‘Prostate cancer’: I say the words, and await the response – which can vary between shock, resignation, a shrug with a comment suggesting everyone’s got it and it rarely causes any problems, to a partners eyes filling with tears. The truth of course is that all prostate cancer is not the same, and although the attitude that it is a condition that one lives with, and doesn’t die from, may sometimes be the case in the elderly, it can also be an incurable life-threatening disease diagnosed in a relatively young man.
Unlike many other types of cancers, prostate cancer usually progresses slowly
One way of looking at the difference is the aggressiveness of different prostate cancers. Unlike many other types of cancers, prostate cancer usually progresses slowly. However, in some cases it is more aggressive, spreads more quickly and may more obviously benefit from treatment. Sometimes this difference is clear from the outset when assessing a man’s results such as PSA (prostate-specific antigen) level, examination findings and biopsy grade (Gleason grade). However, this is most often the case with the most aggressive cancers – the real challenge comes with the patients in whom a cancer has apparently been identified very early: could it be more advanced than we think? When is the best time to treat? Does it need treatment at all?
Recent controversies surrounding diagnosis and screening for prostate cancer stem in part from these dilemmas. Two large trials into screening for prostate cancer have produced somewhat conflicting results, and are far from demonstrating a clear benefit for screening, and warn of both the dangers in the increased rate of prostate biopsy and an over diagnosis of small cancers that would never impact of the mans natural life span. A genuinely small low grade prostate cancer will remain ‘dormant’ for many, many years and has thus been the theory behind a form of delaying treatment called active surveillance whereby the PSA is monitored regularly, the prostate examined from time to time, and biopsies are repeated at varying intervals.
In my view, this is all very well if the biopsy information is fully representative of the whole prostate. But we are increasingly including an MRI scan in the diagnosis, in order to gain additional conformation that this is the right course of action to take for the patient.
However, as a surgeon, there remains the worry that by delaying treatment, because things such as PSA have changed or a repeat biopsy is taken that shows a change, the outcome from surgery may be compromised. It should be emphasized; the chance of cure still remains excellent. The challenge for the surgeon in prostate cancer is to remove all the cancer, whilst maintaining normal function afterwards with rapid return of both bladder control and erectile function. This is most successful when the incisions around the prostate are as close as possible, which poses a risk in larger volume tumours of leaving some cancer behind.
So: ‘Prostate cancer’ I say, and know that I am then entering a long conversation explaining the potential impact of the results, the various options of treatment together with the pros and cons of each – a process that requires plenty of time to allow a diagnosis to sink in, and the implications to be absorbed, before a decision can be made.
To make an appointment at Spire Parkway Hospital please call 0845 850 1451
Prostate, Lung, Colon, and Ovarian screening trial (PLCO). (Andriole GL, Crawford ED, Grubb RL, 3rd, et al. Mortality results from a randomized prostate-cancer screening trial [published erratum in N Engl J Med. 2009;360:1797] N Engl J Med. 2009;360:1310–1319)
European Randomized Study of Screening for Prostate Cancer (ERSPC) (Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360:1320–1328)