How can Prostate Cancer be Diagnosed and Treated?

Prostate cancer is a type of cancer that occurs in the prostate, a small walnut-shaped gland in men that produces seminal fluid.

In the UK, an annual estimate suggests approximately 52,300 new cases of prostate cancer, with about 12,000 deaths attributed to the disease every year. Remarkably, the survival rate has seen significant improvement, with nearly 77.6% of men in England diagnosed with prostate cancer in its early stages now expected to live ten years or more. This dramatic increase in survival highlights the effectiveness of modern treatment strategies, and the importance of early diagnosis. Also, the type and grade of prostate cancer play an important role in determining survival outcomes.

How is prostate cancer diagnosed?

Prostate cancer diagnosis typically involves initial screening with a Prostate-Specific Antigen (PSA) blood test and a Digital Rectal Exam (DRE). If these indicate potential cancer, further tests such as biopsies, Magnetic Resonance Imaging (MRI), and ultrasound may be conducted to confirm the presence of cancer and determine its stage.

Prostate-Specific Antigen blood test

The PSA test checks for elevated levels of prostate-specific antigen (PSA) in the blood, a protein produced by the prostate which can indicate cancer or other prostate issues.

Digital Rectal Exam

The DRE involves examining the prostate for abnormalities, such as hardened areas or lumps, through the rectum.

MRI-Ultrasound Fusion Biopsy

This test combines MRI and ultrasound for more accurate prostate cancer localization and sampling, targeting suspicious areas for biopsy with greater precision and reducing the likelihood of needing repeat biopsies.

How is the prostate cancer stage determined?

Cancer staging, a crucial step after diagnosis, determines the extent of the cancer’s spread and is crucial for doctors to propose the most effective treatment options and to estimate the patient's prognosis, or likelihood of recovery.

TNM System for Staging

This system is a method used by doctors to categorize the stage of cancer, focusing on three main aspects:

• Category T, which evaluates the size and location of the primary tumour. T0 indicates no evidence of tumour, while T1-T4 identify the size and extension of the tumour, with progressive enlargement and invasiveness from T1 to T4.
• Category N, which assesses whether the cancer has spread to regional lymph nodes and the extent of this spread. N0 indicates no regional nodal spread, while N1 and N2 indicate varying degrees of regional nodal involvement.
• Category M, which determines whether the cancer has metastasized, or spread to other parts of the body, and the extent of this spread. A tumour is classified as M0 if no distant metastasis is present and M1 if there is evidence of distant metastasis.

Gleason score for Grading

This is a way to grade prostate cancer based on how the cancer cells look under a microscope compared to healthy cells. Less aggressive cancers look more like healthy tissue and get a lower score, while more aggressive ones that are likely to spread and grow fast look less like healthy tissue and get a higher score. The score ranges from 6 to 10, with 6 being low-grade cancer and 8 to 10 indicating high-grade, more aggressive cancer.

To get the overall prostate cancer stage, also called the stage grouping, the T, N, and M categories should be determined, and combined along with the Gleason score and PSA level.

The overall prostate cancer ranges from Stage I, where the cancer is early and slow growing, to Stage IV, where it has spread beyond the prostate.

• Stage 0: Indicates carcinoma in situ, where abnormal cells are present but have not spread beyond the prostate gland.
• Stage I: Represents localized cancer, typically characterized by small tumours confined within the prostate gland.
• Stage II: Refers to locally advanced cancer in its early stages, where tumours may be larger and show signs of extending beyond the prostate gland.
• Stage III: Represents locally advanced cancer in its late stages, indicating tumours that have spread further into nearby tissues or organs surrounding the prostate gland.
• Stage IV: Indicates metastatic cancer, where the cancer has spread beyond the prostate gland to distant sites in the body, such as lymph nodes, bones, or other organs.

Recurrent cancer refers to cancer that returns post-treatment, possibly in the prostate or elsewhere, necessitating further tests to assess the spread.

Which prostate cancer treatment options are available?

Treatment options for prostate cancer vary widely based on the cancer's stage, possible side effects in the patient's overall health, and personal preferences. They can be used alone or in combination, depending on the cancer's aggressiveness and response to initial treatments.

Local therapies

Radical prostatectomy

This involves the surgical removal of the prostate gland. It can be performed traditionally (open surgery) or using minimally invasive techniques, such as robot-assisted surgery, aimed at reducing recovery times and side effects.

Radiation therapy

This treatment uses high-energy rays to target and kill cancer cells. Options include:

• External Beam Radiation: A radiation oncologist uses a machine located outside the body to focus a beam of X-rays on the area with the cancer.
• Brachytherapy: An internal radiation therapy where radioactive sources are placed directly into the prostate.

Bilateral Orchiectomy

This surgical procedure involves the removal of both testicles and is used as a form of hormone therapy.

Systemic therapies

Androgen Deprivation Therapy (ADT)

ADT uses drugs to reduce testosterone levels that fuel prostate cancer growth. This hormone therapy is used for blocking testosterone production (with drugs like Leuprolide, Leuprolide mesylate, Goserelin, Triptorelin), or inhibit its action (Flutamide, Bicalutamide, Nilutamide).

Chemotherapy

In chemotherapy, drugs are used to kill rapidly growing cancer cells, it’s often used when the cancer has spread outside the prostate gland. Some of the chemotherapy drugs used to treat prostate cancer include Docetaxel, Cabazitaxel, Mitoxantrone, Estramustine, Carboplatin.

Immunotherapy

Immunotherapy involves using drugs that harness the body's immune system to recognize and attack cancer cells. In prostate cancer, immunotherapy may include vaccines like sipuleucel-T (Provenge), which stimulates the immune system to target prostate cancer cells.

Targeted therapy

Targeted therapy focuses on targeting specific parts of cancer cells that differentiate them from normal cells. In prostate cancer, targeted therapy may involve drugs that block the action of PARP proteins inside cells that normally help repair damaged DNA. This type of therapy blocks the repair of cancer cells damaged DNA, which often leads to the death of these cells. Meanwhile, PARP drugs are only helpful if DNA repair genes have changed in cancer cells. The oncologist will likely conduct tests to be sure the cells have a DNA repair gene change before starting treatment with a PARP inhibitor. Examples of drugs include: Rucaparib, Olaparib, Talazoparib, Niraparib/abiraterone acetate.

Emerging therapies and clinical trials

Focal therapies are emerging, minimally invasive treatments that target small prostate tumours without treating the entire prostate gland. These therapies employ methods such as heat or cold to treat cancer, primarily for low or intermediate-risk prostate cancer. While still under investigation in clinical trials, most focal therapies have yet to gain approval as standard treatment options. Numerous focal therapies have been developed over the years and include but are not limited to:

Cryotherapy

Cryotherapy freezes cancer cells using a metal probe inserted through a small incision between the rectum and the scrotum.

High-intensity focused ultrasound (HIFU)

HIFU is a heat-based focal therapy. It involves directing sound waves from an ultrasound probe inserted into the rectum at cancerous parts of the prostate to destroy cancer cells while sparing the surrounding tissue. FDA approved in 2015, HIFU may be appealing for some, but its ideal candidates are still unknown. It should only be performed by experienced specialists, and the decision to pursue HIFU should be thoroughly discussed with your doctor.

Deciding on a prostate cancer treatment plan is a multifaceted process, influenced by various factors including the cancer's stage, patient's age, health status, and personal preferences. It's imperative for patients to engage in open discussions with their healthcare team, weighing the benefits and risks of each option. Considering potential side effects of treatment such as urinary, bowel, sexual, and hormone-related issues is crucial in making an informed decision that aligns with the patient’s lifestyle and quality of life expectations.

Key Takeaways

Prostate cancer treatment has made significant strides, offering patients various options tailored to their specific conditions. From traditional approaches like surgery and radiation therapy to innovative treatments such as immunotherapy and targeted therapy, the landscape of prostate cancer treatment continues to evolve. Moreover, emerging focal therapies like cryotherapy and high-intensity focused ultrasound offer promising alternatives for managing localized tumours with minimal invasiveness.

Ultimately, the key to navigating prostate cancer treatment lies in open communication with healthcare providers, a thorough understanding of available options, and active participation in decision-making. Empowered with knowledge and support, patients can face their diagnosis with confidence and hope.

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