Prostate cancer

The prostate gland is part of the male reproductive system and produces some of the fluid that makes up semen. Prostate cancer is one of the most common cancers in men, with around one in five men affected. This information is relevant for everyone who has a prostate gland. Every body is different, so it helps to know what is normal for you.

Risks and causes#

The exact causes of prostate cancer are unknown, but some risk factors are recognized, including:

• getting older — your risk increases as you age
• a family history of prostate cancer — if your father or brother has been diagnosed, your risk roughly doubles
• a family history of breast or ovarian cancer, or carrying a BRCA1 or BRCA2 gene change

Symptoms#

Early prostate cancer usually causes no symptoms. When symptoms do occur, they may include:

• difficulty starting and stopping urination
• pain or a burning sensation when passing urine
• urinating more often than usual, particularly at night
• a feeling that the bladder cannot be fully emptied
• dribbling urine
• blood in the urine or semen
• pain in the lower back, upper thighs or legs
• bone pain
• unexpected weight loss

Many of these symptoms are not caused by cancer and can be easily treated, but you should discuss any of them with your doctor.

Diagnosis#

Prostate cancer is diagnosed using a number of tests, which may include:

• Prostate-specific antigen (PSA) test — the prostate makes a protein called PSA, and large amounts in the blood can indicate prostate cancer or other prostate problems.
• Digital rectal examination (DRE) — using a gloved finger in the rectum, the doctor feels for enlargement or irregularities of the prostate.
• MRI — a scan to assess the size of the prostate and look for abnormal areas, helping to judge the likelihood and location of cancer.
• Biopsy — tissue samples are taken from the prostate and examined in a laboratory for cancer cells.

If prostate cancer is diagnosed, more tests may be needed to see whether it has spread. These may include CT scans, MRI, Prostate-Specific Membrane Antigen PET (PSMA-PET) and bone scans. Results can take a few days, and it is natural to feel anxious while you wait — it can help to talk to a close friend or relative about how you are feeling.

Treatment#

Treatment depends on a range of factors, such as your age, physical condition, the stage of the cancer and your personal preferences. There are several options, so discuss them carefully with your doctor and ask for referrals to other specialists to talk through each one.

When the cancer is contained within the prostate#

• Active surveillance — if immediate treatment is not needed, the cancer may simply be monitored with regular PSA and DRE tests, MRI scans and repeat biopsies. If anything changes, your doctor will discuss other options.
• Surgery (radical prostatectomy) — removal of the prostate. It can be done by open surgery, by keyhole (laparoscopic) surgery, or by robotic surgery, which is available only in some centres with specially trained surgeons. The hospital stay is usually between one and 10 days, and recovery can take up to six weeks.
• Transurethral resection of the prostate (TURP) — surgery to remove blockages and relieve urination problems. It is sometimes used before radiotherapy.
• Radiation therapy — high-energy beams deliver a controlled dose of radiation to damage and kill cancer cells by damaging their DNA. It is usually given as a course over several days or weeks. Internal radiation therapy (brachytherapy) places radioactive material directly into the prostate, at either a low dose rate (permanent radioactive seeds) or a high dose rate (material placed temporarily). Not all techniques suit every man, and a radiation oncologist can advise which options suit you best.
• Watchful waiting — monitoring the cancer and treating symptoms and side effects as they arise, with the aim of relieving symptoms and slowing growth rather than curing the cancer. It may be offered if you are older or in poorer health and the cancer is unlikely to cause problems in your lifetime. It involves fewer tests than active surveillance, usually regular PSA tests, with imaging if levels rise or symptoms develop.

When the cancer has spread beyond the prostate#

• Hormone therapy (androgen deprivation therapy, ADT) — prostate cancer is driven by male sex hormones (androgens) such as testosterone, so reducing testosterone can slow its growth wherever it is in the body. It may be used in short bursts, for 1 to 3 years, or indefinitely. It was once done by removing the testicles (orchidectomy) but is now usually given as injections, tablets or both.
• Radiation therapy — for advanced or metastatic cancer, it may be used to treat cancer that has spread to the bones and to reduce pain (palliative radiation therapy).
• Chemotherapy — anti-cancer medication that cannot eradicate prostate cancer but can shrink it and slow its growth. It is commonly given with hormone therapy to improve survival, either when the cancer has spread at diagnosis or has become resistant to hormone therapy.
• Targeted therapy — PARP inhibitors prevent cancer cells from repairing their DNA so the cancer stops growing, and may help people with a BRCA1 or BRCA2 gene change.
• Radioisotope therapy — Lutetium PSMA therapy injects radioactive molecules into the bloodstream that travel to find and kill prostate cancer cells anywhere in the body. It is not widely available and is mainly accessed through specialist providers and clinical trials.

Research into new medications and therapies for advanced prostate cancer is essential to finding better treatments. If a new treatment looks promising, researchers run clinical trials, which are often the only way to access it — it is worth asking your doctor whether a suitable trial is available.

Many people with cancer also try complementary therapies. Used alongside conventional treatment, some can help you feel better and improve quality of life, while others may be unhelpful or even harmful. Discuss any you are considering with your doctor.

Side effects of treatment#

Side effects vary depending on the treatment and can be distressing, so talk through your options and concerns with your doctor before deciding.

Surgery#

• Incontinence — most men have some urinary leakage after the catheter is removed, which can be managed with pads. For most men it improves within 2 to 12 weeks, though for some it takes 3 to 12 months and occasionally becomes a long-term problem that may need further surgery. Continence usually returns more quickly in younger men and in those who have done pelvic floor exercises before surgery.
• Erection problems (erectile dysfunction) — common after surgery and may be temporary or permanent. Erections can take 18 to 24 months to recover, depending on your situation and the extent of surgery. Discuss this with your urologist or healthcare team.
• Loss of fertility — after surgery you will be unable to father a child naturally. If this is a concern, ask your doctor about sperm banking.

Radiotherapy#

During treatment you may feel tired. Afterwards, erectile dysfunction and bowel problems can occur, and some men have painful urination and bladder irritation for several months. Urinary incontinence is not usually a problem. Other effects can include urinary and bowel changes (frequency, urgency, discomfort or bleeding), erection and ejaculation problems, and loss of fertility.

Hormone therapy#

Side effects may include erectile dysfunction, tiredness, mood changes, hot flushes, weight gain, breast swelling and tenderness, and loss of sex drive.

Chemotherapy#

Side effects may include fatigue, appetite changes, nausea and vomiting, constipation or diarrhoea, temporary hair loss, a sore mouth or throat, numbness or tingling in the fingers or toes, skin and nail changes, low red blood cells (anaemia) and low white blood cells (neutropenia).

Coping with these effects can be difficult, but there are ways to manage and reduce their impact, and support is available. It is important to discuss possible side effects with your specialist before treatment starts.

Sexuality, relationships and support#

Most prostate cancer treatments affect your sex life to some degree, which can have a big effect on your mood, self-esteem and relationships. Discuss your concerns with your specialist before treatment so you know what to expect and how to limit the impact. If you have problems after treatment, ask your doctor or nurse for help, and if you have a partner, try to be as open as possible with them about how you are feeling.

Caring for someone with prostate cancer can also be difficult and emotional, and support is available for carers and families too.

Advanced prostate cancer and palliative care#

Many men with advanced prostate cancer can live for a long time thanks to the treatments available. During this time, men may receive palliative care or end-of-life care. Palliative care aims to quickly identify and treat physical symptoms and side effects, and to support emotional, social and spiritual wellbeing. Research suggests it reduces pain and distress, improves comfort, mood and wellbeing, and may even help extend survival. It also helps partners, family and friends manage the impact of the disease, benefiting the whole family, not just the person with cancer.

Key points#

• Prostate cancer is one of the most common cancers in men, affecting about one in five.
• The exact causes are unknown, but age, a family history of prostate cancer, and a family history of breast or ovarian cancer or a BRCA gene change increase risk.
• Early prostate cancer usually causes no symptoms; discuss any urinary or other changes with your doctor.
• Treatment options range from active surveillance and watchful waiting to surgery, radiation, hormone therapy, chemotherapy and newer therapies, depending on your situation.
• Treatments can affect continence, erections, fertility and your sex life; support is available to help you manage side effects.

Where to get help#