What is prostate cancer? - How is it diagnosed, screened for and how do I know I have got it?
Prostate cancer is a malignant tumour that begins in the male prostate organ which sits below the bladder. The function of the prostate is to make seminal fluid and is important in fertility. It has no hormone function and no erection function. Early prostate cancer has no symptoms and can only be detected initially by a blood test called a PSA test. The PSA test itself is elevated in the bloodstream not only in prostate cancer but in other conditions of the prostate, so further investigations are required to establish the cause of the elevated PSA. These usually involve a careful history and examination as well as a multiparametric MRI of the prostate.
If my PSA test is elevated, what happens next?
Usually, once a PSA test is elevated, it is important that sexual activity is avoided for 48 hours before repeating the test. If the test is still elevated, then a referral to a urologist for an opinion and likely multiparametric MRI will occur. At this stage the urologist will be able to decide whether the PSA elevation is due to inflammation, benign prostate enlargement or prostate cancer. The next step is usually a biopsy if the MRI and the PSA suggest that there is a likely cancer. These biopsies are now done under a light anaesthetic behind the skin of the scrotum. This new technique called transperineal avoids the old risks of transrectal biopsy.
I have heard that most prostate cancers are not dangerous.
Over the last 30 to 40 years it has become apparent that there are different grades of prostate cancer, grade 1 to grade 5. It has been clearly established now that grade 1 prostate cancers (previously called Gleason 6 prostate cancer) are not a dangerous cancer and even over a long followup period can be safely monitored. On the other hand level 3, 4 and 5 prostate cancers are dangerous and have the ability to spread to lymph glands and bones and cause considerable side effects. Level 2 prostate cancers (Gleason 7 prostate cancer) on occasions behave aggressively and on other occasions behave similar to a grade 1. As you can see from this, there are some good ones and bad ones and the job of the urologist is to try and differentiate between these two groups. The things that tend to make it a bad one are genetic abnormalities such as a strong family history of prostate cancer or even a strong family history of breast cancer as well as certain genes which are now known to be associated with prostate cancer such as the BRCA gene. If one has a strong family history of prostate cancer, it doubles your risk, whilst if you have two members of the family who have prostate cancer diagnosed at a young age, it increases the risk by five-fold. If one carries the BRCA gene, it increases the aggressiveness of prostate cancer.
How can I prevent getting prostate cancer?
There is a lot of evidence that lifestyle has a big impact on the development of prostate cancer. For example, in certain Japanese cultures prostate cancer in traditional families is rare. Interestingly, if these traditional families immigrate to a Western society, they rapidly increase the risk of significant prostate cancer. It is speculated that diet and lifestyle are the main factors and these dietary factors could be excessive saturated fats, refined sugars, eating too much causing obesity and a lack of social cohesion and support. Less prominent factors include the possible protective influence of a Mediterranean-type diet, cooked tomatoes (lycopenes).
When should I go to a specialist?
If you have developed new urinary symptoms, your general practitioner will do some basic investigations such as a urine test and an ultrasound to establish the cause of this. If simple medications do not help this, this is often an indication for referral to a specialist. With patients with slightly more advanced prostate cancers, this may lead to urinary symptoms. So whilst it is much more common for urinary symptoms to reflect a benign enlargement of the prostate, it is worth checking with your GP.
If I do have prostate cancer, what options do I have?
In 2023, the options have become fairly broad. The factors that dictate which treatment is going to be the right one are obviously the nature of the tumour and its grade but also the nature of the prostate and whether the man is having difficulty passing urine or if he has an enlarged prostate and also most importantly individual patient priorities and fears. As there are many options now including active surveillance, removal of the prostate by robot-assisted surgery, radiotherapy to the prostate either with the use of brachytherapy, external beam radiotherapy or one of the latest developments in this area - radiotherapy machines inside an MRI machine to improve accuracy (MR-Linac radiotherapy) as well as the evolution of focal therapy which has been pioneered at St Vincent's by Professor Stricker. The treatments have further become more personalised and tailored to the individual patient's needs because of improved biopsy techniques and improved imaging with multiparametric MRI and new PET scanning techniques with PSMA PET scanning. In this modern age, second opinions and multidisciplinary teams often sit together to make a final decision about what is best for an individual patient.
What about if my cancer is beyond the realms of curing it?
Even patients with advanced prostate cancer has had a virtual revolution of new treatments which significantly prolong life and often put it into full remission. These include new tablets called novel antiandrogens, new radiotherapy techniques called theranostics, combining different treatments together which have a more than additive effect, genetic testing which can sometimes allow certain drugs such as PARP inhibitors to be used and modern radiotherapy techniques to irradiate secondary cancers in bones or lymph glands with minimal side effects. Once one gets to the advanced stage, one normally has a team of specialists looking after a patient and these include not only a urologist and radiation oncologist but also medical oncologists, clinical psychologists, sexual health physicians, physiotherapists, genetic experts, pathologists, radiologists, nuclear medicine physicians and that is to name but a few. Clearly, this combining of expertises is leading to a better outcome in all patients with advanced prostate cancer.
What is the most exciting research going on with prostate cancer at the moment?
In the area of advanced cancer of the prostate, new tablets are being developed such as different types of novel antiandrogens and PARP inhibitors. An attempt is being made to make immune medications work with prostate cancer but this has been unsuccessful to date. Theranostics using radioactive labelled chemicals attached to PSMA have been developed and these are working in combination with other therapies to hopefully control prostate cancer. In the area of early prostate cancer more and more work is being done to decide whether we have a good or bad cancer, so that an increased number of patients can have active surveillance and monitor it and a middle group of people can have focal therapy thus avoiding some of the side effects of surgery and radiotherapy.
Written by Professor Phillip Stricker AO, St Vincent's Clinic.
Professor Phillip Stricker AO is a Urologist at St Vincent's Clinic, specialising in prostate cancer, minimally invasive and robotic prostate surgery, focal therapy with NanoKnife. He is a leading expert in the treatment of prostate cancer in Australasia and is a pioneer in prostate cancer imaging. He is Chairman of the Department of Urology at St Vincent's Campus, Director of St Vincent's Prostate Cancer Centre and Clinical Director of The Australian Prostate Cancer Research Centre at the Garvan Institute.