Prostate cancer

In this video, Consultant Urologist, Jonathan Aning talks you through:

• what prostate cancer is
• the main types
• risk factors
• stages
• common treatments available to you

Prostate cancer starts in the cells of the prostate. The prostate is a small gland just below the bladder and in front of the rectum (back passage).

It's a common cancer. In the UK about 48,600 men are diagnosed with it each year.

Prostate cancer is more common over the age of 65. It can happen at a younger age, but it's uncommon under 50.

Your risk of getting it at a younger age is higher if you're Black or have a strong family history of prostate cancer.

There are different types of prostate cancer

• early prostate cancer (or localised prostate cancer): the cancer is only inside the prostate gland
• locally-advanced prostate cancer: the cancer has spread through the capsule (covering) of the prostate gland and may have started to spread into tissue or organs close by
• advanced prostate cancer (or metastatic prostate cancer): the cancer has spread to other parts of the body, like the bones

If you're a trans woman or are non-binary assigned male at birth, you also need to be aware of prostate cancer.

Prostate cancer only causes symptoms once the cancer is big enough to press on the urethra, the tube that carries urine from the bladder. In the early stage, it may not cause any symptoms at all.

The prostate gland can also become enlarged because of a condition called benign prostatic hyperplasia (BPH), which is non-cancerous.

The symptoms of these benign (non-cancerous) prostate conditions and of prostate cancer are similar. They can include:

• having to rush to the toilet to pee
• peeing more often or at night
• difficulty starting and stopping the flow when you pee
• dribbling after you pee
• a feeling that you haven't emptied your bladder completely
• problems getting or keeping an erection
• blood in your pee or semen

Many of these symptoms are also seen in other conditions, so they don't necessarily mean you have prostate cancer.

If you have any of them, you should have them checked by your doctor. The doctor can do tests to find out whether you need to be referred to a specialist doctor.

If prostate cancer spreads, it usually goes to the bones. It may cause pain in the bones, such as in the back. This is called advanced prostate cancer (or metastatic prostate cancer).

You'll usually start by seeing your doctor to have your symptoms checked. The doctor will usually arrange some tests. The first tests used to diagnose prostate cancer are:

The doctor gently puts a gloved finger, with some lubricating gel on it, into your back passage (rectum). Because the rectum sits close to the prostate gland, the doctor can feel for anything unusual in the prostate.

A rectal examination is quick and it shouldn't be painful. You may also hear it called a Digital Rectal Examination (DRE).

The PSA test is a blood test that measures the level of prostate-specific antigen (PSA) in your blood. Prostate cancer often causes a raised PSA level. But it isn't the only cause. A urinary tract infection (UTI), non-cancerous prostate conditions and getting older can also push your PSA up.

If your PSA level is raised, or your rectal examination shows something unusual, your doctor will refer you to a specialist doctor (urologist). If your PSA is raised but your prostate feels normal, your doctor may test your PSA level again.

A specialist doctor or nurse will ask about your symptoms and any other medical conditions. They'll also check whether you have any risk factors for prostate cancer.

The doctor may do another rectal examination and arrange another PSA test. They'll talk to you about any further tests you may need, and these may include the following.

Your doctor may ask you to have this specialised scan to help decide whether you need a prostate biopsy. A multi-parametric MRI scan gives a more detailed picture of the prostate gland and the area around it than a standard MRI scan does.

If tests show you may have prostate cancer, your doctor may suggest a TRUS biopsy (trans-rectal ultrasound biopsy). A fine needle is used to take small samples of prostate tissue, and these are then examined for cancer cells. Your doctor passes an ultrasound probe into your back passage, and the needle is guided through it. Before this starts, you'll be given an injection of local anaesthetic to numb the area.

You may have a Trans-Perineal biopsy instead of a TRUS biopsy. The doctor takes samples of the prostate gland through the area between the scrotum and the back passage (called the perineum).

It can be done under a general anaesthetic, or the doctor can use a local anaesthetic to numb the area first.

Whether you need any more tests after a prostate cancer diagnosis depends on how likely the cancer is to grow quickly. Doctors work out this risk by looking at your PSA level, the stage, and the grade of the cancer.

To help diagnose or stage prostate cancer, you may have staging tests:

• an MRI (magnetic resonance imaging) scan
• a bone scan
• a CT scan
• more blood tests

Once you know the stage, grade and risk group of your prostate cancer, you and your doctor can decide which treatment is best for you.

Your test results tell doctors the stage of prostate cancer, which describes how big the cancer is and how far it has spread. Doctors often use the TNM staging system or a number staging system to record it.

Your doctor decides the grade of the prostate cancer by looking at the cancer cells from your biopsy under the microscope. This shows how quickly the cancer might grow or spread.

Doctors use 2 systems together to grade prostate cancer:

• Gleason score: looks at the pattern of cells in the prostate tissue and grades them from 1 to 5. The most common grade and the highest grade are added together to give your Gleason score
• Grade Group: grades the cancer between 1 and 5, based on your Gleason score

Doctors also sort prostate cancer into risk groups, and the group your cancer falls into decides which treatments are open to you.

To work out the risk group, your doctor looks at the stage of the cancer, your PSA level and your Gleason score. They use a system called the Cambridge Prognostic Group (CPG), which divides prostate cancer risk into 5 different groups.

A team of specialists meets to discuss the best possible treatment for you. This is called a multidisciplinary team (MDT).

There are different treatments for prostate cancer, and which one you have will depend on:

• your general health
• your age
• the Gleason score, cancer grade
• the stage of the cancer
• the risk group of the cancer
• your preferences

Your doctor and nurse will talk through the things to think about when making treatment decisions. They'll explain the benefits and disadvantages of each treatment. You and your doctor can then decide on the best treatment for you.

Treatment for early or locally advanced prostate cancer may include one or more of the following.

Radiotherapy uses high energy rays to destroy cancer cells. In prostate cancer, it can be given from outside the body (external beam radiotherapy) or from inside the body (brachytherapy). In early prostate cancer, brachytherapy is sometimes the only treatment you need.

If you have locally advanced prostate cancer, you usually have external radiotherapy and brachytherapy together.

Surgery to remove the prostate gland is called a prostatectomy. If you have early prostate cancer, your doctor may ask you to choose between a prostatectomy and radiotherapy. In locally advanced prostate cancer, a prostatectomy is not often done.

Active surveillance for prostate cancer means having regular tests to keep an eye on the cancer while it is still at an early stage. The aim is to avoid treatment you don't need, or to put it off for a while, along with the side effects that treatment can bring.

Prostate cancer needs the hormone testosterone to grow, and hormonal therapies work by reducing the amount of testosterone in your body.

You may have hormonal therapy as tablets or injections. Sometimes it's given together with radiotherapy and continued for some time afterwards. In some cases, hormonal therapy is given on its own.

Chemotherapy for prostate cancer uses anti-cancer (cytotoxic) drugs to destroy cancer cells.

Doctors sometimes use it when the cancer is locally advanced and has a higher risk of coming back. It's more commonly used to treat advanced prostate cancer.

You'll have regular follow-up appointments after treatment for prostate cancer. Between those appointments you may feel anxious, and that's natural. It may help to get support from family, friends or a support organisation like Prostate Cancer UK.

Macmillan Cancer Support also has further information to support you. You can:

• phone the Macmillan Support Line on 0808 808 00 00
• chat to Macmillan specialists online
• use the prostate cancer forum, where you can talk to others affected by prostate cancer, ask questions and share your experience

Treatment for prostate cancer can affect your sex life. It can lower your sex drive (libido) and make it hard to get an erection, which is called erectile dysfunction, or ED. This may worry you a great deal. The good news is that there are different treatments and support to help with sexual difficulties.

Talk to your doctor or nurse about any sexual difficulties or concerns you have. They're used to talking about these issues. You may want your partner to be part of these discussions too.

Treatment for prostate cancer can affect your fertility. If that worries you, talk to your doctor or nurse about it. You may be able to store sperm before your treatment starts.

Even if you already live a healthy life, you may still want to make some positive changes after your prostate cancer treatment. Small changes to the way you live, such as eating well and keeping active, can improve your health and wellbeing and help your body recover.