Dr Anthony Cunliffe, Dr Nicola Harker, and Sophia Nicola provide 10 top tips on the diagnosis and management of prostate cancer for primary care
Read this article to learn more about:
- how to identify individuals who are at risk of developing prostate cancer
- what investigations and treatments are available
- how to manage the adverse effects caused by prostate cancer treatment.
P rostate cancer is the most common cancer in UK men with around 50,000 new cases diagnosed each year. Incidence increases with age, with over one-half of new cases occurring in men aged over 70 years.1 Fortunately, most cases are diagnosed at an early stage, and the survival rate of prostate cancer is good (the 5-year survival rate is around 85%).2
General practitioners will often see men presenting with potential symptoms of prostate cancer, expressing concerns about developing prostate cancer, or requesting a prostate-specific antigen (PSA) test. With this in mind, it is important to be able to differentiate those patients who may be at higher risk of developing the disease.
1 Consider family history
A small percentage of prostate cancer cases (around 5–9%) are linked to family history.3 This is partly attributable to genetic factors, but may also be partly due to increased testing in families with a history of prostate cancer. When considering the family history of an individual with suspected prostate cancer, keep in mind:
- family members who have been diagnosed with prostate cancer at a young age
- one or more first-degree relatives with a diagnosis of prostate cancer.
Other factors to consider are:
- whether the person has the BRCA2 gene
- any history of breast cancer in female first-degree relatives3
- any family members with Lynch syndrome (hereditary nonpolyposis colon cancer).
No modifiable or preventable risk factors have been conclusively linked to prostate cancer.4
2 Consider ethnicity
Prostate cancer incidence varies significantly with ethnicity. Black African and Black Caribbean men are twice as likely to develop prostate cancer compared with white men, and may also develop it at an earlier age. As a result, the incidence and mortality rate of prostate cancer in Black African and Black Caribbean men is higher. It is important for GPs to be aware of this increased risk and communicate it, as appropriate, to their patients. Asian men are significantly less likely to develop the disease.5
3 Ask about specific symptoms
Prostate cancer may present with lower urinary tract symptoms (LUTS), including:
It may also present with impotence. Advanced prostate cancer may present with bone pain or weight loss.6 In 2015, NICE published NICE Guideline (NG) 12 on Suspected cancer: recognition and referral, which recommends that a digital rectal examination (DRE) and a PSA test should be considered when a man presents with any of the following: LUTS, visible haematuria, or erectile dysfunction (ED).7 This information can also be found in the Macmillan Cancer Support Rapid referral guidelines.8
4 Give clear information about the referral process
When referring a person for suspected prostate cancer, it is important to give them the appropriate Urgent Suspected Cancer Patient Information Leaflet (PIL). Robust safety netting for the referral is paramount to ensure that the person is seen. It can also be helpful to counsel the person on what to expect when they are seen at hospital.
5 Inform men on the potential side-effects of investigations
The majority of men with suspected prostate cancer will undergo a prostate biopsy, which may be transrectal or trans-perineal. Most men will have haematuria (usually mild) after the procedure, and this may last for up to 3 weeks. Around 80% of men will also have some mild rectal bleeding, but this should last only for 2–3 days, although it can sometimes persist for up to 2 weeks. Other side-effects following a biopsy include haematospermia (for up to 6 weeks), pain (usually settles within hours), or a urethral haematoma (can occasionally cause an obstruction and result in acute urinary retention). Patients are given prophylactic antibiotics before the biopsy but may come back to their GP with symptoms of infection, which may require further antibiotics.9
6 Know what treatments are available for prostate cancer
Decisions regarding treatment for prostate cancer can be complex and men need to be fully informed about their options, including the potential long-term consequences. General practitioners should have a good understanding of the available treatments and their adverse effects, as men with prostate cancer may want their GP to help with the decision making process.
Treatment options will depend on various factors including PSA level, Gleason score (this is based on the histological appearance of the biopsy), any evidence of the disease spreading, and the patient's performance status. These factors are used to 'risk stratify' the patient into low, intermediate, and high risk.6
Monitoring and surveillance
'Watchful waiting' (i.e. monitoring the cancer over the long term, and avoiding treatment until symptoms present) should be discussed with men who have localised disease and who decline curative treatment, or for those for whom it is decided that treatment is not appropriate. Many of these patients will not progress to receiving any other treatment.10
Low-risk patients (who are able to cope with treatments such as surgery or radiotherapy if required) should be offered 'active surveillance' as a treatment option, which involves monitoring the patient closely with regular PSA, DRE, and repeat MRI scans if there is any concern regarding progression of the disease.11 Radical treatment involving surgery or radiotherapy is delayed until there are signs that the cancer may be growing.
Surgery and radiotherapy
Those stratified to be at intermediate risk will also (in addition to monitoring/surveillance) be offered other treatments including brachytherapy, radical prostatectomy, and radical radiotherapy.6 It is very important that the patient is robustly counselled regarding the potential complications and consequences of these various active treatments (see tip 7 below) in order that he can make a truly informed treatment choice. There is a wealth of supporting information that can be offered to patients to help them in this decisionmaking process, including patient information from Prostate Cancer UK12 and Macmillan Cancer Support.13
Another treatment option in prostate cancer is hormone therapy, especially in men with metastatic or progressive disease. The most commonly used hormonal treatment is androgen deprivation therapy (ADT) in the form of a luteinising hormone-releasing hormone (LHRH) agonist. This treatment works by reducing the amount of testosterone produced by the testicles and is a preferable option for most men to bilateral orchidectomy.14 It is important to be aware that initially, testosterone can temporarily rise after starting treatment and cause an exacerbation of bone pain in those patients with metastatic disease, or potentially urinary retention.15 Androgen blockade with drugs such as bicalutamide is another option for hormonal treatment but is rarely used in isolation. Bicalutamide can be used in combination with LHRH agonists if single treatment is no longer effective, or on starting treatment to prevent the tumour flare described above.16,17 Another treatment that can be used for advanced prostate cancer is abiraterone, which reduces the amount of testosterone produced by the body and so can shrink prostate tumours. It may be used alone or alongside other hormonal treatments.18
7 Manage the side-effects and long-term effects of treatment
Men who have had radiotherapy for prostate cancer are at risk of long-term gastrointestinal (GI) consequences including bowel incontinence, rectal bleeding, urgency of defaecation, tenesmus, and flatulence. These symptoms can have a profoundly negative effect on a man's quality of life and it is vital that they are managed early and appropriately. All men who develop these symptoms following cancer treatment should be offered referral to a specialist service; however, Macmillan Cancer Support and the Royal College of General Practitioners have developed useful guidance detailing how practitioners can manage some of these symptoms within primary care.19 It can be useful to advise patients to obtain a radar key, which ensures they have access to all public disabled toilets, or a Macmillan toilet card discreetly explaining that they may need urgent access to facilities.20 General practitioners should also be alert to the possibility of other causes of GI symptoms including a colorectal malignancy.6
Urinary symptoms can also be a significant problem for men following surgery or radiotherapy and again can similarly impact on quality of life. Urinary incontinence is common, and up to 20% of men need to use incontinence aids following radical prostatectomy. The cause may be multifactorial and may involve bladder irritability, poor bladder compliance, or sphincter failure.21 Again, men who have any of these symptoms should be offered referral to a specialist service to ensure they receive appropriate advice regarding urinary containment options and, if the effect on quality of life is very significant, access to surgery.6
8 Manage the adverse effects of hormonal treatment
Hormone therapy can cause several side-effects—some of these, along with appropriate treatments, are listed below.
NICE CG175 recommends the use of medroxyprogesterone or, if this therapy is ineffective, cyproterone acetate to treat hot flushes caused by hormonal treatment.6 These treatments do not always work, and some men may want to explore the use of complementary therapies. If this is the case, they should be signposted to appropriate advice.22 NICE CG175 recommends that men are told there is no good evidence to support the use of complementary therapies.6
NICE CG175 recommends that practitioners should not routinely offer bisphosphonates prophylactically for men who are receiving ADT; however, practitioners should consider assessing for fracture risk, and offer bisphosphonates to all men diagnosed with osteoporosis.6
Men with sexual dysfunction should be treated as described in tip 9 below and potentially offered psychosexual counselling if available.6
Fatigue is a common problem and should be managed proactively.6 Physical activity is an important treatment for fatigue as well as having multiple other possible benefits including a positive effect on mood and weight gain.22 It could be incredibly useful to find out what local physical activity or exercise referral schemes are available in your area, and ensure that patients are informed about these.
Other potential side-effects include:
- cardiovascular events
9 Ask about erectile dysfunction
Erectile dysfunction is not only a potential symptom of prostate cancer, but it is also a common consequence of all treatments in both the short and long term. After surgery to remove the cancer, some degree of ED is likely; this may or may not recover over time depending on the extent of surgery. Following radiotherapy, the onset of symptoms may be more gradual but can persist over the long term. Erectile dysfunction is less common when radiotherapy treatment is more localised, and occurs less with brachytherapy than with radical radiotherapy.23 Most men have loss of libido and ED during hormonal therapy; in most cases, symptoms usually alleviate after treatment has been completed, but not always.18
Understandably, ED can have a significant impact on a man's quality of life and therefore should be discussed openly to ensure that the patient has access to all the available treatment options. All men should be offered an appropriate phosphodiesterase type 5 inhibitor and if they have little success with this, be referred to a specialist ED service.23
10 Understand PSA results and safety netting
It can be helpful to set up a system on the practice computers that allows clinicians to easily see what threshold a PSA result should trigger a referral back to a urology specialist. For example, after radical prostatectomy and radical radiotherapy, the patient should have a PSA of <0.1 ng/ml, so any rise in the PSA (even to 0.2 ng/ml) may be significant and hence should indicate a referral. In other patients who are under active surveillance, a PSA of 5.0 ng/ml may be considered stable.24 Some practice surgeries have a pop-up alert on the computer so that clinicians are aware if the patient is under active surveillance, and will alert the GP to the relevant PSA threshold for referral.
It is important to remember that some men with prostate disease may be on medications such as 5-alpha-reductase inhibitors, which can reduce PSA levels by about 50% and this needs to be considered when testing and monitoring PSA levels.25
Screening for prostate cancer is a highly debated topic due to limitations in the sensitivity and specificity of the PSA test, and also due to the potential harms of unnecessary investigations. In the UK, there is currently no formal screening programme. The Department of Health has developed the Prostate Cancer Risk Management Programme (PCRMP) for men aged over 50 years, which includes a pathway, see Figure 1, below. The programme aims to help ensure that the GP and the patient make robust, informed decisions regarding investigation for prostate cancer. A simple 2-page document to help GPs understand the programme is also available.26
In UK men, prostate cancer is the most common cancer, and the second most common cause of cancer death. General practitioners play a very important role in the diagnosis of the disease as early as possible, and an increasingly significant role in longterm monitoring and managing the long-term consequences of the cancer and the therapies used to treat it.
- Cancer Research UK. Prostate cancer incidence statistics. www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/incidence (accessed 14 February 2017).
- Cancer Research UK. Prostate cancer survival statistics. www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/survival (accessed 14 February 2017).
- Chen Y, Page J, Chen R, Giovannucci E. Family history of prostate and breast cancer and the risk of prostate cancer in the PSA era. Prostate 2008; 68 (14): 1582–1591.
- Cancer Research UK. Prostate cancer risk factors. www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/risk-factors (accessed 14 February 2017).
- Lloyd T, Hounsome L, Mehay A et al. Lifetime risk of being diagnosed with, or dying from, prostate cancer by major ethnic group in England 2008–2010. BMC Medicine 2015; 13: 171.
- NICE. Prostate cancer: diagnosis and management. NICE Clinical Guideline 175. NICE, 2014. Available at: www.nice.org.uk/cg175
- NICE. Suspected cancer: recognition and referral. NICE Guideline 12. NICE, 2015. Available at: www.nice.org.uk/ng12
- Macmillan Cancer Support. Rapid referral guidelines. Macmillan, 2015. Available at: www.macmillan.org.uk/documents/aboutus/health_professionals/pccl/rapidreferralguidelines.pdf
- Guy's and St Thomas' NHS Foundation Trust. Having a trans-rectal ultrasound (TRUS) and prostate biopsy. Available at: www.guysandstthomas.nhs.uk/resources/patient-information/urology/enlarged-prostate/trus.pdf
- Prostate Cancer UK. Watchful waiting. prostatecanceruk.org/prostate-information/treatments/watchful-waiting (accessed 14 February 2017).
- NICE. Prostate cancer: protocol for active surveillance—implementing the NICE guideline on prostate cancer. Clinical Guideline 175. Tools and resources. NICE, 2014. Available at: www.nice.org.uk/guidance/cg175/resources/protocol-for-active-surveillance-191674477
- Prostate Cancer UK. Treatment information. prostatecanceruk.org/prostate-information/treatments (accessed 14 February 2017).
- Macmillan Cancer Support. Prostate cancer. www.macmillan.org.uk/informationand-support/prostate-cancer (accessed 14 February 2017).
- Prostate Cancer UK. Hormone therapy. prostatecanceruk.org/prostate-information/treatments/hormone-therapy (accessed 14 February 2017).
- Thompson I. Flare associated with LHRH-agonist therapy. Rev Urol 2001; 3 (suppl 3): S10–S14.
- Kumar R, Barqawi A, Crawford D. Adverse events associated with hormonal therapy for prostate cancer. Rev Urol 2005; 7 (Suppl 5): S37–S43.
- Macmillan Cancer Support. Bicalutamide. www.macmillan.org.uk/cancerinformation/cancertreatment/treatmenttypes/hormonaltherapies/individualhormonaltherapies/bicalutamide.aspx (accessed 15 February 2017).
- Macmillan Cancer Support. Abiraterone acetate. www.macmillan.org.uk/cancerinformation/cancertreatment/treatmenttypes/hormonaltherapies/individualhormonaltherapies/abiraterone%20acetate.aspx (accessed 14 February 2017).
- Macmillan Cancer Support. Managing lower gastrointestinal problems after cancer treatment: a quick guide for healthcare professionals. Available at: www.rcgp.org.uk/clinical-and-research/toolkits/consequences-of-cancer-toolkit.aspx (accessed 14 February 2017).
- Be.Macmillan. Generic toilet card. be.macmillan.org.uk/be/p-22493-generic-toilet-card.aspx (accessed 14 February 2017).
- Doherty R, Almallah Z. Urinary incontinence after treatment for prostate cancer. BMJ 2011; 343: d6298.
- Prostate Cancer UK. How hormone therapy affects you. prostatecanceruk.org/prostate-information/living-with-prostate-cancer/how-hormone-therapy-affects-you (accessed 14 February 2017).
- Macmillan Cancer Support and Prostate Cancer UK. Treating erectile dysfunction after radical radiotherapy and androgen deprivation therapy (ADT) for prostate cancer. Available at: www.macmillan.org.uk/_images/supporting-men-with-erectile-disfunction-after-radiotherapy_tcm9-297844.pdf
- Prostate Cancer UK. The PSA test. prostatecanceruk.org/prostate-information/prostate-tests/psa-test (accessed 14 February 2017).
- Knezevich E, Knezevich J, Spangler M. Benign prostatic hyperplasia and the medication management of associated lower urinary tract symptoms—5-alphareductase inhibitors. www.medscape.com/viewarticle/745454_4 (accessed 14 February 2017).
- Public Health England. Advising well men aged 50 and over about the PSA test for prostate cancer: information for GPs. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/509193/Prostate_Summary_Sheet.pdfG