Prostate Cancer FAQ’s for GP’s

GPs - Your Frequently Asked Questions Answered

APC consultant Homi Zargar, expert uro-onocologist and robotic surgeon, answers some of the most frequently asked questions posed by general practitioners.

What are the new approved Medicare Benefits Schedule (MBS) items for multiparametric magnetic resonance imaging (mpMRI) of the prostate?

Since 1 July 2018, Medicare rebates have become available for new items covering mpMRI prostate scans for both the diagnosis of prostate cancer and the active surveillance of patients with a proven diagnosis following biopsy histopathology

What are the patient eligibility requirements?

These items are for scans of patients with specified indications. The request form must list the relevant clinical indications. Urologists, radiation oncologists and medical oncologists are eligible to request these items. General practitioners are not eligible to request these items.

For MBS items 63541 the patient must be suspected of having prostate cancer based on:

a) a digital rectal examination (DRE), which is suspicious for prostate cancer; or

b) in a person aged less than 70 years, at least two prostate specific antigen (PSA) tests performed within an interval of one to three months are greater than 3.0 ng/ml, and the free/total PSA ratio is less than 25 percent or the repeat PSA exceeds 5.5 ng/ml; or

c) in a person aged less than 70 years, whose risk of developing prostate cancer based on family history is at least double the average risk , at least two PSA tests performed within an interval of one to three months are greater than 2.0 ng/ml, and the free/total PSA ratio is less than 25 percent; or

d) in a person aged 70 years or older, at least two PSA tests performed within an interval of one to three months are greater than 5.5ng/ml and the free/total PSA ratio is less than 25 percent.

Benefit for MBS item 63543 is payable for patients with proven diagnosis of prostate cancer following biopsy histopathology who:

a) have not had a diagnostic mpMRI, and are placed on active surveillance following confirmed diagnosis; or 12 months following confirmed diagnosis and then every third year thereafter; or at any time there is a clinical concern, or concern with PSA progression.

b) or 12 months following confirmed diagnosis and then every third year thereafter,

c) or at any time there is a clinical concern, or concern with PSA progression.

I have a 38-year-old patient who has some lower urinary symptoms and his US showed a 55-cc prostate, how do I treat him?

Prostate size by itself does not warrant medical treatment. Although gland size can have an impact on male lower urinary tract function, but in the absence of moderate to severe symptoms and lack of any medical indications such as infection, large post void volumes etc, no form of medical or surgical therapy is justified. Furthermore, transabdominal US can overestimate prostate size and is highly operator dependant and the findings of the US should be considered in the context of clinical scenario.

What are the newer non-invasive surgical options for the treatment of symptomatic prostate enlargement?

UroLift, Rezum and prostatic artery embolisation are some of the newer non-invasive procedures for addressing the male LUTS (lower urinary tract symptoms).

The UroLift system works by lifting and holding the enlarged prostate tissue out of the way to relieve the compression on the urethra. The procedure involves placement of up to four implantable prostatic retractor to the prostate lobes without any cutting, heating or removing of prostate tissue. This procedure works well for small to medium size prostate glands, is minimally invasive and does not impact ejaculatory function.

The Rezūm system applies thermal energy to the prostate using heated sterile water vapor, which rapidly and uniformly disperses through the tissue. With condensation of water vapour stored thermal energy is released leading to cell membranes’ denaturation and cell death. Over time, this ablated tissue is reabsorbed, reducing the volume of tissue allowing the urethra to open, relieving LUTS. The indication for use and benefits of this technique are similar to UroLift.

Prostatic artery embolisation (PAE) works by reducing or stopping blood flow to the central part of the prostatic tissue. There are usually one or two vessels on each side (right and left), which supply the blood for the prostate. The interventional radiologist will insert a catheter into a blood vessel via the groin and guide the catheter under imaging to each prostatic artery. The micro particles (resin particles smaller than a grain of sand) are injected into the prostatic arteries, causing the blood flow to the central tissue of the prostate to decrease or stop. Overtime the prostate size will reduce assisting improvement in urinary symptoms.

What is nonmetastatic castration-resistant prostate cancer (CRPC)?

In men with prostate cancer, castration either surgical or medical, results in a serum testosterone level of < 50 ng/dL. This generally results in PSA responses in most men with a rising PSA level. However, the cancer eventually becomes resistant to the castration in nearly all men, at which point serum PSA start to rise and/or radiographically detectable metastases emerge, despite a maintained low serum testosterone level ( < 50 ng/dL). This is termed ‘castration-resistant disease’. If the imaging studies – nuclear medicine technetium-99m scintigraphy (bone scan) as well as computed tomography (CT) of the chest, abdomen and pelvis – remain negative for metastatic lesions, this disease state is known as nonmetastatic castration-resistant prostate cancer (CRPC). In Australia, due to liberal use of PSMA PET/CT scan, this entity is less encountered as PSMA PET often detects disease where other imaging modalities have failed to discover. The distinction between nonmetastatic CRPC and metastatic CRPC (mCRPC) is important, as many newer treatment agents for prostate cancer are not currently funded for the nonmetastatic CRPC.