Prostate Cancer

Introduction

Prostate cancer accounts for nearly a quarter (24 per cent) of all new male cancer diagnoses. In 2004, for example, the number of new cases diagnosed in the UK reached approximately 35,000. It is largely a disease of older men, as most diagnosed with the disease are aged 50 years and older, so risk increases with age.

What is prostate cancer?

Prostate cancer is a serious disease, but in many cases it is a slow-growing cancer. Some men may have prostate cancer, but because it is in the very early stages, they have no symptoms at all.

In other cases, (particularly in younger men) there may be more symptoms and the cancer may be more aggressive

Where is the prostate gland and what does it do?

The prostate is only found in men. It is a small gland about the size of a walnut, which lies at the base of the bladder, just in front of the back passage (rectum).

The prostate wraps around the tube that carries urine as it passes from the bladder to the penis (urethra). When healthy, the prostate adds a special fluid to semen (sperm) and it also produces a protein called prostate specific antigen (PSA), which turns semen into liquid form.

What are the symptoms of prostate cancer?

Early prostate cancer rarely shows symptoms. And confusingly, the following signs and symptoms that may occur can also be a sign of other prostate problems, such as benign enlargement of the prostate or inflammation of the prostate - which have nothing to do with prostate cancer.

Symptoms of prostate cancer can include:

• Needing to urinate more often, especially at night
• Needing to urinate urgently
• Dribbling urine after using the toilet
• Difficulty in beginning to urinate or a weak flow
• A feeling that the bladder hasn't emptied properly
• Pain on passing urine
• Bone pain
• Problems getting or keeping an erection
• Blood in the urine or semen (this happens rarely)

If you experience any of these symptoms, you should consult your GP to find out what is causing the problem.

The causes of prostate cancer are presently unknown, but according to The Prostate Cancer Charity, there are a number ofrisk factors that increase a man's chance of developing the disease:

• Age: the risk of getting prostate cancer increases with age. Although it can affect men in their forties, most men diagnosed with prostate cancer are over the age of 50
• Family history: prostate cancer often clusters in families. If a close relative (father, brother, uncle) has been diagnosed with prostate cancer, patient risk increases. If the affected relative was under the age of 60 at the time of diagnosis or if more than one relative has been diagnosed with prostate cancer, the risk is becomes greater
• Ethnic background: African-Caribbean and African-American men are three times more likely to be diagnosed with prostate cancer than white men. It is also more common in Western countries. It is thought that diet and genes may play an important part
• Diet: a diet high in saturated animal fats and proteins may increase the risk of prostate cancer

How is prostate cancer diagnosed?

• Rectal examination (DRE): the doctor will examine the prostate by inserting two fingers of a gloved hand into the rectum (back passage). This allows the doctor to feel if the prostate is enlarged in size and if it is irregular in shape. If it is, you will be referred for more tests. A rectal examination may feel somewhat uncomfortable, but shouldn't be painful
• PSA test: Prostate Specific Antigen (PSA) is a protein produced by the prostate which is released into the bloodstream. A PSA test is a simple blood test that measures these levels. Although a high level of PSA can be an indication of cancer, it can also be an indication of other non-malignant conditions, such as enlargement or infection of the prostate. If the PSA levels are raised, you may be referred to a urologist
• Transrectal ultrasound guided prostate biopsy (TRUS): during a TRUS biopsy, small tissue samples are removed (often under a local anaesthetic) for examination under a microscope. Side effects of the biopsy can include passing blood in the urine and faeces - this can last for two to three days. Results can take up to two weeks. Examination of the tissue samples will show whether they contain cancer. Even if no cancer if discovered, your doctor may well want to keep an eye on you with further PSA tests and rectal examinations
• Further tests: if the biopsy confirms cancer, further tests will help your doctor see the size of the cancer and if

How is prostate cancer graded?

If the biopsy shows cancer cells, they will be 'Gleason graded'. The Gleason grade tells the doctor how aggressive the cancer is likely to be and how quickly it may spread.

Gleason grading uses a scale from one to 10. Grade 1 cancerous tissue looks like normal prostate cells. From two to four, the cancer is less likely to spread. From five to seven: the cells look less like normal prostate cells and are more likely to spread. From eight to 10: the cancer is more aggressive and most likely to spread.

Basically, the lower the grade, the closer the malignant cells' appearance and function to normal cells. Two samples of abnormal tissue patterns are usually analysed, and their individual score is added together. The lowest possible Gleason score is two (both samples are grade one), and the highest score is ten. Higher Gleason scores indicate that the cancer is more active, but not always.

What will my treatment be?

Treatment options for prostate cancer depend on the grade and stage of the cancer (how aggressive it is and whether it has spread), as well as the patient's age and state of health. It is important to discuss them with your doctor.

Treatments can include:

• Active monitoring or watchful waiting:prostate cancer patients are seen on a regular basis for PSA tests, but no other treatment is prescribed unless their condition deteriorates. Watchful waiting may be used for small, slow-growing non-aggressive cancers in elderly men where the cancer will not shorten their life expectancy
• Surgery:a prostatectomy is an operation where the whole prostate is removed. It is only effective in younger men who have aggressive small cancers that have not spread outside the prostate. A prostatectomy is major surgery with serious side-effects. These include: mild to severe urinary incontinence; difficulty in obtaining or maintaining an erection; infertility
• Radiotherapy:this can be given either externally or internally, which is called brachytherapy. It is carried out under a general anaesthetic, or sometimes an epidural (spinal anaesthetic). The surgeon will place small radioactive metal seeds into the tumour within the prostate gland. The seeds release small doses of radiation very slowly over a period of time. The seeds are not removed, but stay in the prostate tissue, while the radioactivity fades away gradually over about a year. The radiation affects only the area a few millimetres around the seeds, so doesn't damage other internal organs
• Hormone therapy:prostate cancer needs the hormones testosterone and androgens, the hormones produced by the testicles, in order to grow. Hormonal therapies reduce the amount of testosterone and androgens in the body. They can be given as injections or tablets, and occasionally an operation (subcapsular orchidectomy) will be done to remove the part of the testicles that produces testosterone

What happens after treatment?

When your treatment is finished, you will have check-ups (PSA test) on a regular basis. If you notice any new symptoms between check ups, or if you are having problems (side-effects from treatment), you should let your doctor know.

Clickthrough information and support links:

The Prostate Cancer Charity
Prostate UK
CancerBACUP
Cancer Research UK
Macmillan Cancer Support
PCaSO Prostate Cancer Network

The NHS Cancer Screening Programmes and CancerBACUP have produced a downloadable booklet called Understanding the PSA Test for men requesting further information