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The Diagnosis of Prostate Cancer
- Nov 9, 2022
- Latest Journal
By Chris Dawson MS FRCS LLDip, Consultant Urologist
In this brief article Chris Dawson details the difficulties in the diagnosis of Prostate Cancer.
The case described is fictitious, but based on the author’s clinical experience.
Kevin presented to his GP, aged 56, with some difficulties passing urine. For about 3 months he had noticed a slight hesitancy before passing urine and a reduction in his urinary flow. He had also started to get out of bed 1 or 2 times at night.
His GP listened to the story and arranged for a blood test for Prostate Specific Antigen (PSA). He did not examine Kevin’s prostate at this initial consultation.
PSA is an enzyme found in the blood of men, and has a role in male fertility.
The PSA value came back at 4.2 ng/ml, which is slightly raised for a man of Kevin’s age. By now Kevin’s symptoms had improved on the medication given at the initial consultation so the GP arranged to see Kevin again in 6 months time.
Unfortunately because of work commitments Kevin did not make this appointment and it was nearly a year before he saw his GP again. His symptoms had begun to deteriorate by this time so the GP retested the PSA, but did not examine Kevin’s prostate.
The PSA by this time had risen to 8.3 ng/ml. Alarmed by the change in the result the GP referred Kevin urgently to the local Urologist for an opinion.
Kevin was seen two weeks later (in line with national guidelines). Examination of his prostate showed a firm left side of the prostate with a hard nodule. The Urologist arranged for an urgent MRI followed by a prostate biopsy. The MRI confirmed abnormalities in the left side of the prostate gland (corresponding to the rectal examination findings), and the biopsies showed moderately aggressive cancer.
Kevin was seen urgently by the Urologist and offered treatment with either surgery or radiotherapy, eventually opting for radical prostatectomy surgery to remove his prostate.
Kevin and his family were devastated by the diagnosis of cancer and concerned at what they believed to have been a delay in diagnosis by the GP.
A review of the notes by an expert witness concluded that Kevin’s initial PSA was raised above the age specific reference range and this alone should have led to a referral to the Urologist for consideration of a biopsy. The expert was also critical that the GP did not examine Kevin’s prostate as this may well have shown changes that would have reinforced the need for an urgent referral.
It was therefore concluded that a breach of duty had occurred in Kevin’s care. However the expert also pointed out that the cancer was found to be organ confined on the specimen removed at surgery and that Kevin’s chance of complete cure remained high. Moreover given that his cancer was moderately aggressive on biopsy it was felt that earlier biopsy would have led to the same treatment options as Kevin was given when his cancer was diagnosed.
Prostate cancer is notoriously hard to diagnose in some men. A raised PSA is not diagnostic of cancer, nor is a palpable abnormality in the prostate. Nevertheless either abnormality should be followed by an urgent Urology referral for advice. The usual response would be (as in Kevin’s case) an MRI scan of the prostate and a biopsy, after appropriate counseling.
Furthermore a negative MRI scan and negative biopsy results, whilst obviously good news for the patient, do not exclude the diagnosis of prostate cancer and Urology monitoring is usual practice in such cases to determine if further investigations are required.
