What is prostate cancer?
Prostate cancer is a disease that affects men from around the age of 45 years.It involves the prostate gland, which is a small gland about the size of a walnut, positioned just beneath the bladder, and is responsible for producing fluids that nourish and protect sperm.
The disease is the commonest male cancer in the UK.
Around 32,000 men in this country are diagnosed each year. Sadly, approximately 10,000 British men die of prostate cancer every year, so it's a disease that needs to be taken very seriously.
At present evidence does not support a role for routine screening for prostate cancer.
Why or how do I get prostate cancer and how can it progress?
It is still not entirely clear why some men develop prostate cancer and others do not. However, we do know that there are both genetic and environmental factors that can influence it.In terms of genetic factors, you have a higher risk of developing prostate cancer if your father or brother had prostate cancer, although the increased risk is still relatively small.
Perhaps more important are environmental factors such as diet and lifestyle.
Vegetarians are half as likely to develop cancer as meat eaters. When we look at geographical differences, people living in the Far East such as the Chinese and Japanese have an extremely low risk of developing prostate cancer compared with those who live in Western countries such as America and Britain.
Scientists are currently investigating whether certain dietary factors may help to prevent prostate cancer. Much of this work is focussing on the mineral selenium and a substance from processed tomatoes called lycopene.
Several very large studies have shown that both these agents lower the risk of developing prostate cancer.
- You cannot catch prostate cancer through sex, nor can you infect your partner with prostate cancer.
- Smoking is not linked to the occurrence of prostate cancer.
- Vasectomy was once thought to predispose men to prostate cancer but this is no longer considered to be the case.
What are the symptoms?
Most cases of early prostate cancer do not produce any symptoms at all – therefore the absence of any urinary symptoms does not rule out the presence of prostate cancer!As men get older the prostate tends to enlarge (benign prostatic hyperplasia) and if the prostate gland grows significantly, it can put pressure on the urethra and this may cause various problems.
Common symptoms of benign prostatic hyperplasia (BPH) include:
- frequent visits to the bathroom to pass urine (frequency)
- having to wake up regularly throughout the night to pass urine (nocturia)
- a sense of urgency in getting to the bathroom in time (urgency)
- hesitation before the urine begins to flow (hesitancy).
However, if you do have any of these symptoms, please consult your doctor for advice.
How is prostate cancer diagnosed?
There are two very simple and painless tests that can help to diagnose prostate cancer.Firstly, a test will be carried out to measure levels of prostate-specific antigen (PSA) in the blood. The other test that can be carried out is a digital rectal examination.
- PSA is a protein produced by the prostate gland. All men have a small amount of PSA in their bloodstream (around 4ng/ml). If this level rises your GP may wish to refer you to a urologist for further tests.
- A digital rectal examination involves the doctor placing a finger inside your back passage and feeling the prostate gland to check its size and shape and whether any lumps can be detected. Although not very pleasant, this should not hurt in any way.
Your doctor may also take into account any family history of prostate cancer.
What else could it be?
A raised PSA does not necessarily mean that you have prostate cancer. Almost any condition that causes the prostate gland to grow or swell will result in a raised PSA test result.PSA also rises slightly as you get older. Similarly, a digital rectal examination can be very difficult to interpret and may require the expertise of a doctor with specialised knowledge.
What can your doctor do?
If a prostate gland feels large and smooth on a digital rectal examination, then this generally indicates benign prostatic hyperplasia, which is not life threatening and can be treated in many ways. However, if it feels lumpy, there may be cause for concern and this will require further tests.Equally, the PSA result can be high in men with benign prostatic hyperplasia or prostatitis as well as in those with prostate cancer. Most urologists now use age-specific reference values for PSA that take account of a small rise in PSA with age.
Always take a pen and notepad (or perhaps your partner or friend) to the consultations that you have with your doctor. This will enable you to remember what has been said to you and will help you discuss your condition with others later on.
In men with either an abnormal feeling prostate or a PSA raised above the age-specific reference value, a referral is usually made to a specialist known as a urologist. The urologist will discuss the risk of prostate cancer with you in more detail.
In most cases a trans-rectal ultrasound of the prostate and biopsy of the prostate will be recommended. Here, a small ultrasound probe is placed inside the back passage, which provides an image of the prostate gland and its surrounding tissue. The urologist can then insert a biopsy needle into the prostate gland under local anaesthetic to take small biopsy samples.
This tissue can then be analysed under a microscope to give a much clearer understanding of the cause of the problem. You will be given antibiotics during this time to prevent any possible infections after the biopsy.
You may also notice a small amount of blood in your urine or faeces. This is not usually a problem, but if it persists you must consult your doctor.
Sometimes blood may be noticed in the semen after a prostate biopsy, and this may persist for up to 6 to 8 weeks but usually settles without specific treatment.
One further source of uncertainty relates to the results of the prostate biopsy. If the biopsy shows prostate cancer then this will be discussed with you in detail. This is covered in the section below.
Whilst a negative biopsy is reassuring, it does not exclude prostate cancer completely – sometimes prostate cancers are very small and unless the needle biopsy passes through the area of cancer, it will not show up on the biopsy results. This concept can lead to some undertainty and anxiety.
Normally the doctor will suggest surveillance with a further PSA blood test after 4 to 6 months. If the PSA rises further after this time then further biopsies may be required.
How is prostate cancer treated?
If prostate cancer has been detected in the biopsy specimens, you now have several difficult choices to make with regard to treatment.The way the disease is treated depends on many factors, including your age and the size and grade of your cancer.
The biopsy specimen is often given a score known as the Gleason Score. Evidence has shown that the Gleason score (a measure of the 'aggressiveness' of the tumour) is closely linked to the risk of dying from the prostate cancer.
Under the microscope, the pathologist looks at all the areas on the biopsies that show cancer and gives a Gleason grade of between 1 and 5 to each of the two most common patterns seen.
Grade 1 is the least aggressive and Grade 5 is the most aggressive. These grades are then added together to give a Gleason score which may be phrased as (for example) Gleason 4+3, or Gleason 7.
Cancers with a Gleason score of 6 or below can often be managed by active surveillance. Essentially this means repeating the PSA at frequent intervals (usually every 4 to 6 months) and then having further biopsies.
There's no consensus at present as to how often these 'staging' biopsies should be repeated but most centres would normally repeat them every 12 to 18 months.
The reason for the repeat biopsy is that in some cases the PSA may not change despite the fact that the cancer is progressing – therefore prostate biopsies are one further way of assessing whether continued surveillance is reasonable.
The main advantage of active surveillance is the avoidance of any of the complications associated with active treatments (see below), but some patients find the uncertainty associated with the surveillance process too difficult.
Cancers localised to the prostate
Other than active surveillance these cancers are normally suitable for treatment either with surgery, radiotherapy or brachtherapy.Surgery
For localised cancers (those which are contained), it's possible to remove the entire gland in an operation called a radical prostatectomy.In the past this operation involved the surgeon making an incision in your lower abdomen and taking out the whole prostate gland. Recent advances in laparoscopic (telescopic) surgery mean that most cases are now done with robotically.
This is a tricky operation and requires a very skilled surgeon to avoid cutting through the nerve bundles that surround the prostate gland. Because of the likelihood of some nerve damage, impotence is a common problem, and around 70 per cent of men will not be able to achieve a natural erection after the operation.
Because laparoscopic surgery uses only small incisions the recovery from surgery is much quicker than it used to be with 'open' surgery.
There's also a slight risk of incontinence, with around 3 to 5 per cent of men requiring the long term use of incontinence pads.
Radiotherapy
This technique can also be used to treat contained cancers. It can be done in several ways. In external beam radiotherapy, radioactive beams are aimed at the prostate from outside the body.However, radiotherapy beams cannot distinguish between normal and cancerous cells, so the beams need to be focussed very carefully on the prostate gland itself.
A newer method, known as 3D conformal radiotherapy, is now used in many hospitals.
This technique involves feeding the co-ordinates of the prostate (size, shape, position) into a computer, which then shapes the beams to fit the prostate to limit the damage to normal tissue.
There are fewer side-effects with this treatment, with around 60 per cent of men becoming impotent and around 1 per cent of men experiencing incontinence.
There's also a 5 per cent risk of developing bowel related symptoms, such as bleeding from the back passage, frequent or painful opening of the bowels. These symptoms can be long term.
Brachytherapy
This is type of radiotherapy involves placing radioactive seeds inside the prostate gland itself, thereby delivering radiation directly to the cancer.In this procedure, the doctor inserts needles into the prostate gland under anaesthesia and then passes the seeds through the needles into the gland, where they remain forever. The seeds eventually lose their radioactivity and become ineffective. Because there's no need for surgery, the procedure can generally be carried out in a day or two, and you should be able return to normal life immediately.
Around 3 in 10 men will become impotent after brachytherapy, and a small number of men will experience a burning sensation while urinating, although this normally disappears within weeks.
Brachytherapy in its current form is a relatively new technique, but new studies have monitored men for 10 years and found it to be comparable to surgery in its ability to destroy the cancer.
Cancer that has spread from the prostate
Hormone therapy
If the cancer has already spread from the prostate gland by the time it has been detected, it will normally be treated with hormone therapy.Prostate cancers require the male hormone testosterone to grow and spread. Therefore, if you deprive the cancer of testosterone, the cancer is starved.
Hormone therapy does just that, and although it will not completely remove the cancer, it can place it on hold for several years and can relieve a number of symptoms including bone pain and urinary problems.
Hormone therapy can also be used in men whose cancer has spread slightly, because this treatment can kill some of the cancer and will shrink the remaining gland, making it easier to then be treated with either surgery or radiotherapy.
Hormone therapy can cause side-effects the most common of which is 'hot flushes' (similar to the ones experienced by women during the menopause).
Longer term usage can cause loss of libido (sex drive), impotence, muscle loss, weight gain and depression.
How do you live with prostate cancer?
Ironically, prostate cancer itself may not cause you too many problems, whereas the treatment of the disease itself may do.Many men are diagnosed through screening tests and have no symptoms at all until they are subsequently treated.
The most common problems resulting from treatment are impotence and incontinence. However, a diagnosis of cancer is enough to frighten anybody, so you may well experience some psychological effects such as depression.
In most men, impotence can now be treated very effectively with various therapies.
It's important to ask your specialist about the risk of impotence if you would like to maintain a physical relationship. Your doctor can also refer you to an impotence adviser who can help you to find the most suitable treatment for you and your partner.
Incontinence can be more difficult to manage and men often resort to wearing incontinence pads.
However, there are other devices, and your doctor can refer you to an incontinence nurse, who will help you find the best solution to the problem. In extreme cases, it's also possible to have a surgical operation to minimise incontinence.
Above all, there is no right or wrong way to deal with your diagnosis.
If you feel like sharing your experiences with somebody, there are plenty of organisations and support groups that can provide extra information for you, your family and even your friends.
If desired, they can also put you in touch with other men with the condition. It's important to become informed about this disease before you select a treatment. By arming yourself with knowledge of the various pros and cons of each treatment, you can make an informed choice that is right for you.
