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The first step is to make an appointment with your GP. They will discuss your symptoms, and enquire about your lifestyle and any medication you are taking to come to a decision about whether you should undergo further tests, such as a PSA test. If you wanted to, you could also skip the GP stage and arrange an inexpensive PSA test through a private clinic.

Know your rights!

Under the NHS Prostate Cancer Risk Management Programme you can request a PSA test from your GP once you are over the age of 50.

Your GP may also conduct a rectal examination (known as a digital rectal exam, or DRE) to feel your prostate with a finger. If it is firm, hard to the touch or otherwise irregular this needs investigation to investigate the possibility of cancer.

Prostate digital rectal exam diagram

Prostate digital rectal exam diagram

Interview with a GP

Dr Philip Whitehead GP

Dr. Philip Whitehead has been on both sides of the patient/doctor divide: as a GP, he has tested, referred and supported men with prostate cancer for 30 years while in 2009, he was himself diagnosed with prostate cancer before undergoing a radical prostatectomy. He shares with us his insights into the process, and importantly what patients should ask of their GP.

 

How has being a prostate cancer survivor has changed your view of how GPs should approach the disease?

In my early sixties, I had mild symptoms of benign prostate enlargement with reduced stream as well as nocturia (having to frequently get up during the night to urinate). I went to my GP for a consultation, and a digital rectal examination showed prostate enlargement and a PSA test showed a level that was marginally above the normal range for my age. My GP suggested repeating the test after three months, and this showed a further rise. He referred me to a urologist but did not feel it merited a two week referral, and I was seen some months later by Professor Eden.

GPs are in a difficult situation when a patient presents with symptoms of an enlarged prostate, because this could be simply benign prostate enlargement, or it could be caused by cancer. It requires awareness of how the PSA level can change over time, and caution when interpreting a single reading. When cancer is a possibility, referral under the two week rule is required.

Having gone through successful treatment, what do you know now that you wish you had known before the diagnosis?

I would say that the most important things for a patient to know about are:

  • The various treatment options of active surveillance, brachytherapy, targeted radiotherapy, radical prostatectomy (whether laparoscopic or robotic), medication;
  • Your Gleason score determines the best treatment option for you
  • The complications – early, medium and long term – of each treatment
  • The importance of the 3Ps in follow up as a measure of success – namely PSA, potency and peeing
  • Impotence is not inevitable, although a change in sexual experience and ejaculation will be apparent if radical prostatectomy has been undertaken
  • Flaccid penis length may change but erect length would be unchanged
  • Tadalafil (or similar) reduces incidence of erectile dysfunction when taken during the early period after the operation, as well as later.

What should your GP know about prostate cancer?

  • They should have an up to date knowledge of prostate carcinoma, NICE guidelines, higher incidence in Afro-Caribbean men and those with close family history, Gleason scoring, treatment options
  • They should be aware that normal findings from a digital rectal exam do not exclude malignancy, and that further testing may be required
  • They should have knowledge of (age-adjusted) normal PSA values, and the significance of an elevated reading
  • They should be aware of the need for serial PSA tests (where a series of PSA tests are conducted and the results monitored over time) if a patient’s PSA results are borderline worrisome, while bearing in mind how PSA levels can fluctuate
  • They should know about the two week rule – that you should be referred to a urologist within 2 weeks if malignancy is a possibility.

What is the role of the GP in all of this (not only before testing, but after treatment too)?

  • They should offer a PSA test in older patients (even if they do not show any symptoms) if they are worried – especially if the patient has Afro-Caribbean heritage or close family history of prostate cancer
  • Include PSA test as well as fasting glucose and cholesterol during Well Man screening
  • Arrange PSA test if symptomatic
  • Inform patient of low risk of malignancy (~25%), even if they have an abnormal PSA result
  • If referral is required, advise the patient of the possibility of a biopsy and further procedures to determine the stage of the cancer
  • If cancer is found, discuss treatment options and outcomes, and reassure patient that impotence and urinary/faecal incontinence is not inevitable.

If the patient undergoes surgery to treat their cancer, what are the GP’s roles and responsibilities after the operation?

  • They should advise the patient of the need (in the first few days after the operation) for high fluid intake, regular use of painkillers and keeping mobile to prevent blood clots
  • They should arrange nursing referral for catheter care and wound management
  • If a Urinary Tract Infection is suspected, it should be treated promptly with appropriate antibiotics
  • Liaise with urologist regarding prescribing of Tadalafil to reduce the incidence of erectile dysfunction
  • Discuss potency with patient (and perhaps partner too), and if necessary, make a referral to a suitable sexual dysfunction clinic
  • Arrange regular follow up for the patients by way of PSA testing to ensure that the level is close to zero, following an agreed protocol for how frequently these tests should be conducted and what might trigger a re-referral back to the patient’s urologist in case there are signs that the prostate cancer has not been completely eradicated.

Next chapter: the PSA test

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