Assessments and treatments

The PSA is an enzyme made by the prostate as a component of the sperm fluid. The test measures the PSA concentration in the blood stream as it can leak from the prostate into the blood vessels. It can be raised for various reasons:

Prostate enlargement – the level rises slowly over time whilst the prostate grows due to age (called Benign Prostatic Enlargement (BPE or BPH))

Prostate inflammation or infection – the level rises steeply during the infection and then drops back to normal levels after recovery

Prostate cancer – the level rises steeper when the cancer starts to accelerate.

The following normal values are a vague guidance:

Age - PSA

40-49 years - less than 2ng/ml

50-59 - less than 3ng/ml

60-69 - less than 4ng/ml

over 70 - less than 6ng/ml or more

PSA can also provide good information when used with prostate size (PSA density; PSA/prostate volume in ccm or ml; less than 0.1 is good) or when used in repeat measurements over time (PSA doubling time or velocity).

At Addenbrooke’s Hospital is leading in the introduction and use of imaging and technology-based assessment.

An MRI (magnetic resonance imaging) scan uses strong magnetic fields and radio waves to produce a detailed image of the inside of the body. An MRI scan is often used in patients with suspicion of prostate cancer, to see whether the cancer is sizable and worthwhile taking a targeted biopsy of. The MRI also shows if there is spread into the tissues around the prostate gland or into the lymph nodes near the prostate.

In Cambridge we have access to the latest high quality multi-parametric 3 Tesla MRI which gives the best images.  Our radiologists are one of the leading groups in the world in interpretation of these images and together with collaborators from Europe and the UK teach other radiologists in this highly skilled practice.

The scan is painless and can take about 30 minutes. During the test you will be asked to lie very still on a couch inside a metal cylinder. It can be slightly uncomfortable and some people feel a bit claustrophobic during the scan. It is also very noisy. You will be given earplugs or headphones to wear.

It is not possible for you to have an MRI scan if you have any metal in your body, such as a pacemaker or certain types of surgical clips.

Men will almost always need to undergo a prostate biopsy in order to establish the diagnosis of prostate cancer. From the above assessment we will establish the need for biopsies.

At Addenbrooke’s Hospital is leading in the introduction and use of imaging and technology-based assessment and we are proud to offer our patients the most comprehensive choice of biopsy techniques and technology:

Transrectal prostate biopsies using:

• MRI Fusion or visual targeting technology
• Systematic 12-core

Transperineal prostate biopsies under local or general anaesthesia using:

• MRI Fusion or visual targeting technology
• Systematic 12 to 24-core distribution (Ginsburg standards)

The biopsy involves taking several cores of prostate tissue using an ultrasound probe placed in the rectum. The needles are either inserted through the rectum wall (transrectal) or the skin between scrotum and anus (transperineal). This can be done either under local or general anaesthetic. An MRI performed before the biopsy may guide the needle either with fusion technology or by the eye of the surgeon. Using MR image guidance we have achieved some of the highest prostate cancer detection rates in the world.

The biopsy will give information such as the grade of the tumour (how aggressive the cancer looks), which is called the Grade group or Gleason score.

Further tests may then need to be done to determine the stage of the disease, and these might include a MRI scan or bone scan.

There may be a number of suitable treatments, and for patients with suitable disease, these might include:

• Active Surveillance and Watchful monitoring
• Radical Prostatectomy (using the da Vinci TM Robot)
• Radical Radiotherapy (IMRT)
• Brachytherapy (Whole-gland, Focal and Boost)
• Hormonal treatment (suppression or blocking of testosterone)
• Chemotherapy (incl. tablet-agents with minimal side-effects)
• Palliative measures

This describes one method of management where we carry out frequent, careful observation of your prostate gland. The reason we sometimes recommend this method of management is because not all cancers are at high risk of progression.

The rationale is that, if a cancer does not progress on monitoring, you will not need more radical forms of treatment and thereby you avoid the side-effects which will affect quality of life.

In younger men we carry out PSA measurements, MR imaging and further biopsies over time to ensure the cancer has not changed in nature. This is then known as active surveillance/monitoring. Treatment with an intervention only need be commenced when tumour progression is proven. The cure rates are the same. The advantage of active monitoring is that it involves no aggressive intervention and there are, of course, no side-effects. MRI and PSA level are used to predict if a tumour has grown and sometimes further biopsies of the prostate gland are required.

In more elderly men with cancers without symptoms, the risks are very low and watchful monitoring can be a very good form of treatment. This can often be performed by the GP with a general assessment and a PSA test.

At the Robotic Prostatectomy Centre Cambridge we offer robotically assisted laparoscopic radical prostatectomy, also known as robotic prostatectomy. This has the advantages over traditional open prostatectomy of shorter hospital stay, less pain,less risk of infection,less blood loss and transfusions, less scarring, faster recovery and quicker return to normal activities.

Robotic prostatectomy can be used in patients with any prostate cancer which is within the prostate or has just breached the capsule.

Robotic prostatectomy involves the insertion of five small openings (ports) in the abdominal wall, each around 1-2 cm in length. Through these ports, a variety of different instruments can be introduced to allow clear visualisation of the prostate and careful manipulation by the surgeon on the 3D-computer console.

We will give you a detailed information sheet about the operation of robotic prostatectomy if this is what you decide to have done.

Our Results for Robotic Prostatectomy

We have now done over 1000 operations and have been impressed with our initial results. The cancer removing results have been good in that less than 15% of men have had what we call a positive margin. The risks of positive margins are dependent on the stage and grade of the cancer.

The average length of stay has been less than 24 hours after the operation, with over 80% of men going home after the first post-operative day. Less than 1.5% of men have required a blood transfusion. In our hands, recovery time has been much improved over open surgery.

In addition we have been able to preserve the delicate neurovascular tissue around the prostate; we believe this will improve the ability of patients to retain erectile function (still some effects seen in 80% of patients) and a sense of orgasm after the operation. Our continence rate is high and comparable with the published literature.

Brachytherapy and Radiotherapy can be delivered as single treatments or, if indicated as combination treatments to optimise the cancer cure and minimise side-effects.

Brachytherapy has been offered at Addenbrooke’s for almost 10 years, lead by Dr Simon Russell (Clinical Oncologists), Mr Andrew Doble and Mr Christof Kastner (Consultant Urologists). We are one of the highest volume centres in the UK with one of the best outcomes. We are reference and training centre for this specific technique and technology (Elekta).

Brachytherapy is a good form of treatment in a man with low to intermediate risk prostate cancer which has taken less than half the gland.

We would only advise Focal Therapy using our brachytherapy technique for prostate cancer which only occurs in a single limited area of the gland identified by MRI and transperineal biopsies. The aim would be provide a curative treatment with minimal or no side-effects.

Brachytherapy can also be given to boost radiotherapy and provide stronger doses with minimal side-effects.

Brachytherapy involves a single day stay and is performed under a general anaesthetic. Patient’s with urinary symptoms may benefit from a limited de-obstructing procedure to the prostate (by Holmium Laser / HoLEP) prior to their brachytherapy. Side-effects are minor and reversible.

A number of seeds are placed throughout the prostate gland under ultrasound control using a sophisticated software based planning system and highly accurate automated delivery (Elekta). These seeds contain radioactivity and provide a high local dose of radiation to the prostate gland minimizing the side-effects to adjacent tissue.

The main side-effects are increased lower urinary tract symptoms and erection problems in about 40% of men. Most side-effects are temporary.

This involves a total of up to 37 treatments over several weeks with the radiotherapy being given in low doses to minimise side effects.

Sometimes we advise you to have three months of hormone treatment before starting the radiotherapy in order to shrink the prostate gland and to improve the effectiveness of the radiotherapy. In men with higher risk cancers, hormonal treatment is continued for 12 to 24 months after the radiotherapy is completed.

Once again if you wish to have further information about this we will provide you with a detailed information sheet.

In general terms, radiotherapy, can be an effective treatment in men with early to locally advanced prostate cancer. It has side effects, including irritation to the bladder (blood in the urine), bowel (rectal bleeding) and impotence (80%). These are usually mild in nature and frequently settle after a period of time. More severe, permanent, side-effects occur in about 5-10% of people.

There is increasing evidence that surgery and radiotherapy can be a good treatment for men with more locally-advanced or high risk cancers. Both is offered here in Cambridge. Surgery is accompanied by extended resection of local lymph nodes. It has become clear that surgical treatment can offer continued and sustained cure rates in such patients even if they require radiotherapy post-operatively. External beam radiotherapy with hormonal manipulation is carried out with high accuracy.

For high-risk prostate cancer almost always a combination of both options is most effective.

There is good evidence from randomised clinical trials that following radical prostate surgery for more locally aggressive cancers, a short course of radiotherapy has minimal side-effects but improves the long-term outcome of surgical treatment. Usually we offer careful PSA monitoring under such circumstances.

In cancers which have spread to other areas of the body, treatment of the prostate alone is not helpful in most of the cases.

In those cases, reduction of testosterone levels or its connectors to the tumour cells is a good treatment to keep the tumour at bay and stop its progression for a good period of time.

Similarly chemotherapy, which can now be given as tablets can extent the time the tumour can be controlled. Usually these have only minor side-effects.

Please read our information leaflet on these agents.