News

What is prostate cancer and how to diagnose it

Prostate cancer is the most common solid neoplasm in the adult male population, with an incidence of over 40,000 new cases per year in Italy. It is a very heterogeneous disease, with different levels of aggressiveness, and the second leading cause of cancer deaths in men worldwide.

We met Professor Alberto Briganti, deputy director at the Urological Research Institute (URI), and head of the Prostate Cancer Research Unit at the IRCCS Ospedale San Raffaele, to learn more about new strategies for diagnosing and treating prostate cancer.

Early diagnosis

In the past, prostate cancer diagnosis was based exclusively on measuring blood levels of Prostate Specific Antigen (PSA). Today, international guidelines recommend the use of new diagnostic techniques, such as nuclear magnetic resonance, in case of clinical suspicion of prostate cancer.

This combined approach is important to avoid overdiagnosis of prostate cancer. Diagnosis based only on the evaluation of PSA in the blood risks exposing patients to unnecessary biopsies, given that a high level of the biomarker is not automatically associated with the presence of the disease.

The use of targeted strategies for prostate cancer diagnosis is not only important in the older groups, which have a higher risk of contracting the disease. Recently, we have understood the importance of developing risk adapted strategies to optimize cancer diagnostics in young men (around 45 years old) with a simple initial evaluation of PSA. Based on this initial analysis, personalized strategies are devised, and magnetic resonance imaging is used to increase the sensitivity and specificity of the initial PSA detection. If biomarker levels are below a certain threshold (about 1-1.5 ng/ml) in young men in their forties, patients can stay reassured that the probability of developing the disease in the following ten years is very low. If, however, PSA values exceed this threshold, then patients must undergo more frequent and in-depth evaluations. Therefore, measuring PSA at a young age can help tailor prevention to the patient,” explains Professor Briganti.

Early assessment of PSA levels is particularly indicated for subjects with a family history of prostate cancer. Compared to the general population, people with a first-degree relative affected by the disease are two and a half times more likely to develop the tumor themselves.

Furthermore, familiarity for prostate cancer can also go along with familiarity for breast cancer as well as other gynecological diseases. "Today we know that mutations in some genes that regulate DNA repair, such as the BRCA2 gene, which is mutated also in breast cancer, are associated with a higher risk of developing prostate cancer", continues the Professor.

New diagnostic techniques and artificial intelligence

Magnetic resonance imaging is the first-level test to be performed if there is clinical suspicion of prostate cancer.

Based on MRI outcome, there could be two different scenarios:

  • If MRI results are negative, that is, there is no clinically relevant tumor, biopsy is not necessary.
  • If MRI results are positive, there is suspicion of a clinically relevant tumor, hence targeted biopsy of the affected prostate areas is needed.

To further improve prostate tumor diagnosis, Professor Briganti's group is currently testing the use of PET with PSMA, an imaging technique using a new tracer called PSMA (Prostate Specific Membrane Antigen). This method helps the targeted classification of the tumor stage and the identification of metastases. "Here at San Raffaele, we are testing the combined use of PET with PSMA and nuclear magnetic resonance also for the diagnosis of the pathology and we are obtaining excellent results", adds the Professor.

In this context, Professor Briganti's group is also experimenting with the use of artificial intelligence, which "enables to analyze images in a more homogeneous and standardized way, improve tumor classification, and optimize the diagnosis, staging and treatment of prostate cancer".

Treatment and prevention

Prostate cancer treatment depends on the characteristics of the disease. If this presents low risk, as calculated with standardized criteria, active surveillance is the first option for patients with a life expectancy of more than ten years, which means undergoing regular check-ups with the urologist.

For more aggressive tumor forms that do not present metastases, the other options are:

  • Surgery (now increasingly frequently performed with robotic technique);
  • Radiotherapy combined with hormone therapy, which is based on drugs that reduce testosterone levels.

Both treatments are indicated for patients with a life expectancy of at least ten years, given that prostate cancer has slower progression rates than other tumors.

Here at San Raffaele, we also propose focal therapy for targeted treatment of only the prostate area affected by the disease. However, this option is indicated only for a well-selected group of patients, since prostate cancer tends to be multifocal, that is, it affects multiple areas of the gland at the same time”, continues the Professor.

In case of tumor metastases, hormone therapy is used in combination with androgen receptor inhibitors, and possibly chemotherapy. “We should note that local radiotherapy has proven to be effective in improving patient survival even in cases of initial metastases, as long as their number is limited. Therefore, in cases of oligo-metastatic disease (i.e. with few metastases), treatment is based on radiotherapy in combination with systemic drugs”.

Finally, the only possible prevention of prostate cancer is early monitoring, together with regular consultation with a urologist after the age of fifty. “To date, there is no convincing scientific evidence indicating specific behaviors to adopt for prostate cancer prevention, other than the commonsense measures that are advisable for a healthy lifestyle,” concludes Professor Briganti.