BPH, PSA and Prostate Cancer

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BPH, PSA and Prostate Cancer

• Mike Foster
• Good Hope Hospital

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Is it BPH ?

• it could be
• carcinoma prostate
• stricture
• primary unstable bladder
• neuropathic bladder
• overactive
• underactive

• UTI
• prostatitis
• bladder tumour
• bladder stone
• ureteric stone
• diabetes

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Symptoms of outflow obstruction

• Hesitancy
• Poor stream
• Terminal dribbling

• Difficulty starting
• Difficulty going
• Difficulty stopping

• Sensation of incomplete emptying

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• Other symptoms are secondary symptoms or symptoms
  of other pathology
• i.e. frequency, nocturia, urgency etc
• secondary symptoms are more bothersome

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Chronic retention Dangerous because of -
renal failure bladder failure
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Treatment options

• No treatment
• Drugs
• 5 alpha reductase inhibitors
• alpha blockers
• Surgery
• Heat treatment
• Stents, catheters etc

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5 alpha reductase inhibitors

• Finasteride / Dutasteride
• Genuine reduction in prostate size by up to 30
• Work in c. 50 of patients
• Better in bigger prostates
• Dont work immediately
• Small effect on symptom score and flow rates
• Well tolerated can decrease libido

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Alpha -blockers

• Relax muscles around bladder neck
• Work immediately
• Doesnt effect natural history of disease
• More side effects than 5 ? R I
• Slightly better results than 5 ? R I
• Work in all sizes of gland

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Selective alpha blockers

• Alpha - Phenoxybenzamine
• Alpha 1 etc - Indoramin
• Alpha 1a etc - Tamsulosin

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Dutasteride Phase IIIa studies Pooled data for
first episode of acute urinary retention
6 5 4 3 2 1 0
Placebo Dutasteride 0.5 mg
Patients ()
0
6
12
18
24
Months
Placebo group No. of events, cumulative 28 49 70 9
0 No. at risk 2158 2039 1919 1793 Dutasteride
group No. of events, cumulative 19 27 31 39 No.
at risk 2167 2052 1928 1827
Roehrborn et al (2002)
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Drug treatment

• Improves symptoms
• Decreases risk of retention / intervention by
  approx half
• Combination therapy is more effective
• 5 alpha reductase inhibitors work best in bigger
  prostates, but slowly
• Alpha blockers work immediately

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Managing BPH in the community

• Is it BPH?
• Are the symptoms right?
• Flow rate?
• Exclude cancer
• Exclude chronic retention
• U and E s
• Scan ?
• Trial of drugs
• Refer if no response / symptoms worsen

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TURP

• Remains the gold standard for the treatment of
  BPH
• 100 improvement in flow
• Retrograde ejaculation but otherwise few side
  effects
• Good results depend on good patient selection
• 10 may need further surgery in 10 years

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Heat treatment

• Prostatic hyperthermia / thermatherapy / thermal
  ablation (TUMT, TUNA)
• Laser prostatectomy
• Short stay, safe, variable side effects, unproven
  in long term
• Will almost certainly have a future
• The best method of heat delivery is as yet
  uncertain

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PSA - specific for the prostate but not for
prostate cancer

• PSA is raised in
• cancer
• prostatic infection
• urinary retention
• BPH

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The normal PSA

• PSA less than 4.0 Ca unlikely
• PSA 4 10 Ca in 25
• PSA 10 Ca in 33
• PSA over 10 Ca in 66
• PSA over 20 Ca highly likely
• or age related reference range

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Improving the PSA test

• PSA density
• Age related PSA
• 40 - 49 2.5
• 50 - 60 3.5
• 60 - 69 5.5
• 70 - 79 6.5
• PSA velocity
• Free PSA

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P.S.A.

• To test or
• not to test

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• Localised prostate
• cancer is
• not a fatal
• disease

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Survival at 5 years
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• Metastatic disease
• rare if PSA is under 20
• Very very rare if PSA under 10

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• No point searching for cancer aggressively if
  youre not going to treat it aggressively
• Lots of old men die with prostate cancer without
  knowing they ever had it

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Aggressive case finding and treatment, or not ?

• Against
• Lifetime risk of disease 9
• Lifetime risk of mortality 3
• Localised prostate cancer is not a fatal disease,
  and it may never progress in patients lifetime
• Significant complication rate of treatment, so
  why overtreat ?
• No proven overwhelming benefit to treatment

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Aggressive case finding and treatment, or not ?

• In favour
• Some men do die of prostate cancer
• Catch the disease early and remove it

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Prostate cancer - treatment

• Localised
• No treatment
• Radical prostatectomy
• Radiotherapy
• External beam
• Brachytherapy
• No randomised controlled trials of treatment

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• All treatments have
• significant side effects

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Is aggressive treatment effective?

• Results are biased
• by patient selection
• by more accurate staging in surgical patients

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191 patients with localised prostate cancer (all
grades) treated with radiotherapy
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148 patients with localised prostate cancer
treated by radical prostatectomy
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61 pts under 70 with mod / well diff T1 / T2
prostate cancer, no specific treatment
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In the early years

• Most patients with localised
• prostate cancer do well,
• however they are treated..

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But after 10 years or more

• Untreated patients do less well if they havent
  died of anything else in the meantime
• 80 of men diagnosed age 60 or under who receive
  no treatment die of prostate cancer
• cure rates after radical surgery of 70 - 90
  are often claimed

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Common sense (and a little knowledge) suggests..

• Some men will do well, treated or not, and die of
  other causes in due course
• Some will progress and die of Ca
• We cant predict who will do what
• The younger you are, the more likely the disease
  will progress eventually
• Radical treatment probably decreases the chance
  of progression

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• Consider radical treatment in patients with a
  life expectancy of 10 years (70 ish or less and
  fit)..

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• ...but accept that some patients may be having
  treatment (and complications of that treatment)
  which they may not need

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P.S.A.

• To test or
• not to test

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Anti-screening

• Not cost effective
• Doesnt save enough (or even any) lives
• No proven intervention which modifies the natural
  history of the disease
• Poor take up rate

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Pro-screening

• It must save lives if you catch the tumours early
• Its good enough for women
• Trials in progress

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If you have a PSA blood test

• you have to seriously consider a biopsy if
  raised
• what if the biopsy is equivocal ?
• what if the biopsy is benign and PSA remains high
  ?

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In an ideal world

• Invite men under 70 for PSA screening after
  informed consent
• .with serious consideration of radical treatment
  if cancer diagnosed

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In the real world

• Some men just want the test
• Informed consent is difficult and time-consuming
• Screening is not economically viable
• Low take up rate
• Questionable benefit in terms of population
  survival

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Who should have a PSA ?

• Patients with significant outflow symptoms
• (? age cut off)
• Patients over 40 with haemospermia, unexplained
  haematuria or abnormal DRE
• Patients with suspected metastatic disease
• Informed patients age 45 - 70 who ask for it

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Who shouldnt have a PSA

• Men under 40
• Elderly asymptomatic men with normal feeling
  prostates
• unless high suspicion of metastatic disease
• Uninformed asymptomatic men of any age

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Who should be referred?

• Patients with significant outflow symptoms
• Patients with likely cancer
• Abnormal DRE
• PSA over 20
• Metastatic disease
• Patients with life expectancy of 10 years or more
  with high age related PSA
• ? Patients with PSA 10 -20 aged over 75

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Do not be concerned about

• Unfit elderly men with PSAs of under 15
• Men unlikely to survive 10 years with PSA of less
  than 10
• Raised PSA in men in retention or with infection