Guide to prostate cancer care… The most diagnosed cancer in Britain

Your guide to the best prostate cancer care… As it becomes the most diagnosed cancer in Britain, this is what every man (and his other half) should read

Prostate cancer is the most common cancer in men, with more than 47,500 new cases in the UK each year.

Now ground-breaking research, together with greater awareness — highlighted by the Daily Mail’s End The Needless Prostate Deaths campaign — is changing the outlook for men with the condition. The latest figures suggest it is the most commonly diagnosed cancer, ahead of breast and lung cancers.

‘For many years, prostate cancer was a neglected form of the disease but UK scientists are leading the way in prostate cancer research,’ says David Montgomery, director of research at the charity Prostate Cancer UK.

Today, men with the disease are living longer, with fewer side-effects than ever, thanks to advances in detection and more precise methods used to target it.

Research this week revealed genetic screening could spot thousands of cases of prostate cancer that would otherwise go unnoticed until it is too late.

Today, men with the disease are living longer, with fewer side-effects than ever, thanks to advances in detection and more precise methods used to target it

The study at the Institute of Cancer Research, presented at the American Society of Clinical Oncology conference, found DNA testing in GP surgeries identified the disease in a third of apparently healthy men. A larger study is planned.

And in some rare good news from the lockdown, it was recently announced that for three months men with advanced prostate cancer will be given hormone treatment tablets to take at home instead of going to hospital for chemotherapy. Experts have been campaigning for years for enzalutamide and abira- terone tablets to be given as a ‘first-line’ therapy as soon as men are diagnosed.

Trials show that giving patients the drugs early can cut the risk of dying within three years by a third.

There is still a long way to go: by the time around a third of men are diagnosed, the disease is advanced, and more than 12,000 still die each year.

Currently, a blood test checking for levels of prostate-specific antigen (PSA) — a protein made by the prostate gland, which increases when cancer is present — remains the most common way of diagnosing the disease despite the test being notoriously unreliable.

All men over 50 can ask their GP for a PSA test if they are concerned about prostate cancer or have any symptoms, which can include frequent trips to the loo (especially at night), blood in the urine and erectile dysfunction.

A PSA score of 3 or above requires further investigation. However, PSA levels can rise after vigorous exercise or sex — as pressure from such activities squeezes more PSA from prostate tissue into the blood — and 75 per cent of men who get a high score are cancer-free (a false positive), while 15 per cent who do have cancer don’t have a raised PSA level (a false negative).

However, there’s a plethora of new technology in the pipeline that could improve outcomes for men with different types of prostate cancer, as the country’s leading specialists tell Good Health . . .


NOW: High-tech scans

UNTIL recently, men with a PSA score of 3 and above underwent a biopsy — cells extracted from the prostate — to see if they were cancerous. This can be painful and risks bleeding and infection.

However, a study published in The Lancet in 2017, found that giving men with raised PSA a detailed MRI scan using four images (known as a multi-parametric MRI), identified 27 per cent as cancer-free without a biopsy. It also almost doubled the rate of correct diagnosis of fast-growing prostate cancers.

Last May, the National Institute for Heath and Care Excellence (NICE) recommended the NHS use this scan for all men with suspected prostate cancer. But, figures published by Prostate Cancer UK earlier this year revealed a quarter of UK hospitals are still not using these scans. The charity put this down to a shortage of scanners and staff.

‘This is not good enough,’ says Professor Hashim Ahmed, chair of urology at Imperial College London. ‘Men are entitled to an MRI scan before a biopsy, and if they are not offered it, they should ask for it.’

FUTURE: Screening and a ‘fingerprint’ blood test

TWO UK trials — PROSTAGRAM and ReIMAGINE — are looking at whether a 15-minute MRI scan, the prostate equivalent of a mammogram for breast cancer, is better than the PSA test.

Patients identified as being high risk by this scan go on to have more detailed assessments, such as the multi-parametric MRI. Results of the PROSTAGRAM trial, carried out by Imperial College London and announced last month, revealed screening men aged 50 to 70 for prostate cancer using the MRI scan would pick up 8,000 additional cases of the disease. This would save thousands of lives as the earlier cancer is picked up, the better the prognosis.

The trial, which involved 411 healthy men, found MRIs picked up 50 per cent more aggressive cancers than using the standard PSA test.

Old drugs with new tricks: A DRUG for ovarian cancer called olaparib stops damaged DNA repairing in cancer cells, leading to the cells dying, and could be used to fight prostate cancer

In the ReIMAGINE trial, 300 men will receive a PSA test and a 15-minute MRI scan. Scientists will compare results to work out which is better at finding signs of cancer.

‘We want to see if MRI could be effective for screening healthy men, in the same way that there are NHS screening programmes to detect breast or cervical cancers,’ says Mark Emberton, a professor of interventional oncology at University College London, who is part of the research. To introduce a screening programme would be a massive undertaking, but is a possibility in ten to 15 years, says Professor Ahmed, who led the PROSTAGRAM trial.

Meanwhile, researchers at University College Hospital in London have developed a blood test that could diagnose prostate cancer even before PSA levels rise, by detecting DNA fragments released into the bloodstream by tumours.

They say the test, which could be available in five years, could also monitor how well a treatment works, because if DNA fragments are detected this indicates the cancer is spreading, suggesting a treatment is not working — and a different approach can be tried.

‘This test could be the first to identify prostate cancer before it is large enough to see on a scan,’ says Professor Emberton. And a new urine test, revealed in journal The Prostate in March, could reduce unnecessary biopsies by 60 per cent. The ExoMeth test used a computer program to pinpoint markers for identifying the disease, based on urine samples collected from 197 patients. In the future, GPs could carry out these tests, send them to a lab and have results within days, says Professor Ahmed.


NOW: Ultrasound, cryotherapy and precision radiotherapy

AROUND two-thirds of prostate cancers are diagnosed before the disease has spread. However, traditional techniques — surgically removing the entire prostate and standard radiotherapy — can damage nearby tissue and nerves, with side-effects such as incontinence and impotence.

More precise treatments, known as ‘focal’ therapies, which minimise side-effects, have been developed.

These include high-intensity focused ultrasound (HIFU), introduced in the UK in 2005, to heat and destroy cancer cells, or a freezing technique known as cryotherapy, both of which are carried out under general anaesthetic and only target the cancer, preserving the rest of the prostate.

With HIFU, a probe put in the back passage delivers ultrasound energy into the prostate, while to freeze the tumour, thin needles are put into the prostate and gas is passed down them to kill the cancer cells. Both techniques can also be used to treat the whole prostate if needed.

This sort of therapy is only available at specialist centres or as part of clinical trials.

New radiotherapy technology also reduces side-effects by minimising the amount of healthy tissue damaged during treatment.

It also means that men with prostate cancer can have five high-dose treatments rather than the standard 20, lower-dose sessions.

The technology is delivered using machines called MR Linacs, which use real-time MRI to provide live, detailed images of the tumour and surrounding tissue.

A study in the journal Lancet Oncology last year showed this type of radiotherapy was just as effective for early stage prostate cancer, with shorter treatment, while side-effects such as incontinence and sexual dysfunction were comparable despite giving higher doses of radiotherapy.

‘It’s a real breakthrough,’ says Professor Pat Price, chair of the charity Action Radiotherapy.

FUTURE: Curved radiotherapy and testing during surgery

EARLIER this year, scientists revealed a new ‘curved’ radiotherapy technique, which could halve side-effects. Scientists at the Institute of Cancer Research said the therapy involves ‘intensity modulated’ radiotherapy — in which beams of radiation of different intensities are ‘curved’ around other parts of the body so that they target the tumour and reduce damage to surrounding tissue.

The prostate is also injected with tiny pieces of gold — which show up on scans — to make sure the beams hit the tumour. The new approach is expected to be available within months.

Another approach on the horizon is testing the prostate during surgery, by sending the removed prostate to the lab for checks — a process that takes around 30 minutes.

Identifying the precise location of the tumour in the prostate gives surgeons greater confidence in the operating theatre to only remove nerve and tissue close to the tumour, preventing unnecessary damage to other areas.

The NeuroSAFE trial, run by University College London, will compare side-effects after a year in men who had standard full prostate removal using MRI and biopsy results, with those having the tumour tested during surgery. BEST FOR ADVANCED PROSTATE CANCER

Researchers at University College Hospital in London have developed a blood test that could diagnose prostate cancer even before PSA levels rise

NOW: Hormone treatment and chemotherapy

FOR the 15,000 men each year diagnosed with advanced prostate cancer, that has spread, commonly to the bones, the standard treatment is hormone therapy to block the testosterone which encourages its growth.

These drugs are initially effective, but often eventually stop working as the cancer becomes resistant.

Recently chemotherapy — which works by stopping the growth of the most quickly dividing cells and is normally administered intravenously in hospital — has been added to the treatment, after a trial in 2015 found that men who were taking the chemotherapy drug docetaxel at the same time as hormone therapy lived an average of 15 months longer than those on hormone therapy alone.

However, chemotherapy can have side-effects such as fatigue, nausea and vomiting, a significant proportion of men don’t respond to it, and as with hormone therapy, the cancer can eventually become resistant to its effects.

FUTURE: Old drugs with new tricks and immunotherapy

A DRUG for ovarian cancer called olaparib stops damaged DNA repairing in cancer cells, leading to the cells dying, and could be used to fight prostate cancer.

Research presented at the European Society for Medical Oncology conference in Barcelona last year revealed these drugs, known as PARP inhibitors, slowed progression of the disease by about four months compared with standard hormone therapy, and prolonged survival by over three months.

Another drug being investigated at Imperial College London targets a type of genetic material called microRNAs which change as prostate cancer progresses. By working out which microRNAs are most important for cancers that are becoming resistant to treatment, it may be possible to develop new drugs to block them.

Immunotherapy, harnessing the body’s immune system to attack the cancer, may be another option. So far success has been limited with prostate cancer, but research published in the Journal of Clinical Oncology last year found one in 20 men — so-called ‘super responders’ — gained up to an additional two years of life thanks to an immunotherapy drug called pembrolizumab.

Another radical approach is treating the cancer in the prostate even when it has spread.

‘Cancer cells in the prostate send growth signals to cancer elsewhere in the body,’ explains Professor Ahmed. ‘The idea is if we treat the prostate with radiotherapy or surgery, it could break this communication.’ A trial of 900 men is under way and results should be available within five years.

Identifying tumours that have become resistant to treatment and ‘picking’ them off is another option. The theory is that when cancer begins to grow again despite hormone treatment, it may be just some of the tumours that have become resistant rather than all of them.

Dr Alison Tree, a consultant clinical oncologist at Royal Marsden Hospital, is researching whether identifying and treating just these resistant tumours with targeted radiotherapy means the rest of the cancer will respond to hormone treatment.

‘I hope that in five years we’ll be using radiotherapy as standard to pick off drug-resistant parts of the cancer, and this will mean we can keep men on hormone therapy for longer,’ she says.

‘That means fewer men will die.’

‘Ultrasound spared me from side-effects’ says one of the first patients to benefit from a new treatment to treat the tumours called high intensity focused ultrasound

Andy Cutler visited his doctor in 2009 after suffering stomach pains, which turned out to be irritable bowel syndrome.

Andy Cutler photographed at his home in Guildford, Surrey. He was diagnosed with prostate cancer eleven years ago

As a precaution, his GP sent him for blood tests and, to Andy’s surprise, they revealed elevated levels of prostate-specific antigen (PSA).

Andy, 58, a retired salesman from Guildford, Surrey, says: ‘I was only 48 and had no typical symptoms, so it was a real surprise.’

He was referred for a scan and biopsies, which showed he had prostate cancer — it hadn’t spread.

Andy was given a choice of options to remove the tumour. ‘I couldn’t bear the idea of incontinence and erectile dysfunction, so whole prostate removal or radiotherapy wasn’t for me,’ he says. ‘Focal therapy, where only the part of the prostate containing the tumour is removed, seemed a better option, so I went for that.’

The treatment was carried out using high-intensity focused ultrasound (HIFU) energy to destroy the cancer cells.

At the time, this technique had been available for only a couple of years in the UK, but Andy wasn’t concerned. ‘It seemed the least risky option,’ he says.

Mr Cutler visited his doctor in 2009 after suffering stomach pains. As a precaution, his GP sent him for blood tests and, to Andy’s surprise, they revealed prostate-specific antigen

The treatment was a success, but it took longer to recover than he expected; he experienced pain and needed frequent trips to the loo for the first three months, and erection problems for about six to seven months.

He has since made a good recovery, although monitoring has revealed a small number of low-grade prostate cancer cells that do not require treatment.

‘I’m so pleased to have had the opportunity to have HIFU,’ he says. ‘I couldn’t bear the side-effects of traditional treatment.

‘I go for check-ups every six months, but otherwise my prostate cancer doesn’t affect me at all any more.’


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