Men’s health

Mr Williams Mr Williams is 56, African-Caribbean and comes to see you with a 6month history of increasing difficulty passing urine and nocturia x2. He wonders if he should have his prostate checked for cancer.

Prostate cancer and ethnicity White per 100,000 Asian Black Cancer research UK

Risk GroupRR for Prostate Cancer (95% CI) CI = confidence interval; FDR = first-degree relative. aAdapted from Kiciński et al.[25]25 Brother(s) with prostate cancer diagnosed at any age 3.14 (2.37–4.15) Father with prostate cancer diagnosed at any age 2.35 (2.02–2.72) One affected FDR diagnosed at any ageaffected 2.48 (2.25–2.74) Affected FDRs diagnosed <65 y2.87 (2.21–3.74) Affected FDRs diagnosed ≥65 y1.92 (1.49–2.47) Second-degree relativesSecond-degree relatives diagnosed at any age 2.52 (0.99–6.46) Two or more affected FDRs diagnosed at any age 4.39 (2.61–7.39) Table 1. Relative Risk (RR) Related to Family History of Prostate Cancer Don’t forget BRCA2 AGE still more important as risk factor for prostate cancer. 90% diagnoses made over age 65 AGE still more important as risk factor for prostate cancer. 90% diagnoses made over age 65

The 10 Most Common Causes of Cancer Death in 2012 Numbers of Deaths, Males, UK 6% of all male cancer deaths are registered without specification of the primary site Source: cruk.org/cancerstats You are welcome to reuse this Cancer Research UK statistics content for your own work. Credit us as authors by referencing Cancer Research UK as the primary source. Suggested style: Cancer Research UK, full URL of the page, Accessed [month] [year]. 40% men have prostate cancer at autotopsy at aged 70 14% lifetime risk of getting prostate cancer 4% men die from it. 40% men have prostate cancer at autotopsy at aged 70 14% lifetime risk of getting prostate cancer 4% men die from it.

NICE – prostate cancer ActionPresentation Refer via cancer pathway-Prostate feels malignant on DRE -PSA above age-specific range Consider DRE and PSA test to assess for prostate cancer in men with: -Any lower urinary tract symptoms such as nocturia, urinary frequency, hesitancy, urgency or retention. -Erectile dysfunction -*Visible haematuria (in the absence of UTI or not resolving/recurring after successful treatment.) *the same guideline recommends referral via cancer pathway for suspected renal tract cancer anyone >45 with unexplained visible haematuria

Does having LUTS increase you chances that you have prostate cancer?

Fig 3 Benefits and harms of screening men aged years* with a prostate specific antigen (PSA) test every 1-4 years for 10 years. Timothy J Wilt, and Hashim U Ahmed BMJ 2013;346:bmj.f325 ©2013 by British Medical Journal Publishing Group 1000 men screened and 37 men diagnosed with cancer to prevent 1 cancer death

How does PSA relate to risk of metastatic disease? A reading of <1.0ng/ml at age 60 = very low risk of metastatic disease

Mr Williams decides to have a PSA test after clinical examination that reveals a benign feeling prostate. The result is 6.3ng/ml

PSA performance Cut off level> 4.0ng/ml>3.0ng/ml Sensitivity21%32% Specificity91%85% PPV30%28%

PSA testing 15-20% of men will have a test result that triggers biopsy 30% of men with a raised aged related PSA will have prostate cancer 15% of men with a normal result will have prostate cancer

He is referred to the urology team for further investigations He has a TRUS and biopsy. Complications: Pain 41% Haematuria 66% PR bleeding 37% Haemoejaculate 27% Fever 17% Sepsis 2-4% Death 0.1% He is diagnosed with Cancer: T2aN0M0, Gleason score 3+3

Prostate Cancer Staging Nodes 0/1, Metastasis 0/1

NICE guidelines 2014

Radical Therapy Radical prostatectomy (ED -80%, urinary incontinence 15%) Radical External Beam Radiotherapy (radiation enteropathy 33%, ED 65%) Androgen Deprivation therapy ( risk of sexual dysfunction, osteopororis, gynaecomastia, fatigue) in combination with XRT

What is the best treatment for localised disease? We don’t know yet. Previous studies prior to widespread PSA testing showed no or minimal benefit for RP over watch and wait. ProTect study – results awaited. – RP, radiotherapy, Active surveillance

Fig 5 Forest plots demonstrating subgroup effects (hazard ratio with 95% confidence intervals and P value for interaction) in the Prostate Cancer Intervention versus Observation Trial (PIVOT) comparing radical prostatectomy with observation. Timothy J Wilt, and Hashim U Ahmed BMJ 2013;346:bmj.f325 ©2013 by British Medical Journal Publishing Group 15yr follow up

BMJ 2009

Prognosis Type5yr survival %10yr survival % Localised67-98 (high vs low grade)65-90 Locally advanced70% Metastatic30%

Lower urinary tract symptoms Over 1/3 of men aged 50+ in the UK are living with moderate to severe LUTS

LUTS increase the risk of recurrent falls in older men esp urgency, nocturia and hesitancy.

IPSS – useful in monitoring response to treatment

Further assessment Abdominal and prostate examination Consider Renal function if: – Nocturnal enuresis – Palpable bladder – Hx of renal stones – Recurrent UTI No need for USS in uncomplicated LUTS Urinalysis PSA?

Prostatic enlargement

Management of LUTS in GP Lifestyle advice re fluids, double voiding, urethral milking Think about co-prescribed medications – Diuretics, antidepressants, bronchodilators Alpha adrenoceptor blockers eg tamsulosin – Moderate reduction in symptoms – Work quickly but may take 1/12 to reach maximum effect – Smooth muscle relaxation – prostate and bladder neck – No effect on progression to surgery – May improve storage problems

Management of LUTS in GP 5 alpha reductase inhibitors eg finasteride Block testosterone  dihydrotestosterone Take up to 6months to work Reduce size of prostate Reduced risk of progression to retention or surgery Only effective if prostate enlarged >30gram Reduction in libido

Lifestyle advice eg caffeine/alcohol/ Bladder retraining Antimuscarinics eg tolterodine – Better outcomes in combination with alpha blockers – Low risk of causing acute retention Mirabegron beta3 adrenoceptor agonist as second line Incontinence products Referral

Further reading Prostate cancer screening and the management of clinically localized disease TJ Wilt BMJ 2013;346:f January 2013 The management of lower urinary tract symptoms in men J Rees BMJ 2014;348:g June 2014