Prostate Cancer

Prostate is a walnut-sized gland in the male reproduction system, located between the bladder neck and the urinary passage (urethra). Prostate secretes whitish fluid that nourishes and transports sperm; when mixed with sperm, the fluid becomes semen. Male hormone secreted by testicles directly affects the growth and functions of prostate.

Swollen prostates are common among middle aged and elderly males but most of the cases are benign hyperplasia (abnormal increase in number of cells). When there are abnormal genetic mutations, malignant tumours may develop in the prostate, causing prostate cancer. Prostate cancer may spread to other parts of the body, particularly the bones and lymph nodes in the pelvis.

High risk factors of prostate cancer include:

• Aged over 50.
• Males with family history of prostate cancer.
• Prolonged intake of food with high calorie and high fat.
• Smoking, over-weighted and prostate diseases, etc.

Most prostate cancers are slow growing, which may exist in patients’ bodies for years without being detected. Often there is no obvious symptom at the early stages. However, if one or more of the following symptoms appear, it may represent the gradual growth in cancer tumour or metastasis.

• Passing urine more often than usual, especially at night.
• Difficulty in passing urine.
• Pain on passing urine.
• Blood in the urine or semen.
• Pain in the pelvis or spine, swelling in legs.

As symptoms above are very similar to those of prostate enlargement, patients should consult doctor as soon as possible for diagnosis. Pain in pelvis, back or hips suggest advanced disease with tumour spreading to other sites.

The causes for prostate cancer are not yet fully understood. However, several risk factors for prostate cancer are identified, which include advancing age, a family history of prostate cancer (especially in first-degree relatives like father, brother or son), being African American and obesity.

In general, adopting a healthy lifestyle (e.g. regular physical activities, maintaining a healthy body weight and waist circumference, having well balanced diet and avoiding smoking and alcohol consumption) may lower risk of prostate cancer.

Two common screening tests for prostate cancer are digital rectal examination (“DRE”) and prostate-specific antigen (“PSA”) test. If the screening test is abnormal, further diagnostic investigation is needed. DRE and PSA test have their limitations and they are not 100% accurate. One should discuss with the doctor about the benefits and potential risks about screening to make an informed choice.

Asymptomatic individuals at average risk

• At present, there is insufficient scientific evidence to recommend for or against population-based prostate cancer screening for asymptomatic men in Hong Kong.

Increased risk individuals

• Men at increased risk of prostate cancer (e.g. with first-degree relative diagnosed with prostate cancer before the age of 65) should consider seeking advice from doctors about their screening need and approach. The PSA test should start at an age not earlier than 45 until 70, and the interval should not be more frequent than once every two years.

For proper diagnosis of prostate cancer, doctors may need to perform one or more of the following examinations:

1. anchor

   Digital rectal examination

   The doctor will insert his gloved finger into the patient’s rectum to check for any abnormal enlargement or hardening.

2. anchor

   Blood test

   Blood prostate-specific antigen (PSA) might be elevated in prostate cancer. However, it could also be abnormally high in other conditions such as inflammation of prostate gland, benign prostate enlargement, etc.

3. anchor

   Ultrasound scan and biopsy

   A small ultrasound probe will be inserted into the rectum to measure the size and detect abnormality of the prostate. Tissue samples can also be obtained through needle biopsies for further microscopic examination.

4. anchor

   Biopsy

   The doctor will insert a needle into the prostate and obtain biopsies for further examination to check if it is benign or malignant.

5. anchor

   Endoscope examination of the urinary bladder

   Once the diagnosis of prostate cancer is confirmed, the following additional tests may be needed in some patients:

   • Bone X-ray and/or bone scan.
   • Pelvic ultrasound and/or computer tomography (CT) scan, magnetic resonance imaging scan (MRI).
   • PET Scan.
   • Chest X-ray.

If a patient is diagnosed with localized prostate cancer, choices for treatments will depend on the estimated tumour growth rate, extent of disease, age and medical conditions of the patient:

1. anchor

   Early stage of prostate cancer – small localized tumours without invading surrounding tissues

   The prostate and surrounding lymph nodes will be removed in surgery (prostectomy).The resection can be done through conventional incisions or newer laparoscopic approach. After surgery, the patient may have some risk of urinary incontinence and impotence. External radiotherapy and internal radiotherapy (brachytherapy) are viable alternatives with similar treatment outcomes.

   For elderly patients or those with chronic ill health, especially those with early slow-growing tumours with no significant discomfort, doctors may recommend only regular monitoring (i.e. “wait and see”) and no specific treatment. It is because some prostate cancer cells can grow very slowly and will not threaten the patient’s life in the near term.

2. anchor

   Intermediate stage of prostate cancer – more extensive disease with invasion of surrounding tissues

   The usual treatment is external radiotherapy, often used together with hormonal therapy to improve the treatment outcome.

3. anchor

   Advanced stage of prostate cancer – cancer cells have spread to bones or other distant organs

   The main treatment is hormonal therapy (androgen deprivation treatment) by either surgical removal of testicles or medication. The rationale is to control the growth of prostate cancer by suppressing the male hormone levels. This treatment may control the growth of cancer cells for a few years and relieve the discomfort and pain. For tumours resistant to ongoing hormonal treatment, chemotherapy and oral novel hormonal agents can relieve symptoms and control tumour growth. Studies have found that during the initiation of hormonal therapy, the additional use of chemotherapy or oral novel hormone agents in selected patients; or prostate radiotherapy in patients with low disease burden, can further improve the treatment efficacy and disease outcome.

If prostate cancer is not properly controlled, the condition may worsen and result in the followings:

• Prostate cancer may spread along lymphatic vessels to the surrounding lymph nodes and then bones or other distant organs.
• If cancer cells invade the bones, patients may suffer from severe pain.

Patients of prostate cancer may also suffer from the following complications caused by treatments:

• Incontinence of urine.
• Impotence (inability to get and maintain an erection sufficient for a satisfactory sexual intercourse).
• Radiotherapy usually cause rectum and bladder bleeding or ulcer.

Before and after surgery and during recovery, patients should keep the following in mind:

• Pay attention to diet and reduce intake of fat.
• Moderate daily exercise helps maintain a healthy body by strengthening immunity and reducing the chance of recurrence.
• Weight management for obese patients, which helps maintain the health of the heart.
• Maintain sexual contacts with partner, patients with impotence may express themselves by embracing and touching their partners.

• Cancerinformation.com.hk
• Hong Kong Cancer Fund
• Hong Kong Cancer Registry
• The Hong Kong Anti-Cancer Society
• The Hong Kong Society for Rehabilitation

1. Introduction

   Transrectal prostate biopsy is recommended if patients are suspected to have prostate cancer. It is an invasive procedure with potential complication. The procedure is suitable for patient with clinical suspicion of carcinoma of prostate, palpable prostate nodule on digital rectal examination, elevated serum level of prostatic specific antigen (PSA) or re-staging carcinoma of prostate. However, a negative biopsy does not completely rule out the possibility of the disease.

2. Preparation before the procedure

   • Inform the doctor if taking drugs that affect blood coagulation, such as Aspirin or Warfarin, as these drugs may need to be stopped few days before the procedure.
   • Before the procedure, it would be useful to inform the doctor if there are any symptoms of urinary tract infection, such as fever and painful voiding.

3. The procedure

   Before the procedure, the patient will be given medication to clear the rectum and antibiotic prophylaxis. The procedure usually takes 10 to 15 minutes. An ultrasound sensor is passed into the rectum, and a thin needle is inserted through the rectum under ultrasound guidance to take tissue sample of your prostate. Doctors usually collect multiple samples, which are sent for laboratory testing.

4. After the procedure

   • Patients are advised to drink plenty of fluid over the next few days. Patients may find blood in urine, faeces or semen after the procedure.
   • If significant bleeding occurs, or if fever develops, medical attention is needed.

5. Risks and complications

   The procedure may cause the following:

   • Life-threatening septicaemia (<1%).
   • Infection of the urinary tract (1-5%).
   • Bleeding from rectum.
   • Blood-stained urine (can last up to 1 to 2 weeks).
   • Blood-stained semen (can last up to 6 weeks).
   • Difficulty in passing urine or urinary retention (acute inability to urinate with lower abdominal pain that requires emergency medical attention).

6. Follow-up

   Patients will be discharged when considered appropriate. If fever or other serious events develop after discharge, patients should seek medical advice at the nearest Accident and Emergency Department.

7. Remarks

   For further information, please contact your doctor.

1. Introduction

   When suspecting a prostate cancer, the doctor may suggest a transperineal ultrasound-guided prostate needle biopsy for the patient. It is an invasive procedure to diagnose prostate cancer. The procedure is suitable for patient with clinical suspicious of prostate cancer, digital rectal examination shows prostate nodule, elevated serum prostate specific antigen (PSA) level or re-staging of a known prostate cancer. However, negative result cannot completely rule out the possibility of prostate cancer.

2. Preparation before procedure

   • Inform the doctor if taking drugs that affect blood clotting, such as Warfarin or Aspirin, as these drugs may need to be stopped few days before the procedure.
   • If there are symptoms of urinary tract infection such as fever or dysuria before the examination, it is also advisable to report the symptoms to the doctor.

3. The procedure

   Before the transperineal ultrasound-guided prostate needle biopsy, the patient will be given medication to clear the rectum and antibiotic prophylaxis. After placing the ultrasound probe into the rectum, the doctor obtains multiple biopsies from the prostate through perineum. The whole procedure takes about 10 to 15 minutes.

4. After the procedure

   • On the same day after the procedure, the patient can be discharged if stable with one-day course of antibiotic and anti-pyrexia medication. Drink more water if there is no contraindication.
   • Haematuria and haematospermia may occur as charted above. If severe bleeding, fever or other symptoms occurs, consult your doctor or visit the Accident and Emergency Department nearby.

5. Risks and complications

   The procedure may cause the following:

   • Life-threatening sepsis (0.1%).
   • Urinary tract infection (1%).
   • Haematuria (may last for 10 days).
   • Haematospermia (may last for 6 weeks).
   • Difficulty in passing urine or urinary retention (acute inability to urinate with lower abdominal pain and require emergency medical care) (5%).
   • Mild perineal bruising or swelling (10%).
   • Short-term erectile dysfunction (5%).

6. Follow-up

   The patient will be given a follow-up date to review the pathology of prostate biopsies.

7. Remarks

   For further information, please contact your doctor.

1. Introduction

   Radical prostatectomy is one of the curative treatment options for early stage prostate cancer. The procedure could be done with open abdominal surgery, laparoscopically (with or without robotic assistance), or through a perineal operation.

   The aim of the surgery is to remove the entire prostate gland with the cancerous part. Sometimes the regional lymph nodes are removed in the same operation. Both open surgery and laparoscopic surgery can achieve comparable and satisfactory cancer control. The complication rate and recovery are also similar. The blood loss in laparoscopic surgery is usually less and the recovery is sometimes quicker in certain patients. However, not every patient is suitable for the laparoscopic approach. Patients should discuss with their surgeons for the most suitable surgical approach.

2. Preparation before the procedure

   • Blood tests and other checkup would be done before the surgery to make sure the patient’s body condition is fit for general anesthesia and the major surgery.
   • Sometimes, cleaning up the bowel is necessary and the patient would be required to drink laxative fluid or would be given suppositories.
   • Generally, the patient is advised not to eat or drink for at least 6 hours before the surgery.

3. The procedure

   • Despite the different possible approaches for the operation, the procedure within the body is very similar.
   • During the operation, the regional lymph nodes may be removed and sent for histological exam if indicated. The surgery may be stopped if the lymph nodes are found to harbor cancer cells and alternative treatment may be offered instead of proceeding with this curative surgery.
   • Then the entire prostate gland together with the seminal vesicles is removed. The bladder is sutured back to the residual part of urethra.
   • By the end of the surgery, it is usual for surgeons to put in a urethral catheter to drain the bladder and a surgical drain around the site of surgical resection.
   • Open abdominal surgery involves using a lower abdominal wound or a perineal wound for the procedure depicted above.
   • In laparoscopic and robotic-assisted laparoscopic approach, 5-6 small incisions are made over the umbilicus and the lower abdomen to allow the entry of the laparoscope and other instruments.

4. After the procedure

   • Sometimes intensive care may be required after this major surgery.
   • The urethral catheter and the surgical drain would be kept for a few days to a few weeks, depending on the condition of recovery.

5. Risk and complication

   • Peri-operative Complications:
     • Anaesthetic complications and complications caused by pre-existing diseases.
     • Systemic life threatening complication including myocardial infarction, cerebral vascular accident, deep vein thrombosis and pulmonary embolism.
     • Bleeding requiring massive transfusion.
     • Injury to adjacent organs including ureter, rectum, bowel, and pelvic nerves and vessels.
     • Anastomotic leakage or urinary leakage with or without intra-abdominal abscess and sepsis, requiring further surgical interventions including colostomy.
     • Bowel obstruction or ileus.
     • Urinary tract infection, chest infection, wound infection causing life threatening septicemia
     • For laparoscopic surgery (with or without robot assistance), special risks include: Fatal gas embolism and hypercarbia (<1%); Postoperative crepitus (popping or crackling sound under the skin) and pneumothorax; conversion to open surgery.
   • Post-operative Complication:
     • Various degree of urinary incontinence (~5-15% after one year).
     • Anastomotic stricture and urethral stricture (<10%).
     • Positive resection margin (refers to cancer cells being found at the edge or border of the tissue removed in cancer surgery, indicating the possibility of metastasis or cancer recurrence).
     • Erectile dysfunction.
     • Loss of ejaculation and infertility (normal consequence).
     • Fecal incontinence in perineal approach.
     • Wound dehiscence and hernia formation.
     • Further intervention including operation for management of complications, positive resection margin and tumour recurrence.
     • Mortality related to tumour surgery or pre-existing diseases (0.5-2%).

6. Remarks

   For further information, please contact your doctor.