Prostate Cancer

Definition

Prostate cancer is a malignant tumour that develops in the prostate gland, a small walnut-shaped gland in males that produces seminal fluid. It is one of the most common types of cancer in men.

Aetiology

The exact cause of prostate cancer is not known, but it involves changes in the DNA of prostate cells. Factors that can increase the risk include:

Age: Most common in men over 50 years old.
Family history: A family history of prostate cancer can increase risk.
Genetic mutations.
Hormonal factors: High levels of androgens may contribute to prostate cancer development.

Pathophysiology

Prostate cancer typically begins in the glandular cells of the prostate (adenocarcinoma). It can grow slowly and remain confined to the prostate gland, or it can grow aggressively and spread to other parts of the body, particularly bones and lymph nodes. The progression involves a series of genetic mutations that lead to uncontrolled cell growth and tumour formation.

Risk Factors

Age: Risk increases significantly after age 50.
Family history: Having a father or brother with prostate cancer more than doubles a man's risk.
Race: More common in black men than in men of other races.
Diet: High-fat diet and obesity are associated with increased risk.
Geography: More common in North America, northwestern Europe, Australia, and the Caribbean islands.

Signs and Symptoms

Frequent urination, especially at night.
Difficulty starting or stopping urination.
Weak or interrupted urine flow.
Blood in urine or semen.
Discomfort in the pelvic area.
Bone pain (in advanced cases).
Unexplained weight loss and fatigue (in advanced cases).

Investigations

Digital rectal examination (DRE): To feel the prostate for abnormalities.
Prostate-specific antigen (PSA) test: Blood test to measure PSA levels.
Transrectal ultrasound (TRUS): Imaging test to visualize the prostate.
Prostate biopsy: To confirm the presence of cancer cells.
Magnetic resonance imaging (MRI) or computed tomography (CT) scan: To assess the extent of cancer spread.
Bone scan: To check for bone metastases in advanced cases.

Management

Primary Care Management

Initial assessment: Referral to a urologist if prostate cancer is suspected based on symptoms, DRE, or elevated PSA levels.
Supportive care: Management of urinary symptoms, pain relief, and psychological support.
Monitoring: Regular follow-up and monitoring of PSA levels in men with elevated PSA but no confirmed cancer.

Specialist Management

Active surveillance: Regular monitoring for men with low-risk, localised prostate cancer.
Radical prostatectomy: Surgical removal of the prostate gland.
Radiation therapy: External beam radiation or brachytherapy (internal radiation).
Hormone therapy: Androgen deprivation therapy to reduce levels of male hormones that stimulate cancer growth.
Chemotherapy: For advanced or metastatic prostate cancer.
Targeted therapy and immunotherapy: Emerging treatments based on specific genetic mutations and immune responses.
Multidisciplinary care: Involvement of urologists, oncologists, radiologists, and palliative care specialists for comprehensive management.

Example Management for Prostate Cancer

A patient presenting with symptoms such as frequent urination and blood in the urine should undergo a digital rectal examination (DRE) and PSA test. If the PSA is elevated or the DRE is abnormal, the patient should be referred to a urologist for further evaluation, including a prostate biopsy. If prostate cancer is confirmed, treatment options such as active surveillance, radical prostatectomy, radiation therapy, or hormone therapy may be considered based on the stage and aggressiveness of the cancer. Regular follow-up is essential to monitor for recurrence and manage any side effects of treatment.

References

NICE. (2024). Prostate Cancer: Diagnosis and Management. Retrieved from NICE
NHS. (2023). Prostate Cancer. Retrieved from NHS
American Cancer Society. (2023). Prostate Cancer. Retrieved from American Cancer Society
European Association of Urology (EAU). (2022). Guidelines on Prostate Cancer. Retrieved from EAU