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Navigating the minefield: prostate cancer diagnosis and treatment

 - Risk factors and high-risk groups for developing prostate cancer

 - Screening and the role of prostate specific antigen (PSA) testing

 - Treatment and long-term outlook of the disease

 

Prostate cancer is the most common cancer in men. It kills more than 10,000 men every year and currently there are over a quarter of a million men living with the disease in the UK.1

Prostate cancer affects almost as many men as breast cancer affects women, but surveys indicate that awareness of the disease lags far behind. It is estimated that by 2030 prostate cancer will be the most common cancer overall, highlighting the urgency for more research and better diagnostic tests to ensure men aren't unnecessarily treated for cancers that may never cause them harm.

If diagnosed early enough, prostate cancer can often be successfully treated. But in many cases men don't experience any symptoms, which coupled with a distinct lack of awareness surrounding the disease has made detecting prostate cancer at an early stage incredibly difficult.

The lifetime risk of developing prostate cancer is one in eight for men overall in the UK,2 yet we still don't understand nearly enough about it. Research has been badly underfunded, the main tests can be unreliable, and treatments may result in damaging side effects.

Who's most at risk?

A man's risk of prostate cancer significantly increases with age, with the average age of diagnosis being between 70 and 74 years old.

Family history of the disease is another important risk factor. If your brother, father or uncle has had prostate cancer, you are two and a half times more likely to develop the disease yourself.

African and African Caribbean men are also more at risk, with one in four Black men predicted to develop prostate cancer in their lifetime. This is double the risk faced by all men in the UK.

The PSA debate

The prostate specific antigen (PSA) test has long been a contentious topic of debate when it comes to diagnosing prostate cancer. It can be a useful test but has specificity and reliability problems, which produces significant challenges for health professionals when it comes to informing men about PSA testing.

The blood test measures the total amount of PSA in a man's blood. A raised PSA level may indicate a problem with a man's prostate, but not necessarily prostate cancer. Similarly, some men with prostate cancer may not have a raised PSA at all.

There are some studies that suggest that introducing the PSA test to screen men over 50 for the disease could reduce the number of deaths. But this comes at the cost of diagnosing many more men with indolent cancer and exposing them to unnecessary treatment with the subsequent adverse impact on their quality of life.

In spite of these tensions it is still vital that nurses inform men about the risks of prostate cancer and help them to navigate their way through the complexities of the pros and cons of PSA testing.

Diagnosing and treating prostate cancer

There are a number of treatments for prostate cancer depending on the grade and stage of the cancer and the patient's age. Treatments include active surveillance to monitor low risk cancer, surgery to remove the prostate, radiotherapy, hormone therapy and watchful waiting for men who are unsuitable for radical treatment due to poor health. Many of these treatments can result in damaging side effects such as erectile dysfunction and incontinence, and many men may experience significant stress as they struggle to come to terms with the changes.

Over-diagnosis and over-treatment of prostate cancer is arguably one of the biggest challenges facing those with, or involved in, the management of the disease today. Current diagnostic tests can fail to distinguish between aggressive and non-aggressive forms of the disease, meaning that in some cases men are treated for cancers that may never cause them any harm. Acknowledging this, the National Institute for Health and Care Excellence (NICE) has recently issued a new set of guidelines which emphasise active surveillance as a viable option for men with low volume, slow-growing cancer.3

To this end, finding a test which can more accurately predict which cancers are more likely to spread is vital, and will save many men from enduring the unwelcome side effects of treatment unnecessarily.

Genetic testing is one promising area of research that could revolutionise how we diagnose and treat prostate cancer. A new study from the Institute of Cancer Research, mainly funded by Prostate Cancer UK, identified 13 gene mutations in known cancer genes that could predict the development of the disease. It suggested that screening men with a family history of prostate cancer for a range of these gene mutations could identify those who are at high risk of aggressive forms of the disease and therefore in need of close monitoring or more aggressive treatment. This was an early proof of concept study in a small number of men, all of who already had prostate cancer. Large trials are already underway to establish whether large scale genetic testing could improve the diagnosis and treatment of prostate cancer in practice. These are focused on the genetic mutations that have been shown to have the biggest impact on the risk of developing prostate cancer such as BRCA1 and BRCA2. This latest work suggests that, eventually, a panel of many mutations may need to be screened to maximise the impact of this kind of genetic screening.

Further research is still much needed. The launch of the UK's first ever Centres of Excellence in prostate cancer research were announced recently. The Movember Centres of Excellence, in partnership with Prostate Cancer UK, comprises Belfast-Manchester and the London Consortium, and will see an injection of £10 million over a five year period - the largest single investment into the disease by the partnership to date. The aim of the programme is to accelerate our understanding of the disease through innovative research and ensuring lab breakthroughs are translated into clinical benefits for men as quickly as possible. The centres will concentrate on developing new ways to distinguish between aggressive and non-aggressive forms of the disease, and on developing new treatments for men with advanced prostate cancer.

Nurses working in primary care and in the community have a valuable role to play in informing and supporting men who are at risk of, worried about, or suffering with prostate cancer. With the development of world-class research into prostate cancer in the UK, we look forward to the day when men receive the treatments they deserve.

Resources

Prostate Cancer UK - information for healthcare professionals
0800 074 8383

References

1.    Maddams J, Utley M, Møller H. Projections of cancer prevalence in the United Kingdom, 2010-2040. Br J Cancer 2012;25;107(7):1195-202.
2.    Prostate cancer incidence statistics: Lifetime risk. Cancer Research UK. 2010.
3.    National Institute for Health and Care Excellence (NICE). Prostate cancer: NICE clinical guideline 58.