The prostate is a small gland in the pelvis that is found only in men. About the size of a walnut, it is located between the penis and the bladder. It surrounds the urethra, the tube that carries urine from the bladder to the penis.
The main function of the prostate is to help in the production of semen. The prostate produces a thick white fluid that is then liquefied by a special protein known as prostate-specific antigen (PSA). The fluid is mixed with sperm, produced by the testicles, to create semen.
The prostate may get bigger as men get older. This causes no problems for two out of three men over 50. But if the prostate gets bigger it can press on the urethra and cause urinary symptoms. This is called benign prostate disease or benign prostatic hyperplasia (BPH). It usually affects men over 50 but is not cancer, and is treatable.
How common is prostate cancer?
Prostate cancer is the most common cancer in men. Each year in Ireland about 2,750 men are diagnosed with prostate cancer. It accounts for 30% of all newly diagnosed cases of cancer in men.
The chances of developing prostate cancer increase as you get older. Most cases develop in men aged 70 or older.
For reasons that are not understood, prostate cancer is more common in men of African-Caribbean or African descent, and less common in men of Asian descent.
The causes of prostate cancer are largely unknown.
The outlook for prostate cancer is generally good. This is because, unlike many other cancers, prostate cancer usually progresses very slowly. Depending on the type of prostate cancer, some mens' life expectancy may not be affected by the cancer.
Prostate cancer can usually be cured if it is treated in its early stages. Treatments include removing the prostate, hormone therapy and radiotherapy (using radiation to kill the cancerous cells).
If the cancer spreads from the prostate to other parts of the body (metastasis), typically the bones, it cannot be cured and treatment is focused on prolonging life and relieving symptoms. Approximately 500 men die from prostate cancer every year in Ireland.
All the treatment options carry the risk of significant side effects, including loss of sexual desire (libido), the inability to maintain or obtain an erection (sexual dysfunction) and urinary incontinence.
Prostate cancer normally causes no symptoms.Rarely the cancer can grow large enough to cause pressure on the waterworks or cause problems with errections, but in the vast majority of men these symptoms are part of the normal aging process.
Symptoms can include:
- needing to urinate more frequently, often during the night
- needing to rush to the toilet
- difficulty in starting to urinate or pee (hesitancy)
- straining or taking a long time while urinating
- weak flow
- feeling that your bladder has not emptied fully.
Many mens' prostates get larger as they get older because of a non-cancerous condition known as benign prostate hyperplasia or prostate enlargement.
Symptoms that the cancer may have spread include bone and back pain, a loss of appetite, pain in the testicles, and unexplained weight loss.
- Benign refers to a condition that should not become life-threatening. In relation to tumours, benign means not cancerous.
- The bladder is a small organ near the pelvis that holds urine until it is ready to be passed from the body.
Cancer is caused when something affects the genetic material of our cells. This causes the cells to reproduce in an uncontrollable manner, creating a lump of tissue, known as a tumour.
What makes the cells in the prostate become cancerous is unknown.
There are a number of known risk factors for developing prostate cancer, which are discussed below.
- Age - the risk of prostate cancer rises with age, from about 50 years, and increases as you get older.
- Ethnic group - prostate cancer is more common among men of African-Caribbean and African descent. The condition is relatively rare among men of Asian and South and Central American descent.
- Family history - having a close male relative, such as a brother, father or uncle, who had prostate cancer seems to increase the risk of you developing prostate cancer. Research also shows that having a close female relative who developed breast cancer may also increase the risk of you developing the condition.
- Obesity, diet and exercise - recent research suggests that there may be a link between obesity and prostate cancer. Research is ongoing into the links between diet and prostate cancer. There is evidence that a diet high in calcium is linked to an increased risk of developing prostate cancer.
If you have symptoms that could be caused by prostate cancer, your GP will discuss the pros and cons of the tests with you. Your doctor is likely to:
- ask for a urine sample to check for infection
- take a blood sample to test your level of prostate-specific antigen (PSA)
- examine your prostate (digital rectal examination)
Prostate-specific antigen (PSA) testing
Prostate-specific antigen (PSA) is a protein produced by the prostate gland. All men have a small amount of PSA in their blood, and it increases with age. Prostate cancer can increase the production of PSA. A prostate-specific antigen (PSA) test looks for raised levels of PSA in the blood and may be able to detect prostate cancer in its early stages.
However, PSA testing is not a specific test for prostate cancer and on its own cannot diagnose or rule out a prostate cancer.Most men who have prostate cancer will not have a raised PSA level. More than 65% of men with a raised PSA level will not have cancer, as PSA levels rises in all men as they get older.
Digital rectal examination
The next step is a digital rectal examination (DRE). This can be done by your GP.
During a DRE, your GP will insert a finger into your rectum. The rectum is close to your prostate gland, so your GP can check to feel if the surface of the gland has changed. This will feel a little uncomfortable but it should not be painful.
Prostate cancer can make the gland hard and bumpy. However, in some cases, the cancer causes no changes to the gland and a DRE may not be able to detect the cancer.
DRE is also useful in ruling out benign prostatic hyperplasia, as this causes the gland to feel firm and smooth.
Your GP will assess the risk of you possibly having prostate cancer based on a number of factors, including your PSA levels, the results of your DRE and associated risk factors, such as age, family history and ethnic group. If it is felt that you are at risk, you will be referred to a hospital to discuss the options of further tests.
The most commonly used test is known as a transrectal ultrasound-guided biopsy (TRUS).
During a TRUS biopsy, an ultrasound probe (a machine that uses sound waves to build up a picture of the inside of your body) is put into your rectum. This lets the doctor or specialist nurse see exactly where to pass a fine needle through the wall of your rectum to take small samples of tissue from your prostate (biopsy).
The procedure can be uncomfortable and sometimes painful. You may be given a local anaesthetic to minimise any discomfort. As with any procedure, there may be complications, including bleeding and infection.
Although it is much more reliable than a PSA test, a biopsy may miss up to 20% of cancers. Therefore, you may need to have another biopsy if your symptoms persist, or your PSA level continues to rise.
The samples of tissue from the biopsy are then studied in a laboratory. If cancerous cells are found, they can be studied further to see how quickly the cancer will spread.
This measure is known as the Gleason score. The lower the score, the less likely the cancer will spread.
- A Gleason score of 6 or less means the cancer is unlikely to spread.
- A Gleason score of 7 means that there is a moderate chance of the cancer spreading.
- A Gleason score of 8 or above means there is a significant chance that the cancer will spread.
If there is a significant chance that the cancer has spread from your prostate to other parts of the body, further tests may be recommended.
Two tests that are commonly used are:
- Magnetic resonance imaging (MRI) or computed tomography (CT) scan - these scans build up a detailed picture of the inside of your body. They can be used to check if the cancer has spread beyond the prostate to the surrounding tissue.
- An isotope bone scan - this test uses a small amount of radiation dye injected into the vein, which gradually moves through the bloodstream and collects in the parts of the bone where there are any abnormalities. An isotope bone scan can tell if the cancer has spread to your bones.
Staging of prostate cancer
Doctors will use the results of your prostate examination, biopsy and scans to identify the 'stage' of your prostate cancer (how far the cancer has spread). The stage of the cancer will determine which types of treatments will be necessary. It is a relatively complex system, reflecting the many varieties of prostate cancers.
Doctors identify the stage of prostate cancer by using the TNM system (Tumour, Nodes, Metastases):
- 'T' describes the tumour: whether it can be felt on DRE, how much cancer was found when the biopsy was done (Gleason score), and if it has spread from the prostate gland into nearby tissues.
- 'N' shows whether your cancer has spread to your lymph nodes where the body fluid lymph is filtered and where cancers often spread first.
- 'M' shows whether your cancer has spread (metastasised) to other parts of your body.
Your Multidisciplinary team will discuss treatment options with you. If the cancer is in its early stages and is causing no symptoms, it may be decided to delay any treatment, and wait to see if any symptoms of progressive cancer develop. This is often recommended for older men when it is unlikely that the cancer will affect their natural life span.
Active surveillance aims to avoid unnecessary treatment of harmless cancers, while still providing timely treatment for men who need it.
When they are diagnosed, we know that around half of men with low-risk prostate cancer do not need any treatment. We just don't know which half. Surveillance provides a period of observation to gather extra information to help men decide whether or not to have treatment.
Active surveillance involves you having regular PSA tests and biopsies to ensure that any signs of progression are found as early as possible. If these tests reveal that the cancer is likely to spread beyond the prostate, you can then make a decision about further treatment.
Many men who undergo surveillance (perhaps 30-40%) will later have treatment. This does not mean that they made the wrong initial decision. Provided that delayed treatment is as effective as immediate treatment, they will not have been harmed. They will have delayed any treatment side effects, and they will be reassured that their treatment was actually necessary. It is therefore important that men considering active surveillance are prepared to attend every single appointment scheduled with their specialist.
A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing localised prostate cancer and locally-advanced prostate cancer.
Like any operation, this surgery carries some risks, and there may be some side effects. These are outlined below.
- Some men have problems with urinary incontinence. This can range from leaking small drips of urine, to leaking larger amounts. However, for most men, this often clears up within 3-6 months of the operation. Less than 5% of men have long-term problems requiring the use of pads.
- Some men have problems getting an erection (erectile dysfunction). For some men, this improves with time. But around half of men will have long-term problems.
- In extremely rare cases, problems arising after surgery can be fatal. For example, 0.1% of men under 65 years old and 0.5% of men over 65 will die following a radical prostatectomy.
For many men, having a radical prostatectomy will get rid of the cancer cells. However, for around one in three men, the cancer cells may not be fully removed, and the cancer cells may return some time after the operation.
Radiotherapy involves using radiation to kill cancerous cells. This treatment is an option for curing localised prostate cancer and locally-advanced prostate cancer. Radiotherapy can also be used to slow the progression of metastatic prostate cancer and relieve symptoms.
The levels of radiation are safe but they can cause side effects (see below).
Radiotherapy is normally given as an outpatient at a hospital near you. It is done in short sessions for five days a week, for four to eight weeks. There are short-term and long-term side effects associated with radiotherapy.
Short-term effects of radiotherapy can include:
- discomfort around the rectum and anus (the opening through which stools pass out of your body)
- loss of pubic hair
- cystitis - an inflammation of the bladder lining, which can cause you to urinate frequently; urination may be painful.
Possible long-term side effects can include:
- an inability to obtain an erection - this affects 30 to 50% of men
- urinary incontinence (less than 1%)
As with radical prostatectomy, there is a one-in-three chance that the cancer will return.
Brachytherapy is a form of radiotherapy where a number of tiny radioactive seeds are surgically implanted into the tumour. It is also known as internal radiotherapy.
This method has the advantage of delivering a high dose of radiation to the prostate, while minimising damage to other tissues. However, the risk of sexual dysfunction and urinary problems is the same as with is delivered at a single sitting under a short,full anaesthetic.
Hormone therapy is often used in combination with radiotherapy. For example, you may receive hormone therapy before undergoing radiotherapy in order to increase the chance of a successful treatment. Or hormone therapy may be recommended after radiotherapy to reduce the chances of cancerous cells returning.
Hormone therapy alone should not normally be used to treat localised prostate cancer. Hormone therapy can be used to slow the progression of advanced prostate cancer and relieve symptoms.
Hormones control the growth of cells in the prostate. In particular, prostate cancer needs the hormone testosterone to grow. The purpose of hormone therapy is to block the effects of testosterone, either by stopping its production or by stopping your body being able to use testosterone.
There are three ways to give hormone therapy:
- Injections to stop your body making testosterone, called luteinising hormone-releasing hormone (LHRH) agonists.
- Tablets to block the effects or reduce the production of testosterone, called anti-androgen treatment.
- Combined LHRH and anti-androgen treatment.
The main side effects of hormone treatment are caused by their effects on testosterone. They usually go away when treatment stops. They include loss of sex drive and impotence (this is more common with LHRH agonists than anti-androgens).
Other possible side effects include:
- hot flushes
- weight gain
- swelling of the breasts
A surgical alternative to hormone therapy is to surgically remove the testicles, called orchidectomy. The operation does not cure prostate cancer, but by removing the testosterone it controls the growth of the cancer and its symptoms. However, many men prefer to have hormone treatment to block the effects of testosterone.
Trans-urethral resection of the prostate (TURP)
This is a surgical procedure perfromed in theatre under a full anaesthetic,where part of the prostate gland putting pressure on the water channel are removed. It is done through a telescope passed into the penis so that there are no cuts or scars. Inpatient stay is two to four days and it is done purely to alleviate urinary symptoms. The procedure does not help overall cancer control.
High intensity focused ultrasound (HIFU)
HIFU is sometimes used to treat men with localised prostate cancer that has not spread beyond their prostate. HIFU treatment is still going through clinical trials for prostate cancer. It is not widely available.
An ultrasound probe put into the rectum releases high-frequency sound waves (which cannot be heard by humans) through the wall of the rectum. These sound waves kill cancer cells in the prostate gland by heating them to a high temperature.
The side effects of HIFU can include impotence, urinary symptoms or fistula - an abnormal connection (fistula) between the urinary system and rectum. In a small number of men (about 1-3%), an abnormal connection occurs between the rectum and the urethra (which carries the urine down to the penis). Patients undergoing HIFU may require more than one treatment to control their cancer.
Cryotherapy is a method of killing cancer cells by freezing them. It is still undergoing clinical trials for prostate cancer. It is sometimes used to treat men with localised prostate cancer that has not spread beyond their prostate gland.
Tiny probes called cryoneedles are inserted into the prostate gland through the wall of the rectum. They freeze the prostate gland and kill the cancer cells, but some normal cells also die. The aim is to kill cancer cells while causing as little damage as possible to healthy cells. The side effects of cryotherapy can include impotence, urinary symptoms and rectal problems.
Treating advanced prostate cancer
If the cancer has reached an advanced stage, it is no longer possible to cure it. But it may be possible to slow its progression, prolong life and relieve symptoms.
Treatment options include:
- hormone treatment
Chemotherapy is mainly used to treat prostate cancer that has spread to other parts of the body (metastatic prostate cancer) and which is not responding to hormone therapy.
Chemotherapy destroys cancer cells by interfering with the way in which they multiply. Chemotherapy does not cure prostate cancer, but it can keep it under control and reduce symptoms (such as pain) so that everyday life is less affected.
The main side effects of chemotherapy are caused by their effects on healthy cells, such as immune cells. They include infections, tiredness, hair loss, sore mouth, loss of appetite, nausea and vomiting. Many of these side effects can be prevented or controlled with other medicines, which your doctor can prescribe for you.
Steroid tablets are used when hormone therapy no longer works because the cancer is resistant to it. This is called hormone-refractory cancer. Steroids can be used to try to shrink the tumour and stop it from growing. The most effective steroid treatment is dexamethasone.
Deciding against treatment
As many of the treatments above have unpleasant side effects that can affect your quality of life, you may decide against treatment. Especially if you are at an age when you feel that treating the cancer is unlikely to significantly extend your life expectancy.
This is entirely your decision, and your MDT will respect it.
If you decide not to have treatment, your GP will still give you support and pain relief. This is called palliative care. Support is also available for your family and friends.
Routinely screening all men to check their prostate-specific antigen (PSA) levels is a controversial subject in the international medical community.The evidence currently does not show any benefit from screening older men who do not have symptoms
There are several reasons for this:
- PSA tests are unreliable and often produce results that suggest the presence of prostate cancer when no cancer exists (a false-positive result). This means that many men often have invasive and sometimes painful biopsies for no reason.
- Some experts question whether an early diagnosis of prostate cancer is actually worthwhile.
- While it is true that treating the condition in its early stages is normally more successful, the side effects of the various treatments are potentially so serious that men may choose to delay treatment until it is absolutely necessary.
- Although screening has not been shown to reduce a man's chance of dying from prostate cancer, it increases his chances of being diagnosed with and treated for prostate cancer. It is not yet clear whether the benefits of screening outweigh the risks.
Because there are many reasons why PSA levels may be high at any one time, researchers are trying to make the PSA test, or a variation of it, more accurate. These include looking at how PSA levels change (or not) over time, and comparing the PSA level to prostate size. There is also a test that measures 'free' PSA. These variants of the PSA are still being investigated by clinical researchers. They are not standard tests in prostate disease.
There is an informed choice programme on prostate cancer risk management. It aims to give men good information on the pros and cons of a PSA test. If you decide to have your PSA levels tested even if you do not have any symptoms, your GP will be able to arrange it for you.
Should I have a PSA test?
Because the results of the PSA test are not as reliable as doctors would like, other tests and investigations are needed to diagnose prostate cancer. It cannot identify prostate cancer on its own, and changes in PSA levels alone are not a good reason to start treatment.
If you are going to have a PSA test, it is important that you first discuss with your GP whether it is right for you, so that you understand what the results might mean.
Impact on everyday activities
If you have no symptoms, prostate cancer should have little or no effect on your everyday activities. You should be able to work, care for your family, carry on your usual social and leisure activities and look after yourself. However, you may be understandably worried about your future. This may make you feel anxious or depressed, and affect your sleep.
If your prostate cancer progresses, you may not feel well enough to do all the things you used to. After an operation or other treatment, such as radiotherapy or chemotherapy, you will probably feel tired and need time to recover.
If you have advanced prostate cancer that has spread to other parts of your body, you may have symptoms that slow you down and make it difficult to do things. You may have to reduce your working hours or stop working altogether. Whatever stage your prostate cancer has reached, try to give yourself time to do the things you enjoy and spend time with those who care about you.
Complications of prostate cancer
If you have erection problems or you have lost the ability to obtain an erection, speak to your GP. It may be possible to treat you with a type of medicine known as phosphodiesterase type 5 inhibitors (PDE5). PDE5s work by increasing the blood supply to your penis.
The most commonly used PDE5 is sildenafil (Viagra). Other PDE5s are available if sildenafil is not effective. Further medicines delivered directly into the penis in the form of jellys and injectibles are also available
Another alternative is a device called a vacuum pump. It is a simple tube connected to a pump. You place your penis in the tube and then pump out all the air. This creates a vacuum which causes the blood to rush to your penis. You then place a rubber ring around the base of your penis. This keeps the blood in place and allows you to maintain an erection for around 30 minutes.
If your urinary incontinence is mild, you may be able to control it by learning some simple exercises. Pelvic-floor exercises can strengthen your control over your bladder.
To carry out pelvic-floor exercises:
- Sit or lie comfortably with your knees slightly apart.
- Squeeze or lift at the front as if you were trying to stop the passage of urine, then squeeze or lift at the back as if you were trying to stop the passage of wind.
- Hold this contraction for as long as you can (at least two seconds, increasing up to 10 as you improve).
- Relax for the same amount of time before repeating.
If your urinary incontinence is more severe it may be possible to treat with surgery. This would involve implanting an artificial sphincter or placement of a sling to give extra support i.e. a hydraulic valve with a control button sited in the scrotum to open and close the water channel as desired. A sphincter is a muscle that is used to control the bladder.
Getting a diagnosis of prostate cancer often brings families and friends closer, although it can put pressure on relationships too. Most people want to help, though they may not know what to do. A few people find it hard to talk to someone with prostate cancer, and may try to avoid them. Being open and honest about how you feel and what your family and friends can do to help you may put others at ease. But do not feel shy about telling people that you need some time to yourself, if that is what you need.
Talk to others
If you have questions, your doctor or nurse may be able to reassure you, or you may find it helpful to talk to a trained counsellor, psychologist or specialist telephone helpline. Your GP surgery will have information on these.
Some people find it helpful to talk to other people with prostate cancer at a local support group or through an internet chat room.