Prostate Cancer

Prostate cancer

What is prostate cancer?

Prostate cancer is a common type of cancer in men that starts in the prostate gland (a collection of male sex glands encased as one walnut-sized organ). The prostate gland is located just below the bladder (the organ that collects and empties urine) and surrounds the urethra (the tube that carries urine from the bladder through the penis). The prostate produces fluid that becomes part of the semen and helps to control the rate and flow of urination.

Prostate cancer occurs when cells within the prostate glands begin to grow and divide abnormally. If left untreated, the cancer will gradually spread to surrounding tissues (this spreading process is called metastasis) — first, to the lymph nodes, which drain the prostate and then to the bones, usually the spine and ribs. Prostate cancer generally develops very slowly, although it can grow quickly and spread to other parts of the body. If the cancer is found before it has spread outside the prostate, the survival rate is excellent. The survival rate decreases if the cancer has spread to tissues surrounding the prostate or to elsewhere in the body.

What causes prostate cancer?

The cause of prostate cancer is not yet known, but there are certainly risk factors associated with developing the disease. These include:

  • Age — prostate cancer generally affects men over 50 years of age. Risk increases as you get older.
  • Family history — some families may share certain genetic similarities that cause cancer cells to develop abnormally, so men who have close male relatives (brother, father, uncle) who had prostate cancer are more at risk, particularly if your relative was diagnosed at a young age. A strong family history of breast cancer in close female relatives (mother, sister, aunt) also increases risk – particularly if they were diagnosed under the age of 40.
  • Race — prostate cancer is more common among African-American and African-Caribbean men than among white men.
  • Diet — it has been suggested that a diet that is high in fat, particularly dairy foods and red meat, may play a part in causing prostate cancer.

What are the symptoms of prostate cancer?

In the early stages, the symptoms of prostate cancer may be mild and go unnoticed. However, as the disease progresses, you may experience the following symptoms:

  • Frequent urination, especially at night.
  • Difficulty in controlling the flow of urine.
  • Inability to urinate.
  • Urgent need to urinate.
  • Pain or stiffness in the lower back, hips or upper thighs.

How is prostate cancer detected?

There is no screening programme for prostate cancer available in Ireland at present, as there is debate on the effectiveness of regular screening for all men. However, it is important that you are checked by your doctor if you have any of the symptoms of prostate cancer, and that you have regular check-ups if you are over the age of 50 if you have a family history of breast or prostate cancer.

At present, there is no single test to diagnose prostate cancer, so a number of tests must be done. Initial tests your GP may carry out include a rectal examination and a blood test to check your level of a protein called prostate specific antigen (PSA).

Rectal Examination

In the digital rectal examination, the doctor will insert a gloved lubricated finger into the rectum (back passage) to feel the prostate for bumps or nodules. This is a quick test and will not be painful, but may just be slightly uncomfortable.

PSA test

The PSA test involves taking samples of blood to check the level of PSA. Men with prostate cancer tend to have higher levels of PSA in their blood; however, a raised PSA does not necessarily mean you have prostate cancer. Likewise, men with prostate cancer do not always have a raised PSA. Your doctor will therefore refer you for further tests at a hospital if they have any cause for concern.

Transrectal ultrasound and biopsy

Following a PSA test and digital rectal exam, you may be referred to a hospital to have a biopsy. This involves taking a microscopic sample of the prostate tissue with a needle through the rectum and is often carried out at the same time as the transrectal ultrasound (TRUS) test. The TRUS test uses a small lubricated metal tube placed in your back passage to take an image of the inside of your body. The biopsy, together with the TRUS test, will normally reveal whether you have prostate cancer and how quickly it may develop.

If you are diagnosed with prostate cancer, you may need further tests to show whether the disease has spread to other parts of the body. These may include a bone scan, bone x-ray, CT scan and an MRI scan.

What does the diagnosis mean?

Grading

A grading system is used to describe the appearance of cancer cells under the microscope, and predict how the cancer will grow. Different grading systems may be used, although the Gleason grading system is most common. This system gives a score of 2-10, with the higher the number the more likely the tumour is to grow and spread. Ask your doctor to explain what the grade on your biopsy result means.

Staging

Staging indicates the size and location of the cancer, and is very important in deciding the best treatment for you. Early-stage tumours are contained within the prostate gland, while late-stage tumours may have spread beyond the prostate into surrounding tissues. Cancer that has spread to other parts of the body is known as secondary or metastatic prostate cancer.

Again, different staging systems are used, so ask your doctor to explain what the staging on your biopsy result means.

How is prostate cancer treated?

There are a number of different treatments available for prostate cancer, which may be used on their own or in combination. Which treatment you are given will depend on a number of factors, including your age, overall health and the stage and grade of your cancer, as well as your own personal preference. The earlier the cancer is detected, the greater the chance that treatment will be effective.

Watchful waiting

Also referred to as ‘conservative management’ or ‘expectant therapy’, this option may be recommended by your doctor if your cancer is at a very early stage, is expected to grow very slowly and is not causing any symptoms. Your doctor may feel that aggressive treatment would be more stressful than beneficial (for older people who have other health problems, for example). The progress of your cancer will be closely monitored with regular blood tests and check-ups, and active treatment recommended if it begins to change or cause problems.

Surgery

The most common surgery for prostate cancer is the total prostatectomy (also known as a radical prostatectomy). This procedure involves removing the entire prostate gland and some the tissue around it from the body. It is usually recommended for young men with a relatively early-stage tumour that is confined to the prostate, as removing the prostate will then removes the entire tumour, curing the cancer.

After the surgery, a temporary catheter (tube to drain urine) will be inserted through the penis into the bladder, which will allow you to urinate easily while you are healing. This remains in place for three weeks after the operation. You will be able to urinate on your own when the catheter is removed. Most men are ready to go home 7 to 10 days after surgery.

The main long-term side-effects of surgery are urinary incontinence (loss of bladder control) and erectile dysfunction (or impotence – failure to achieve and sustain an erection), and the severity of these side-effects will vary from individual to individual. Most men are likely to have some problems when the catheter is first removed, but this usually improves with time. Normal bladder control will usually return within several weeks or months — ask your doctor about pelvic exercises that will strengthen your muscles. Again, the degree of impotence suffered will depend on your age, the type of surgery that was performed and whether any nerves were damaged or removed. You may need to take medication or use mechanical aids to achieve an erection for a period following the operation. You will still orgasm, although there will not be any semen.

Another type of surgery that is sometimes carried out for prostate cancer is called transurethral resection of the prostate (TURP). This involves removal of the diseased section of the prostate only, and not the whole gland. It may be carried out in men who cannot have a total prostatectomy due to age or illness. TURP does not require the same length of hospital stay as the radical procedure. Neither does it have the same level of risk of side effects such as incontinence and impotence.

Cryotherapy

Cryosurgery (or cryotherapy) uses cryogenic gases to freeze and destroy the cancer. The treatment is normally used in men with early-stage prostate cancer who want to avoid surgery, or in men whose disease has come back after radiotherapy. As with a prostatectomy, a temporary catheter is inserted after the procedure. New techniques have helped to reduce side effects with this treatment, such as erectile and urinary dysfunction. However, long-term benefits or drawbacks of this therapy are still being evaluated.

Radiotherapy

Radiotherapy may be used to treat cancer that has not spread outside the prostate gland or has spread only to nearby tissue. High-energy x-rays are used to shrink or kill the cancer cells. Radiotherapy may also be used to alleviate pain when cancer has spread to the bone. This treatment does not guarantee that surgery will not be necessary at a later date.

Two types of radiation therapy are used for treating prostate cancer:

  • External beam radiation therapy — radiation is focused on the tumour for a few minutes every day for about seven weeks. This treatment is painless and can be performed on an outpatient basis. Side-effects you may experience while receiving treatment can include incontinence, diarrhoea, rectal discomfort, skin changes, tiredness, weight loss and hair loss from around the pubic area. Some men may also experience erectile dysfunction following radiotherapy.
  • Brachytherapy — also known as internal radiation therapy, brachytherapy is the implanting of radioactive pellets (about the size of a grain of rice) into the prostate. The seeds emit radiation for several months and are left in place when the radioactive material is used up. The pellets are very small and cause little discomfort. Brachytherapy may cause the same side-effects as external beam radiotherapy, but some of the side effects are less likely.

Hormonal therapy

The male sex hormone testosterone fuels the growth of prostate cancer cells. By blocking the effects of testosterone the growth of prostate cancer cells can be slowed down. This is achieved through the use of hormones that oppose the effects of testosterone. A variety of hormones are available which can be administered in the form of a tablet or injection. Hormonal therapy may also involve an operation to remove the testes – this is called an orchidectomy. This option avoids having to use drugs, but may not be suitable for everyone.

Hormonal therapy can shrink the tumour and symptoms often fully disappear. This is the standard treatment for prostate cancer that has spread to other parts of the body. Unfortunately, most hormonal therapies usually cause erectile dysfunction and loss of sexual desire; however some drugs are more likely to cause side effects than others. You may also be able to receive treatment in intervals of 3 or 4 months at a time.

Chemotherapy

Chemotherapy is drug-treatment, which may be given as an injection or infusion (drip), or in tablet form. Depending on the type you need, you may have to stay in hospital overnight, or it may be given in day care.

Chemotherapy is used if there is evidence of cancer spreading beyond the prostate gland, which cannot be controlled by hormone therapy. These cancer cells act almost like seedlings from a plant and can set up secondary cancer sites beyond the prostate gland. Prostate cancer has a tendency to spread to bone. Chemotherapy helps to suppress the growth of such bone deposits. Tumour deposits in bone can be painful and chemotherapy is often used to assist in pain relief. By suppressing the growth of cancer cells in bone the overall level of pain can be reduced.

What can I do?

  • Allow yourself time to absorb the diagnosis — ask questions and learn as much as you can about the disease before deciding how to manage it.
  • Discuss the treatment options with your doctor and ask for advice on the pros and cons of each treatment.
  • Tell your doctor if you are experiencing side-effects from treatments, as they may be able to prescribe medication to alleviate any discomfort.
  • Join a support group. These groups allow you to talk through your feelings with others. Men Against Cancer is a support group run by the Irish Cancer Society for men with prostate and testicular cancer. Contact them on freefone 1800 380 380.

Reviewed: October 4, 2006