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Prostate Cancer Assessment & Treatment

  • Prostate biopsy (including ultrasound / MRI fusion techniques)
  • Multiparametric MRI
  • Multidisciplinary team meetings on patient treatment options of surgery and radiotherapy
  • Publications on Dr Louie-Johnsun’s results on active surveillance and minimally invasive laparoscopic radical prostatectomy

What is the Prostate?

The prostate is a male reproductive organ located just below the bladder with the rectum sitting directly behind it. The prostate’s main function is to produce part of the ejaculation (seminal fluid) which carries the sperm which is made by the testes to the female for fertilisation. In younger men the prostate is about the size of a walnut. The prostate is like a doughnut surrounding the urethra (the tube that conveys urine from the bladder to the penis). The nerves that control erections surround the prostate.

Benign Prostatic Hyperplasia (BPH) – Non cancerous prostate enlargement

Benign Prostatic Hyperplasia (BPH) or enlargement is common in men as they get older. Some enlargement of the prostate is usual in most men from age 50 onwards. If the enlargement is sufficient to squeeze the urethra, which passes through the prostate, difficulties with urination may occur. Treatment of BPH may require medications or an operation to widen the urethral passage such as a transurethral resection of the prostate (TURP).

It is a non cancerous condition and symptoms include:

  • Lower urine flow with dribbling.
  • Reduction in strength of flow (not being able to hit the back of the pan).
  • Needing to strain or push to pass urine.
  • Feeling your bladder is not empty after you have finished urinating.
  • Urinating more frequently with urgency (need to hurry to the toilet and sometimes with leakage).
  • Getting up at night more frequently to pass urine.
  • Difficulty starting and stopping the flow.

Although early prostate cancer has NO SYMPTOMS, locally advanced prostate cancer can have similar symptoms.

What is my risk of Prostate cancer?

Each year in Australia, close to 3,300 men die of prostate cancer – equal to the number of women who die from breast cancer annually, making prostate cancer the second largest cause of male cancer deaths, after lung cancer. Almost one man in eleven will develop prostate cancer during his lifetime with around 20,000 new cases diagnosed in Australian every year.

The known risk factors for prostate cancer include:

  • Family history
    • A man with a father or brother with prostate cancer has about double the risk of prostate cancer compared to a man with no family history
    • Risk is further increased if the cancer was diagnosed in family members at a younger age (less than 55) or if it affects more than one family member
  • Age
    • Older men are more likely to develop prostate cancer
  • Race
    • African Americans have more than double risk and Asians are at lower risk than caucasians
  • Diet
    • High saturated fat diet may increase the risk of prostate cancer
    • Some dietary factors may be important in the primary prevention of prostate cancer such as lycopenes, Vitamin E, soy products (isoflavonoids) and some fruit and vegetables

What is prostate cancer?

Prostate cancer occurs when cells of the prostate reproduce far more rapidly which is unregulated and uncontrolled causing a swelling or tumour. However, unlike BPH, prostate cancer cells can eventually break out of the prostate and invade distant parts of the body, particularly the bones and lymph nodes, producing secondary tumours, a process known as metastasis. Once the cancer escapes from the prostate, treatment is possible but “cure” becomes less likely.

Prostate cancer is usually one of the slower growing cancers. What is complicated with prostate cancer is that some cancers grow very slowly and don’t threaten life, whilst others grow rapidly and do pose a threat. Prostate cancer is often encountered in men over 70, and some of these men die of other causes before their prostate cancer can kill them. This led to the saying “most men die with, not of, prostate cancer”. However, this is not entirely true and the reasons are:

  • Men are living longer, giving the cancer more time to spread beyond the prostate, with potentially fatal consequences.
  • More men in their early sixties, fifties and even forties are being detected with prostate cancer. Earlier on-set, combined with the greater male life expectancy, means those cancers have more time to spread and become life-threatening unless diagnosed and treated.
  • Prostate cancer in younger men often tends to be more aggressive and hence more life-threatening within a shorter time.

How is prostate cancer diagnosed?

Prostate cancer can be cured if detected early and treated while still confined to the prostate gland. Early detection is the key to enabling better outcomes and potential cure of prostate cancer. The tests for prostate cancer are the prostate specific antigen (PSA) blood test and the digital rectal examination (DRE). These tests do not give a conclusive diagnosis of cancer but can predict the risk of prostate cancer and the need for further investigations such as a prostate needle biopsy.


PSA or Prostate Specific Antigen is a protein that is produced exclusively by the prostate. Its role is to liquefy the seminal fluid to assist in fertilisation. The presence of an elevated PSA result on a blood test can indicate prostate cancer although there are other common causes for a PSA result outside the normal range such as

  • Prostate infection (prostatits) or urinary tract infection
    • usually associated with symptoms of burning on urination, with frequency, urgency and cloudy odorous urine and a fever can also be present
  • Enlarged prostate
    • PSA usually only rises slowly over time however
  • Recent prostate operation or urethral instrumentation
    • This includes insertion of urethral catheters but generally not rectal examinations
  • Recent ejaculation (sex or masturbation)
    • This usually only causes a mild rise in the PSA

As a general rule, the higher the PSA result the greater the chance that prostate cancer is present. Where cancer is present, the PSA can predict the volume of disease and likelihood of spread to other organs (metastases). Other PSA parameters that Dr Louie-Johnsun will discuss with you can also give an indication of prostate cancer including PSA velocity (change in PSA over time) and free to total PSA ratio. As a general rule, the higher the PSA result the greater the chance that prostate cancer is present. Newer methods of determining prostate cancer risk and aggressiveness such as Prostate Health Index (PHI) and urinary markers PCA3 can also be discussed with Dr Louie-Johnsun.. Newer methods of determining prostate cancer risk and aggressiveness such as Prostate Health Index (PHI) and urinary markers PCA3 can also be discussed with Dr Louie-Johnsun.

If you have a single elevated PSA reading, Dr Louie-Johnsun will usually suggest a repeat PSA (with free/total ratio) and urine test to exclude infection with abstinence of ejaculation for 72 hours prior to recommending a biopsy or further investigations.

Should I have a PSA test?

The European Association of Urologists (EAU) has recently updated their guidelines for the detection of prostate cancer (Eur Urol 2013; 64: 347-354) and has made the following statements based on the best available current evidence:-

  • Early detection of prostate cancer reduces prostate cancer-related mortality (by 21-44%).
  • Early detection of prostate cancer reduces the risk of being diagnosed and developing advanced and metastatic prostate cancer (by 30-49%).
  • A baseline PSA level should be obtained in men 40 – 45 years of age (men aged 45 years who have a PSA greater than or equal to 1, and men aged 60 years who have a PSA greater than or equal to 2, have a significantly greater risk of dying of prostate cancer).
  • Intervals for early detection of prostate cancer should be adapted to the baseline PSA level (a safe screening interval for patients with a PSA within these limits could be up to 8 years, whereas patients with a PSA outside these limits need to be screened every 2-4 years).
  • PSA screening should be offered to men with a life expectancy of 10 years or more (there is little evidence of benefit in screening elderly men).

With the above medical evidence, Dr Louie-Johnsun recommends in accordance with the USANZ 2009 PSA Testing Policy.

  • Men with NO family history should be tested with annual DRE and PSA from age 50-70
  • Men with a family history (especially if first degree relative) should be tested from 40
  • A single PSA from 40 can help stratify future risk based on median PSA levels

Some men, when enquiring about prostate cancer, may be confused by conflicting views expressed about methods of diagnosing and treating the disease. Perhaps the most controversial is the view that it would be better for men not to know whether they have the disease and therefore they should not be tested or treated.

Every man should make their individual choice on whether to be tested for prostate cancer and should initially hold this discussion with their GP

Digital Rectal Examination (DRE)

DRE involves inserting a gloved finger in the anus to feel the back wall of the prostate as it lies just in front of the rectum. This gives information about the overall size of the prostate as well as possible tenderness to suggest prostate infection (prostatitis) and most importantly the presence of abnormal nodules, asymmetry and hardness to raise the suspicion of prostate cancer. This assessment must be used together with a PSA as a normal DRE does NOT exclude prostate cancer as the entire gland cannot be palpated via a DRE.

Prostate Needle Biopsy

If there is sufficient suspicion of prostate cancer risk based on DRE and PSA (and sometimes other factors including family history and MRI findings if performed), the definitive procedure to diagnose prostate cancer is a prostate needle biopsy. This involves taking multiple samples of the prostate, which can be done in a few ways:

  • Transrectal Ultrasoud (TRUS) Guided Prostate Biopsy

    Worldwide, (and in Australia) this is still the most common method used by Urologists to biopsy the prostate. The procedure is most often performed under local anaesthetic (although it can be performed under general anaesthesia in hospital if requested) with the patient on their side and a small ultrasound probe inserted into the anus to produce an image of the prostate. A systematic biopsy of all areas of the prostate via the rectum is performed and if abnormal areas are detected further biopsies are taken from these areas.

  • Transperineal Grid Biopsy of the Prostate

    This newer method of biopsying the prostate must be performed under a general anaesthetic as needles are passed via the skin overlying the perineum (between the scrotum and anus). Imaging is obtained by an an ultrasound probe in the rectum.

    Dr Louie-Johnsun can offer this method of biopsy to his patients at either Gosford Private Hospital or the SAN Hospital in Sydney.
  • MRI-Ultrasound Fusion Prostate Biopsy

    This is a developing technology, in which a previously performed prostate MRI is fused with real-time ultrasound using a digital overlay, allowing the target(s), previously delineated by a radiologist on MRI, to be “fused” into the aiming mechanism of the ultrasound guided biopsy. MRI–ultrasound fusion will likely result in fewer and more accurate prostate biopsies than the present use of systematic biopsies.

    Dr Louie-Johnsun now performs this technique.

Biopsy Outcomes

The prostate biopsies will be analysed by a pathologist to determine the grade (severity) and volume of prostate cancer if present. The results will be discussed at the time of your follow up usually 2 weeks after your biopsy.

What Should I Expect after a Prostate Needle Biopsy?

After the procedure, expect:

  • Pain around the prostate / perineum for a day or two
  • Blood in the stool for a few days
  • Blood in the urine for a few days and up to two weeks
  • Blood in the semen (ejaculate) for up to 2-3 months

Please be aware that all of the above will occur, but will resolve. Usually, you should have 1-2 days off work.

Risks and Complications

  • Heavy bleeding requiring hospital admission, dizziness, and difficulty passing urine requiring catheterisation are uncommon problems after a biopsy.
  • Infections after a biopsy are also uncommon but can be very serious. Dr Louie-Johnsun will reiterate the importance of presenting to hospital immediately if you feel unwell with fevers, chills and weakness after a biopsy. The risk can be increased with recent overseas travel to certain destinations.

Please refer to Dr Louie-Johnsun’s Prostate biopsy information sheet for further information including preparation for your biopsy eg antibiotics schedule.

Multiparametric MRI

Recent developments in magnetic resonance imaging (MRI) have improved the ability of MRI to detect tumours, stage cancer and help in management decisions using multiparametric techniques.  They are also helping to more accurately target biopsies as detailed above on MRI-Ultrasound Fusion Prostate Biopsy. Dr Louie-Johnsun is finding the benefits of multiparametric MRI particularly in men with previous negative prostate biopsies and a rising PSA, planning surgery or radiotherapy especially in high risk disease and monitoring men on active surveillance.

Treatments for Localised Prostate Cancer

Please note only widely accepted mainstream treatment options are discussed in this section that have long term proven successful results in the treatment of prostate cancer. Experimental and novel treatments with no long term data are not detailed.

Surgery – Radical Prostatectomy

Surgery for prostate cancer is called radical prostatectomy (RP). It involves complete removal of the prostate gland and some of the tissues around it including the seminal veiscles. The primary goal of the surgery is to remove all the prostate cancer whilst maintaining urinary and erectile function as urinary incontinence and erectile dysfunction are the two main long term side effects.

A radical prostatectomy can be done in a number of ways:

  • Open– This is the traditional approach with a cut from below the navel to the pubic bone
  • Laparoscopic (keyhole)– This is performed with 5 small cuts with the benefits / advantages including improved visualization, reduced blood loss and transfusions, reduced post operative pain, fewer wound complications, a shorter hospital stay and earlier recovery with a more rapid return to normal activity and work.- Read more
  • Robotic assisted- This is a similar approach to laparoscopic surgery but the surgeon uses an expensive machine to assist them to perform the surgery. As detailed by the Prostate Cancer Foundation of Australia, there is no difference in outcomes between laparoscopic and robotic assisted approaches. Dr Louie-Johnsun is able to arrange your robotic surgery if requested at the SAN hospital.

Image Guided and Intensity Modulated Radiotherapy (External Beam)

Image guided radiotherapy (IGRT) and intensity modulated radiotherapy (IMRT) are two newer external beam radiotherapy techniques that allow the radiotherapy beams to best target the prostate and spare the surrounding normal tissues. Duration of treatment is for five days a week for approximately seven weeks.

IMRT uses dozens of mini-beams of radiation in order to ensure the prostate is completely covered with high doses of radiation whilst minimizing the doses to surrounding normal tissues. IGRT allows the treatment machines (linear accelerators or “linacs”) to target the prostate more accurately. IGRT usually requires insertion of gold seeds (or “fiducial markers”) as a one-off procedure prior to the course of IMRT. The fiducial markers (which can be placed under local anaesthetic transrectally similar to a biopsy) allow the linacs to see where the prostate is before each treatment to ensure the prostate is targeted and normal tissues are avoided. Hormonal therapy immediately before or after radiation is usually a part of the treatment.


This is a more recent development in radiation treatment with radioactive seeds placed directly in the prostate. There are 2 forms of brachytherapy:

  • Low Dose Rate (LDR) Brachytherapy

    Permanent radioactive seeds are placed through the skin between the scrotum and anus (perineum) under a general anaesthetic with a short hospital stay. This treatment is best suited for men with low risk disease who have a small prostate and minimal urinary symptoms with at least a 10 year life expectancy. Common side effects include urinary frequency and urgency and although erections may initially be preserved, they can deteriorate over time.
  • High Dose Rate (HDR) Brachytherapy

    This treatment is usually reserved for men with high risk localized prostate cancer and involves temporary placement of radioactive seeds directly into the prostate which is followed by external beam radiotherapy. It is combined with a course of hormone therapy. 

Active Surveillance (Delayed Definitive Treatment)

  • Why Consider Active Surveillance?
  • Who is Suitable for Active Surveillance?
  • Advantages of Active Surveillance
  • Disadvantages of Active Surveillance
  • When will definitive treatment (surgery or radiotherapy) be recommended/offered?

For some patients with low volume, low risk prostate cancer it may be reasonable to observe the cancer with serial PSA measurements (blood test), prostate rectal examination (DRE) and periodic prostate biopsies and intervene with curative intent if there is progression of the disease.

Dr Louie-Johnsun strongly advocates active surveillance for appropriate prostate cancer patients. He has presented his cohort of patients on Active Surveillance in state and national meetings and in fact has published one of Australia’s first series on Australian men living with prostate cancer on active surveillance with results confirming minimal anxiety and minimal effects on quality of life.

Why Consider Active Surveillance?

Not all prostate cancers that are detected are considered to be clinically significant. Active surveillance aims to prevent the overtreatment of clinically insignificant cancersthat may never cause you a problem.

Who is Suitable for Active Surveillance?

The criteria for active surveillance are yet to be fully defined and validated but generally include low volume, low risk, low grade cancer in patients with a life expectancy of at least 10 years. For example:

  • PSA<10
  • Normal rectal examination (Clinical stage T1)
  • Gleason Score <6
  • <3 prostate biopsy scores positive for cancer (with <50% any core involved)

IF YOU FALL JUST OUTSIDE THE ABOVE CRITERIA, YOU MAY STILL BE A CANDIDATE FOR ACTIVE SURVEILLANCE. The timing of when to intervene is ill-defined and studies are currently underway to determine what constitutes disease progression and when to intervene.

Advantages of Active Surveillance

  • Aims not to over-treat a potentially clinically insignificant cancer.
  • Avoids the complications of treatment.
  • Quality of life is maintained.

Disadvantages of Active Surveillance

  • The cancer may progress or spread while on surveillance
  • Patient and family anxiety associated with living with untreated cancer
  • The need for close follow-up

When will definitive treatment (surgery or radiotherapy) be recommended/offered?

  • Evidence of disease progression(increased volume, Gleason score on repeat biopsy or rising PSA or abnormal rectal examination with MRI abnormalities).
  • Patient makes informed decision for treatment(This may be due to patient wishing NOT to have regular testing/biopsies or anxiety of disease progression).

Advanced Prostate Cancer

Advanced prostate cancer is defined as prostate cancer that is not curable and is no longer confined to the prostate. Prostate cancer typically spreads to lymph nodes in the pelvis and to the bones and is more likely with late diagnosis with higher PSAs (eg >20) and higher Gleason Scores (8-10).

Unfortunately surgery and radiotherapy have a more limited role in these situations and often hormonal therapy (androgen deprivation therapy) is needed.

Hormone Therapy (Androgen Deprivation Therapy)

Testosterone is a male sex hormone which helps the prostate and prostate cancer cells to grow larger. Hormone therapy involves stopping the production of testosterone or blocking testosterone from reaching the prostate cancer cells. Historically, reduction of testosterone production required the surgical removal of the organs that produce testosterone i.e. the testicles (orchidectomy) but now the same effect is achieved with medications.

  • Drugs that stop production of testosterone: Luteinizing hormone-releasing hormone (LH-RH) agonists and antagonists are given by injections monthly to 6 monthly.
  • Drugs that block testosterone from reaching cancer cells: Anti androgens are taken orally.

Side Effects of Hormonal Therapy (ADT)

Although not all patients will experience all the side effects, they include:

  • Sexual dysfunction – loss of libido and erections
  • Hot flushes
  • Tiredness (fatigue), depression
  • Weight gain, loss of muscle mass and strength
  • Thinning of bones (osteoporosis)
  • Breast pain

Treatment with Hormones (ADT)

Hormone therapy can often be used intermittently when the PSA is low and stable known as “intermittent therapy”. However, there can come a time when the prostate cancer cells are no longer responsive to hormonal therapy known as “hormone refractory” or “castrate resistant” prostate cancer. Unfortunately this is when prostate cancer begins to progress and a referral to a medical oncologist is required to consider systemic therapies such as chemotherapy.