Everything you need to know about Prostate Cancer

According to Prostate Cancer UK, around 1 in 8 men get prostate cancer during their lifetime. This type of cancer mostly affects those aged 50+ and the risk of getting the disease increases the older you get. Those with a family history or who are black also have a higher risk. On average, over 52,000 men receive a diagnosis of prostate cancer each year, which equates to 143 a day. Also, over 12,000 men die from the disease each year; that’s equivalent to one person every 45 minutes.  This article will tell you everything you need to know about prostate cancer.

What is prostate cancer?

Prostate cancer is cancer of the prostate, which is a gland the same shape and size as a walnut. This gland sits beneath the bladder and surrounds the urethra, in front of the rectum. It enlarges with age.

Not everyone has a prostate. It is an organ associated with the male sex, which means then men, trans women, non-binary people assigned male at birth, and some intersex people have them.

There are three common problems associated with the prostate. These are prostatitis, an enlarged prostate and prostate cancer.

What is the role of the prostate?

The prostate’s function is to make semen, the fluid responsible for carrying sperm. It also works to push semen out of the urethra. Besides being an accessory gland of the reproductive system in males, it is also a mechanical switch driven by muscles that alternate between ejaculation and urination. All male mammals have this gland but it differs physiologically, chemically and anatomically between species.

What causes prostate cancer?

Cancer in the prostate occurs when prostate cells have a mutation in their DNA, which makes them cancerous. There is no known exact cause but there are risk factors that can increase a person’s chance of developing the disease.

Risk factors of prostate cancer

Known risk factors for prostate cancer are:

• Advanced age – Prostate cancer is most common in people who are over 50 years old and a person’s risk increases the older they get. The most common age of diagnosis is between age 70 and 74.
• Family history – If there is a family history of prostate cancer (as in someone in your immediate family has been diagnosed with it), your risk is higher. Your risk can also be higher if a female family member has had ovarian or breast cancer. In terms of statistics, you are 2.5 times more likely to develop prostate cancer if your brother or father has had it. This risk increases further if they were under 60 years of age at diagnosis.
• Obesity/poor diet – Having a higher body mass increases a person’s risk of prostate cancer. Not only that but the cancer is more likely to spread (be aggressive).
• Being black – It is not known why but there is a greater prevalence of prostate cancer in black men and 25% of black men get prostate cancer at some point in their life.

The role of the BRCA genes

Some people have a mutation in their BRCA gene. This is a hereditary mutation. Around one person in every 300-400 have a mutation, generally speaking. However, around 1 in 40 people with Ashkenazi Jewish heritage carry a mutation.

People who carry a BRCA2 gene mutation will have a higher risk of getting prostate cancer in their lifetime. A BRCA1 mutation only slightly increases the risk. There is some evidence to suggest that these mutations mean the cancer is more likely to spread or occur at a younger age.

In females, this is the gene mutation that causes some ovarian and breast cancers, which is why men who have these cancers in their immediate family members have an increased risk of prostate cancer.

What are the signs of prostate cancer?

The majority of men in the early stages of prostate cancer won’t have any symptoms, which is why knowing your risk is important.

One of the first signs of changes to the prostate is changes in urination. However, this is more likely to be caused by an enlargement of the prostate rather than cancer. It should still be checked out, however.

Possible symptoms of prostate cancer include:

• Difficulties emptying the bladder or starting urination.
• Having a weak flow of urine.
• Feeling that the bladder hasn’t fully emptied.
• Experiencing urine dribbling after urination has finished.
• Feeling the need to urinate more frequently, especially overnight.
• Feeling a sudden urge to urinate – you might even leak urine before getting to the toilet.

Because of the way prostate cancer grows, symptoms don’t become obvious until the cancer is large enough to press on the urethra to cause symptoms.

When prostate cancer has broken out of the prostate this is called locally advanced prostate cancer. If it has spread to other areas, this is called advanced prostate cancer. When either of these situations arise, other symptoms can be present.

These include:

• Back, hip or pelvic pain.
• Problems maintaining or getting an erection.
• Blood appearing in the semen or urine.
• Unexplained weight loss.

Staging of prostate cancer

When prostate cancer is diagnosed, it is given a stage and a grade. This helps doctors to understand how best to treat it. Because there are processes involved in grading and staging a cancer, patients might not be given this information straight away when they receive a diagnosis. This information also helps predict the prognosis and chance of recovery.

Scans and tests will take place to determine:

• The type of cell involved in the cancer and where the cancer started.
• How abnormal the cancer cells look compared to normal cells when viewed under a microscope – this is the grade.
• The cancer’s size and where it has spread to – this is the stage.

The PSA Test

This is a blood test that can help diagnose prostate cancer. It measures how much PSA (prostate specific antigen) is in the blood. The levels are compared to the normal range for age. If a person’s level is elevated, this could indicate cancer is present. A diagnosis won’t be made on this alone because there are other conditions besides cancer that cause elevated PSA levels, including commonly occurring urine infections.

The Tumour Stage

The four stages of prostate cancer refer to its size and area.

Here is a simple description:

• T1 – This means you can’t see or feel the cancer during an examination or on a scan.
• T2 – This means the cancer hasn’t gone outside of the prostate gland.
• T3 – This means the cancer has gone through the prostate gland capsule (the covering of the gland).
• T4 – This means the cancer has gone into other nearby organs like the bladder.

The Gleason Score or Grade Group

When a pathologist looks at prostate cancer cells under the microscope, they will grade them on a scale of 3 to 5 depending on how quickly they will grow and how aggressive they are. The two numbers are added together to create the Gleason score. The end result is converted to a Grade Group between 1 and 5 with 5 being the most aggressive.

In the United Kingdom, prostate cancer is graded with either a Gleason score or Grade Groups. There are five different groups, referred to as the CPG or Cambridge Prognostic Group.

The Cambridge Prognostic Group System

There are five risk groups used in the UK to determine whether a cancer is localised or advanced. The risk groups are CPG1 to CPG5. Knowing the risk group helps the doctors to tailor treatment.

The risk group is decided by three factors:

• The stage of the tumour – there are four stages of tumour associated with prostate cancer and these are numbered T1 to T4.
• The PSA (prostate specific antigen) level – this is a measurement of a protein that is made by prostate cells – both cancerous ones and normal ones. When PSA levels are higher, this is an indicator of cancer.
• The Gleason score or Grade Group – this tells you how much the cells look like normal cells. A cancer is graded after a pathologist looks at cells from a biopsy under a microscope. The samples are graded depending on how aggressive they look and how likely they are to grow.

CPG 1 – Cambridge Prognostic Group 1

This is given when the tumour is stage 1 or 2, the PSA level is less than 10 ng/ml (nanograms per millilitre), and the Gleason score is 6 (grade group 1).

CPG2 – Cambridge Prognostic Group 2

This is given when the tumour is stage 1 or 2, the PSA level is 10-20 ng/ml, or the Gleason score is 3+4=7 (grade group 2).

CPG3 – Cambridge Prognostic Group 3

This is given when the tumour is stage 1 or 2, the PSA level is 10-20 ng/ml and the Gleason score is 3+4=7 (grade group 2).

Or

The tumour stage is 1 or 2 and the Gleason score is 4+3=7 (grade group 3).

CPG4 – Cambridge Prognostic Group 4

This is given when the tumour stage is 3 or the Gleason score is 8, or the PSA level is above 20 ng/ml.

CPG5 – Cambridge Prognostic Group 5

This is given for having at least two of the following:

• The tumour stage is 3.
• The PSA level is above 20 ng/ml.
• The Gleason score is 8 (grade group 4).

CPG5 is also given if the Gleason score is 9 or 10 (grade group 5) or the tumour is stage 4.

How is prostate cancer diagnosed?

If a patient goes to the GP with symptoms of prostate cancer, the doctor will usually perform or request further testing. If cancer is suspected, the patient will be referred to a specialist who deals with prostate cancer. This would be a urologist. If cancer was confirmed, an oncologist (cancer doctor) will also be involved.

To determine the presence of prostate cancer, a number of tests will be performed.

These include:

• A digital rectal examination – this involves inserting a finger into the rectum to feel the prostate gland.
• A blood test to check the PSA level.
• A rectal ultrasound to obtain images.
• A biopsy of any mass present to be examined under a microscope. The biopsy might be a transperineal biopsy (taken through a needle behind the scrotum) or a transrectal biopsy (taken through the rectum).

Can prostate cancer be prevented?

There is no proven prevention strategy for prostate cancer. However, it is possible to reduce your risk by eating a healthy, balanced diet and exercising. Being overweight is a risk factor and so you can reduce your risk by maintaining a healthy weight. Studies have also shown that men who consume a lot of dairy (milk, yogurt and cheese) had a higher incidence of prostate cancer and so it is recommended to eat a moderate amount of dairy.

If you know there is a family history of the disease, it’s also a good idea to keep up to date with checks, if required, with your doctor.

Complications of prostate cancer

The most serious complication of prostate cancer is, of course, the cancer spreading. This can be local invasion where the cancer spreads to the bladder, the urethra or the seminal vesicles, for example. It can also mean the cancer metastasises elsewhere in the body like the bones. This can cause effects like spinal cord compression, pathological fractures and pain.

Lower urinary tract symptoms are not usually present in early prostate cancer so when these do appear, it’s usually a sign that the disease is not curable.

Other side effects of the disease include urinary incontinence and erectile dysfunction. Erectile dysfunction occurs because the nerves controlling erectile responses are situated in close proximity to the prostate gland. Tumours or treatments to treat them can cause damage to the nerves, causing problems maintaining or achieving an erection.

Urinary incontinence also happens due to nerve damage as well as muscle damage.

Treatment for prostate cancer

When doctors know the CPG, they can tailor a patient’s treatment accordingly. There are different types of treatment. Besides the CPG, the treatment given will also be determined by the patient’s general health, their age and how they feel about treatments and side effects.

For patients with CPG 1, 2 and 3, treatment might not be given immediately. At first, this might be monitored – a process that might be called ‘watchful waiting’ or ‘active surveillance’.

People with CPG 2, 3, 4, or 5 might be recommended to have treatment.

This includes:

• Surgical removal of the prostate.
• Radiotherapy (external).
• Radiotherapy (internal) – this is called brachytherapy.
• Chemotherapy.
• Hormone therapy.
• Treatment to control symptoms.
• Cryotherapy (clinical trials).
• High frequency ultrasound therapy – HIFU (clinical trials).

Surgery

This is one of the main prostate cancer treatments. Surgeons might remove the prostate gland in a bid to cure the cancer. This operation is called a radical prostatectomy. This can be done as open surgery or by ‘Da Vinci’ surgery, which uses a robotic system.

Some patients also have their testicles removed to stop the production of testosterone. This is a type of hormone therapy called an orchidectomy.

Radiotherapy

Radiotherapy destroys the cancer cells by using rays similar to X-rays. There are two types – internal radiotherapy, which is called brachytherapy, and external beam radiotherapy.

Hormone therapy

Prostate cancer is typically dependent on testosterone for its growth. Hormone therapy works to lower and block the amount of testosterone. This lowers a person’s risk of the cancer returning when combined with other treatments.

Besides removing the testicles (orchidectomy), it can be done via tablets and injections.

Cryotherapy

This is a treatment that involves the use of extreme cold to destroy cancer cells. It can also be called cryosurgery or cryoablation. This can be used for localised prostate cancer or prostate cancer that has returned following radiotherapy. It is currently available as a clinical trial in specific areas of the UK.

High intensity focused ultrasound (HIFU)

This is a treatment involving high frequency sound waves to destroy and kill cancer cells in the prostate. The sound waves create heat, which destroys the cells. This treatment is available for localised prostate cancer or cancer that has returned after treatment. Like cryotherapy, it is a clinical trial that’s only available in certain areas.

Support available

The main charity in the UK supporting prostate cancer is Prostate Cancer UK. This charity provides a range of support services that are open to patients as well as their friends and family members. There are specialists available to offer practical support, financial support, sexual support and emotional support.

Final thoughts: prostate cancer and the long-term outlook

After non-melanoma skin cancer, prostate cancer is the most common cancer in men. Deaths from the disease have declined dramatically in recent years and most people with prostate cancer live a long time with their diagnosis. When prostate cancer hasn’t spread, the five-year survival rate is almost 100% and the 15-year survival rate is an impressive 94%.