21st June 2023

Prostate Cancer

Prostate cancer is now the most commonly diagnosed cancer in the United Kingdom, overtaking the incidence of breast cancer in 2018. It is a cancer associated with advancing age, most diagnosed over the age of 75. There are no clearly identifiable reversible risk factors. There is a greater prevalence in black-African men, and it is least commonly found in Asian men. There are genetic associations with the BRCA2 gene and, to a lesser extent, BRCA1. It is also associated with Lynch syndrome. At present, there is no standard screening program in the UK.

Prostate cancer commonly presents asymptomatically. Men may present with lower urinary tract symptoms, however, this is commonly secondary to benign prostatic hypertrophy, which presents at a similar age and prostate cancer may be found as an incidental finding. The reason for this is that the majority of prostate cancers arise within the peripheral zone of the gland, whereas the urethra runs through the centre of the gland, through the transition zone. Advanced malignancies can present with urinary symptoms, haematuria, haematospermia and symptoms secondary to spread e.g. bony pain. Diagnosis is made using information from a digital rectal examination, serum PSA, MRI of the prostate, biopsies, and staging radiology.

Grading of prostate cancer is quantified using the composite Gleason score, expressed as a primary and secondary pattern e.g. 3+4=7. Prostate cancer has a minimum Gleason score of 3+3=6 and a maximum score of 5+5=10. Lower Gleason grades are no longer considered malignant. Treatments depend on the Gleason grade, TNM staging as well as the age and fitness of the patient.

Radical treatments include surgery, brachytherapy, and radiotherapy. Androgen deprivation therapy is typically co-administered with radiotherapy to reduce local and distant recurrence. Androgen deprivation is the foundation of treatment in advanced disease. In addition to this, novel oral antiandrogen therapies, chemotherapy, radiotherapy, and radium treatment have roles in the management of advanced disease.