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Prostate cancer
Why is there currently a problem?
Prostate Cancer Advisory Group April 2007
• ‘Prostate cancer patients in the NHS have historically reported
a worse experience than patients with other cancers. The gap
in reported experience between prostate cancer and other
cancers has actually widened between 1999 and 2004. Not all
men currently get access to high standards of advice and
support on treatment options’
Background
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What does the prostate gland do?
What diseases affect the prostate?
What is the incidence and prevalence of prostate cancer?
What is the workload?
How do we grade prostate cancers?
What disease scoring systems are used?
What are the clinical features of prostate cancers?
Are they all the same?
What are the known risk factors?
Are there any preventive treatments?
What does the prostate gland do?
• Makes, stores and secretes an enzyme-rich fluid that makes
up about 1/3 of the ejaculate volume (the rest is produced by
the seminal glands)
• The main role is to liquefy semen and protect sperm during
fertilisation
• Smooth muscle around the prostate helps to expel semen
during ejaculation
• The function of the prostate is regulated by androgens (mainly
testosterone)
What diseases affect the prostate?
Diseases of the prostate
www.cancerscreening.nhs.uk/prostate
• Prostate cancer
– Malignant growth of prostate cells, localised and may spread
– Nearly all prostate cancers are adenocarcinomas, mainly occurring
in the peripheral zone of the prostate gland
– Rare in men < 50, and is more common with increasing age
• Benign prostatic hyperplasia
– Non-malignant increase in size of the prostate with age
– Rare in men under 50
• Prostatitis
– Inflammation of the prostate
– Can occur in men of any age
The early symptoms of prostate diseases are very similar
What is the incidence and prevalence of
prostate cancer?
Prostate cancer: Incidence and prevalence
www.info.cancerresearchuk.org
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Most common cancer in men in UK
In 2005 >34000 men in the UK were newly diagnosed
¼ of all newly diagnosed cancers in men
Accounts for 12% of male deaths from cancer in the UK and is
the 2nd most common cause of cancer death in men after lung
cancer
• Lifetime risk is 1 in 14
• ½ of men in their 50’s have histological evidence of prostate
cancer, which rises to 80% by 80 years, but only 1 in 26 men
(3.8%) die from the disease
• Men are more likely to die with it than from it
What is the workload?
What is the workload?
NICE 2002
• A GP with a list size of 2000 is likely to see 1-2 new patients
with urological cancer each year
• A DHG serving 200000 people deals with 70 men with
prostate cancer each year out of 150 urological cancers
How do we grade prostate cancers?
TNM stages of prostate cancer
www.cancerhelp.org.uk
• Tumour
– T1 – Tumour too small to be seen on scans or be felt on
examination
– T2 – Tumour completely inside the prostate gland
(palpable)
– T3 – Tumour has broken through the capsule of the
prostate gland
– T4 – Tumour has spread to other body organs nearby such
as rectum or bladder
TNM stages of prostate cancer
www.cancerhelp.org.uk
• Lymph nodes
– N0 – No cancer cells found in any lymph nodes
– N1 – one +ve lymph node smaller than 2cm across
– N2 – more than one +ve lymph node. Or one that is
between 2-5cm across
– N3 – Any +ve lymph node that is >5cm across
• Metastases
– M0 – No cancer spread outside the pelvis
– M1 – Cancer has spread outside the pelvis
What disease scoring systems are used?
Gleason score
EUA guidelines 2007
• Most commonly used system
• Total score ranges from 2 (least aggressive) to 10 (most
aggressive)
– The sum of the 2 most common patterns (grades 1-5) of
tumour growth found in the biopsy specimen
• The Gleason histological score correlates well with prognosis
in localised prostate cancer, but there is considerable observer
variation
What are the clinical features of prostate
cancers?
Clinical features of prostate cancer
www.cancerscreening.nhs.uk/prostate/prostate-booklet-text.pdf
• Prostate cancers (unlike BPH) tend
to develop in the outer part of the
prostate gland
• Unusual for early cancers to cause
any symptoms
• Locally advanced prostate cancers
that have extended outside the
capsule are also frequently without
symptoms
• If the tumour is large enough, it
can cause lower urinary tract
symptoms (LUTS) eg frequency,
urgency, hesitancy, leaking, but by
the time this happens the cancer
will usually have reached an
advanced stage
• LUTS are similar to those of BPH.
Most men with LUTS will not have
prostate cancer
• Often the first sign of prostate
cancer is evidence of metastases
(frequently in bone, causing bone
pain)
– About 20–30% of patients in
the UK present with metastatic
disease
Are they all the same?
Prostate cancers vary in their natural histories
• Prostate cancer is biologically heterogeneous
• Some grow very slowly and never cause symptoms, others
grow fast and metastasise quickly, other types grow at a
modest pace
What are the known risk factors?
Risk factors for prostate cancer
www.info.cancerresearchuk.org
• Age
– Increases with age
• Ethnicity
– Highest rates in African-American men
– Lowest rates in Asians
• Family history
– 2-3x higher for men with FH in 1st degree relative,
particularly is a brother, or were affected when young
• Diet
– Associated with Western diet
Are there any preventive treatments?
Finasteride: Preventative therapy?
Thompson IM, et al. N Engl J Med 2003; 349: 215-24
• Increases sexual side effects but decreases urinary symptoms
• May prevent or delays the appearance of prostate cancer but
this possible benefit and reduced risk of urinary problems
must be weighed against sexual side effects
• There is no evidence that preventative therapy increases
survival
• Not licensed in the UK for the prevention or treatment of
prostate cancer
Screening and diagnosis
• How do you detect prostate cancer?
• What is the role of PSA detection?
• Can we use digital rectal examination to improve prostate
cancer detection?
• What are the referral guidelines for specialist investigations?
How do you detect prostate cancer?
Detection of prostate cancer
NICE 2002
• Prostate cancer can be detected by:
– Digital rectal examination (DRE)
– Prostate specific antigen (PSA) testing
– Trans-rectal ultrasound (TRUS) guided biopsy
– Pathological examination of tissue samples removed
following TURP
– CT/MRI scans provide information on staging and spread
– Before referral men should be offered DRE and PSA testing
as set out in ‘Referral guidelines for suspected cancer’
CG27 - NICE CG 58, 2008
What is the role of PSA detection?
Prostate specific antigen (PSA)
• PSA is produced by prostatic epithelium and is present in
seminal fluid, urine and serum. It is involved in the
liquefaction of seminal coagulum formed at ejaculation
• With cancer the epithelial cells are disorganised and the
barrier between the prostate and blood vessels is disrupted.
More PSA leaks into the blood vessels as a result
Prostate specific antigen (PSA)
NICE 2002. Improving outcomes in urological cancers
• Men with cancer tend to have higher levels in their blood (up
to 30% have normal levels)
• There is no level below which a man does not have prostate
cancer, nor is there a level that is agreed as diagnostic
• Levels tend to increase naturally with age
• Levels tend to increase with other conditions eg BPH, urinary
infection
• Different assay systems can produce different results and
levels can vary in response to
– Exercise
– Sexual activity
– Clinical investigation
– Other forms of treatment
Can we use digital rectal examination to
improve prostate cancer detection?
Digital rectal examination
NICE 2002. Improving outcomes in urological cancers. The
Manual. 2002. www.NICE.org.uk
• The cancer may not produce symptoms until it is at an
advanced stage, but early cancer can be detected by DRE,
which is used to investigate LUTS
• A positive test cannot be used for diagnosis but does indicate
a need for further investigations &/or referral
What are the referral guidelines for specialist
investigations?
Referral guidelines for suspected cancer:
Prostate cancer
NICE CG 27. June 2005
• A DRE and PSA (after counselling) are recommended for a
patient with any of the following symptoms:
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Inflammatory or obstructive urinary tract symptoms
Erectile dysfunction
Haematuria
Lower back pain
Bone pain
Weight loss, especially in the elderly
• Exclude UTI before PSA testing. Postpone a PSA for at least 1
month after treatment for a proven UTI
Referral guidelines for suspected cancer
NICE CG 27. June 2005
• In an asymptomatic male with a borderline PSA, repeat test
after 1-3 months. If PSA is rising, refer patient urgently
• Refer a patient with symptoms and signs or a urological
cancer to a specialist team
• Urgent referral:
– Patient with a hard irregular prostate. Measure PSA and
send with referral (not urgent if prostate is simply enlarged
and PSA is in the age-referenced range)
– Patients with a normal prostate but rising / raised agespecific PSA with or without LUTS
– Patients with symptoms and high PSA levels
What are the age specific cut offs for PSA
measurements and referral?
Age-specific cut offs for PSA measurements and referral
NICE CG 27, June 2005
Age range
PSA measurement
50-59
≥ 3.0ng/ml
60-69
≥ 4.0ng/ml
≥ 70
≥ 5.0ng/ml
>80
No age specific reference ranges
Nearly all men have over 80 have at least a focus or cancer in the prostate.
Only need to be diagnosed if likely to need palliative treatment
What ten principles should govern a
screening programme?
Ten principles which should govern a national
screening programme
www.cancerscreening.nhs.uk/prostate/index.htlm
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The condition is an important health problem
Its natural history is well understood
It is recognisable at an early stage
Treatment is better at an early stage
A suitable test exists
An acceptable test exists
Adequate facilities exist to cope with abnormalities detected
Screening is done at repeated intervals when the onset in
insidious
• The chance of harm is less than the chance of benefit
• The cost is balanced against benefit
The Department of Health view
• There is often increased anxiety amongst men with risk
factors. If these men present in primary care it is important
that they receive the best available information to assist them
in deciding whether or not to have a PSA test
• Until more evidence is available about screening active case
finding of men with risk factors is not recommended
Prostate cancer risk management
• Although evidence does not yet support population screening
there is considerable demand for the PSA test amongst men
worried about the disease
• In response the Government has introduced a PSA Informed
Choice Programme – Prostate Cancer Risk Management
• Key elements:
– Provision of high quality information for those requesting
testing
– Enables them to decide whether to have the test based on
available evidence about risks and benefits
Should you take the test?
Should you take the test?
www.cancerscreening.nhs.uk/prostate/prostate-summarysheet.pdf
Benefits
Risks
• May provide reassurance if
normal
• May find cancer before symptoms
develop
• May detect cancer at an early
stage when treatments could be
beneficial
• If treatment is successful the
consequences of more advanced
cancer is avoided
• It can miss cancer and provide
false reassurance
• It may lead to unnecessary
anxiety and medical tests when
no cancer is present
• It might detect slow growing
cancer that may never cause any
symptoms or shorten life span
• The main treatments have
significant side effects and there
is no certainty that Rx will be
successful
What would happen to 1000 men aged 50-70
years having a PSA test?
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900 are –ve and 7 later develop prostate cancer
100 are +ve
100 undergo biopsy
74 are –ve and 7 later develop prostate cancer
26 are +ve
• It is not known how many of these would have suffered any
morbidity or mortality are a result of their cancer if it have
been detected earlier
Detecting prostate cancer: Biopsy
NICE CG58 2008
• Provide
– Information
– Support
– Time to make decisions
• Discuss
– Risks and benefits of biopsy
– Individual risk factors
– Estimated prostate size
– DRE finding and PSA level
– Comorbidities
Treatment and service issues
• What are the treatment options for prostate cancer?
• What factors influence choice?
• What clinical evidence is there for the effectiveness of current
treatment options?
• What about harms of treatment?
• What support should be offered to patients with prostate
cancer?
• How can we improve standards of care for patients with
prostate cancer?
What are the treatment options for prostate
cancer?
www.nice.org.uk/CG58
TREATMENTS
Localised
Metastatic
Watchful waiting
Active surveillance
Radical prostatectomy
External beam radiotherapy
Brachytherapy
Orchidectomy or continuous
LHRHa
High Intensity Ultrasound or
Cryotherapy
Only as part of a clinical trial
Localised advanced
Neoadjuvant and concurrent
LHRHa with radiotherapy
Adjuvant hormonal therapy
with radiotherapy
Pelvic radiotherapy
Bicalutamide or androgen
withdrawal
Intermittent androgen
withdrawal
Hormone refractory
Docetaxel
Corticosteroids
Spinal MRI (spinal metastases)
Decompression of urinary tract
(obstructive uropathy)
Palliative care
Managing side effects of
treatment
Erectile dysfunction (PDE5
inhibitors first line)
Urinary incontinence – refer
for possible artificial
sphincter
Side effects of hormonal
treatments
Hot flushes — progestogens
Gynaecomastia with
bicalutamide — radiotherapy to
breast buds (or tamoxifen if fails)
Painful bone metastases –
strontium-89 or
bisphosphonates
What factors influence choice?
Factors influencing the decision to treat
www.cancerbackup.org.uk
• Deciding on the best treatment is not always straightforward.
The most important factors to consider are:
– General health
– Grade and stage of the cancer
– Whether it has spread beyond the prostate
– PSA level
– Likely side effects of treatment
– Views about the possible side effects and how much this
will be risked vs. Benefits in controlling the cancer
– Age
Communication and support
NICE Clinical Guideline 58; 2008
•
Health professionals should:
– Support men and their partners or carers in making treatment decisions,
taking into account the effects on quality of life as well as survival
– Inform men, their partners or carers about the effects of prostate cancer and
their treatment options on:
• Their sexual function
• Physical appearance
• Continence
• Other aspects of masculinity
– Offer sperm storage and access to specialist support services as appropriate eg
• Erectile dysfunction
• Urinary complications
Risk stratification criteria for men with localised
prostate cancer
NICE Clinical Guideline 58; 2008
PSA
(ng/ml)
Gleason score
Clinical stage
Low risk
< 10
and
≤6
and
T1 – T2a
Intermediate risk
10-20
or
7
or
T2b – T2c
High risk
> 20
or
8-10
or
T3 – T4
MDTs should assign a risk category to all men newly diagnosed with prostate cancer
What clinical evidence is there for the
effectiveness of current treatment options?
Treatment options for localised prostate cancer
NICE Clinical Guideline 58; 2008
Low risk
Intermediate risk
High risk
Watchful waiting
□
□
□
Active surveillance
●
□
◊
Prostatectomy
□
●
●
Brachytherapy
□
□
◊
Conformal radiotherapy
□
●
●
Cryotherapy
◊
◊
◊
High intensity focused
ultrasound
◊
◊
◊
● Preferred Rx
□ Treatment option
◊ Not recommended
Watchful waiting
NICE Clinical Guideline 58; 2008
• Involves the conscious decision to avoid treatment unless
symptoms of progressive disease develop
– Older men
– Those with significant comorbidity
– Those unlikely to have significant cancer progression
during their lifespan
• Measure PSA once a year
• Routine DRE not recommended
Active surveillance
Wilt T and Thompson IM, BMJ 2006; 333: 1102-1106
•
Active plan to postpone intervention. Involves monitoring (reassessment of risk) at
regular intervals with serial PSAs and repeat biopsy, with further treatment
(curative or palliative) based on patient preference, symptoms and clinical findings
•
Potential benefits
– No immediate side effects
– Low initial cost
– Most (especially low to intermediate risk) do not need treatment and survive
at least 10 years
•
Potential risks
– Cancer not removed so could advance, become incurable and cause death
– Quality of life could be painfully restricted
– Other Rxs may be necessary, not effective, have side effects, patient may be
too worried to monitor cancer without Rx
Radical prostatectomy
Wilt T and Thompson IM, BMJ 2006; 333: 1102-1106
• Complete surgical removal of the prostate gland with seminal
vesicles, ampulla of vas, and sometimes pelvic lymph nodes
• Potential benefits
– May eliminate cancer
• Potential risks
– Major surgery
– May not eradicate cancer
– Long term urinary incontinence
– Urethral stricture
– Bladder neck contracture
– Bowel and erectile dysfunction
External beam radiotherapy
Wilt T and Thompson IM, BMJ 2006; 333: 1102-1106
•
Multiple doses of radiation from an external source applied over several weeks. Conformal radiotherapy
uses 3-D planning systems to maximise dose to prostate cancer and to spare normal tissue
•
Potential benefits
– May eliminate cancer
– Generally well tolerated
– Avoids operative risks
•
Potential risks
– Prostate not removed and eliminated
– 5-8 weeks of outpatient Rx
– Rx related death
– Incontinence
– Proctitis
– Diarrhoea
– Cystitis
– Erectile dysfunction
– Urethral stricture
– Bladder neck contracture and bleeding
– Contraindicated with IBD
Brachytherapy
Wilt T and Thompson IM, BMJ 2006; 333: 1102-1106
•
Radioactive implants placed under anaesthesia using radiological guidance. Lower dose
permanent implants typically used. External beam ‘boost’ radiotherapy or androgen
deprivation sometimes recommended
•
Potential benefits
– May eliminate cancer
– Generally well tolerated
– Avoids operative risk
– Single outpatient session
•
Potential risks
– Does not eradicate cancer
– May not be effective for larger glands or more aggressive tumours
– Urinary retention
– Incontinence
– Impotence
– Cystitis or urethritis and proctitis
– Contraindicated if previous TURP
Radical treatments
NICE Clinical Guideline and Full Guideline 58; 2008
• Radical prostatectomy or radical radiotherapy should be offered to:
– Men with intermediate-risk localised cancer
– Men with high-risk localised cancer where there is a realistic prospect
of long-term disease control
• Brachytherapy not recommended for men with high-risk localised cancer
• Adjuvant hormonal therapy recommended for minimum of 2 years in men
receiving radical radiotherapy for localised prostate cancer with a Gleason
score ≥ 8
• PSA levels should be checked 6 weeks following treatment, at least every 6
months for 2 years and then at least once per year
Cryotherapy and HIFU
Wilt T and Thompson IM, BMJ 2006; 333: 1102-1106
Cryotherapy (cryoablation)
High-intensity focused ultrasound (HIFU)
Destruction of cells through rapid freezing
and thawing using transrectal guided
placement of probes and injection of
freezing and thawing gases
Destruction of cells through heat
generated through absorption of
ultrasound emitted from endorectal
probe. A cooling balloon surrounding the
probe protects the rectal mucosa
Potential benefits – May eliminate cancer; generally well tolerated; avoids operative
risk; single outpatient session (general or regional/spinal anaesthesia
Potential risks – Does not remove prostate gland and may not eradicate cancer. More
research needed – no long-term outcome data
Main side effects: Impotence (72-100%),
Incontinence (1-19%), fistula (<1-2%)
Main side effects: Impotence (24-100%),
UTI and stress incontinence (4-48%),
fistula (0.7-3%)
High-intensity focused ultrasound and cryotherapy
NICE CG and full guideline 58; 2008
• Insufficient evidence of clinical and cost-effectiveness in
comparison with established interventions
• Not recommended for men with localised prostate cancer
other than in the context of controlled clinical trials
comparing their use with established interventions
Hormone therapy (androgen deprivation therapy)
EAU Guidelines 2005; NICE TA101 2006;
Damber JE, Aus G. Lancet 2008;371:1710–1721
• Prostate cells are physiologically dependent on androgens (mainly
testosterone) to stimulate growth, function and proliferation
• The testes are the source of 90–95% of androgens (5–10% from adrenal
glands)
• If prostate cells are deprived of androgenic stimulation, they undergo
apoptosis (programmed cell death)
• Any treatment that ultimately results in suppression of androgen
activity is called androgen deprivation therapy (ADT)
• Can be achieved by suppressing secretion of the testicular androgens
(castration, LHRH agonists), by inhibiting the action of circulating
androgens (anti-androgens), or both (complete androgen blockade)
Methods used for androgen depletion
NICE. Improving outcomes in urological cancers. 2002
Method
Advantages
Disadvantages
Orchidectomy
Low cost in long term
No other treatment is more
effective
Irreversible
Unacceptable to some men
Loss of libido
Symptoms similar to female
menopause
LHRH agonists
eg gosereline
Reversible
Probably as effective as
orchidectomy
Side effects similar to surgery
but with a wider range of
symptoms. Initial stimulation
of testosterone can produce
tumour ‘flare’
Anti-androgens
eg biclutamide, flutamide,
cyproterone
Can be used with LHRH
agonists to reduce tumour
flare
Can be used alone in certain
circumstances
Side effects may be less severe
than LHRH agonists
Side effects similar to LHRH
agonists. May be less effective
than surgery or LHRH agonists
when used alone. Common
side effects include
gynaecomastia and risk of liver
failure
NICE recommendations for managing the
complication of hormonal therapy
NICE Clinical Guideline and Full Guideline 58;2008
• Offer oral or synthetic progestogens for hot flushes. Offer oral therapy
for 2 weeks and re-start when flushes recur, if effective
• Offer prophylactic radiotherapy to breast buds within the first 6 months
of long-term (>6 months) treatment with bicalutamide
• Consider weekly tamoxifen if radiotherapy does not prevent
gynaecomastia
• Do not routinely offer bisphosphonates to prevent osteoporosis in men
receiving androgen withdrawal
– More research is needed into the prevention and management of
osteoporosis in men receiving long-term withdrawal deprivation
therapy (NICE)
Case Study
• Jim is a 66-year-old retired accountant who comes to see you with his
wife. He has always enjoyed good health and is an active walker. He is
reluctant to discuss any symptoms associated with his 'waterworks' and
puts these problems down to 'old age‘
• His wife is concerned that he has been getting up more frequently than
usual at night to go to the toilet; she adds that he seems to be taking
longer to return to bed. She is becoming more anxious about her
husband's symptoms as her brother developed similar symptoms a few
years ago and was subsequently diagnosed with prostate cancer
• Together they think that an urgent medical opinion is needed. During his
subsequent GP consultation Jim admits to having to get up at 2-3 times at
night to go to the toilet, but denies having lost weight or having developed
any additional aches or pains. His GP considers that the symptoms may be
due to a urinary obstruction
What would you do next?
• A PSA test and DRE are appropriate if the symptoms are
considered to be due to obstruction, but it is best to exclude
the possibility of an infection before offering the test
• Patients presenting with symptoms suggesting prostate
cancer should have a DRE and PSA test after counselling
• Symptoms will be related to the lower urinary tract and may
be inflammatory or obstructive
• Prostate cancer is also a possibility in male patients with any of the
following unexplained symptoms:
– Erectile dysfunction
– Haematuria
– Lower back pain
– Bone pain
– Weight loss, especially in the elderly
• If Jim had any of these symptoms then he should also be offered a DRE
and a PSA test
• Urinary infection should be excluded before PSA testing, especially in men
presenting with lower urinary tract symptoms. The PSA test should be
postponed for at least 1 month after treatment of a proven urinary
infection
• Jim's urine test does not indicate the presence of bacterial
infection. Jim's GP offers him a DRE and a PSA test. Jim agrees
to the DRE, which reveals no abnormal findings. He has read
about PSA testing on the internet but isn't sure whether it's
right for him and asks his GP's advice
Which of the following statements are true
•
•
•
•
•
Men with prostate cancer tend to have higher levels of PSA in their
blood but up to 10% of men have normal levels
There is a clear criterion below which men may be reassured that they
do not have prostate cancer, and an agreed level that is considered
diagnostic
PSA may also be increased by conditions other than cancer, for example
benign prostatic hypertrophy (BPH) and urinary infection and levels
tend to increase naturally with age
Different assay systems can produce different results and levels can vary
in response to exercise, sexual activity, clinical investigations and some
other forms of treatment
PSA is found in two forms in the bloodstream - either bound to another
protein or free. The greater the proportion of PSA that is bound, the
more likely the occurrence of prostate cancer. A free to total PSA ratio
of less than 20% and PSA velocity of greater than 0.75 ng/mL/year are
accepted as being associated with a higher risk of prostate cancer
• False (Although estimates vary, up to 30% have normal levels) Men with
prostate cancer tend to have higher levels of PSA in their blood but up to
10% of men have normal levels
• False (There is no clear criterion) There is a clear criterion below which
men may be reassured that they do not have prostate cancer, and an
agreed level that is considered diagnostic
• True PSA may also be increased by conditions other than cancer, for
example benign prostatic hypertrophy (BPH) and urinary infection and
levels tend to increase naturally with age
• True Different assay systems can produce different results and levels can
vary in response to exercise, sexual activity, clinical investigations and
some other forms of treatment
• True PSA is found in two forms in the bloodstream - either bound to
another protein or free. The greater the proportion of PSA that is bound,
the more likely the occurrence of prostate cancer. A free to total PSA ratio
of less than 20% and PSA velocity of greater than 0.75 ng/mL/year are
accepted as being associated with a higher risk of prostate cancer
• After discussion Jim agrees to a PSA test, as he thinks it would
be good to be able to rule out the possibility of prostate
cancer
• Jim's PSA results are 4.2 ng/mL. The age-specific cut-off PSA
measurements recommended by the Prostate Cancer Risk
Management Programme are as follows:
– Aged 50-59 years >= 3.0 ng/mL
– Aged 60-69 years >= 4.0 ng/mL
– Aged 70 years and older >= 5.0 ng/mL
What course of action would you now advise?
• Repeat PSA testing in the next 3 months
• Discuss accuracy and validity of this with Jim and agree a plan
• After 6 months, Jim's repeat PSA test results have increased
from 4.2 to 5.0 ng/mL
Is an urgent referral (within two weeks) the
recommended course of action?
• Jim's PSA level has risen rapidly since his baseline test (greater
than 0.75 ng/mL/year) therefore an urgent specialist referral
is appropriate
• Jim attends the urology outpatient clinic, and, after discussion
with the urologist, agrees to have a biopsy performed. He is
subsequently diagnosed with clinically localised prostate
cancer
What does NICE advise about the treatment
options available?
• Recommended treatment options for localised prostate cancer include:
– Watchful waiting
– Active surveillance
– Radical prostatectomy
– External beam radiotherapy (EBRT)
– Brachytherapy
• Of these, active surveillance, a method of managing men with low or
intermediate-risk localised prostate cancer that, aims to target radical
treatment only, to those who would benefit most is the preferred option
for men with low-risk cancer. Active surveillance is particularly suitable for
a subgroup of men with low-risk localised prostate cancer who have
clinical stage T1c, a Gleason score of 3+3, a PSA density of less than 0.15
ng/mL/mL and who have cancer in less than 50% of their total number of
biopsy cores with less than 10 mm of any core involved