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Introduction

Prostate cancer is the most common cancer in men in the UK, with over 40,000 new cases diagnosed every year.

Prostate cancer usually develops slowly, so there may be no signs you have it for many years.

Symptoms often only become apparent when your prostate is large enough to affect the urethra (the tube that carries urine from the bladder to the penis).

When this happens, you may notice things like an increased need to urinate, straining while urinating and a feeling that your bladder has not fully emptied.

These symptoms shouldn’t be ignored, but they do not mean you definitely have prostate cancer. It is more likely that they are caused by something else, such as benign prostatic hyperplasia (also known as BPH or prostate enlargement).

 

What is the prostate?

The prostate is a small gland in the pelvis found only in men. About the size of a satsuma, it's located between the penis and the bladder and surrounds the urethra.

The main function of the prostate is to help in the production of semen. It produces a thick white fluid that is mixed with the sperm produced by the testicles, to create semen.

 

Why does prostate cancer happen?

The causes of prostate cancer are largely unknown. However, certain things can increase your risk of developing the condition.

The chances of developing prostate cancer increase as you get older. Most cases develop in men aged 50 or older.

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

Men who have first degree male relatives (such as a father or brother) affected by prostate cancer are also at slightly increased risk.

 

Tests for prostate cancer

There is no single test for prostate cancer. All the tests used to help diagnose the condition have benefits and risks, which your doctor should discuss with you.

The most commonly used tests for prostate cancer are blood tests, a physical examination of your prostate (known as a digital rectal examination or DRE) and a biopsy.

The blood test, known as a prostate-specific antigen (PSA) test, measures the level of PSA and may help detect early prostate cancer. Men are not routinely offered PSA tests to screen for prostate cancer, as results can be unreliable.

This is because the PSA blood test is not specific to prostate cancer. PSA can be raised due to a large non-cancerous growth of the prostate (BPH), a urinary tract infection or inflammation of the prostate, as well as prostate cancer. Raised PSA levels also cannot tell a doctor whether a man has life-threatening prostate cancer or not. This means a raised PSA can lead to unnecessary tests and treatment.

However, you can ask to be tested for prostate cancer once the benefits and risks have been explained to you.

 

How is prostate cancer treated?

For many men with prostate cancer, treatment is not immediately necessary.

If the cancer is at an early stage and not causing symptoms, a policy of "watchful waiting" or "active surveillance" may be adopted. This involves carefully monitoring your condition.

Some cases of prostate cancer can be cured if treated in the early stages. Treatments include surgically removing the prostate, radiotherapy and hormone therapy.

Some cases are only diagnosed at a later stage when the cancer has spread. If the cancer spreads to other parts of the body, typically the bones, it cannot be cured and treatment is focused on prolonging life and relieving symptoms.

All treatment options carry the risk of significant side effects, including erectile dysfunction and urinary incontinence. For this reason, many men choose to delay treatment until there is a risk the cancer might spread.

Newer treatments, such as high-intensity focused ultrasound (HIFU) or cryotherapy, aim to reduce these side effects. Some hospitals may offer them as an alternative to surgery, radiotherapy or hormone therapy. However, the long-term effectiveness of these treatments are not yet known.

 

Living with prostate cancer

As prostate cancer usually progresses very slowly, you can live for decades without symptoms or needing treatment.

Nevertheless, it can have an effect on your life. As well as causing physical problems such as erectile dysfunction and urinary incontinence, a diagnosis of prostate cancer can understandably make you feel anxious or depressed.

You may find it beneficial to talk about the condition with your family, friends, a family doctor and other men with prostate cancer.

Financial support is also available if prostate cancer reduces your ability to work.

 

Symptoms of prostate cancer

Prostate cancer does not normally cause symptoms until the cancer has grown large enough to put pressure on the urethra.

This normally results in problems associated with urination. Symptoms can include:

  • needing to urinate more frequently, often during the night

  • needing to rush to the toilet

  • difficulty in starting to pee (hesitancy)

  • straining or taking a long time while urinating

  • weak flow

  • feeling that your bladder has not emptied fully

Many men's prostates get larger as they get older due to a non-cancerous condition known as prostate enlargement or benign prostatic hyperplasia.

Symptoms that the cancer may have spread include bone and back pain, a loss of appetite, pain in the testicles and unexplained weight loss.

 

 

Causes of prostate cancer

It is not known exactly what causes prostate cancer, although a number of things can increase your risk of developing the condition.

These include:

  • Age – risk rises as you get older and most cases are diagnosed in men over 50 years of age.

  • Ethnic group – prostate cancer is more common among men of African-Caribbean and African descent than in men of Asian  descent.

  • Family history – having a brother or father who developed prostate cancer under the age of 60 seems to increase the risk of you developing it. Research also shows that having a close female relative who developed breast cancer may also increase your risk of developing prostate cancer. 

  • Obesity – recent research suggests that there may be a link between obesity and prostate cancer.

  • Exercise  men who regularly exercise have also been found to be at lower risk of developing prostate cancer.

  • Diet  research is ongoing into the links between diet and prostate cancer. There is evidence that a diet high in calcium is linked to an increased risk of developing prostate cancer.

In addition, some research has shown that prostate cancer rates appear to be lower in men who eat foods containing certain nutrients including lycopene, found in cooked tomatoes and other red fruit, and selenium, found in brazil nuts. However, more research is needed.

 

 

Diagnosing prostate cancer

If you have symptoms that could be caused by prostate cancer, you should visit your GP.

There is no single, definitive test for prostate cancer, so your GP will discuss the pros and cons of the various tests with you to try to avoid unnecessary anxiety.

Your doctor is likely to:

  • ask for a urine sample to check for infection

  • take a blood sample to test your level of prostate-specific antigen (PSA)

  • examine your prostate (digital rectal examination)

 

PSA testing

PSA is a protein produced by the prostate gland. All men have a small amount of PSA in their blood, and it increases with age.

Prostate cancer can increase the production of PSA, and so a PSA test looks for raised levels of PSA in the blood that may be a sign of the condition in its early stages.

However, PSA testing is not a specific test for prostate cancer. Most men who have prostate cancer will not have a raised PSA level. More than 65% of men with a raised PSA level will not have cancer, as PSA levels rise in all men as they get older.

Digital rectal examination (DRE)

The next step is a DRE, which can be done by your GP.

During a DRE, your GP will insert a lubricated and gloved finger into your rectum. The rectum is close to your prostate gland, so your GP can check to feel if the surface of the gland has changed. This will feel a little uncomfortable, but should not be painful.

Prostate cancer can make the gland hard and bumpy. However, in most cases, the cancer causes no changes to the gland and a DRE may not be able to detect the cancer.

DRE is useful in ruling out prostate enlargement caused by benign prostatic hyperplasia, as this causes the gland to feel firm and smooth.

Biopsy

Your GP will assess your risk of having prostate cancer based on a number of factors, including your PSA levels, the results of your DRE, and your age, family history and ethnic group. If you are at risk, you should be referred to hospital to discuss the options of further tests.

The most commonly used test is a transrectal ultrasound-guided biopsy (TRUS). A biopsy may also be taken during a cystoscopy examination or through the skin behind the testicles (perineum).

During a TRUS biopsy, an ultrasound probe (a machine that uses sound waves to build a picture of the inside of your body) is inserted into your rectum. This allows the doctor or specialist nurse to see exactly where to pass a needle through the wall of your rectum to take small samples of tissue from your prostate.

The procedure can be uncomfortable and sometimes painful, so you may be given a local anaesthetic to minimise any discomfort. As with any procedure, there may be complications, including bleeding and infection.

Although it is more reliable than a PSA test, the TRUS biopsy can have problems. It can miss up to one in five cancers, because the location of the cancer is unknown when it is carried out. The doctors can see the prostate using the ultrasound scan, but not the tumour(s) if they are present.

You may need another biopsy if your symptoms persist, or your PSA level continues to rise. Your doctor may request an MRI scan of the prostate before another biopsy.

The TRUS biopsy can also find small low-risk cancers that do not need treatment, but may cause you anxiety. Many men often choose to undergo surgery or radiotherapy that may not benefit them but causes side effects, such as incontinence and erectile dysfunction.

The samples of tissue from the biopsy are studied in a laboratory. If cancerous cells are found, they can be studied further to see how quickly the cancer will spread. This process is known as "staging and grading" and helps doctors to decide which treatment is the most appropriate.

 

 

Further testing

If there is a significant chance the cancer has spread from your prostate to other parts of the body, further tests may be recommended.

These include:

  • A magnetic resonance imaging (MRI) or computerised tomography (CT) scan – these scans build a detailed picture of the inside of your body.

  • An isotope bone scan – this can tell if the cancer has spread to your bones. A small amount of radiation dye is injected into the vein and collects in parts of the bone where there are any abnormalities.

 

 

Screening for prostate cancer

There is currently no screening programme for prostate cancer in the UK, because it has not been proven that the benefits would outweigh the risks.

 

PSA screening

Routinely screening all men to check their prostate-specific antigen (PSA) levels is a controversial subject in the international medical community.

In some countries, all men aged over 50 are recommended to have an annual PSA test. However, this is not the case in the UK.

There are several reasons for this:

  • PSA tests are unreliable and can suggest prostate cancer when no cancer exists (a false-positive result). This means that many men often have invasive and sometimes painful biopsies for no reason. Also, up to 20% of men with prostate cancer have normal PSA levels, so many cases may be missed.

  • Treating prostate cancer in its early stages can be beneficial in some cases  but side effects of the various treatments are potentially so serious that men may choose to delay treatment until it is absolutely necessary.

  • Although screening has been shown to reduce a man’s chance of dying from prostate cancer, it would mean many men getting treated unnecessarily.

More research is needed to determine whether a screening programme would reduce the number of deaths. One European study has shown that deaths from prostate cancer could be reduced by 20% if there was a screening programme, but found many men were being treated unnecessarily. Between 33 and 48 men would need to be diagnosed and treated to save the life of one man over a 10-year period.

A recent large study in America found no reduction in the number of deaths.

As there are many reasons why PSA levels may be high at any one time, researchers are trying to make the PSA test, or a variation of it, more accurate. This includes looking at how PSA levels change over time, and comparing the PSA level to prostate size. Researchers are also looking at whether new imaging tests, such as MRI scans, or other blood and urine tests, can be used to decide which men with an elevated PSA should have a biopsy.

Instead of a national screening programme, there is an informed choice programme on prostate cancer risk management. It aims to give men good information on the pros and cons of a PSA test.

If you are aged over 50 and decide to have your PSA levels tested, your GP will be able to arrange for it to be carried out for free.

If results show you have a significantly raised level of PSA, your GP may suggest further tests.

However, the exact figure for a "normal" PSA level can change, depending on your age and GP surgery location.

 

Should I have a PSA test?

Because the results of the PSA test are not as reliable as doctors would like, other tests and investigations are needed to diagnose prostate cancer. A PSA test cannot identify prostate cancer on its own, and changes in PSA levels alone are not a good reason to start treatment.

If you are going to have a PSA test, it is important that you first discuss with your GP whether it is right for you, so you understand what the results might mean.

The Prostate Cancer Risk Management Programme gives you information on the risks and benefits of the PSA test to help you decide whether or not to have it.

 

 

Treating prostate cancer 

Your treatment for prostate cancer will depend on your individual circumstances.

For many men with prostate cancer, no treatment will be necessary. Active surveillance or "watchful waiting" will mean keeping an eye on the cancer and starting treatment only if the cancer shows signs of getting worse or causing symptoms.

When treatment is necessary, the aim is to cure or control the disease so it doesn't shorten life expectancy and affects everyday life as little as possible. Sometimes, if the cancer has already spread, the aim is not to cure it, but to prolong life and delay symptoms.

 

Your cancer care team

People with cancer should be cared for by a multidisciplinary team (MDT). This is a team of specialists who work together to provide the best care and treatment.

The team often consists of a specialist cancer surgeon, an oncologist (a radiotherapy and chemotherapy specialist), a radiologist, pathologist, radiographer and a specialist nurse. Other members may include a physiotherapist, dietitian and occupational therapist. You may also have access to clinical psychology support.

When deciding what treatment is best for you, your doctors will consider:

  • the type and size of the cancer

  • what grade it is

  • your general health

  • whether the cancer has spread to other parts of your body

 

Good prostate cancer care

Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision is yours.

Your MDT should also let you know about any clinical trials you may be eligible for. See prostate cancer clinical trials for a database of trials currently studying prostate cancer.

The National Institute for Health and Care Excellence (NICE) has made recommendations about treatments offered to men with the three main stages of prostate cancer:

  • localised prostate cancer (cancer that is just in the prostate gland)

  • locally advanced prostate cancer (cancer that has spread beyond the prostate capsule, but is still connected to the prostate gland)

  • relapsed (cancer that has returned after treatment) and metastatic prostate cancer (cancer that has spread outside the prostate gland, with no remaining link to the original cancer in the prostate gland)

 

 

Staging of prostate cancer hide

Doctors will use the results of your prostate examination, biopsy and scans to identify the "stage" of your prostate cancer (how far the cancer has spread). The stage of the cancer will determine which types of treatments will be necessary.

A widely used method of staging is a number staging system. The stages are:

  • Stage 1 – the cancer is very small and completely within the prostate gland

  • Stage 2 – the cancer is within the prostate gland, but is larger

  • Stage 3 – the cancer has spread from the prostate and may have grown into the tubes that carry semen

  • Stage 4 – the cancer has spread into the lymph nodes or another part of the body, including the bladder, rectum or bones; about 20-30% of cases are diagnosed at this stage 

If prostate cancer is diagnosed at an early stage, the chances of survival are generally good. About 90% of men diagnosed at stages 1 or 2 will live at least five more years and 65-90% will live for at least 10 more years.

If you are diagnosed with stage 3 prostate cancer, you have a 70-80% of chance of living for at least five more years.

However, if you are diagnosed when your prostate cancer has reached stage 4, there is only a 30% chance you will live for at least five more years.

 

Living with prostate cancer

Depending of the type of prostate cancer you have, your life may be affected in different ways.

Unlike many other types, most prostate cancers get worse slowly. Men may have it for years without symptoms. During this time, men with low-risk prostate cancer (which has not spread beyond the prostate gland) may not need treatment.

About one in five men with prostate cancer have fast-growing cancer. Men whose cancer is more likely to spread may decide to have surgery or radiotherapy, which aims to cure the cancer. However, these treatments can have side effects.

 

 

Impact on everyday activities  hide

If you have no symptoms, prostate cancer should have little or no effect on your everyday activities. You should be able to work, care for your family, carry on your usual social and leisure activities, and look after yourself. However, you may be understandably worried about your future. This may make you feel anxious or depressed, and affect your sleep.

If your prostate cancer progresses, you may not feel well enough to do all the things you used to. After an operation or other treatment, such as radiotherapy or chemotherapy, you will probably feel tired and need time to recover.

If you have advanced prostate cancer that has spread to other parts of your body, you may have symptoms that slow you down and make it difficult to do things. You may have to reduce your working hours or stop working altogether.

Whatever stage your prostate cancer has reached, try to give yourself time to do the things you enjoy and spend time with those who care about you.

Urinary PSA test
Urinary PSA test