Prostate Cancer

Prostate cancer is the most common internal cancer affecting males. In Australia 20,000 new cases are diagnosed every year. Over the last 2 decades the early detection and treatment of prostate cancer has lead to a decline in the mortality rate. 

Diagnosis

Prostate cancer is diagnosed by having a digital rectal examination, a blood test called a PSA and a prostate biopsy. 

PSA Test

This is a blood test that measures the amount of Prostate Specific Antigen (PSA) in the blood.  PSA is protein produced by normal prostate cells and also by prostate cancer cells.  A raised PSA may be indicative of an abnormality in the prostate, but it may not necessarily be cancer.  Prostate cancer can be a cause of an elevated PSA.  Other conditions such as infection in the prostate or urinary tract, or simply benign prostatic enlargement (BPH) can also cause it to be elevated. The PSA and the digital rectal examination are used to determine if a prostate biopsy is indicated.

Prostate Biopsy

Prostate cancer is diagnosed by performing a prostate biopsy and obtaining samples and tissue to be examined by a pathologist.

A prostate biopsy involves taking small pieces of prostate tissue to be examined under the microscope by a pathologist.  The most common way this is performed is by a Trans Rectal Ultrasound  (TRUS).  This is where an Ultrasound probe is inserted into the rectum.  This provides an image of the prostate, which appears on a screen, and is used a guide to direct a long thin needle which is passed along the side of ultrasound probe, through the rectal wall into the prostate. 

Other ways of performing a prostate biopsy include; a transperineal biopsy, where the needles are inserted through the skin between the scrotum and anus and an MRI guided biopsy.

For further information on preparing for a prostate biopsy download Prostate Biopsy 

Staging and Grading

All individual patient's cancers are placed into risk categories based on the stage and grade of the cancer. This helps determine the best management options for each individual patient.

The grade is the aggressiveness of the cancer. A grading system used specifically for prostate cancer uses the Gleason score, which is a score given to the cancer by the pathologist based on the appearance and pattern of the cells when examined under the microscope. The Gleason score is expressed as the sum of two numbers, the primary grade and the secondary grade e.g. 3+4=7.  The higher the Gleason score the more aggressive the cancer is.

The stage defines how extensive a cancer is. Whether it is localised, extensive or if it has metastasised (spread to other parts of the body). This is determined by carrying out imaging tests including a CT scan, bone scan and MRI.

Management

Active Surveillance

Prostate cancer does not always need to be treated with surgery or radiotherapy. The increased public awareness of prostate cancer has led to an increase in the diagnosis of very early low risk cancers that may not pose a risk to patients.

Active surveillance is a term applied to a management protocol for prostate cancer, which your Doctor may consider, poses little risk in the future.  The suitability for an individual patient to embark on an active surveillance protocol depends on a number of factors including the age and general fitness of the patient, the pathological features of the cancer as determined by the Pathologist on the biopsy, and the PSA.  The individual patient’s willingness to accept this conservative approach is also important.  To find out if a patient has a cancer that is suitable for active surveillance he needs to consult his urologist.

Radical Prostatectomy

This is an operation where the entire prostate is removed. This includes removing the part of the urethra that is within the prostate.  Continuity of the urinary tract is re-established by joining the bladder to the urethra using fine sutures. It is important to note that there are some nerves very close to the capsule of the prostate that are necessary for erectile function.  A nerve sparing operation aims to preserve these nerves to maintain erectile function.  Sometimes the cancer has penetrated the capsule and may be very close to the nerves.  In this situation it may be necessary to remove these nerves to avoid leaving cancer cells behind. The most common complications of this operation are erectile dysfunction and urinary incontinence.  A radical prostatectomy can be performed by several surgical approaches.  The most common approaches are the traditional open Radical Prostatectomy (performed through an incision in the lower abdomen) and the Robotically assisted Laparoscopic (keyhole) Radical Prostatectomy.

Robotically Assisted Radical Prostatectomy

A robotically assisted radical prostatectomy is performed through a few small incisions.  The surgeon operates from a remote console and controls four interactive arms, one fitted with a high tech 3-D camera that provides a magnified view of the surgical field; the other three are fitted with tiny wristed instruments that have a greater range of motion than the human wrist. This enables the dissection and suturing to be done accurately, with less bleeding.  It is important to understand that the robot is not performing the operation, but rather the surgeon is using the capabilities of this very sophisticated device to enhance his ability to carry out this delicate surgery.

Compared to the traditional open radical prostatectomy patients who have a robotic prostatectomy have less pain, less scarring, a lower requirement for a blood transfusion, a shorter hospital stay and are able to resume physical activities and return to work sooner. 

Dr Lazzaro performs robotically assisted Radical Prostatectomies using the Da Vinci ™ Robot at Macquarie University Hospital.

Radiotherapy

This treatment involves the use of high dose X-rays to damage the cancer cells.  This stops the cells dividing and stops the cancer growing.  A Radiation Oncologist supervises this treatment.  Radiotherapy can be given in the traditional way.  This is called External Beam Radiotherapy (EBRT), which involves having daily treatment for up to 8 weeks.  Alternatively a treatment called Brachytherapy can be used where the radiation source is inserted directly inside the prostate.

Hormone Treatment

In some cases the cancer has metastasised, cells have spread to other parts of the body.  In this instance the cancer is not curable by local forms of treatment like surgery or radiotherapy.  These cases are treated with hormone treatment.  The aim of this treatment is to lower the bodies production of testosterone which is necessary for the cancer cells to grow.  Up to 90% of advanced prostate cancers will respond to hormone treatment.  This treatment may control the cancer for several years.