Everything you need to know about looking after your prostate health

Once you turn 50, your risk for prostate cancer begins to increase—more than 80 per cent of men diagnosed are over 65, with northern Europe and North America leading the trend.

Even a few years ago, prostate cancer patients had limited options, essentially choosing between mere surveillance and intervention that involved removing or destroying the entire prostate gland.

The former risked letting cancer progress too far while the latter brought prolonged side effects that left men miserable—incontinence, erectile dysfunction, loss of libido. And while less invasive treatments did exist, many clinicians were skeptical about their effectiveness.

“It’s been pretty stark,” says Dr Mark Emberton, professor of interventional oncology at University College Hospital, London (UCHL). “We either don’t treat you or we treat you maximally.”

But now some experts are reconsidering this view. With the latest technologies, once-experimental methods may prove advantageous in some cases. New drugs have been approved, and studies have found that some novel drug combinations expand lifespan in patients whose tumour is aggressive. Some trials have had success in treating prostate cancer with immune vaccines.

These options offer more hope and less suffering, but they also present patients with more choices than ever. Even being screened for prostate cancer is now a choice—and a very debated one. And even if you are diagnosed, it doesn’t mean you need to be treated because many prostate cancers are so slow growing that men would succumb to other causes first. “You’re very unlikely to die from a low-risk prostate cancer within ten years of the diagnosis,” says Dr Henk van der Poel, a urologist at the Netherlands Cancer Institute.

While the debates continue, here’s what patients should know.

It used to be that if your PSA (prostate-specific antigen) was elevated on an annual blood test recommended for men over 50, doctors would order a biopsy. If your biopsy showed a high Gleason score (a measure of malignancy and aggressiveness), doctors suggested interventional treatment.

But some people may have higher PSA levels due to a benign enlargement of the prostate or other reasons, and biopsies sample tissues randomly, so they sometimes found low-risk tumours but missed the aggressive ones. Studies found that nationwide PSA screenings weren’t saving enough lives but instead upped the risk of over-diagnosis and over-treatment.

One study found that doctors had to screen 1,400 men and treat nearly 50 in order to prevent one from dying. But biopsies and treatments caused pain and suffering, so doctors questioned whether this was ethical. Ultimately, experts advised against nationwide screenings. Today, doctors won’t run a routine PSA test unless they feel a growth during the prostate rectal exam or if patients complain of urinary or erectile problems.

But there are serious downfalls to not testing for the cancer. The UK cancer charity Orchid found that four in ten prostate cancers are diagnosed late, and at an advanced stage. A study published in the British Journal of Cancer found that prostate cancer had become the most common cancer in men in 2014 in the UK, and is expected to remain so through 2035, with deaths increasing by an average of 2.38 per cent a year.

It is hoped, however, that new imaging technologies will change the screening paradigm once again, by adding precision. The prostate gland had been hard to image due to its location in the body (it sits behind other organs) but the new multi-parametric (MP) MRI allows radiologists to differentiate clearly between low- and high-risk prostate tumours and outline their exact location. That significantly improves biopsy results because it tells doctors where to sample tissue. However, patients’ access to this new MRI still varies between different European countries.

With no systematic screening, how do men navigate this diagnostic hurdle to assure their health? For starters, patients should inform their doctors of their symptoms or concerns (pain, discomfort, trouble urinating or urinating often—basically anything out of norm), and request a PSA test. If that proves high, they should ask for an MP MRI before having a biopsy. And if they are diagnosed, they should thoroughly research the burgeoning list of options.

Aggressive cancers that haven’t spread outside the prostate are treated with prostatectomy—a surgical removal of the gland. For very small localised cancers, surgeons may do a partial prostatectomy: they remove the tumour and a surrounding margin to assure no cancer cells are left behind, leaving the unaffected part intact to preserve the nerves.

Historically, prostatectomy was done as “open” surgery, via an abdominal incision. Today, many hospitals offer robotic prostatectomy in which surgeons make small punctures in the abdominal wall and operate by manipulating tiny robotic arms and a 3-D camera from a computer screen. The methods are comparable in efficacy and side effects, including urinary incontinence and erectile dysfunction, but the robotic option limits blood loss and shortens recovery time.

Radiation is very effective in killing cancer and can be done in two ways. Brachytherapy, in which radioactive seeds are planted into the prostate, delivers less radiation but is more suitable for smaller cancers, says Professor van der Poel. An external beam radiation method is used for larger or more aggressive tumours because it can irradiate an extra surrounding area to assure the cancer doesn’t spread. Compared to surgery, radiation has similar survival rates, and it may cause less incontinence but longer sexual dysfunction, says Professor van der Poel, adding that age is a factor because younger men heal better. “I would have surgery, but for my father I would probably recommend opting for radiotherapy.”

Recently approved enzalutamide and abiraterone acetate extend life in late-stage cancers. The latter proved even more effective in combination with hormonal androgen deprivation therapy (ADT) in the latest trials. The combo has been approved for advanced cancers that have metastasised to bones or other organs and can’t be removed surgically. These drugs suppress the body’s production of testosterone, which tumours use for growth, but side effects include loss of libido, joint or muscle pain and weakness. Yet patients with very poor prognosis do live longer, says Dr Karim Fizazi, head of the department of cancer medicine at Gustave Roussy Institute, Paris, who has been running combination studies with abiraterone. “It’s almost a 40 per cent reduction in the risk of death.”

The most debated treatment approach, focal therapy offers a range of approved cancer-killing methods. In high-intensity focused ultrasound (HIFU) doctors heat the tumour; in cryotherapy they freeze it with liquid nitrogen or argon gas. They can also electrocute it with the NanoKnife or deliver toxic chemicals into it. The radiation treatment brachytherapy is also a focal technique.

All focal treatments destroy the tumour and spare healthy tissues, causing significantly less sexual dysfunction and incontinence. Yet doctors had been wary of recommending them because it’s hard to tell whether all cancer cells are killed. But Professor Emberton thinks that paradigm is changing too—because MP MRI can outline the tumour precisely before therapy and verify that it’s fully gone afterwards. Once MP MRI is widely available, patients won’t have to destroy their prostates entirely.

“Men certainly place a very high utility on preserving their genitourinary functions,” Professor Emberton says. And if half the gland is preserved, they have 95 per cent chance of having erections sufficient for intercourse.

Another focal therapy method with very few side effects was approved in 2017. It injects intravenously a cancer killing drug called Tookad and activates it in the tumour by means of light.

Many experts still remain cautious in recommending focal treatments—at least until more studies confirm efficiency. But all agree that men should thoroughly research their increasingly varied options and choose the best for their specific case. “We’re moving away from one-size-fits-all approach,” Professor Emberton says, “to a world in which you tailor the treatment to the individual.” And that, he adds, “is very exciting.”

“I was 79 when my GP asked if I wanted to check my PSA. It was slightly elevated and my prostate was slightly enlarged, but after researching the side effects of biopsies, I chose active surveillance,” says Harry Paice, a retired insurance broker, now 84. “For the next four years my PSA kept climbing so I researched my options again and chose an MP MRI. The picture showed some benign growth and a small node that was cancerous. But there was no spread outside the gland itself.

“I really wanted to avoid surgery so I decided on cryotherapy—freezing the tumour. Because I have a pacemaker some techniques like the NanoKnife wouldn’t be safe to use. I had it done in August 2018, and I’m happy about it. I had no side effects and I’ve even played golf a few times. I just received my MRI results and I am told the tumor is gone, so I am all clear.

“The motto of my athletic club is Nil Desperandum (don’t despair). There is a relevant treatment out there for all prostate sufferers—tailor-made!”

“I went to see a urologist because I had problems with urination and erectile dysfunction. When he did the exam, he said ‘Ooh la la.’ He could feel a big bump under his finger,” says Jean-Luc Girard, a retired 66-year old computer consultant. “Before that, my PSA level was very high on blood tests, but my doctor wasn’t concerned. So I went to the Gustave Roussy Institute in Paris to get a second opinion. The doctors confirmed it was a fast-growing cancer. It was too late for surgery.

“They offered me a new experimental treatment because it could improve my life expectancy. I agreed. My wife had a cancer with life expectancy of less than 24 months but she lived for 15 years, so I was ready to fight. First I had radiotherapy and chemotherapy and then a combination of two hormonal-based chemotherapy drugs—abiraterone and Zoladex, plus steroids. I got all the side effects—I lost my libido, my muscle tone and my strength—but as long I can enjoy my family, and travel, they are bearable."

“The average life expectancy for a patient in this trial was 48 months. Last September I overstepped this border. I’ve already survived longer than expected.”

“I’d had my PSA test every five years since I was 45, but in 2009 when I was approaching 60, it came back slightly higher than before,” says Jukka Karhula, a retired logistics manager. “The biopsy found cancer, although not a very fast-growing one. One doctor recommended active surveillance, but two others suggested surgery. No other options were discussed. I chose to wait for three months for robotic surgery, because the recovery was two-thirds faster. They took the entire left side of the prostate and the cancer with it—but spared the right. I was back at work in three weeks.

“After surgery, I had incontinence problems for three months and erectile problems for four years even with Viagra. But then the nerves around my prostate began to recover and today I don’t always need pills.

“If I were doing this now, I would ask about other treatments—at the time there weren’t many. I also wish I’d known to do pelvic muscle exercises while I waited for surgery, because it speeds recovery. So now I volunteer at the hospital, talking to new patients, telling them what I know. And I’m checking my PSA twice a month, even though the guidelines say every five years is enough.”