Prostate Cancer

employee-41

 Topics Discussed

  • Risk factors and prevention
  • Prostate check-up
  • PSA
  • Treatment options
  • Lifestyle, Diet, Supplement options

A most common cancer in males; it is not just a disease of old men for its likely to begin as early as in the 30’s or 40’s but manifest later in life. A slow cancer usually, but more rapid acceleration being a marker of severity often. It is in many ways the male equivalent to female breast cancer sharing certain characteristics.

PC is becoming epidemic some say.

Anatomy of the male genital tract
prostca1The image shows a large prostate cancer (yellow tissue) beneath the bladder. Notice on the very right side of the image is part of the rectum; this particular cancer would be felt by a digital rectal examination (DRE). In the early stages, a cancer of only a few mms or cms even may not be picked up by DRE. Unfortunately, by the time it is palpable (felt) it will be quite large. This is fortunately still very treatable, though early is better.

See how the prostate gland wraps around the urethra, the tube carrying urine and semen out. Symptoms of urination slowing may result from an enlarging prostate – but may be common benign or non-cancerous prostate hypertrophy (enlargement).


 

Diagnosis of PCa

Regard the body as a fine-tuned, performance engine – treat it accordingly

Hereditary PC: (HPC)

About 1:20 cases of PC will be passed down blood lines – just like 5% in breast cancers. Its defined as either:

  • Three generations of PC
  • Two relatives with PC under 55 age
  • Three first degree relatives ie fathers, brothers and sons

The gene is passed from father to son, and from father to daughter and her son. So if HPC is present about half of the sons will get PC, and half of those before 55. So maternal grandfather history of PC is most relevant. So is all family PC incidence. To make it more complex, even breast cancer in a family line can increase the risk of prostate cancer!

So how can we check for PC with a family risk of PC or breast cancer? Doing regular PSA tests after 40 is one recommendation. PSA will be covered later.

  • Are there symptoms – these do not mean cancer necessarily, more often just benign enlargement
    • poor flow
    • dribbling
    • night urination
    • slow to start
    • incomplete emptying
  • Examination – the doctor does a simple digital rectal examination (DRE) to check:
    • size of prostate
    • texture for softness or hardnessDRE
    • surface for unusual irregular ‘lumps’
    • compare right and left lobes
    • lower rectal check while there
    • testes and local gland exam.
  • Blood tests
    • General health check tests
    • PSA (Prostatic Specific Antigen)
    • Free PSA to Total PSA ratio
    • PAP – Prostatic Acid Phosphatase enzyme

PSA

Prostate Specific Antigen is a substance, a normal enzyme, produced by the prostate to liquify semen amongst othe functions. There is a ‘normal’ range, usually up to 4, depending on age. However, younger men should really be under 2. If there is a higher level for age, then this warrants investigation. Other factors can also increase PSA such as inflammation, ejaculation, riding bicycles and so on. So several tests may be needed to be sure about a raised level.
Currently there is vigorous controversy, and highly emotive too, about whether we should even do PSA testing. Some ague it leads to many unnecessary invasive procedures with risks, false results and even unjustified treatments – others say lives are saved. The truth is somewhere in the middle. As testing procedures advance hopefully we will have a clearer path for PCa screening and management.

Free PSA to Total PSA ratio. (FPSA:TPSA) as a percentage

PSA itself has several sub-types. The ‘free’ type is usually from non-cancerous enlargement, while the ‘total’ type is from the growing cancer clone cells. So the LOWER the ratio, under 15%, the more likely its cancer. Even lower % can mean the cancer has spread. However, inflammation (prostatitis infection) can also have a low ratio so if the gland is tender with no other suspicious features on DRE, then treat with antibiotics for 6 weeks and recheck PSA’a later.
PSA has become a very controversial in the last 2-3 years with one side saying men should not have the test – as it may lead to false results and worry. The other say, get over it! If you have family risk, symptoms, especially younger (ie 50’s or less – do the PSA and then have the discussion. The worrying thing is, to be fair, we know prostate is a slowly progressing condition and in older men  the ‘cure’ is often worse than the condition when considering the high risk of bladder incontinence and loss of erections. All the facts need to be carefully weighed and fully discussed.
Technology, surgical skills are improving and one hopes that better technology is close such as thermal treatments, water blasting, intense ultrasound and so on.

Meantime rectal exam and PSA is all we have guys. Unless you can afford CTC testing for example  – looking for circulating prostate cancer stem cells…..

PSA is up, what happens next

Its not an automatic diagnosis, it depends upon:

  1. symptoms and DRE
  2. how high is the PSA
  3. how quickly PSA rises (PSAV) – or how quickly the PSA is accelerating
  4. the FPSA:TPSA ratio
  5. age
    1. Men over 60 with PSA less than 1 have very low risk of significant cancer.
    2. No men > 75 with PSA less than 3 died of PCa. Stop screening.
  6. Increasing number of aggressive cancer in 70-74 year olds.

UPDATE Prostate Cancer Conference Melbourne 2014 (Courtesy Mr Dirk Drent)

There is a new ‘PSA Manager App’ for patients to monitor their PSA.

NCCN – National Comprehensive Cancer Network, of 23 of World’s leading cancer centres.
They suggest for testing:

  • PSA testing and DRE (digital rectal examination) from 45.
  • For PSA < 1 ng/ml and DRE normal – then test 5 yearly.
  • If PSA > 1 ng/ml then 1-2 yearly

Indications for BIOPSY:

  • Suspicious DRE even if normal PSA
  • PSA > 3 in age 45-69
  • PSA > 4 in age 70-74
  • 15% men with normal DRE and  PSA > 4 will get PCa
  • 30% with PSA of 4-10 will have PCa
  • PSA > 10 have 67% PCa.
  • Risk is increased with family history of PCa, rapid increase in PSA
  • If NO biopsy done, then do 6-12 monthly PSA and DRE plus free and total PSA

If the results suggest PC the next thing is to do is find out if it IS cancer and whether it is confined within the prostate gland or spread. Treatment options depend completely upon this.

Also to consider is the age and overall condition of the man. With a man of 78 with severe heart disease or Alzheimers it may not be appropriate to have him undergo biopsies, MRI scans etc. PC does tend to be a quite slowly progressing disease and many men can live 10-20 years with their cancer.

Now its important to ‘stage’ the PC. The notation of TNM is used. ‘T’ describes the Tumour itself and its location and spread. ‘N’ describes Nodes; these are local lymph nodes where cancer cells first go to. ‘M’ describes Metastasis, which is spread beyond to other organs or tissues. Bone is the first target usually.

By doing regular PSA and DRE exams, men can have their PC diagnosed way before it has spread to nodes and bones. Treatment is far more successful early. This good news is somewhat dimmed by the risks as stated above.

PSA is not absolute. Sometimes there can be a normal PSA but high Gleason scores of 4-5. Here the skill and experience of the prostate oncologist is crucial to put together all information.

PSA testing can be done regularly at intervals depending on individual factors. The speed that it goes up is called the ‘acceleration’. Another way of looking at cancer progress is the ‘doubling rate’ of the PSA.

Biopsy

This is crucial to understanding the ‘degree’ of cancer and planning treatment. Under local and general sedation, multiple biopsies are carefullly taken to get a good representaton of the whole gland. Its not 100% as a small cancer could be missed – its a bit like poking sticks into a haystack to find a hidden object. Its still the best we have. Once taken, these are examined and scored according to degree of cancer. This is the GLEASON SCORE.

Gleason Score

This is a scale of 5 grades, 1-5 and subgrades 1-5 of each as well. The two are added together to egt a score, so a Gleason 3,4 is a 7. A Gleason 3,4 is also a 7. The higher the score the more malignant or cancerous the PC. Gleason grade 4-5 usually means more aggressive and more likely spreading cancer.

Unfortunately, the diagnosis and staging by Gleason Scoring can vary from pathologist to pathologist depending on experience with PC. Discuss this with your doctors. A second opinion to validate may be indicated if a borderline result or the implications serious.

PAP – Prostatic Acid Phosphatase

Another enzyme blood test which can correlate with predicting risk of recurrence of PC. Its ideal to get a baseline bPAP to then follow regularly. Check if available in your region.

Transrectal Ultrasound

An ultrasound probe inside the rectum can ‘view’ the consistency of the gland. It also ‘guides’ the biopsy process.

MRI – CT – Bone scans – PET scan 

These more sophisticated imaging techniques are used to further assess the extent of spread of cancer beyond the prostate gland. They can only ‘see’ macro dsiease, maybe 1cm. Micro-disease of ‘cells’ cannot be ‘seen’. However, if there is a high PSA, Gleason score and PAP, it is certain there will be cells out there. Measures should be taken to aggressively treat these cells with combined mainstream and other natural supportive strategies.

CT scans aren’t that great. CT cant ‘see’ small cancer spread. The PA and Gleason score gives far better information. More sophisticated MRI and PET scans are better but not available in some areas.

Bone scanning is the most important imaging procedure to assess the presence of bone metastases (secondary deposits). It is necessary if the PSA is high (above 10) and the Gleason above 6.

Treatment Strategies

Risk Factors

Must be tactical approach

Management of PC varies from centre to centre and physician to physician. Experts have an array of computerised tools for assessing all information and the providing predictive results from which an optimum management plan is derived. It all depends on whether the cancer is confined to the prostate gland. If so, cure is more likely. It is based on the following options:

Watchful waiting – wait and watch! – depends on above factors – can be a very good option in certain cases. But MUST do diet, lifestyle and supplements.

Destroy the prostate and cancer – how though is the $64,000 question. With several options available, there is no clear winner. All depends on local skill, facilities and experience of the surgical or radiotherapy ‘artists.’

    • Radical Prostatectomy RP – surgical removal. Only an option if all evidence strongly indicates NO spread beyond the prostate. Consider side-effects like impotence, penis shortening and incontinence from nerve damage. Some surgeons are better at Nerve Sparing RP. Ask your doctor.
    • Radiotherapy RT options. Very complex and evolving all the time with more advanced techniques to achieve higher doses but more restrined to the actual prostate. RT by nature will damage all tissues it contacts so local radiation side-effects will happen with older techniques.
      • External Beam Radiation Therapy EBRT. There are newer variations of the traditional radiation with significant side-effects.
      • Brachytherapy – brachy means ‘close by’. Local RT to the tumour by placing
        • Permanent radioactive ‘seed’ implants
        • Temporary radioactive wire through straw implants called High Dose Rate (HDR) . Less risk of damage to the bladder outlet (urethra) compared with other RT methods.

Often combined Brachytherapy and EBRT is used.

Must do full and thorough evaluation beforehand as once you have RT you cannot do anymore Gleason testing.

Radical Prostatectomy and RT when compared has about the same results long term.

Side-effect risks to bladder and rectum from all radiation methods is balanced against the need for a dose of RT that will kill maximum tumour. Severe side-effects can occur even with advanced methods. It is a big skill on the part of the oncologists.

Androgen Deprivation Therapy – ADT – Hormone Therapy. LHRH agonist. They block the pituitary gland secretion of LH hormone. Exampe is Zoladex. Also referred to as non-surgical orchidectomy as it blocks male hormones Testosterone T and dehydrotestosterone DHT . Older ways were to remove the testicles. Cancer cells once deprived of T and DHT will die off. Blood vessels to the area shrink further stopping cell growth. It can be very effective when the major bulk of the cancer is ‘androgen-sensitive’.

  • Its main use is for hormone-sensitive PC and where the tumour has spread beyond the gland and removal by RP or RT is not an option.
  • Also ADT is used to shrink tumour before having RP or RT especially if the tumour size is large.
  • There are many complex decisions in designing ADT
  • A ‘flare’ can occur starting LHRH agonists. It can be serious. So another drug is used, an anti-androgen like Flutamide, to prevent this. Side-effects of ADT, some serious, are common and do need to be considered
  • Its all a balance against the long term risks of the cancer itself.
  • There are also options here for men with early PC who decide they dont want to risk bladder incontinence, impotence, bowel radiation complications, so commence one of many protocols of ADT. They involve either blocking production of T and DHT, or, blocking T and DHT from getting to the prostate cancer cells. These can invoke a male ‘andropause’ with its effects. But with timing, sequential bursts of treatment – many effects can be better managed.

New data from CHAARTED Trial 2014. J.Clin.Oncol.

Now evidence that combining Docetaxil and ADT gives better survival in metastatic (spreading) disease. Especially in worse spreading cases.

PDT and SPDT option – a novel treatment in several centres in the world. Beaming safe intense energy in the form of light has captured the imagination of researchers for decades. Getting light to penetrate the skin and deeper has been the challenge. PDT means, Photodynamic Therapy. Many medical specialist clinics use this for skin cancers – first applying a sensitizer, which intensifies the light energy effects, killing cancer cells. Advances in Ireland 10 years ago resulted in sensitizers of chlorophyl structure (almost the same as human haemoglobin without the iron) being injected before the intense light bed exposure.
This is no longer available in Australia – the nearest is now China. Here advances are happening ahead of the West.

Thermal Treatments

Prostacare is an Ultrasound Guided heat probe which is positioned tras-rectally or per urethra – to ‘cook’ the prostate cancer. Done under high tech calibration. Available in Europe.

HIFU is relatively new – intense beam ultrasound.
Hyperthermia machines – BSD from USA, Morestep from China – all best in conjunction with RTx or CTx.

Water Blasting

Arterial feed destruction

Lifestyle, Diet and Supplements

Our clinic can advise a protective prostate supplement regime and for Cancer, a range of supplement that have been shown to have effects on cancer cells. These will not have official approval or registered medicines. None have claims to treating or curing cancer.