Prostate cancer: warning signs, diagnosis and treatment

Written by: Mr Rick Popert
Published:
Edited by: Bronwen Griffiths

The prostate is an organ that is unique to men rather than women. Men are born with a prostate gland that is small and as one gets older, the prostate gland gets bigger. As it gets bigger, it can restrict your urinary flow and that can cause problems in men as they get older. It can also be the site or development of a prostate cancer which requires treatment in men as they get older. Mr Rick Popert, expert urologist, discusses the most important warning signs for prostate cancer, and how it is diagnosed and treated.

What are the main warning signs & symptoms to be aware of for prostate cancer?

The first issue with the prostate gland is that because it gets bigger, it may restrict the urinary flow between the bladder and the urethra so men may complain of hesitancy, poor flow and incomplete emptying. These are usually signs of prostate enlargement and in people who have got an enlarged prostate with a significant cancer, this may be how they present their symptoms.

However, most men will present with no symptoms. They may simply have an elevated PSA blood test. This blood test stands for prostate specific antigen and is prostate specific, it is not prostate cancer specific. However, a PSA level can give an indication that somebody is at risk of developing prostate cancer. We usually recommend that this is tested from the age of 50 or from the age of 40 in men who have a family history of prostate cancer. It is also important to know what your own baseline PSA is. If the PSA in the 40-year-old man is above 2, that could certainly be suspicious for early prostate cancer; above 3 in a 50-year-old man and above 4 in a 60-year-old man.

How is prostate cancer diagnosed?

Men may present signs of prostate cancer because they have urinary symptoms or because they have the elevated PSA blood test. We can sometimes identify prostate cancer on a physical examination of the prostate which is done through the back passage with a finger. However, that is not the most accurate way to diagnose prostate cancer.

The most modern technique is to use an MRI scan of the prostate which allows us to visualise the shape of the prostate and identify if there is any area within the prostate gland that we might say does not look right and looks like it may be a cancer. In those situations we can then do prostate biopsies in which we take some samples from the prostate to see if we can find the cancer visualised by the MRI scan or if the MRI scan is normal. However, if the PSA blood test remains elevated, we may still want to do biopsies around the prostate gland. The important thing to understand is that the prostate gland can harbour prostate cancer silently and therefore biopsies are necessary to identify whether there is any cancer in the prostate.

How is prostate cancer treated?

Once a prostate cancer diagnosis has been made, we have some information from the biopsy that gives us an idea about the grade of the cancer. That tells us something about how potentially aggressive it may be. Some prostate cancers are low grade, non-aggressive and they may grow very, very slowly for many, many years and they may require no treatment. In that situation, we will monitor the PSA over time and that is called active surveillance.

In patients who have a higher grade of tumour, we may offer them either some form of radiotherapy treatment or some form of surgery. The radiotherapy treatments lie between brachytherapy where we put radioactive seeds individually into the prostate to kill a prostate cancer in situ or external beam radiotherapy where the radiation is beamed in from outside the body.

In both of these treatments, the prostate gland remains in place in the body. Surgery, however, requires removal of the prostate gland. From 10 years ago, this surgery was routinely done by open surgery. Nowadays, we can actually do the surgery less invasively using keyhole surgery and robotics. This allows us to remove the prostate gland much more safely with less morbidity, particularly with regards to urinary incontinence or erectile dysfunction.

What is the outlook for people with prostate cancer?

Although prostate cancer is the commonest form of malignancy in men, most men will not die from prostate cancer. If it can be caught early and adequately treated, most people will have a normal life expectancy. The critical thing with diagnosing and treating prostate cancer is to identify significant disease early and to offer an appropriate treatment early so that the long-term effects of prostate cancer spreading outside the prostate gland itself are avoided. In that way, most patients will have a normal life expectancy.

 

If you would like an expert's opinion, make an appointment with a specialist.

By Mr Rick Popert
Urology

Mr Rick Popert was appointed as a consultant to Guy’s & St Thomas’ Hospitals in 1996, having completed his higher surgical training at Guy's and urological research at King's College Hospital.  Mr Popert's clinical expertise is in the comprehensive evaluation and surgery of benign and malignant prostatic disease.
 
PROSTATE CANCER SURGERY:
- Robotic Prostatectomy with the Da Vinci Robot  – Conventional, Retzius Sparing & Salvage Prostatectomy

He successfully transferred his experience from conventional open radical prostatectomy (over 200 cases between 1997 and 2005) to the Da Vinci robotic assisted approach in 2006 and since then has carried out over 800 robotic prostatectomies. He has the UK’s largest experience of salvage prostatectomy following radiotherapy and brachytherapy and has helped to establish a tertiary referral “salvage surgery” clinic at Guy’s Hospital. He is also establishing a “Retzius sparing” surgery programme at Guy’s, in selected cases.
 
PROSTATE BRACHYTHERAPY: 
- Focussed Dynamic Prostate Brachytherapy – Day Case Procedure for low to intermediate risk prostate cancer
- Brachytherapy as a boost to External Beam Radiotherapy for intermediate to high risk prostate cancer.
 
He has the UK's largest experience of single visit dynamic intra-operative “focussed” prostate brachytherapy and has carried out over 900 of these cases since 2004. The oncology team with Dr Stephen Morris and Dr Ronald Beaney, Consultant Clinical Oncologists. can also offer brachytherapy as a “boost” to external beam radiotherapy and the insertion of Fiducial Markers and the SpaceOAR rectal spacer to reduce rectal dosing.
 
PRECISION PROSTATE CANCER DIAGNOSTICS:
- MRI – US Fusion Targeted Prostate Biopsies + Systematic Transperineal Biopsies (General Anaesthetic)
- Precision Point – 2 Puncture Targeted and Systematic Transperineal Biopsy (Local Anaesthetic)
 
He is an expert in Precision Prostate Diagnostics and has developed a rapid access prostate MRI assessment service with Dr Giles Rottenberg, Consultant Radiologist, combined with a unique systematic transperineal biopsy approach providing accurate tumour localisation, an approach that has been further enhanced by the technique of MRI US Fusion Targeted biopsy of the prostate which he introduced in March 2012. Over the last year he has been evaluating the Precision Point Transperineal Access System, which facilitates targeted and systematic transperineal biopsies using a 2 puncture approach under local anaesthetic.
 
BENIGN PROSTATIC DISEASE:
- Holmium Laser Prostate Enucleation for benign prostate disease - HoLEP
- Prostate Arterial Embolisation - PAE
 
For benign prostatic disease, he has one of the UK's longest experience of holmium laser prostatectomy (HoLEP), establishing a service at Guy’s in 2002. He has carried out over 800 holmium laser enucleations with reduced bleeding and length of stay in patients with prostate volumes larger than 100 cc compared with standard transurethral prostatectomy (TURP), the only hospital in London to do so. He established a Prostatology service at Guy’s Hospital attracting tertiary referrals from across London of very large prostates. In 2014 he introduced a prostate arterial embolisation service in association Dr Tarun Sabharwal, Consultant Interventional Radiologist.  This is an alternative to the surgical management of benign prostatic disease avoiding the complications of urinary incontinence, erectile and ejaculatory dysfunction. 

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