by Dr Julian Hellig
Urologist
The month of Movember is an opportune time to ponder some pertinent points on prostate cancer.
Prostate cancer is the second most commonly diagnosed cancer in men. The incidence is set to rise and the disease, as well as treatment, is a significant cause of potential morbidity and mortality. Genetic predisposition, ethnic and cultural variations and access to healthcare all play a role. The goal is to diagnose and treat clinically significant cancer, which is defined by PSA (prostate specific antigen), digital rectal examination (DRE), Gleason score/ISUP grading, and MRI findings.
Prostate cancer screening is one of the most controversial topics in urological literature. Indiscriminate population-based screening has doubtful survival benefit and there is risk of harm from unnecessary biopsy and overtreatment of insignificant cancer. A life expectancy of 10-15 years is considered when deciding to screen and a risk-adapted screening strategy is required. The 2024 South African Prostate Cancer Guidelines provide an excellent summary.
It is important to note that PSA is not specific for cancer and there are several other causes of an elevated PSA other than cancer, such as prostatitis, acute urinary retention, instrumentation/urological procedures, recent ejaculation, a very large prostate and regular long bicycle rides. Useful adjuncts to PSA are free: total PSA ratio and PSA density.
Pre-biopsy multiparametric prostate MRI is beneficial as it identifies possible high-grade lesions for a targeted biopsy, has a high negative predictive value and facilitates staging when treatment is planned. DRE remains relevant although it has a low sensitivity and negative predictive value. An abnormal DRE has a 42% associated risk of cancer, and other peri-anal or rectal pathology may be detected. The transperineal route has become the preferred method for biopsy mainly due to the lower risk of sepsis.
Management options are based on patient and disease factors and include active surveillance, surgery (radical prostatectomy) and radiation (brachytherapy or external beam radiotherapy.)
Increasing use of advanced imaging such as MRI and PSMA-PET, artificial intelligence, risk calculators and biomarkers, genetic testing, focus on patient related outcomes and men’s health are all set to gain traction and will hopefully allow for improved overall outcomes.
