What is prostate cancer?
Prostate cancer is the commonest non-skin cancer in men in the UK. It is different from most cancers in that a significant proportion of men, particularly older men with a shorter life expectancy, have a non-aggressive form of this cancer, meaning that it is unlikely to cause symptoms or progress beyond the prostate gland during their lifetime. Sometimes in younger men the cancer can be small, slow growing and present only a limited risk to the patient. Clinically important prostate cancers can be defined as those that threaten the well-being or life span of a man.

• difficulty in starting to pass urine
• slowing of the urinary stream
• dribbling at the end of the stream
• bladder irritability, or feeling the need to pass urine often, including at night, and the feeling that you need to rush to pass urine
• passing blood in urine

Most patients are diagnosed after they are found to have a raised PSA (prostate specific antigen) blood test, or because they have an abnormal feeling prostate. However, the PSA test is not entirely accurate. There is no real safe lower limit. Even in men with "normal" levels of PSA (less than 3 to 4 ng/ml) around 15% may have small prostate cancers. Conversely, the PSA level may be increased by conditions other than the presence prostate cancer, such as BPH or prostatitis (infection in the prostate).

The PCA3 urine based test may help. Prostate Cancer gene 3 (PCA3) is a new gene-based test carried out on a urine sample. PCA3 is highly specific to prostate cancer and this gene is overexpressed in over 95% of prostate cancer cases. This is in contrast to PSA which may be increased by conditions such as benign enlargement of the prostate (BPH or BPE) or inflammation of the prostate (prostatitis). The PCA3 test result is not affected by these conditions. For more information on this test please click here

Men will almost always need to undergo a prostate biopsy in order to establish the diagnosis of prostate cancer. This involves taking several cores of prostate tissue using an ultrasound probe placed in the rectum, and is usually done under local anaesthetic. The biopsy will give information such as the grade of the tumour (how aggressive the cancer looks), which is called the Gleason score.

A microscopic picture of a prostate biopsy showing a Gleason grade 3 tumour. The grade is determined by what the cells look like under the microscope.

After a diagnosis of prostate cancer further tests may then need to be done to determine the stage of the disease. This tells your doctor whether the disease has spread. Such tests might include an MRI scan, CT scan and/or bone scan. Once the grade and stage have been established, you will be able to discuss with your urologist which treatments are suitable.

Staging tests will help determine if the cancer has spread outside the prostate, and if so how far.

There may be a number of suitable treatments, and for patients with suitable localised disease these might include: active surveillance, radical prostatectomy (surgical removal of the entire prostate gland, which we are able to do using the Da Vinci TM robot in a minimally invasive way), radical radiotherapy and brachytherapy.

At Cambridge Urology Partnership we are able to offer suitable men who choose radical prostatectomy as their preferred treatment option a robotically assisted laparoscopic prostatectomy, also known as robotic surgery for prostate cancer. This has the advantages over traditional open prostatectomy of shorter hospital stay, less pain, less risk of infection, less blood loss and transfusions, less scarring, faster recovery and quicker return to normal activities. For more information on this please read our guide to treatment option for men with localised prostate cancer and see our information sheet about robotically assisted laparoscopic prostatectomy, or robotic surgery for prostate cancer.

Click here to read the recent article in The Times on April 11th 2008, talking about robotic prostatectomy. You may also watch a video of the operation by clicking this link.

Below are tesimonials of two patients who have undergone this operation:

"11 months after my "radical prostatectomy" robotic assisted op performed by Mr Shah, and the three months of aftercare with Mr Shah and Sr Basnett, I would like to express my gratitude for their professionalism and genuine concern. It is always a pleasure to return to see them! Thanks to them I now feel that I can look forward to a healthy life ahead! They deserve the highest praise for the valuable work they do. Thankyou so much!" Mr DR aged 63

"Dear Mr Shah, I would like to thanks you and your team for the care and attention I received from the outset of the robotic prostatectomy including my hospital stay and aftercare. Following the operation I was surprised how quickly I was up and about, with very little discomfort internally and the small external wounds only taking a couple of weeks to heal. I was able to return to work just four weeks after the operation, (most helpful as I am self-employed). But I think that the best thing other than the abvious removal of the cancer is the speed with which my waterworks have recovered. Once again I would like to thank you for taking my case, and for a very satisfactory outcome of the operation." Mr PG

Below are two nomograms that help determine the risk of prostate cancer in patients who have not had a diagnosis of prostate cancer made :

1. Risk of prostate cancer

Recently a risk calculator has become available for men with suspected PCa based on an abnormal DRE or elevated PSA. It predicts the probability of a positive biopsy, including the probability of a high grade (high Gleason score) biopsy. It takes into account

• race
• age
• family history of PCa
• DRE outcome
• serum PSA
• whether or not a prior biopsy was negative.

This risk calculator is based on the Prostate Cancer Prevention Trial (PCPT). In this study, 5519 older men with a relatively low PSA ( = 3 ng/mL) who did not receive active treatment for 7 years had a 6-core biopsy.

2. Prostate risk indicator

This risk calculator currently consists of 2 prostate risk indicators accessible to patients. They predict the probability of a positive biopsy. They take into account

Risk indicator 1

1. family history of prostate cancer
2. age
3. frequency of urinary symptoms according to the International Prostate Symptom Score (I-PSS)

Risk indicator 2

1. PSA

The Prostate Risk Indicator is based on data from 6288 Dutch men aged 55-74 years living in Rotterdam and participating in the European Randomized Study of Screening for Prostate Cancer (ERSPC) [2]. These men were tested for serum PSA and for any prostate abnormalities by DRE and TRUS and were subsequently followed-up over time.

For patients who have a diagnosis of prostate cancer , the best known nomograms to help predict pathological stage are below. The risk calculators are developed for men who have had a positive biopsy but have not yet received active treatment (e.g. radical prostatectomy, radiation therapy or hormone therapy). They are trying to answer the questions:

• is the tumour still confined to the prostate?
• has the tumour spread beyond the prostate into surrounding tissues such as the seminal vesicles?
• has the tumour spread to the lymph nodes or to more distant organs?

To use these risk calculators, the following clinical data should be available:

• clinical stage(based on examination of biopsy tissue)
• Gleason score in biopsy
• pre-treatment PSA.

Note that these tables are based on a population of patients from the USA , and as such may not translate to patients from elsewhere.

1. Partins Tables

This is best-known risk calculator for predicting pathological stage. This risk calculator takes into account

1. pre-treatment PSA
2. biopsy Gleason score
3. clinical stage.

It is based on data from 5000 patients who underwent radical prostatectomy by a single surgeon at Johns Hopkins in the US .

2. Center for Prostate Disease Research Tables (CPDR)

Similar to the Partins Tables, the CPDR Tables predict pathological stage based on pre-operative clinical parameters:

1. race
2. pre-treatment PSA
3. biopsy Gleason score
4. clinical stage.

In contrast to Partins tables, they are based on a more racial diverse US population who underwent surgery at multiple institutions.

3. Memorial Sloan-Kettering Cancer Center (MSKCC) or Kattan pre-treatment nomogram

The Kattan pre-treatment nomogram helps to predict pre-operatively pathological stage based on

1. pre-treatment PSA
2. biopsy Gleason score
3. clinical stage
4. age
5. percentage of positive biopsy cores.

Further information about prostate cancer can be found at the following sites

Cancer Backup information on prostate cancer

Cancer Research UK: prostate cancer

Holmium for BPH : about the holmium laser

Lumenis website: information about HoLEP (holmium laser enucleation of the prostate)

The Da Vinci Robot for radical prostatectomy, or robotic surgery for prostate cancer

The Prostate Cancer Network: a patient-led Support Group whose aims are to improve the diagnosis, treatment, care and support to those affected by prostate cancer.

The Prostate Cancer Charity: the UK’s leading voluntary organisation working with people affected by prostate cancer. There are a number of excellent information sheets provided by them, and direct links to these can be found at the bottom of this page.

Prostate UK: fund medical research, the training of healthcare professionals and provide information on all prostate diseases

NICE guidance on prostate cancer

The prostate cancer foundation: funds research into prostate cancer and has information about prostate cancer.

Orchid: Orchid exists to save men's lives from testicular, prostate and penile cancers through pioneering research and promoting awareness

UK prostate link: a resource site for prostate cancer information