gland (this will be discussed in detail below). If however you are 89 years old and have bad heart disease your doctor would be unlikely to biopsy your prostate if your PSA is marginally elevated. There are of course many shades of grey in between and this is where the skill of the surgeon comes into play. Your urologist will advise you further on what applies to you.

Prostate Biopsy, What's involved?

Because of the position of the prostate gland the best method of taking a small amount of tissue to examine under the microscope is via the back passage. An ultrasound probe, which is a similar shape to a cigar tube, is placed in the back passage. The doctor can then see the prostate and guide his biopsies accurately. Between six and 12 biopsies will be taken. Because there are few nerve endings in the back passage the procedure is uncomfortable rather than painful. In Derby our patients are given local anaesthetic to further reduce the discomfort of the procedure.

Are There Any Possible Complications to the Biopsy?

Your doctor will prescribe you antibiotics to minimise the risk of the most severe complication, infection. Before antibiotics were routinely prescribed some patients developed septicaemia. A few patients in other parts of the world even died from this severe form of blood poisoning. Antibiotics however have massively decreased the risk of infection.

Many patients also suffer bleeding. This can be mixed with the bowel motions, in the urine or seen in the sperm. It can continue for up to 2 weeks.

A Final Word

Don't panic. Prostate cancer is common, there is a great deal that doctors can do to either cure you of prostate cancer or hold it at bay.

Prostate Cancer

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