With the introduction of PSA and PCA-3 testing, prostate cancer is being diagnosed earlier than ever before; the corollary to this is that the potential for cure is much greater.
Whilst it is true that for some elderly and frail patients, the diagnosis of prostate cancer is irrelevant (in that it will not progress and threaten within their expected life time) for most others the warning signs of a raised PSA, prostatic urinary symptoms (although much more commonly due to benign prostatic disease), positive family history of the disease etc. merits investigation, diagnosis and curative treatment.
This article on prostate cancer treatment is written by Dr Nick Plowman, MD, Senior Clinical Oncologist to St. Bartholomew’s Hospital, and The Hospital for Sick Children, Great Ormond Street, London.
Prostate biopsy (via trans-rectal ultrasound) is the definitive method for diagnosing early prostate cancer and involves 8-12 core biopsies taken from different areas of the gland. The microscopic appearance of the prostate cancer will give a clue as to how aggressively it will grow in the future (Gleason score).
Once the diagnosis of prostate cancer has been made, it is very important to discern whether it is ‘organ confined’ or not and a high quality MRI scan is important in this regard. Where the capsule of the gland is intact (T1-2 stage disease) management is different from those cases where the disease has breached the capsule and extended outside the gland (T3-4 disease). Similarly, the pelvic MRI scan will show if there is spread to pelvic lymph nodes and a bone scan is used to exclude (as far as possible) spread to bone.
From the investigations discussed so far, the disease has been diagnosed and staged. From these tests it is also possible to prognosticate into higher and lower risk patients (with regard to potential for later relapse risk). Higher risk patients will have higher PSA levels, higher Gleason grades and a tendency to have trans-capsular spread, whereas lower risk patients will have low PSA levels, average Gleason scores (6-7) and have no capsular breach or distant evidence of disease outside the gland, on pelvic MRI.
For lower risk patients, radical surgery (by either open or robotic means) has been a popular method of cure for many years, although it is a large pelvic operation and there are definite risks of urinary incontinence and impotence and a lengthy recovery period post-operatively – all of which present drawbacks to the procedure. The microscopic margin-free rates of the robotic surgical series are of some potential concern and it will require long term follow up rates to discern as to whether the long term cure rates are as high as for open surgery. Nevertheless, for younger patients with obstructive urinary symptoms it remains an important curative option.