Prostate Cancer

Title. Prostate Cancer. Class. Year 2. Course. Surgery.

[Audio] Prostate cancer is a significant health issue affecting many men worldwide. One in eight men will develop prostate cancer during their lifetime, making it the most common cancer diagnosed in men. Furthermore, it is the third leading cause of cancer-related deaths among men..

[Audio] Prostate cancer is primarily adenocarcinoma of the prostate gland, occurring mainly in the peripheral zone. This type of cancer is becoming increasingly prevalent, with diagnosis rates rising each year. One in eight men will develop prostate cancer during their lifetime, making it the most common cancer diagnosed in men. Additionally, it is the third leading cause of cancer-related deaths in men. However, survival rates have improved over time, with five-year survival rates increasing from 65% in 1998 to 91.5% in 2013..

[Audio] The symptoms of prostate cancer can manifest in various ways. Storage symptoms include urgency, frequency, nocturia, and urinary incontinence, which are caused by the compression of the urethra by the growing tumour. This can lead to exhaustion due to frequent nighttime awakenings. Other symptoms include voiding symptoms like hesitancy, weak flow, straining, terminal dribble, and feeling of incomplete emptying. These symptoms can significantly impact a man's quality of life, making it difficult to perform daily activities. Additionally, some men may experience blood in their urine or semen, dysuria, and dysejaculation, which are indicative of advanced disease and require prompt medical attention..

[Audio] Prostate cancer can manifest clinically in various ways. Bone pain is one of the primary symptoms, which occurs when cancer cells spread to the bones. This can lead to pathological fractures, typically affecting the spine, hips, and ribs. Additionally, hypercalcemia, an elevated level of calcium in the blood, can result from the destruction of bone tissue by cancer cells. These symptoms can greatly affect a patient's quality of life and necessitate immediate medical attention..

[Audio] Prostate-specific antigen, or PSA, plays a crucial role in the body's reproductive system. Its primary function is to liquefy the ejaculate, allowing for successful fertilization. Additionally, it is excreted in both semen and urine, with small amounts present in the bloodstream. The exact role of serum PSA remains unclear, but its presence has been linked to various conditions, including prostate cancer, benign prostatic hyperplasia, urinary tract infections, and post-digital rectal examination of the prostate. The availability of PSA testing has enabled the diagnosis of prostate cancer at an earlier stage, making it a valuable tool in the detection and management of this disease..

[Audio] The PSA test is not ideal because it is not specific for prostate cancer. Even if the result is high, there could be other reasons for this. If a patient has a high PSA reading, further tests would need to be done to confirm whether they have prostate cancer. These tests include DRE, TRUS, and MRI. Each of these tests has its own limitations, such as being unable to detect all areas of the gland or missing clinically significant cancers. Treatment discussions would then follow a diagnosis, and active surveillance might be considered for patients with low-grade and low-volume disease. It is essential to discuss the PSA test with patients prior to taking it and provide them with information about what it entails..

[Audio] The PSA level ranges from 0 to 0.5 nanograms per milliliter, corresponding to a 6.6 percent risk of developing prostate cancer. As the PSA level increases, so does the risk of developing prostate cancer. For instance, a PSA level between 0.6 and 1 nanogram per milliliter carries a 10.1 percent risk of developing prostate cancer, whereas a PSA level between 2.1 and 3 nanograms per milliliter carries a 23.9 percent risk of developing prostate cancer. The risk of developing prostate cancer is highest when the PSA level exceeds 10 nanograms per milliliter, with a risk of more than 50 percent..

[Audio] Age is a significant risk factor for prostate cancer, with 75% of diagnoses occurring above the age of 65 years. Furthermore, ethnicity also plays a crucial role, with black individuals being more susceptible than white and Asian populations. Additionally, westward migration has been linked to an increased risk of developing prostate cancer. Hereditary factors also contribute to the development of prostate cancer, with approximately 9% of cases being hereditary. The number of genetic defects implicated in this process remains unclear. Dietary habits have also been linked to an increased risk of developing prostate cancer. Specifically, excessive alcohol consumption, smoking, and obesity have been identified as potential risk factors. On the other hand, regular exercise has been shown to protect against the development of prostate cancer. Finally, 5-alpha reductase inhibitors have been used to treat benign prostatic hyperplasia, but their role in reducing the risk of developing prostate cancer is still uncertain..

[Audio] The controversy surrounding prostate-specific antigen, or PSA, screening is well-documented. Despite its widespread use, many associations do not recommend it due to its limitations. Specifically, PSA lacks both specificity and sensitivity, making it an unreliable tool for diagnosing prostate cancer. Furthermore, the long latency period between initial diagnosis and eventual mortality means that many men die from other causes unrelated to their prostate cancer. This highlights the need for more effective and reliable methods for detecting and managing this condition..

[Audio] The guidelines for diagnosing prostate cancer vary depending on the patient's age. According to the NICE guidelines, patients with a PSA level greater than 3 nanograms per milliliter should be referred for further assessment. The National Comprehensive Cancer Network (NCCP) guidelines, on the other hand, recommend different age-adjusted cut-offs for referring patients for assessment. For example, patients under the age of 50 with a PSA level less than 2 nanograms per milliliter may not require referral, while those between 50 and 59 years old with a PSA level of 3 nanograms per milliliter should be referred. Patients over the age of 70 with a PSA level of 5 nanograms per milliliter should also be referred. In addition to PSA levels, digital rectal examination (DRE) can also be used to diagnose prostate cancer. Any irregularities detected during a DRE should be referred for further assessment, regardless of the patient's PSA level. However, it's worth noting that DRE has significant inter- and intra-observer variability, with some studies suggesting that it can detect abnormalities in as few as 17% of cases. Magnetic resonance imaging (MRI) is increasingly being used in the diagnosis of prostate cancer, particularly in the pre-biopsy stage. Finally, prostate biopsy is another diagnostic tool used to diagnose prostate cancer. This can be done through either transrectal or transperineal routes, but both methods have significant complication rates associated with them..

[Audio] Multiparametric MRI is used in the management of prostate cancer to provide valuable information on the extent and location of the tumor after the confirmation of cancer. A report with PIRADS is essential when using this imaging technique, which includes T2-weighted images, diffusion weighted images, and dynamic contrast enhancement. These imaging techniques help to obtain a complete and detailed picture of the cancer, guiding treatment decisions and monitoring the response to treatment..

[Audio] The traditional method of biopsy for prostate cancer diagnosis is transrectal biopsy, which involves blocking the nerves in the area around the prostate with a local anaesthetic, followed by the insertion of a needle into the prostate gland to collect six tissue samples from each lobe. This method has been used for many years, but it carries a small but significant risk of complications, including sepsis, haematuria, haematospermia, blood in the urine or semen, and transient lower urinary tract symptoms. In contrast, transperineal biopsy is rapidly becoming more widely adopted, allowing for the collection of up to 40 tissue samples from the prostate gland. The risks associated with transperineal biopsy are much lower than those associated with transrectal biopsy, with near zero risk of sepsis and only a slight increase in the risk of acute urinary retention. However, transperineal biopsy does require additional training and infrastructure..

[Audio] The Gleason score is a classification of the histological pattern of prostate cancer, based on the degree of glandular de-differentiation, from well differentiated to poorly differentiated. It is calculated by adding the most common histological pattern score to the second most common histological pattern score. A higher score indicates a more aggressive and advanced cancer. Research has shown that the Gleason score is a good predictor of the likelihood of spread and overall prognosis. A Gleason score of less than 3 is considered low grade, while a score higher than 7 is classified as high grade..

[Audio] Staging may involve bone scans, CT scans, TAP, and PSMA PET scanning. A bone scan uses a radioactive tracer to identify abnormalities in the bones, indicating possible cancer spread. A CT scan creates detailed X-ray images of the body, helping determine the stage of the cancer and its spread to other organs. TAP combines transrectal ultrasound and biopsy, providing information about the tumor's size and location. A PSMA PET scan detects small amounts of cancer in the prostate, identifying potential areas of spread..

[Audio] For patients with early-stage prostate cancer and a life expectancy greater than ten years, radical prostatectomy, radical radiotherapy, and brachytherapy are available treatment options. The entire prostate gland is removed through radical prostatectomy, while high-energy radiation beams are used to destroy cancer cells through radical radiotherapy. In brachytherapy, small radioactive seeds are implanted into the prostate gland to kill the cancer cells..

[Audio] Radical prostatectomy involves the surgical removal of the prostate gland and seminal vesicles, along with any affected lymph nodes. This procedure can be performed using open, laparoscopic, or robotic techniques. While no single technique has been proven superior to others, radical prostatectomy remains the most common robotic procedure worldwide. Following surgery, patients may experience side effects such as incontinence, affecting approximately 20% of individuals at one-year post-surgery, and erectile dysfunction, impacting around 70% of men at one-year post-surgery..

[Audio] Radiotherapy plays a significant role in the treatment of prostate cancer. External beam radiotherapy (EBRT) is the mainstay of treatment, usually given over a period of five weeks. This type of therapy can cause transient side effects such as cystitis, proctitis, haematuria, and fatigue. Patients may also experience incontinence and erectile issues, although these complications are generally less severe than those associated with radical prostatectomy (RRP). Hormone therapy may be necessary for six months. Brachytherapy, on the other hand, involves the implantation of radioactive seeds within the prostate gland. This minimally invasive procedure offers a more targeted approach to treating the tumor, reducing the risk of damage to surrounding tissues. Both EBRT and brachytherapy are effective treatments for prostate cancer, providing patients with a range of options for managing their condition..

Brachytherapy for prostate cancer | Irish Cancer Society.

[Audio] The staging process for prostate cancer involves a series of tests to determine the extent of the disease. These tests include bone scans, computed tomography, transrectal ultrasound-guided biopsies, and prostate-specific membrane antigen positron emission tomography scanning. These tests help identify whether the cancer has spread to other parts of the body, such as the bones, lymph nodes, or distant organs. The results of these tests guide further treatment decisions..

[Audio] Prostate cancer is highly responsive to hormonal manipulation because testosterone plays a crucial role in driving prostate development, and castration can halt this process. Two primary methods are used to suppress the production of testicular androgens, including luteinizing hormone releasing hormone agonists, such as leuprolin, and antagonists, like degarelix. Both types of medications can cause side effects, including hot flashes, lethargy, osteoporosis, cardiovascular dysfunction, and loss of sexual function. Steroidal and non-steroidal anti-androgens are also available, inhibiting the action of circulating androgens. Examples of these medications include cyproterone acetate and bicalutamide, respectively, which can cause side effects such as gynaecomastia, nipple tenderness, and weight gain..

[Audio] Active surveillance, also known as treatment deferral, is a suitable approach for patients with low-risk prostate cancer, often referred to as clinically insignificant. The goal of this strategy is to minimize the potential side effects associated with treating prostate cancer while still closely monitoring the patient's condition. This involves regular testing, including PSA and DRE, as well as repeat biopsies, all of which are typically conducted according to a predetermined protocol. However, active surveillance may not be appropriate for patients who would not be candidates for radical therapy..

[Audio] For patients who are not suitable for any curative therapy or even biopsy, watchful waiting is an option. This involves monitoring them for the potential development of metastases. In some cases, androgen deprivation therapy can be introduced without the need for a tissue diagnosis. Additionally, symptomatic metastases can be treated as they develop. According to the data, the 10-year cancer-specific mortality rate for these patients is 15%, with a 20% risk of developing metastases..

[Audio] After radical therapy, follow-up care involves monitoring PSA levels alone. Ideally, these levels should remain undetectable. If PSA becomes detectable, it signals biochemical recurrence, which may prompt salvage radiotherapy treatment. Biochemical recurrence can occur before metastases are detected using conventional imaging techniques, a delay that can span several years. Additionally, PSMA PET/CT scans have demonstrated the ability to identify metastases at lower PSA values, though their accessibility is currently restricted..

[Audio] Some patients who undergo treatment for prostate cancer may experience various side effects. These can include incontinence after local treatments, as well as conservative management strategies such as pelvic floor muscle training, compression devices, and lifestyle changes. Surgery, including procedures like slings and artificial urinary sphincters, can also have a cure rate of approximately 60 percent. Additionally, erectile dysfunction may develop, which can be treated with medications like PDE5 inhibitors, vacuum pumps, and alprostadil injections. In certain instances, penile prostheses may be required. Moreover, systemic treatments can lead to the onset of symptoms such as loss of libido, hot flashes, non-metastatic bone fractures, osteoporosis, metabolic syndrome, cardiovascular morbidity, and fatigue..

[Audio] After monitoring, surgery, or radiotherapy, patients with localized prostate cancer have shown promising outcomes over a period of ten years. Research has demonstrated that these treatments can effectively manage the disease, reducing the risk of complications and improving quality of life. The study highlights the importance of early detection and timely intervention in achieving optimal results..