Professor Roger Kirby
Editor-in-Chief, Trends in Urology and Men’s Health
The need for treatment following a diagnosis of prostate cancer should take into consideration, not only the stage and grade of the disease, but also patient preferences.
In low-risk cases (PSA <10ng/ml and Gleason score ≤6), the majority of men are now advised to undergo a period of active surveillance in order to determine whether or not intervention by surgery or radiotherapy is required.
The recently revised NICE guidelines1 on the diagnosis and management of prostate cancer have proposed PSA measurement and accompanying digital rectal examination every four months, with reassessment at 12 months using a multiparametric MRI, followed by a repeat biopsy. In the absence of evidence of progression, follow up should continue with regular PSA determinations either in primary or secondary care.
If cancer progression becomes apparent, then the need for more definitive treatment will need to be discussed. Evidence currently shows that patients treated by surgery or radiotherapy, after an initial period of active surveillance, do not seem to have worse outcomes than those that were treated at the time of the original diagnosis.
In intermediate-risk cases (PSA 10–20ng/ml, or Gleason score 7), following an initial discussion about active surveillance, most urologists advise definitive treatment to prevent the development of local complications and/or metastatic spread.
Eliminating early prostate cancer by removing the gland
The most reliable way of permanently eliminating early prostate cancer is to remove the gland before the cancer has spread. This is most commonly achieved by keyhole surgery, with or without robotic assistance.
With careful technique and an experienced surgeon, the risk of more than temporary stress urinary incontinence is 2–5%. The chances of erectile dysfunction (ED), however, are considerably greater. This risk needs to be discussed with patients.
ED can be managed reasonably effectively with regular phosphodiesterase 5 inhibitor therapy and/or prostaglandin injections.
Alternatively, the patient can be offered treatment by radiotherapy, using either external beam radiation, usually preceded by at least three months androgen blockade, or brachytherapy. Other newer ‘focal’ therapies, which target the tumour rather than the entire prostate, such as high-intensity focused ultrasound (HIFU), are still regarded as experimental and should only be employed within the context of a clinical trial.
Active surveillance is not advised for high risk cancer
In high-risk patients (PSA >20ng/ml or Gleason score 8–10) with localised disease, active surveillance is not advised. Instead, surgery or radiotherapy, plus hormone treatment is recommended.
The choice between these options will depend on patient preference and on the local extent of the tumour. If, for example, there is evidence of bulky local disease and/or seminal vesicle involvement, the decision should be more likely to include radiotherapy. If it looks as though the tumour can be removed in its entirety, with negative surgical margins, then radical prostatectomy may be possible. However, patients in this category should be informed that subsequent ‘multimodality’ treatment with radiotherapy and hormone treatment may often be required.
The patient must have an active involvement in treatment decisions
The diagnosis and management of early prostate cancer continues to generate much discussion and controversy. Recently, several studies have reported superior outcomes for surgery as opposed to either radiotherapy or ‘watchful waiting’.
However, every treatment option carries the risk of side-effects, which need to be carefully explained to both the patient and his partner.
The recent vogue for active surveillance, which features prominently in the recently updated NICE guidelines, will reduce the potential for ‘overtreatment’ of low-risk cancers that are destined never to affect the patient within their natural lifespan.
Anxieties persist that current methods of initial diagnosis and staging, and subsequent identification of disease progression, are still suboptimal. The use of genomic markers may prove useful refinements by providing prognostic information.
These include the ProlarisTM or Oncotype DxTM tests, which identify and quantify markers of cell cycle progression. Current extensive research seems likely to identify other clinically useful biomarkers, as well as alternative treatment options, which cause less morbidity.
1.National Institute for Health and Care Excellence (NICE). Prostate cancer: diagnosis and management (NG131), May 2019 (https://www.nice.org.uk/guidance/ng131; accessed 22 July 2019).