This information has been prepared to help you understand more about prostate cancer.
Many people feel understandably shocked and upset when told they have prostate cancer. This information is intended to help you understand the diagnosis and treatment of the disease
We cannot advise you about the best treatment for you. You need to discuss this with your doctors. However, we hope this information will answer some of your questions and help you think about the questions you want to ask your doctors or other health carers.
The prostate is a small doughnut-shaped gland that sits below the bladder and is found only in men.
A normal prostate is about the size of a walnut and is rubbery and smooth. It produces part of the fluid that makes up semen. It surrounds a tube called the urethra that carries urine (from the bladder) and semen (from the prostate and other sex glands) though the penis and out of the body.
The prostate normally gets bigger as men grow older. The growth of the prostate depends on the male sex hormone, testosterone, which is made by the testes (testicles).
The growing prostate may narrow or block the urethra, which can change urinary patterns. This enlargement is called benign prostate enlargement, but it is not cancer. Benign prostate enlargement usually begins on the outer surface of the prostate. It may cause the following symptoms:
- frequent urination, especially at night
- an urgent need to urinate
- difficulty starting to urinate
- leaking or dribbling after urinating.
The prostate gland is found near nerves, blood vessels and muscles needed to control bladder function and achieve an erection.
What is prostate cancer?
Prostate cancer develops when the cells in the prostate gland grow more quickly than in a normal prostate, forming a malignant lump or tumour. Most prostate cancers grow slower than other types of cancer. Early (or localised) prostate cancer is growth that has not spread beyond the prostate. Some prostate cancers may spread to other parts of the body, such as the bones and lymph nodes. This is called advanced prostate cancer.
How common is it?
Prostate cancer is the most common cancer in Australian men. If you would like any additional facts and statistics about prostate cancer, please refer to the Cancer Institute NSW website:
Causes of prostate cancer
While the causes of prostate cancer are unknown, the chance of developing prostate cancer increases:
- as you get older – it mainly affects men over 65
- if your father or brother has had prostate cancer
- if you have a strong family history of breast or ovarian cancer
- if you are of African descent – men of African descent have a higher risk than men of European descent
It is important to be aware of your family medical history, as it may indicate the presence of an inherited faulty gene. Genes such as BRCA2 increase the risk of prostate cancer in some men; however, this affects less than 10% of Australian men. You may have an inherited prostate cancer gene if you have:
- multiple relatives with prostate cancer, breast cancer or ovarian cancer on the same side of the family (either the mother’s or the father’s side)
- younger male relatives (under 50) with prostate cancer.
If you are concerned about your family history of prostate and other related cancers, you may wish to ask your doctor for a referral to a family cancer clinic or a urologist. They can advise you on suitable testing for you and your family.
What are the symptoms?
Early curable prostate cancer rarely causes symptoms. This is because the cancer is not large enough to put pressure on the urethra.
If the cancer grows and spreads beyond the prostate (advanced cancer), it may cause the following problems:
- pain or burning when urinating
- increased frequency or difficulty urinating
- blood in the urine or semen
- pain in the lower back, hips or upper thighs
- weight loss.
These symptoms are common to many conditions and may not be a sign of advanced prostate cancer. If you are concerned, see your doctor.
Your doctor will confirm the diagnosis with a number of tests. You may have some or all of the following tests.
Prostate specific antigen (PSA) blood test
Prostate specific antigen (PSA) is a protein made by both normal prostate cells and cancerous prostate cells. PSA levels are measured using a blood test. You may have an elevated PSA level if you have prostate cancer, but other factors can increase PSA levels in your blood, such as:
- infection or inflammation in the prostate
- benign prostate enlargement (a non-cancerous condition)
- recent sexual activity.
The PSA blood test is not a definitive test, so it is normally used with other tests to diagnose prostate cancer.
After diagnosis, PSA is useful for checking the growth of the prostate cancer and how it is responding to treatment.
Digital rectal examination
The digital rectal examination (DRE) is also used to look for prostate cancer and is often performed at the same time as a PSA test. During a DRE, the doctor inserts a gloved finger into the rectum to feel the back of the prostate gland. If your doctor feels a hardened area or an odd shape, further tests will be done.
A DRE may be uncomfortable but is rarely painful. Doing this test with a PSA test improves the chance of finding early cancer.
A biopsy is when small pieces of tissue are removed from the prostate for examination under a microscope. A biopsy is usually done if the PSA test or DRE show abnormalities. The biopsy is usually able to determine if you have prostate cancer, how much cancer is in the prostate (the volume) and how fast the cancer might grow (the grade).
- Between 12 and 18 samples of prostate tissue are taken from different parts of the prostate to be checked.
- Most biopsies are done with some form of anaesthetic. It may be uncomfortable and there may be some bleeding.
- You will be given antibiotics to reduce the possibility of infection.
New diagnostic tests
Tests are emerging to help better identify men who are more likely to have an aggressive underlying prostate cancer. These include blood tests such as the Prostate Health Index (PHI), and urine tests such as PCA3. These tests are available in Australia; however, rebates are not currently available through Medicare.
If the biopsy shows you have prostate cancer, other tests may be done to work out the extent of cancer in your prostate and whether it has spread to other parts of the body. This helps the doctor recommend the best treatment for you.
- Blood tests
- Bone scan
- MRI scan
- CT scan
Staging prostate cancer
Staging refers to how far the cancer has spread. It may be described as localised, locally advanced or advanced. A standardised international system called TNM is used to stage prostate cancer:
T (Tumour) 1-4: indicates the size and depth of the primary tumour. The higher the number, the more likely the cancer has spread beyond the prostate gland.
N (Nodes) 0-3: indicates whether the cancer has spread to the regional lymph nodes near the bladder. No nodes affected is 0; increasing node involvement is 1, 2, or 3.
M (Metastasis) 0-1: indicates whether the cancer has (1) or hasn’t (0) spread or metastasised to the bones or other organs.
As described above, in the TNM system each letter is assigned a number that shows how advanced the cancer is. The lower the number, the less advanced it is. This information is combined to describe the stage of the cancer from stage I to IV.
Grading prostate cancer
Prostate cancer is also given a grade to show how fast the cancer might grow. A system called the Gleason score is used. It is obtained by giving the two most common tissue types from the biopsy a grade out of five. These two grades are added together to get a final score out of 10.
- A low score (6) indicates a slow-growing, less aggressive cancer.
- An intermediate score (7) indicates a faster-growing and moderately aggressive cancer.
- A higher score (8-10) indicates a faster-growing, more aggressive cancer.
Your doctor will consider the volume of cancer too. For example, if you have one small cancerous spot, your doctor would consider this a low-volume cancer. With a low-volume, low-grade cancer, you might choose to have less aggressive treatment.
Prognosis means the expected outcome of a disease.
Prostate cancer usually grows slowly. Even fast-growing prostate cancer grows slower than other cancer types. This means that for many men, the prognosis will be favourable and there will be no urgency for treatment. Most men with prostate cancer return to normal or near normal good health after treatment.
You may want to discuss your prognosis with your doctor. It is important to understand that it is not possible for any doctor to predict the exact course of your disease. However, your doctor will be able to consider your test results and other factors such as your age, fitness and medical history. These factors will help the doctor to decide, with you, on the best treatment options and let you know what to expect.
Deciding on treatment
Your urologist and radiation oncologist will advise you on the best management or treatment after considering your age, general health, and the stage and grade of your prostate cancer. The side effects you are prepared to accept is also important.
Localised prostate cancer may be managed through surveillance, or treated with surgery and/or radiotherapy. If the cancer has spread beyond the prostate, surveillance is not recommended and, in addition to surgery and/or radiotherapy, hormone therapy may be used.
In some cases, your doctor may recommend no treatment but will monitor your health with regular checkups. This is called active surveillance (or watchful waiting) and is an option when:
- the cancer is small (early stage) and slow growing
- you are over 70, as the cancer is unlikely to grow fast enough to cause any problems during your lifetime
- the possible treatment side effects will have more impact on your life than the cancer.
If you are younger than 70, you can change your mind and have treatment later. If the cancer grows or spreads, other treatment may be recommended.
If living with an untreated cancer makes you feel anxious, discuss this with your urologist.
Your doctor may suggest surgery if:
- you have early prostate cancer
- you are fit for surgery
- you expect to live longer than 10 years
- you have not yet had radiotherapy.
A radical prostatectomy involves removal of the whole prostate gland, part of the urethra, and the seminal vesicles, which are nearby glands that store semen.
There are several different ways to perform a radical prostatectomy:
An open radical prostatectomy is usually done through a 10-12 cm cut in your lower abdomen. After the prostate is removed, the urethra is rejoined to the bladder.
A nerve-sparing radical prostatectomy may be an option, depending on the stage and grade of your cancer. The procedure involves removing the prostate and seminal vesicles and trying to preserve the nerves that control erections. These nerves can only be saved if the cancer has not spread along them and there were no problems with the nerves before surgery.
A laparoscopic radical prostatectomy is a when the prostate is removed via keyhole surgery. That is, about five small cuts are made in the abdomen and small surgical instruments are inserted. A small tube and a very small telescope are some of the instruments that are used during this procedure. The telescope with a camera attached (the laparoscope) allows the surgeon to see inside the abdomen and the prostate can be cut away and removed through the tube.
Another option that is becoming more widely available in Australia is a robotic-assisted radical prostatectomy . This procedure is also a form of keyhole surgery. The robotic-assisted device allows the surgeon to see a three-dimensional picture and also to use more advance instruments than those used for conventional laparoscopic surgery. The robotic-assisted radical prostatectomy usually results in a shorter hospital stay, less blood loss, a smaller scar and faster healing compared with open radical prostatectomy.
External beam radiotherapy
External beam radiotherapy uses X-rays to kill cancer cells or injure them so they cannot multiply. You may be treated with external beam radiotherapy if you have early cancer and you are otherwise in good health and it may be used instead of surgery or in combination with it.
The X-rays used during therapy are aimed at the cancer in your prostate from an external machine. Preparation for each treatment may take an hour or so in order to ensure as little harm as possible is done to the normal tissue and organs surrounding your prostate. The treatment itself takes about 15 minutes and you may also have to undergo blood tests.
You will probably have treatment each weekday for up to eight weeks; however some newer machines have shortened treatments to five sessions. You can have radiotherapy as an outpatient and, as a result, many men continue to work during the course of radiotherapy.
Brachytherapy is a type of internal radiotherapy where the radiation source is placed directly within the tumour. This allows higher doses of radiation to be given with minimal effect on nearby tissues such as the rectum.
Brachytherapy can be given at either a low-dose rate, by inserting permanent radioactive seeds, or at a high-dose rate, through temporary needle implants.
It is not suitable for men with significant urinary symptoms.
Low-dose rate brachytherapy
Low-dose rate radiotherapy involves implanting tiny, radioactive seeds (about the size of a grain of rice) into or next to the tumour. The seeds are inserted using needles and are guided into place by ultrasound. They release radiation that kills the cancer cells. The seeds lose their radioactive effect over time.
Implantation takes 1-2 hours and is done under general anaesthetic. It is usually done as a day procedure and allows for a quicker recovery than external beam radiotherapy.
High-dose rate brachytherapy
High-dose rate brachytherapy is usually given to men with a high PSA level, a high Gleason score and more advanced cancer. It is often combined with external beam radiotherapy and hormone treatment.
Hollow needles are placed in the prostate under general anaesthetic and high-dose radioactive wires are passed down them.
After 1-3 treatments over 36 hours, the needles are removed. The procedure usually requires a couple of nights in hospital, although some cancer treatment units perform the implant as a day procedure and repeat it approximately two weeks later.
Androgen deprivation therapy (ADT)
For widespread disease, androgen deprivation therapy (or hormone therapy) reduces the stimulus of the male hormones. Prostate cancer needs the male hormone testosterone to grow, so slowing the production of testosterone may slow the growth of the cancer or shrink it.
ADT is normally used when the prostate cancer cells have spread beyond the prostate. The timing of ADT may vary – it is often given for several months before radiotherapy to make the prostate smaller. This reduces the area that needs radiation and increases the effectiveness of the treatment. It may also be used during and/or after radiotherapy.
Injections of luteinising hormone-releasing hormone analogue (LHRHa) control the production of testosterone. It will not cure the cancer but will often slow its growth for several years. LHRHa is usually given as monthly, three-monthly or six-monthly injections.
ADT can also be given intermittently – in cycles which are started and stopped at irregular intervals. You may receive ADT until your PSA level is low, at which point treatment would stop. Treatment would then recommence when your PSA level started to rise again. The major advantage of intermittent ADT is that you may be able to reduce side effects such as tiredness, erection problems and reduced sex drive.
Tablets, known as anti-androgens, can be used to control cancer growth. They may be used together with injections. The combined therapy is known as combined androgen blockade.
ADT by surgery
Surgery involves the removal of part or both of the testes (orchidectomy). There are two types of surgery, both of which are uncommon compared with LHRHa injections. However, surgery has the advantage of providing a permanent solution for reducing testosterone levels.
A bilateral orchidectomy is the removal of the testes. A plastic prosthesis can be put into the scrotum to keep its shape.
A subcapsular orchidectomy is the removal of only the inner part of the testes and does not require a prosthesis.
Chemotherapy involves the use of cytotoxic drugs to treat cancer by killing cancer cells or slowing their growth. It is not routinely used when prostate cancer is first diagnosed, but is often used in advanced cancer or when hormone resistance occurs.
Palliative treatment helps improve quality of life by alleviating the symptoms of cancer without trying to cure the disease. It is particularly important for people with advanced cancer.
Sometimes treatment is concerned with pain relief and stopping the spread of cancer. In other cases, it manages emotional symptoms of cancer.
Treatment may include radiotherapy, chemotherapy and other medication.
Which health professionals will I see?
Health professionals who may care for you while you are being treated for prostate cancer include:
- General practitioner – monitors cancer activity (PSA levels), administers hormone treatment and promotes overall wellbeing
- Urologist – specialises in treating diseases of the urinary system and male reproductive system
- Radiation oncologist – prescribes and co-ordinates the course/s of radiotherapy
- Medical oncologist – prescribes and co-ordinates chemotherapy in more advanced cases
- Oncology nurses – administer treatments and support and assist you through all stages of your management and/or treatment
- Cancer nurse coordinator – supports patients throughout treatment and liaises with other care providers
- Urology care coordinator – supports patients that are experiencing bladder and bowel problems after cancer treatment.
- Continence nurses – nurses who have expertise in continence (urinary and bowel) issues
- Sexual health physician or sex therapist – can help you and your partner with sexuality issues before and after treatment
- Continence physiotherapist – provides exercises to help rehabilitate your pelvic floor muscles and improve continence
- Social worker, occupational therapist, counsellor, psychologist – advise you on support services, help you to get back to normal activities and provide emotional support
- Dietician – recommends an eating plan to follow while you are in treatment and recovery