Prostate cancer causes too many deaths but we can stop the threat early
TODAY is the start of prostate cancer awareness month in the UK. Prostate cancer is the most common cancer in Western men, and is now responsible for more deaths than breast cancer in the UK. Prostate cancer is more common in older men, and twice as common in Afro-Caribbean men compared to Caucasian men and in those whose fathers or brothers have had it. Lifestyle factors also play a part, and men can reduce their risk of the disease by eating a diet high in fruit and vegetables, low in red meat and fat, and by doing regular exercise and keeping their weight down.
The NHS supports an informed choice programme, called prostate cancer risk management, as an alternative to screening for prostate cancer. This is partly because screening the whole population will detect lots of men with low-risk prostate cancer, which is not deadly and can be monitored.
But targeted or “smart” screening, where we screen men who are at risk of higher-risk prostate cancer, would potentially save the lives of thousands of men whose cancers are potentially lethal. Such “smart” screening is common in the US and much of Europe, for Afro-Caribbean men over 45, Caucasian men over 50, and men over 45 with a family history.
It involves a simple blood test (the PSA) and a finger examination of the prostate. If the PSA is normal, it serves as a baseline result from which future PSAs can be compared, and a quickly rising PSA is highly suggestive of significant cancer.
A small percentage of prostate cancers, however, do not lead to an elevated PSA and thus the finger examination is required to pick up those cancers. Difficulty passing urine, going frequently and rushing to the loo, waking up at night to pass urine, and a slow flow, are usually symptoms of benign enlargement of the prostate rather than cancer. In fact, most prostate cancers do not cause symptoms during their early, curable stage, and this is why it is important to not base testing on the presence of symptoms.
If, on testing, either the PSA or finger examination are abnormal, the next step is to perform an MRI scan specifically to look for prostate cancers, followed by a biopsy. This represents one of the major advances in prostate cancer diagnosis, as it allows, for the first time, the surgeon to see where the cancer is within the prostate and to tailor treatment to the patient’s case.
If the above diagnostic pathway is followed, most cancers will be caught at the early stages when treatment can cure them. One treatment option is robotic surgery to remove the prostate. Most men go home the day after the operation and return to routine activities soon after. The risk of the cancer returning is low and the impact on men’s erections and continence is often limited and temporary, especially if novel techniques such as Retzius-sparing robotic surgery are used. The most important factor in determining success of the surgery, though, is not the exact technique but the surgeon’s experience and training. In London we have some of the most highly skilled robotic prostate cancer surgeons in the world, with University College London Hospitals (UCLH) being the largest centre for robotic surgery in the UK.
An effective alternative to surgery is radiotherapy, often used in combination with hormone therapy. There are more bowel and bladder side-effects from radiotherapy than surgery, but it has virtually no risk of urinary inconti-
If you are a man at risk, get tested. It could save your life, and with less impact on your quality of life than you think
nence even in the short term. Advances in radiotherapy mean that the chance of second cancers of the bowel and bladder is low, but still present, in the long term. Generally, younger men who are fit for surgery usually opt for that option, and radiotherapy is more commonly used in older men with shorter life expectancies.
A novel alternative to surgery and radiotherapy is focal therapy, which is also offered at UCLH, the world’s largest and most experienced centre for this treatment. Here, experts treat only the main cancer in the prostate and spare the rest of the prostate, potentially having less impact on continence and erections than robotic s u r g e r y. T h e procedure is also quicker, meaning that older, less fit men can undergo it.
In case of the low likelihood of recurrence requiring further treatment, performing surgery after focal therapy is more complex than upfront surgery, and patient outcomes might be worse than if they had undergone initial surgery. Only certain cancers, typically smaller ones, are eligible for focal therapy, and long-term outcomes are not available.
All in all, prostate cancer can be confusing. There is a lot of it out there, and so many treatments to choose from, ranging from active surveillance for men with low-risk cancer, to surgery and radiotherapy for men with significant disease. Each treatment choice must be tailored to the individual cancer and the quality-of-life wishes of the patient.
In London we are fortunate to have world experts in all the therapies. So, if you are a man at risk, please go and get tested. If you are diagnosed, please go and see one of the experts. It could save your life and with far less impact on your quality of life than you might think. As prostate cancer awareness month begins, we must seize this opportunity to stop more unnecessary deaths from prostate cancer.
⬤ Prasanna Sooriakumaran is a consultant urologist at University College London Hospitals and the Santis Clinic