Prostate Cancer - Understanding Your Diagnosis
Prostate cancer behaviour ranges from very indolent disease requiring no immediate treatment to aggressive tumours requiring multimodal therapy. PSA level, biopsy Gleason score (ISUP grade), and clinical stage together define the risk group.
Risk stratification (EAU/NCCN):
| Risk Group | PSA | Gleason (ISUP) | Clinical Stage | Approach |
|---|---|---|---|---|
| Very low / Low | <10 | ?6 (Grade 1) | T1-T2a | Active surveillance; radical treatment if preferred |
| Intermediate | 10-20 | 7 (Grade 2-3) | T2b-T2c | Radical prostatectomy OR radiotherapy - ADT |
| High | >20 | 8-10 (Grade 4-5) | T3a | Surgery + adjuvant RT; or long-course RT + ADT |
| Very high / Locally advanced | Any | Any | T3b-T4 | Combined modality; ADT + RT - surgery |
| Metastatic | Any | Any | N1 / M1 | Androgen deprivation therapy - systemic agents |
Diagnosis - modern multiparametric MRI: mpMRI of the prostate (PI-RADS scoring) before biopsy has become standard - allowing targeted biopsy of suspicious lesions rather than systematic random sampling. This significantly improves significant cancer detection while reducing overdiagnosis of insignificant disease. BB Global Health coordinates remote review of mpMRI and PSA for initial assessment.
Active surveillance: For low-risk prostate cancer, active surveillance avoids the side effects of radical treatment while monitoring closely for progression. Protocol: PSA every 3-6 months; repeat MRI and biopsy at defined intervals. Curative treatment initiated if progression detected. BB Global Health supports active surveillance patients who prefer treatment in Turkey when intervention becomes indicated.
Radical Prostatectomy - Open, Laparoscopic, and Robotic
Radical prostatectomy (RP) removes the entire prostate gland along with the seminal vesicles and regional lymph nodes (for intermediate-high risk disease) and aims for negative surgical margins (cancer-free edges).
Approaches:
Open radical retropubic prostatectomy (RRP):
- 15-20 cm lower abdominal incision; direct anatomical access
- Less common now where robotic platforms are available
- Suitable when robotic surgery is unavailable or for very large prostates
Laparoscopic radical prostatectomy:
- 4-5 port keyhole approach; magnified 2D view
- Lower blood loss than open; longer learning curve
Robot-assisted radical prostatectomy (RARP, da Vinci):
- The current standard at high-volume centres worldwide
- 4-5 robotic arms; 3D magnified HD view; tremor filtration; wristed instruments
- Allows precise nerve-sparing (critical for erectile function preservation)
- Lower blood loss; fewer transfusions; shorter catheter time; faster recovery than open
- Available at BB Global Health partner hospitals (da Vinci Xi)
Nerve-sparing technique: The neurovascular bundles (NVBs) running along the posterolateral prostate govern erectile function. In patients with organ-confined disease and good pre-surgical erections, nerve-sparing RP preserves or partially preserves these nerves. Robotic precision enables safer nerve-sparing vs. open/laparoscopic approaches.
Outcomes (robot-assisted RP):
- Negative surgical margins (organ-confined): 85-95%
- 10-year biochemical recurrence-free survival (low-risk): 70-80%
- Continence recovery -(no pad at 12 months): 85-95%
- Erectile function recovery at 12 months (nerve-sparing, good pre-op function): 50-70%
Post-operative recovery:
- Catheter in situ: 7-14 days
- Hospital: 2-3 nights
- Light work resumed: Week 3-4
- Lifting and exercise: Week 6
- PSA check at 6 weeks (should be undetectable < 0.1 ng/mL)
Radiotherapy and Hormone Therapy
For patients preferring radiotherapy, or for locally advanced disease, external beam radiotherapy (EBRT) with or without androgen deprivation therapy (ADT) is an equally effective curative alternative for localised/locally advanced prostate cancer.
IMRT/IGRT (Intensity-Modulated and Image-Guided Radiotherapy):
- Precision conformal radiotherapy delivering high doses to the prostate and seminal vesicles while minimising dose to rectum and bladder
- 20-28 fraction schedules (hypofractionation) deliver treatment in 4-6 weeks
- Combined with ADT for intermediate-high risk disease (6 months-3 years ADT depending on risk)
- Available at BB Global Health radiotherapy partner centres
HIFU (High-Intensity Focused Ultrasound):
- Focal treatment option for localised low-to-intermediate risk disease
- Ablates prostate tissue using focused ultrasound (focal or hemi-ablation)
- Preserves surrounding structures; lower incontinence and erectile dysfunction risk than whole-gland therapy
- Not yet considered standard - discuss with uro-oncologist for appropriateness
Androgen Deprivation Therapy (ADT):
- For high-risk or metastatic disease; reduces testosterone to castrate levels
- LHRH agonists (Zoladex/goserelin) or LHRH antagonists (Firmagon/degarelix)
- Combined with docetaxel chemotherapy or next-generation antiandrogens (enzalutamide, abiraterone) for high-risk localised or metastatic disease
Follow-up after curative treatment:
- PSA monitoring: every 3 months year 1, every 6 months year 2-5, annually thereafter
- PSA nadir after radiation: typically 12-18 months to reach lowest level
- PSA after RP: should be undetectable (< 0.1 ng/mL); persistently detectable or rising PSA = biochemical recurrence