/The symptoms, diagnosis and treatment of prostate cancer

The symptoms, diagnosis and treatment of prostate cancer

The symptoms, diagnosis and treatment of prostate cancer2018-08-14T19:16:11+00:00

Summary

CT scan showing large cancer arising in region of prostate and invading bladder anteriorly and posteriorly

Prostate cancer is the second most common cancer in European males, with a lifetime risk approaching 10%. It is predominantly a disease of older men.

The usual type of prostate cancer is an adenocarcinoma and this arises from the cells that line the secretory ducts of the prostate. A measure of the aggressiveness of the cancer is made by the pathologist from the biopsy using Gleason scoring, which is a scoring system that grades by different characteristics associated with aggressiveness and leading to scores between 2 (very indolent) to 10 (very aggressive). Research assays may, in the future, detect more aggressive characteristics by other means. One research assay detects mutated copies of the gene (p53 in the healthy form being a tumour suppressor gene). Damaged versions occur in many malignancies and are associated with tumour progression. Other genetic assay work may become relevant in the future.

Causes

The cause of prostate cancer is not known.

There is evidence for a genetic predisposition for this disease as evidenced by the increased incidence in families with a history of the illness. For example, the risk of an individual whose father or brother has suffered prostate cancer is approximately two-fold higher than the background population and when there are two close relatives three and a half times higher of developing the disease.

Some oncogene testing  is worthwhile in some patients (e.g. BRCA-2), and very interesting predictive testing can now be performed to identify those who, quite apart from any family history of the disease, may be at greater genetic risk of developing the disease (see below). Recently, it has been shown that prostate cancer is associated with chromosomal re-arrangements that bring about the over-expression of members of the ETS family of transcription factors, the most common of these re-arrangements is the fusion of coding sequences of the ERG gene to androgen-(male hormone)-regulated sequences in the promoter of the prostate specific TMPRSS2 gene. Other fusions between other ETS family members and TMPRSS2 and ETS re-arrangements involving other fusion partners (including androgen suppressed and androgen insensitive genes) occur. In the future, the evaluation of these genetic markers may be of diagnostic and prognostic value.

Even now, there are genetic predictive tests that may help to forecast the risk of an individual from developing prostate cancer, apart from family history of the disease. Thus the deCode ProCa 8 marker genetic profile of men can identify those individuals (white European males) with a twofold chance of developing the disease. This genetic profiling is now available to well men (the controversy is as to how far this extension to screening programmes should be promoted to the public).

There are also well recognised racial and geographical differences in the incidence of the disease. For example, there is an almost two-fold higher incidence of prostate cancer amongst black Americans than amongst whites. Interestingly, environmental studies demonstrate a higher incidence of prostate cancer occurring over the generations in migrants from a lower risk area to a higher risk one.

In general, the incidence of the disease is lower in Far East and Asia through the Middle East than in the West.

Links of incidence to dietary influences, such a dietary saturated fat intake, has been documented but the link is not strong.

Whilst there is some epidemiological evidence for a link between exposure to some pollutants such as heavy metals and chemical fertilisers, any such link is weak.

The hypothesised link between incidence and either sexual activity or some venereal diseases (e.g. herpes or cytomegalovirus) is unfounded.  However, there is no doubt that the male hormone: testosterone has some/a lot of influence on the risk of developing the disease (eunuchs do not develop prostate cancer).

In general, prostate cancer is a disease of the elderly, although, with PSA screening, the disease is now being detected at earlier ages.

Incidence

The male genitourinary anatomy.

Prostate cancer is the second most common malignancy of men in the Western world and its incidence has been increasing over the last decade (a higher prevalence being partly due to the PSA screening programme). There are 6500 deaths in the UK annually from this cancer and a lifetime risk of developing this disease of around 7-10 %.

With the increased usage of PSA screening, the disease is being more readily picked up in its early stages and it is in this group of patients that very high cure rates (90% +) are now being achieved, either by surgery, external beam conformal radiotherapy or prostate seed brachytherapy.

(Brachytherapy is becoming more popular, over radical surgery in the last few years).

Symptoms & diagnosis: Prostate cancer

The patient usually comes to the doctor with complaints of slow urinary stream, hesitancy of initiating urination and often of frequency of urination (e.g. having to get up several times at night to pass urine). These are the symptoms of ‘bladder outflow obstruction’ which is most usually associated with the commoner benign prostatic hypertrophy of older age, but occasionally they may augur the development of a cancer in the prostate. Nowadays, with the earlier diagnosis of prostate cancer due to the PSA screening programme, we are more frequently diagnosing prostate cancer in patients who have no new symptoms referable to the urinary tract.

Occasionally, the patient comes with back pain or some other symptom caused by spread (metastasis) of the tumour but this is unusual and most patients present without overt evidence of spread of this cancer.

Diagnosis

Prostate radiation brachytherapy using a transrectal ultrasound probe to ‘map’ the prostate. This figure is shown here to illustrate the transrectal ultrasound probe. For diagnosis, the biopsies are made transrectally.

A DRE (digital rectal exam) and a PSA serum test are routine tests and if the doctor is suspicious from the results of these (possibly augmented by a PCA-3 test) he will order a trans-rectal ultrasound (TRUS) directed biopsy (actually 4-12 biopsies by fine needle) from different areas of the prostate, but particularly any suspicious areas that are seen on the ultrasound.

The specimens from the biopsy are then carefully examined by microscopy and any cancer confirmed and graded (Gleason grading; see introductory section).

Stages

Scanning of patient to detect the extent of cancer.

Once the diagnosis has been established by biopsy of the gland (with the microscopic diagnosis of carcinoma of prostate), the doctor will order an MRI scan of the pelvis (the modern high resolution MRI being more sensitive than CT or ultrasound for picking up any extracapsular extension of tumour and is also an excellent imaging method for detecting spread to pelvic lymph nodes). The MRI scan will hopefully demonstrate no disease outside the gland i.e. ‘organ confined disease’).

He will also order a bone scan (although this test is not indicated in everyone presenting with a very early prostate cancer) as the bones are the first site of more distant spread, if this has occurred.

Other tests are of a more routine nature.

Treatment & outcomes: Prostate cancer

Prostate seed radiation implant brachytherapy – left panel. X ray showing seeds in prostate. Middle panels : CT scan showing seeds in prostate. Right panel: Shows planning distribution for implanting seeds through a template.

Early and ‘organ confined’ prostate cancer:

If the tumour is localised to the prostate (i.e. the staging tests reveal no evidence of spread), then there are three well validated curative options, not all equally relevant to every case. The vast majority of patients who have organ confined disease (that is no sign of cancer breaching the prostate capsule – that envelope that surrounds the prostate gland and forms a barrier to spread – on  a modern multiparametric MRI scan) will be cured by all the options.

The first option is radical surgery, where a skilled surgeon removes the whole gland at operation, either by ‘open’ operation or nowadays more often robotically via key-hole surgery.

The operation is a moderately large one and recovery times are a month or so to regain good continence of urination but, in the skilled hands of a good surgeon recovery is usually excellent and incontinence rates low. There are slight risks of major complications, as with any major abdominal operation, and then there are the more specific risks. These include a small risk of incontinence of urine and a risk of sexual impotence, although the modern operation aims to spare the nerves that subserve this function (nerve sparing, radical prostatectomy).

The PSA falls rapidly in cured patients, to zero or thereabouts (less than 0.01).

If there are positive microscopic margins or there is residual detectable PSA in the blood, then the patient may well require post-operative radiotherapy to the prostate ‘bed’ as it is likely that residual disease remains.

For patients with obstructive problems (slow urinary flow) there are merits for the operation over other methods as not only is the cancer treated but also the obstructive element.

For localised prostate cancer, the cure rate of radiation therapy is comparable with surgery. There are those who psychologically feel the need to have their gland cut out but others who do not want a large operation if the alternatives carry the equivalent chance of cure.

The classical form of radiotherapy is the external beam, conventionally fractionated course, which takes place over a period of some seven to eight weeks.

The modern linear accelerator that delivers this type of therapy catches the target volume – the prostate-  to effect a highly concentrated radiation course on the gland/tumour. The patients attends every week day for 4 weeks.

Towards the end of the course he may feel slightly tired, have some symptoms of cystitis (urinary frequency and discomfort) and often some temporary rectal discomfort. These symptoms have been minimised since the routine use of Intensity Modulated Radiation Therapy (IMRT), which allows beam shaping (by altering the flux across the radiation beams) such that the encompassment of even irregular shaped targets is better conformed than previously.

The IMRT methodology in particular reduces the dose to the rectum. However, even then the anterior rectal wall lies very close to the posterior prostate surface, which is receiving full dose. This can still harm the anterior rectal wall with the risk of an ulcer. Recently, we have started to inject Hydrogel into the potential space between the rectum and the posterior prostate wall to increase this space. This allows the dose gradient a chance to fall from the full dose at he posterior prostate capsule to the anterior rectal wall,  which is now >0.5-1.0 cm distance away. Where this is needed, this represents a new method of sparing that organ-at-risk viz. the anterior rectal wall whilst not compromising full dose to the posterior prostate.

Following therapy, the PSA falls over six months and the late side effects should be minimal. However, some loss of sexual potency occurs in 30-40% of men, interestingly, this usually responds to sildenafil (Viagra) , or tadalafil (Cialis) or other non-hormonal methods.

External beam radiotherapy is particularly appropriate for the elderly (where no anaesthetic or operative procedure is appropriate) and those with some evidence of transcapsular disease on the staging MRI scan of pelvis (T3 disease).

For these latter T3 patients, it is now recommended that they start off their treatment with anti-hormonal therapy to both, downstage the disease and facilitate later radiotherapy, which starts a few months later (so long as the PSA is falling well at one month). Indeed, the patient usually stays on the anti-hormonal therapy for two years in total for T3 cases (i.e. those patients whose cancer is through the prostate capsule on high quality MRI staging). For patients with T3 disease, operation is usually not usually appropriate as clear microscopic margins will not be achieved and good results are obtained by the anti-hormonal therapy and IMRT beam radiotherapy option.

A third method of curative therapy now has good ten years of follow-up to defend its position side by side with radical surgery and conventional radiotherapy as another acceptable definitive method of therapy. This interstitial radiotherapy implant method, also called brachytherapy (Greek word meaning ‘close therapy’) involves the implantation of radioactive seeds into the prostate gland, where they remain to radioactive extinction delivering an ablative radiation dose to this organ. The ability of a template against the perineal skin to direct the seed deposition in two planes (x and y axes) and a trans rectal ultrasound probe to call the depth of implantation in the third axis (z axis) has allowed very exact seed deposition in the current methodology and it has the advantage of relative simplicity for the patient who can go home the same or next day. The figure photo at the beginning of this section above shows, on the left, the distribution of seeds within the prostate on a frontal x-ray. The middle panel shows the seeds within the prostate on a CT scan at different levels within the prostate from top (nearest the bladder) to bottom (nearest the perineal skin) and the right panel shows the computer plan from which the seeds were deposited.

The seeds are implanted under general anaesthesia in a procedure that usually lasts typically less than one (small glands) to a couple of hours. Since the radiation dose falls off at the square of the distance from the seed (inverse square law), so a very intense dose is delivered within the gland and yet the surrounding structures receive a much lower radiation doses, thus sparing them damage.

15 years ago, prostate brachytherapy became the preferred cure option in the USA over radical surgery (radical prostatectomy) and the reasons are to do with the now proven equivalence as regards disease free survival/cure rates and the lesser nature of the post-procedure with regard to side effects. For example in our own experience and analysing four hundred consecutive patients implanted at our unit, there was no case of urinary incontinence (although one man leaks just enough after urination such as to require a pad inside his underpants) and one man (only) requires to self-catheterise once daily – no other long term problems. These sorts of figures are now routine from experienced centres, practising brachytherapy and explain why this methodology is becoming more popular than surgery. Having said this, case selection is important as this methodology is not suitable for everyone (those with large glands and obstructive symptoms are particularly unsuitable).

In an attempt to reduce the size of a large tumour/prostate gland prior to implant or radical external beam radiation therapy, it is now common for the doctor to prescribe a two month course of anti-androgen (anti-hormone/anti-testosterone) therapy prior to the radiation therapy. There are accumulating data to support this practice in terms of disease free survival advantages for the less good risk patients, and for continuing this anti-hormonal therapy longer term (e.g. two to three years after therapy).

Sometimes, for intermediate risk patients, we combine external beam radiotherapy (first) with a brachytherapy boost; this has a perceived advantageous strategy of spreading the radiation dose wider over the first 2/3 of the dose and then adding a more focal boost to the gland itself; such a policy would seem most sensible for the tumours filling the gland and for which there might be early transcapsular spread (albeit not shown on the staging MR scan).

From the foregoing it is clear that for the patient with localised prostate cancer there are three types of potentially curative therapy – with really high cure rates – up to 90% in the earliest stages of the disease.

Other methods of curative therapy are now becoming available and cryotherapy and high intensity frequency ultrasound (HIFU) therapies are the two that spring to mind. Both are interesting methods of ablating the prostate but neither have the length of follow-up or ‘pedigree’ that the other methods discussed here have at this time.

How does the doctor and the individual patient make up their minds as to which they should choose? There has been no head to head trial of the main three types of therapy (surgery, brachytherapy and IMRT external beam radiotherapy) but a broad consensus of recommendations is as follows:

For patients with small gland and early tumours therein, and PSA values of less than 10 (the PSA being a prognosticator for the future), all three main methods seem to have comparable cure rates that should be up in 85-90%+ for such early disease.

When the tumour fills the gland and there is extracapsular spread seen on the MR then external beam radiotherapy is the preferred option – nowadays preceded by anti-hormone (antiandrogen) therapy (as above). Certain other considerations apply: The patient who will not accept a risk of urinary incontinence might be best advised to accept a non-surgical option. Elderly patients are best served by external beam/IMRT radiotherapy.

Patients with obstructive symptoms (slow urinary flow – unable to achieve a flow rate in excess of 10 ml/second) or leaving a large residuum in the bladder after urination, may be best served by surgery – or at least a trans-urethral resection prior to radiotherapy. Those with very large prostates may also be so advantaged by surgery.

Brachytherapy is used  for patients with organ confined disease as a low risk alternative to surgery and one that is usually much better tolerated than surgery – fast recovery time. Like surgery it is usually used for the lower Gleason grade tumours (up to Gleason 7) or, in combination with external beam radiotherapy and anti-hormonal therapy, for Gleason 8 disease. In patients with good urinary flow rates, it is an excellent and proven high cure rate therapy, with usually low risk of side effects.

A final word concerning the use of anti-hormonal therapies. Five of six men with prostate cancer will respond well to anti-hormonal therapy (either the use of injections which switch off the pituitary’s driving hormone that keeps the testes secreting the male hormone, testosterone, or anti-androgen tablets: which block the testosterone receptors on testosterone target tissues such as the prostate; the use of orchidectomy/castration is less used nowadays, although a remarkably effective method that requires no repeating!) – but such treatment is not, in the long run curative. Anti-hormonal therapy alone may be used for elderly and frail men, for whom any of the curative options are unable to be tolerated.

For men with early prostate cancer, those with no evidence of metastatic disease (no spread beyond the environs of the prostate itself), anti-hormones are used in patients with local progression (such as spread beyond the capsule of the gland or into the seminal vesicles or high PSA), specifically in order to shrink the tumour back inside the gland/ downstage it prior to radiotherapy. The fall in the PSA can be dramatic. The anti-hormonal therapy may be continued for some time after the radiotherapy to maximise its usefulness.

I should emphasise that anti-hormonal therapy alone is not curative but assists radiotherapy to increase the cure rate in intermediate to higher risk patients

For intraprostatic relapse after radiotherapy, then cryotherapy or High Intensity Frequency Ultrasound  (HIFU)are the preferred ablation techniques.

Advanced and metastatic prostate cancer.

For patients with metastatic cancer of the prostate, the first therapy will be systemic and either anti-hormonal therapy alone or anti-hormonal therapy with chemotherapy (usually and drug called docetaxel/taxotere).

For patients who present with high PSA levels and high volume metastatic disease and visceral metastases (e.g. liver metastases) then there are good data supporting the combination of chemotherapy and anti-hormonal therapy. For the elderly patient with low volume metastatic disease – such as some pelvic node involvement on the PSMA scan or one bony metastasis, then the case for combination chemotherapy and anti-hormonal therapy is less compelling and many Oncologists would place the patient on anti-hormonal therapy alone.

The anti-hormonal therapy will usually be be an anti-gonadotropin (gonadotropin is the hormone form the pituitary that is needed to keep the testis active in secretion of the male hormone: testosterone). Blocking the gonadotropin renders the patient medically castrate – no testicular production of testosterone. Of course, surgical castration does the same job but is nowadays socially less acceptable.

There are LHRH agonists and antagonists – the former creating an initial stimulation of testosterone before paralysing it long-term (this only being of relevance if there is an imminently threatening metastasis – such as one about to cause spinal cord compression, in which scenario the LHRH antagonist is preferred). These drugs effect a medical castration and render the patient devoid of testicular testosterone. As >80% od prostate cacner is dependent on testicular testosterone, this therapy causes a very good remission in most patients with the PSA falling to very low levels

In addition (or alternatively) there are the androgen receptor antagonists: of which the drug bicalutamide and the next generation one: enzalutamide. These are both powerful on their own but are best in conjunction with LHRH inhibitors (or castration).

The important new drug is abiraterone. In the  absence of testicular testosterone, there is a small amount of androgen synthesis taking place in the adrenal glands and androgen target tissues.

After the elimination of the testicular androgens, there remains a small source of androgens in the body, synthesised in the adrenal glands and also in the androgen target tissues. Abiraterone inhibits the biosynthetic pathway at a criticalstep between the base molecule of cholesterol and the C-19 androgen. It inhibits P 450 17alpha-hydroxylase (CYP 17) and this leads to a marked lowering of the post-castration male’s circulating androgen and even more so in the androgen target issues as this is where this source of androgen is synthesised.

As the abiraterone inhibits the adrenal biosynthetic pathways, the lowering of output of adrenal hormones is sensed by the pituitary feed-back loop and increased ACTH is released into the circulation which could at least partially overcome the inhibitory effects of abiraterone on the adrenal androgen production line – by ACTH stimulatory effects. For this reason (and others), we give low dose glucocorticoid steroid (typically prednisolone 5mg twice daily orally) to prevent this phenomenon.

There are now strong data demonstrating that an LHRH analogue plus abiraterone (with low dose prednisolone) will lead to very good and durable remissions in the majority of men with metastatic prostate cancer.

Eventually, however, and this may be after many years, the cancer will become resistant to the anti-androgens and the mechanism of how this occurs are of interest. typically, the ligand binding domain of the androgen receptor (to which the male hormone binds to effect stimulatory events and to which the anti-androgens bind to effect inhibitory events – becomes mutated and then constitutively activated (i.e. is in a constant state of stimulation). The AR-V7 splice variant is the best example of this and the evolutionary appearance of this in a prostate cancer harkens the development of anti-hormonal resistance.

When the cancer becomes resistant to anti-hormonal therapy, the next step is chemotherapy. As has been stated above, in high risk patients, there is a case for giving chemotherapy with the anti-hormonal therapy up-front.

In the setting of metastatic prostate cancer that has resisted anti-hormonal therapy, the first drug of choice is a taxane (doctaxel/taxotere or cabazitaxel) and there are patients who respond to cabazitaxel having failed front-line taxotere. THe sdie effects of the taxanes include hair loss, allergy, low blood counts and peripheral neuropathy

Outcomes

If there is local (i.e. relapse in the prostate region) after surgery, usually called to attention by a rising PSA and in the face of negative restaging tests for disease further afield, then external beam therapy to the prostate ‘bed’ is successful in a minority of bringing about PSA control again, but these patients are obviously at greater risk for both further local and distant (i.e. metastatic) relapse. It is an interesting observation that of patients who develop a rise in PSA after radical surgery, we can predict those who are likely to have relapse only in the prostate ‘bed’. Those patients whose PSA fails to almost disappear (<0.05) after surgery or who suffer a rise in the first six months after surgery are likely to have metastatic disease. Those who have a late and slow rise in PSA (e.g. a rise to 0.1 after 2 years and then 0.3 after 2.5 years) are likely to have disease relapse in the prostate ‘bed’ and it is this group that is likely to benefit from radiotherapy to the ‘bed’. For patients who go down the radical prostatectomy route and whose prostate margins are histologically involved when the histologist microscopically examines the surgical specimen, then early post-operative radiotherapy to the prostate ‘bed’ is to be recommended. The fact that we sometimes employ radiotherapy after surgery is used by some surgeons to argue that, as surgery can be followed by radiotherapy and so surgery should always be used first. This is a spurious argument in that if one had known that the margins of the operative specimen were going to be positive, then the operation was probably the wrong thing to do in the first place (as patients having transcapsular disease at the outset are best served by neoadjuvant hormonal therapy followed by conformal external beam radiotherapy). For patients with metastatic relapse (i.e. disease that has spread to other organs) then anti-hormone therapy is indicated.

This is first aimed at cutting off the production of testosterone from the testes and this is achieved by either orchidectomy (the removal of the testes, castration) or the delivery of quarterly injections of a drug (LHRH agonist) which blocks the pituitary gland’s stimulating hormone, which keeps the testes active. Either of these methods is effective at reducing the serum testosterone (male hormone) to castrate levels, the desired objective, as this hormone (testosterone) is undoubtedly the main growth factor for prostate cancer.

Sometimes, an antiandrogen drug will be added as well (so-called total antiandrogen blockade). Approximately four fifths of patients will respond to this hormone therapy and may well maintain this remission for up to some years. When the patient eventually relapses, a further hormone remission (usually shorter than the first) can sometimes be achieved by the removal of one anti-androgen drug and the substitution of another or the giving of the physiological steroid hormone hydrocortisone which suppresses the adrenal glands production (the last source of male hormone once the testes have been ablated). A low dose oestrogen may be added at this time. For painful relapses in bone (the commonest site for metastatic relapse) the use of radiotherapy is useful and the use of isotope therapy (e.g. strontium-90) can be useful at arresting the progression of the metastases for a time. Chemotherapy has recently made inroads into the therapy of ‘hormone refractory’ prostate cancer management notably the drugs: taxotere and mitozantrone -usually not combined at the same time) have been shown to be useful in good performance status patients (i.e. patients whose condition warrants more therapy), and can achieve remissions for some months. A new generation of drugs targeting vascular growth receptors (the stimuli for the essential new growth of tumour blood vessels) are starting to make a place for themselves in the therapy of hormone resistant prostate cancer. Further information concerning the developments in therapy – updated every few months from the published literature – is given by clicking onto the Research and Development section or from Dr. P. N. Plowman at St. Bartholomew’s Hospital, London (tel 44-207- 601 8351).

Screening

The digital rectal exam (DRE) of the prostate is the age old and extremely crude method of screening and will only pick up definitely abnormal glands, which will be at a later stage of the disease than we would wish.

PSA (prostate specific antigen) is a protein that is secreted within the lumen of the prostate ducts at very high concentrations and some gets into the blood stream where the levels may be easily and accurately assessed. Assay methods have greatly improved over the last decade and with controlled calibration standards the results are very accurate. In general, the development of prostate cancer leads to a rise in the serum PSA early in the course of the disease allowing for this blood test to be a potentially important screening test for healthy males The problem is that the normal range is difficult to exactly define and rises with age and the majority of slight rises in PSA are due to benign prostatic hypertrophy. It is largely for this reason (and the fact there is a slight risk to biopsying everyone with a slightly raised PSA) that the routine adoption of the PSA screen is not universal. Several attempts have been made to refine the PSA test such that it is more specific for detecting cancer.

Age specific PSA cut-off’s, have been taken into account to acknowledge that PSA gradually increases with time. PSA density is a method of adjusting the serum value with respect to the gland size/volume.

PSA velocity looks at the rise of the PSA over time, as the latter will be faster in cancer than in benign disease.

PSA isoforms can be used to establish the ratio of free: total PSA in the serum, which leads to a lower ratio in cancer.

With these refinements, the PSA test is an important health screen test for males and has allowed the diagnosis of early prostate cancer to be made more frequently. Although the ‘controlled trials’ upon which the medical profession puts so much weight are still running, the PSA screening ‘revolution’ is well and truly here.

(N.B. Whilst most regard PSA as also standing for ‘Providentially Sent Antigen’ there are those men who get hooked on measuring a trivially raised result and for them it has also been known as ‘Promoting Stress and Anxiety’ !).

Where the PSA test is slightly above normal and there is a question as to whether a biopsy needs to be performed, then a relatively new test called the PCA-3 test may be useful. This is a urine test that seeks to find the product of an oncogene that is almost always over-expressed in prostate cancer cases. Specifically, the PCA gene is highly over-expressed (median 66-fold) in more than 95% of malignant (tumours) prostate tissue. The Progensa PCA3 test measures the (post digital rectal examination) first-catch urine PCA-3 mRNA concentration and calculates a score. High score levels strongly suggest that the prostate is infiltrated by cancer. Where the PCA-3 test is positive (high score), then a biopsy should be performed as there is a high likelihood that the patient has cancer.

Questions & answers about prostate cancer

Question

My husband has had 5 PSA tests over the last 22 months, the first test score was 7, then it jumped to 11, then to 15, then 16 and in June it was at 20. He has had 2 DRE’s on both ocassions the prostate was very enlarged. He has also had 2 biopsis, which came back negative. At no time has he had any treatment for BPH, he recently saw another consultant (he has been diagnosed with low testestrone) who has now referred him to an Oncologist, should he be worried? I read one of the articles on your site that says that if a PSA score is over 15 most surgeons won’t preform surgery??

Answer

I think your husband ought to have a PCA3 test. A PSA of 20 may be due to benign disease but is suspicious, and a PSA free:total ratio and a PCA3 test would be the best way forward.

Question

Is ablative treatments for early prostate cancer the best way forward?

Answer

Ablative treatments for early prostate cancer is available to patiemts with early prostate cancer.Additionally, HIFU and cryotherapy are available, although the radiation options may be best. If the MRI scan shows the disease to be confined within thecapsule of the prostate gland, if the PSA is less than 20, the Gleeson Gradeless than 8 and the patient’s urinary function is satisfactory with aprostate volume of less than 50 cc, then, of all the non-surgical options,radiation seed brachytherapy is probably the best.

Question

I have newly diagnosed advanced prostate cancer with spread to left side lymph nodes in pelvis, bone scan clear. I have been put on hormone treatment decapeptyl every 3 months. No other treatment. Is radiotherapy used for lymph nodes?

Answer

We agree with the hormone treatment of three months. If there is a goodresponse and there was no evidence of disease beyond the lymph nodes, thereis a case for radiotherapy. This should be performed by an IMRT technique.You should ask your oncologist about this.

Question

I have prostrate cancer and was reading in my newpaper about a new drug treatment. I cannot find the paper with the name of drug. It was a very expensive drug, 10,000.00 per month. I asked my doctor if he had knowledge of it. He did not. So, I am looking for the name of drug.

Answer

I suspect the name of the drug you are seeking is Arbiraterone. It is questionable whether it is better than Hydrocortisone 20 mg b.d. Both drugs will only work in patients who have been orchidectomised or who are on an LHRH agonist.

Question

How long after biopsy is there blood in the semen?

Answer

This should last only a matter of a few weeks.

Question

Would you advise bone protection medication for a man who has been on hormone therapy (zolidex implants) for 2yrs plus?

Answer

Bone protection, for example bisphosphonates, may be appropriate if a bone densitometry shows the bones to be significantly thinning (as they may well after prolonged Zoladex therapy)

Question

To what extent can diet and lifestyle factors give a high reading for psa. I am 60 and normal for me is 0-4. I have recently had readings of 5.3 and 6.7 I have had two PSA tests taken within 11 days of each other. The first had a reading of 6.3 and the second 5.7. I have been given the option of waiting 6 weeks and having a biopsy if necessary OR having a biopsy next week. I have chosen the first option will delaying the biopsy for 6-8 weeks put me at a disadvantage. I am 60 years old and the digital rectal examination showed my prostate to be okay.

Answer

Lifestyle factors have little effect on PSA. You may wish to opt for a PCA3 test. If this is raised a biopsy would be recommended. If not, it would be advisable to adopt the watch and wait policy. A free:total PSA ratio might also influence a decision in this regard. Whilst neither of these tests are 100%accurate, they are being used to “sift out” those patients who could be watchedand those who should proceed to biopsy.

Question

I was put on a diet before a course of radiotherapy to reduce the chance of wind that can apparently move the prostate slightly is this true and is it very important?

Answer

Gas in the rectum can (curiously to you) alter the position of the prostate.Modern radiotherapy is sufficiently sensitive that its accuracy can be prejudiced by such wind. Therefore, the recommendations that have been made to you are correct.

Question

I am currently in Thailand on a long vacation visiting my son. I recently went for a consultation with my prostrate, I was given a PSA blood test which read 8.5 . i was given a couse of antibiotics for 3 weeks in case i had an infection , my next PSA test came back 9.5. I was then given a rectal examination and the doctor informed me my prostrate was hard on the right side. I was then given a biopsy test and it came back positive for cancer. My doctor has now advised me to have a MRI scanand a Bone scan to see if the cancer has spread. My question is: Is this a normalprocedure? Can you not tell if the cancer has spread fom the biopsy test?

Answer

It will be the scans that tells us if the cancer has spread outside the capsule of the gland rather than the biopsies.

Question

I was diagnosed in 2005 with prostate cancer. Started on zolodex then to radiotherapy to casodex. Age: 76 In 2007: psa 0.106, now it is 0.625.My next appointment is three months. What should I ask my doctor?

Answer

There is a small but significant rise in your PSA and the question you should ask your doctor is whether he wants to add to the Casodex, withdraw the Casodex and watch for a response or move to alternative endocrine therapy.

Question

I am 83 years old under treatment for Prostate cancer with 3 monthly injections of Zoladex. My cancer is semi aggressive, my PSA is 0.3.One of the Urologists at the hospital advises me to stop the treatment, wait and watch until the PSA reaches around 5. This will give my body a break from the side effects and also extend the effective life of the drug. I have been on this treatment since 2007.The other Urologist advises me to continue the treatment and when it ceases to be effective change it.Both have stressed the decision is mine, but I do not have the necessary knowledge to make this choice. Pkease can you give me any guidance

Answer

Your urologist’s suggestion is very reasonable. It has now been shown that”intermittent anti-androgen therapy” with recommencement when the PSA goesup is a good idea and does not prejudice the patient’s overall longevity.

Question

I have now had prostate cancer for 14 years. The first 12 years were watchful waiting and then my PSA count, which had been rising slowly, reached 24. I went through radiotherapy 2 years ago with 2 hormone Injections prior to treatment and my PSA count dropped to 0.01. It has now increased again. 6 months after the treatment it rose to 0.9 and then at my last check it was 11.4. I had another test a fortnight later and it is now 16. My consultant urologist has advised that I start a 4 month course of hormone treatment before seeing what further treatment is required; he suggested that cryotherapy would probably be the most suitable course of action. I am concerned as I feel that an MRI scan, which was suggested as unnecessary, should be taken to ascertain whether the cancer is contained within the gland or whether it has metastased. This may indicate that we should be looking at cryotherapy straight away rather than delaying for 4 months. What should I do?

Answer

It would be wrong to contradict or give advice other than your consultant urologist. He would need to perform an MRI scan to ascertain that there was no disease outside the prostate before contemplating local therapy to the prostate. If there is no evidence of disease outside the prostate, then it is possible that some form of local treatment might be offered. However, the majority of your treatment will likely be based on systemic hormonal (anti-hormonal) therapy.

Question

Regarding prostate biopsy:1. What is the prerequisite for biopsy?2. What is the duration of hospital stay followig biopsy under general anaesthesia?3.What is the cost of prostate biopsy?4. What is the treatment cost of robotic prostate surgery?

Answer

A prostate biopsy is indicated if have an abnormality detectable in your prostate and a raised PSA, for example. A prostate biopsy is performed as a day case and would require two days on antibiotics (starting one day before the procedure). The approximate cost of this procedure is in the region of ?1,000. Robotic surgery is one of several methods of treating localised prostate cancer and has approximate costs in the region of ?20,000-?25,000.

Question

My father is 71 years old and has the Prostate Specific Antigen (PSA) test every year.Recently, his results were as follows:PSA total 5.69 ng/MlFree PSA 1.25 ng/mLPSA_ratio 0.22 ng/MlTwo years ago, he was prescribed Tamsu tablets (Genericon ? retard 0.4 mg) and jas been taking these ever since.Could you please tell us if is better to perform a Prostate biopsy, to ensureeverything is okay, even though he was told that this is un-necessar? We are concerned if these levels of PSA are acceptable for his age.Are there any other accurate tests to be done before going forward witha biopsy.

Answer

The PSA of 5.69 is slightly elevated. The free:total ratio is just on theright side of 0.19. It would not be necessary to rush to biopsy your father butan extra test called a PCA3 test might be advisable. If this was abnormalthen a biopsy would be indicated.

Question

Can you tell me if it is possible that a prostate cancer has metastasized to distant parts (e.g. bones or lymph) if it cannot be felt with DRE examination?

Answer

It is possible that a prostate cancer can have metastasised and the yet the DRE examination be normal, unusual though it may be.

Question

Many American specialist prostate cancer centres recommend using triple androgen blockade for patients with rising PSA after RRP and/or radiotherapy. They also use dutasteride as a ‘maintenance’ treatment during off periods in Intermittent ADT. Is this a generally accepted view? And if not, what are the arguments against it?

Answer

It is policy is to use a HRH agonist for a rising PSA after radical prostatectomy with radiotherapy to the tumour bed if there is no evidence of disease away from the prostate region. Dutasteride is not used at this time. Intermittent ADT is an acceptable policy but, once again, Dutasteride as maintenance treatment during the off periods id not used as there appears no rationale for doing so.

Question

My dad has just been diagnosed with prostate cancerHe’s 52 years of age has no pre-existing medical conditions and is very healthy. His PSA is 13 so he has been given 3 options to choose from: Surgery Radiotherapy BrachytherapyI know you can’t advise him on which treatment to go for, but I just wondered which is the more effective.

Answer

Surgery and radiotherapy (for example, radiation seed brachytherapy) are equivalent in terms of cure rates. Patients with small glands and no obstructive urinary flow may well elect for brachytherapy as it does not involve extensive surgery in the pelvic area. However, patients with larger glands and obstructed urinary flow may be better advised to have surgery.

Question

My psa count is 14. I do not have increased frequency in urinating of any noticible anount. I have had difficulty in retaining an erection for about 5 or 6 years, gradually getting worse. My prostrate is enlarged, and will be having a biopsy. Can you confirm whether or not the fact that my bladder function seems the same, is an indication that I do not have cancer. All the information seems to say that it is a primary sympton. If the results are positive can I then get a second opinion as to treatment from a consultant with a high level of experience and expertise at short notice?

Answer

Bladder symptoms may be due to an enlarged prostate or a diseased prostate. The nature of the bladder symptoms do not necessarily help us differenitate one type of disease from another. The biopsy will tell you whether you have prostate cancer or not. Should this be the case, and you would like a second opinion, I would be very pleased to see you (however, I would require a formal referral from your general practitioner or current specialist).

Question

I was wondering if you could provide me information on how ethynylestradiol treatment works in prostate cancer. Also how the drug metabolises and how the drug is synthesised.

Answer

Testosterone is a growth factor for prostate cancer and oestrogens are antagonistic to this growth effect.

Question

On the average, how long does hormone treatment with Zoladex prolong the life of a prostate cancer patient? Prostate cancer was diagnosed upon discovery that the psa level was 194 with no sign of the cancer spreading to the bone. Psa dropped to 1.5 after treatment.. stopped the zoladex after 16 months but resumed taking it as psa rose again to 57.

Answer

The patient is having what we call intermittent anti-androgen therapy.This has been shown to be equivalent to continuing Zoladex but now his PSA has risen again to 57, I imagine his oncologist will recommend that the Zoladex is restarted. If the PSA falls rapidly again then the patient remains a hormone responder and hopefully this will prolong his life by a long time. It is a little difficult to give a median survival estimate as duration of treatment with Zoladex is not known, nor other factors.

Question

I have successfully had radiotherapy treatment for prostate cancer nearly two years ago, and so far no sign of return. Lately I am experiencing a little blood with my semen, should i worry?

Answer

Mild haematospermia can occur after radiotherapy to the prostate but if it persists you should seek further advice from your urologist.

Question

My father (80 years old) has an advanced prostate cancer with metastases with pain in leg. Zoladex started before about 18 months (PSA dropped from 50 to 5 and stayed so for more than a year), now PSA is 50, Bicalutimide was used for about 2 months and stopped for some chest pain. Can you advise please on any herbal or non herbal treatment to improve the condition.

Answer

Herbal treatments containing phyto-oestrogens may be helpful but, in general, there are better oestrogenic compounds when we need them. Certainly, it could not be considered an optimal second-line hormonal treatment and if the Bicalutamide has outlived its usefulness the patient needs a proper consultation.

Question

I have heard about fighting against prostate cancer byusing the high intensity focused ultrasound (HIFU).

Answer

HIFU is one of several focal forms of curative treatment for early prostate cancer, besides surgical removal.

Question

My best friend is diangosed with prostate cancer in 2004 and it has mestatisized. He was on hormone therapy but is now off the treatment for the last 6 months. He is experiencing impotency, incontinence and hot flushes and low energy. I am wondering if there are any other treatments that can help him?

Answer

The hormone therapy that is essential for your friend’s wellbeing tends to cause impotence. There is no way around this.

Question

I have had a radical prostatectomy followed by radiotherapy to the prostate bed due to a rising PSA level. Now the PSA level is rising again (0.18 – 0.22 – 0.3). My consultant suspects micrometastasis. He says it is too early for hormone therapy. I am not so sure. I would like to be referred to a specialist centre.

Answer

Despite a a radical prostatectomy and radiotherapy your PSA is rising. If it doubles again then hormone treatment would be appropriate. There is a case for performing an MRI scan of the pelvis. Probably a bone scan would not detect disease at this PSA level

Question

How long do hot flushes last after hormone therapy and radiation treatments for prostate cancer?

Answer

The hot flushes are due to the hormone treatment rather than the radiation therapy and tend to wear off over time. There are non-pharmacological treatments that may help, such as Evening Primrose Oil, and pharmacological ones about which your specialist will tell you.

Question

I have been diagnosed with prostate cancer stage 2c (Gleason 7, psa 52). My consultant in Singapore suggests treating with Tomotherapy.As I belong to BUPA International their 2nd Opinion service using a consultant in USA is suggesting surgery.So I am going mad! How can I assess which is correct? How can one compare surgery and radiotherapy for stage 2 prostate cancer?

Answer

Although your prostate cancer is said to be Stage 2c, there is concern thatyour PSA is as high as 52. One would assume you have had an MRI scan of the pelvis and a bone scan to rule out metastatic disease? If the tumour is”organ-confined” then either surgery or tomotherapy would be options(although the high PSA of 52 may argue slightly against the surgicalapproach).

Question

In view of the fact that the patient’s prostate cancer is of an aggressive nature, how soon can adjuvant cancer treatment(s) be given after surgery where all detectable disease has been removed , but where remains a statistical risk of relapse due to occult disease? Generally what are the possible adjuvant cancer treatments?

Answer

A 68 year old man has undergone radical prostatectomy for, what was considered from pre-operative assessment, to be a T2 case.It is presumed that bone scan and MRI of Pelvis show no evidence of more distant spread and it is believed that the histology of the resected prostate specimen showed Gleason grade 4+5 disease. It is not known whether the histology of the operatiove specimen showed clear margins (i.e whether there was the desired ‘buffer zone’ of normal tissues/uninvolved capsule between the disease/cancer and the surgical margin, i.e. the limit of surgical resection), and this is relevant as is the PSA at one month after the operation.If the margins are not clear of tumour (and I regret to say that this is more common in Gleason 9 cases) then post-operative radiotherapy to the prostate ‘bed’ should be considered. If the PSA is still detectable at one month post-operative then, again, radiotherapy to the prostate bed should be considered. With regard to adjuvant endocrine therapy, there is a case for this (LHRH [ant]agonist or Bicalutamide/other, but the consultant might well choose to do one thing (RT versus endoccrine therapy) at a time, particularly as GLeason 9 disease does not always respond well to endocrine therapy.Other typres of therapy would not be consdiered at this time.

Question

My husband who is 63 is about to start 5 weeks of Radiotherapy for Prostate cancer, then 3 weeks after he will have brachytherapy. Once he has had all this treatment other than the side effects mentioned should he be feeling himself again after 10 – 12 weeks, I would like to book a surprise holiday for us 3 months after the brachiotherapy but not sure whether this would be advisable.

Answer

One would expect that by 10-12 weeks after the procedure your husband will be fine to go on holiday.

Question

Following a radicle prostatectomy 5 years ago in Harley St., my follow ups have taken place under the NHS locally. My PSA has recently risen from 0.1- 0.2, 6/12 ago, and now has risen again to 0.3. (asymptomatic) (2 consecutive rises).My routine follow up consultation has highlighted that this may require radiotherapy, – (oncologist to be contacted by registrar for his opinion) What form does radiation at this stage normally take?Will it require time off work… other than for the treatment itself and is this is advised?

Answer

Your PSA is slowly rising five years after radical prostatectomy. If an MRI scan of the pelvis shows no disease outside the prostate bed then I agree that radiotherapy is indicated. This would take approximately 7 weeks with you attending every weekday a radiotherapy department (each treatment taking about 15 minutes). It would be quite possible to continue your work during this time. The side effects would be urinary and rectal, should be mild and only affect you in the last week of treatment.

Question

Is the PCA3 test used for screening purposes of men who are not exhibiting any prostate symptoms?

Answer

A PCA3 test is not used for screening purposes. It is used to refine the PSA test when the latter is slightly raised (perhaps before a biopsy is considered).

Question

I am to have a prostate biopsy in 2 weeks. Next week my doctor wants me to come in for a swab. I understand that this involves antibiotic issues. However, is the pre-biopsy swab the standard of care, or just a study?

Answer

All prostate biopsies are performed under antibiotic cover because there isa risk of introducing infection. Usually antibiotics are started the daybefore the procedure. It is not clear what the swab is for – it may (or may not) be a swab for MRSAwhich many hospitals insist on having prior to any procedure being performed- but certainly the antibiotic cover is standard care.

Question

Is it possible to buy the cancer treatment drug Zytiga (Abiraterone Acetate) for my father who is in Russia and does not have a possibility to buy it there. I live and work in th UK and know it is available here.

Answer

It is possible to obtain Abiraterone for appropriate patients. However, the patient would need to be seen by the prescribing oncologist first.

Question

I was diagnosed with prostate cancer with a Gleason score of 8 and a stage T1.I have received radiotherapy over 7.5 weeks and continue receiving Zoladex injections every 3 months for a 3 year period. Would it be possible for me at any future time to opt for the operation to have the prostate removed?

Answer

It would not be considered standard care to proceed to prostatectomy afterthe radiotherapy treatment you have received for a Gleason 8 carcinoma.That is not to deny that there are local treatment options available to theprostate should you only relapse at that site.

Question

My father had prostate cancer at the age of 35 and two uncles on my father’s side also had tumors quite young (before 50). I am currently 28 and my wife and I are considering having children. Is there any test I can take which will indicate whether I have a genetic pre-disposition to prostate cancer which I am likely to pass on to my children?

Answer

If there is also a strong family history of breast cancer in the female members of your family then the BRCA-2 gene test is worth taking. Otherwise, it would be sensible for you to have PSA screening from the age of 30 (a relaxed once two-yearly test throughout your 30’s so long as the level remains low).

Question

My father’s GP has just told him that all older men get prostate cancer. He is 79, turning 80 in July and is now convinced he has prostate cancer. He has had a PCA3 test which the GP has requested a repeat of in July. Can I reassure him that not all older men get prostate cancer?

Answer

Whilst the instance of prostate cancer in elderly men is quite high and sometimes it is incidental and does not require treatment, nevertheless, in otherwise fit men of 79 who have definite prostate cancer, occasionally, one of the less invasive forms of treatment (for example, external beamradiotherapy) may be indicated.

Question

etails of your request (Required): My father was diagnosed with prostate cancer three years ago at the age of 71. He has responded to treatment in various forms fom hormones to radiotherapy which was given because the cancer is in his hip and legs which causes mobility problems.> My question is about my recent visit to my GP to discuss the issue regarding preventative measures that I could pursue as a start to monitoring my health. I am a healthy/fit 48 year old man, I take regular exercise, have a reasonably healthy diet and maintain my weight at around 11 stone but have been told that my chances of getting prostate problems are much higher now that my father has it.> My GP was quite negative about my enquiry and even went as far as saying that early detection does not necessarily affect the treatment or outcome. He discouraged a PSA level check stating that a lot of men have undergone very uncomfortable biopsy based on PSA results which are not a good method of cancer detection.> Can you please advise me, i am confused as to whether or not I should be concerned at this stage of my life about the future threat of this and should I insist on a check (I have no symptoms)?

Answer

Whilst your general practitioner may be following the NICE guidelines, we do believe in PSA screening and with your father’s history (albeit not developing prostate cancer until the age of 71) PSA screening would certainly be sensible on you from the age of 50.

Question

My dad had brachytherapy to treat prostate cancer yesterday and is coming home this afternoon. Is the radiation dangerous to me and other members of our family? Could it effect my future health/ fertility etc? Is there anything we should refrain from eg. hugging for too long, sitting closely on the sofa, etc? Please message back as the idea of him being “radioactive” is unsettling us quite a lot!!

Answer

Young children, such as grandchildren, should not sit on your father’s lap and pregnant women should not be too close to him. Other adults are relatively screened. Your father’s consultant will give you further advice.

Question

My husband (53) had a PSA of 7 on routine screening. He has recently had a rectal needle biopsy which has been reported as benign. The Consultant explained there may be areas within the prostate that have been missed or microscopic spots in the prostate that may develop into cancer. He has a follow up appointment in 4 months for a repeat PSA and we’ve been advised if the PSA continues to rise he may need a repeat biopsy. Is there anything we can do to keep the PSA level down? If the biopsy was clear, why is the PSA raised?

Answer

The PSA test can be refined. At first we would want to know if the free:total PSA ratio was low. Secondly, in patients with a marginally raised PSA such as in the case of your husband, the PCA3 test can be useful to determine which patients should be re-biopsied. Although no tests are 100% accurate, the above is fairly sound advice.It is not advisable to take measures to try and keep the PSA level down, it would be better to concentrate on getting a diagnosis.

Question

Last June I had a routine medical at work and my psa reading was normal. First week of Oct.I got a kidney infection which was treated with a one week course of anti-biotocis. After that I had my bloods checked and my psa reading was 18.2. A few weeks later I had it re-checked and it was 12.2. A few wks later I had it checked again and it was down to 8.3. This week.checked again and my reading is 8.0.

Answer

Whilst it is good that your PSA has fallen after the course of antibiotics, a value of 8-10 is not normal and should be followed up once the infection is over. A low free:total ratio, an abnormal feeling prostate on digital examination by an expert or an abnormality on ultrasound would definitely require further investigation. Otherwise, a urinary PCA3 test might be useful in allaying a suspicion of cancer.

Question

I have a PSA of 28 and visited Charing Cross yesterday for a consultation.They want to do a biopsy under local anaesthetic but were pretty frank about the process. They say there would be a significant delay if I requested total anaesthetic.

Answer

It is much more common for men to have the prostate biopsy under local anaesthetic – indeed it would be most unusual for an adult patient to need a total anaesthetic as the procedure is considered quite minor.

Question

Please could you inform me if you have any information or advice about lymphoedema in prostate cancer patients. Risk factors and preventitive steps patients can take?

Answer

Lymphoedema should be a rare consequence of radical prostate treatment. Only if a full pelvic node dissection had been performed should this be encountered.

Question

My partner has prostate cancer which has spread to his bones. He is on drug therapy. He was diagnosed 3 years ago.> What is his life expectancy? Average.> What symptoms do we need to watch out for, or changes?> Where can I find out more about patients that have cancer in their bones please?

Answer

If your partner’s PSA has fallen then he is responding to treatment and hopefully has a life expectancy of some years. If the PSA (which marks for the response) is not falling then there may be further trouble.

Question

Details of your request (Required): My father-in-law was diagnosed with prostate cancer in early 2006. It had spread out of his prostate to his lymph nodes and he now has spots on his liver. He tried every treatment offered to him including chemotherapy and different pills, none of which have worked. He has now been given only weeks to live. I note from your website that you comment on alternative approaches and so thought emailling you may be beneficial. We have been told about a treatment called Miracle Mineral Solution (MMS) which claims to cure you of your cancer. It was apparently invented by a man called Jim Humble who field tested it in Africa and it claims to cure many illnesses caused by pathogens in the body. We are sceptical about trying this but just wondered if you had ever heard about Miracle Mineral Solution (MMS) and if so any information you have about it, whether good or bad. Do you think it is worth a try?

Answer

If your father-in-law is under a reputable specialist and they have tried all endocrine treatment and chemotherapy and have given him a prognosis of only weeks, then it is very unlikely that something more hopeful is on offer.

Question

Because of a raised PSA level of 4.6 I was referred to a Urologist. At the moment I have decided to follow the course of monitoring the level of my PSA level every six months. My last test showed a drop of 0.2 percent to 4.4.> After reading Dr Patrick Walsh’s book a ‘Guide to Surviving Prostate Cancer’ 2nd edition – I read with great interest his comments on the advantages of finding out what your ‘percent free’ or ‘free PSA’ reading was as this can give you a clear indication of if you do have Prostate Cancer and of how aggressive it might be or otherwise. My question is if I would like to go down the path of obtaining a ‘percent free PSA test’ where could I go to get this test done as I am given to believe that it is not offered by the NHS in this country on the grounds of cost ? Could you tell me also if this specific test also has another name given to it such as a ‘PCA3 Plus’ or ‘Progensa Test’ ?Any help you can give me would be greatly appreciated.

Answer

A a free:total PSA ratio (which is the test you are enquiring about) can be arranged with a private Clinic and a GP or Specialist’s referral letter, and if this is normal then the PCA3 test is also a predictor as to whether you should go forward to prostate biopsy.

Question

My 64 year old husband had reduced urine flow and had a DRE test 13 months ago which was negative. He was advised that PSA tests could give false/negative results and were not very helpful so he didn’t have one. He was referred to a kidney consultant in two weeks ago because of tiredness and high creatinine levels in his blood. She tested his blood for PSA, among other things, which showed a level of 351. DRE tests have confirmed cancer. He has been in hospital ever since whilst they try to stabilise his kidneys before doing a bone scan to see if the cancer has spread. Had he had the PSA blood test 13 months ago would it have shown high leves even though his prostate felt normal? What does a level of 351 suggest?

Answer

You are right to be very concerned about a PSA of 351. It is correct that the kidney function must be optimised and then, if safe to do so, he requires a bone scan and an MRI scan of the pelvis. The level of 351 suggests that the prostate cancer may have spread outside the gland. It may be necessary to perform a biopsy of the prostate additionally. These tests will give the extent of the tumour and help the oncologist decide which is the optimal treatment.

Question

My father’s prostate cancer has returned; this is after a 3 months of radiotherapy (2007) and zoladex injections, which ended in Nov 2008. His PSA started rising and consultation has revealed that the cancer has travelled to one of the lymph nodes which a CT scan has revealed has grown. They state that this is the first step in the cancer proliferating throughout the body. However this can be controlled with Zoladex and should that fail the introduction of additional casodex. He is 73 years old and any further radiotherapy to the area is no longer and option.Can i ask what other therapies are available for him apart from Homone therapy?

Answer

I agree with your father’s physicians that restarting hormonal treatment with Zoladex is appropriate. If this fails then secondary endocrine options including the addition of Casodex or other endocrine therapies. If thedisease resists that and remains in pelvic side wall nodes, then some local treatment could be considered but I have to say that it is likely that this is the beginning of systemic disease and therefore systemic options (i.e. those that travel all around the body) would be the appropriate ones.Chemotherapy is usually kept in reserve until all the anti-hormonal options have been used to the full.

Question

I am writing in the name of my father, 76 years old. During recently medical examination his PSA value has reached 5. He wants to know if it is possible to precisely diagnose the state of the prostate without any biopsies, but using non invasion methods, such Early Prostatic Specific Antigen EPCA,EPCA 2.19, EPCA 3plus, or Progensa Prostatic Cancer Antigen PCA3?

Answer

If your father is an otherwise fit 76 year old man and this PSA is rising, then a PSA3 test would be a good idea. One would only proceed to biopsy if the PCA3 was positive in a 76 year old man with a PSA of only 5.

Question

I have recently been diagnosed with Prostate Cancer and I’m waiting for the results of the MRI and bone scans.I am trying to establish where to get the best advice and treatment.I note your comments on the site advising that there are cures for certain metastases. However, it is my understanding that if it has reached the bone then it is incurable. Is this correct?

Answer

Regrettably, once prostate cancer gets to the bone the disease, finally, is incurable. However, it is possible to give patients very long remissions with modern treatment (at least in the first instance, based on hormonal treatment).

Question

I have recently registered a high PSA level and am due to have a biopsy at the whittington hospital at the end of the month. My GP told me that there is an alternative procedure to establish the presence of cancer by means of a blood test, avoiding the need for a biopsy. I’ve seen a reference on your website to gene testing of a urine sample which seems to do the same thing but can’t find reference to a blood test. Do you in fact offer this alternative to a biopsy? If so, could you give me a rough estimate of what it might cost ?

Answer

You are probably referring to the PCA3 test in your email. This can be arranged at a private London laboratory. The cost is in the region of ?300-?400. A first consultation in London would be ?250. Following the result of this test the consultant would discuss whether a biopsy is required. No test is infallible but the PCA3 test does direct the specialist towards those patients who ought to proceed without delay to biopsy.

Question

My partner has blood in his semen every time we have sex, he has been to our Doctor twice and both times has been told it’s normal for 61. Can you please advise us, he does not have pain or blood in his urine and sex does not hurt him but we are both worried it could be cancer. Are there any tests you can carry out on him as we feel the Doctor he is seeing doesn’t seem to be taking it seriously.

Answer

Continuing haemospermia is not normal and should probably be investigated further.

Question

I am 68 years of age. Is it normal for a man of that age to produce semen which has no turbidity whatsoever- entirely clear and transparent? If it is NOT normal, could this be due to a malfunction of the prostate gland? I am due for prostate examination shortly but would appreciate your opinions on this matter.

Answer

The truthful answer to your question is I have no idea! May I suggest you ask your specialist when you see him next.

Question

My father has just been diagnosed with prostate cancer. It was such a shock that i cannot recall half of what was said when we went to see the doctor at the hospital. We are now going to have his next appointment in August, however the doctor wanted to see my dad in 4 months time. When i rang the hospital they said that there were no sooner appointments available. Is there anyway to get my dad seen on time?The doctor has taken the wait and observe approach but i would like a second opinion. Is this possible? I do not feel well informed about why he has taken the wait and see approach. I am concerned that he made this decision because of his age, 72 yrs. Also, I do not know what stage the cancer is at and whether treatment should be available to him. Do we have the right to ask to see a cancer specialist? As you can gather from my email i am very new to this and any advice you can give me is much appreciated. I have an appointment with his GP next week but i am not sure of what i need to ask for.

Answer

Sometimes it is reasonable to “watchfully wait” a patient with early prostate cancer but obviously from the details provided, we cannot advise on the individual case. A second opinion from a specialist would require a formal referral from his general practitioner or current specialist. A consultation would cost ?200.

Question

My father has prostrate cancer, which has gone into his spine, and according to his consultant, 1or 2 discs have collapsed. Before they discovered that, my dad has been unable to walk, and has a lot of swelling in his feet and legs. He has had radiotherapy.

Answer

If your father is in reasonably good condition from the disease point of view at other sites then some sort of stabilisation procedure of the spine might be indicated. However, if he has widespread disease this might not be advisable. The effort would then be directed into achieving a more durable remission of his prostate cancer.

Question

My dad has been diagnosed with prostate cancer. He is 70. They thought it had affected his bones but that came back all clear.However it has spread around the prostate. He is waiting for an MRI Scan. He’s been given a few options; removal of testicles, injection in the stomach or some sort of patch.He knows it can’t be cured but they are going to try to suppress the spread of the cancer. He is thinking of having the injections in the stomach, which I believe is monthly, and has side affects of flushes, brittle bones. I was wondering if this would be the best for him ?

Answer

If your father’s bone scan is clear and MRI scan shows no spread beyond the prostate region (although, in his case, there is local spread through the capsule) then he would be best advised to have hormone treatment (either removal of the testicles or the LHRH injection into the stomach to which you refer) followed by a course of radical prostate radiotherapy

Question

My father’s GP has just told him that all older men get prostate cancer. He is 79, turning 80 in July and is now convinced he has prostate cancer. He has had a PCA3 test which the GP has requested a repeat of in July.Can I reassure him that not all older men get prostate cancer?

Answer

Whilst the instance of prostate cancer in elderly men is quite high and sometimes it is incidental and does not require treatment, nevertheless, in otherwise fit men of 79 who have definite prostate cancer occasionally one of the less invasive forms of treatment (for example, external beamradiotherapy) may be indicated.

Question

50 ys old, psa 189, free psa 4, extracapsular prostatic lesion; angio CT showing 1cm limphnodes in the pelvis and near the aorta, no brain, lung, liver lesions; bone scan negative for lesion; gleason 3+4. What do you suggest for treatment, radical extracapsular prostatectomy or radiation therapy?

Answer

Certainly, hormonal treatment is recommended and if there is really no evidence of disease outside the pelvis then radiotherapy could be brought in after a period (by which time, hopefully,the PSA would have fallen greatly).

Question

Radical Prostatectomy September 2004 with pre-op psa 1.7. PSA readings had been constantly less than 0.1 until June 2009. In 2010 psa moved rapidly and had reached 0.8 by June and further scans showed several small tumours on the lymph nodes in the same region. Earlier thoughts of surgery and radiotherapy were then abandoned and treatment for advanced prostate cancer followed. Since July 2010 Casodex 150g daily PSA then dropped to 0.25 in May 2011 from 0.8 in June 2010. Then increased September 2011 to 0.75 and January 2012 to 0.356Should he consider:1. Stop or consider Casodex and review psa in two months?2. Commence alternative anti androgen, oestrogen, LHRH agonist now or in two months?3. Could radiotherapy still be deployed around the prostate bed and adjoining lymph nodes curatively?

Answer

It is noted that this 68 year old man had a radical prostatectomy in 2004 and that postoperatively his PSA readings remained very low until 2010 when they started to rise. MRI scan showed nodal relapse adjacent to the prostate bed and the patient was placed on Bicalutamide (Casodex). This successfully controlled the PSA until the last five months during which the PSA has risen to 0.75 in September although dropping to 0.4 in January.The two treatment options to be considered are alternative hormone treatment (and we agree with the LHRH agonist) or pelvic radiotherapy.We would suggest that the patient is changed to the LHRH agonist as alternative endocrine therapy and I would not add other alternative endocrine therapies (such as low dose oestrogen or Arbiraterone) until we had seen the response to the LHRH agonist.Before considering radiotherapy to the prostate bed and pelvic nodes, it would be advisable to perform a bone scan (although it is unlikely to be positive in a patient with a PSA of only 0.4). If the patient does not respond well to the LHRH agonist and there is no evidence of disease outside the pelvis then pelvic radiotherapy would be a sensible suggestion.

Question

What level of PSA is considered to be of concern?

Answer

A significant rise in the PSA or an absolute level above 4 in a young man, 5-6 in a middle aged man or above 6 in an elderly man would cause concern. There are tests to refine the PSA count.

Question

What options are there for prostate cancer that has spread to the bones?

Answer

Metastatic prostate cancer is treated primarily with endocrine therapy (hormonal therapy). There are several different methods of hormonal therapy which can be sequenced. For bone metastases that are painful, radiotherapy or Strontium-89 therapy can help in selected patients.When endocrine options have failed, chemotherapy based on Taxotere or Mitozantrone may be used.

Question

Following prostate cancer and the removal of the prostate gland, no further treatment was prescribed. 4 years later cancer has now been diagnosed in the cavity left by the removed prostate.The cavity has now been filled by his bowel and bladder according to the> scan he had recently, it has been suggedt that the only course of treatment available will be a course of radiotherapy. The aside effects of this are almost guarenteed risk of bladder and bowel problems. Are there any other treatments available?

Answer

Local recurrence in the prostate bed is usually treated by radiotherapy. If there is a lot of bladder or bowel in the area then the radiotherapy will have to be given carefully and an IMRT (Intensity modulated radiotherapy) technique would be preferable.Such radiotherapy stands a minority but significant chance of “salvage cure”. The alternative way forward would be to place your father on some anti-hormone treatment which is likely to hold the situation for some time. It is unlikely to be curative and in that respect it differs from the potential of radiotherapy.

Question

Is it possible to have proton treatment for my diagnosis?> Ooriginal diagnosis 850 PSA Gleason 10 3.5 yrs ago with 2 small spots found; 1 lower back, one left hip. Treated with zoladex and a multi tude of supplements.Vegan + fish lifestyle my psa went down to 0.7 however it is now doubling every 4 months and was 7.1 in December.

Answer

If you presented with a PSA as high as 750 and evidence of early metastatic disease (for example, the left hip), the emphasis of treatment should undoubtedly be with hormones. If you are starting to relapse after Zoladex then second-line hormonal therapy ought to be strongly considered.

Question

I have been on hormone therapy for four and half years after being diagnosed with aggressive prostate cancer which had come out the capsule but hadn’t spread. I had a Gleason scale of 8. Because of rising PSA results, i was put on to Casodex last Spring which lowered the PSA but it is rising again month over month and is now at 2. Does this mean the cancer is starting to spread?

Answer

If there was no evidence of spread beyond the transcapsular element when you were placed on the hormone therapy and if the PSA is now starting to rise, then restaging is recommended followed by, if your expert oncologist agrees, prostate radiotherapy -preferaby by IMRT.

Question

My brother who lives in Melbourne, Australia has been diagnosed with early prostate ca (Gleason 1). He has been told the best treatment in his case is keyhole surgery using a robot which luckily for him is available albeit privately over there. I cannot find anything about this on our medical websites. Can you briefly enlighten me? Many thanks.

Answer

Robotic surgery for early prostate cancer is, in skilled hands, a good technique. It avoids the large open operation as the operation is done through fibreoptics and computer controlled microsurgery.

Question

I have been diagnosed with prostate cancer and have been told that I will need to have tablets for the next 21 days and then injections in my stomach for the rest of my life. I asked about the alternatives but was told that this was the best way forward.

Answer

The treatment you have been recommended is standard endocrine therapy for the treatment of prostate cancer that is beyond an early stage. There is an alternative tablet which you should discuss with your specialist if you are averse to the injection but let me reassure you that an LHRH agonist injection is standard care.

Question

My grandfather is diagnosed as suffering from prostate cancer, he is 80 years old. His doctor does not suggest surgery. Is it possible I buy some drug for him, or can you advise another suggestion?

Answer

If your father’s prostate cancer is localised then, at his age, radiotherapy would be a good option. If his tumour has spread then hormone treatment is best.

Question

There are many articles saying that tomatoes, pineaplejuice , Vitamin D and Soya will delay prostate cancer. Is one expected to eat these daily? If yes, why is it not recomended as a treatment?

Answer

There are some interesting data concerning tomatoes which are not exactly “level 1” evidence but persuaded me. Soya and other herbs that contain plant oestrogens may be active by virtue of androgen antagonism

Question

My uncle is in his 90s and has Parkinsons as well as prostate cancer. The doctors have just said that the prostate cancer is serious but that he is too old for treatment. My aunt wants to know what the symptoms are if the cancer spreads and grows and how this will actually affect him. I have just looked up lots of site on the internet – many speak of back pain. Is there anything helpful you could tell me about these symptoms so I could inform my aunt please?

Answer

Five out of six prostate cancers respond to simple hormone treatment and even a man in his 90’s with Parkinson’s disease may well benefit from that treatment. Of course, it is difficult to say more without knowing about the case but this possibility should be discussed with your physicians as it may be relevant

Question

I had a radical protastectomy operation in March 2004. My psa has now slowly risen to 0.1. At what level of psa should I be concerned and when, if needed, should further treatment be required.

Answer

In the situation you describe an MRI scan of the pelvis would be recommended and if there is no evidence of relapse overtly outside the prostate bed and there have been no significant rises in the PSA, then radiotherapy to the prostate bed is advised on the presumption that that is the site of disease persistence. If there was microscopic disease at resection margins at the time of your radical prostatectomy, that too increases the strength in the argument to early prostate bed radiation.

Question

I’m 76 years old and have prostate cancer that is untreated. My PSa is 185. Whatcan I expect if I continue to have no treatment?

Answer

I would respectfully suggest that you would be foolish to ignore modern treatment for prostate cancer. With a PSA of 185 it is likely (not 100% but likely) that you have disease outside the prostate. Under those circumstances you would be best treated by some form of hormonal measure (to which 5 out of 6 men respond well and usually has relatively few side effects).

Question

Aged 73. Diagnosed with Prostate Cancer Kings College Hosp. PSA scores 7.2 and 7.9.Biopsy 12 strikes, 3 Positive. Gleason 3+3; 3+3; 3+4. The Prostate mass is quite large, but the cancer is only on one side and was categorised as T2. What are the options?

Answer

Surgery may not be the best option at the age of 73. If surgery is not an option and providing the MRI scan shows no extracapsular spread then one of the radiotherapy options would be best and your specialist will discuss these with you.

Question

My last PSA test result was 4.7. What are the units of measurement used to determine this figure?

Answer

A PSA of 4.7 is slightly raised for a young to middle aged man. Forpatients in their 70’s or 80’s in whom the PSA is not fast rising, a PSA of4.7 would be of lesser concern. If you wanted to investigate further at thistime then the free:total PSA ratio (blood test) and a PCA3 (urine test) aretwo diagnostic tests which might help to assess whether a biopsy isindicated.

Question

Can you please tell me what is an acceptable amount of alcohol units to be consumed while being treated by Brachytherapy?

Answer

The answer is a small amount of alcohol.

Question

We have been told by our current doctor that the best course of action is active surveillace, with a follow up biopsy in 3 months time, followed by surgery if cancer appears to be spreading. He mentioned that radiation therapy may not be a good option in this situation.Would brachytherapy be an appropriate treatment option for a 58 year-old in such a situation?

Answer

A 58 year old man with a Gleason 3+3 in one biopsy and a PSA of 11.3 is, at first glance, a good candidate for radiation seed brachytherapy if urinary function is good and that an MRI scan shows no extracapsular spread.

Question

Under the heading Radiotherapy on your very helpful site no mention is made of the Cyberknife and the differences in treatment, side effects of outcome. Is this because St Barts doesn’t have access to the equipment or for some other reason please.

Answer

Cyberknife is a good alterative to brachytherapy and for early cases ofprostate cancer where the urinary flow is reasonable and the gland is not oftoo large a volume.

Question

I have a slowly increasing PSA level, with the last result being 9.3 ng/mL. A biopsy 18 months ago was negative. I would like to know about the PCA3 gene test – the sample required, whether this can be collected at the clinic, and the cost of the procedure.

Answer

The PCA3 gene test is a fairly specific test for a gene product that is produced by most prostate cancers and appears in the urine. It guides the doctor as to whether a repeat biopsy should be performed. Nothing is 100% accurate but it is a very good indicator.A first consultation in London is ?250. The laboratory cost for the PCA3 test is approximately ?300 but additional laboratory fees are also incurred of approximately ?100. It takes approximately 14 days for the results to come through. It would probably be best to arrange the test and then for the specialist to see you approximately two weeks’ later when the result is available.

Question

I am 71 years of age and as far as I know I am asymptomatic with regards to prostate problems. I do not urinate frequently and I have no difficulty urinating, although the flow is not as strong as it used to be. In 2003 I had a series of PSA tests over the course of 6 months. The first test was 8ug/L and the last 4ug/l. The consultant suggested that I had had a minor bladder infection causing the raised PSA.I have since had 2 new PSA blood tests in the last 6 weeks. 1. 19 March 2009 10ug/LAfter a course of bladder specific anti-biotics, a second test.2. 27 April 2009 7.7ug/L My GP has advised me to see a consultant with a view to having a biopsy.I have read that there is a new urine test, the Progensa PCA3, which can detect early cancer cells. I am reluctant to undergo the biopsy procedure unnecessarily, as some of my friends have told me it is invasive, painful and has left them with bladder problems.

Answer

A free:total PSA ratio and a PCA3 test might well obviate the need for a biopsy (although one has to say that a biopsy is the definitive test). However, if these other two tests were not suggestive then it might be possible to leave matters alone.

Question

My father was diagnosed with prostate cancer a few months ago. He had an open surgery about a month ago but the surgery was not successful due to his other medical conditions. His doctor recommended him to start radiotherapy, and we are planning to take him to the UK where we can receive a better treatment. I know Texas University, Sloan Kettering and John Hopkins are the best in the US, but I dont have any information about UK cancer centers. Since two weeks ago I have been searching on the Internet to find a reputable prostate cancer treatment center in the UK, but unfortunately I have not been able to make my mind based on online data. Can you introduce to me any specific hospital or treatment center considering he is not covered by NHS and we will pay for the treatment.

Answer

Your father might consider treatment at the Cromwell Hospital which has tomotherapy (the world’s most advanced IMRT for prostate cancer). The treatment course is given over seven and a half weeks as an outpatient. Cyberknife treatment is also available in London at the Harley Street Clinic, but it is probably not yet as conventionally validated as the other options