If only a small amount of slow growing (low grade) prostate cancer is found, a ‘wait and see’ policy may be chosen to assess if the cancer is growing quickly enough to warrant treatment. This is because multiple studies have now demonstrated that low grade prostate cancer will not spread or lead to death.

This does not mean doing nothing but involves a series of tests to decide what threat the cancer poses, and to monitor this carefully over time. If there are signs the cancer is growing or becoming more aggressive (higher grade) then curative treatment can be undertaken.

Tests used to monitor the prostate include:

• PSA testing, including:

o Age adjusted PSA levels

o PSA velocity – how quickly it is rising

o PSA density – adjusting for the prostate size

• Prostate MRI

• PSMA PET scanning

• Repeat prostate biopsy

If treatment is ultimately required, it may be in the form of curative treatment (such as surgery or radiotherapy), or control with hormonal therapy (particularly in the elderly or those with other medical conditions posing a more serious threat)

Radical prostatectomy historically was performed as an open procedure, most often through a cut between the belly button and pubic bone.

From 2000, keyhole approaches to this operation were developed, called laparoscopic radical prostatectomy. This approach offered advantages include a better view of the operation for the surgeon, less blood loss, a shorter hospital stay and a quicker recovery.

A further advancement in key-hole surgery was the development of a robotic system that enhances the visualization and precision of the procedure. The first robotic surgical procedure was performed in Australia in 2003. This system replicates the surgeon’s hand movements with instruments that articulate in all dimensions and eliminate tremor, with a full 3D image of the anatomy.

Robotic surgery has steadily replaced open surgery in a number of areas, particularly in prostate cancer surgery, where a meticulous technique is required to preserve the fine and fragile structures involved in bladder control and erectile function. It has been proven in the only randomised trial comparing open and robotic surgery to offer a safer procedure with lower risk of complications. Robotics does require subspecialised training however, and the best results are seen in centres or surgeons performing a high volume of procedures.

Radiotherapy is the delivery of radiation beams at the prostate, aiming to destroy the cancerous cells, with minimal impact on surrounding normal structures (bladder, urethra and rectum). It can also be used in a palliative setting, directed at areas of cancer outside the prostate, eg for relief of bone pain due to cancer spread.

Radiotherapy can be administered like an X-ray, by directing the beam from outside the body onto the prostate (external beam radiotherapy), or by inserting radioactive ‘seeds’ or needles into the prostate (brachytherapy). Following radiotherapy, the PSA slowly declines and is monitored to assess the success of treatment, although this can take up to 12-18 months.

While most prostate cancer is “multifocal” – occurring in multiple parts of the prostate at the same time, some men have prostate cancer in just one area of the prostate. This can be confirmed through systematic biopies, along with imaging of the prostate using MRI and PSMA-PET scanning. In these men it may be possible to treat just this area of the prostate using techniques such as:

- Nanoknife – uses electrical currents to treat the tumour

- High Intensity Focused Ultrasound (HIFU)

- Focal brachytherapy

Advantages of this form of treatment include avoiding side effects of treating the whole prostate through surgery or radical radiation therapy, and still having the option of radical prostatectomy if the cancer grows back. Disadvantages include the need for closer monitoring after treatment including repeat biopsies to assess treatment success, the higher risk of recurrence, and the lack of long term outcome data, as this form of treatment is relatively new.

This treatment is usually offered to patients in whom the cancer has spread beyond the prostate, eg to lymph glands or bone. Prostate cancer is partly driven by the male hormone, testosterone, which is made by the testicles. By stopping the production of testosterone, the cancer usually significantly shrinks in size throughout the body, and is held dormant for a period of time that may last many years. Ways to achieve this consist of either:

• surgically removing the testicles (orchidectomy) taking medications, or

• 3-6 monthly injections to ‘turn off’ the testicles.

The effectiveness of treatment can be monitored by the PSA reading, which quickly drops in most patients.

Side effects are those of a loss of the male hormone and are similar to the menopause experienced by women as they lose their female hormones.

These may consist of fatigue, loss of libido, loss of erections, hot flushes, tender or enlarged breasts, loss of muscle bulk.

Over time the bones may lose strength (osteoporosis) with increased risk of fracture, and therefore it is recommended to have regular bone density scans.

Hormonal therapy is not a cure, as with time the cancer begins to grow again despite the treatment, but is an effective control that in some patients can last for a long period of time.