An in-depth guide to prostate cancer

Prostate cancer is a condition that is common in older men, and can develop very slowly. In his latest online article, leading consultant in urology and robotic pelvic surgery Mr Edward Calleja explains the most common risk factors, symptoms and treatment options.

What are the most common risk factors associated with prostate cancer, and how do they contribute to the development of the disease?

Age: Prostate cancer is rare in men younger than 40, but the chance of having prostate cancer rises rapidly after age 50. According to Cancer Research UK, about 6 in 10 cases of prostate cancer are found in men over 65.

Race/ethnicity: Prostate cancer is more common in black men. In the UK, for example, 1 in 4 black men will get prostate cancer at some point compared to 1 in 8 men in the general population. Asian men have a lower risk than black and white men.

Family history: Men who have a relative with prostate cancer are 2-3 times more likely to develop the disease than those without a family history. The risk increases with the number of affected relatives and if the relatives are diagnosed at a younger age.

Genetic factors: Approximately 5-10% of prostate cancers are thought to be due primarily to high-risk inherited genetic factors. Men with BRCA2 mutations have an estimated lifetime risk of prostate cancer of about 15%.

Diet: High intake of red meat and dairy products might increase the risk of prostate cancer by 12%, according to some studies. Men who eat a lot of fruits and vegetables appear to have a slightly lower chance, although the effect is modest.

Obesity: A study published in "Cancer Epidemiology, Biomarkers & Prevention" found that obese men (BMI of 30 or higher) had a 33% higher risk for aggressive prostate cancer than men of average weight.

Other factors: Chronic inflammation or infections in the prostate might increase the risk of prostate cancer, but this is still under study.

What are the early signs and symptoms of prostate cancer that patients should be aware of? Are there any specific symptoms that may indicate an advanced stage of the disease?

In its early stages often has no signs or symptoms. This is because the prostate gland, where the cancer develops, is deep inside the pelvis. This means low-volume, contained prostate cancers may not cause any symptoms.

However, when symptoms do occur, they might include:

• Frequent urination, especially at night
• Difficulty starting or stopping urination
• Weak or interrupted urinary stream
• Painful or burning urination
• Difficulty having an erection
• Painful ejaculation
• Blood in urine or semen
• Discomfort or pain when sitting caused by an enlarged prostate

These symptoms aren't always indicative of prostate cancer. They can be caused by non-cancerous conditions such as benign prostatic hyperplasia (BPH), an enlarged prostate, or prostatitis, which is inflammation of the prostate gland.

Symptoms that might indicate prostate cancer that has spread (metastasised) to other parts of the body include:

• Pain or aching in the lower back, hips, pelvis, or thighs
• Unexplained weight loss
• Fatigue
• Changes in bowel habits
• Swelling in the legs or pelvic area

If you have any of these symptoms, it's essential to consult with a healthcare provider. They can perform tests to determine the cause of the signs and suggest appropriate treatment.

Regular screenings such as prostate-specific antigen (PSA) testing and digital rectal exams (DREs) are often recommended for men over 50, or younger for those with specific risk factors, as they can detect prostate cancer at an earlier, more treatable stage.

What screening methods do you recommend for detecting prostate cancer, and at what age should men consider undergoing these screenings?

Screening methods for prostate cancer remain a subject of active discussion among healthcare professionals, mainly due to the potential for false positives, overdiagnosis, and balancing the advantages and risks of early detection.

The two primary screening tests for prostate cancer are:

The prostate-specific antigen (PSA) blood test is a blood test that measures the level of PSA, a protein produced by normal and cancerous cells in the prostate. Elevated PSA levels can suggest the presence of prostate cancer. However, high PSA can also be due to non-cancerous conditions such as prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (an enlarged prostate). It's also worth noting that activities like recent ejaculation can temporarily raise PSA levels. These factors contribute to false-positive results with PSA testing.

It's important to note that there's no specific normal level of PSA. Most doctors previously considered PSA levels of 4.0 ng/mL and lower normal. Therefore, doctors often recommend a prostate biopsy if a man had a PSA level above 4.0 ng/mL. However, more recent studies have shown that some men with PSA levels below 4.0 ng/mL have prostate cancer, while others with higher levels do not.

An example of the chances of having prostate cancer per PSA level, based on age, is as follows:

For men aged 50 to 59, a PSA level of up to 2 ng/mL is normal; the chance of having prostate cancer is about 1 in 100.

For the same age group, with a PSA level of 2.5 to 4 ng/mL, the chance of having prostate cancer is about 1 in 7.

If the PSA level is 4 to 10 ng/mL, the chance of having prostate cancer is about 1 in 4.

Digital Rectal Exam (DRE): This physical examination involves a doctor or nurse inserting a gloved, lubricated finger into the rectum to assess the prostate for any irregularities in size, shape, or texture. While this test can be uncomfortable and has limitations in detecting prostate cancer, it is often performed alongside the PSA test to help identify abnormalities.

Deciding when to commence screening depends on an individual's risk profile:

• Men with average risk might consider testing starting from age 50.
• For men at higher risk — like black men or those with a first-degree relative (father, brother) diagnosed with prostate cancer before age 65 — they might consider testing starting from age 45.
• However, these are general suggestions, and the decision to screen for prostate cancer should be personalised after discussing potential benefits, risks, and uncertainties with a healthcare provider. Men should weigh their risk factors, overall health, and personal preferences in making this decision.

Once a diagnosis of prostate cancer is confirmed, what are the treatment options available? How do you determine the most appropriate treatment approach for each patient?

Active Surveillance: This method is often chosen for men with low-risk or slow-growing prostate cancers. It involves closely monitoring the cancer through regular PSA blood tests, digital rectal exams, prostate biopsies, and multiparametric MRI scans, which provide detailed imaging to assess the size and potential spread of the tumour. Treatment is initiated if tests show the cancer is progressing.

Radical Prostatectomy: This surgical procedure involves removing the entire prostate gland and lymph nodes when indicated. It can be performed through open surgery, laparoscopy, or robot-assisted laparoscopy. Surgery is typically chosen if the cancer is localised within the prostate. Still, it can also be an option for some locally advanced prostate cancer instances, where the disease has spread to nearby tissues but not to other parts of the body.

Radiation Therapy: This method uses high-energy particles to destroy cancer cells. External beam radiation therapy (EBRT) delivers radiation from outside the body, while brachytherapy involves implanting radioactive seeds directly into the prostate.

Hormone Therapy: Also known as androgen deprivation therapy (ADT), this approach lowers levels of male hormones, such as testosterone, to either shrink prostate tumours or slow their growth.

Experimental Treatments: High-intensity focused ultrasound (HIFU), cryotherapy, and electroporation (also known as NanoKnife) are among the experimental treatments being studied. HIFU uses high-frequency ultrasound energy to heat and destroy cancer cells in the prostate. Cryotherapy involves freezing prostate tissue, thereby causing cancer cells to die. NanoKnife uses electric currents to create tiny holes in the cell membrane of the cancer cells, leading to cell death.

Chemotherapy: This method employs drugs to kill rapidly growing cells, including cancer cells. This is for prostate cancer that has spread.

Determining the most suitable treatment approach depends on several factors, including the stage and grade of prostate cancer, the patient's age and overall health status, the potential side effects of the treatment, and the patient's values and preferences. These decisions should be made with a healthcare team, including urologists, oncologists, and radiation oncologists.

Are there any advancements or new techniques in the field of prostate cancer treatment that you find particularly promising or innovative? How do these advancements benefit patients in terms of outcomes and quality of life?

In the field of prostate cancer treatment, several recent advancements and techniques hold considerable promise:

Precision Medicine and Genomic Testing: Researchers can now look at the unique genomic profile of a person's cancer to understand its behaviour better and potentially tailor treatments accordingly. Genomic tests, such as Oncotype DX and Prolaris, can help predict how aggressive the tumour is, providing valuable information to guide treatment decisions. Some genetic mutations (like BRCA mutations) may also make patients eligible for newer targeted treatments, such as PARP inhibitors.

Immunotherapy: While the role of immunotherapy in prostate cancer is still being investigated, some early results are promising. For instance, certain immunotherapy drugs called checkpoint inhibitors, which help the immune system recognise and attack cancer cells, are showing potential in treating certain types of prostate cancer.

Radioligand Therapy: A relatively new type of internal radiation treatment called radioligand therapy has shown promise in treating advanced prostate cancer. In this approach, a radioactive substance is attached to a molecule that can specifically target prostate cancer cells, delivering radiation directly to the tumour. Lutetium-177 PSMA is one such radioligand that's currently under investigation.

Prostate-Specific Membrane Antigen (PSMA) PET Scanning: PSMA PET scanning is a new imaging test that can help doctors better identify the location of prostate cancer that has recurred after initial treatment, even when the PSA level is very low. It is more sensitive and accurate in detecting prostate cancer than conventional imaging methods, improving diagnosis and treatment planning.

Use of Artificial Intelligence (AI) and Machine Learning: AI and machine learning can potentially revolutionise prostate cancer care. From improving the accuracy of MRI scans and the prediction of disease progression to helping identify which patients might benefit from specific treatment strategies, these advanced technologies hold considerable promise. AI can have a role in robotic surgery in future and as well in radiotherapy planning.

These advancements aim to improve patient outcomes, including survival rates, and minimise side effects, thereby enhancing the quality of life for prostate cancer patients. Each technique or approach requires further research and is currently at other clinical testing and adoption stages. Still, they all illustrate the exciting progress being made in this field.

Mr Edward Calleja is a renowned consultant in urology and robotic pelvic surgery based in East Sussex, with over 15 years of experience. If you would like to book a consultation with Mr Calleja, you can do so today via his Top Doctors profile.