Dr James Thompson is an experienced robotic, laparoscopic, endoscopic and open urological surgeon. He has sub-specialty training in (and passion for) the treatment of prostate, bladder and kidney cancer using the latest robotic surgery techniques and for high-impact cancer research that has the ability to immediately improve quality of life and cancer cure rates for the community.
Prostate Cancer
“Prostate cancer can be a ‘silent’ killer, meaning usually it does not cause any symptoms until it has reached an incurable stage however the good news is PSA screening can save lives by detecting prostate cancer at an early and curable stage.”
What is prostate cancer?
The prostate gland is a male body organ that produces semen fluid. This fluid surrounds the male sperm (which are produced in the testes) to protect and nourish sperm during fertilisation of the female egg. As we age, small groups of prostate cells commonly start to grow in an abnormal way, forming tiny lumps inside the prostate, known as ‘tumours’ or ‘cancers’.
How common is it?
In fact, prostate cancer is the most common of any cancer. One in six men will experience prostate cancer. The good news, however, is most prostate tumours grow very slowly. Many prostate tumours are so ‘benign’ (NOT dangerous) that they don’t even need treatment, because they will never spread or cause symptoms.
How is Prostate Cancer Diagnosed?
SCREENING - psa & dre
Usually, it starts with a PSA test (see section on raised PSA), which is done as part of ‘screening’, in a man who feels perfectly well.
This is usually combined with an examination of the prostate via the back passage (known as a DRE – Digital Rectal Examination); the doctor feels the prostate with one finger, looking for an abnormal lump (similar to a breast examination for breast cancer).
Prostate MRI Scan
If a man has an abnormally high level on PSA blood testing, or an abnormal lump on prostate examination, the next step is usually an MRI scan.
The MRI scan is completely safe and involves no radiation. It gives a clear picture of the entire prostate in 3-D, and can pinpoint the location of the cancer in most men.
Prostate PSMA Scan
Sometimes, the MRI scan shows an abnormality but is not strongly suspicious enough to definitely require a biopsy. Traditionally these men undergo biopsy.
We are currently offering the opportunity to participate in a world-first clinical research trial of a PSMA-PET scan, which is a cutting edge new scan that we believe will better select which men need a biopsy.
Prostate biopsy
Making a definite diagnosis of prostate cancer still requires a biopsy. Under a general anaesthetic (you are asleep to avoid any pain or discomfort), a fine needle is inserted via the perineum (under the scrotum, in front of the anus) to take 3-D targeted prostate biopsies from a specific location corresponding to the area suggestive of cancer on the MRI and/ or PSMA scan.
A pathologist then examines the biopsies in order to confirm the presence of cancer, as well as its size and ‘grade’ (how aggressive i.e. rapidly growing it is).
Why does prostate cancer develop?
AGE
Age is the biggest risk: it is rare to be diagnosed before age 50, but becomes progressively more common such that more than half of men in their 80s have cancer, of which most will never cause harm.
Lifestyle and diet
Lifestyle and diet appear to play a small role but the scientific evidence is weak: A diet which is high in calories, high in fat, high in red meat, low in fruit and low in vegetables may increase the risk of prostate cancer. Obesity and a lack of exercise may also contribute.
Family History (Genetics)
Family History is a strong risk: if you have a first-degree relative (e.g. a brother or father) with prostate cancer, this increases your risk of prostate cancer substantially. If your family has a genetic condition known as ‘BRCA-2’ then your risk is even higher.
Evaluating Prostate Cancer
Are all Prostate Cancers the same?
Not all prostate cancers are the same. Many grow slowly and require no treatment at all, ever. Others are aggressive and require urgent treatment.
When cancer is contained to the prostate (i.e. has not spread), then in order to select the best treatment and give an accurate prognosis, we divide men into 4 risk groups: low, intermediate, high-risk or metastatic. This refers to the ‘risk’ of a man’s cancer causing harm if left untreated and his risk of the cancer recurring (coming back) if he does undergo treatment now.
Unfortunately, men are sometimes diagnosed at a stage where their cancer has already spread (known as ‘metastatic’ by health professionals), but the good news is that using a combination of hormone therapy, chemotherapy and radiotherapy these men can still live for many years.
Useful resources
Prostate Cancer Foundation of Australia - https://www.prostate.org.au/
NSW Cancer Council - https://www.cancercouncil.com.au/
Urological Society of Australia and New Zealand - https://www.usanz.org.au/
European Association of Urology - https://uroweb.org/
British Association of Urological Surgeons - https://www.baus.org.uk/
American Urological Association - https://www.auanet.org/
National Comprehensive Cancer Network (USA) https://www.nccn.org
Prostate Cancer Treatment options
If you or a loved one have been diagnosed with prostate cancer, the first and most important thing I want to do is to reassure you that most cases of prostate cancer are curable, that it is usually a slow moving cancer that progresses over years , not days or weeks, and that there are a huge number of treatment options so we can tailor a personalised treatment to you that best fits your individual cancer and your overall needs and priorities.
The first steps in selecting and tailoring the best treatment option are a whole body PSMA-PET scan to check the stage of the cancer, detailed assessment of symptoms, urinary and sexual function and medical history and examination of the prostate, then review of the MRI and biopsy results.
Then with all this information we can weigh up the pros and cons of each treatment which includes active surveillance (observation), robotic or open surgery to remove the prostate, radiotherapy (x ray therapy), focal therapy, hormone therapy and/ or chemotherapy.
In general, if the cancer is low grade (slow growing) and small, either grade group 1 (previously called Gleason 6) or some in grade group 2 (Gleason 7) then you may be suitable for close observation (known as active surveillance) which allows us to avoid the risks and side effects on quality of life from surgery, whilst keeping a close eye on you via regular MRI scans, PSA blood tests and occasional biopsies, such that we can still treat the cancer early in future, if it becomes larger or higher grade.
If the cancer is of a higher grade but remains contained to the prostate and you are under 75years and in good health, then usually surgery to remove the prostate is the preferred choice.
If the cancer has started to grow beyond the edge of the prostate into surrounding areas such as the seminal vesicles, nerves, bladder, rectum or lymph nodes or there are a couple of distant spots in the bones, then radiotherapy combined with hormone therapy is likely a better option as surgery is unable to completely remove the rumour.
Some older men also choose radiotherapy due to a complex medical history that would mean a high risk of complications with surgery, or because they choose to avoid the slightly higher risk of incontinence or weakness of erections with surgery. On the other hand, men aged under 60 years or with urinary symptoms or bowel problems are generally unsuitable for radiotherapy.
A small number of men with a small intermediate-grade cancer in one part of the prostate on MRI, PSMA-PET and biopsy may be suitable for a new treatment called Nanoknife focal therapy (irreversible electroporation), where we use special electrical energy to destroy the cancer in one part of the gland, whilst sparing the rest of the prostate gland and thus avoiding the need for surgery or radiotherapy.
Finally, if in rare cases the cancer has already spread to several areas such as the bones and lymph nodes, then a combination of hormone therapy and chemotherapy can shrink the cancer and often keep it in remission for many years. We also have exciting clinical trials into new therapies such as next-generation hormone therapies, immunotherapies and PSMA- targeted therapies.
Choosing the best treatment for you requires a urologist to take the time in multiple consultations to weigh up the pros and cons of each treatment with regards to your specific circumstances, and often to see a radiation and/ or medical oncologist or seek a second opinion from another urologist too. I am happy to provide an independent second opinion for men who wish to be sure before choosing their treatment.