Update on Prostate Cancer and BPH Gary Das MS, FRCS, FRCS (Urol) Lead Cancer Urologist, Croydon University Hospital Pelvic Cancer Surgeon, St George’s Hospital
Introduction
Function of the prostate PSA Prostate Cancer Incidence Symptoms Management
BPH (Benign Prostatic Hypertrophy) Incidence Symptoms Management
What is the prostate?
Walnut sized gland in pelvis
Prostate produces about 30% of seminal fluid
Nourishes and activates sperm
PSA
Blood test for protein produced by prostate cells
May be elevated in benign conditions or cancer
May be raised in benign prostatic enlargement, retention, prostatitis, urological instrumentation, sexual activity, cycling
Rises with age
Elevated PSA Not
specific for prostate cancer
Decision
to investigate also depends on prostate size, digital rectal examination, general health, patient’s wishes
NICE guidelines
Key priority:
PSA
6630 male volunteers over 50 years old PSA (ng/ml) 10
809 (12%) 174 (3%)
143/548 (26%) 73/138 (53%)
J Urol 1994; 151:1287
Prostate Cancer
Most common male cancer in UK
35,000 new cases / year 10,000 deaths / year
Cancer Research UK
Incidence & mortality rates
Cancer Research UK
Mortality stable since 1990s
Cancer Research UK
Age distribution
Cancer Research UK
UK does favourably compared to Western World
Cancer Research UK
Patients are surviving longer
Cancer Research UK
Risk factors Hereditary Early age onset Double risk if one first-line relative
Environmental Risk increases in Japanese men moving to USA Diet Good: lycopenes (tomatoes), vitamin
pomegranate, pumpkin seeds Bad: red meat, dietary fat Social
Class
E, selenium,
Symptoms Often
asymptomatic
Lower
Urinary Tract Symptoms
Bone
pain (pelvis / vertebral)
Lower Urinary Tract Symptoms
Sensation of incomplete emptying of bladder
Frequency – urinating every 2 hours or less
Intermittency – stop/start stream
Hesitancy
Urgency – difficult to postpone urination
Nocturia – number of times urinating at night
Weak stream
Straining
Diagnosis Digital
rectal examination
Nodular Firm Loss of median sulcus
PSA
TRUS
and prostate biopsy
TRUS and prostate biopsy Antibiotic
prophylaxis
Risk
of bleeding, infection and septicaemia (1 in 1000)
Require
hospitalisation if rigors or fever post procedure
If
first set of biopsies negative 10-35% detection rate in second set
Detection
biopsies
rate extremely low after three negative
Imaging
MRI of pelvis
Bone scan
Gleason score Grading Sum
system
of two most common patterns (grade 1-5)
Most
cancers are 6 or more
Multidisciplinary meeting To
discuss histology, imaging and management
Urologists,
oncologists, pathologists, radiologists, specialist nurses
Local
and regional
Recruitment To
to clinical trials
improve and standardise patient care and increase patient choice
Treatment Few
comparative studies between the different treatments exist
No
randomised trials between radical prostatectomy and radiotherapy for localised prostate cancer exist
Treatment Organ
confined
Men with a
life expectancy of greater than 10-15 years should be treated with curative intent
Active Surveillance Radical Prostatectomy External beam radiotherapy Brachytherapy Cryotherapy HIFU
Treatment
Locally advanced Watchful waiting Hormones Radical prostatectomy and radiotherapy / hormones Radiotherapy and hormones
Metastatic Hormones Oestrogens & corticosteroids for hormone refractory disease Chemotherapy – docetaxel, mitoxantrone & steroids
Active surveillance Well-informed
asymptomatic patients with small volume disease with a low Gleason score
Reduces over-treatment
and morbidity by selecting out patients with significant cancers who would benefit from curative treatments
Choo R et al. J Urol 2002; 167: 1664-9 Parker C. BJU Int 2003; 92: 2-3
Active surveillance Closely
monitor PSA every 3 months
Repeat
prostate biopsies within 2 years
Radical
treatment if PSA progression (doubling time
