Prostate Cancer

Prostate cancer is formed when the prostate cells turn malignant. In its early stage, prostate cancer does not cause symptoms. Later on, urinary symptoms or backache caused by a metastasis may appear. Most often, cancer suspicion is aroused when the PSA test is abnormal or a doctor diagnoses a prostate lump or sclerosis or asymmetry of the lobes. In such a case, the doctor refers the patient to Tays for examinations.

Prostate cancer is the most common malignant cancer among men. Annually, approximately 5,000 new cases of cancer are diagnosed in Finland and approximately 500 in Pirkanmaa. Becoming ill under the age of 40 is rare, but the incidence increases with age and the average age is over 70.

The prognosis is also impacted by the cancer’s cell pattern and spread at the time of diagnosis. From among the diagnosed prostate cancer cases, approximately 93% are alive after five years.

Examinations at Tays

The PSA value is rechecked at the hospital. This is to ensure that it is not a case of an occasionally elevated value, for example due to inflammation.

A doctor examines the prostate with ultrasound and take samples in the same connection for determining the cell and tissue structure. This may also be preceded by magnetic resonance imaging (MRI) of the prostate.

When we have received a statement regarding the samples from the pathologist, we report the result and prepare a continuation plan. Further examinations depend on the cancer stage and PSA value. If the value is only slightly abnormal and the cancer cell pattern is non-aggressive, i.e. benign, further imaging is not necessarily needed.

If there is reason to suspect prostate cancer with a high progression risk based on the findings, we also examine the possible spread of cancer with diverse imaging. Situation-specifically, we choose the best-suited examinations for each patient:

A bone map, i.e. gamma radiography of the bones, is used to determine whether prostate cancer has spread to the bones.
Full-body CT scanning, PET-CT scanning and MRI are used to determine whether cancer has spread to the soft tissue or bones.
An MRI of the prostate is usually performed when surgery is considered and it needs to be established whether cancer has spread outside the prostate.

Treatment negotiation and active monitoring

After the examinations, the patient meets with an urologist, i.e. a urinary organ surgeon. We discuss the results of the performed examinations, go over different treatment options and select the best possible treatment method.

If prostate cancer has a benign cell pattern, samples include minor volumes of cancer and the PSA level is low, the situation can be monitored. Active monitoring involves the PSA measurement every 3–6 months and taking of new samples at the one- and three-year marker. Before making the monitoring decision, an MRI of the prostate is often performed.

If cancer is diagnosed as requiring active treatment, we treat it with either surgery or radiation therapy.

If the spread examinations reveal metastases, the urologist prescribes hormonal medication. If prostate cancer progresses while hormonal medication is taken, a referral is made to the cancer clinic.

Surgical treatment of prostate cancer

If cancer has not spread outside the prostate, it can be removed with surgery. In addition to the prostate, the seminal vesicles are removed. In the case of an aggressive cancer, in terms of its cell pattern, the local lymph nodes are also removed. The most common surgery side effects are erectile dysfunction and urinary incontinence.

The surgery is preceded by a pre-visit during which the patient meets with a nurse and the operating surgeon, unless the patient has already met with the surgeon during the treatment negotiation. If necessary, the patient also meets with the anaesthetist.

We perform the surgery as a robot-assisted endoscopy procedure. The patient comes in for the surgery in the morning and is usually discharged the following day.

The urinary tract catheter placed during surgery is removed at the outpatient clinic after one week. Before the catheter is removed, contrast medium imaging is performed in order to ensure that the suture between the urinary bladder and urethra has healed. During the same visit, the patient receives instructions from a physiotherapist for the strengthening of the muscles that support urinary continence.

The pathologist examines the removed tissue. We plan the follow-up procedures and monitoring based on the statement provided by the pathologist

Radiation therapy of prostate cancer

If curative radiation therapy is chosen as a treatment option, the urologist prepares a referral to the cancer clinic, where a new treatment negotiation is held. External radiation therapy is implemented by the oncologists of Tays, i.e. the doctors who treat cancer at Radius.

Radiation treatment is used to destroy the cancer cells of the prostate and to prevent their division and growth. If radiation therapy is the sole treatment option, the PSA level that indicates the effect of the treatment decreases slowly. The lowest PSA values are obtained on average six months after the end of radiation therapy. Radiation therapy does not decrease the PSA level to a point beyond measure.

Three aiming marks are inserted into the prostate with the help of ultrasound for radiation therapy. After approximately one week, a CT scan is performed for planning radiation therapy. Radiation therapy begins two or three weeks after the scan. It usually involves 5–39 treatment visits, i.e. from 1½ to 8 weeks.

The patient stays at home and only come in for the radiation therapy sessions. One treatment session lasts approximately 15 minutes. Radiation therapy for prostate cancer is painless and does not cause skin irritation or nausea. During the treatment, the typical side effects include irritation of the urinary bladder, such as a need to urinate more often than normally, and a need to defaecate more often than normally due to rectal irritation. The long-term side effects may include bowel irritation, urinary bladder irritation and a decline in erectile capacity.

In the case of advanced prostate cancer, radiation therapy is used to treat painful metastases of the bones. In such cases, radiation therapy is used to alleviate pain. Usually, one treatment session is used, but more detailed radiation therapy planning is case-specific.

Hormonal therapy

Hormonal therapy can be used in curative radiation therapy to boost treatment effect and, in the case of advanced prostate cancer, to slow down its progression. The treatment is implemented by means of hormonal injections or by removing the testicular tissue. The goal is to end the male hormone, i.e. testosterone, production so that prostate cancer enters a dormant, i.e. inactive, state, its progression stops and the PSA value declines.

Typical hormonal therapy side effects include hot flashes, loss of erectile capacity, decline in sexual desire, loss of muscle power, bone embrittlement and fatigue. Due to bone embrittlement, we launch a course of calcium and vitamin D treatment in the same connection. If prostate cancer has spread to the bones, we can also prescribe medication meant for the treatment of bone metastases.

Chemotherapy

Chemotherapy is used for the treatment of prostate cancer with metastases in cases where hormonal therapy alone is insufficient to slow down the progression of cancer. Chemotherapy aims to destroy cancer cells by preventing their division.

Because chemotherapy puts the body under considerable strain, weak patients are not considered suitable for it. Cytostatics are dosed intravenously usually in a set of six doses, after which the therapy impact is evaluated. In the treatment of prostate cancer, the most commonly used cytostatic is docetaxel. Its typical side effects include decline in blood count, irritation of the peripheral nerves, swelling, tenderness of the oral mucosa, fatigue and rash.

New medication for treating prostate cancer

Pharmacotherapy of prostate cancer develops continuously. New medication prevents cancer cell communications and the production of testosterone in the adrenal glands and treats the bone metastases.

According to the current permit practice, new medication can only be used if cytostatic therapy does not work or causes difficult side effects. In the future, the permit practices probably change to enable their use already before cytostatic therapy.

Post-treatment monitoring

The first control after surgery or radiation therapy is scheduled to take place within 3–5 months at the surgery outpatient clinic.

If the situation is good after the surgery and the patient has recovered well, we proceed to mobile monitoring. Mobile monitoring involves automatic checking of the PSA levels every six months for 10 years. If any further controls are needed, the next one is scheduled to take place one year after the surgery.

If the situation is good after radiation therapy, monitoring is carried out in outpatient health care.

A patient referred to cytostatic therapy is monitored by oncologists.

Treatment team

Robot-assisted prostate cancer surgeries are performed by three surgeons trained for this purpose who also primarily ensure treatment negotiations and controls.

The treatment team also includes a physiotherapist who provides guidance in muscle training and men who have not regained their continence capacity during the control period are referred to see the physiotherapist. Patients suffering from erectile dysfunction are referred to a urotherapist and sexual counsellor.

Problematic prostate cancer patient cases are discussed at a weekly meeting of urologists and oncologists, i.e. a meeting of specialists.

Persons in charge

Chief Physician (urology) Teuvo Tammela
Chief Physician of the unit (urology) Juha Koskimäki
Deputy Chief Physician (urology) Jarno Riikonen
Specialist (urology) Tomi Pakarainen
Specialist (radiation therapy) Hanna Mäenpää
Specialist (radiation therapy) Petri Reinikainen
Specialist (oncology) Petteri Hervonen
Specialist (oncology) Anna-Liisa Kautio