Prostate cancer: Get to know your treatment and testing options
There are now more ways of treating prostate cancer than ever, with new technologies expanding the available options.
Prostate cancer is one of the most commonly diagnosed cancers in men. According to the Irish Cancer Society, around 4,000 men in Ireland are told they have it every year, and one in six can expect to get it in their lifetimes.
These seem like terrifying statistics. But, says the Irish Cancer Society’s cancer awareness nurse Michelle Lonergan, “the good news is that if detected early and treated promptly, nine out of ten men will survive the disease”.
There are now more ways of treating prostate cancer than ever, with new technologies expanding the available options.
Helen Forristal, the Marie Keating Foundation’s director of nursing services, explains the factors that determine the course of treatment.
“It depends on the type of cancer cells found at diagnosis and how quickly that cancer is expected to grow,” she says.
“Prostate-specific antigen (PSA) levels, which are measured by a blood test, are taken into consideration. So is the stage of cancer as shown by MRI scan results, the age of the patient, and the patient’s general level of health.”
In the case of men with low-risk prostate cancer, the chosen treatment may be no treatment at all.
These men will have regular blood tests to check PSA levels, digital rectal examinations to check the size of their prostate, and MRI scans: all to make sure their cancer has not grown so that treatment and potential side-effects can be delayed or even avoided altogether.
Dr Peter Lonergan, a consultant urologist at St James’s Hospital, did his clinical fellowship training at the University of California, San Francisco, which has one of the largest active surveillance cohorts in the world.
He published extensively on this while he was there and was subsequently chosen by the National Cancer Control Programme (NCCP) to contribute to its guidelines for active surveillance, published in April.
He says that “active surveillance is suitable for men with low-risk early-stage cancer” and that the reason it’s suitable is because “prostate cancer is generally slow growing.”
Research shows it’s effective. A 15-year British study published in 2023 demonstrated that survival rates were similar to surgery or radiotherapy.
The one major drawback of active surveillance is that some men find it anxiety-inducing to live with cancer without treating it.
“The patient’s mindset has to be able to cope with the fact that cancer is present in their body and that treatment will be delayed or avoided unless tests show signs the cancer is growing,” says Forristal.
Radiotherapy or surgery is usually recommended for men whose tumours are large or fast-growing but still localised in their prostate. “Both have equivalent outcomes,” says Lonergan.
There are two main types of radiotherapy. External beam radiotherapy aims high-energy rays at the prostate from outside the body, and internal radiotherapy (also known as brachytherapy) involves placing a small radioactive source directly into the prostate to target cancer cells from inside.
Both are effective forms of treatment. Some eight in ten men who undergo radiotherapy will see their cancer either disappear completely or shrink in size.
The side-effects of both treatments are similar. The most common are urinary problems such as urgency and pain on passing urine, tiredness and fatigue, erectile dysfunction and diarrhoea, which usually resolve with time.
Of these side effects, the thought of erectile dysfunction is the one that worries many men. Forristal reassures them that there are treatments and medications that can help. “Erectile dysfunction usually returns with the use of medication or treatment but it may take time and some effort on a man’s part for the treatments to work,” she says.
One of the longest-established treatments for prostate cancer is a prostatectomy, which removes the entire prostate gland. Its success rates are high but it can have major long-term effects.
Forristal lists those effects: “Shortening of the penis; dry ejaculation; infertility; urinary incontinence — which usually gets better over time — and erectile dysfunction”.
Encouragingly, new techniques like robotic-assisted technology are improving surgical recovery rates. “Earlier return of continence is usually seen after robotic surgery,” says Lonergan.
“There are lower blood transfusion rates and an earlier return to normal activities. Robotic surgery has now pretty much replaced open prostatectomy in Ireland.”
Prostate cancer depends, in part, on the male hormone testosterone to grow and spread. So tablets or injections that reduce the level of testosterone produced by a man’s body can slow down or stop its growth.
“Hormone treatment is the first line of treatment for stage four cancer where the cancer has spread beyond the prostate,” says Forristal.
She adds that it can also be prescribed as neoadjuvant therapy, meaning it’s given before another course of treatment, such as radiotherapy, to shrink the tumour so the subsequent treatment is more effective.
Its side effects can be significant. Falling testosterone levels can cause low energy, tiredness and fatigue, weight gain, muscle loss, hot flushes and sweating, breast pain, memory loss or foggy brain, difficulty getting an erection and loss of libido.
“Medications can help with some of these problems,” says Forristal. “As can intermittent hormone therapy, which involves stopping treatment when your PSA level is low and steady and starting again when it begins to rise.”
Focal therapy differs from surgery, radiation, and hormone therapy, which target the entire prostate.
Instead, it targets only the cancerous part of the gland, sparing the rest. It does this in a variety of ways, including high-density ultrasound waves, cryotherapy (freezing the tumour), and laser treatment.
Lonergan says it’s offered to “men with early stage localised prostate cancer that is visible on an MRI but is not yet regarded as a routine treatment”.
The reason is that, although focal therapy has shown promise in early trials, there is a lack of long-term outcome data. “We don’t yet know what its impact is on the likes of recurrence rates,” he says.
Lonergan expects robotic-assisted surgery to develop further and for intraoperative image-guided surgery to become standard within the next 10 years.
This surgical technique uses CT and MRI scans to create a 3D model of the patient’s anatomy before surgery, and cameras and sensors to track the movements of the surgeon’s instruments during surgery, helping to make the procedure more precise.
“New androgen receptor pathway inhibitor drugs (hormone therapies) are being developed all the time, and new combinations of treatments are being used,” he says.
One recent development is MRI scans being used to detect prostate cancer prior to taking a biopsy.
Previously, men with elevated PSA levels were immediately referred for biopsies in which random samples were taken from their prostate. As well as being invasive, this method risked missing some tumours or detecting lower-risk ones.
Lonergan says that the additional MRI scan has two advantages. “One is that if the MRI is normal, a man may be able to forego a biopsy. The other is that it allows for a more targeted biopsy of the abnormal area if a biopsy is needed.”
It’s natural to be uncertain and worried when making serious decisions about your health. But, as Michelle Lonergan from the Irish Cancer Society explains, there often isn’t one right answer but “several treatment options that are equally effective”.
When it comes to choosing one, Forristal says it is crucial that all parties are consulted. “Patient case presentations are discussed at multidisciplinary team meetings where an optimal care plan is recommended,” she says.
“This is then relayed to the patient and their family, who are part of the decision-making process. They are made aware of the benefits and risks of treatment, including possible longer-term effects. The ultimate goal for everyone is cancer control and maximum quality of life.”
‘Early detection and prompt treatment are key to survival rates’
The Irish Cancer Society advises speaking to your family doctor about any concerns or symptoms you have regarding your prostate health.
They may do a digital rectal examination (DRE) or a prostate-specific antigen (PSA) blood test. Your GP will refer you to hospital if they think you need more tests.
A DRE involves inserting a gloved finger into your back passage to see if your prostate feels normal. It can be a little uncomfortable, but it is quick.
This test checks the level of prostate-specific antigen (PSA) in your blood. A raised PSA level can be a sign of prostate cancer, but it can also be caused by other conditions like a urinary infection or inflammation of the prostate (prostatitis).
A raised PSA doesn’t always mean cancer. Two out of three men with a raised PSA do not have prostate cancer.
Some men with prostate cancer have a normal PSA level.
This is a type of MRI scan that creates more detailed pictures of your prostate than a standard MRI. It may be done before a biopsy to help doctors determine where to collect cell samples. .
A prostate biopsy uses a needle to take small samples of prostate tissue. A pathologist examines these to see how abnormal the cells are. There are two ways to do a prostate biopsy:
Most prostate biopsies are transperineal biopsies. The needle goes through the skin between the testicles and the back passage (perineum).
The biopsy is guided by an ultrasound probe inserted into your back passage.
An ultrasound probe is put into your back passage. It uses sound waves to produce pictures of your prostate. A biopsy can be taken through the back passage.
Michelle Lonergan, cancer awareness nurse at the Irish Cancer Society, says: “If prostate cancer is detected early and treated promptly, nine out of 10 people will survive the disease. If prostate cancer is found at a later stage, survival rates drop significantly, making early detection essential. For example, for those diagnosed at stage four, the five-year survival rate drops to 50%.
“The quicker prostate cancer is detected, the quicker your treatment can begin and the more likely you are to have a successful outcome.”
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