Key Questions
When you know you have a problem with your prostate – it has swollen, or is painful, or there is blood coming out in the urine – you need to take action. What are the questions to which you will need to find answers?
What is causing the problem?
It could be:
- Prostatitis (inflammation of the prostate) – this can be cured with antibiotics, or if necessary surgical intervention.
- Benign prostate hypertrophy – this is a common occurrence for older men. The prostate gets bigger and impinges on the urethra (the urine channel), causing difficulty in passing urine. The solution is usually a surgical intervention, which is speedy and safe.
- Cancer – this affects a great many men, specially over the age of 50. The key marker is the famous PSA test. If it is elevated – that is higher than 4 (nanograms per millilitre of blood) – you need to check it out.
How do doctors diagnose prostate cancer?
Although it is common for doctors to do a digital rectal exam (DRE), it is well known that this is not a reliable way of diagnosis. There is far too great a risk of a ‘false negative’ – that is where the doctor cannot feel the tumour, and assumes the patient is safe. This is because the rectal examination allows the doctor to only feel one side of the prostate (through the wall of the bowel). If the tumour is on the other side, he/she will not feel it.
The first course of action should be imaging – that wonder of modern science that allows medicos to look inside the body without cutting. Here are the typical options:
- TRUS (trans rectal ultrasound) – this involves a sonic probe being inserted in the bowel. It is more accurate than a DRE, but still not reliable – for the same reasons. A CT scan is better, though still not completely accurate.
- MRI (magnetic resonance imaging) – this provides a complete 3D picture of the prostate area. It has an accuracy of 70-80%.
- Bone scan – this is a whole body scan. The reason it may be prescribed is that the doctor suspects cancer, and wants to know if it is confined the prostate gland (‘localised’, in the jargon), or if it has spread (‘metastised’). This distinction makes all the difference to treatment.
- PSMA PET (a PET scan targeting PSMA) – this uses the recently discovered ‘prostate specific membrane antigen’ as a marker. It (PSMA) is ‘expressed’ if there is cancer. The scan is very accurate indeed.
How bad is the cancer?
It is almost certain that a man suspected of having prostate cancer will have a biopsy. This involves needles being inserted (under anaesthetic) into the gland and samples taken. The samples are then sent to a lab for analysis.
The samples will show how aggressive the cancer is. That is calculated in terms of a ‘Gleason’ score (named after the American pathologist who invented the scale). In simple terms, a low score (2-10) indicates that the risk is low. A score of 7 or more suggests that the cancer is more dangerous.
If it is cancer, what happens next?
The major options for treatment are three:
- Surgery – the surgeon will cut out the prostate gland, endeavouring to spare the nerves around it. A very common method these days is robotic surgery – where the surgeon operates remotely on the patient, using a highly sophisticated machine that can do the work inside the body with minimal blood loss and maximum control.
- Radiation – typically ‘external beam radiation’ (EBRT) – in which the prostate and its surrounds is irradiated in small bursts over a number of weeks. The reason for the slow approach is to minimise damage to healthy tissues.
- Other treatments – these are brachytherapy (insertion of radiative rods in the prostate), ‘focal ablation’ (use of a high intensity sonic or electrical wand to cauterise the tumour) and cryoblation (use of intense cold to destroy the tumour). However, these treatments represent a minority. They are typically used for small tumours and their efficacy is not necessarily as high.
What are the side effects of treatment?
All men who undergo treatment will experience side effects. In the hands of a skilled surgeon or radiotherapist, they will be as minimal as possible – commensurate with the seriousness of the tumour. Doctors will always put saving the patient first, above minimising side effects. To put it bluntly, if the cancer is bigger, you will have more side effects.
The major issues following on from treatment are two:
Erectile dysfunction (ED) – this is almost inevitable in the short term, because both surgery and radiation have an effect on tissue and nerves. A good surgeon can try to minimise cutting the nerves (the way the body generates erections), but it is a serious challenge to the body. In the best case scenario, the erectile function will return within months, with or without Viagra. In the worst case scenario, you will need medical assistance. This tends to be injections, or for those who are prepared for it, an implant.
Incontinence – this is inevitable in the days and weeks after surgery, and to a lesser extent after radiation. The good news is that exercise can make all the difference. Within a short time, you will be dry again. If problems persist, there are medical solutions.
What if the cancer comes back?
After treatment for localised prostate cancer, men will go on a surveillance plan, which will last indefinitely. If the cancer stays away, the intervals will lengthen over time.
If however, the cancer comes back, different strategies are needed. The main way doctors deal with ‘advanced’ or ‘recurrent’ cancer is hormone therapy (ADT – androgen deprivation therapy). This involves regular injections of female hormone. The idea is to suppress the effect of testosterone, the male hormone that ‘drives’ the cancer. There are side effects (naturally), but ADT can prolong life for a long time.
There are some cases where immunotherapy might be helpful, and even in advanced cases, chemotherapy, but ADT is the mainstay of treatment.