Posted on 20th February, 2024 at 7:29:18 AM
What is Prostate cancer?
According to the definition of National Cancer Institute(NCI) prostate cancer is a type of cancer that forms in tissues of the prostate (a gland in the male reproductive system found below the bladder and in front of the rectum). Prostate cancer usually occurs in older men.
What is the global burden of Prostate cancer?
It is the 4th most common cancer worldwide accounting for 7.1% of all cancer. According to Globocon 2018 data, 1.3 million people was diagnosed with prostate cancer worldwide in 2018. In India 25,700 patients were diagnosed with prostate cancer in 2018 with 17200 death.
What causes prostate cancer?
Androgens (male hormones), such as testosterone, promote prostate cell growth. Having higher levels of androgens might contribute to prostate cancer risk in some men.
Family history- The relative risk of having prostate cancer doubles if one first degree relative diagnosed with prostate cancer before the age of 70 years. The risk is 4 times higher if two relatives are diagnosed and if one under the age of 65 years.
Germline mutations in BRCA2 gene increase the risk of developing prostate cancer by up to 5 times.
Other inherited gene mutations- DNA repair genes like CHEK2, ATM, PALB2, RAD51D, MSH2, MSH6, MLH1, and PMS2. Tumour suppressor genes like RNASEL (formerly HPC1).
Ethnicity- Men of Afro-Caribbean descent having a higher risk of prostate cancer cancer and earlier onset of disease than caucasions
What is prostate cancer screening?
Cancer screening means looking for cancer before it causes symptoms. The goal of screening for prostate cancer is to find cancers that may be at high risk for spreading if not treated, and to find them early before they spread. Two tests that are commonly used to screen for prostate cancer are a blood test called Prostate specific antigen(PSA) and digital rectal examination. According to American cancer society, the discussion about screening should take place at:
Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years.
Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father or brother) diagnosed with prostate cancer at an early age (younger than age 65).
Age 40 for men at even higher risk (those with more than one first-degree relative who had prostate cancer at an early age).
If no prostate cancer is found as a result of screening, the time between future screenings depends on the results of the PSA blood test:
Men who choose to be tested who have a PSA of less than 2.5 ng/mL may only need to be retested every 2 years.
Screening should be done yearly for men whose PSA level is 2.5 ng/mL or higher.
If a patient have a PSA of ≥4.0 ng/mL, he needs further evaluation to confirm presence of prostate cancer.
What are the symptoms of prostate cancer?
In early stage following symptoms might be present e.g, Increase frequency of micturition, Urinary urgency, Urinary hesitancy, Nocturia.
In locally advanced stage following symptoms may be present
Haematuria, haematospermia, erectile dysfunction, rarely perineal pain.
In advanced stage patient may present with bone pain, leg weakness, lower leg swelling.
What are the investigations done in a suspected patients of prostate cancer?
Clinical examination including digital rectal examination.
Serum PSA
Transrectal ultrasound(TRUS) guided biopsy from prostate to confirm the diagnosis.
Multi-parametric MRI (mp MRI) of pelvis.
Bone scan
CT Scan in selected cases.
Choline C-11 PET-CT scan or PSMA PET-CT scan in selected cases.
What are the different stages or risk groups of Prostate cancer?
When the cancer is confined to prostate gland it is called localised prostate cancer. When it has spread outside pelvis to any distant organs or lymph nodes; it is called metastatic prostate cancer. Localised prostate cancer can be divided into three risk groups based on Serum PSA, Gleason’s score (This is a grading system for prostate cancer. The pathologist looks at how the cancer cells are arranged in the prostate and assigns a score on a scale of 3 to 5 from 2 different locations) and extent of tumour within prostate gland. These risk groups are low risk, intermediate risk and high risk.
What is the treatment of Prostate cancer?
Treatment of localised prostate cancer-
Treatment options for low risk prostate cancer includes the following: Active surveillance, Surgery with Radical prostatectomy or Radical radiotherapy which can be in the form of external beam radiotherapy (EBRT) or seed brachytherapy with Radioactive Iodine.
Treatment options for intermediate risk prostate cancer includes the following: Active surveillance (selected cases ), Surgery, Seed Brachytherapy, EBRT +/- 6 months of hormone therapy, High dose rate(HDR) brachytherapy +/- 6 months of hormone therapy.
Treatment options for high risk patients includes the following: Surgery in very well selected cases, EBRT+ 3 years of hormone therapy, EBRT+HDR brachytherapy + 3 years of hormone therapy, Watchful waiting in very elderly unfit patients with limited life expectancy.
Decision regarding choice of treatment depends on many factors including patient’s factor, treatment factor, tumour factor, patient’s preference and local expertise. Surgery and Radiotherapy is equally effective in most localised prostate cancer. Recent advance in surgical technique includes Robotic assisted laparoscopic prostatectomy. After surgery some patients might need radiotherapy based on post-operative PSA level. This is to reduce the risk of recurrence. EBRT is currently dose with Intensity modulated radiotherapy (IMRT) technique ( Volumetric arc therapy or Rapid arc) with use Image guided radiotherapy(IGRT). With this technique prostate cancer can be targeted precisely with mimimal dose to surrounding critical organ like rectum, urinary bladder, bowel. Recently hypofractionated course of radiotherapy (Giving larger dose per session for fewer session) has shown to be equally effective compared to conventional fractionation radiotherapy. This 4 weeks course of radiotherapy is becoming standard in most radiotherapy centres.
Treatment of metastatic prostate cancer-
Primary modality of treatment in metastatic prostate cancer patients is combination of chemotherapy and hormone therapy. Selected patients may need palliative radiotherapy for symptom control.
What is the prognosis of Prostate cancer?
Overall prognosis of prostate cancer is better than other cancer. Most localised prostate cancer can be cured with available treatments. Low risk prostate cancer has excellent prognosis, 80-90% patients remain disease free at 10 years. Prognosis of intermediate risk prostate cancer patients is good but still there is small chance of death at 10 years. The prognosis of high-risk prostate cancer is fair. There is significant chance of death due to cancer within 10 years. Metastatic prostate cancer is not curable but it can be controlled for long period of time with available treatment.
