PSA AND PROSTATE CANCER RESOURCES
These pages are primarily intended to provide more in depth information for GPs or interested patients. More medical in nature, they contain links to external resources also.
PSA is an enzyme produced in the prostate as part of normal semen production. It is raised in benign prostatic hyperplasia, infection, retention of urine, post-instrumentation eg catheterisation, post-ejaculation and possibly post vigorous exercise in particular cycling. Tests should therefore be taken 4 days after any of these or longer after infection (probably 4-6 weeks). Accepted PSA values have been changed to allow for the natural benign growth of the prostate with age (NICE 2021). Therefore the upper acceptable limit has now been set at 2.5 for men aged 40-49, 3.5 for ages 50-59, 4.5 for men aged 60-69, 6.5 for men aged 70-79, and aged 80 or above the clinician and patient are advised to discuss individually. Bear in mind in more frail older men, treatment for localised prostate cancer is unlikely to be of benefit.
Any man asking regarding his prostate cancer risk should be assessed to exclude infection, his risk factors eg family history, ethnicity (2-fold increased risk in Afro-Caribbean men), and be informed of the potential inaccuracies of the test and what options follow a test.
The links below are the latest advice from NHS England for GPs and patients.
Prostate cancer screening
Population screening for prostate cancer is not currently recommended based on the evidence thus far and the implications on health and economics of investigating and treating the numbers of men involved. The best evidence thus far is from the European Randomised Study of Screening for Prostate Cancer, which has tested 182,000 men, demonstrated a 27% reduction in population prostate cancer mortality after 13 years of follow up. However this still meant 27 diagnoses to prevent one death. Importantly though, the advent of multiparamentric MRI and targeted biopsies will dramatically improve the detection rate of significant prostate cancer whilst helping to avoid over-diagnosis of indolent disease, therefore leading to much improved screening overall. Some data emerging from this study with longer follow up has described results on a par with existing screeinig programs such as cervical and breast cancer screening, so it is likely that with refinement of the diagnostic techniques in future screening will become commonplace. A PSA based prostate cancer risk calculator is linked below also.
Prostate Cancer online risk assessment calculators
Post mortem studies have demonstrated that a man's risk of having prostate cancer is roughly the same as his age. However, only 4% of men in th UK die from prostate cancer. It is vitally important therefore that men understand their risk, and also whether treatment will make any difference. The online tools below will help in decision making. Firstly, prior to biopsy, using PSA, examination findings, ethnicity and family history, the risk of prostate cancer can be assessed broken down into low (unlikely to require treatment), intermediate (likely to progress but slowly, possible treatment required), and high (likely to progress and therefore requiring treatment sooner) risk groups.
The second tool will estimate how much benefit treatment is likely to offer, and is based on biopsy results as well as other clinical features. To put the cancer into perspective, it also estimates a man's chances of living a normal life expectancy and dying after many years of something else. Sometimes there is a tendency to overstate the risk of prostate cancer, so this can help reassure and put things into perspective.
MRI and Targeted biopsies
We have been performing pre-biopsy multiparamentric MRI locally for 5 years in order to reduce the risk of missing the cancer at biopsy and more recently help men to avoid biopsy altogether if they are less likely to have significant prostate cancer. A number of studies have demonstrated about 85% of significant prostate cancers will be detected on MRI, so if a scan is negative and no other red flags are present, then men can be offered monitoring rather than proceed to biopsy. This needs careful discussion and follow up.
Treatment options for localised prostate cancer
Evidence has shown that radical treatment for prostate cancer can halve the risk of death over 10 years or more, so the benefits very much depend on how aggressive the cancer is. For this reason we often recommend active surveillance for low grade or low volume prostate cancer. This involves serial PSA blood tests and repeated scans and potentially biopsies after a period of monitoring. With improved diagnostic techniques, including MRI and targeted biopsies, we can hope to improve the outlook for those men who do not need immediate treatment. It should be remembered that though the majority of men of retirement age have prostate cancer, only 4% of men in th UK die from the disease, therefore in most cases it is slow growing and indolent. Correct risk assessment with PSA, scans and biopsies is crucial in this regard.
Robotic assisted laparoscopic prostatectomy (RALP):
Now the mainstay of surgical treatment for prostate cancer in the UK. It involves telescopic removal of the whole gland, and preservation of urinary continence and erectile function (where applicable) are important, with advantages to robotic surgery over other approaches. Mr Streeter has been a high volume prostate surgeon for 12 years. The link below will take you to the BAUS leaflet on Robotic Prostatectomy.
External beam radiotherapy:
Usually performed over a 5 -7 week period, and is combined with hormone therapy (testosterone blockade) for a period of 3 months before treatment and up to 3 years afterwards. Side effects can include tiredness, hot flushes and sexual side effects from htrmone therapy, plus bladder and bowel inflammation from the radiotherapy. Occasionally these can be permanent, especially erectile problems. There are no direct head to head studies of radiotherpay versus surgery, but several studies have suggested higher recurrence rates and lower overall survival with radiotherapy, but these results are not conclusive.
involves radioactive beads being placed under anaesthetic into the prostate to deliver a prolonged radiotherapy dose. It has less side effects than external beam radiotherapy, but is usually used for relatively low risk disease compared that which can be managed by other options. Again, it is likely to have a higher recurrence rate long term compared to surgery, and causes scarring thereafter making surgery much more difficult. However it may be a good option for a subset of men.
Another option for localised prostate cancer is High Intensity Ultrasound (HIFU), which can be used to treat small parts of the prostate only. This is still considered an experimental option to be performed only as part of ongoing research trials.