Your Questions Answered: Prostate Cancer

In this month’s Your Questions Answered series we take a look at some of the common urological conditions that people experience.

Mr Leye Ajayi is a Consultant Urological Surgeon at St John & St Elizabeth Hospital, specialising in minimally invasive surgery for urinary tract stone disease, prostate cancer and other conditions of the urinary tract.

Here, he speaks to us about some of the warning signs of prostate cancer, and the treatment pathways available to patients with the disease.

What is prostate cancer?

Prostate cancer is the most common form of cancer in men in the UK, and has quite a high incidence in the Western world, which might be related to diet. The prostate is an organ just at the base of the bladder that produces nutrients to aid the survival of sperm outside of the body. In your youth, having a prostate is very useful because it aids conception and survival of the sperm externally. As men get older, the prostate gets larger and they start developing urinary symptoms. Unfortunately, in a proportion of patients the prostate develops prostate cancer.

What are some key warning signs of prostate cancer? 

The vast majority of our patients are very often asymptomatic, but if a patient does become symptomatic of prostate cancer it is often when the disease is in an advanced stage.

The vast majority of prostate cancer is picked up because the patient has some urinary symptoms which are not always related to the prostate cancer itself. It can be related to the fact that the patient has difficulty urinating or if they have a poor stream. They might need the toilet a lot at night or when they go to the toilet the stream is very poor. They also might have urgency and a strong, sudden need to urinate.

When they attend a medical appointment, the primary care physician will perhaps run a blood test called a PSA – prostate specific antigen. It’s an antigen that is released by the prostate under normal circumstances but when a patient has prostate cancer the cells release a higher volume of the antigen – giving patients a high PSA. In addition, the physician will also carry out a digital rectal examination. That gives us an idea of consistency and texture of the prostate, and helps in identifying a patient who has the potential to have prostate cancer.

Is prostate cancer curable? 

It is curable – but first you have to identify the cancer and the way we do that is by carrying out a biopsy of the prostate.

There are various ways to biopsy a prostate. All over the world, the conventional method has been to approach via the rectum, but we now have more sophisticated methods at our disposal – involving MRI fusion biopsy or transperineal biopsy. These are thought to be more targeted, lead to a lower risk of infection and a lower chance of complications.

Once we have diagnosed the prostate cancer, we usually need to check whether there are cancers elsewhere in the body. Often we do a bone scan because frequently the first place for the cancer to metastasize is in the spine. Then there are more sophisticated investigations such as a PSMA PET scan, which is a very expensive test but highly useful in checking for metastatic disease.

What is the treatment for prostate cancer?

Some cancers are not necessarily aggressive. Urologists use an analogy called the pussycat and the tiger; some cancers – the pussycats – are very indolent and don’t really affect the patient’s quality of life or life expectancy. Then you have the aggressive tiger, which if left untreated will certainly cause harm to the patient.

The way we assess this is by looking at what’s called the patient’s Gleason score, where the pathologist looks at the pathology specimen and gives us an idea of how aggressive that cancer is. If a patient has a low Gleason score and a low PSA, it could be that only one of the biopsies is positive. In that case, it might be that we offer the patient what’s called active surveillance, meaning we do not necessarily offer treatment for that cancer and just watch the patient by performing annual PSAs and an MRI every two years. If the PSA does not rise or the MRI does not change, then that individual does not need treatment and we can just watch that cancer over a period of time. We have a lot of patients who we currently manage on active surveillance.

However, if the patient does have a cancer that’s thought to be high grade – or a ‘tiger’ – then we offer treatments. The treatment could be to remove the prostate in its entirety, and in modern medicine we offer what’s called robotic assisted radical prostatectomy. This is a procedure that’s carried out using the Da Vinci robot, and allows you to get very close to the areas you want to dissect, rather than making a big cut into the lower abdomen. As you’re able to get the camera into a very small area, you only need to dissect a small amount of the patient.

That has a number of advantages. One is that fact that you’re not doing a large dissection, meaning the analgesic requirements of the patient are lower and the inpatient stay is significantly shorter. But the really big benefit of robotic assisted surgery is that it’s precision reduces the risk of damaging the nerves which supply the patient’s erections – nerves which are often sacrificed during open surgery. The robotic assistance means there is a reduction in the incidence of erectile dysfunction and incontinence associated with this form of surgery.

Some patients decide that the risk of losing potency or being incontinent should be avoided entirely, and they might choose to have radiotherapy as their primary treatment. There is evidence that radiotherapy is equally effective for patients who have intermediate-grade prostate cancer.

If the patient’s prostate cancer is deemed to be low risk, they might be offered a treatment called HIFU – high intensity focused ultrasound – which essentially identifies a small area of the prostate containing the cancer, and uses ultrasound in an effort to try and eradicate that small area.

If the patient has advanced disease or metastatic disease, there will be an oncologist involved in the patient’s care, and often the patient goes on hormone manipulation which involves drugs to try and dampen down the testosterone and starve the cancer of testosterone in an effort to control it. Often this is more palliative rather than treating and removing the cancer – so they might have radiotherapy as well as hormone manipulation in an effort to control the cancer.

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