Oxford Screening - Prostate Blog

    PSA Testing - Blog -

    A Personal View - 8th October 2013

    It is surprising to me to know that there have been many millions of PSA tests carried out but there are still no organised screening programmes for prostate cancer. Screening pro Cancer charities would make a greater fuss about establishing a proper screening programme because early detection can make a difference. Raising money for research, supporting men and their families after a diagnosis of protate cancer and advising men about PSA testing are fantastic aims and objectives of Prostate Cancer UK but pressing for an organised screening programme should be much higher up their agenda in my opinion. There is interesting dietary advice on the Prostate Cancer UK website that we should take note of but knowing how we are so poor, talking about middle aged men now, at altering our diet such that most of us are overweight and heavily over indulging in carbohydrates, I wonder how many of us would act on that advice. Certainly, those in high risk groups for prostate cancer should take all measures they can to reduce their risk in addition to regular PSA testing. Black men, men whose father suffered from prostate cancer and men with a PSA in the grey zone should take particular note of their diet, lifestyle as well as getting tested annually.     Useful information   The age related referral points outlined in the Department of Health Referral Guidance and adopted by the Prostate Cancer Risk Management Programme are:

    Age               PSA ng/ml

    50-59            ≥ 3.0

    60-69            ≥ 4.0

    70 and over  > 5    

    PSA for different age ranges - US data

    Age 40-49 years – 0-2.5 ng/mL

    Age 50-59 years – 0-3.5 ng/mL

    Age 60-69 years – 0-4.5 ng/mL

    Age 70-79 years – 0-6.5 ng/mL  

    Age specific ranges for Black men

    Age 40-49 years – 0-2 ng/mL; 93% specificity

    Age 50-59 years – 0-4 ng/mL, 88% specificity

    Age 60-69 years – 0-4.5 ng/mL, 81% specificity  

    Causes of a high PSA level (other than prostate cancer)

    Race - Black

    Age - a gradual increase in PSA occurs from middle age onwards

    Drugs -

    Massage of the prostate - such as digital rectal examination

    Prostatitis - inflammation of the prostate

    BPH - a benign enlargement of the prostate

    Prostate volume - the overall size of the prostate

    Biopsy - taking a tissue sample from the prostate gland

    Urinary retention - when the prostate is enlarged it can press on the passage that the urine goes down, the urethra, and urine collects in the bladder expanding it like a balloon causing great abdominal discomfort

    No diurnal variation - if the PSA level is high it will not vary during the day or night it will be high continuously (although it can still be even higher after exercise, ejaculation etc)  

    Author: Dr Colin Clelland, Oxford Screening  

    10th October 2013   Symptoms of prostate disease - Blog  

    Clearly there may me no symptoms of prostate disease and these men are called a symptomatic. Hence the strongest argument for prostate cancer screening. A middle aged man may be harbouring an aggressive prostate cancer that will shorten his life, he does not know it and he has no symptoms. If he had a PSA test there is a strong chance that it would be abnormal and treatment could be given that may save his life. This was the comment made by the then CEO of Prostate Cancer UK, when the decision was made not to go ahead with a UK prostate cancer screening programme in 2010. So what is a man likely to notice when a problem develops in the prostate? As the prostate enlarges as it commonly does in middle age it presses on the tube that carries urine from the bladder, the urethra. This makes it more difficult to urinate. The bladder has to work harder to expel urine through the narrowed tube so the bladder wall becomes thicker and more muscular. The bladder may also show signs of back pressure by expanding like a balloon but the bladder bursting is not  likely as the pressure feeds back to the kidneys and so on. The result in terms of symptoms will be a slow stream of urine, some dribbling and ultimately it maya prove impossible to pass urine a condition called urinary retention that is treated by passing a catheter. Less severe symptoms may include going to the toilet more frequently, simply called 'frequency', and difficulty in getting urination started such that one needs to stand for 20 - 30 seconds waiting. Frequency may quite disabling as one may not feel confident to spend time where there is closely accessible toilet or at night it may disturb sleep. Urinary infection can cause frequency also but in this instance there is often a burning sensation when passing water, a condition that may be related to prostate conditions. A urinary infection can develop due to stagnant urine building up in the bladder if the bladder is incompletely emptied. Complete emptying is hampered by an enlarged prostate. Blood in the urine can be a sign of prostate disease but more usually it indicates a problem in the bladder or kidneys. If you have any of these symptoms you should see your doctor to have a PSA test and a digital rectal examination to assess the size and contour of the prostate. Symptoms may arise from the prostate for reasons other than pressure on the urethra from enlargement of the gland. If the prostate is inflamed then this may be painful and blood may be passed in the urine too. If you were unlucky enough to have an undetected aggressive prostate cancer then symptoms might arise from the places in the body where the cancer has spread to. Most likely this would be spread to various bones so continuous severe pain in the back, hip, thigh etc would be a bad sign that would need urgent attention. So there may be a variety of symptoms that point to a problem in the prostate gland but none is specific or even particularly concerning for prostate cancer except for the rare instances of bone pain. Therein lies the problem, that all men with any of these symptoms, and arguably any man over 50 with no symptoms, may have prostae cancer or a benign harmless enlargement of the prostate. Men with symptoms are advised to have a PSA test. But still the question arises, why would you wait for symptoms to occur before being tested?  

    Author: Dr Colin Clelland, Oxford Screening  

    What is Prostate cancer? - Blog  

    What is prostate cancer? Well let's start at the beginning! Cancer is a tumour, an abnormal mass, normally. Cancers like leukaemia do not always form a mass but fill the blood with cancer cells so that is why I said cancer normally forms a mass. But you may know that some tumours are called benign and are generally harmless where as cancer means a potentially harmful or lethal mass that can spread through the body. A good example of a benign tumour is a fibroid of the uterus that causes heavy periods and so the uterus may need to be removed for the symptoms but it is not a life threatening tumour. The effects it has are local and it slowly enlarges over time. Most benign tumours do not spread but there are always exceptions in medicine. In other circumstances a benign tumour can be dangerous for example if it is in the brain and presses on vital parts of the brain. At the other end of the spectrum are highly aggressive malignant tumours like high grade prostate cancer but included in prostate cancer are many types that are slow growing and these would be called low grade. So you can see that really there is a continuum of tumours from at one end, harmless benign tumours with tumours, in the middle, tumours that may be harmful over a prolonged period of time and at the other end, tumours that will threaten life in a matter of weeks or months. Cancers, malignant tumours often arise from cells that form glands, structure that produce something to help the body function. Stomach cells produce acid, salivary gland cells produce saliva and prostate gland cells produce semen to carry sperm. This type of cell is particularly prone to becoming cancerous presumably because these cells divide frequently as part of their normal life cycle. Uncontrolled growth of cells is the hallmark of tumours. There are two elements to uncontrolled growth of cells. The cells may divide faster than normal - excess prolifertion. Or the normal mechanism of cell death fails. In this situation the cells continue to divide at a fairly normal rate but as they are 'immortal' the result is that an abnormal mass is formed. One other characteristic of tumour cells is that they behave badly. Cells that are supposed to line a gland should line up in rows to form flat sheets that curl around to produce cup shaped structures with the product of the cells expelled into the cavity of the cup. Badly behaved tumour cells do not obey the normal cells instructions and they simply pile up on top of each other with no or few cup shapes. This is called differentiation, the closeness that the tumour resembles the normal tissue structure. Under the microscope this alteration in the structure that pathologists call architecture may be the only sign of cancer. The individual cells may look almost identical to normal cells. At the individual cell level microscopically the pathologist is looking abnormalities principally In the nucleus and this may be signified by a nuclear grade (usually high or low grade nuclei). The edge of a tumour may give away information about its behaviour too. Benign tumours will have a smooth edge and with regular growth ought to be generally round in outline. A malignant tumour may have an irregular edge,that pathologists call invasive as it infiltrates into neighbouring tissues rather than expanding like a balloon as would a benign tumour. To summarise a tumour a Pathologist will list various basic findings, benign or malignant and the cell type, that is to say in the case of prostate carcinoma it would be from a glandular cell and called an adenocarcinoma (by contrast, a benign tumour of a glandular structure is called an adenoma, similar by radically different in meaning. By using the term carcinoma it is by definition a malignant cancer so it is not usual to see a report saying malignant adenocarcinoma it would just read adenocarcinoma. The refinements to a diagnosis of adenocarcinoma of the prostate are important and these include a grade, how malignant the tumour appears. For prostate cancer this is expressed as a Gleason score. Other cancers may be scored simply by saying low grade, intermediate grade or high grade for increasingly abnormal appearing tumours. Confusingly there are other ways this may be expressed as outlined above, by the degree of differentiation, how much the tumour resembles the normal tissue in terms of its structure / architecture. The nuclear grade would be taken into account too with the final judgment reading as well differentiated, moderately differentiated or poorly differentiated for increasingly abnormal appearing tumours. Other terms that can be applied by pathologists to tumours include an aplastic and undifferentiated that both imply an aggressive tumour that does not resemble the tissue of origin at all and indeed there may be uncertainty about the origin of such tumours and the exact location of the tumour will be important in deciding its origin, for example whether it is mainly in the bladder or the prostate for example. Gleason grading is Aside from a diagnosis and a grade for the tumour it is important to establish its extent, the stage. An early stage tumour will be confined to the prostate. Examination of the edges of the prostate by a pathologist or examination of scans by a radiologist will show no sign of tumour breaching the outer limit of the prostate gland, the capsule. If the tumour does breach the capsule, the stage will go up. If the tumour has spread to bone then the stage will go up again so you can see that the stage is a measure of the extent of the tumour. The stage is useful to determine the appropriate treatment, for example, a small tumour confined to the prostate might be removed by surgery whereas a tumour that had breached the capsule might be better treated by radiotherapy. With this core information doctors can help patients to make informed decisions about their treatment.    

    Author: Dr Colin Clelland, Oxford Screening    

     

    Future blogs to include:

    Diagnosis of Prostate Cancer - Blog   PSA   Prostate biopsy   CT and MRI scan   Prostate chippings     Other Blog Topics   Prostate Cancer Risk Factors   Diet and Prostate Cancer   Genetics and Prostate Cancer   Raising Awareness of Prostate Cancer   Surgery for Prostate Cancer   Summary Of Treatments for Prostate Cancer   NHS Prostate Risk Managment Programme   Prostate Cancer Research   PSA Nomograms   Prostate Cancer Facts   Bibliography   Keywords / Abbreviations / Dictionary / Glossary   Your PSA is raised - What to say to your doctor          

    Author: Dr Colin Clelland, Oxford Screening  

 

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