The case for early pick up and prevention in prostate cancer

So, having found a prostate cancer, we return to the question of what we need to do about it. For cases of advanced disease, where the cancer has already spread, there’s broad agreement about the best management, which includes approaches like chemo, radio and hormone therapy. But it’s how to manage the majority in the middle - men with early stage, local disease - where the path of opinion divides. Some advocate for a surveillance-based, minimally-invasive approach - empower people to monitor themselves and only escalate the care as required - pointing to no differences in mortality and fewer risks from interventions as a result; others argue for early intervention with tissue-sparing approaches, like focal surgery, to remove the disease locally but leave the prostate intact. Mark Emberton - who we heard from earlier - is a strong proponent for early pick-up and intervention…

Mark - Now we've got this thing called imaging — or MRI — so if somebody is at risk, the first thing we do now is see if we can see the cancer. And now, if your MRI is normal, we reassure the patients and discharge them back to their GP. If the MRI is abnormal, then we have two options — we can watch that lesion (we call these things lesions — little nodules within the prostate), or we can verify its nature by putting a needle into it. And the big difference to 10 years ago is that that needle is now directed into the heart of that lesion, so it’s very, very likely to give us the ground truth of what's going on — is it a benign process, is it inflammation, or is it cancer?

Chris - So you can map the coordinates, as it were, of where that abnormality is based on the MRI scan, and you can say, “That's where I want the biopsy from.” And that's the breakthrough, to your mind?

Mark - It's a huge breakthrough in terms of the precision of the biopsy process. And we use lots of kind of complicated computing now to import the MRI images onto the ultrasound — there's a bit of AI involved in that — and so the biopsy process has gone from a very imprecise, unreliable, dangerous test (done through the rectum — infection, bleeding, etc.) to something more like a brain biopsy.

Chris - Okay, so let's say someone has that and the news isn’t good — the biopsy, I suppose in some respects it’s good news because it’s found — but the biopsy is positive, there is a prostate cancer there. What are the next steps?

Mark - The histology will confirm the cancer — so the histology is when we look down the microscope at the tissue that we get from the biopsies. Like most cancers, there are cancers that behave pretty well, and there are other cancers that have features we know are associated with a very aggressive clinical pathway, and we grade them. Then, with that information, we make a treatment decision. If we deem the individual to be low risk, we can watch the disease — because the risk of progression is low and the risk of death over 10–20 years is known to be low. If the cancer is high risk, we tend to offer quite a bit of treatment — we call that multimodal. So that might involve surgery, it might involve radiotherapy, it might involve chemotherapy, hormones, and these days immunotherapy. But most are in the middle, and those men will be offered either surgical removal of the prostate or radiotherapy to the prostate. The other big revolution that imaging has given us is the opportunity to just treat the cancer plus a margin — in the same way that a woman might have a lumpectomy, or someone with a small lung cancer might have the cancer removed plus a bit of the lung lobe. That’s transformed things, because we can do that without the usual harms associated with surgery and radiotherapy. And moreover, it can be done as a day case.

Chris - There are side effects of these interventions, though, aren’t there? And in men, we worry about impotence, for example — a big concern, especially for younger men — also disturbance of the ability to pass urine the normal way. What are the outcomes like now we’ve got this better imaging and more guided therapy — have they improved? And for a man having this sort of intervention, what outcome can he expect?

Mark - Yeah, no, you're absolutely right. The problems associated with the traditional treatments have been kind of collateral damage to surrounding structures — bladder, urethra, the vessels and nerves that serve the penis and drive erections, the rectum behind. Radiotherapy, although it’s got a lot more precise, can still cause collateral damage and cause symptoms as a result. Removing the prostate means that at least one of the sphincters — the things that keep you dry — is removed, and then you're reliant on the sphincter you can initiate — the one we can control. About 10 percent, sometimes more, will leak urine and require a pad. The big problem with surgery — and indeed radiotherapy — has been the impact on sexual function. Many, many men will lose the ability to get or maintain an erection, and that's largely due to damage to the vessels and nerves required for erectile function. The new treatments obviously preserve those structures by limiting the treatment just to the cancer and a margin around it. We can now avoid incontinence completely. So I quote one percent now for focal treatment, and 90 to 95 percent of men will preserve erections sufficient for penetration — so a dramatic improvement in the long-term quality-of-life aspects of care.