Many cancers are undiagnosed, slow growing and harmless. Most elderly men do have microscopic areas of cancer within their prostate, though nearly all will live and die from other conditions.

However, other types may be more aggressive, and may grow and spread to cause symptoms and harm. The incidence of prostate cancer is rising in the UK, with more and more patients coming forward for testing.

Prostate cancer can be diagnosed quickly and easily with simple outpatient tests, offering men the chance to detect tumours at an early and curable stage, often when no symptoms are present. Prostate cancer is more common in Afro-Caribbean men, the overweight, and men with a strong family history. Carriers of the breast cancer genes BRCA1 or 2 are at increased risk of more aggressive disease.

Symptoms

Many men may have prostate cancer without being aware of any symptoms. Some men may have urinary symptoms, with a poor flow, blood in the urine, difficulty urinating or urinating more frequently.

These symptoms may occur with benign (non-cancerous) enlargement of the prostate, so specific tests are needed to differentiate if a man’s symptoms are due to cancer or not. Some men may have advanced cancer, with vague symptoms such as back pain, or weight loss.

Assessment & Diagnosis

PSA

This simple blood test detects the Prostate Specific Antigen protein in the bloodstream. This is a normal product of the prostate and aids fertility. It may leak into the bloodstream at elevated levels due to infection, inflammation (prostatitis) or prostate cancer. Some men may have prostate cancer even with a normal PSA, so the test is not 100% accurate. However, it remains the single most useful test to detect early prostate cancers. The level of PSA can be used to decide if further tests, such as a prostate biopsy are necessary.

The use of PSA testing has led to a significant increase in the diagnosis of prostate cancer in Europe and the USA over recent years, with more cancers diagnosed at an early (curable) stage. A large European multi-national clinical trial has shown that PSA screening reduces the risk of death from prostate cancer by 30 %, while screening of high risk groups may see greater pick-up of higher grade, more aggressive tumours in younger men.

PSA testing has led to many small non-aggressive cancers being diagnosed which might have otherwise been unknown. Many of these insignificant cancers need no treatment.

PCA3

This is a new molecular urine test for prostate cancer. It detects minute amounts of products expressed by the PCA3 gene which is found in higher levels in cancer tissue, using techniques similar to forensic scientists detecting DNA at a crime scene. A positive result indicates a higher chance of cancer being present and the need for further tests. A negative result is greatly reassuring and may save a patient the need for further investigations or repeated prostate biopsies. This novel test is not available on the NHS.

Prostate ultrasound and biopsy

The modern diagnosis of prostate cancer relies on tissue biopsies taken using accurate ultrasound guidance. This outpatient test, performed under local anaesthetic also gives information on prostate size, and the ‘PSA density’, which aids prostate cancer risk assessment.

Midlands Urology carries out targeted transrectal prostate biopsies in addition to the standard 12 sectors of the prostate, to identify which areas within the prostate are abnormal, allowing more accurate treatment planning and more informed decision-making by patients than unmapped biopsies.

Pre-biopsy MRI

Many surgeons only offer MRI scanning of the prostate after a biopsy has been taken. This can lead to misinterpretation due to inflammation or haemorrhage. MRI scanning of the ‘virgin’ prostate allows more accurate and reliable assessment of the gland and aids targeted biopsies to areas which look suspicious. It helps in risk assessment for nerve-sparing surgery by more accurately quantifying cancer location and volume, and may also reduce the need for biopsies in patients considered at low risk of having cancer based on multiple diagnostic parameters.

This gives patients the opportunity to make an informed choice as to how to be investigated/treated further. ‘Multiparametric’ MRI scanning before biopsy has been recommended by NICE in January 2014 to improve cancer pick up rates and diagnostic accuracy.

Treatments

Radical prostatectomy

This highly specialist and technically demanding operation involves the removal of the whole prostate and reconstruction of the urinary tract to cure early prostate cancer, while preserving patients’ continence, sexual function and quality of life. It can be performed by open, laparoscopic or robotic (da Vinci) surgery. Midlands Urology is the first private clinic in the Midlands offering robotic prostate surgery, and one of a small number of providers in the UK with the expertise in this field, indicating the training and skill required to offer this form of surgery.  In the USA, robotic prostatectomy has replaced laparoscopic surgery which now constitutes less than 1% of procedures annually. In the UK 75% of prostate surgery is now performed robotically, supporting its advantages over open surgery.

Robotic prostatectomy has replaced open radical prostatectomy in specialist units as the operation of choice, due to reduced bleeding, more accurate dissection, less post-operative pain, shorter hospital stay and faster recovery.  In Wolverhampton over 90% of patients are treated as an overnight stay, and are able to return to full leisure and work activities within a few weeks.

Peter Cooke performed hundreds of laparoscopic prostatectomies between 2008 and 2011, and was one of the first surgeons in the UK to perform laparoscopic radical prostatectomy as a day case. He is amongst the highest volume NHS urological surgeons and has audited outcomes similar to large series published from the USA and Europe.

Peter Cooke switched to robotic surgery in 2011, convinced of the superiority of da Vinci over standard laparoscopic surgery. Since then he exclusively performs prostate surgery robotically, and performs over 100 cases annually. His own results show high cancer clearance rates, greater lymph node removal and earlier return to full urinary continence and sexual function. He closely audits his outcomes and is constantly striving to minimise unwanted side effects. Young, fit patients with normal sexual function pre-operatively should expect to regain full continence within weeks and potency rapidly, depending on nerve-sparing surgical technique.

Nerve-sparing prostatectomy

Any surgery or treatment to the prostate may entail removing, or damage to, the nerves responsible for attaining an erection. In selected patients with smaller, low-risk cancers, it may be possible to preserve these nerves with precise and specialist surgical techniques. Robotic surgery with 3D high definition vision offers the best possible view to achieving this. Post-operative medical therapy can enhance recovery of erections, but accuracy in surgical dissection, enabling preservation of the delicate nerves, is crucial in maintaining normal sexual activity. These techniques are not suitable for all patients, as higher risk cancers may not be cured by dissecting too close to the prostate. Careful pre-operative counselling and patient selection by an experienced surgeon are required to choose the most appropriate procedure for each individual, with the grade (degree) of nerve-sparing tailored according to prostate cancer risk.

Peter Cooke individualises nerve-sparing for every suitable patient, based on more accurate targeted biopsies, and MRI scans. Each case is assessed and allocated a risk score which defines what grade of nerve sparing is appropriate, without compromising cancer clearance. A pre-operative planning tool is used to map out the tumour and safely guide how close to the prostate dissection can be performed. The erectile nerves lie within layers of fascia (tissue) like layers of an onion. Choosing precisely which layer to preserve is critical in optimising outcomes. The enhanced vision and dexterity of robotic surgery over open surgery enables the surgery to be performed with pin-point accuracy, often within fractions of a millimetre.

Our prospective audit of 500 cases of robotic surgery in Wolverhampton has shown that patients with full erections preoperatively undergoing full nerve sparing on both sides can expect a 90% chance of maintaining their sexual function. This falls to 65% if only one nerve is fully spared or only partial nerve preservation is carried out, in the case of more extensive tumours. Patients who have both nerves excised will not have spontaneous erections, nor are they likely to respond to oral medication such as Viagra tablets. Other treatments such as a vacuum device or injection therapy will be required.

Surgery for locally advanced/’high risk’ prostate cancer

Many patients with prostate cancer have disease which has not spread to the bones, but is ‘locally advanced’ ie on the surface of the prostate, or ‘high risk’ ie likely to have microscopic disease (not visible on MRI or CT scan) affecting local structures or the pelvic lymph nodes. Previously these men were generally not offered surgery as the chance of cure was low. Recent evidence and expert opinion now favours offering surgery in selected cases in order to give the best long-term outcome, even if cure by surgery alone is unlikely. Many men go on to have radiotherapy as well, possibly in combination with hormone therapy. This is called ‘multi-modal’ therapy, an approach consistent with other cancers such as breast or colo-rectal, where sequential treatments are standard practice.

Experienced robotic surgeons are now offering surgery with fast recovery and minimal complications as the first step in treating locally advanced prostate cancers, including removing the pelvic lymph nodes. It is likely that this will influence the long-term behaviour of the cancer, delay the need for subsequent treatments, reduce treatment-related side effects, and control local pelvic symptoms such as pain, bleeding, urinary frequency or poor urinary flow. In Wolverhampton, figures show that locally advanced disease is present in over 50% of men treated with robotic prostatectomy. Many of these men would only have been offered radiotherapy elsewhere.

Active surveillance

Active surveillance of early prostate cancers may be appropriate for some selected patients who are more elderly, or who have other medical problems, where the cancer is thought to pose a low risk of causing harm. This entails regular check-ups and repeat PSA testing in a carefully monitored schedule, often with repeat MRI and/or biopsies. Treatment may be offered later if there is evidence of the cancer growing, or if the patient prefers it. Low risk slow-growing small volume cancers are usually monitored in order to avoid unnecessary treatment, as recommended by NICE in January 2014. This is a safe alternative in selected patient to undergoing immediate, and possible unnecessary, curative treatment.

Other treatments

Other treatments exist to treat early cancers, including Cryosurgery (freezing the cancer), and HIFU (High Intensity Focused Ultrasound). These treatments are not recommended by NICE as preferred treatment options. They are still subject to clinical research, as their long-term effectiveness has not yet been proven. Focal HIFU is gaining popularity as a concept, with only part of the prostate treated. This is aimed at reducing physical side effects, but entails complex follow-up with multiple scans and biopsies, and uncertainty of outcome. Brachytherapy (internal radiotherapy using radio-active seed implantation) is unsuitable for patients with significant urinary symptoms, large prostates or higher risk cancers. Midlands Urology does not offer these treatments.

Medical (Drug) treatments

Some men may not be suitable for direct (‘radical’) treatment to the prostate, particularly if there is evidence that the cancer has grown outside the prostate, either to the lymph nodes in the pelvis or the bones. Generally, these men are treated with hormone treatments which work by starving the cancer of the male hormone, testosterone. Testosterone-blocking treatment can be given orally, but many men required testosterone suppression by monthly injection. Commonly men experience metabolic side effects with this, with hot flushes and weight gain. Patients need to have dietary advice, a program of exercise and vitamins and calcium supplements to maintain bone strength. Bisphosphonate drugs help bone metabolism. Men may live for many years, even with disease that has spread to the bones, and ultimately the hormone treatments may become ineffective.

Previously chemotherapy and/or steroids were then offered by an Oncology specialist. Abiraterone and Enzalutamide have now been licensed for use in the UK for hormone-resistant prostate cancer, with improvements in survival shown in clinical trials. These oral medications have fewer side effects.

Other trials have investigated the use of these medications at diagnosis in combination with hormone therapy, and one trial has shown benefit of using Docetaxel chemotherapy or Abiraterone early to improve long-term survival.

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Peter Cooke

Mr Peter Cooke MB ChB MD FRCS England FRCS Ireland FRCS (Urology) is a leading urological surgeon and cancer specialist.

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