Prostate cancer

Overview

Prostate cancer is the most common malignancy in men in the UK and the second most common cause of cancer death in males. Most cases are indolent; a clinically important minority are aggressive with bone metastases.

Presentation

•Localised - often asymptomatic; incidental raised PSA

•LUTS (hesitancy, poor stream, frequency, nocturia) - only when tumour extends centrally or coexists with BPH

•Haematuria / haematospermia

•Bone pain - lower back, pelvis, hips from osteoblastic metastases

•Pathological fracture - bone metastases weaken cortical integrity

•Cauda equina syndrome - back pain with bilateral leg weakness, saddle anaesthesia, bowel/bladder dysfunction from vertebral metastasis

🚨

Cauda equina syndrome in a man with known or suspected prostate cancer = spinal cord/cauda equina compression from vertebral metastasis. This is a surgical emergency.

Investigations

•PSA - serum glycoprotein; raised >4.5 ng/mL in the 60-69 age group warrants urgent referral (thresholds vary by age); high false-positive rate (~75%), false-negative rate (~15%)

•DRE - hard, irregular, or nodular prostate is suspicious; urgent 2-week-wait referral if hard/nodular or PSA exceeds age-specific threshold

•Multiparametric MRI (mpMRI) - first-line staging investigation in secondary care before biopsy; identifies clinically significant lesions and guides biopsy

•Prostate biopsy (transperineal preferred) - histological confirmation and Gleason grade - gold standard

•Bone scan / CT / PSMA PET-CT - staging for intermediate/high-risk disease

⚠️

PSA is prostate-specific, NOT cancer-specific. Other causes of raised PSA: BPH, prostatitis/UTI, recent ejaculation or prostate stimulation, vigorous exercise (especially cycling). Avoid these confounders in the 48 hours before testing.

Management

•Led by urology MDT; approach is stage- and risk-stratified

•Active surveillance - intensive monitoring with curative intent; treat if progression detected (not palliative)

•Watchful waiting - palliative approach in older men with significant comorbidity; aim is symptom management, not cure

•Radical prostatectomy or external beam radiotherapy - for localised/locally advanced disease with curative intent

•ADT (androgen deprivation therapy) - combined with radiotherapy for higher-risk disease; also used in metastatic disease

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Active surveillance ≠ watchful waiting. Active surveillance is curative intent with planned treatment on progression. Watchful waiting is palliative in men where cure is not the goal.

Complications

•Bone metastases - pain, pathological fractures, hypercalcaemia

•Spinal cord/cauda equina compression - oncological emergency; urgent steroids and neurosurgical/oncological input

•Ureteric obstruction and hydronephrosis - local tumour extension

•Radical prostatectomy - urinary incontinence, erectile dysfunction (neurovascular bundle damage)

•ADT - hot flushes, osteoporosis, metabolic syndrome, loss of libido, anaemia

•Castration-resistant prostate cancer (CRPC) - progression despite ADT; marks more aggressive disease phase

Prognosis

•Localised - 5-year survival >95%

•Locally advanced - 5-year survival ~70-80% with radical treatment

•Metastatic - median survival 2-3 years

•Many elderly men die with prostate cancer rather than from it

Key facts

•~47,600 new cases/year in the UK; ~11,600 deaths/year

•Most common age at diagnosis: 65-69 years; >50% in men aged 70+

•95% are adenocarcinomas arising from the peripheral zone - away from the urethra, so early disease causes no urinary symptoms

•Androgen-dependent tumours - basis for androgen deprivation therapy (ADT)

•Metastases are characteristically osteoblastic (sclerotic) - axial skeleton (lumbar spine, pelvis, ribs)

Grading

•Gleason score - two most prevalent architectural patterns each scored 1-5 (most to least differentiated), summed (e.g. 3+4=7); higher = more aggressive

•Maps to Cambridge Prognostic Groups (CPG 1-5) combining PSA, Gleason score, and clinical stage