Prostate cancer

Prostate cancer is a malignant tumour arising from the epithelial cells of the prostate gland and represents one of the most common cancers affecting men worldwide. It predominantly occurs in men aged over 50 years, with incidence increasing significantly with advancing age.

Early-stage prostate cancer is frequently asymptomatic, and many cases are detected through screening using prostate-specific antigen (PSA) testing or digital rectal examination (DRE). Approximately 20% of patients present with systemic manifestations such as weight loss or bone pain due to metastatic disease.

The disease course ranges from indolent slow-growing tumours to aggressive metastatic cancer.

Risk Factors

Non-Modifiable Risk Factors

• Increasing age (>50 years)

• Family history of prostate cancer

• Genetic mutations (e.g., BRCA1, BRCA2)

• African ancestry

• Hormonal influences (androgen exposure)

Modifiable Risk Factors

• High-fat diet

• Obesity

• Sedentary lifestyle

• Smoking

• Chronic inflammation of the prostate

Signs and Symptoms

Localized Disease (Often Asymptomatic)

• Mild lower urinary tract symptoms (rare early)

• Weak urinary stream

• Hesitancy

• Nocturia

Locally Advanced Disease

• Urinary retention

• Hematuria

• Erectile dysfunction

• Pelvic discomfort

Metastatic Disease

• Bone pain (especially spine, pelvis, ribs)

• Pathological fractures

• Back pain due to spinal metastasis

• Weight loss

• Fatigue

• Lower limb lymphoedema from lymph node involvement

• Spinal cord compression symptoms

Diagnostic Criteria

Diagnosis requires clinical suspicion supported by investigations:

• Hard, irregular or nodular prostate on digital rectal examination

• Elevated serum PSA level

• Definitive confirmation by prostate core biopsy

Additional diagnostic considerations:

• Axial skeleton is the most common metastatic site

• Elevated PSA levels may be markedly high in metastatic disease

Investigations

Laboratory Investigations

• Serum Prostate Specific Antigen (PSA)

• Full blood count

• Renal function tests

• Liver function tests

• Alkaline phosphatase (elevated in bone metastases)

Imaging Studies

• Transrectal ultrasound (TRUS)

• Multiparametric MRI prostate

• CT scan abdomen and pelvis

• Bone scan for metastasis detection

• PET-CT (where available)

Histological Confirmation

• TRUS-guided prostate core biopsy

• Gleason scoring for tumour grading

Staging

Commonly staged using TNM classification:

• T – Tumour extent

• N – Lymph node involvement

• M – Metastasis

Risk stratification:

• Low risk

• Intermediate risk

• High risk

• Metastatic disease

Management

Management depends on:

• Cancer stage

• PSA level

• Gleason score

• Patient age

• Life expectancy

• Comorbidities

• Patient preference

Non-Pharmacological Management

1. Watchful Waiting

Indicated for:

• Elderly patients

• Limited life expectancy

• Low-risk disease

Focuses on symptom control rather than cure.

2. Active Surveillance

For:

• Low-risk localized cancer

• Life expectancy >10 years

Includes:

• Regular PSA monitoring

• Repeat biopsy

• Periodic MRI assessment

3. Radical Prostatectomy

Indicated for:

• Localized prostate cancer

• Life expectancy >10 years

Complications:

• Urinary incontinence

• Erectile dysfunction

4. Surgical Androgen Deprivation Therapy

Bilateral orchidectomy for advanced disease.

5. Radiotherapy

• External beam radiotherapy

• BrachytherapyUsed in localized or locally advanced disease.

Pharmacological Management

Medical Androgen Deprivation Therapy (ADT)

Indicated in:

• Advanced prostate cancer

• PSA >50 ng/ml

• Poorly differentiated tumours

• Patients unsuitable for surgery or radiotherapy

Luteinising Hormone Releasing Hormone (LHRH) Agonists

• Goserelin 3.6 mg subcutaneous every 4 weeksOR

• Goserelin 10.8 mg subcutaneous every 12 weeks

Mechanism:Suppresses testosterone production.

Anti-Androgen Therapy

• Bicalutamide 50–150 mg orally once daily

Often combined with LHRH therapy.

Castration-Resistant Prostate Cancer (CRPC)

When disease progresses despite androgen deprivation:

• Docetaxel 75 mg/m² IV every 3 weeks

Additional options (specialist level):

• Abiraterone

• Enzalutamide

• Cabazitaxel

Referral

All suspected or confirmed cases must be referred to:

• Urologist

• Oncologist

• Multidisciplinary cancer team

Urgent referral required for:

• Suspected spinal cord compression

• Pathological fractures

• Severe urinary obstruction

Complications

• Bone metastases

• Spinal cord compression

• Urinary obstruction

• Renal failure

• Erectile dysfunction

• Treatment-related metabolic complications

• Cancer-related cachexia

Prevention

Primary Prevention

• Healthy diet rich in vegetables and fruits

• Regular physical activity

• Weight control

• Smoking cessation

Secondary Prevention

• PSA screening in high-risk men (>50 years or >45 with family history)

• Early medical evaluation of urinary symptoms

Patient Education

Patients should be informed that:

• Early prostate cancer may have no symptoms.

• Regular screening improves early detection.

• Treatment choice depends on disease aggressiveness.

• Long-term follow-up is essential.

• Bone pain or neurological symptoms require urgent review.

Prognosis

Prognosis varies widely:

• Localized disease → excellent survival (>90% 5-year survival)

• Advanced metastatic disease → chronic controllable condition with therapy

Early detection significantly improves outcomes.