Do all prostate cancers need active treatment?
Not all prostate cancers need active treatment. And in fact, when we do a biopsy, sometimes we’ll actually diagnose low-grade prostate cancer.
What is Low-grade prostate cancer?
Low-grade prostate cancer in the main is actually not harmful and can be safely watched. So, we have whole management option called ‘active surveillance’. This option’s now been available for several years and has been published on widely. And as long as it’s done carefully and properly, it’s actually very safe, and you can avoid either forever or for a period of time, any curative treatment that might otherwise lead to side effects, such as urinary incontinence, erectile dysfunction, or bowel disfunction in the case of radiotherapy.
What is active surveillance?
So, active surveillance is actually a really important option for patients to be aware of in the setting of low-grade prostate cancer. Just to clarify what I mean by low-grade prostate cancer, it’s either what we call grade group 1 prostate cancer, or in the old system called Gleason 6 or lower, anything above that is not really called low-grade prostate cancer.
If a patient goes onto active surveillance, the way we do that is, as I mentioned, you have to start with a biopsy to get tissue confirmation so that we know that it’s low-grade, and then, after that, we would perform serial PSA blood tests. These don’t have to be done too often, some people will say every 3 months, but really 6-monthly would typically be a quite reasonable guideline for checking somebody’s PSA during active surveillance.
Active surveillance is, how we do it is actually changing, it’s evolving quite rapidly and that’s because of the introduction of MRI. MRI’s been really important, not only in the initial diagnostic space, but also for men who are on active surveillance. In the past, we would always recommend a so-called confirmatory biopsy within 12 months of the first biopsy, but that was really making sure that the patient didn’t have something that had been missed on the first biopsy.
What is an MRI?
Now, we have MRI which is far more accurate, it’s got a higher detection rate of the higher grades of prostate cancer, and MRI can be done down the track as well. So, that might be done, for example, at 12 months, and if everything is stable, then we can just continue on monitoring with a PSA, we may do another MRI down the track. And if anything changes, if your PSA rises significantly or the MRI shows a lesion, where before there wasn’t, then we may need to do another biopsy, particularly if there’s a lesion that is now present that wasn’t there before, then we would target our biopsies to that lesion. Sometimes, prostate cancer needs to be treated.
There’s low-grade prostate cancer which can be dealt with with active surveillance. But if it’s not low-grade prostate cancer, in other words, if it’s got elements of more aggressive cells or tissue within the actual tumour, then that can potentially spread and it can cause death. So, prostate cancer is one of the highest causes of cancer death in men, certainly in Australia, but also around the world. But it’s also a very common cancer, such that many men do not die of prostate cancer.
So, our job is to try and tease out which can be safely monitored and which men actually need treatment. For those then who need treatment, the mainstream options are either surgical removal of the prostate, which is called radical prostatectomy, or a form of radiotherapy to the prostate, which can take the form of either insertion of radioactive seeds called brachytherapy into the prostate, or by delivering external beams into the prostate. And when the external beam radiation is given it’s often in combination with hormone therapy, as that combination has been shown to have better outcomes for the patient.
What is hormone therapy?
Now, hormone therapy is a whole other type of treatment for prostate cancer, which involves an injection every three to six months. And that injection basically knocks out that man’s testosterone, because we know that prostate cancer, the growth of it can be fuelled by testosterone, and when we take testosterone away, prostate cancer growth can become quiescent and lie dormant, but hormone therapy on its own doesn’t cure prostate cancer.