The routine check-up

Published on 10/04/2015 by admin

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Last modified 22/04/2025

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Problem 21 The routine check-up

Jimmy Lam

A 65-old-man presents for a routine prostate check. He is otherwise healthy and takes no regular medication. There is no family history of prostate cancer. He has mild lower urinary tract symptoms (LUTS) with slightly reduced flow and mild hesitancy. He looks fit and abdominal examination is unremarkable. On digital rectal examination (DRE) the prostate gland feels enlarged with areas of induration on the right side. Perineal sensation and gross lower limb motor function are intact.

Q.1

What is the significance of his symptoms and physical findings?

It is explained to the patient that while he almost certainly has benign prostate hyperplasia some investigations should be considered. The pros and cons of screening are explained to the patient.

Q.2

What investigations would be appropriate and why?

His PSA is 8.1 ng/mL (normal <4.5 ng/mL) and the serum haematological and biochemical estimations within normal limits. His renal tract ultrasound showed a moderately enlarged prostate and trabeculations within the bladder consistent with chronic outflow obstruction.

Q.3

What is the significance of the results and examination findings and what should be done next?

The patient is advised to undergo a transrectal ultrasound guided (TRUS) biopsy of the prostate. This confirms the presence of a small focus of Gleason 3+3 = 6 prostate cancer in the right apex, one of the eight areas biopsied.

Q.4

What are the management options and issues?

Q.5

What is the rational for active surveillance?

The patient is reviewed at 3-monthly intervals with repeat PSA and DRE. After 12 months of active surveillance a further TRUS biopsy is performed and shows Gleason 3+3 = 6 prostate cancer. This time four of the eight areas biopsied show involvement with prostate cancer.

Q.6

What staging tests should be arranged?

A whole body bone scan is performed and is negative.

Q.7

What are treatment options and their side-effects?

Following consultations with the urologist, radiation oncologist and a prostate cancer support nurse, the patient decides to proceed with radical prostatectomy via the robotic approach. Twelve months post surgery, he remains well and his PSA remains undetectable. He is continent and able to achieve erection with the use of phosphodiesterase inhibitors.

Answers

A.1 Benign prostate hyperplasia is a common process in ageing males and accounts for most of the lower urinary tract symptoms in these patients. Incidence of prostate cancer also increases with age but it is unlikely the cause of this patient’s lower urinary tract symptoms. Early-stage prostate cancer rarely causes any symptoms and is usually picked up via screening.

Risk factors for prostate cancer include increasing age, family history, long-term exposure to high levels of testosterone as well as a diet high in saturated fat and animal protein. Having one first-degree relative with prostate cancer doubles the risk of developing prostate cancer; having two or more first-degree relatives increases the risk of prostate cancer by as much as fivefold.

A.2 Investigations should include:

• Serum prostate specific antigen (PSA).
• Midstream urine (MSU) – exclude any urinary tract infection.
• Serum biochemistry – to assess baseline renal function given his mild lower urinary tract symptoms (LUTS).
• Renal tract ultrasound – to assess for signs of urinary outflow obstruction.

A.3 About 50% of patients with an abnormal digital examination are subsequently found to have prostate cancer on biopsy and those with an abnormal PSA have about 30% chance of having prostate cancer detected. Because digital rectal examination and PSA testing are complementary, they should be used in combination as a tool for assessing prostate cancer risk.

A.4 His staging investigations have confirmed clinically localized prostate cancer and his options for treatment include radical prostatectomy (via open or laparoscopic/robotic approach), radical radiotherapy (external beam or brachytherapy) or active surveillance. The patient is concerned about the possible side-effects of treatment and elects to defer treatment, opting for regular monitoring with active surveillance.

A.5 The lifetime risk of developing prostate cancer is 1 in 3, the lifetime risk of prostate cancer causing problems is 1 in 10 and the lifetime risk of dying from prostate cancer is 2–3 in 100. Therefore clearly not everyone who develops prostate cancer will die from it. The rationale behind active surveillance is that some patients with low-risk and low-volume cancer may have clinically insignificant or indolent cancer that may not necessarily cause them problems in their lifetime. Provided these patients are appropriately monitored for disease progression and then offered more active treatment, the risk of over-treatment can be reduced and the risks of side-effects of active treatment can be deferred in order to maximize quality of life.

A.6 Staging investigations for prostate cancer generally involve the use of whole body bone scan to detect evidence of bony metastatic disease. In the absence of bone pain and with a PSA <10, the yield of the bone scan is low (<1%). In patients with intermediate and high-risk disease staging with CT/MRI of the abdomen and pelvis may also be appropriate.

A.7 There are no randomized studies comparing radical prostatectomy with either external beam radiotherapy or brachytherapy for localized prostate cancer. The long-term survival results are similar with either treatment. Hormonal therapy for prostate cancer provides some control but does not cure the patient of the cancer.

Surgical removal of the prostate for cancer can be done via open retropubic, laparoscopic or robotic-assisted laparoscopic approach. The laparoscopic and robotic approaches offers some short-term benefits including reduced blood loss, less postoperative pain, quicker recovery and short hospital stay. Other treatment outcomes such as cancer control, continence and potency are similar to the traditional open approach. Side-effects of surgery include: urinary incontinence (5–15%), erectile dysfunction (30–100%), bladder neck obstruction (<10%) and death (<1%).

Radiotherapy can be given either as external beam radiotherapy (EBRT), low-dose seed brachytherapy or high-dose brachytherapy. EBRT is an outpatient treatment over 6–8 weeks. Side-effects include urinary incontinence (5%), erectile dysfunction (40–80%), long-term bowel and bladder problems (5–10%). Low-dose seed brachytherapy involves the placement of permanent radioactive seeds into the prostate gland. The aim is to deliver a higher dose of radiation more directly to the prostate and reduce radiation damage to the normal surrounding structures. For low-risk cancer it offers similar outcomes to the other treatment but has reduced risks of erectile dysfunction (40%) as well as reduced rectal and bladder morbidity. High-dose seed brachytherapy is usually used in combination with EBRT for higher-risk cancer patients in whom cancer may have spread beyond the prostate.

Hormonal therapy or androgen deprivation is used to slow the growth of prostate cancer. This form of treatment does not cure the cancer but rather suppresses its growth. This can be achieved by surgical castration (bilateral orchidectomy) or chemical castration (anti-androgens or luteinizing hormone-releasing hormone agonists – LHRH agonist). This form of treatment is usually offered to patients who already have cancer spread beyond the prostate or older patients who are not candidates for radical surgery or radiotherapy treatments.

Revision Points

Prostate Cancer

In men, and after skin cancers, carcinoma of the prostate is the most common malignancy in Western communities and the second commonest cause of cancer-related death.

Risk Factors

• Increasing age.
• Family history.
• Diet high in saturated fat and red meats.
• Weak association to cadmium exposure.

Pathology

Most are adenocarcinoma of acinar cell origin. The tumours usually arise from the peripheral zone of the prostate, and 20% are in the transitional zone of the prostate. Eighty-five per cent of cases are multifocal.

Prostatic adenocarcinoma is most commonly graded based on the Gleason grading system which assesses glandular pattern of the tumour at low magnifications. The Gleason pattern ranges from 1 to 5. The Gleason score is the sum of the two most prevalent patterns identified, giving a score between 2 and 10, 10 being the most aggressive.

Natural History

Pattern of spread via direct extension into surrounding tissues, lymphatic spread to region lymph nodes are not uncommon. Most of the distant metastases are to the bones and visceral metastases are less common.

Staging

Staging is based on the American Joint Committee on Cancer (AJCC) modified TNM system.

Signs and Symptoms

Most patients have few signs in the early stages, but may present with urinary obstructive symptoms or haematuria. Advanced disease may present with signs of metastases such as bone pain. Clinical findings of a palpable prostate nodule or induration may be the only sign.

Diagnosis

Confirmation is usually on transrectal ultrasound-guided prostate biopsy following investigation with PSA and DRE but is sometimes detected incidentally from transurethral prostate resected specimens. Further staging with bone scan, CT and MRI may sometimes be useful.

Treatment

• Watchful waiting – expectant management for those not likely to be affected by the diagnosis of prostate cancer.
• Active surveillance – deferral of active treatment for patients who may have clinically insignificant or indolent disease. These patients are followed up regularly for signs of progression.
• Radical prostatectomy (open, laparoscopic or robotic assisted), radiotherapy (EBRT, brachytherapy) for those with localized prostate cancer.
• Androgen deprivation therapy.

Role of Screening

The Urological Society of Australia and New Zealand (USANZ) currently does not recommend the use of mass population-based PSA screening as public health policy. However, based on recent data from one of two large randomised screening studies, there was a reduced risk of prostate cancer death with PSA testing and treatment in selected patient groups (Aged 55–69 years). Therefore PSA based testing, together with digital rectal examination should be offered to men in his age group, after appropriate counselling about the risks and benefits of such testing. Men over the age of 40 who are concern about their prostate health could have a single PSA test and DRE performed to provide an estimate of their prostate cancer risk over the next 10–20 years based on age-specific median PSA values, with subsequent individualised monitoring according to their risks.

Issues to Consider

• Should an upper age limit be imposed for screening for prostate cancer?
• Why is prostate cancer commoner in developed communities?

Further Information

, www.andrologyaustralia.org. – Andrology Australia

, www.auanet.org. – American Urological Association

, www.cancer.org.au. – Cancer Council Australia

, www.prostatehealth.org.au. – Australian Prostate Cancer Collaboration

, www.usanz.org.au. – Urological Society of Australia and New Zealand

, www.uroweb.org. – European Association of Urology

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