Prostate cancer is the most common cancer among men.
There are hereditary forms with predisposing genes: BRCA2 (most often with oncology at an early age).
If certain risk factors exist such as:
- family history of prostate cancer,
- ethnicity (African or Caribbean), in this case, cancer screening should be performed from the age of 45.
Otherwise, screening should be performed from the age of 50, with a general PSA test and rectal palpation.
Functional signs, such as frequent and difficult urination, are not characteristic signs of prostate cancer, but rather these may be signs of benign prostatic hyperplasia or a sign of inflammation / infection.
In case of an increased PSA level, in general > 4 in two doses and/or in case of suspected intraprostatic formation during rectal palpation, an MRI of the pelvis and prostate should be performed. If a multi-parameter MRI (T2 sequence) is performed before the biopsy, this can help to conduct a more accurate biopsy: targeted biopsies.
Radiologists describe suspicious areas using the latest version of the PIRADS (Prostate Reporting and Image Processing System) rating from 1 to 5: 1 normal, 2 probably normal, 3 doubtful or extremely doubtful, 4 suspicious and 5 very suspicious, MRI also evaluates capsule expansion T3a or involvement of seminal vesicles T3b.
A prostate biopsy is used to diagnose cancer, but most often it is an adenocarcinoma. Assessment of tumor aggressiveness is established by pathologists. Aggressiveness is estimated by points according to Gleason, from 6 points. Cancer with a good prognosis with a differentiated tumor, 7 points with an intermediate prognosis and 8, 9 points and 10 points with a poor prognosis and with an undifferentiated tumor.
A prognostic score (Amico score) is established in accordance with the initial total dose of PSA, Gleason score and rectal examination. Prostate Cancer:
- low risk: PSA <10 ng / ml and Gleason score ≤ 6 and clinical stage T1c or T2a;
- intermediate risk: PSA from 10 to 20 ng / ml or Gleason score 7 or stage T2b; medium low risk if the Gleason score is mostly 3, and high risk if the Gleason score is 4.
- high risk: PSA> 20 ng / ml or Gleason score ≥ 8 or clinical stage T2c.
An extended assessment is performed for prostate cancer with an intermediate prognosis and a high-risk prognosis with CT of the entire body (chest, abdomen, and pelvis) and bone scintigraphy.
PET with choline or PSMA is recommended only if PSA is elevated (PSA> 2) after local treatment. This helps to locate the recurrence: local, when the lymph node is affected, or the metastatic process, when the tumor has spread to other organs.
The choice of treatment is confirmed at a multidisciplinary coordination meeting of doctors
Several options for the treatment of prostate cancer can be offered: active monitoring is offered to patients with an anticipated life expectancy of more than 10 years, with low-risk prostate cancer, an Amico score, and low tumor burden (from 1 to 3).
Radical or complete prostatectomy is offered to patients whose life expectancy is more than 10 years with localized or locally advanced prostate cancer (damage to the pelvic lymph nodes).
The prostate and seminal vesicles are removed, and ileum lymph nodes are dissected for moderate to high risk cancer.
Surgery is not necessary for patients at low risk because lymph node invasion is rare.
There are various surgical approaches: open retropubic surgery, perineal, laparoscopic or robotic.
Possible side effects of surgery are:
External radiotherapy consists of irradiating the prostate, seminal vesicles and, in some cases, pelvic lymph nodes under screening control.
As a method of radiation therapy, intensity modulation (modulated volumetric arc therapy) is used. A total dose of 76-78 Gy for 38-39 sessions can be offered, 1 session per day, 5 sessions per week for 8 weeks. There are also shorter regimens, known as hypo fractional, which are intended for treatment in 20 sessions of cancer, performed in case of a good or intermediate prognosis for 4 weeks. For cancer with a good prognosis, Gleason 6, stereotactic radiation therapy can be offered for a week in 5 procedures.
- temporary urinary incontinence,
- erectile dysfunction,
Possible side effects of radiotherapy are:
- transient cystitis,
- erectile dysfunction (aggravated while taking hormonal therapy),
- proctitis (accelerated intestinal transit, diarrhea, or rectal bleeding).
Radiation therapy can be combined with short-term hormone therapy for 6 months.
Anti-hormonal treatment consists of an LH-RH agonist or antagonist, such as triptorelin, together with antiandrogens, for cancer with medium risk, for long-term cancer (from 18 months to 36 years) or with a high risk of progression.
For cancer with a good prognosis, it makes no sense to combine antihormonal treatment. Brachytherapy is indicated for patients with localized prostate cancer and a low risk of developing on the Amico scale with an estimated life expectancy of more than 10 years.
It consists of irradiation of the prostate by implantation of iodine 125 grains.
Focused ultrasound or HIFU is a treatment that is also proposed for good prognosis cancer (gleason 6).
Side effects of anti-hormonal treatment are:
- decreased libido,
- erectile dysfunction,
- hot flashes,
- weight gain.
Second generation antihormonal therapy may be suggested for patients resistant to chemical or metastatic castration.
Abiraterone acetate or Zytiga, an inhibitor of the synthesis of androgens or Xtandi (enzalutamide). An oncologist may also suggest chemotherapy (Taxotere or Cabazitaxel or Jevtana type), especially in case of visceral metastases. Apalutamide is indicated for the treatment of men with non-metastatic castration-resistant prostate cancer.