Prostate Cancer

Prostate cancer is the most commonly diagnosed cancer in men, accounting for 13% of all new cancer diagnoses and with an estimated 220,000 cases being diagnosed in 2015.[1] The vast majority of these cancers are not lethal. However, each patient with prostate cancer presents with his own medical and family background, and these factors must be taken into account when considering treatment options.

[1] SEER data

PSA screening

The majority of prostate cancer diagnoses are discovered by an initial blood test called prostate specific antigen (PSA). The demographic that benefit the most from PSA screening are men between the ages of 55 and 69. However, patients with a family history of prostate cancer or African-American ethnicity are particularly at risk and should obtain PSA screening sooner.

Prostate cancer diagnosis

If a screening PSA is elevated, this typically prompts a prostate biopsy, which is a procedure that is generally well tolerated in the clinic using local anesthetic. A pathologist then examines the core tissue samples using a microscope to see if there is prostate cancer present. If prostate cancer is detected, features of the cancer can be described, such as how aggressive the particular cancer is. Additional imaging tests may be ordered to determine the stage of the cancer. In other words, the imaging is used to determine if the cancer is still confined within the prostate or if it has evidence of local or distant spread.

Treatment options

If cancer is confined to the prostate, the options are:

Active Surveillance – In men with low risk prostate cancer features, aggressive treatment may not make sense. In these individuals, low risk prostate cancer is unlikely to impact quality of life during his lifetime, either due to age and other medical co-morbidities. Regular PSA checks and surveillance prostate biopsies every 1-2 years are typically employed to keep an eye on the prostate cancer.

Radiation therapy – A radiation oncologist delivers radiation to destroy prostate cancer either via external beams or radioactive seeds. Radiation may be given in tandem with hormone therapy depending on the type of prostate cancer. Although this is a non-invasive treatment option, radiation side effects must be considered.

Surgery – Robotic radical prostatectomy and lymph node dissection can now be performed using minimally invasive robotic surgery. The surgeon uses keyhole incisions to remove the prostate, seminal vesicles and lymph nodes. The advantages of robotic surgery include removal of the cancerous organ and lymph nodes, which provides more accurate staging of the cancer. Typical hospital stay is one night, and return to daily activities within 2 weeks. The main side effects include erectile dysfunction, and urinary incontinence.

Focal Therapy, Ablation therapy, High-intensity Frequency Ultrasound – Focal Therapy, Ablation therapy, High-intensity Frequency Ultrasound – These are alternative therapies for prostate cancers with different ways of delivering energy to destroy prostate cancer. Many of these techniques are still experimental and are only performed at select centers around the world.

If cancer has spread widely throughout the body, aggressive treatment of the prostate itself is not indicated. In these scenarios, traditionally patients are started on anti-testosterone therapy and their PSA is monitored. Over time, the prostate cancer may become hormone resistant, and other chemotherapy drugs would be indicated. Referral to a medical oncologist may also be warranted to discuss clinical trials.