Diagnosis of Prostate Cancer

Not all prostate tumours are equally aggressive. They are classified based on a prostate biopsy, PSA levels, and a digital rectal exam. It is now known that low-risk tumours may behave in an indolent and non-aggressive manner, with a very low risk of spreading to other organs, either from the pelvis or at a distance, and that active treatment is therefore not necessary.

On the other hand, prostate treatments (surgery, radiotherapy, brachytherapy, and cryotherapy) may involve complications that can be quite disabling for the man. In the case of surgery or cryotherapy, these complications are urinary incontinence and erectile problems. For radiotherapy, in addition to these, there may be lesions on the bladder or rectum and the appearance of secondary tumours after some time.

Considering that some prostate tumours are non-aggressive and some prostate treatments have adverse effects, a strategy has been developed where non-aggressive prostate tumours are monitored, to prevent complications in tumours that do not progress and actively treat those that do. This is known as "Active Surveillance".

Occasionally, the lymph nodes surrounding the pelvic vessels are also removed. An ilio-obturator lymphadenectomy is performed when there is a risk of involving these nodes, which is measured according to the PSA level and biopsy results, among other parameters.

The operation may involve open or laparoscopic surgery.

As far as the oncological and functional results are concerned, at the moment the three techniques are comparable.

The risks involved in the different radical prostatectomy techniques are the same as for any major surgery, and include reactions to the anaesthetic, bleeding during surgery, and damage to adjacent organs.

In the postoperative period there may be bleeding, infection of surgical wounds or the formation of blood clots in the legs or lungs, which are usually avoided by taking a course of heparin in the postoperative period, which lasts about three weeks.

In rare cases, it is possible that part of the intestine, specifically the rectum, could be damaged during surgery. This can cause abdominal infections and requires another operation to solve the problem.

The idea of focal therapy is to selectively treat the injury observed in the imaging tests and preserve, as far as possible, those functions affected in more radical therapies, such as erectile function and urinary continence.

This type of treatment is currently being developed and experience in it is still limited. It must be performed in centres with a well-established follow-up protocol.

Focal therapy can be performed using various techniques, particularly HIFU and cryotherapy.

HIFU is indicated for tumours located in the prostate and, particularly, tumours visible in an MRI. It is a minimally invasive treatment involving a short stay in hospital, and the patient can leave the day after the operation.

The procedure is performed under general or spinal anaesthetic. A tube is inserted through the rectum to reach the prostate. The probe emits high intensity ultrasonic energy, which travels through the wall of the rectum into the prostate where the heat kills the tumour cells.

The most common side effects are related to the preservation of neighbouring organs such as the urinary sphincter and erectile nerves. Adverse effects that may occur at an earlier stage are urinary retention, perineal pain, urinary tract infection, haematuria or irritation when urinating.

Long-term adverse effects may include erectile dysfunction, retrograde ejaculation, and stenosis, or narrowing of the urethra.

To offer this technique as initial treatment, the patients should have small prostates (less than 60 g) and fulfil a series of clinical and anatomopathological criteria.

This technique can also be offered as rescue therapy in patients who have already been treated with radiotherapy or brachytherapy for a prostate tumour and have a recurrence.

This procedure is performed in the operating room under general anaesthetic. A transrectal ultrasound machine is used to place the cryoprobes, through which the prostate is frozen and thawed. At the end of the procedure, a bladder catheter is inserted, which the patient has to keep in for about two weeks. The patient usually stays in the hospital for 24 hours.

Cryotherapy is less invasive than radical prostatectomy surgery because it minimises blood loss and possible complications, but is a treatment that is only offered in certain situations, such as if the prostate is small.

External radiotherapy uses high-energy X-rays to destroy cancer cells. Since radiation can also affect cells in neighbouring organs (close to the irradiation zone), such as the bladder, it is important that the radiation beams are precisely directed at the cancer cells, limiting damage to other tissues.

The treatment is painless and applied on a daily basis for seven or eight weeks using specialised equipment. While receiving the radiotherapy sessions, the patient can carry out their daily activities as usual. In the sessions, the patient lies on an examination table for about 20 minutes and receives the treatment. They do not need to be admitted to hospital.

Before starting radiotherapy treatment, a CT scan is necessary to indicate the location of the treatment with small marks on the skin. The healthcare team provides detailed information on what to prepare for the procedure and recommendations on what to eat and drink before each session, to ensure that your bladder is properly filled and your rectum is empty before the procedure.

The CT scan is performed to locate the radiation area, as well as the surrounding tissues that should not be treated. In recent years, the image-guided radiation technique has become widespread. Recent technological development has increased its accuracy and allows a higher dose to be delivered to the tumour, with fewer side effects. For this type of treatment, radiation oncologists locate the prostate very precisely with the help of X-rays or CT scans, to ensure that the radiation is delivered to the prostate.

Before treatment begins, an ultrasound scan is performed to plan the treatment. The seeds are introduced in an operating theatre in an outpatient surgical procedure. General and, in some cases, epidural or local anaesthetic is usually administered.

Hospital admission is usually not required and the patient may return home after recovery.

The health professional may opt for brachytherapy as one of the options if the patient has suitable characteristics for this: favourable pathological anatomy with a low Gleason score, adequate prostate volume, and an absence of urinary symptoms.

Side effects occur because the organs surrounding the prostate, particularly the bladder and rectum, also receive radiation. These symptoms usually appear by the third week of treatment and disappear some weeks after the therapy has been completed. The treatment may cause fatigue, which is largely due to the daily visits to the hospital for treatment.

Side effects vary from person to person and are related to the general state of health and the type of radiation treatment administered.

A man’s ability to have an erection may be affected, in whole or in part, after treatment. The possibility of becoming impotent as a result of the treatment depends on several factors, including the man’s ability to have erections before treatment, treatment damage to nerves and areas adjacent to the prostate, age, and state of health.

For prostate cancer there are two chemotherapies: docetaxel and cabazitaxel. In patients with metastatic prostate cancer, both drugs have been shown to help control the disease. Docetaxel can be administered both in the hormone-sensitive stage of metastatic prostate cancer and in castrate-resistant prostate cancer; cabazitaxel can be used only in castrate-resistance in patients who have previously been treated with docetaxel.

These drugs, like all medicines, may have a number of adverse effects, but they are generally well tolerated and some of the adverse effects can be avoided by observing a few specific recommendations. Both drugs are given intravenously and must be administered by healthcare staff who are specialists in the use of these treatments.

Another pharmacological treatment option is the administration of radium-223. This drug is a radioactive isotope of radium which, due to the way it works, only acts on bone metastases from prostate cancer. Its use is therefore restricted to this type of patients. This drug is also administered intravenously and, due to the way it works, involves a series of recommendations and specific precautions.

The best therapy for each patient is selected based on the efficacy and safety data reported in the literature, together with an evaluation of the patient’s characteristics (general condition, age, other illnesses that preclude the use of certain drugs, etc.) and the qualities of the prostate cancer itself (aggressiveness of the disease, location of metastases, etc.).

Androgen deprivation can be performed surgically or with hormone treatment. Currently, hormonal androgen deprivation or hormonal castration is usually performed.

Hormonal castration can be carried out in various ways. Treatment is usually initiated with the association of anti-androgens and LHRH analogues.

Anti-androgens are drugs that attach to the androgen receptors and reduce the action of these cells. They are administered orally, as tablets. Several types of anti-androgens are available, depending on the stage of the disease.

• Bicalutamide. Given in the initial stages of the disease, associated with or prior to the start of the LHRH analogues.
• Enzalutamide. This is a next-generation anti-androgen that is administered in specific instances when treatment with only LHRH analogues is not enough.

Other next-generation hormonal agents, such as abiraterone and enzalutamide, are also available and these are used in conjunction with the analogues in some cases of disease progression.

Many of these effects of hormone therapy can be prevented or treated with medication. Physical exercise plays a very important role in reducing the impact of the possible side effects, as it improves, in particular, tiredness and loss of muscle mass.

Despite oncological improvements over recent years, the option of participating in clinical trials should always be considered as a way to gain access to potentially more effective and innovative medication than that currently available. At this time, prostate cancer clinical trials are available that evaluate the use of immunotherapy, drugs that act on molecules involved in the repair of nucleic acids, or other drugs that act on other molecular pathways.