Prostate cancer

Prostate cancer is often asymptomatic in its early stages. When symptoms do appear, they may include:

It is important to note that these symptoms can also be caused by other, non-cancerous health problems.
In the case of metastases, other symptoms may appear, such as bone pain or pathological fractures, lymphatic edema, neurological symptoms (in the case of vertebral bone involvement), or signs of liver dysfunction.

The precise causes of prostate cancer remain unknown. However, certain risk factors appear to influence its development, including:

The diagnosis of prostate cancer is based on several examinations and tests.

Screening:

Regular screening is recommended from the age of 50. However, for men with risk factors, such as a family history of prostate cancer, screening should begin as early as age 45.

• Digital rectal examination (DRE): enables the doctor to palpate the prostate and detect any abnormalities. It is often combined with a PSA test for greater diagnostic efficiency.
• Prostate Specific Antigen (PSA) blood test: this blood test measures levels of PSA, a protein produced by the prostate. High levels may indicate cancer. However, prostate cancer can develop despite low PSA levels. A rapid rise in PSA (over 0.75 ng/ml per year) is an indicator of increased cancer risk. PSA is more reliable than DRE alone, with a sensitivity of 82% versus 55% for DRE.

• Multiparametric magnetic resonance imaging (MRI): Used to obtain detailed images of the prostate and identify suspicious areas, particularly in the peripheral zone, where 95% of cancers develop.
• Transrectal ultrasound: an ultrasound probe is used to visualize the prostate, assess its size and detect any abnormalities.
• Prostate biopsy: if the preceding tests are abnormal, a biopsy is performed to confirm the presence of cancerous cells.

Extension work-up:

These examinations are designed to assess whether the disease has invaded other organs around the prostate.

• Bone scintigraphy: used to check whether the cancer has spread to the bones, a frequent occurrence in the advanced stages of the disease.
• PET-scan: Used to detect metastases. The tracers used, such as 68Ga-PSMA, improve early detection of metastases, even at very low PSA levels.

Prostate cancer is classified according to the severity and extent of the cancer cells. The Gleason score, used since the late 1960s, assesses the aggressiveness of cancer cells based on their microscopic appearance. The higher the score, the more aggressive the cancer.

• Gleason score ≤ 6: well-differentiated, low-risk cancer.
• Gleason score = 7: moderately differentiated cancer, intermediate risk.
• Gleason score ≥ 8: poorly differentiated, high-risk cancer.

In addition, the TNM classification is used to describe the extent of the cancer:

• T: Size and extent of the tumor in the prostate.
• N: Presence or absence of lymph node invasion.
• M: Presence or absence of distant metastases (bone, lymph nodes).

Prostate cancers are also grouped into risk categories according to the NCCN (National Comprehensive Cancer Network) classification:

• Low risk: localized tumor, PSA < 10 ng/ml, and Gleason score ≤ 6.
• Intermediate risk: PSA between 10 and 20 ng/ml, or Gleason score = 7.
• High risk: PSA > 20 ng/ml, or Gleason score ≥ 8.

Treatment of prostate cancer can be curative (aimed at cure) or palliative (focused on quality of life), depending on the stage and type of tumour. Standard treatment of localized prostate cancer is based on three options: surveillance, surgical removal or radiotherapy. For the most advanced metastatic cases (stage IV), or high-risk cases (stage III), androgen suppression, achieved by surgical or chemical castration, can lead to prolonged remission. There are several treatment options for prostate cancer, each with its own advantages and disadvantages.

Active surveillance:

Regular observation of cancer progression without immediate treatment. The surveillance strategy must be both frequent and varied. It is based on regular examinations: digital rectal examination and PSA test every 3 to 6 months, prostate biopsies at least once a year, and possibly an annual prostate MRI.
Advantages: Avoids treatment side effects. Particularly suitable for elderly patients or those with significant comorbidities. 
Disadvantages: Risk of cancer progression.

Surgery (radical prostatectomy):

Radical prostatectomy involves removal of the prostate and surrounding tissues. This treatment is particularly effective when the cancer is localized. Surgical techniques vary, with the option of open or robot-assisted surgery, the latter allowing greater precision and faster recovery. The choice between open and robotic surgery depends on the patient's specific needs.
Advantages: Possibility of complete cure if the cancer is localized.
Disadvantages: Risk of urinary incontinence and erectile dysfunction. The risk of erectile dysfunction depends on the extent of removal of surrounding tissues, notably the neurovascular bands that play a role in erection. Surgeries that preserve these strips can reduce this risk.

External Radiotherapy:

External radiotherapy uses X-rays to destroy cancer cells. It is often used as an alternative to surgery for patients for whom surgery is not indicated, or for those who prefer to avoid surgery.
Advantages: Non-invasive, outpatient treatment, identical in efficacy to surgical intervention.
Disadvantages: Side-effects include fatigue and irritability. Several sessions are required.

Hormonal therapy:

Hormonal therapy, or androgen suppression, aims to reduce levels of testosterone, a hormone that stimulates the growth of prostate cancer cells. The duration of hormone therapy varies according to risk, ranging from 6 months for intermediate-risk to 36 months for high-risk cancers.
Advantages: increased efficacy for advanced cancers
Disadvantages: Hormonal side effects such as hot flushes and loss of libido. Increased cholesterol and weight gain, gynecomastia, osteoporosis, fatigue.

Chemotherapy:

Chemotherapy is reserved for advanced cancers. The drugs used destroy fast-growing cancer cells.
Advantages: Effective in controlling cancer progression in advanced and metastatic stages.
Disadvantages: Side effects such as fatigue, nausea, hair loss, and greater susceptibility to infection.

Proton therapy:

Proton therapy is an advanced form of radiotherapy that uses protons instead of X-rays. This technique delivers a more precise dose of radiation to tumors, reducing damage to surrounding healthy tissue.

Brachytherapy:

Brachytherapy involves implanting radioactive seeds directly into the prostate to destroy cancer cells. This technique is often used for localized, low- to medium-risk cancers. It is considered a non-invasive option to surgery, with a shorter recovery time.

Cryotherapy:

Use of a probe at very low temperature to destroy cancer cells.

The course of prostate cancer depends on its stage at diagnosis and the effectiveness of treatment. Possible complications include :

• Bone metastases: Prostate cancer often spreads to the bones, particularly the hips, spine and ribs. Bone metastases can cause severe pain and increase the risk of fractures.
• Biochemical recurrence: After treatment, some patients may experience a rise in PSA levels. The PSA doubling time (PSADT) is an important indicator of recurrence. A PSA that doubles in less than 6 months indicates a more aggressive recurrence.
• Local or regional recurrence: After prostatectomy or radiotherapy, close monitoring is required to detect any signs of local or regional recurrence, particularly in the lymph nodes. Local cancer progression can lead to urinary or digestive problems.

Regular monitoring is essential to detect and manage these complications promptly.

Although some causes of prostate cancer cannot be avoided, a few measures can reduce the risk. It's important to maintain a healthy lifestyle by adopting a healthy diet. Regular physical activity and maintaining a healthy weight are also important. Avoid smoking and limit alcohol consumption. For early detection, particularly if risk factors are present, it is advisable to consult a doctor regularly.

There are a number of situations in which it is advisable to consult a doctor, especially if unusual or persistent urinary symptoms occur. For example, in the event of urinary burning, blood in the urine, urinary urgency or frequent night-time urination. Regular screening is recommended from the age of 50, and from 45 for men at risk, particularly if they have a family history of prostate cancer.

Hôpital de La Tour offers a personalized, multidisciplinary approach to prostate cancer care. Our specialized team includes urologists, oncologists, radiation therapists and specialized nurses, working together to provide the best possible care.

Highly specialized, multidisciplinary care

Hôpital de La Tour offers highly specialized, multidisciplinary care for urological cancers, thanks to a comprehensive technical platform and the necessary skills brought together on its campus. To ensure that patients suffering from this disease receive the best possible treatment, a multidisciplinary colloquium, also known as a tumor board, is held every week, bringing together specialists from different disciplines. This enables specialists to discuss treatment options, validate a protocol by comparing opinions, and then set up optimal follow-up care.

Holistic approach

Hôpital de La Tour offers a holistic approach to support patients throughout their cancer journey: complementary care such as nutritional consultations, adapted physical activity programs, and care for the often neglected psycho-emotional aspects is also provided thanks to the support of a team of psychologists and sexologists. The OTIUM Center, supported by the institution, offers supportive care and advice for cancer sufferers and their families.  

What are the first symptoms of prostate cancer?
Early symptoms may include urinary problems, such as difficulty urinating, frequent urination, especially at night, and weak or interrupted urine flow.

At what age should I start screening for prostate cancer?
Screening is generally recommended from the age of 50, or 45 for high-risk men.

Is prostate cancer hereditary?
There is a hereditary component, but not all prostate cancers are hereditary.

How is prostate cancer diagnosed?
Diagnosis includes digital rectal examination (DRE), prostate-specific antigen (PSA) test, prostate biopsy and magnetic resonance imaging (MRI).

What are the risk factors for prostate cancer?
The main risk factors are age, family history, ethnicity and diet.

What are the treatment options for prostate cancer?
Treatment options include active surveillance, surgery (radical prostatectomy), radiotherapy (hypofractionated, stereotactic), hormone therapy, and chemotherapy.

What are the most common side effects of treatment?
Erectile dysfunction and urinary incontinence are the most common, but their importance varies from one treatment to another.

Can prostate cancer be prevented?
Although some causes cannot be prevented, adopting a healthy diet, exercising regularly and consulting a doctor for early detection can reduce the risk.

Can prostate cancer be cured?
Yes, especially if detected at an early stage. Survival rates are high for localized cancers.

Find out more about prostate cancer

To find out more about prostate cancer and uro-oncology, the BRO Genitourinary System is a book that makes the field of uro-oncology accessible to professionals of all specialties.

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