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Referral and warning signs
When to refer
Refer to Urology for: Abnormal DRE. Significantly elevated or rising PSA warranting biopsy. Confirmed prostate cancer diagnosis for staging and management.
Red flags
- Hard, nodular, irregular prostate on DRE
- Significantly elevated PSA (>10-20 ng/mL or rapidly rising)
- Symptoms of metastatic disease (bone pain, neurological deficits)
- Haematuria
Signs and symptoms
- Often asymptomatic in early stages.
- Lower Urinary Tract Symptoms (LUTS): Hesitancy, weak stream, intermittency, straining, frequency, urgency, nocturia, incomplete emptying.
- Haematuria or Haematospermia.
- Erectile dysfunction.
- Advanced/Metastatic Symptoms: Bone pain (back, hips, pelvis), Pathological fractures, Spinal cord compression, Weight loss, fatigue, Lower limb oedema.
Risk factors
- Increasing age (>50, esp. >65 years)
- African ancestry
- Family history of prostate cancer
- Inherited genetic mutations (BRCA1/2, Lynch syndrome)
- Diet high in red meat/dairy fat (possibly)
- Obesity (possibly)
Diagnosis
Clinical assessment
Suspect based on abnormal Digital Rectal Exam (DRE - nodule, hardness, asymmetry) or elevated Prostate-Specific Antigen (PSA) level. Assess LUTS. PSA interpretation requires caution.
Investigations
- Digital Rectal Examination (DRE).
- Prostate-Specific Antigen (PSA) blood test.
- Transrectal Ultrasound (TRUS)-guided Prostate Biopsy: Required for diagnosis. Determines Gleason score (grading).
- Multiparametric MRI (mpMRI) of Prostate: Increasingly used before/to guide biopsy or for local staging.
- Staging Investigations (If high-risk): Bone Scan, CT Scan (Abdomen/Pelvis) or MRI, PET Scan (e.g., PSMA PET-CT).
Diagnostic criteria
Histopathological confirmation of adenocarcinoma from prostate biopsy.
Management
Non-pharmacological management
- Referral to Urologist/Oncologist.
- Management depends on stage, Gleason score, PSA, age, co-morbidities, preferences.
- Localized Disease: Active Surveillance (low-risk), Radical Prostatectomy (Surgery), Radiotherapy (EBRT or Brachytherapy).
- Locally Advanced Disease: Radiotherapy + Androgen Deprivation Therapy (ADT), +/- Surgery.
- Metastatic Disease: ADT (medical/surgical castration) is mainstay. Newer hormonal agents, Chemotherapy, Radium-223. Palliative radiotherapy.
- Supportive care (bone health).
Pharmacological treatment
- Androgen Deprivation Therapy (ADT): GnRH Agonists (Leuprolide, Goserelin), GnRH Antagonists (Degarelix).
- Anti-androgens (Bicalutamide).
- Newer Hormonal Agents: Abiraterone, Enzalutamide, Apalutamide, Darolutamide.
- Chemotherapy: Docetaxel, Cabazitaxel.
- Bone-modifying agents: Bisphosphonates (Zoledronic acid), Denosumab.
- Pain management.
Monitoring
Monitor PSA levels regularly. Monitor for treatment side effects (ADT, Chemo). Monitor for disease progression (symptoms, imaging).
Complications
- Metastases (esp. bone)
- Spinal cord compression
- Pathological fractures
- Urinary obstruction / Renal failure
- Pain
- Treatment side effects: Erectile dysfunction, Urinary incontinence, Bowel problems, Hot flushes, fatigue, osteoporosis.
Prevention
- Screening (PSA +/- DRE) controversial, requires shared decision making.
- Maintaining healthy lifestyle may play minor role.
- 5-ARIs not routinely recommended for prevention.
Patient education
- Explain diagnosis, Gleason score, stage.
- Discuss PSA testing.
- Treatment options with risks/benefits/impact on quality of life.
- Importance of shared decision making.
- Need for long-term monitoring.
- Managing side effects.
Uganda-specific notes
Common cancer in older men. Presentation often late. Access to PSA, biopsy, pathology, staging scans, radiotherapy, hormonal therapies (beyond orchidectomy/basic GnRH agonists), and chemotherapy limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 12, Section 12.3.2