Cancer of the prostate – the walnut-sized gland situated at the base of the bladder and surrounding the first part of the uretha, the tube that carries urine and semen – is the most commonly diagnosed cancer in the UK and is second only to skin cancer among men globally. According to the charity Cancer Research UK, more than 52,000 men are diagnosed with prostate cancer each year in the UK, with an average of 35% of new cases in men aged 75 or over. About one in eight of men in the UK will be diagnosed with prostate cancer in their lifetime, rising to one in four among black men of Caribbean and African origin.
However, despite such concerning statistics, the good news for older men is that prostate cancer is among the most treatable and manageable of cancers. “The important thing to realise is that, unlike other cancers, not every prostate cancer will result in that individual suffering, or indeed dying, of it,” explains Mark Emberton, a professor of Interventional Oncology and Dean of the UCL Faculty of Medical Sciences, and a consultant at London’s King Edward VII’s Hospital. “The key question is not whether a patient has prostate cancer, but whether it is clinically significant – in other words, cancer that can affect quality or quantity of life.”
The likelihood of a man developing prostate cancer is dependent on a number of factors, including his age, genetics and family history of the disease, and lifestyle. So what can men do if they are concerned about prostate cancer? As the early stages produce no symptoms, regular testing is the key to identifying whether cancer is present and its extent, when detected.
“If you have a symptom from prostate cancer then, unfortunately, it usually means it is too late to be treated, as the cancer will be either locally advanced or will have spread,” says Professor Emberton. “The only way to find cancer early is to test for it. As prostate cancer is so age-related, testing wouldn’t be required before the age of 50, because the risk is so low prior to this time, and the frequency of testing would depend on the level of cancer detected.”
Initial testing for prostate cancer is a straightforward process, requiring a simple blood test that detects levels of prostate-specific antigen (PSA). “If your PSA is less than one, you can pretty much ignore it,” says Professor Emberton. “If the PSA is above one, then it is probably worth having a test every couple of years. Should the PSA levels start going up rapidly – in other words, if the doubling time gets close to two to three years – then it would be advisable to see a specialist.”
Professor Emberton warns that no test in medicine is perfect and that the PSA blood test is no exception, occasionally producing ‘false positives’ when there is no underlying cancer present. “The way we can improve the performance of the blood test is to combine it with magnetic resonance imaging (MRI),” he explains. “MRI scanning for the prostate was developed in the UK, where we were among the first to use this method, and it is now recommended all over the world when a man has a high PSA.”
One factor that has, perhaps, made men reluctant to come forward for testing is the thought of a doctor examining for an enlarged prostate using their finger, inserted into the patient’s rectum. However, this method is now somewhat outdated, as Professor Emberton confirms: “Although this procedure can still be carried out, it’s not very precise. A finger can only feel the back of the prostate, so this isn’t a good method for estimating size or whether cancer is present. As a cancer test, the finger is among the poorest performing.”
Modern developments in treatment and monitoring of the disease mean that up to 95% of patients can expect to be free from progression of the cancer after 10 years, if it is detected at an early stage. Men with low-risk prostate cancer often require only monitoring to make sure that the disease does not develop, while those with aggressive cancer will require their whole prostate to be treated, often with surgery and radiotherapy.
However, most patients fall in the middle of this range, with a small amount of clinically significant cancer, which Professor Emberton explains can now be tackled with a new method of treatment – focal therapy. “This represents a major breakthrough, which has only come about because of improvements in diagnostics due to MRI. Such therapy needs to be carried out in a hospital under anesthetic, but much of it is non-invasive and involves projecting sound waves, electric current, lasers and ice balls to remove parts of the prostate in a targeted fashion.” The work of Professor Emberton and his fellow specialists has seen London become the world centre for focal therapy, in terms of both capability and the capacity to offer such treatments.
“One example of focal therapy is NanoKnife, which exposes the cancer to high-voltage electricity that blows holes in the cell membrane of the cancer cell and forces it to kill itself.” A further benefit is that that NanoKnife is usually pain-free and completed in around 45 minutes, with patients requiring a catheter for a couple of days following the treatment. “It’s a very low-impact procedure, and the next day they can be out walking and exploring London,” says Professor Emberton.
“With focal therapy, we eliminate the cancer plus a margin, but try to retain the areas of the prostate that are healthy, and thereby preserve some of the key structures around the prostate that typically become damaged when the whole gland is treated.” These structures include the bladder neck and the rectum – damage to which could result in urinary and fecal incontinence – plus the nerves and blood vessels that supply the penis to give and maintain erections.
A common concern for men being treated for men with advanced prostate cancer is that their sexual function will be affected following treatment, but Professor Emberton is able to provide some words of reassurance. “Most men will lose their erections when the whole prostate gland is treated,” he says. “But recent work led from London has demonstrated that, if a man is treated focally with the aim of preserving as much tissue as is reasonable, he has a 95% chance of being able to have erections afterwards.”
Looking ahead, Professor Emberton sees a role for new technologies in helping to identify cancer as early as possible. “Currently, we rely on the radiologist’s eye,” he says, “but images may be interrogated more effectively using artificial intelligence.” He also expects continuing developments in terms of treatment. “There has been a revolution in surgical techniques, which have gone from open to keyhole surgery, and robotic surgery, which has become the standard of care now, and I’m not aware of anybody in the UK that isn’t using this. There may be some development in terms of augmented reality to assist the surgeon with an operation, and there are new energy sources that will allow us to treat prostate cancer with great precision.”
For more information on prostate cancer services at King Edward VII’s Hospital, visit www.kingedwardvii.co.uk/prostate-cancer