Introduction
Prostate cancer is the commonest cancer in men. Each year in Europe approximately 302,000 men will develop prostate cancer, 24% of all new cancers. It is mainly a disease of the over 50s, becoming more common as you get older. It is said that all men would develop prostate cancer if they lived long enough.
A sensitive blood test for Prostate Specific Antigen (PSA) allows very early diagnosis of prostate cancer, in some cases up to 14 years before the first symptoms are likely to develop. For these patients, a period of careful monitoring is often suggested rather than active treatment with radiotherapy or surgery. Both surgery and radiotherapy are very effective treatments and as with most cancers, improved diagnosis leads to better results. For more information on symptoms and treatment see the relevant sections below.
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The Prostate Gland
The prostate gland is only present in men. It is made up of 30 to 50 individual glands that produce a milky fluid, discharged when semen is ejaculated. The prostate is about the size of a small egg and lies under the bladder in the pelvis. The urethra, the tube that empties urine from the bladder, passes through the prostate gland which is why enlargement of the gland can cause difficulty and pain on passing urine, or the need to pass urine more frequently. The same symptoms can also be due to non-cancerous conditions, for example, benign enlargement of the prostate gland, also referred to as benign prostatic hypertrophy (BPH).
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Prostate Cancer
All cancers are uncontrolled growths of cells. In prostate cancer this uncontrolled growth happens in the cells of the prostate gland, and is a type of cancer known as an adenocarcinoma.
Not all prostate cancers are the same or behave in the same way, some prostate cancers are very slowly growing and require careful monitoring with regular blood tests and samples, rather than immediate treatment. Others are more aggressive and need to be treated with radiotherapy, surgery, hormone therapy or a combination of these.
One of the characteristics of cancer is that it can spread to other parts of the body, either by direct invasion of neighbouring areas or because the cancer cells travel through the blood or lymphatic system to other parts of the body. Prostate cancer may spread to surrounding structures such as the bladder and rectum, as well as through the blood stream to the bones of the back causing back pain and more rarely problems from pressure on the spinal cord.
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Prostate Cancer Risk Factors
There is no certain method of eliminating the risk of prostate cancer, but there are a number of risk factors which men can take steps to avoid (see also Preventing Prostate Cancer below), and others which should alert individuals at risk to enrol in a screening programme.
Prostate cancer is rare below the age of 50, but becomes more common as men get older. The disease can be more common in particular families and several sites on the human genome have been identified as having a link with prostate cancer.
Obesity is a further risk factor. Overweight men are more prone to develop a range of cancers, and some studies suggest that obesity is associated with more aggressive forms of prostate cancer, leading to the recommendation that exercise and diet should be incorporated into health strategies to reduce the risk of prostate cancer.
Some studies have shown that fathers are more likely to develop prostate cancer than childless men although the risk falls after the second child and for each subsequent child the risk falls by approximately 5%.
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Preventing Prostate Cancer
There is no foolproof way to prevent prostate cancer but there are things which may reduce the risk.
Having a healthy low-fat diet, combined with regular exercise, combats obesity which is one of the risk factors for prostate cancer. In addition, vitamins D and E, selenium and lycopene (found in tomatoes) are reported to offer some protection against developing the disease. Some studies have shown that diets high in dairy produce and calcium carry an increased risk of prostate cancer and so these should be eaten in moderation, especially if there is a family history of prostate cancer.
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Symptoms of Prostate Cancer
The classic symptoms of an enlarged prostate gland due to any cause 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.
These symptoms may be due to a variety of conditions of which one is cancer of the prostate but men, and particularly younger men, with these symptoms should seek medical advice quickly.
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Diagnosing Prostate Cancer
- Prostate specific antigen (PSA) testing. High PSA levels occur in prostate cancer, benign prostatic hypertrophy (BPH) and infections of the prostate gland. A higher than normal result requires further investigation, usually a biopsy.
- Rectal ultrasound. By using a probe placed in the rectum, it is possible to scan the prostate gland, to show any abnormal areas in the gland. If an abnormality is found it will require further testing, probably a biopsy.
- Biopsy. A sample taken from the gland, and examined under a microscope. Cancer cells look different from normal cells and experts will be able to make a diagnosis by examining them closely.
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Treating Prostate Cancer
There are a number of very successful treatments for prostate cancer. These include radiotherapy, surgery, hormone therapy or a combination of these although close monitoring, often referred to as active surveillance, careful monitoring or 'watchful waiting' is sometimes all that is required.
The radiotherapy options include brachytherapy and external beam treatment.
Active Surveillance (Careful Monitoring or Watchful Waiting)
We know that many patients diagnosed with prostate cancer will live a long time with their disease without being troubled by it to any significant degree, and will eventually die from something else. So careful monitoring with regular blood tests and biopsy samples, if appropriate, is the best management for some forms of prostate cancer. PSA (Prostate Specific Antigen) testing is now widespread and the diagnosis may be made as long as 14 years before the first symptoms appear.
Criteria, including 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, can be used to discriminate between cancers that require immediate treatment and those not needing urgent intervention. Monitoring requires regular follow up with PSA blood tests and serial prostate biopsies, which saves patients the side effects of radiotherapy or surgery and their potential complications.
Radiotherapy - Brachytherapy
Low-dose brachytherapy is a highly effective option for patients with low risk disease. This involves inserting radioactive pellets into the prostate gland under a general or local anaesthetic. About 50 or 60 pellets of radioactive iodine coated with silver are placed in the prostate gland, at sites calculated to have the maximum effect on the cancer cells whilst having minimal effects on surrounding normal tissues. From the point of view of the patient, its popularity lies in its convenience.
The procedure often needs just one hospital visit, where the treatment is planned and delivered in a special treatment room and the patient goes home the same day. Nevertheless brachytherapy can deliver a high dose of radiation very precisely, without concern over having to focus external beams of radiation at a moving prostate target. Brachytherapy is also cost effective (particularly compared with prolonged courses of external beam radiotherapy).
Radiotherapy - External Beam
External beam radiotherapy uses high-energy X-ray beams generated from machines to kill cancer cells. Some normal cells will also be affected, but the treatment is planned so that the radiation is focused on the affected areas from a variety of different angles so normal tissues receive a smaller dose. In addition normal cells are better at repairing themselves than cancer cells.
External beam radiotherapy is normally given as a series of short regular treatments in a radiotherapy department (each treatment may be referred to as a fraction).
All radiotherapy treatments conform to the shape of the cancer, so a higher dose of radiation can be more precisely targeted at the cancer avoiding neighbouring healthy tissue and resulting in fewer side effects.
Surgery
Surgery is an effective form of treatment for prostate cancer. The aim is to remove the entire prostate, and the cancer with it. Surgery is usually recommended when the cancer is confined to the prostate gland but can be used to relieve symptoms in more advanced cancers.
The operation most commonly used is radical prostatectomy. The entire prostate gland is removed from around the urethra together with nearby lymph nodes.
Surgery for prostate cancer is equivalent to radiotherapy in terms of effectiveness especially in early stage prostate cancer. But the side effect profiles are different so the decision between surgery and radiotherapy usually turns on the patient's age, general health and personal preferences.
The side effects of radical prostatectomy may include urinary incontinence and impotence. The risk for both these side effects increases with age, and they are often most severe soon after the operation, getting better with time.
Hormone Therapy
Prostate cancer depends on a hormone called testosterone for its growth, so reducing testosterone assists in the treatment of the cancer, and usually works well for a few years. Testosterone levels are usually reduced by drugs that act either on the pituitary gland (the body’s hormone command centre) and examples of these drugs include goserelin and leuprorelin, or directly combat the effects of testosterone, the so called anti-androgens (for example flutamide and bicalutamide).
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Looking after Yourself
Radiotherapy for prostate cancer, as the sole treatment or in combination with surgery is highly effective in many cases but can cause a number of side effects. Some patients will not experience any side effects, whilst others may find several troublesome. Fortunately, many of these side effects disappear soon after the treatment ends and the symptoms can usually be treated, so if you do experience any problems it is important to mention them to your doctor or nurse, so they can give you the treatment you need.
Diarrhoea may occur during radiotherapy, and can be treated with medication if necessary. Many clinicians suggest that a low residue diet is helpful but not everyone agrees with this approach. Diarrhoea quickly clears up once treatment is finished. A related symptom is a feeling that your bowels have not emptied properly, i.e. that there is something more to come.
Having to pass urine more frequently, sometimes with discomfort or a stinging pain is common. In most cases this will be helped by drinking plenty of fluids, but many doctors will check to make sure that there is no infection present. If there is an infection antibiotics will be prescribed.
Skin irritation over the lower part of the spine (sacrum), between the buttocks and between the legs, can be quite marked, but usually responds well to treatment with hydrocortisone cream or ointment.
Whatever the problem, do not assume that nothing can be done about it – ask your doctor or nurse: do not just grin and bear it.
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Questions for your Doctor
Before making up your mind about the best treatment option for you, you will need information about your cancer, the treatments available in your area and what this will involve, what to expect from the treatment, what side effects you might experience and how these may change over time as well as what your doctors believe would be most effective in combating your cancer.
For different patients the answers will be different, so it is important to discuss all these issues with your doctor so that you make the right choice for you.
You will have your own questions but some issues you might want to raise are:
- What does the treatment involve?
- What are the benefits I might get?
- How good are my chances of getting those benefits?
- Could having the treatment make me feel worse? If so, in what way?
- Are there alternative treatments?
- What are the risks of the treatment?
- Are the risks minor or serious? How likely are they to happen?
- What care will I need after treatment?
- What happens if something goes wrong?
- What may happen if I don’t have the treatment?
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Conclusion
There is no one correct solution to the management of prostate cancer, but for clinical and personal reasons particular treatments will suit some patients better than others. So patients need comprehensive information to help them make the right choice for them.
Prostate cancer can be treated very effectively in a variety of ways. Exactly which treatment is best for you will depend on a number of factors including the how fast the tumour is growing, whether it has spread to other parts of the pelvis or more distant areas of the body and your personal preferences.
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