Prostate cancer: An in-depth guide to risk factors and diagnosis

We invited revered consultant urological surgeon Mr Vivek Wadhwa to share his expert insight on the risk factors associated with prostate cancer and the forms of testing involved in diagnosis. The leading specialist also details which signs and symptoms can be indicative of conditions affecting the prostate in this, his first article of an in-depth series on prostate cancer.

What are the risk factors associated with prostate cancer?

Prostate cancer is one of the most common male cancers. In terms of risk factors for prostate cancer, we always ask about family history. Prostate cancer does seem to run in some families and I often see patients whose fathers I have treated some years ago. Obviously, age is a major risk factor. Prostate cancer is rare in men younger than 40, but the chance rapidly rises after 50. I would say around sixty per cent of prostate cancers are generally found in men over 65.

The other thing to consider is race and ethnicity as in African American men or Caribbean men of African ancestry, there is a higher risk of prostate cancer. Geography is also very important as prostate cancer is very common in North America, North Western Europe, Australia and Caribbean islands, and perhaps less so in Asia, Africa, Central America and South America. When I see my patients, I'll ask them how long they've been in the UK, if they've been to those countries or they've grown up there.

We also look at gene changes and within certain families, prostate and breast cancer can be very rampant. There are certain genes we can look at to assess risk, like BRCA 1 or 2 genes or men with Lynch syndrome.

In terms of other factors with less clear effects, things like diet are sometimes considered although this is quite controversial. Some people say if you eat too much dairy, for instance, that you may have a slightly higher risk or if you take too much calcium. Obesity, however, does not seem to increase the overall risk although this has been the subject of numerous studies. With smoking, there also hasn't been any definite link established with prostate cancer. There was some pertinent evidence relating to chemical exposures, particularly in firefighters due to something known as Agent Orange. I certainly see a lot of men with chronic inflammation, prostatitis, and that has been shown to be linked to prostate cancer in some studies, although not in others so this is contested.

How is prostate cancer diagnosed?

In the UK, we do not have prostate cancer screening, whereas in America and certain parts of Europe, just like women have annual breast screening, men get annual PSA checks and rectal examinations. In the UK, however a man can always go to his GP and request a check. Quite often, men hear something on the radio or see prostate cancer on the news, or a family member or friend gets diagnosed with prostate cancer and this will prompt them to request a PSA test from their GP. I would say that most of our two week wait referrals now seem to be for men who have had these screening tests, or have been offered checks at their local British Legion Club or Rotary Club.

Signs that we look out for are a sudden onset of bothersome urinary symptoms, flow problems or visible blood in the urine. These symptoms can be caused by a number of things, but when they are investigated, we perform a PSA test and prostate cancer can be detected. In later stages, the prostate cancer may have spread into the bones and patients come in with bone pain and so we perform a PSA check. Metastatic prostate cancer was more common years ago but is less common now as many cases are picked up early with screening.

When we see patients, we take a full history and do an examination. In the history, it's important to know if patients are on any medication, particularly if they're on blood thinners like Warfarin or Apixaban because if we need to perform a prostate biopsy, they will need to stop these a certain number of days beforehand. We then do a rectal examination, which not only gives us an idea of the volume of the prostate but also the consistency - i.e. is it smooth and normal or hard and irregular? Once we've done that, we can list the patient for investigations, including a possible repeat of the PSA test, check the renal function, and a clotting study if required or check the urine for any infection. The PSA is very sensitive and it's not specific and so I always tell my patients it can be raised in a number of conditions, including large prostate infection, inflammation or prostate cancer.

The next test is generally a multiparametric MRI scan and this allows us to see the prostate volume and then you can calculate the PSA density. Clearly, if a patient has a large prostate, they're allowed to have a higher PSA. Even more accurate than PSA is PSA density, which is your PSA divided by your volume. Also, if the MRI scan shows any particularly suspicious areas, these can be targeted when it comes to the prostate biopsy. In a prostate biopsy, we go through the back passage or through the perineum, which is a piece of skin between the back of the scrotum and the anus. This allows you take samples of tissue from the prostate - systemic and targeted.

Following this, we see patients in clinic a few weeks later with the results of those tests. If you've not got prostate cancer, this is obviously reassuring and we may perhaps recommend that your PSA can be checked on a regular basis by your GP. If you have got prostate cancer, then it tends to be discussed in a multidisciplinary cancer team meeting, which in my case would be at University Hospital Birmingham. After that, we look at the Gleason score and the grade stage. If necessary, the patient may need further staging scans, CT bone scan, and then we discuss management options.

For more expert insight on prostate cancer, including the available forms of treatment and how patients are monitored going forward, take a look at Mr Wadhwa’s second informative article in this series.

If you are concerned about your prostate health and would like to schedule a consultation with Mr Wadhwa, you can do so by visiting his Top Doctors profile.