Prostate Cancer

What is Prostate Cancer?

Prostate cancer is the most common cancer among males in South Africa. It occurs more frequently in men older than 50.

Key facts:

• Most prostate cancers grow slowly and are non-aggressive
• Many men won’t die from prostate cancer
• According to the SA National Cancer Registry (2013), the average lifetime risk is:
  • 1 in 18 for all males
  • 1 in 9 for white males
  • 1 in 15 for coloured males
  • 1 in 27 for Asian males
  • 1 in 29 for black males

Symptoms

Early prostate cancer often has no symptoms – making screening essential.

When present, symptoms may include:

• Frequent urination (especially at night)
• Difficulty urinating (dribbling, weak stream, hesitancy)
• Erectile dysfunction
• Blood in urine or semen

These symptoms may also occur due to non-cancerous conditions, like prostatitis or benign prostatic hyperplasia (BPH).

Screening

Who Should Be Screened?

• All men 50+ years
• Start at 45 if a first-degree relative was diagnosed before age 65
• Start at 40 if a close relative had early-onset prostate cancer

What Screening Involves:

1. Digital rectal examination (DRE) – physical exam via rectum
2. Prostate-specific antigen (PSA) blood test

Understanding PSA (Prostate-Specific Antigen)

• PSA is a protein made by prostate cells
• Some PSA passes into the bloodstream
• PSA is prostate-specific, but not cancer-specific

A normal PSA level doesn’t rule out cancer. Elevated PSA may also be caused by:

• BPH (benign enlargement)
• Prostatitis (inflammation)

PSA Testing Guidelines

Avoid blood collection for PSA testing:

• 2 days after cycling, heavy exercise, or sex
• 1 week after DRE or rectal sonar
• 6–8 weeks after prostatitis, bladder infection, biopsy, or surgery

PSA is not diagnostic – it helps identify high-risk patients who may need a biopsy.

PSA Interpretation

PSA levels increase with age and prostate size. Suggested age-specific reference ranges:

• 40–49 years: 0–2.5 ng/mL
• 50–59 years: 0–3.5 ng/mL
• 60–69 years: 0–4.5 ng/mL
• 70+ years: 0–6.5 ng/mL

Cancer Probability Based on PSA:

• < 2.5 ng/mL: Low risk (< 2%)
• > 10 ng/mL: High risk (≈ 67%), though 33% may still be negative on biopsy
• 2.5–10 ng/mL: Intermediate → test free PSA

Free PSA & PHI

• Free PSA is PSA not bound to protein
• A lower % free PSA = higher risk of cancer

Risk by % free PSA:

• <10%: >80% chance of cancer
• >25%: <10% chance

PHI (Prostate Health Index):

• Combines total PSA, free PSA, and proPSA
• Helps assess grey zone (2–10 ng/mL) cases
• Improves specificity and reduces unnecessary biopsies

Diagnosis

Diagnosis is confirmed by prostate biopsy under transrectal ultrasound (TRUS) guidance.

What to Expect:

• A spring-loaded needle collects tissue samples
• Guided by a TRUS probe inserted via rectum
• Samples are analysed by a histopathologist

Most common prostate cancer:

• Acinar adenocarcinoma – usually low-risk, slow-growing

Cancer Grading

Grading Systems:

• Gleason Score:
  • 6 or less: Low-grade
  • 7: Intermediate-risk
  • 8–10: High-grade
• Grade Group System:
  • Group 1: Most favourable
  • Group 5: Least favourable

Reports also include:

• Number of positive cores
• Volume of cancer per core

Treatment

Treatment depends on:

• Patient’s age
• Tumour aggressiveness

Options include:

• Active surveillance
• Surgery
• Radiation therapy
• Hormonal therapy
• Chemotherapy

Prognosis is excellent if diagnosed early and treated appropriately.

Additional support and information at: www.cansa.org.za