Prostate Cancer

Dr Kingsley’s comments

Prostate cancer is a condition of men as they grow older, being the third most common cancer in the male. Various stages are described of the degree of cancerous change, namely well, moderately or poorly differentiated. This effectively means the seriousness of the cancer. Cancer of the prostate can spread to the local tissues or, most commonly, to bones.

The symptoms that subsequently end with a diagnosis of prostate cancer are the same as those of benign prostatic hypertrophy (BPH), namely some sort of change in the normal flow of urine.

It may begin as a little difficulty starting your stream, or you may notice you are going to the toilet more often than previously (known medically as ‘frequency of micturition’), yet the amount you pass each time is not as much as usual.

You may also be aware of an increase in the need to pass water (called ‘urgency’ by doctors). You may also find you are getting out of bed to pass water, either as a new feature, or more often than previously.

And stopping drinking anything later in the evening doesn’t seem to help. While there may be a degree of ‘hesitancy’, you may also find that you dribble when you thought you had finished.

These symptoms merely indicate that your prostate has become enlarged and is simply pressing on the urethra, which is the tube that passes through the prostate, leading from your bladder to your penis. This is shown in the drawing.

If there is pain in your perineum (the area between your legs), this can indicate that your prostate has become inflamed, so will be called prostatitis. This is usually caused by some sort of infection (which will be explained in more detail later).

On the other hand, if you already have cancer in your prostate, pain in your perineum can indicate that the cancer has spread outside the capsule of your prostate into the surrounding tissues.

On rare occasions, the first indication of prostate cancer is a pathological facture of any bone. An injury that would not normally cause much damage leads to a fracture, which, when it is x-rayed, looks abnormal to the Radiologist.

There may also be noticed other areas of loss of structure within the skeleton, which makes doctors suspect the diagnosis.

On rare occasions, lymph glands in the local area, usually inside the lower abdomen, are affected by local spread, which then causes obstruction the flow of blood from a leg, which then becomes swollen. It can sometimes cause swelling of both legs.

It must be pointed out that about 30% of men over the age of 75 years, on whom a post-mortem is carried out, are found to have had cancer in their prostate, suggesting that it can often run a very benign course. As lots of men over that age do not undergo a post-mortem, the figure could be considerably higher.

Occasionally cancer of the prostate is discovered when a sample of the prostate is examined in the laboratory, after an operation to ream out the prostate through the penis (under anaesthetic of course) for benign prostatic hypertrophy has been carried out. Finally, cancer of the prostate may be suspected if a routine blood test shows an elevated level of PSA (Prostate Specific Antigen)

Investigations.

There may be little to find wrong on a simple physical examination in the early stages of cancer of the prostate, but a rectal examination reveals a harder prostate than is considered normal. Most standard blood tests are found to be normal, but the PSA is likely to be raised, though not always particularly high.

The older you are, the higher the allowance, but the standard cut-off point is around 4.0, anything above that being regarded as suspicious, and worthy of further investigation. I have known patients to have cancer at 4.0, and not to have cancer at 10.0. Another blood test called acid phosphatase, if raised, increases the likelihood of cancer being present in the prostate.

Doctors like to make a definite diagnosis, to be able to advise what they consider to be the appropriate treatment. So a biopsy is very likely to be recommended. This can be a very painful procedure, the sample being taken by inserting an instrument into the rectum and sticking a number of needles through the front wall of the rectum into the prostate.

Various scans, including ultrasound, CT or MRI of the local area may well be carried out to clarify any degree of spread, as well as a scan of the whole of the bony skeleton.

Conventional Treatment.

The treatment that is likely to be offered will depend on whether the cancer is in its early stages, has spread locally, or has spread to other parts of the body, nearly always to bones.

There are effectively two options available to surgeons, namely a simple transurethral prostatectomy or a prostatectomy through the lower abdomen. Occasionally both testicles are surgically removed. Local radiotherapy is often recommended, and can certainly be very effective for treating the pain of secondaries in bones. Hormonal drugs, usually by regular intra-muscular injection of a depot preparation, fall into two categories, namely gonadotrophin releasing hormone antagonists, which block the pituitary-gonadal axis, and drugs that compete with testosterone where it binds to tissues. Treatment Dangers.

Surgical removal of the prostate can cause impotence, although newer techniques to preserve local nervous tissue cause less damage. Some patients lose a degree urinary control after a prostatectomy.

With radiotherapy, the rectum and bladder can be burned badly, but, again, better targeting can reduce the incidence and severity of such adverse effects.

The drugs invariably feminise men, which they can find to be very uncomfortable. This is effectively chemical castration, but can be reversed on stopping the drugs. The man’s voice can change, breasts may develop and male pattern of hair distribution may change to that of the female. There can be reduced libido and even ‘menopausal-like’ sweats. When these drugs are first started, there can be a flare up of the tumour.

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