Prostate Cancer

Prostate Specific Antigen (PSA) is a substance produced almost exclusively in the prostate and plays a role in fertility. The vast majority is actually released into the ejaculate but tiny amounts are released into the blood stream and can be detected by a simple blood test. Abnormally high levels of PSA can be an indication of disease of the prostate. Common reasons for a high PSA level in the blood stream may include prostate cancer, large prostates, and age related inflammation of the prostate or infection of the prostate. Obviously the first concern is to exclude prostate cancer.

The bladder is the organ that stores urine and the urethra is the tube that drains urine out through the penis. The prostate lies immediately beneath the bladder and completely surrounds the urethra and lies immediately in front of the rectum (back passage). Your doctor will perform a digital rectal examination (DRE), an examination via the back passage of the prostate, an otherwise inaccessible internal organ. Age related enlargement is not a particular concern but if the gland feels abnormally firm or hard, it may sometimes be an indication of an abnormal growth in the prostate gland.

The bladder is the organ that stores urine and the urethra is the tube that drains urine out through the penis. The prostate lies immediately beneath the bladder and completely surrounds the urethra and lies immediately in front of the rectum (back passage).

Age related enlargement is not a particular concern but if the gland feels abnormally firm or hard, it may sometimes be an indication of an abnormal growth in the prostate gland.

During a digital rectal examination, your doctor inserts a gloved finger into the rectum to feel the condition of the prostate that lies close to the rectal wall. If your doctor feels something suspicious such as a lump or bump, further tests will be carried out.

Your doctor will discuss the test results with you. If he or she detects a suspicious lump or area during the exam, or if your PSA level is elevated, an MRI, ultrasound or biopsy may be recommended.

After the test, you may continue your normal activities.

Multi-parametric prostate MRI (mpMRI) is a new technique available to men that assists in the diagnosis of prostate cancer. The technique was validated in Australia at the Wesley Hospital in Brisbane in conjunction with Professor Jelle Barentsz (Rabdoud University, Nijmegen, The Netherlands) who is a world leader in mpMRI. mpMRI informed prostatic biopsy has subsequently been popularised world-wide. Wesley Medical Imaging, along with its unit at Buderim Private Medical Imaging is currently one of the most experienced and high-volume mpMRI centres in the world.

Buderim Private Medical Imaging performs mpMRI at the highest standard and is my preferred provider for this service on the Sunshine Coast. Ted O’Brien MP – Federal Member for Fairfax has now launched an online petition to advocate for a full MRI license at the Buderim Private Hospital. An MRI license would allow us to reduce the burden of out of pocket costs to our patients on the Sunshine Coast. We encourage our patients and friends to sign this petition below and support the push for better access to MRI Medicare rebates. https://our-mri.squarespace.com/

The technique is a non-invasive test that uses a powerful magnetic field to obtain pictures of the prostate gland. The test requires you to lie still on the MRI table and typically takes around 30 minutes to perform. Several images are then taken of the prostate to see if there are any areas that are concerning for cancer.

After the test you will be seen at a follow-up appointment to review your scan. Essentially the scan will either show suspicious areas or not. If suspicious areas are seen, then a biopsy can be arranged and the abnormal areas sampled. This biopsy is performed in the operating theatre where the urologist can target the abnormal areas by fusion the already obtained MRI image with ultrasound in theatre.  A robotic guidance system is employed to ensure highly accurate targeting of the biopsies.The biopsy involves inserting a needle into the prostate through the skin between the scrotum and the anus (transperineal) – a safer technique with a very low chance of infection compared to classical transrectal prostatic biopsy.

It is important to note that some important prostate cancers can still be missed by mpMRI. Often it may be reasonable to simply observe your PSA level if the scan is negative. However in other cases we may still elect to proceed with a prostate biopsy if other factors such as Family History, DRE findings, PSA density indicate that there is a moderate to high risk of cancer. Patients often then ask, why do the scan at all if that is the case? The reason is that if the scan is positive, then that will help make any biopsy more accurate because it can clearly demonstrate the abnormal areas that need to be targeted.

In summary, a positive scan is useful in identifying that a biopsy is needed and in directing where the needles should go, so if there is something significant there, we are not likely to miss it. A negative scan may allow you to avoid biopsy and just have your PSA watched in some cases, even though in others a biopsy may still be required.

A biopsy is where a sample of cells is taken for examination under the microscope by a pathologist. It is the only way that a diagnosis of early prostate cancer can be proven. This test is commonly performed because either a blood test called PSA is abnormally high or the examination of the prostate through the back passage is abnormal. Often (but not always), MRI of the prostate is also abnormal and may result in the need for a biopsy.

There are several ways a prostate biopsy can be performed. For many years, this was performed transrectally (biopsy taken through the rectum). Especially since the recent increase in multi-resistant infections, it is now recognised that a transperineal approach where the needles are inserted through the skin between the scrotum and the anus is significantly safer.  The risk of infection is very much lower than that with the transrectal approach at around 0.2%.

Transperineal biopsy – Preparation for the test
You do not need any antibiotic before or after the biopsy, but will be given a dose of antibiotics intravenously when asleep. You will be given a general anaesthetic for the procedure so you will need to fast (nothing to eat or drink) for 6 hours before the test. So if the test is in the morning (as is usually the case) you should have nothing by mouth from midnight the night before. That also means nothing to drink (including no water), though you can take any medications with a some water. If your test is in the afternoon, then you can have a light breakfast at around 6 AM and then nothing after that. Please let Dr Gianduzzo and the staff know if you are on any blood thinners or diabetic medications as you may need to stop these before the test. You will be advised of this at your appointment when the test is scheduled.

You will have a Microlax enema to use (same as before your MRI)  at home soon after you get up for the day – this usually works immediately, but if nothing happens, don’t worry – it only works if it needs to.

Robotic-assisted Transperineal Biopsy – Procedure
You will have a general anaesthetic for the procedure. You will receive one dose of antibiotic intravenously at the start of the procedure. A probe-like instrument about 2 cm in diameter is gently inserted into the back passage. This is an ultrasound probe that allows visualisation of the prostate beyond what can be felt by the finger alone. More importantly, it allows construction of a real-time 3-D image of your prostate, that can then be “fused” with the previously obtained MRI image, to accurately place the position of any lesions seen on the MRI. A biopsy schema is then planned, which then allows highly accurate robotic assistance in planning the depth and trajectory of each biopsy core.  A number of specimens are collected by inserting the biopsy needle through the skin between the scrotum and the anus, with each biopsy monitored in real-time to ensure ongoing accuracy of the procedure. Typically, 15 to 30 biopsy cores are obtained. The procedure takes about 40 minutes. You will then need a couple of hours routine observation as you recover from the anaesthetic. You then need someone to drive you home – generally around lunchtime or soon afterwards.

Biopsy Risks
Following a prostate biopsy, you can expect to see some blood in the urine, bowel motions and semen. Any blood in the urine or bowel motions usually settles by a week or two, although brownish discolouration of the semen can last for up to a couple of months.

Retention of urine is an uncommon risk – typically less than 5%, and we make sure you can pass urine freely before you go home after the procedure, though it can occasionally happen later. In that event, ring the hospital on 07 5430 3303

Rarely (~0.2%), you may develop an infection but this risk is minimised by the antibiotics administered. If you develop fevers and begin to shake, you should contact the hospital on 07 544 0672 and/or go to the nearest emergency department to be assessed. Infections can be very serious after a biopsy so it is important that you seek medical attention if you have symptoms of infection even if it is in the middle of the night!

Very occasional patients notice temporary decline in their erections – this is not common, and reflects some swelling affecting the erectile nerves running alongside the prostate. If it occurs, it settles within one to three months.

Obtaining results
It generally takes a few days to obtain the results of your biopsy. You should already have had an appointment made to return for review, generally 2 or 3 days after your procedure. If not, please contact the rooms.

Anticoagulants and Blood-Thinning Medication
If you are taking any of the following anticoagulants: Warfarin, Clopidogrel (Plavix, Iscover), Pradaxa, Xeralto, Eliquis, Effient, Brilinta or any other blood-thinning medication, we should have already have discussed with you what needs to be done – if not, contact the rooms. Aspirin or fish oil does not need to be stopped.

Diabetic Medication. The diabetic medications Forxiga, Xigduo, Jiardiance, and Jardiamet should be stopped three days before the procedure. If your diabetes is particularly difficult to manage, discuss alternative medications for the period with your GP.

Treatment options and recommendations are heavily influenced by the stage and grade of the cancer.

The staging system describes how far the cancer has spread within and/or beyond the prostate.

Stage T1: The tumour seems confined within the prostate and the prostate feels normal.

Stage T2: The tumour seems confined to the prostate but the prostate feels irregular to examination.

Stage T3: The tumour has spread just beyond the shell of the prostate into nearby tissue and / or the seminal vesicles at the back of the prostate gland.

Stage T4: The tumour has spread into adjacent organs such as the bladder, rectum, or pelvic side wall.

Prostate cancer can also spread to lymph glands and to other parts of the body such as to bone and other organs.

If the cancer is advanced, then symptoms may include fatigue, weight loss, bone pain and difficulty urinating. It is important to note that prostate cancer does not typically produce symptoms until it is advanced. This is why it is important for men to get PSA tests as this is the main way that prostate cancer will be diagnosed before it has spread.

Grade describes how aggressive the cancer looks under a microscope, from low grade disease that may not need treatment at all, through to high-risk aggressive cancer.

The International Society of Uropathologists (ISUP) has now recommended a simplified grading system, based on the Gleason Score which grades the cancer from 1-5. The Gleason Score was a score out of 10, but typically the lowest score was 6 which does not make inherent sense. The ISUP classification addresses this so that:

ISUP 1 – Gleason Score 3+3 = 6

ISUP 2 – Gleason 3+4 = 7

ISUP 3 – Gleason 4+3 = 7

ISUP 4 – Gleason Score 4+4=8

ISUP 5 – Gleason Scores 4+5=9, 5+4=9, 5+5=10

Gallium-68 PSMA Scan
This is a newer scan is much more accurate than CT and bone scan. It uses a radioactive marker that binds to prostate cancer cells. It is combined with positron emission tomography (PET) and CT scanning technology to help identify areas where prostate cancer may have spread to. Patients only need to present well hydrated and are not required to fast prior to the scan. Patients are given an injection approximately 45 minutes before the scan which then takes around 30 minutes. Patients are generally in the radiology department for around 2½ hours in total. In about 5% of patients the prostate cancer does not show up at all, so the scan on occasion is not helpful.  As it is new, it is not yet covered by medicare so patients should check the cost of the procedure with the radiology practice. Due to the expense (approximately $800 out of pocket) it is generally only used in higher-risk cases, where the chance of distant spread showing up on the scan is greater than a few percent.

Bone scans
Your doctor may want to see if the cancer has metastasised and has affected you bones.

A small amount of radioactive material is injected into your arm, abnormal bone absorbs more of the radioactive substance than normal bone and shows up on the scan as highlighted areas (known as ‘hot spots’). Your arm will then be scanned an hour later to view the activity of the bone and ascertain whether the cancer has spread.

The level of radioactivity that is used is very small and does not cause any harm.

This scan can also detect other conditions affecting the bones such as arthritis, so further tests such as an X-ray of the abnormal area may be necessary to confirm that it is cancer.

CT scan (CAT scan)
A CT scan is basically an X-ray tube that rotates in a circle around the patient and takes a series of pictures as it rotates. The multiple X-ray pictures are reconstructed by a computer in axial slice images at different levels. Each level can be examined separately.

A CT scan may show if cancer has spread beyond the prostate to other parts of the body such as the lymph nodes.

The scan takes from 10-30 minutes. You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand.

You will probably be able to go home as soon as the scan is over.

Magnetic Resonance Imaging (MRI or NMR scan)
Magnetic resonance imaging (MRI) is a non-invasive imaging technique. This test is similar to a CT scan but uses magnetism instead of X-rays to build up cross-sectional pictures of your body. It is used to view organs, soft-tissue, bone, and other internal body structures. In an abdominal MRI, the person’s body is exposed to radio waves while in a magnetic field. Cross-sectional pictures of the abdomen are produced by energy emitted from hydrogen atoms in the body’s cells.

An individual is not exposed to harmful radiation during this test.