Care pathway for prostate cancer

Prostate cancer, or prostate carcinoma, develops when cells in the prostate become cancerous. There is no single known cause of prostate cancer, but it is estimated that about 5–10% of cases are linked to a genetic predisposition.  

Prostate cancer is the most common cancer among men in Finland. The typical age of onset is around 70, and age is the most significant risk factor. Most patients can be treated with a curative goal, and even advanced disease can often be managed long-term with effective treatment.

Prostate cancer is usually asymptomatic for a long time. Possible local symptoms may resemble those of benign prostatic hyperplasia:

• weak urine stream
• a sensation of incomplete bladder emptying, and
• frequent urination and the need to urinate at night.

Prostate cancer and benign prostatic hyperplasia can also occur at the same time.

If you are suspected of having prostate cancer, your general practitioner will make an initial assessment of your situation. The initial assessment includes finding out the symptoms and background information through an interview, a physical examination and the necessary laboratory tests.

The most important blood test is PSA, or prostate-specific antigen. In prostate cancer, plasma PSA levels are elevated. PSA levels can also be elevated due to benign prostatic hyperplasia, urinary retention, and infections. Hence, a PSA level above reference values does not automatically indicate prostate cancer.

If examinations carried out in primary healthcare, occupational healthcare, or at a private medical clinic have given reason to suspect prostate cancer or you have already been diagnosed with prostate cancer, the physician will make you a referral to HUS Urology Outpatient Clinic for further examinations.

If a referral to urology is made for you, you will be invited directly to the appointment or for additional scans, such as magnetic resonance imaging of the prostate on the basis of your referral. You will usually receive an invitation by mail or via the Maisa Portal.

In general, we will also inform you of the result of the scan by letter or via Maisa. Based on the results of your MRI, you will be invited to a urologist’s appointment for a prostate biopsy.

At the appointment, the urologist will interview you and perform a palpation of the prostate. During the examination, the physician will assess whether any lumps or nodules can be felt in the prostate.

We confirm a diagnosis of prostate cancer by taking biopsy samples from the prostate under ultrasound guidance. We take biopsies through the rectum or perineum under local anesthesia from an abnormal area in the prostate observed in an MRI scan. The whole procedure takes about 20 minutes, and biopsies take about 5–10 minutes.

If necessary, we order various laboratory tests and imaging studies to determine the extent of the disease.

You will receive the results of your prostate biopsy either by mail or via Maisa, also in the case where the results indicate prostate cancer. At this stage, we will often refer you to the Omapolku digital care path for prostate cancer. You will receive login instructions from Omapolku via text message or email.

At the appointment, you will receive information on the cancer biopsy classification as well as the extent and risk category of the disease. During the treatment consultation, together with the urologist you will decide on the right form of treatment for you.

In the treatment consultation, we will examine your state of health. In addition to the disease itself, the choice of treatment depends on your wishes, age, general condition, other illnesses, and possible previous treatments for different diseases. We recommend that you involve a family member in the treatment consultation meetings.

After the treatment consultation, if necessary, we will send your treatment decision to a multiprofessional treatment meeting that convenes once a week, where in addition to the urologist, there will be oncologists, a radiologist, a pathologist, and a prostate cancer nurse. We will review your examination results and medical records again in the meeting. After the multiprofessional treatment meeting, we will notify you of our treatment recommendation.

After the treatment consultation meeting, you will meet with a nurse. The nurse will go over the chosen treatment and its side effects with you.

We can treat prostate cancer with different forms of treatment and their combinations. The choice of treatment for prostate cancer depends on whether the disease is local, locally advanced, or metastasized.

In localized prostate cancer with a good prognosis, i.e. a low risk cancer, the primary treatment option is active monitoring. In many patients, prostate cancer can remain localized for a long time or for the rest of their lives, and no treatments are needed. Active monitoring takes place at the Urology Outpatient Clinic.

If there are indications during monitoring that the cancer has developed into a form that requires treatment, meaning medium or high-risk cancer, we will have a discussion with you about the surgery and radiation therapy options best suited for you.

The primary treatment for locally advanced prostate cancer is radiation therapy combined with hormone therapy lasting 2–3 years.

Prostate cancer can recur regardless of treatment and treatment form, and we monitor this at the Urology Outpatient Clinic after treatment has been completed. Prostate cancer usually progresses slowly. The cancer may not recur for years. That is why we often monitor the treatment outcomes for prostate cancer over a long period of time. 

Follow-up is primarily PSA monitoring. Based on PSA levels or new symptoms, we will perform imaging examinations or take new biopsies as needed if we suspect local recurrence of prostate cancer. 

When your situation regarding prostate cancer is stable, in most cases follow-up after your treatment continues at HUS as mobile monitoring of PSA values. PSA mobile monitoring is automated remote PSA monitoring.

We will give you a long-term PSA referral to the HUS laboratory, which is valid for several years. A unique PSA limit value has been set for you in the permanent referral. You will receive a reminder of the test and your test result by text message.  

Your follow-up care may also take place in primary healthcare. We will then determine your follow-up plan and establish the criteria for when further examinations at HUS may be necessary.