Prostate Cancer

Prostate Cancer

What is prostate cancer?

prostate-anatomy2Prostate 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.

What Are The Symptoms Of Prostate Cancer?

Often prostate cancer does not produce any symptoms, or it may produce symptoms similar to benign enlargement of the prostate, BPH. These include:

  • 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 with prostate cancer 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).

Can any other tests help determine the likelihood of prostate cancer?

A multi-parametric MR imaging test (mp-MRI) has been shown to identify areas in the prostate suspicious for cancer. Mp-MRI uses 2-3 sophisticated interpretations of digital information from the scan to allow the radiologist to identify these abnormality. It is now known that the accuracy of MRI is superior to any laboratory test available so far. Although the quality is outstanding, mp-MRI cannot diagnose prostate cancer alone and it also cannot fully exclude prostate cancer either. A biopsy is most commonly still required. However, it can give valuable information regarding the risk of prostate cancer, if it is normal, and suspicious areas can be targeted using MRI-US fusion technology. CUP works closely with the Radiologists at Addenbrooke’s Hospital who are accredited experts in reading Prostate mp-MRI.

How is prostate cancer diagnosed?

Men should undergo an mp-MRI first. This will allow an initial assessment prior to transperineal prostate biopsy using guidance by fusion the MRI to the life ultrasound. Few patients will need to undergo a TRUSP prostate biopsy  in order to establish the diagnosis of prostate cancer. Prostate biopsy involves taking several cores of prostate tissue using an ultrasound probe placed in the rectum, and is usually done under a short general 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.

What other investigations will be needed?

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.

What Are The Treatment Options For Prostate Cancer?

There may be a number of suitable treatments, and for patients with suitable localised disease these might include:

For advanced or metastatic disease, the options may include:

Brachytherapy involves implanting tiny pellets which release low level radiation into the prostate in an attempt to kill of cancer cells whilst sparing healthy surrounding tissue. This technique also offers itself to be used as focal therapy.

Testimonial from a patient who has undergone brachytherapy

MRI Fusion transperineal prostate biopsies & Brachytherapy

To: Mr Kastner and Dr Russell

I am very privileged to have met you and benefitted from your extensive knowledge and very high level of expertise in urology and prostate cancer.

My experience of your consultations, assessment and subsequent treatment was exceptional.

I left with the impression that the service I received was personalized and of the highest standard and have the confidence that I have received the best treatment from the best doctors in the world.

I was particularly impressed with the sense of urgency from top down, including Andrew Styling, your secretaries and of course the staff in the Addenbrooke’s Treatment Centre.

Thank you
Kind regards

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 options for men with localised prostate cancer and see our information sheet about robotically assisted laparoscopic prostatectomy, or robotic surgery for prostate cancer.

The Team of Experts

Oncologists

Urologists:

Testimonials from patients who have undergone robotic prostatectomy:

Mr DR aged 63

"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 PG

"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 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."

Prostate cancer calculators

For patients who have not had a diagnosis of prostate cancer made:

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

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

Risk indicator 2

  • 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. Partin Tables

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

  • pre-treatment PSA
  • biopsy Gleason score
  • 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:

  • race
  • pre-treatment PSA
  • biopsy Gleason score
  • 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

  • pre-treatment PSA
  • biopsy Gleason score
  • clinical stage
  • age
  • percentage of positive biopsy cores
Further Information

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

Macmillan 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

  1. Information Sheets
  2. Videos

IntroductionsThe basics of robotic radical prostatectomy; what the equipment does and how the procedure is carried out by fully-trained laparoscopic surgeons

About the ProstateHow decisions are made about your treatment from initial diagnosis to multidisciplinary discussion of your scan and other investigations before a final decision is made about treatment

What Can You Do For YourselfSome simple measures which will prepare you for surgery and allow you to obtain optimum results (e.g. losing weight, stopping smoking and leading a healthy lifestyle)

Just Before The OperationWhat to expect in advance of your surgery and what measures will be instituted when you arrive in hospital for your operation

Pelvic lymph node samplingLaparoscopic, sampling of the pelvic (obturator) lymph nodes to determine whether there has been spread of the tumour, prior to removal of the prostate gland for cancer

Re-joining the urethra to the bladderRobot-assisted surgery allows accurate placement of sutures to join the bladder back to the urethra after removal of the prostate. A catheter (visible at times in the video) is inserted across the join when it is complete

After The OperationWhat to expect in hospital once the operation has been performed, including advice on the early days after discharge from hospital

Returning HomeAdvice on what to expect when you get home, recovery time and important instructions on what you can and should not do in the post-operative period

Finding Out About The Results Of SurgeryThe prostate will be examined carefully by pathologists and the results will then be collated by the multidisciplinary team who will contact you to let you know the results

Follow-Up VisitsWe have a specific protocol for how patients are followed up and what tests are done at each visit; this allows careful audit of our results and allows us to refine our surgical techniques if necessary

What Happens If I Need More Treatment?Some patients may need further treatment after surgery (e.g. radiotherapy) if all the disease has not been removed or if there are signs of tumour recurrence at a later stage

Patients' Stories