What is low-risk prostate cancer? Podcast Interview with Urologist, Mr Kevin Chu

16th August 2019

Research Nurse, Natalie Richards talks to urologist, Mr Kevin Chu about how prostate cancer is diagnosed, the tests involved and teasing out the differences in treatment pathways . Kevin is a train robotic surgeon with an interest in cancer and minimally invasive surgery.

Transcript

Because prostate cancer is so slow growing, often men don’t need treatment at all. However, they may feel that they needed something done about it. What’s the right treatment for one patient with the same clinical characteristics may not be the right choice for a different patient. It’s important for you to get the right information from the right people.

Natalie: Hello and welcome to Navigate Prostate, providing information and insights for people affected by localised low-risk prostate cancer, which is early stage and slow growing. Hi, my name is Natalie Richards. I’m a research nurse at Peter McCallum Cancer Centre in Melbourne. Getting your cancer diagnosis could be really overwhelming, and it’s sometimes hard to work out what information you can trust and whether you are making the right decision. Today, we’re talking with urologist Mr Kevin Chu about how prostate cancer is diagnosed, the tests involved and teasing out the differences in treatment pathways. Kevin is a trained robotic surgeon with an interest in cancer and minimally invasive surgery. Welcome, Kevin.

Kevin: Thank you very much for having me, Natalie.

Natalie: So firstly Kevin, can you explain for our listeners what is your role as a urologist and why are men referred to a urologist when prostate cancer is first suspected.

Kevin: Well, urologists deal with all aspects of men’s health and that goes for the kidneys, bladder and the prostate. So prostate cancer is very, very common. It’s one of the most common cancer diagnosis on the second highest killer of men diagnosed with cancer. Because prostate cancer is so common, GPs will often screen patients for prostate cancer with a blood test called a PSA blood test that stands for Prostate Specific Antigen. When the PSA is elevated, the patient will be referred onto a urologist to work out what the likelihood of cancer is. The PSA can be elevated for a number of reasons. One of those is prostate cancer. But any kind of infection of the urinary tract or just normal enlargement of the prostate can cause the PSA to raise. It’s the job of the urologist to work out which one of those it is.

Natalie: Okay. In terms of that PSA test, if you’re over forty, so my partner has actually just been invited to have his first PSA test, so it is probably from a personal perspective as well. So it’s just a standard blood test. Is that correct?

Kevin: It is, that’s correct. It’s just a standard blood tests, which can be done with all your other blood tests, such as your renal function and your full blood count and your cholesterol.

Natalie: Okay. His father’s just had surgery for prostate cancer, so he’s probably more considered high risk. So once those results come back, what’s decided with that result?

Kevin: So it depends on what age he is and how high that blood result comes back. If it’s elevated, then he should be referred onto a urologist for consideration of what needs to be done next. So the PSA or prostate specific antigen is an indicator that the patient might have prostate cancer. It certainly doesn’t mean they do have prostate cancer.

Natalie: For someone newly referred by their GP to a urologist, they’ve got an elevated PSA. What tests or what’s the next step? What’s involved?

Kevin: Sure. So generally I don’t do anything on a single PSA reading, so more than likely they are to get a repeat PSA reading. And I’ll also organise a subset of the PSA called a free to total ratio. This helps us work out the likelihood of prostate cancer.

Natalie: What’s the time frame from when the first one was conducted to the second one happening?

Kevin: I generally like to wait a month between the two tests, but there is also other information we need to know. As I’ve mentioned it is a disease of a ten or fifteen years life expectancy that they need to have. So we need to work out what their medical co morbidities are. We need to work out whether they have any symptoms. Such as difficulty weeing, which may be which may be another cause of an elevated PSA. And we need to work out what medications that they are on and any significant family history of prostate cancer. If  the PSA is elevated and the patient’s suitable, then the next stage will probably be a MRI and a prostate biopsy.

Natalie: So in terms of the having an MRI and a biopsy, what’s involved with that?

Kevin: Well, we’re using MRI more and more. The MRI scan has recently been approved by Medicare, so it’s now funded, whereas previously patients had to pay up to $400 for a scan. So that’s great news that patients can get this scan for free.

Natalie: And for the listeners who aren’t familiar with what an MRI scan is, can you just briefly explain what that is? What it involves.

Kevin: An MRI is a Magnetic Resonance Imaging scan and involves a patient going through a tube with magnets inside, and it gives us images of the prostate. It could be used to help diagnose prostate cancer.

Natalie: So when you say it can help diagnose prostate cancer, is that where it can look at kind of the hot spots for cancer cells potentially.

Kevin: That’s right. The pictures show the prostate gland and it can show areas where there might well be prostate cancer in there. It’s not a definitive test. The biopsy is the definitive test.

Natalie: Why is the biopsy the definitive test?

Kevin: Well, with the biopsy, what happens is the tissue goes off to the histopathologist and they look at it under a microscope and work out whether there is or is not prostate cancer there at all. The MRI just gives us the clues to where to search best.

Natalie: With the results of the biopsy, can you just tell us about the results and how that guides the decisions around treatment?

Kevin: Well, when a patient diagnosed with cancer, it’s very important to know three things. Those three things are: the exact type of cancer, what the grade of the cancer is, and what the stage of the cancer is. So with regards to the type of cancer, most prostate cancer is what’s called a adenocarcinoma and that simply means a cancer of the gland, and the prostate is a gland. By far, in the majority of prostate cancers will be this adenocarcinoma . There can be subtypes of this. Which are more aggressive or less aggressive. But that’s usually it’s just the standard type.

Natalie: Where does the Gleason score come into all of this? Because there’s lots of information, and certainly a lot of people are out there Googling ‘Gleason score 6’ ‘Gleason score 7’, because we are talking about the low-risk prostate cancers not the more aggressive cancers. Can you explain that a bit more about what the Gleason scores mean?

Kevin: Of course. So I mentioned there was three things that are important. The type, the grade and the stage. The Gleason score is a grading system, so is involved in the grade of the prostate cancer. What a grade of a cancer is is how the cells of the cancer look under the microscope. Cancer is not necessarily a yes/no thing. There’s different grades of which cancer might be. So normal cells have different stages, it’s all a spectrum. So the normal cells may be very normal and then get increasingly abnormal. And somewhere we draw a line in the sand where we say this amount of abnormal is cancer. But that doesn’t stop there. They can continue to be more abnormal until we can’t even recognise what the original cell is. So with prostate cancer, unfortunately, the grading system is a little bit confusing. When the pathologist look at the cancer cells under a microscope, they assign a score which essentially goes from 3-5. We used to diagnose 1 and 2, which is why the score starts at that number, but 1 and 2 is rarely diagnosed these days, so the score goes from 3 to 5. So essentially, when they look at it under a microscope, it can either be a 3, 4 or 5, or if you like to think it in simple terms, low, middle, high. What they do when they look at these specimen, they look for the most common pattern and the second most common pattern and then add these two numbers up. So if it was all three or all low, then it will be 3+3=6, which is what the total Gleason sum score is. If it’s all aggressive, it might be 5+5=10 and everything in between.

Natalie: Okay, that really clears that up for me as well, actually, because I thought it was actually just a grade of six, it wasn’t the three plus three of the different kinds of cells.

Kevin: That’s right. Unfortunately it can be quite confusing

Natalie: Where you can have some more aggressive cells and some less aggressive cells.

Kevin: Correct. For example, if there was a lot of four and then a little bit of three, you will be a 4+3=7.

Natalie: And is that what’s considered intermediate risk?

Kevin: So we divide cancers into low, intermediate and high risk. If it’s just Gleason 6 then we call that low-risk. Gleason 7 is intermediate risk but that comes in two types . A 3+4=7, which is more favourable, and a 4+3=7 is less favourable. Eights, nines and tens are high risk.

Natalie: Goodness, so it can get quite confusing to interpret.

Kevin: Yes, patients need to be a little bit careful about where they look for information. There’s a lot of misinformation out on the World Wide Web.

Natalie: Absolutely. So prostate cancer is the most commonly diagnosed cancer in Australian males, as you’ve earlier said Kevin. Can you explain a bit more about the different stages of prostate cancer and how this might impact on the treatment choices and the urgency around treatment?

Kevin: Of course. As I said earlier, three important things to know. We’ve talked about that type, we’ve talked about the grade, and the third important thing to talk about is the stage. So the stage of cancer relates to where it is in relation to the organ we’re talking about and where it is in relation to the rest of the body. So most cancers are staged with what’s called a TNM classification on that stands for Tumour, Nodes and Metastases. So the tumour generally refers to where that cancer is in relation to whatever organ it is. So for prostate cancer, a T1 tumour is a tumour that can’t be felt on the prostate. A T2 tumour is where we feel a lump but it’s all confined to within the prostate. A T3 tumour is where it’s begun to breach the gland and beginning to spread outside the prostate and T4 is where it’s invading in other organs. Then we need to consider the Nodes, whether the local lymph nodes were involved, and then metastases whether it’s spread to other organs, such as bone or different or beyond that. So a low-risk prostate cancer would have a PSA under ten, no nodule or just a small nodule and Gleason 6 would be low risk prostate cancer.

Natalie: Once you’ve got the results and the patient presents to you and you talk about the results, how might this impact on the treatment choices, the urgency around treatment and what advice you would give your patients.

Kevin: I think when generally talking about low risk prostate cancer here, generally in low-risk prostate cancer, so low Gleason score prostate cancer with a PSA of under ten, I actually generally don’t recommend staging investigations. Because the chance of this cancer spreading is very, very low, so they don’t need any further investigating in terms of whether looking for whether it’s cancer outside the prostate. Generally, we would advocate for active surveillance. This is generally keeping an eye on the cancer because it doesn’t need treatment at the moment. We do need to monitor cancer to see whether it develops and whether treatment might be needed in the future. Because prostate cancer is so slow growing, often men don’t need treatment at all for their prostate cancer. One of the things we can do is what’s called active surveillance. We can keep an eye on the prostate cancer and see whether it develops or not. If it doesn’t develop, then it doesn’t need any treatment. This form of active surveillance means we don’t need to treat or over treat men and because of that, we minimise the side effects to patients.

Natalie: And what are the tests involved with active surveillance?

Kevin: For active surveillance, the things we would do is: a rectal exam, repeated PSA test and then MRIs and re-biopsies. These will generally follow a schedule, but the schedule may change depending on what the results of the rectal exams and PSA tests are. Generally, the PSA test would be done every three months in the first instance

Natalie: And then, if the results look stable then you would spread that out?

Kevin: So the standard protocol would involve a PSA every three months for the first year, an MRI scan and re-biopsy at the first year and then MRIs and biopsies every three years thereafter. The PSA schedule can be spread out if everything remains stable.

Natalie: And in terms of those appointments, does the patient get a reminder from yourself ? Or does the patient need to remember to go back to you? Or do they in fact, go back to their GP for those follow up appointments?

Kevin: So that depends on which institution you are going to. I would generally follow the patient up and book in appointments for them every time I saw them; I would book in the next appointment at that time.

Natalie: When do you start for that low risk group – I think this may be coming into the intermediate risk potentially. But when do you start saying, “Look, you could have surgery, you could have radiotherapy. You could go into an active surveillance management plan.” And there’s more than one up option, which can get tricky for the patient to make that decision. And, you know, of course, they need to be involved in that decision making process.

Kevin: Of course, it’s very important that patients are involved in decision making processes. Prostate cancer, although we classify them in to low risk, intermediate risk and high risk, they don’t necessarily – it is all a bit of a continuum. It all depends on how much Gleason six prostate cancer there is, how much volume there is, whether it’s in multiple segments of the prostate, what their PSA is, what their PSA velocity is. There’s very many factors involved. Certainly is very clear for the very, very low-risk prostate cancer that we should be keeping an eye on things. If things are starting to fall [into the] towards the intermediate risk, then we can think about treatment for these patients. Although some patients will opt for treatment even if their prostate cancer is very low risk.

Natalie: Yeah, that was one thing that I wanted to ask you about. What are you finding with the patients that you do see? Do they lean – You know where they may have the same profile, clinical profile – but they make very different decisions. Where one may decide to just be monitored and [the other] another patient may decide, “No, I need to get this cancer out.”

Kevin: Correct. So unfortunately medicine is not a one size fits all in terms of treatment options. What’s the right treatment for one patient with the same clinical characteristics may not be the right choice for a different patient because of things like side effect profiles of different forms of treatment. So generally, if a patient had very low-risk prostate cancer, we would advocate for monitoring – active surveillance. However, if they were particularly anxious about their prostate cancer, they may feel that they needed something done about it. For example, surgery.

Natalie: And in terms of the side effects of that treatment, for example, surgery or radiotherapy – for people listening, for men that may be going through a diagnosis at the moment and deciding on their treatment, and their partners and their family. What are some of the side effects of that treatment that they should also be considering or asking the questions about?

Kevin: Absolutely. So for surgery, there’s two main side-effects. The prostate acts as a kind of stopper, so when we take that away, they lose this stopper for the urine and therefore they may develop incontinence or leakage of urine. We call this Stress Urinary Incontinence for men, and this is leakage of urine when they cough or sneeze or get up out a chair. After surgery, this improves over time. It may take up to a year for them to improve to their maximum. At a year, about ninety or ninety-five percent men will be happy. By happy I don’t necessarily mean completely dry. They may leak a little bit when they cough or sneeze or swing a golf club. They may need to wear a security pad, but realistically, there going to be much the same position as a lady that had had a couple of children of the same age.

Natalie: Are there any other key side effects of surgery?

Kevin: The second main side effect is that the nerves for erections run very close to the prostate. Now, depending on the degree of cancer, we can attempt to spare these nerves, but either way, the erections may well be affected. Again, this will improve over time, but it does take up to a couple of years for the erections to improve.

Natalie: And the other common treatment is radiotherapy or another option.

Kevin: That’s right. There’s two main types of radiotherapy. External beam radiotherapy where beams of radiation come from the outside. Or low dose brachytherapy, which involves putting radioactive seeds inside the prostate and those seeds emit the radiation.

Natalie: And so, with radiotherapy, common side effects that someone needs to consider.

Kevin: So for the radiotherapy side effects, the problem is you can’t just get the radiotherapy just into the prostate. So the organs around the prostate do get irradiated to some degree. The most common organs to be affected are the bladder and the bowel, so the patient may get side effects from these. So with the bladder, they may get blood in the urine. They may get irritation of having to rush the toilet. They may get frequency of urination. With the bowels, they might get diarrhoea, blood in the stools and urgency of going to the toilet for the bowels.

Natalie: If the patient went down the course of radiotherapy treatment, do you refer the patient on or do you manage the care for that particular part of treatment?

Kevin: So I always recommend to men to see a radiation oncologist to discuss the options with their [radiation oncologist]. I’m a surgeon so I don’t deliver radiation. Therefore, it’s important that men see a radiation oncologist to discuss the intricacies of that kind of treatment with them. And they will be the one to deliver those treatment, and they will be involved in the aftercare of that treatment.

Natalie: So that’s a perfect segue way into my next question. For those still considering their treatment choices or are wondering if they’d in fact made the right decision about their cancer treatment. What is your advice?

Kevin: So just like I said, it’s important for you to get the right information from the right people. So I’d recommend seeing a surgeon, seeing a radiation oncologist, and talking to other people that might be able to help. Getting information from websites that are of good standing. And we would recommend websites such as the Cancer Council , the PCFA or Prostate Cancer Foundation for Australia. And of course, they can use our Navigate website, which helps men make those treatment decisions for prostate cancer. Other things they should consider are speaking to a prostate cancer nurse or any friends and relatives, and also their GP with regards to what are their treatment options like. The more information they get the better.

Natalie: But to get the right information and not listen to the outside noise that may not actually be helpful in your journey of deciding what to do.

Kevin: True. I’d avoid things like testimonies because they just show one person’s story and stick to governor approved websites. I think the main point of core would be your GP, your family doctor. They’ll be able to appoint you in a good direction for websites and resources that are helpful.

Natalie: If you have recently been diagnosed with localised low-risk prostate cancer and are listening before June 2020, please consider joining our research trial to help navigate your treatment options. This podcast is part of an NHMRC funded project sponsored by Swinburne University and a collaboration with leading academic institutions, prostate cancer organisations and hospitals. Go to www.navigateprostate.com.au where you can check your eligibility and register. If you’ve got questions for us, we’d love to hear from you. Please email [email protected] If you have any questions you need answered now called Cancer Council 13 11 20 from anywhere in Australia and talk to a health professional for information and support. The stories and experiences contained within this podcast represent the views and opinions of the speakers. We recommend that you obtain independent advice specific to your circumstances from your health professional.

If you are reading this article before June 2020 and have recently been diagnosed with early-stage, low-risk prostate cancer, please consider joining our research trial www.navigateprostate.com.au to help navigate your treatment options.

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