What are the Symptoms?

Men with early prostate cancer are unlikely to have any symptoms as these only occur when the cancer is large enough to put pressure on the urethra. Men over the age of 50 often have enlargement of the prostate due to a non-cancerous condition known as benign prostatic hyperplasia (BPH) or hypertrophy.

The symptoms of both benign enlargement of the prostate gland (BPH) and malignant tumours (cancer) are similar and can include any of the following:

• Difficulty in passing urine
• Passing urine more frequently than usual, especially at night
• Pain on passing urine
• Uncommonly, blood in the urine
• Pain in the bones (if the cancer has spread to the bones)

If you have any of the above symptoms it is important that you have them checked by your doctor. But remember, most enlargements of the prostate are not cancer.

Cancer of the prostate is often a slow growing cancer, and symptoms may not occur for many years. Occasionally the first symptoms are pain in the back, hips or pelvis caused by cancer cells which have spread to the bones.

In most cases, an enlarged prostate is not due to cancer, but it’s still important to get any symptoms checked promptly.

Risk Factors for Prostate Cancer

The cause of prostate cancer is unknown. However, certain risk factors (and protective) factors are recognised.

There are many factors that may affect your risk of developing prostate cancer. Patients and their loved ones should discuss any decisions regarding prostate cancer risks, screening, and treatment with their physician.

Increased Risk

Family History

• One first-degree relative = 2-fold or greater risk [1]
• One first-degree relative and one second-degree relative = 8.8 times greater risk [1]
• Family history of BRCA1 and BRCA2 gene mutations carries greater risk for prostate cancer. BRCA1 and BRCA2 are genes associated with familial breast cancer that may be identified in high-risk individuals/families undergoing genetic testing.

Race

• Scandinavian [4,5]
• African American [5,6]

Potentially Increase Risk

• Circulating male hormone levels [5,7,8]
• Diet high in:
  • Fat [9,10] (fatty meats, dairy food)*
  • Vitamin A from animal sources [11] (red meats, especially liver)* [12]

Decreased Risk

Race [5]

• Asian

Potentially Decrease Risk

• Diet high in:
  • Vitamin A from plant sources, beta carotene11 (orange, red or dark green leafy vegetables)* [12]
  • Isoflavonoids [9,13] (plant-based weak estrogens found in soy products)*
  • Lycopenes [14] (carotenoid antioxidant found in tomatoes)*
  • Selenium [15] (seafood, meats, grains)*
  • Vegetable and seed oils, whole grains, wheat germ, green leafy vegetables* [12]

* Foods cited are examples, not an all-inclusive list

No Definitive Correlation

• Vasectomy
  • Men undergoing vasectomy demonstrate greater health-seeking behavior and are more likely to be screened for prostate cancer [17]
• Occupation
  • Weak association with cadmium exposure (e.g., mining, newspaper printing) [18]
• Smoking [5]

Diagnosis & Staging of Prostate Cancer

Although the following tests can be used to diagnose cancer of the prostate you do not need to have all of them done. The advantages and disadvantages of each method should be explained to you before you agree to any of them. Your doctor will be able to tell you how and when you will get the results.

Digital Rectal Examination (DRE)

As the rectum (back passage) is so close to the prostate gland, your doctor can feel any abnormalities in the prostate by inserting a gloved finger into the rectum. This may be uncomfortable but should not be painful.

If cancer is present in the prostate gland it may feel hard and knobbly, whereas with BPH it is usually enlarged, firm and smooth. However, sometimes the prostate may feel normal, even when cancer cells are present.

Following the examination, your doctor may recommend a PSA blood test to help assess prostate health further.

PSA

PSA is a substance produced by both normal and cancerous prostate cells. When prostate cancer grows or when other prostate diseases are present, the amount of PSA in the blood often increases.

The amount also varies with age.

• A PSA test is generally said to be in the normal range when it is reported to be between 0 and 4 nanograms per milliliter, sometimes abbreviated as ng/mL on the lab report.
• If the results are in the high range (reported to be greater than 10 ng/mL), then your doctor will suggest a biopsy, which is the only test to actually diagnose prostate cancer.
• Sometimes, PSA results are in the “borderline high” range. This occurs when the results are between 4 and 10 ng/mL. PSA test results in this range can be confusing and do not always mean that cancer is present. Certain other conditions, such as benign prostatic hyperplasia (also called BPH – a type of noncancerous prostate enlargement) and prostatitis inflammation of the prostate), may cause an abnormal PSA result. Mostly, the doctor will recommend a biopsy to ensure that cancer is not missed.

Trans-Rectal Ultrasound Scan (TRUS)

Ultrasound scans use sound waves to build up a picture of the inside of the body. To scan the prostate gland a small probe is passed into the back passage and the image of the prostate appears on a screen. This type of scan is used to measure the size and density of the prostate. A sample of cells (biopsy) can be taken at the same time for examination under the microscope by a pathologist.

The procedure may cause some discomfort, but it is quick and usually completed within a few minutes.

Biopsy

If the initial tests (rectal examination, PSA or ultrasound) show that there is a possibility of cancer, you may be asked to have a biopsy, in which a sample of cells is taken from the prostate to be looked at under a microscope.

The biopsy is usually done at the same time as the ultrasound. A needle is passed through the wall of the back passage (rectum) and into the prostate. This test is usually uncomfortable, and can sometimes be painful, but it does not need a general anaesthetic.

Antibiotics are given to reduce the risk of infection. For a few days following this test you may notice bleeding when passing water, when having your bowels open or after sex.

Unfortunately, even if there is cancer in the prostate it may not be picked up on biopsy. This occurs in approximately one fifth of men. If a biopsy is negative it may need to be repeated (which will detect most of the cancers missed the first time) or the PSA may be measured again after a few months and the biopsy repeated if the PSA level starts to rise.

There is a more detailed way of biopsying the prostate gland, called transperineal template prostate biopsy. Rather than the standard 12 cores of prostate tissue taken in the TRUS biopsy technique, a template biopsy will take 30-40 cores. This does require a general or spinal anaesthetic and specialised equipment.

If the biopsy shows that a cancer is present further tests will be needed to check whether the cancer has spread beyond the prostate gland.

These may include:

Isotope Bone Scan
A very small amount of mildly radioactive liquid is injected into a vein, usually in your arm. A scan is then taken of the whole body. Abnormal bone absorbs more of the radioactive substance than normal bone and shows up on the scan as highlighted areas (known as ‘hot spots’).

After the injection you will have to wait for up to three hours before the scan can be taken, so it is a good idea to take a book or magazine with you. The level of radioactivity that is used is very small and does not cause any harm.

This scan can also detect other conditions affecting the bones such as arthritis, so further tests such as an X-ray of the abnormal area may be necessary to confirm that it is cancer.

CT Scan
A CT scan takes a series of pictures of an area of the body. These are fed into a computer which creates detailed pictures of the inside of the body. A CT scan may show if the cancer has spread beyond the prostate to other parts of the body such as the lymph glands

The scan takes from 10-30 minutes. You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand. You will probably be able to go home as soon as the scan is over.

Magnetic Resonance Imaging (MRI or NMR Scan)
This test is similar to a CT scan but uses magnetism instead of X-rays to build up cross-sectional pictures of your body. An MRI scan is the most accurate way we have of determining if a prostate cancer has spread beyond the margin of the prostate. More recently specialised MRI techniques called multiparametric MRI (mMRI), have become available in some hospitals in the UK. These offer the hope of being able to diagnose areas of prostate cancer and thus guide where the biopsies need be taken.

Treatment Options

The method selected to treat prostate cancer depends on its stage, speed of growth, and the general health of the patient.

It is also important to consider the benefits and potential side effects for each treatment option that is available to you. All of these factors can and should be discussed thoroughly by you and your doctor.

At the present time, certain choices are made more frequently than others for the treatment of each stage of prostate cancer. Prostate cancer stages and common treatment choices:

• Radical prostatectomy, either open surgery (retropubic or perineal), laparoscopic, robotically assisted
• Radiation therapy – external beam or brachytherapy*
• Watchful waiting – uncommon
• Active surveillance
• Cryotherapy
• HIFU
• Hormonal Therapy
• Chemotherapy
• Clinical trial

* the author has particular expertise in brachytherapy

More Information

You can find more information at:

• Prostate Cancer UK
• NHS Prostate Cancer

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