Overview
Prostate cancer is the most common cancer in men. It mainly affects men over the age of 50 and becomes more common with increasing age.
Sensitive blood tests for Prostate Specific Antigen (PSA) enable very early diagnosis of prostate cancer and have resulted in many more men being diagnosed as having prostate cancer. The data on prostate cancer appears to show a marked increase in the incidence of the disease but this is because, following the introduction of PSA testing, previously undetectable cancers are being diagnosed. Many of these patients require surveillance (close monitoring) rather than active treatment.
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Key Figures
| Total number of new cancer cases in Europe (2006) |
3.2 million |
| Total number of cancer deaths in Europe (2006) |
1.7 million |
| Number of new prostate cancer deaths (2006) |
345,900 |
| |
311,100 (EEA) |
| |
301,500 (EU25) |
| Number of prostate cancer deaths (2006) |
87,400 |
| |
70,300 (EEA) |
| |
67,800 (EU25) |
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Cancer Types
The vast majority of prostate cancers are adenocarcinomas.
Some prostate cancers are very slow growing but others are more aggressive.
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Causes of Prostate Cancer
Age: Prostate cancer is rare below the age of 50 and the incidence rises progressively with age.
It is more common in some families - several sites on the human genome have been identified as having a link with prostate cancer.
Obesity is a risk factor.
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Prevention of Prostate Cancer
It is said that every man would develop prostate cancer if he lived long enough.
However, there are ways of reducing the statistical risk of developing prostate cancer. These include reducing weight (by eating a healthy diet and exercising) and including in the diet foodstuffs that have been reported to be protective against prostate cancer - Vitamins D and E, selenium and lycopene (found in tomatoes).
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Common Symptoms
The common symptoms of prostate cancer are the same as those of benign prostatic hypertrophy and are due to partial obstruction of the urethra as it passes through the prostate gland. They are:
- passing urine more frequently
- getting up at night to pass urine
- pain on passing urine
- a poor urinary stream
- difficulty in passing urine (including having to wait before the flow starts and feeling that the bladder hasn't emptied fully)
Other less common symptoms include blood in the urine or semen, pain and stiffness in the back and hips and weight loss.
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Diagnostic Tests
- Prostate Specific Antigen (PSA) testing. High PSA levels occur in prostate cancer, benign prostatic hypertrophy and infections of the prostate gland. This test is highly sensitive and can lead to the diagnosis of prostate cancer many years before clinical symptoms would develop. High PSA titres require further investigation. The test is not diagnostic in itself.
- Rectal ultrasound. A probe placed in the rectum scans the prostate gland for any abnormal areas. Any abnormalities detected require further testing, probably with a biopsy.
- Biopsy. Cancer cells look different from other cells and so a diagnosis is made by histological examination.
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Active Surveillance
Prostate cancers identified after PSA testing are often diagnosed many years before the first symptoms appear. A number of studies have shown that many of these patients will not require treatment as they will not develop symptoms or any complications from the disease in their lifetime. Active surveillance is not in itself a treatment.
For these patients, the psychological impact of being told that they have cancer can be significant. Many patients may not be consoled by the idea that they have no need to worry as they will die from something else before their prostate cancer causes any problems.
For patients in this position being monitored is probably a better option than being subjected to active treatment. The rationale is that by monitoring with appropriate investigations, patients whose cancer develops and therefore requires treatment will receive that treatment at an early stage and local treatment alone will be adequate.
There are particular criteria that can be used to discriminate between those cancers that require immediate treatment and those that do not. These criteria include the PSA level, its rate of increase over time, how advanced the cancer is, and the appearance of the cancer cells when samples are examined microscopically. Monitoring requires regular follow up with PSA blood tests and serial prostate biopsies, but saves patients who will never need it from the side effects of radiotherapy or surgery (and their potential complications).
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Treatment
For patients who do require active treatment for their prostatic cancer the main options are surgery and radiotherapy.
Surgery
Surgery is effective in treating prostate cancer, if the cancer has not spread beyond the prostate.
In a radical prostatectomy, the whole gland is removed. If the cancer recurs, external radiotherapy can be given to the pelvic area.
Prostatectomy frequently causes impotence and less often urinary incontinence.
In some centres, prostatectomy can also be performed laparoscopically. This is just as successful as open surgery.
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Radiotherapy
External radiotherapy is normally given as a series of short, regular treatments in a radiotherapy department (each treatment may be referred to as a fraction).
Complications and side effects of radiotherapy
Radiotherapy affects normal cells as well as cancer cells. The effects on normal cells will be reduced as much as possible but nevertheless, nearby tissues will be affected and as a result, patients experience a range of symptoms including diarrhoea, urinary frequency and a reddening of the skin in the treatment area. These symptoms diminish after treatment has finished and can be treated symptomatically if they occur.
Radiotherapy also caused tiredness (which gradually improves after the treatment has finished).
Hormone Treatment
Hormone therapy is often used before radiotherapy to reduce the size of the prostate so that radiotherapy is more effective and to help prevent metastases.
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Prognosis
Many factors affect prognosis. These include the stage of the prostatic cancer, its histological appearance (Gleason score), the patient's age, general health and their individual response to treatment (which will vary). For this reason, statistics can only be considered as a general guide as they are produced by grouping together patients in whom these factors are similar but not identical. These figures are historical, often covering a 10 or 20 year period, and so do not reflect improvements in survival through more modern treatment.
Survival rates indicate the percentage of people who survive the disease for a specific period of time after their diagnosis - usually 5 or 10 years.
5-year survival rates for prostatic cancer are:
- Up to 98% - Stages 1 and 2. The cancer is completely inside the prostate gland, and is either too small to feel (stage 1) or can be felt as a lump on a rectal examination (stage 2).
- Up to 60% - Stage 3. The cancer has progressed through the capsule surrounding the prostate gland and invaded the seminal vesicles.
- Up to 30% - Stage 4. The cancer has invaded the bladder or rectum, or metastasised to lymph nodes or to other body areas (usually the bones, liver or lungs).
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Key Trends
The use of proton therapy as an alternative to X-ray radiotherapy. Proton radiotherapy exposes the bladder and rectum to high doses of radiation and there is a risk of impotence.
Using a combination of HDR (High Dose Radiotherapy), brachytherapy and external beam radiotherapy together to enhance results.
Using image-guided radiotherapy with cone beam imaging, gold markers and stereotactic ultrasound to improve the targeting of radiotherapy treatment and reduce the effects on nearby healthy tissues.
The use of adjuvant radiotherapy following surgery for prostate cancer. In the treatment of some other cancers, this is commonplace but is an idea which has yet to be fully explored in prostate cancer.
Adjuvant chemotherapy and/or radiation following surgery for prostate cancer.
At present, there are no monoclonal antibodies used in the treatment of prostate cancer - identification of potential monoclonal antibodies is therefore a potential research area.
Preliminary research suggests that proton therapy may be superior to conventional radiation for prostate cancer. However, there is a lack of randomised studies in this area.
The benefits of using combined chemotherapy and radiotherapy/surgery in controlling cancer that may have spread from the prostate gland itself remains an open question.
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