Health

Watching out for a silent threat

Prostate cancer, a once largely silent disease that was often diagnosed in its more advanced stages has become increasingly identified and treated at an earlier phase in men today. 

A greater awareness of disease symptoms coupled with improvements in detection and diagnosis, as well as treatment options has led to a huge benefit in survival over the past few decades. 

Each year there are over 3,000 new cases of prostate cancer in Ireland (about two thirds occurring in those over 65) and overall it accounts for about 500 male deaths annually. Despite this, prostate cancer in its early stages has about a 90% five year survival. However, this reduces to about 30% where there is distant spread highlighting the potential benefit of earlier detection. 

The prostate is a small gland that lies under the bladder and from which the urethra (tube which drains urine from the bladder) passes. 

Hesitancy

From the age of about 40 onwards, benign enlargement of the prostate occurs in most men. Indeed, up to 50% of men at 50 and nearly 75% at 70 will have some degree of urinary symptoms due to benign prostate enlargement. 

This includes increased frequency of urination, hesitancy with initial flow or dribbling and waking at night to empty the bladder. The symptoms of early prostate cancer are similar, though in most cases the tumour originates in the periphery of the gland and therefore may go unnoticed. 

If you have prostatic urinary symptoms, you may have a rectal exam performed by your GP to exam the prostate and also have a blood test to check your PSA level. The Prostate Specific Antigen (PSA) is not specific for prostate cancer and is elevated in benign prostate enlargement and with urinary tract infections and prostate inflammation. 

However, if your PSA level is higher than expected or if tests raise concerns, your GP can refer you to a urologist or a Rapid Access Prostate Clinic where further tests can be done. 

The diagnosis of prostate cancer is ultimately made after a biopsy of the gland. This is done under ultrasound guidance (via the rectum) and usually as an outpatient. If cancer is confirmed, imaging will be done to determine the extent of the tumour and to determine whether it has spread. 

The most important prognostic factors include the extent of disease at diagnosis (whether it has spread or not), the PSA level and the tissue grade (how aggressive the prostate tissue looks). 

In many cases, prostate cancer is a slow growing tumour that may not shorten life expectancy. However, detecting it earlier in some men may result in curative therapy being instituted and/or other treatments that can slow disease progression and delay or prevent complications. 

Minority of men

This is particularly true in a minority of men who get a more aggressive cancer. Detecting this type of disease in your 50s or 60s or in those with a good life expectancy has the potential to offer life saving treatment. 

Despite this, routine screening of all men for prostate cancer is not recommended as it has not been shown to improve overall survival.

Indeed, after a diagnosis is made treatment is not immediately necessary for most men. For early low grade disease, an approach of active surveillance over several years may be taken, whereby the tumour is closely observed with the goal of avoiding early or unnecessary treatment that can have serious and permanent side effects. 

For early high grade disease, particularly in those who are younger or are otherwise healthy cure can be achieved with a radical prostatectomy involving complete removal of the gland. 

This probably offers the best chance of cure though can lead to urinary incontinence and impotence. 

An alternative option for men with local disease is radiotherapy which achieves similar cure rates. With brachytherapy, radiation is delivered within the gland itself, sometimes with the use of radioactive seeds. 

It has fewer immediate side effects and can be done over one to two days with a quick return to usually daily routines. However, it can also cause urinary difficulties and impotence. 

In addition, in high risk early prostate cancer, hormonal therapy can also be given following brachytherapy. Finally, in more advanced cases where there is distant spread and cure is not possible, disease can be contained for several years with hormonal therapy and/or chemotherapy.

From a risk perspective, obesity and poor diet have been linked to prostate cancer while having a first degree relative (brother or father) increases the risk by twofold, rising to  fivefold with two close family members.

Importantly, treatment options for prostate cancer have improved survival greatly. While in many cases there are no early symptoms, getting checked out with routine PSA testing and a rectal examination can detect disease earlier. However, this needs to be carefully considered on an individual basis as can it lead to investigations that prove negative or that don’t alter treatment. 

If you have concerns, you should discuss with your GP.