Prostate cancer is normally diagnosed on the basis of a blood test. The blood test is called the PSA.
Unfortunately, prostate cancer has to be quite advanced; in other words, has
to have grown quite a lot in order for it to give you symptoms, and therefore we rely
on the blood tests, the PSA, to try and detect that cancer before it's got large and before
it's given rise to some symptoms. The PSA has some problems. The PSA can diagnose prostate
cancer early when the disease is very much curable, but it can also be falsely high when
you have not got prostate cancer. So many men have a slightly high PSA and they don't
have prostate cancer. They would therefore be put through a number of investigations
and it's reassuring for us to be able to tell them at the end of it all, their investigations
are negative, but the PSA may, in the meantime, have given them some anxiety. The PSA is very
useful also at monitoring treatment going forward. So, if you do have prostate cancer
and you need to have treatment, after that treatment PSA is very reliable at telling
us whether the cancer’s all gone or whether it's the signs that it unfortunately may have come back.
So, if the PSA is high, what we do is check that you don't have any sign of
infection, and if that was the case you did not have an infection, we then proceed to
the next investigation, which would be an MRI scan normally. This is an MRI scan that
looks inside the prostate to see if there's any abnormality in the prostate that may either
be prostate cancer or something else that might be elevating the PSA.
So, we know that most men will develop prostate cancer if they live long enough and most men
will develop prostate cancer that they'll never know about in their lifetime. They will
live a normal, full, healthy life, unaware they have prostate cancer. Sometimes these
prostate cancers are found either on a biopsy or an MRI scan and because we think they're
never going to affect the patient during their normal lifetime, we recommend what's called
active surveillance, and with active surveillance what we do is we watch patients very carefully
with a combination of a blood test: the PSA, an MRI scan and also sometimes biopsies to
make sure the cancer isn't changing. But essentially this is a way of monitoring cancers that we
think are never likely to affect that patient during their lifetime. Sometimes, these cancers
may show signs of change and then we'll then treat you with one of the normal therapies
for prostate cancer, such as having your prostate removed, radiotherapy, brachytherapy or focal
therapy. But the vast majority of people who start on active surveillance stay on active
surveillance, stay being monitored in other words without the need for any form of treatment.
The challenges of making a diagnosis of prostate cancer lie really in the form of the blood
test: the PSA, which doesn't always tell us whether there's cancer there or not, interpreting
the MRI scan and then once we've done the MRI scan if we need to proceed to do a prostate
biopsy, interpreting the biopsy findings to decide what the best treatment options are.
So, in terms of making a diagnosis in the first place, we do this based on the PSA blood
test and the PSA blood test may be high even if you don't have prostate cancer. This could
be because the prostate is a little enlarged and larger prostates, even though they don't
have cancer, may put the PSA up than a smaller prostate. The other challenge is if you have
a urinary tract infection, that can also elevate the PSA. So, what we do is we look at a number
of things, such as what's happened to the PSA over time, make sure you haven't got a
urinary tract infection and look at the size of the prostate to decide whether or not,
based on the PSA, there's likely to be prostate cancer there. If we do feel as high chance
of prostate cancer, then we then go on and get an MRI scan. Now, MRI scans don't always
give a black-and-white answer. They're much more accurate than a PSA test, they're much
more accurate than a patient who might have symptoms or even the finger examination at
the back passage, but they don't always give us a black-and-white answer. So, what we may
do is do a biopsy if we think that the MRI shows us definitely cancer. If the MRI is
a bit equivocal, in other words it says there may or may not be cancer, we then make a decision
based on the prostate size and the PSA as to whether or not a biopsy is necessary.
Often, the MRI is completely normal and therefore you wouldn't need to have any biopsy at all
but maybe just carry on watching your blood tests, your PSA, going forward just to check.
So, a patient who has undergone an MRI may have an abnormal area that appears on that
MRI scan. MRI is fantastic at looking inside the prostate to see if there is any prostate
cancer there. When we do a biopsy, we can't unfortunately do this using an MRI scanner
to identify exactly where the tumour is. An MRI scanner is a noisy tunnel and it would
be difficult for a urologist to get in to access the prostate down that noisy tunnel to know
they get the right bit. So what we do is we do what's called an ultrasound scan by placing
a small probe up the backside. Ultrasound scan is very good at showing where the prostate
is and the size and shape of the prostate, but unfortunately it doesn't give detail about
what's going on right inside the prostate. So what fusion biopsies have done; and this
is a development really in the last few years is it's taken the MRI scan and what we do
is we outline the prostate on the MRI scan and we outline the abnormal area on the MRI
scan and then we fuse those outlines with the ultrasound image. This enables me to see
on the ultrasound image the abnormalities that we've detected on the MRI scan. What
I can then do with a fusion biopsy is put a needle directly into what is seen on
the MRI scan using the ultrasound scan, so I know I've hit the right target. The fusion
biopsy then also records exactly where I've taken my biopsy, so we have a record going
forward of exactly where that abnormality is and where the biopsy was positive prostate
cancer or negative prostate cancer as this can impact on treatment going forward.
So, the three biggest risk factors for prostate cancer, unfortunately there’s nothing we
can do about. That is, the family history, so if you have a father or a brother, then
you’re at an increased risk of prostate cancer. Depending on how many relatives you
have who’ve had prostate cancer, that increases your risk even further, but clearly you can’t
do anything about that. The second thing is getting older, which none of us can do anything
about, and finally, your ethnicity – if you’re a black man, you’re at an increased
risk, unfortunately, of developing prostate cancer over a white person living in the same country.
So we can do nothing about that, but what we can do things about is reducing
your risk of getting cancer overall, and particularly prostate cancer. So, exercise reduces your
risk of prostate cancer; making sure you’re not overweight reduces your risk of prostate
cancer; and particularly in the diet, having cruciferous vegetables, those are things like
kale, broccoli, Brussels sprouts are all good ways of, not only maintaining a good, healthy
diet, but also reducing your prostate cancer. There’s some evidence that lycopene in tomatoes
– that’s tomatoes ground up, rather than whole, as in salad tomatoes – may help,
and also pomegranates may help.