Prostate cancer treatment

This section provides information about prostate cancer care. This includes its causes, risk factors, symptoms, how it is diagnosed and the different types of prostate cancer treatments available.

About prostate cancer

Prostate cancer is the most common type of cancer amongst men in the UK. It tends to affect men over 50, though younger men can get prostate cancer too.

Prostate cancer often causes no symptoms, and is often detected following a blood test and rectal examination upon routine screening. It is important to consult your doctor if you have pain or discomfort when you urinate, difficulty emptying your bladder, or notice blood in the urine.

On this page you can find out more about the different types of prostate cancer, the risk factors and how it’s treated.

Facts about prostate cancer

• In the UK, prostate cancer is the mostcommon cancer amongst men^[i]
• Over 40,000 new cases of prostatecancer are diagnosed every year^[ii]
• About 250,000 men currently live withprostate cancer^[iii]

What is prostate cancer?

Only men have a prostate. It’s a gland that’s normally the size and shape of a walnut, and it sits below the bladder and around the urethra – the tube that men pass urine and semen through.

The prostate gland produces some of the fluid that delivers sperm through the urethra.

Prostate cancer is different from other cancers. This is because small areas of cancer in the gland are quite common and can remain inactive for years.

Research suggests that the risk of developing prostate cancer increases with age, and that about 80% of men over 80 may have a small area of prostate cancer^[iv]. However, not all cancers are aggressive and many grow slowly and can be monitored.

In some cases the prostate cancer is aggressive and can grow quickly. It can also spread to other parts of the body, most commonly the bones (spine, pelvis, thigh bone (femur) and ribs) or lymph nodes. Though it is not common, prostate cancer can also spread to the lungs, the liver and other organs.

In most cases, prostate cancer is detected in its early stages, before it has spread outside the gland.

For some men, prostate cancer is advanced when it is first detected. This may happen for men who have been treated previously for an early or locally advanced prostate cancer, and have a recurrence of the disease.

^[i] Prostate Cancer UK, Prostate cancer.https://prostatecanceruk.org/information/prostate-cancer
^[ii] Prostate Cancer UK, Prostate cancer
^[iii] Prostate Cancer UK, Prostate cancer
^[iv] Prostate Cancer UK, Prostate cancer

Types of prostate cancer

There are different types of prostate cancer. These are defined by how developed the cancer is, whether it is only the prostate gland that’s affected, or if the cancer has spread to other parts of the body.

Early prostate cancer 
Early prostate cancer – sometimes called localised prostate cancer – is when only the gland is affected, and the cancer hasn’t spread to any surrounding tissues or other parts of the body.

Locally advanced prostate cancer 
Locally advanced prostate cancer is where the cancer has spread to tissues around the gland.

Advanced prostate cancer
Advanced or metastatic cancer of the prostate is when the cancer has spread beyond the gland to other parts of the body. These secondary deposits are called metastases.

Causes and risk factors

What causes prostate cancer is not fully understood. But there are a few things which can increase your risk of developing prostate cancer. These are:

Your age 
As men get older, their chances of developing prostate cancer increase, and most cases develop in men aged 65 and over.

Your ethnicity
For reasons not yet understood, prostate cancer is more common in African-Caribbean or African men, and less common in Asian men.

Your family history
Men with immediate relatives (a father or brother) who are affected by prostate cancer will be at a slightly increased risk.

Prostate cancer symptoms and diagnosis

Prostate cancer tends to develop slowly, so its symptoms may not show for many years, and might never cause any problems in your lifetime.

But some men have cancer that is more aggressive. This will need treatment to stop the disease or at least delay the cancer spreading outside the prostate gland.

Prostate cancer can cause a range of symptoms, none of which are specific only to prostate cancer.

The signs of prostate cancer only become noticeable when the prostate is enlarged enough to affect the urethra – the tube carrying urine from the bladder to the penis. This means you might notice things like a greater need or effort to urinate, and then a feeling your bladder hasn’t properly emptied.

But these signs don’t mean you have prostate cancer. They could be caused by something else, like benign prostatic hyperplasia (BPH) – where your prostate is enlarged but not affected by cancer.

For some men the first symptoms of prostate cancer are when it has spread beyond the prostate gland to the bones. This may cause symptoms such as back, hip or pelvic pain – but again could be caused by benign conditions such as arthritis.

Whatever pain, discomfort or symptoms you feel, it is always best to discuss these with your GP.

GP tests 
Based on your symptoms, your GP can use one of the following tests to help reach the right diagnosis.

Prostate specific antigen (PSA) test
A PSA test is a blood test that measures the total amount of protein produced by the prostate.

All men have a small amount of the PSA protein in their blood, and the amount of this protein increases with age.

Raised levels of PSA can indicate a problem with the prostate, but this alone can’t diagnose prostate cancer. However, other test results, your family history and ethnicity can help assess your risk.

Digital rectal examination (DRE)
This is perhaps the most common way of diagnosing a problem with the prostate gland. The DRE should be done after a PSA test as this examination can raise your PSA levels and, therefore the result may be misleading.

To carry out the DRE your doctor or nurse uses their finger to feel the prostate gland through the wall of your back passage (rectum), feeling for any hard or irregular areas and to estimate the size of the gland.

Urine test for prostatitis
Your GP may also take a sample of your urine to test for prostatitis, which is an infection or inflammation of the prostate gland.

Prostatitis is a common condition that can affect men of any age, but is most common in men aged between 30 and 50. Prostatitis isn’t prostate cancer, nor is it related to an enlarged prostate.

It can however cause a number of symptoms that may be confused with prostate cancer, such as problems passing urine, and pain or discomfort around the testicles, back passage or lower abdomen.

Hospital tests 
Further hospital tests may include more advanced tests such as a prostate biopsy, MRI, CT or ultrasound scan, or prostate mapping.

Prostate biopsy
To see if you need a prostate biopsy or not, you may need to have a multi parametric (MP) MRI scan. This is a high-definition MRI scan of your prostate.

A prostate biopsy is a procedure that takes a small piece of your prostate tissue to be examined under the microscope. It’s perhaps the most accurate way of finding out if you have prostate cancer. Your doctor will talk you through the advantages and disadvantages of a biopsy, and any concerns you might have before you decide upon this kind of test.

You may not need a biopsy if other tests (like an MRI, CT or bone scan) show that cancer has spread beyond the prostate.

MRI scan 
An MRI scan may be carried out to look for primary disease and to see if any disease has spread beyond the prostate gland.
MRI scanning combines a powerful magnet with a very advanced computer to provide exact and detailed images without the use of x-rays.
Each scan or slice is like a single slice from a loaf of bread – when all the slices are put together a 3-D picture of the body can be obtained.  The number of sequences or images depends on the area being scanned.

During the scan you will be asked to lie very still on the MRI table.  A two-way intercom ensures that you may speak and listen to the MRI staff during your scan.

A radiographer will carry out the scan.

CT scan
A CT scan can show whether the cancer has spread beyond the prostate to other organs. 
A C.T. scan is a special type of x-ray test that takes ‘slice’ pictures of organs and structures in the body.

Each scan or slice is like a single slice from a loaf of bread – when all the slices are put together a 3-D picture of the body can be obtained.  The number and width of the slices depends on the area being scanned.

During the scan you will be asked to lie very still on the C.T. table.  No equipment will touch you and nothing will close in on you – the scanner is an open hole, rather like a polo mint – it is not a long or enclosed tube.

A radiographer will carry out the scan.

For some scans you will be given an injection, in your arm, of a contrast agent or ‘radio-opaque’ dye.  This allows the scanned part of the body to be visualised more clearly.

Bone scan
A bone scan can detect if your cancer has spread outside the prostate to your bones.

This test involves administering a small amount of radioactive material into your body.

The radioactive materials used are normally injected into a vein in your arm, similar to a blood test. Depending upon the type of scan you are having you may have to wait before any imaging is carried out. The waiting time depends upon the type of scan you are having; it varies between a few minutes and a few hours.  If the waiting time is more than an hour you may be able to leave the hospital during the interval.

During the scan you will have to lie still on a bed.  In order to get good quality images the equipment, a Gamma camera will have to be close to you, you will not, however, have to go into a tunnel.  Most investigations take approximately twenty minutes.

Prostate mapping
Prostate mapping uses state-of-the-art MRI imaging techniques with a biopsy under general anaesthetic to give information about the prostate to a high degree of accuracy.

Prostate mapping is a way of diagnosing prostate cancer that can enable a more accurate assessment of the risk of prostate cancer. This is because the test gives important information about the location of any cancer, the number of tumours and their grade. Most importantly, this information is more likely to be accurate when compared to standard diagnostic methods.

The stages of prostate cancer 
When you’re diagnosed with prostate cancer, your consultant urologist will tell you the stage of your cancer. This tells you how far the cancer has developed, and if the cancer cells have spread to any other part of your body.

When your consultant urologist talks about the stage of your prostate cancer, they may refer to the TNM (Tumour Nodes Metastases) system.

This is one of the most common methods to label the stages, where each letter describes a feature of the tumour:

• T stage showshow far the tumour has spread in and around the prostate
• N stagemeasures if the cancer has spread to the lymph nodes
• M stagemeasures if the cancer has spread (metastasised) to other organs or partsof the body.

T stage
The T stage is usually determined by a digital rectal examination (DRE), but you might also have a magnetic resonance imaging (MRI) scan to see if the tumour has spread around the prostate.

T1 
At this first T stage, the cancer can’t be felt by a DRE or seen on scans, and may only be seen under a microscope – this would be localised prostate cancer.

T2 
At this second T stage the cancer can be felt by a DRE or seen on scans, but it’s contained within the prostate – this would be localised prostate cancer.

T3 
At the third T stage, the cancer can be felt by a DRE or seen in a scan breaking through the capsule of the prostate – this would now be described as locally advanced prostate cancer. There are two sub stages:

• T3a 
  Where the cancer hasbroken through the capsule of the prostate, but not spread to the seminalvesicles, the small tubular glands that produce some of the fluid in semen.
• T3b
  The cancer has spread to the seminal vesicles.
• T4 
  At this fourth T stage, the tumour has spread to nearby organs, such as the bladder, back passage, or pelvic side wall– this is locally advanced prostate cancer.

N stage
The N stage describes whether the tumour has spread to the lymph nodes, which are a common place for cancer to spread, and can be seen with an MRI or CT scan. There are three N stages:

• NX
  The state of the lymphnodes can’t be measured.
• N0
  The lymph nodes do notlook like they contain cancer
• N1
  The lymph nodescontain cancer – this may be treated as locally advanced or advancedprostate cancer.

M stage
The M stage shows whether the cancer has spread (metastasised) to other parts of the body, such as the bones, and may be measured with a bone scan. There are three M stages:

• MX
  The spread of the cancer was not (or could not) be measured.
• M0
  The cancer wasmeasured, and has not spread to other parts of the body.
• M1
  The cancer has spread to other parts of the body – this will be diagnosed and treated as advanced prostate cancer.

Prostate cancer treatment

If you’ve been diagnosed with prostate cancer, there are several treatments for you, to consider after discussion with your consultant. Your Circle Health consultant urologist and prostate cancer care nurse will talk these options through with you.

Active monitoring 
If your cancer is slow growing, then active monitoring (also called active surveillance) is a way to track the prostate cancer rather than treat it immediately. The idea is to avoid unnecessary treatment, or to delay a treatment and its side effects.

Watchful waiting
If your prostate cancer isn't causing you any symptoms or problems, then watchful waiting is a way of keeping an eye on your condition over the long term, to avoid unnecessary treatment unless you get different symptoms.

Prostatectomy
A prostatectomy or radical prostatectomy is an operation to treat prostate cancer by removing the entire prostate and seminal vesicles.

A radical prostatectomy is offered to fit patients whose prostate cancer has not spread out of the gland. It is considered for men who are at risk of dying from their prostate cancer if it is not successfully treated (men who aren’t suitable for active surveillance).

Specialist urological surgeons perform this operation either through open surgery known as open prostatectomy or keyhole surgery known as laparoscopic prostatectomy.

Open prostatectomy
In this operation, the whole of the prostate gland and the seminal vesicles are removed through a single large abdominal opening. This is major surgery and involves a long recuperation period, with urinary incontinence and impotence as potential side effects. To regain full continence, men would be advised to do pelvic floor exercises. Such advice would be given to you at point of consultation with your urologist surgeon.

Laparoscopic prostatectomy
Using keyhole surgery techniques, five small abdominal incisions are made, through which a small camera and light provide a magnified view of the internal organs.

The prostate gland and seminal vesicles are removed using small surgical instruments, which enter the abdominal cavity through the small incisions. The major advantage of this method is that there isn’t a large wound, which means a much shorter recuperation period.

External beam radiotherapy
This therapy uses high energy X-ray beams to treat the prostate cancer. External beam radiotherapy creates beams that aim to kill the cancer cells and halt their growth. This therapy might be used on its own or to complement permanent seed brachytherapy or temporary brachytherapy (internal radiotherapy).

Permanent seed brachytherapy
This procedure implants tiny radioactive seeds into your prostate gland, and then the radiation from the seeds destroys cancer cells in the prostate. This treatment might be given on its own or with external beam radiotherapy or hormone therapy. Note that permanent seed brachytherapy may also be referred to as low dose rate brachytherapy.

Hormone therapy
Hormone therapy can help to manage prostate cancer by stopping the male hormone testosterone from reaching the prostate cancer cells. While it does not cure the cancer, hormone therapy can keep it under control and manage symptoms, sometimes for several years. Hormone therapy might be given on its own, or combined with other treatments such as external beam radiotherapy or brachytherapy.

Enhancing your recovery
The following lifestyle changes can help make your therapies, treatments and recovery a success:

• Give up smoking – research shows that smokers are more likely to suffer complications during and following surgery
• Eat healthily to maintain an ideal weight – if you’re overweight, you have a greater chance of developing complications
• Exercise regularly – speak to your GP who can recommend appropriate exercises.

Possible complications
A prostatectomy or radical prostatectomy is major surgery with associated side effects and possible complications. These include:

• Pain – a possibility with any operation
• Bleeding during or after surgery
• Infection in the surgical wound, whichmay need treatment with antibiotics
• Discomfort or pain in the groin.

With all surgical methods there is a post-operative risk of urinary incontinence and impotence.

Many skilled specialist urologists practice nerve sparing prostatectomy where they aim to cut the prostate gland out protecting these important nerve pathways to minimise the chances of these side effects occurring. All prostate cancer specialists at Circle health offer a range of prostatectomy treatments.

Recovery
Whatever type of surgery you have, a urinary catheter will be necessary after the operation, and is removed usually 2 to 3 weeks after surgery.

In total it takes about 3 weeks to recover from laparoscopic surgery and 3 months to recover from open prostatectomy.

Your consultant will run through your post-operative recovery in detail including advice on working, driving, lifting etc. before you leave the hospital.

Post-operative cancer checks
After your surgery, the prostate gland and seminal vesicles are taken away for histology.

While the aim of a prostatectomy is to remove the cancer, occasionally (around 7%) there are cancerous cells left behind indicating that additional treatment such as radiotherapy or hormone therapy is required to completely eradicate it.

The PSA level is also monitored post operatively at each outpatient appointment. Initially you will be seen every 3 months for a year, then every 6 months for 5 years and then annually until 15 years after your surgery.

Paying for your treatment 
You have two options to pay for your treatment – your costs may be covered by your private medical insurance, or you can pay for yourself.

You should check with your private medical insurer to see if your diagnostic costs are covered under your medical insurance policy.

If you are paying for your own treatment the cost of the procedure will be explained and confirmed in writing when you book any diagnostic tests or surgery 
Ask the hospital for a quote beforehand, and ensure that this includes the consultants’ fees and the hospital charge for your procedure.

Want to know more?
If you’d like to read more about prostate cancer care, treatment or living with prostate cancer, please visit prostatecanceruk.org