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Prostate Diseases and Prostate Cancer

Prostate problems arise in two main forms: benign enlargement which affects 50% of men over 65 and cancer which is now the commonest male cancer in the UK and kills over 12,000 men each year.

The prostate gland lies immediately below the bladder encircling the tube (urethra) that carries urine into the penis.  It produces fluid (semen) that helps sperm swim and fertilize a female egg.  A Digital Rectal Examination (DRE) helps detect problems (see diagram).
 
The Prostate – Benign Disease (BPH, BPE, BOO)
Normally the size of a walnut, BPH is the process by which prostate cells multiply in middle age, for poorly understood reasons.  This may lead to benign prostatic enlargement (BPE) which in turn may block the urethra causing bladder outflow obstruction (BOO).  These abbreviations are all commonly used.

BOO causes delay, a poor or interrupted stream and dribbling afterwards.  It also upsets bladder control leading to increased frequency of voiding by day or at night (“nocturia”), an urgent desire to void or even wetting on the way to the loo (“urge incontinence”).

In many men BOO progresses and can cause serious complications such as complete inability to pass urine necessitating emergency treatment and surgery.  We don’t know what causes BPH, but there is evidence to show that a diet and lifestyle that are good for the heart are good for the prostate too.

Nowadays a range of drugs can effectively relieve most men’s symptoms, may prevent BPH progression and has greatly reduced the need for surgery, especially when used at an early stage.
 All good reasons for an early check-up.
 
Prostate Cancer – Screening & Early Diagnosis:  The National Picture
Every year in the UK nearly 50,000 men are diagnosed with Prostate Cancer (PCa).  It is the commonest cancer in men and every year it kills over 12,000!  That’s more men dying of PCa than women from breast cancer, yet despite this we still have no national screening programme and our death rate is one of the worst in Europe.  This need not be.
 
CHAPS works closely with the National Federation of Prostate Cancer Support Groups (aka TACKLE Prostate Cancer) and the men’s cancer charity ORCHID.  Together we are campaigning to improve awareness and the availability of PSA testing for appropriate and fully informed men.
 
We have a simple, cheap, screening blood test – PSA – to which men over 45 are entitled under the NHS Prostate Cancer Risk Management Programme, but too few men are aware or make use of this.  Furthermore, too few GPs are aware of the Programme and are discouraged from promoting the PSA tests on the outdated grounds that it is inaccurate and that the “harms” of screening outweigh the benefits – lives saved!  Long-term PSA-based screening studies in Europe have now clearly demonstrated that regular PSA testing can cut the death rate from PCa by a half and that the number of men we need to screen to save a life is lower than all of the current NHS cancer screening programmes!

Screening & Early Diagnosis:  Who Needs Screening?
All men should know about their prostate gland because it causes so many problems, one of which is cancer.  International specialist urological panels recommend all men should start prostate cancer (PCa) screening from age 40, especially men at high risk.  These are:
 
  • Men in their 40s with an initial PSA ≥1.00ng/ml and men in their 50s with a PSA ≥2ng/ml.
  • Black men or mixed race men of African or Caribbean descent.
  • Men with a family history of PCa or breast or ovarian cancer on the mother’s side.
 Men below age 40 DO NOT need screening.  There is no statical evidence of benefit in screening elderly men with less than ten years’ life expectancy, so detailed counselling is necessary for such men requesting a PSA test.
 
PCa usually grows slowly and causes no symptoms till it has spread.  That is why screening needs to be done before symptoms arise whilst the cancer is still inside the prostate and curable.
 
Screening & Early Diagnosis:  How We Screen
Screening is done simply by the blood test PSA, a protein produced only by the prostate.  PSA is thus specific to the prostate but to no particular condition.
 
The NHS Prostate Cancer Risk Management Programme entitles all UK men over 50 to have an NHS PSA test which can be arranged by their GP.
 
About 1 in 4 men with a persistently raised PSA will have PCa and require specialist investigation.  The first specialist test should be an MRI scan of the prostate, though other blood or urine tests may be done before deciding upon an MRI.  If an MRI scan is normal, the risk of an aggressive PCa is very low.  If the scan shows an abnormality, the next step is a biopsy to obtain prostate tissue samples.  If no cancer is detected, the urologist will probably keep an eye on you for a year or two.  If PCa is detected, more scans may be performed to ensure the cancer has not spread.
 
Once all this data has been collected, treatment options will be recommended for you to make an informed choice on the treatment that suits you best.  Not all PCa needs active treatment but screen detected PCa confined to the prostate requiring treatment is nearly always curable and will not curtail your natural lifespan.

Screening & Early Diagnosis: The “Screening Programme”
Whilst a single random PSA might pick up PCa, the biggest benefit – 50% reduction in PCa mortality – can only be achieved by personal commitment to repeated PSA tests within a “Screening Programme” with the frequency of testing determined by risk.  CHAPS, like the majority of screening charities in the UK, uses a traffic light system of Green, Amber and Red to report PSA results:  Green for normal results, Amber for slightly abnormal and Red for clearly abnormal results.  What follows describes the process in detail.
 
Normal “Green” PSA Results

To attain the 50% falls in PCa mortality achieved by the best screening programmes in Europe and North America, your initial PSA is coupled to any risk factors such as a family history of PCa, and used to determine the frequency of future PSA testing within the Screening Programme.  We will therefore start supplying further recommendations on future PSA tests with appointments scheduled from 1 year up to 5 years:  one-yearly for men at high risk, two-yearly for men at intermediate risk and five-yearly for men at low risk.

 PSA tests should be continued in the Screening Programme until your mid-70s, ideally with reminders and appointments issued in due course as above.
 
For men already in their 70s or older who have no risk factors or who have a low, initial normal PSA, the risk of death from PCa is remote and such men can be reassured and discharged, no further PSA tests being necessary.
 
Borderline “Amber” PSA Results

Such results are marginally abnormal and depending on any additional risk factors, we will recommend a repeat test in 3 months’ time with precautions taken beforehand to ensure the PSA is not raised due to activities such as sex or cycling.

 If the follow-up PSA is still abnormal, we recommend referral to a specialist as outlined below for Red results.

 Abnormal “Red” ResultsRaised-PSA
When the PSA is abnormal, there is approximately a 1 in 4 chance that there is an underlying PCa.  Although the odds are clearly in favour of the raised PSA being due to something harmless, such as inflammation or benign enlargement of the prostate (prevalent after age 60), this obviously needs investigating by a specialist urologist.  A referral should then be made via the NHS “2 week wait” potential cancer criterion to a consultant urologist and investigations should proceed along the lines illustrated on the flowchart.
 

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