Ask the Expert: Prostate Cancer
Professor Richard Hindley answers some of the most pressing questions around prostate cancer in the first of our ‘Ask the Expert’ blog series. Professor Richard Hindley is Clinical Advisor for Prostate Cancer for Check4Cancer, Clinical Lead for Urology at Hampshire Hospitals and was recently awarded a visiting Professor working position working with the Department of Health and Wellbeing at the University of Winchester.
Keep an eye out for the rest of our ‘Ask the Expert’ series to hear directly from leading clinical experts and find out answers to some of the most asked cancer questions.
Who is most at risk of prostate cancer?
1 in 8 men in the UK will be diagnosed with prostate cancer in their lifetime. Older men are at greater risk, as are black men and men with a family history of prostate cancer.
Prostate cancer is not clearly linked to any preventable risk factors, but is there anything you can do to reduce the risk of developing prostate cancer?
The latest research suggests that obesity may increase the risk of being diagnosed with aggressive or advanced prostate cancer. Eating a balanced, healthy diet and taking regular exercise is therefore likely to lower the risk.
Is prostate cancer genetic?
5-10% of all prostate cancers diagnosed are hereditary. As an example, a man with a family history of a close relative with prostate cancer is at least twice as likely to be diagnosed themselves. In recent years, studies have begun to identify a number of heritable genetic changes that may contribute to a person’s risk of developing prostate cancer.
What is a PSA test?
A PSA test detects the level of prostate specific antigen (PSA) in the blood and can help diagnose prostate problems, including prostate cancer. PSA is a protein that is produced by both normal prostate cells and prostate cancer cells. It is therefore normal to have a small amount of PSA in your blood, which rises naturally as you get older and your prostate gets bigger. Increased PSA levels may suggest that you have a problem with your prostate, but this does not necessarily mean you have cancer.
What prostate cancer screening is available on the NHS?
There is currently no national screening programme for detecting prostate cancer in the UK. However, the prostate cancer risk management programme (last updated 2016) gives men over 50 the right to have a PSA test on the NHS – as long as they’ve talked through the advantages and disadvantages with their GP or practice nurse.
The evidence to support a national screening programme is growing stronger using the PSA blood test (although other, newer biomarker tests are likely to be helpful too), and most expert Urologists would encourage men to have a PSA at 45 (or younger with risk factors) with risk-adapted screening thereafter. Having an early PSA test ‘marker in the sand’ is helpful, even if the result is normal, as it can determine who needs closer follow-up thereafter.
If you are diagnosed with prostate cancer, what can affect your prognosis?
Your individual outlook is affected by a number of factors, including:
- Stage – whether the cancer localised, locally advanced or advanced
- Grade – the Gleason score (6-10) or the newer group grading 1-5 (5 being the most aggressive)
- Your health or performance status
- Your treatment options and the likelihood of cure or control
- Your PSA blood test level – this is useful before and after treatment and essentially the lower the number the better in most cases
What are the different chances of survival at different stages?
86.6% of all men diagnosed with prostate cancer will survive 5 years and 78% 10 years (England 2013-2017). A localised, early stage and favourable grade (less aggressive) cancer has a favourable prognosis and indeed some men will not require any treatment for this. A more advanced and aggressive cancer is associated with a worse prognosis.
The TNM classification is most commonly used to describe the stage of the cancer. T refers to the tumour itself, N to the lymph glands and M to the presence or absence of metastatic disease (spread of the cancer to a distant site). T1 tumours are the most favourable with regards to staging as these are too small to see on imaging. Indeed, these tumours are often insignificant and with the routine use of high-quality prostate MRI it is likely that fewer of these ‘insignificant’ cancers will be detected and result in unnecessary treatment. T2 tumours are visible on imaging but are confined to the prostate. T4 tumours carry the worst prognosis: five-year net survival decreases from Stage 3 (96%) to Stage 4 (49%), a difference of 47 percentage points.
How is prostate cancer usually treated?
There are several treatment options depending on the stage and grade of cancer.
If the cancer is localised or locally advanced, the options can be divided up into active surveillance (monitoring), focal treatments (targeting the cancerous areas but leaving the prostate in situ), or radical treatment which includes removal of the prostate gland (radical prostatectomy) and radical radiotherapy.
If the cancer is advanced, then systemic (whole body) treatment is generally preferable. This will include treatment to switch off the male hormone testosterone and also in certain cases chemotherapy will be given.
How often would you recommend being screened for prostate cancer?
Recommended PSA screening frequency is dependent on the results of the PSA test, although further studies are required to help provide the necessary guidance.
If the PSA level is between 1 and 3 then the PSA should be repeated every 1-2 years depending on the age of the patient and the risk factors. If you're aged 50 to 69, a raised PSA is 3ng/ml or higher. A PSA level of <1 in the 40-50 age range is reassuring and a repeat PSA could probably be measured 5-10 years later.
Newer blood and urine biomarkers to rival the PSA blood test may also help in the future.
Who can people talk to if they are concerned or want more information?
People can talk to their GP or they can contact us at Check4Cancer for an at-home PSA testing kit. This blood test (which combines both the Free and Total PSA) comes with all the necessary clinical support and advice in the event of the test result being abnormal.
In your experience, how has treatment changed in recent years and how do you see it developing in the future?
The good news is that all aspects of prostate cancer diagnostic and treatment pathway are improving. This will without a doubt improve survival rates over the next decade following a diagnosis of prostate cancer.
If the PSA blood test is above the recommended threshold, or indeed if the prostate gland feels abnormal, you will be referred for a high-quality MRI scan of the prostate gland. This will provide reassurance if the scan is normal but will also allow a targeted biopsy if a visible lesion or lesions are identified within the prostate gland. The MRI will also provide information on the stage of the cancer. A targeted biopsy approach allows for a more accurate pathology report which in turn enables us to make better decisions about whether or not treatment is required, and also which type of treatment is most likely to give a good result.
The treatments themselves are also improving across the board. Newer options to ablate or destroy part of the prostate gland are now available. This includes technologies such as high intensity focussed ultrasound treatment (HIFU) and cryotherapy. The ability to precisely target areas of the prostate has improved also because of the advances in image quality as well as refinements in the delivery devices. Surgical techniques to remove the prostate are also constantly being refined and improved. Most radical prostatectomies are performed using a robot-assisted keyhole technique. Furthermore, the use of the Retzius-sparing technique is reducing the likelihood of urinary incontinence post procedure. The ability to deliver radiotherapy more precisely is also improving our ability to reduce the toxicity of treatment with better outcomes for patients.
Why is screening and early detection so important?
Quite simply, if we detect the cancer earlier it is more likely to be smaller in size and also confined to the prostate gland. In the future, it is likely that a panel of biomarkers using blood, urine and tissue will allow us to better understand which cancers will require treatment and which can be safely monitored. MRI in conjunction with the PSA blood biomarker is already proving to be very useful for men on surveillance. Any signs of significant growth of the cancer can be picked up early on imaging and therefore treatment can be implemented if required before the cancer is advanced.
Professor Richard Hindley
Clinical Advisor for Prostate Cancer at Check4Cancer
Consultant Urologist at Hampshire Hospitals. Visiting Professor at the department of Health & Wellbeing at the University of Winchester.
Richard Hindley is a Consultant Urologist at Hampshire Hospitals and was appointed in 2014. In 2017 he was awarded a visiting Professor position working with the Department of Health and Wellbeing at the University of Winchester. This was in recognition of his growing prostate research portfolio which includes collaborating with other units including UCLH and the University of Oxford. He was privileged to be involved with the PROMIS and PRECISION trials, which have changed forever the diagnostic pathway for men with suspected prostate cancer. He has publications in both the Lancet at the NEJM. His interests relate not only to prostate cancer diagnostics but also focal therapy as a treatment option for men with intermediate risk prostate cancer, as well as minimally invasive treatments for benign prostatic obstruction and men’s health issues in general. He has been central to the successful introduction of Rezum water vapour therapy to the UK, which has recently been endorsed by the National Institute of Clinical Excellence
