Prostate Cancer

Symptoms of prostate cancer usually occur when the prostate grows to a size where it starts pressing on the urethra (the tube that transports urine from the bladder out of the penis). This may cause symptoms such as needing to pee urgently, going to the loo to pee more often, having a poor stream when peeing or dribbling, or a feeling of incomplete emptying after peeing.

However, it is important to note that you can get these symptoms in a number of other conditions (such as harmless enlargement of the prostate gland), so if you have them they do not necessarily mean you have prostate cancer.

It doesn’t usually cause problems with getting or maintaining an erection or with ejaculation. If the cancer spreads to other parts of the body such as the bones there may be other symptoms such as pain and weakness.

Age is the biggest risk factor for men getting prostate cancer, mostly affecting those over 50. For reasons poorly understood, it is much more common in black men than Caucasian men, and Asian men have the lowest risk. Obesity is also a risk factor, and a high-fat diet also appears to increase the risk.

There is also a genetic component, so if you have a father or brother who was diagnosed with prostate cancer before the age of 60 you are at a slightly increased risk.

There is no formal prostate cancer screening programme in the UK, but you can request a check-up if you are over 50. This will involve a blood test checking for prostate specific antigen (PSA, but this requires a discussion with the doctor first because results may not always be clear-cut (you can have a raised PSA result without having prostate cancer) and so can require interpretation and further investigations if positive. Also, if a PSA test is negative, it doesn’t entirely rule out the possibility of prostate cancer.

If you are ethnically black, your doctor may consider checking your PSA from the age of 45, after discussion.

Prostate cancer diagnosis requires several different investigations for confirmation. Along with checking a PSA level your doctor will offer a physical rectal examination of your prostate which involves putting a lubricated gloved finger into the back passage and feeling the size and surface of the prostate gland.

If the PSA level is raised and/or the examination of your back passage is concerning, your doctor will refer you urgently to a urology team for further cancer investigations. This may involve a multi-parametric MRI scan (mpMRI) – which is now recommended as a first-line investigation in suspected clinically localised prostate cancer - or taking a small sample of prostate tissue (a biopsy) to be examined in the lab.

PSA scoring system

The severity of prostate cancer is determined by three factors – the cancer cell grade, its stage and the blood PSA result. To grade the cancer, the biopsy sample is assessed and then scored using a system called the Gleason Score. This gives a rating of:

• 2-6 = low-grade prostate cancer that is likely to grow slowly
• 7 = intermediate prostate cancer, likely to grow at a moderate rate
• 8-10 = high-grade prostate cancer, likely to grow quickly

If tests are required to assess if prostate cancer has spread, these include bone scans, CT and MRI scans and abdominal ultrasound scans – this is known as ‘staging’ the cancer.

The National Institute for Health and Care Excellence (NICE) in the UK now recommends that everyone who is given a diagnosis of prostate cancer should be given a personal risk stratification assessment. This means that how high your risk is should be measured using a combination of how abnormal your prostate cancer cells are, your PSA level and how far your cancer has spread. Treatment is then decided depending on this assessment and on what you and your doctor believe will be best for you.

Some people have prostate cancer which is relatively stable, doesn’t cause any symptoms and therefore may not need any active treatment. This is especially true when caught early and is often called ‘watchful waiting’. In these scenarios, you may have regular (annual) scans to check the progress of the disease.

If treatment is required, this can be done surgically by completely removing the prostate gland (or removing parts) or through radiotherapy with or without hormonal treatment. The side effects can include erectile dysfunction and problems with your urine, so it is important to consider the risks vs benefits and your medical team will discuss this with you.

Hormone treatment is commonly used, with the two main groups used being medicines that work on the pituitary gland in the brain to block the production of the hormone testosterone (such as goserelin), and testosterone hormone blockers such as cyproterone. NICE has also now authorised the treatment of enzalutamide to be used to treat hormone-sensitive prostate cancer that has spread to other parts of the body.

Although prostate cancer is very common, the chance of survival is very good and almost 8 in 10 men will survive prostate cancer for ten years or more with the chances of survival being improved the earlier the cancer is detected.