This section contains information about the diagnosis, follow-up, and treatment of prostate cancer, based on the latest scientific guidelines and information from the European Association of Urology (EAU) and the American Urological Association (AUA) as of 2022.
Urologists around the world base their diagnoses and treatments on the guidelines obtained from research on tens of thousands of patients conducted by these associations. These guidelines are updated periodically, and we apply these updates to our diagnostic and treatment practices.
– Typically seen after the age of 50.
– More prevalent in developed countries, with a prevalence rate of 1 in 8.
– Known causes: obesity, vitamin D deficiency, genetics (the probability increases 2.5 times if family members have it).
Important Information About Prostate Cancer
– Typically seen after the age of 50.
– More prevalent in developed countries, with a prevalence rate of 1 in 8.
– Known causes: obesity, vitamin D deficiency, genetics (the probability increases 2.5 times if family members have it).
Symptoms of Prostate Cancer:
– There are no specific symptoms of prostate cancer in the early stages.
– Patients usually visit doctors with urinary complaints after the age of 45.
– In many cases, the diagnosis is made during routine check-ups.
What Path Do We Follow in Patients Over 45 with Urinary Complaints?
– First, the PSA level in the blood should be checked. PSA is a substance produced by the prostate, and its levels increase in the blood in cases of prostate cancer or prostate inflammation.
– In patients aged 60 and over, the PSA level should not exceed 2.5.
Causes Other Than Prostate Cancer That Increase PSA:
– Benign prostatic hyperplasia (BPH)
– Riding a bicycle or motorcycle
– Infections within the prostate
– Lower urinary tract infections
– Immediately after ejaculation
– Endoscopic procedures / cystoscopy, post-prostate biopsy
Who Should Be Screened with the PSA Test?
– Men who have reached the age of 50.
– Men with a family history of prostate cancer should have a PSA test annually after the age of 45.
– African descent men should start at age 40.
– Those with a positive BRCA2 gene test should start at age 40.
– Patients with hardness detected in the prostate during a rectal examination by an experienced urologist.
– Besides PSA and prostate examination, a urinary system ultrasound should be performed to evaluate the kidneys, bladder, and measure the prostate volume.
What Should Be Done Based on PSA and Prostate Examination Results?
– If the PSA level is high despite the absence of a urinary tract infection.
– Or if the PSA is normal but hardness is detected during a urological prostate examination.
– Or if both PSA is high and hardness is detected during a prostate examination.
In these cases, a multiparametric prostate MRI should be performed.
What Path Should Be Followed Based on MRI Results?
– The MRI indicates whether there are suspicious areas of cancer within the prostate.
– The MRI findings are expressed as PIRADS 1, 2, 3, 4, 5.
– If the result is PIRADS 1 or 2, a biopsy is not necessary.
– However, if the result is PIRADS 3 or higher (4 or 5), a prostate biopsy is planned.
How is the Definitive Diagnosis of Prostate Cancer Made?
– The definitive diagnosis of prostate cancer is made through a prostate biopsy.
– The prostate is visualized through a transrectal ultrasound, and guided by this ultrasound, tissue samples are taken from 12 to 16 locations through the rectum or the perineum for pathological examination.
– This method is known as standard prostate biopsy, where random tissue samples are taken under ultrasound guidance.
What is Prostate Fusion Biopsy?
– Unlike standard biopsy, where random samples are taken, MRI findings are introduced into the fusion device, matched, and biopsy samples are taken from the locations indicated by the MRI.
– The advantage of fusion biopsy is that it is not performed blindly like standard biopsy. The MRI shows the target, and biopsy samples are taken directly from the target area.
– The cancer detection rate in a single session is much higher compared to standard biopsy.
– If no cancer is detected in the first biopsy but the PSA level continues to rise, a second biopsy should definitely be performed as a fusion biopsy.
How Do We Evaluate Prostate Biopsy Results?
– The aggressiveness of prostate cancer is expressed by the Gleason score.
– The least aggressive score is 3+3: 6, and as the score increases, the aggressiveness of the cancer increases: 3+4: 7, 4+3: 7, 4+4: 8 (or 5+3: 8), 4+5: 9, 5+4: 9, 5+5: 10.
– The lowest score is 6, and the highest is 10.
– Besides the score, the size of the cancerous tissue in the biopsy sample is very important; the longer the length, the more aggressive the tumor.
– The ratio of the tumor length to the normal non-tumorous tissue is also a very important criterion for us.
Staging of Prostate Cancer
– Accurate staging is necessary for the correct treatment of any cancer, as the treatment varies by stage.
– After the prostate biopsy result, a Ga-68 PSMA PET (specific to prostate cancer) and contrast-enhanced lower abdominal CT or MRI should be performed.
The following criteria are used to determine the stage of prostate cancer:
– Total PSA level in the blood.
– Whether there is hardness in the prostate during a rectal examination, and if so, how much of the prostate it encompasses.
– Determination of cancer score and the ratio of cancerous tissue in the biopsy result.
– Evaluation of the Ga-68 PSMA PET result.
– Evaluation of the contrast-enhanced lower abdominal CT or MRI result.
Stages of Prostate Cancer
– Stage T1: T1a or T1b, cancer found incidentally in benign prostate tissue removed during a closed prostate surgery.
– Stage T1c: Elevated PSA levels in the blood but no hardness detected during a rectal examination.
– Stage T2: Divided into T2a, T2b, and T2c. If hardness is detected during a rectal examination and it encompasses less than half of the prostate, it is T2a; if it encompasses half of the prostate, it is T2b; if it encompasses both sides of the prostate, it is T2c.
– Stage T3: The disease has spread beyond the prostate, possibly to the seminal vesicles.
Treatment of Prostate Cancer
The treatment protocol is planned according to the latest updates from the EAU (European Association of Urology) and the AUA (American Urological Association) as of 2023.
As with any cancer, the treatment of prostate cancer is planned based on the stage and risk groups:
Treatment Protocol for Low-Risk Prostate Cancer
Who Falls Into This Group?
– PSA level below 10.
– Hardness detected in up to half of the prostate during a rectal examination.
– Cancer with a score of 6 in the prostate biopsy result.
– Cancer detected in no more than 3 out of 12 biopsy samples, with a tumor length of no more than 4 mm.
– These patients can be included in an active surveillance program if they do not want surgery or radiotherapy, but they must be closely monitored, and the following should be done:
– PSA test every 3 months.
– Rectal prostate examination every 6 months.
– Annual repeat prostate biopsy.
– If findings worsen during follow-up, a “Radical Prostatectomy” surgery should be performed.
Treatment of Moderate-Risk Prostate Cancer
These patients have the following findings:
– PSA level between 10-20.
– Hardness detected in one side of the prostate during a rectal examination.
– Biopsy score of 3+4 or 4+3: 7.
– The first treatment option for this type of prostate cancer is surgery.
– For those who do not want surgery or are not in good enough general health for surgery, radiotherapy is the second option. These patients need to receive hormone therapy for a period during radiotherapy (around 6 months).
High-Risk Prostate Cancer Symptoms and Treatment
– PSA level above 20.
– Biopsy score of 8, 9, or 10.
– Hardness detected in the entire prostate during a rectal examination.
– PIRADS 4-5 findings on MRI.
– Evidence of spread outside the prostate on MRI.
What is Radical Prostatectomy Surgery?
It is the gold standard treatment method at every stage of prostate cancer.
Radical Prostatectomy Surgery and Its Advantages
– The first treatment option in T1 and T2 stages.
– Used in combination with hormone therapy and radiotherapy in T3 stage.
– It involves removing the prostate and seminal vesicles and reconnecting the urethra inside the penis to the bladder.
– It requires significant experience.
– Since the prostate is completely removed, the patient will be free from both cancer and age-related prostate enlargement, eliminating urinary complaints.
– The most experienced surgeons have a 3% rate of permanent urinary incontinence, more than 60% loss of erection even if the nerves are preserved, and a 5% rate of bladder neck stricture as undesirable complications.
– If the disease recurs after surgery, small dose radiotherapy can be applied to terminate the disease.
– Unlike biopsy where small samples are taken, the entire prostate is removed and examined, providing detailed information about the disease.
*Post-Radical Prostatectomy Surgeries by Prof. Dr. Tahir Karadeniz Have Resulted in No Urinary Incontinence in Any Patient.*
The experience of the surgeon is crucial in such serious cancer surgeries. Surgeons who perform these types of surgeries frequently throughout the year should be preferred.
How Should This Surgery Be Performed? Classical (Open) Surgery or Robot-Assisted?
1. Classical Surgery, also known as Open Surgery, has been practiced since 1995 and is now a well-established technique. It is performed through an 8 cm incision made below the navel.
2. Robot-Assisted Technique (Da Vinci Robotic Surgery Technique)*: In this method, 6-7 incisions are made in the abdomen through which the camera and robotic arms are inserted. The surgeon performs the operation remotely by controlling these robotic arms like a computer game.
At the session of the European Urology Congress organized by the EAU (European Association of Urology) in March 2023, Prof. Dr. Tahir Karadeniz attended in person and returned with this message:
– “Whether the surgery is performed by the classical method or by the robotic method, there is no difference in surgical outcomes between the two methods. What matters is choosing the right surgeon, not the method.”
*Post-Surgery Recurrence Treatment*
– Patients are monitored by measuring PSA levels in the blood after surgery.
– PSA levels should not exceed 0.1 after surgery. A value above this indicates recurrence of the disease.
– The recurrence rate of prostate cancer after surgery is 33%.
Factors Increasing the Likelihood of Recurrence
– Having a pathology score of 4+3:7 or higher in the prostate pathology report.
– Presence of a tumor that has breached the prostate capsule in the pathology report.
– Cancer spread to one or both seminal vesicles.
– The presence of the + sign at the surgical margin in the pathology report, indicating that some tumor cells remain in the body. In high-risk prostate cancer surgeries, the likelihood of residual tumor cells is around 35-40%.
Ensuring that no tumor remains within the surgical margins after radical prostatectomy, meaning the disease is completely removed from the body, is a critical point for recovery. The experience of the surgeon is crucial at this stage. The pathology results of some surgeries performed by Prof. Dr. Tahir Karadeniz are listed below. It is important to note that in all patients, “No tumor remains within the surgical margins,” meaning the disease was completely removed from the body.
Treatment for Recurrence
– If recurrence is detected in PSA follow-ups after surgery, meaning PSA exceeds 0.1, certain tests should be conducted.
– GA 68 PSMA PET and pelvic MRI with contrast should be performed.
– Even if these tests do not locate the recurrence focus, the patient should not remain untreated.
– The treatment for these patients should involve radiotherapy to the prostate bed.