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The truth about prostate cancer...

Around 1,500 new cases of malignant cancer of the prostate gland develop in Irish men throughout Ireland each year. It makes cancer of the prostate the second most common cancer in men, cancer of the skin being the most common.

On average some 720 deaths in Irish men are attributed to cancer of the prostate each year. This places cancer of the prostate second in the league table to lung cancer as the commonest causes of cancer death in Irish men. These stark statistics underline the fact that cancer of the prostate is a big cause of sickness and death in this country. Yet, we have no public health campaigns to either highlight the importance of the disease or to specifically inform the public about the screening, diagnosis and treatment of carcinoma of the prostate gland.

Screening for prostate cancer

In this article, I want to specifically deal with the subject of screening for prostate cancer but before doing so perhaps we should get down to basics and explain exactly where the prostate gland is located. I strongly suspect that if you asked a sample of Irish men where the prostate gland was, that you would receive a very diverse range of answers.

It would be a reasonable practice for men over the age fifty to attend their GPs at least once in order to be assessed for possible risk of prostate cancer.

The prostate gland is part of the male reproductive system. It is a doughnut shaped organ that is wrapped around the urethra, which is the tube that conveys urine out from the bladder and on through the penis. A normal sized gland is approximately the same size as a plum. If you can imagine the outflow from the bladder into the urethra as being like a funnel, the prostate nestles under the bladder just at the funnel’s neck. Therefore when the prostate enlarges it can compress the urethra and can also press up into the floor of the bladder thereby potentially interfering with the flow of urine from the bladder through the urethra.

Examination

Another important anatomical consideration is that it is possible to identify and feel the prostate gland through DRE (digital rectal examination). Put simply, the doctor can examine the gland by gently inserting a lubricated gloved index finger through the anus. The examining finger is then gently pushed up the rectum and the prostate is felt as a mass located to the front of the examining fingertip. The gland can be felt quite clearly through the wall of the rectum.

DRE is an essential step in the assessment of the prostate gland. The examining doctor can ascertain the size of the gland and whether it feels hard or relatively soft. It is also possible to detect hard lumps within the gland that would be suggestive of the possibility of cancer. However, DRE alone is no longer considered sufficient for the assessment of possible prostate cancer. It is now universally recommended that DRE be combined with a PSA (prostate specific antigen) test in order to establish if a risk of cancer exists.

It is important to emphasise that these two tests combined cannot diagnose if a man has prostate cancer. They simply suggest that further testing is needed in order to establish if cancer is present.

Biopsy

There is a fundamental difference between screening tests and diagnostic tests. Screening tests are designed to screen out those individuals who require further testing to confirm or exclude a particular diagnosis. Diagnostic tests will often involve obtaining tissue samples by biopsy that confirms if a cancer is present or not. The DRE and PSA are screening tests and even if the results are abnormal they are not diagnostic of cancer. This is a very important concept for people to grasp because many men experience great alarm and fear if their PSA result is elevated.

We have no public health campaigns to either highlight the importance of the disease, or to specifically inform the public about the screening, diagnosis and treatment of carcinoma of the prostate gland.

PSA is a protein that is produced within the duct system of the prostate gland. Normally the bulk of this protein is contained within the gland and blood levels of PSA tend to be low. However, if the architecture of the prostate gland is disturbed, increased levels of PSA escape into the general circulation giving rise to elevated levels of PSA in the blood. This can happen with various diseases of the prostate gland and not just cancer. For example, in the case of BPH (benign prostatic hypertrophy), which means non-cancerous enlargement of the prostate, the PSA can also be elevated. This can also happen with inflammation of the prostate or prostatitis to give it its medical name.

Herbal products

Various herbal compounds have also been noted to affect PSA levels. Saw palmetto (Serenoa repens), which is often recommended for 'prostate conditions', can affect PSA levels. So, it is important to mention to your doctor that you are using herbal remedies if you are undergoing PSA testing. Prostate biopsy and cystoscopy (examination of the bladder with an endoscope) also raise PSA levels therefore PSA estimation should be deferred for several weeks after such testing in order to avoid obtaining an artificially high level on blood testing.

As mentioned earlier an abnormal DRE or an elevated PSA may suggest the presence of prostate cancer but that diagnosis can only be confirmed by examining a sample of prostate tissue. In either of those two scenarios it is normal practice to refer the man to a urologist for a biopsy and further assessment.

The sample of prostate tissue can be obtained in a number of ways. The commonest method for obtaining a sample of prostate tissue is by transrectal biopsy. This involves the use of an ultrasound scan, which outlines the prostate gland and allows the doctor to visualise the gland while guiding the biopsy needle into the gland from the rectum.

No anaesthetic needed

This sounds like a gruesome ordeal for the uninitiated but it can be performed as an outpatient procedure without need for an anaesthetic. Although the insertion of the instrument through the anus may cause some pressure, the passing of the needle through the rectum into the prostate is painless because the wall of the rectum does not contain pain nerve fibres. There may be some blood in the stool, urine or semen for a number of days after the procedure but the volume tends to be small, self-limiting and of itself does not require specific treatment. It is very important to stress that an ultrasound scan alone is not sufficient to make the diagnosis. A tissue sample is required.

If a diagnosis of prostate cancer is made following microscopic examination of the biopsy sample the PSA may be of additional value to the doctor. For example, a high pre-treatment PSA level correlates well with risk of cancer spread beyond the capsule enveloping the prostate gland. If the level is even higher again this suggests the possibility that cancer cells have spread to the local lymph glands. Furthermore, if pre-treatment PSA levels are not excessively high in a person with prostate cancer then local treatment alone may be sufficient. In other words additional chemotherapy, hormone therapy or radiotherapy might not be necessary because the cancer has been diagnosed before it had time to spread beyond the prostate gland.

Surgery

In the case of radical prostatectomy, which means total removal of the gland through the abdominal route, it would be expected that the PSA would not be detectable. In that scenario a recurrence of detectable PSA would suggest the possibility of a recurrence of disease. It is standard practice to monitor PSA levels on an ongoing basis when a man has been treated for prostate cancer in order to confirm that he remains disease free.

Screening for prostate cancer usually starts at the age of fifty. If a man has a history of prostate cancer affecting his father or a brother such screening should probably commence at a younger age. Some authorities suggest that screening in such cases should begin at forty but there is no universal agreement on this point. It has also recently emerged that if a female were diagnosed with breast cancer under the age of forty that this would also increase the risk of her first-degree male relatives developing prostate cancer.

DRE and the PSA test are not infallible tests and there is some ongoing controversy regarding their use and interpretation. Further research is clearly needed in this area to improve the precision of our screening and diagnostic tools. In the meantime it would be a reasonable practice for men over the age fifty to attend their GPs at least once in order to be assessed for possible risk of prostate cancer.

* Dr Leonard Condren is the medical editor of irishhealth.com.

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Last Reviewed: 7th February 2003



  maurarua  Posted: 07/02/2003 15:57
at what age range is prostate cancer usually diagnosed? How long are symptoms usually present befre diagnosis?
 
  martin(martinpfsmith)  Posted: 12/02/2003 12:44
What are the usual symptoms ?
 
  Michael(mpascal)  Posted: 12/02/2003 12:58
I have a slightly incresed prostate defined as +1 stagnant for the last 3 years. The only inconvenince is the frequent urination. Is it advisable to go through specific tests?
 
  desmond(desmondcox)  Posted: 12/02/2003 19:51
excellent article very educational would like bottom line language as explanation of DRE. THANK YOU
 
  Anonymous   Posted: 12/02/2003 21:13
Blood in urine. PSA and blood test, was told "nothing significant". Blood disappeared after course of antibiotics. Reappeared later and disappeared again after more antibiotics. Now all is clear. What is likely cause?
 
  martina(Tarmina)  Posted: 07/03/2003 12:43
My dad started hormone therapy for prostate cancer in february,{injections & medication}he will be taking this for 6 months. Originally the doctor said he had secondary cancer and there was traces in the bone, what does this mean and what would you think his chances are? He is 67 and does seem to be good form now. From October to Christmas he was in and out of hospital in a lot of pain with major headaches, so he was only diagnosed a week before Christmas.
 
  martina(Tarmina)  Posted: 20/03/2003 14:58
My dad was diagnosed with Prostate Cancer in December, he had been suffering severe headaches that is how it was effentially discovered{after many tests}he is now on the hormone treatment for 6 months, we were originally told that he had secondary cancer in the bones, & because of the severe headaches they thought in the head area too.But we haven't heard anything about that since. He is well at the moment, much better than he had been before starting treatment. What are his survival chances do you think, & what happens when the treatment finishes?{he is 67 & also smokes & drinks}
 
  Anonymous   Posted: 21/04/2003 14:01
Could impotence have anything to do with the prostate gland? Thank you.
 
  Anonymous   Posted: 13/05/2003 21:10
Is a prewvious vasectomy a risk factor for prostate cancer?
 
  Anonymous   Posted: 23/06/2003 21:38
my dad has been told that he has prostate cancer and may also have cancer of the glands in the stomach. what are the chances that any treatment will help him.
 
  Anonymous   Posted: 05/08/2003 14:29
You say nothing in your article about PSA figures and what they mean. eg my last teat was 3.5 what does that mean. Perhaps this kind of info is somewhere elas in the article and I might have missed it. Any coments? Many thanks.
 
  John(dowduff)  Posted: 02/09/2003 17:37
Thank you for the forthright article on prostate cancer. Can you outline 3 specific symptoms that might make you visit the Doctor.
 
  Anonymous   Posted: 03/09/2003 10:07
Are there any companies in Ireland who carry out prostrate Screening in the Workplace. If so do they charge the Customer. How much is it usually? Thank You. J.P
 
  Anonymous   Posted: 03/09/2003 11:12
Is it very preventable if detection is early?
 
  Michael(erickasdad)  Posted: 06/09/2003 19:34
Is it true that sexual inactivity may put men at higher risk to getting prostate cancer?
 
  Anonymous   Posted: 25/09/2003 19:32
P.S.A. Level should reach what level after radical radiotherapy to assure safety from recurrence in an individual whose cancer was confined to the gland.
 
  Anonymous   Posted: 23/03/2004 18:06
I am 69 years old and I was recently diagnosed with agressive prostatic cancer, Gleeson score 9 and hot spots on bone scan. I am on hormone treatment. I have no symptoms. Will symptoms develop
 
  Brendna(TZV12446)  Posted: 15/04/2004 08:08
My dad was diagnosed with Prostate Cancer in September 2003, it has also spread to the bones. He lost a lot of weight, 3 or 4 stone, that is why we originally took him to hospital. After many tests he is now on the hormone treatment for 6 or 7 months. He is well at the moment, ie not in pain, the weight has fallen off him, and he sleeps a lot. We have been told this week that they treatment is not working in his case and that there is no point in putting him through kemotherophy. He was taken off the drug CASEDEX. He is 71 years old, does not smoke and drink very little if any. What are his survival chances do you think, we have been told 3 to 6 months. Also the PSA levels have been going up throughout his treatment. psa 218 at the moment.
 
  Anonymous   Posted: 13/10/2004 22:04
I am 75 years old and how would I know if I MIGHT have prostate problems WITHOUT having to go to a Doctor ?????
 
  Brendna(TZV12446)  Posted: 14/10/2004 01:24
Unfortunately my father passed away in August 2004, just gone by. He had lost a severe amount of weight. None of the treatments worked at all. THe PSA levels were continually rising over the last year. He was not able to eat very much at all, and in the last few months muscle and bone pains were getting more frequent, in particular about 3 weeks before he passed away, his ankle became swollen and very painfull when touched. He also had a number of incidents of chest pains for which I took him to hospital.
 
  May(WMR21892)  Posted: 11/01/2005 22:00
what are the usual symptons
 
  Anonymous   Posted: 14/03/2005 15:29
I found this information very useful and reassuring. Thank you.
 
  jim(jimcollier)  Posted: 06/05/2005 00:51
HAD VERYENLARGED PROSTATE DISCOVERED 4 YEARS AGO, ATTENDED SPECIALIST FOR 2 YEARS WITH NO PROBLEMS.PSA LEVEL THEN WENT UP SLGHTLY, SO HAD ANOTHER AFTER 4 MONTHS, PSA HAD INCREASED AGAIN SO HAD BIOPSY ( NO ANAESTETHIC QUITE PAINFUL) PROVED POSITIVE. HORMONE TREATMENT FOR 3 MONTHS TO REDUCE SIZE OF PROSTATE, PSA HAD GONE UP TO 8.6,UNDERWENT BRACHATERAPY TREATMENT 21 MONTHS AGO, NO PROBLEMS, PSA NOW 0.6. HAD NO SYMPTOMS OF PROSTATE PROBLEM AND WAS LUCKY TO HAVE ATTENDED EACH YEAR FOR TESTS. ANNUAL TESTS ARE NECESSARY.
 
  Anonymous   Posted: 11/05/2005 17:19
psa gone up from 0.1 to 0.2 originaly 1500, gleason 10 ,on zoladex casadex and zemeta, dianosed 2years 5 months ago, what is my next move
 
  Alan(HKD28658)  Posted: 25/05/2005 00:15
I am 51 and I have just been told that I have stage 3 Prostate cancer. My PSA is over 26. I am torn between having surgery with no guarantee that it will remove all the cancer with some radiotherepy or 6 months of hormone treatment followed by 4 to 6 weeks of radiotherepy. Any advise would be most beneficial.
 
  Polly  Posted: 13/02/2006 14:57
My dad just got diagnosed with Prostate Cancer. He was told it is at the middle stages and is going for a bone marrow next week. We are all totally shocked and devastated by this news. How would I find out what are his chances of the cancer having or not having spread to his bones.
 
  rosco99  Posted: 11/07/2006 01:57
I recently had a psa test that gave a result of 8.1 using Abbott method. My DRE was normal. My doctor wants me to see an urologist for further tests. I have no symptoms and my health is excellent, good BP and cholesterol and fitness. I am concerned that a biopsy could actually release cancer cells into the system whereas leaving the prostate untouched might only result in a very slow growth if at all. I am 66y.o. Would yearly DRE be a satisfactory course of action.?
 
  Michael  Posted: 12/10/2006 19:51
Have been diagnosed as having prostate cancer.Test showed 33.9.Have been put on hormone tablets(casadex) How long does one stay on these before having recommended radiotherepy,please.. Found your articles most informative.Thanks
 
  Anonymous   Posted: 16/11/2006 16:24
how long for prostate biopsy results normally also is psa of60 with no symptoms normal?
 
  Anonymous   Posted: 17/11/2006 09:41
how long for prostate biopsy results and is it normal to be asymptomatic with psa of 60
 
  Peter  Posted: 26/09/2007 13:44
Had my prostate out in May 2003 with later reoccurance and sub. casodex on and off for 2 years. Now being asked to have radiotherepy for 6 weeks. casodex has kept PSA below 0.40 Casodex is making me irritable and very moody as well as other known pyhisical effects. Sould I have the radiotherepy?
 
  wwwsoldiersofdestiny  Posted: 18/01/2008 20:53
I have just had the undesired experience of a radical Prostatectomy. I am perhaps fortunate in living in Spain, where the Surgeon assured me that the hospitals there were not riddled with MRSA etc.He was shocked when I told him of the situation, and the fears of patients in Ireland. That aside,a chance blood test (which everybody over 55 should have yearly) picked up a PSA reading of 12 and the first check by the surgeon(The simple manual touch probe) picked up a roughage on one side of the surface of the prostate. I think he knew where he was going from there..This was confirmed visually by simple follow upultrasonic probe and a bioposy then followed. This tested positive for cancer in three of the 5 samples taken on the suspect side. The Gleeson scale allocation for the removed samples came in at Less than 6 (3 plus 3) which apparently indicated a non aggressive cancer. 8 or more on the Gleeson scale is danger territory, he told me. He indicated surgery or the new less invasive " freezing" treatment,as options. He said the removel by surgery was more sure.I opted for that. No additional gland nodes etc adjacent to the Prostate were removed as the Surgeon was happy not do do so (a good sign I think ) I have never been sick in my life and I dont know from where I got the courage to take it all so calmly.even when I was lying on the operating table for the anaesthetic to be injected intravenously..( I got no pre-op sedative !) My Cancer was ,it appears, at stage two of the four stages, thank God. I am glad I retired 8 years ago (at 53) I am taking every day at a time now reguardless, as it has helped me to confront, think about, and recognize the common mortality within all of us. All that said I have a friend whose Prostate cancer was determined inoperable, 5 years ago and after palliative treatment in St Lukes, Rathgar, he is doing very well today, (although his PSA levels are climbing again.) I hope this is helpful to some who must confront this problem
 
  Jennie  Posted: 04/07/2008 05:46
My husband was diagnosed 3 months ago with a psa pf 95 and gleason score 9. Bone scan and pelvic mri both clear. He is on casodex and zoladex. He has been told he cant be operated on. why? his mri shows the cancer is confined. this has devastated our lives.
 
  wwwsoldiersofdestiny  Posted: 04/07/2008 19:48
Dear Jennie, Your husband's PSA level is relatively high and he has an extremely aggressive tumour as indicated by the Gleeson reading bioposy- near the top of the scale of cellular distortion. Was it not explained to you why an immediate operation was not an option if it had not metastasized-and I think it would have to be immediate operation- at this level. Have you VHI or are is would he be joining the Madonna Hearney waiting list.?
 
  Pfred  Posted: 29/07/2008 20:46
I wouldn't panic is diagnosed with prostate cancer. It is extremely common. What has made it such an issue is the availability of the PSA. It has led to multiple biopsies and multiple surgeries. Whether they are "unnecessary' is arguable. Before doing anything, I would always get a second urologic opinion. If you go with the biopsy, you will have to decide what to do if it finds a minimal prostate cancer. If you do anything, consider brachytherapy--the treatment with the radioactive needles. By the way, I am not telling anyone to ignore their physicians advise. But, like all serious medical problems, the patient should always become actively involved in treatment decisions. And you will find that there is often disagreement between doctors with regard to treatment methods. Ultimately you have to make your own choices.
 
  emcg  Posted: 19/10/2009 14:48

The fact that a man has to go to the local gp for a referral leter for a psa blood test is a load of b*****. This is what is wrong with the hse. Fire the lot of them.

 
  wwwsoldiersofdestiny  Posted: 20/10/2009 17:17

is it criminal that the private health insurance companies will not save many lives by spending the cost of a postage stamp, warning their older male clients of the importance of yearly PSA blood tests to detect this very curable cancer at an early stage?

 
  wwwsoldiersofdestiny  Posted: 20/10/2009 22:48

I agree with EMCG on that assessment.In Spain, for example, no letter from a GP is requested in the local blood laboratory.It is another layer of expense and bureaucracy.

However I would suggest that anyone desiring a PSA blood test should be able to phone their local GP and ask them to leave a letter in the surgery without the necessity to queue for perhaps hours on end and have to pay an attendance fee.

No decent GP would charge a client for this facility.(Mine does not.)

 
  AlbertS  Posted: 06/04/2011 10:24

Good post. A lot of people don't take prostate cancer seriously because they say that it is normal nowadays. Though, I am sure that many will be interested to this since a new  research that suggests screening and catching prostate cancer early won't avoid deaths from the disease. This is far from the first study to suggest it. Many people really don't know that screenings are great for catching prostate cancer early, but more than 2 decades of data revealed that individuals who did not get regular tests and people who did not got cancer of the prostate at the same rate. Here's a proof: Study finds prostate cancer screenings ineffective

 
  AlbertS  Posted: 06/04/2011 10:27

this seems to be a very interesting topic.

 
  Camie  Posted: 08/01/2014 12:43

Lots of interesting questions above, but where do I find the anwers?

 
 
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