Prostate Cancer
Basics
Prostate cancer usually affects men from the age of 60 to 80 years old.
Symptoms
There are two types of symptoms these patients will present with: Symptoms of Obstructive Prostatism and Irritative Prostatism.
- Obstructive Prostatism:
- Hesitancy – the patient feels that the bladder is full but struggles to start or maintain a urine stream.
- Straining
- Weak stream
- Terminal dribbling
- Urinary intermittency – this refers to a urine stream that is not continuous.
- Overflow incontinence – small amounts of urine leak (incontinence) because the maximum bladder capacity has been reached.
- A sensation of incomplete emptying
- Irritative Prostatism:
- Urinary frequency – sometimes defined as voiding more than seven times during the day and more than once per night (nocturia).
- Nocturia
- Urgency
There are other important symptoms to enquire, such as those that may suggest metastasis.
Diagnosis
The diagnosis is made using symptoms, signs and the findings on our investigations. The patient with prostate cancer will may present with symptoms suggestive of urinary tract obstruction, and they may also feature symptoms suggestive of metastasis.
Digital Rectal Examination: Patients who have Prostate Cancer may have a prostate that has a nodular surface, rocky-hard, fixed without a median sulcus and it is also not painful to palpation. In Benign Prostatic Hyperplasia (BPH), the surface of the prostate is smooth, firm, mobile with a sulcus and there is no pain. A smooth, soft prostate that is very tender to palpation suggests acute prostatitis.
Investigations:
- Prostatic Specific Antigen (PSA) – helps to rule out Prostate Cancer.
- Prostate cancer will produce more PSA than in a normal patient or in patients with BPH.
- The PSA levels vary with age.
- A Total PSA level > 4.0ng/ml is suggestive of Prostate Cancer.
- However, when a Total PSA level is between 4 – 10, a Free PSA level should also be measured.
- Free PSA < 21 ng/ml is suggestive of Prostate Cancer.
- If the PSA levels are suggestive of Prostate Cancer, a prostate biopsy should be performed.
- Urea and Electrolyte – deranged urea, creatinine and electrolytes may occur due to obstruction of urine flow.
- Uroflowmetry – this is a test that includes an assessment of the following: volume of urine released from the body, the speed with which it is released, and how long the release takes to release the urine.
- Ultrasound of the abdomen and prostate.
- Cystoscope
- Prostate Biopsy – this allows for a definitive diagnosis to be made.
Management
The management of Prostate Cancer depends on various variablies. However, the most common procedures include:
- Radical prostatectomy
- Brachytherapy
- External radiation
- Active Surveillance
- Hormonal therapy
We should remember that Prostate Cancers are usually testosterone (hormone) -dependant, which means that there is an option for hormone deprivation. This includes:
- Bilateral Orchiectomy (surgical)
- Chemical castration: Use LH-Releasing Hormone agonists such as Goserelin acetate (Zoladex), injected every 3 months.
- Non-Steroidal Anti-androgen treatment: Use cyproterone acetate 50mg PO BD.
- Radiotherapy
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