What is the prostate?
The prostate is a gland located in the lower urinary tract, under the bladder and around the urethra. Only men have a prostate. It produces part of the fluid which carries semen. The prostate contains smooth muscles which help to push out the semen during ejaculation.
A healthy prostate is about the size of a large walnut and has a volume of 15-25 millilitres.
The prostate slowly grows as men grow older.
The medical term for a prostate that has grown in size is benign prostatic enlargement (BPE).
Stages of the disease
There are different stages of prostate cancer. If the tumour is limited to the prostate and has not spread, this is called localized prostate cancer. In locally advanced prostate cancer, the tumour has grown out of the prostate into surrounding tissue such as the seminal vesicles, the bladder neck, or lymph nodes around the prostate. Doctors speak of metastatic disease if the cancer has spread either to distant lymph nodes or other organs.
Prostate cancer is generally asymptomatic, which means that there are no clear symptoms to indicate it. In most cases, symptoms are caused by benign prostatic enlargement (BPE), or an infection. If prostate cancer does cause symptoms it is usually a sign that the disease has advanced. Because of this it is important that you see a doctor to understand what causes the symptoms.
The symptoms may include:
• Urinary symptoms such as urinary frequency or a weak stream of urine
• Blood in the urine
• Erection problems
• Urinary incontinence
• Loss of bowel control
• Pain in the hips, back, chest, or legs
• Weak legs
Bone pain could be a sign that the cancer has spread through the body. This is known as metastatic disease.
One of the most frequently used tools to diagnose prostate conditions is a blood test to check the level of prostate specific antigen (PSA). If the PSA level is too high, this suggests that the cells in the prostate are behaving unusually.
This could be because of a tumour in the prostate, but also because of an infection or a benign enlargement of the prostate.
Digital rectal examination
Your doctor will do a rectal examination with a finger to feel the size, shape, and consistency of the prostate
This test is known as digital rectal examination (DRE)
This section describes the different treatment options which you should discuss with your doctor.
This is general information, which is not specified to your individual needs. Keep in mind that individual recommendations may depend on your country and health care system.
Each treatment has its own advantages and disadvantages. The choice depends on your individual situation.
Which treatment pathway is best for you depends on:
- The tumour characteristics
• Your medical history
• Your age
• The kind of treatment available at your hospital
• Your personal preferences and values
• The support network available to you
Localised Prostate Cancer
If you are diagnosed with localised prostate cancer, your doctor can recommend treating the cancer with conservative management, radical prostatectomy, radiation therapy, or new experimental techniques: ablation therapy.
Conservative management is a type of treatment where the progress of your disease is closely monitored. In prostate cancer, this can be done through active surveillance or watchful waiting.
Radical prostatectomy is a surgical treatment option for localized prostate cancer. The aim is to remove the entire prostate and the seminal vesicles.
Your doctor could also recommend radiation therapy. This therapy damages and kills cancer cells. You may be treated with external beam radiation therapy or brachytherapy.
Your doctor may suggest brachytherapy if you have a low Gleason score and no urinary symptoms.
Locally-advanced Prostate Cancer
If you are diagnosed with locally-advanced prostate cancer, your doctor can recommend treating the cancer with watchful waiting, radical prostatectomy, or a combination of radiation therapy and hormonal therapy.
In watchful waiting the doctor schedules regular visits to monitor your health and recommends further treatment when symptoms appear. This treatment is generally indicated when you are unfit for radical prostatectomy, radiation therapy or hormonal therapy. This may be related to your age or any medical conditions which make those treatments dangerous for you.
Radical prostatectomy is a surgical treatment option for locally-advanced prostate cancer. The aim is to remove as much of the tumour as possible. This is done by removing the entire prostate gland and both seminal vesicles, as well as surrounding tissue affected by the tumour. The procedure also includes the removal of lymph nodes in the pelvic area.
Hormonal therapy and radiation therapy
As an alternative to surgery, your doctor may recommend radiation therapy to cure your cancer. This therapy damages and kills cancer cells. It is a common treatment option for locally-advanced tumours. In locally-advanced prostate cancer, radiation therapy is always combined with hormonal therapy.
Hormonal therapy affects the production of testosterone in the body. The aim is to stop the growth of the tumour. Another name for hormonal therapy is androgen deprivation therapy (ADT)
Prostate tumours are classified according to the tumour stage and the grade of aggressiveness of the tumour cells. These two elements are the basis for your possible treatment pathway.
The doctor does a series of tests to better understand your specific situation. Physical examination and imaging can be used to determine the stage of the disease. Prostate cancer is classified according to how advanced the tumour is, and whether or not the cancer has spread to the lymph nodes or other organs.
The other element of classification is the Gleason score. The Gleason score is determined by the pathologist, based on the tissue taken during biopsy. It gives information about the aggressiveness of the tumour. Based on the pattern that the cancer cells show, the pathologist can see how fast the tumour grows
What is localised prostate cancer?
Localised prostate cancer refers to a tumour which is limited to the prostate and has not extended to other parts of your body. It may be a T1 or T2 tumour, depending on its size and where it is located in the prostate.
T1 means that the tumour is too small to be felt during a digital rectal examination (DRE) or seen on a scan. T1 tumours are confirmed with a biopsy and assigned an a, b, or c based on the analysis of the pathologist. A T2 tumour means that prostate cancer can be felt during a DRE, but is still limited to the prostate. Your doctor will also assign an a, b, or c to this stage, depending on the size of the tumour and whether it is in one or more lobes of the prostate.
What is locally-advanced prostate cancer?
Locally-advanced prostate cancer refers to a tumour which has spread outside of the prostate. It may be a T3 or T4 tumour, depending on where and how far outside of the prostate it has grown. T3 means that the tumour has grown just outside the prostate or to the seminal vesicles. A T4 tumour means that prostate cancer has invaded the bladder neck, the urinary sphincter, the rectum, or the pelvic floor.
Diagnosis and Classification of Prostate Cancer
In most cases prostate cancer is asymptomatic, which means that there are no clear symptoms to indicate it. Most prostate cancers are detected after a test to check the level of prostate-specific antigen (PSA) in the blood. If the level of PSA in the blood is high, the doctor will recommend more tests to see what causes the increase. A PSA test alone can never be used to diagnose prostate cancer.
The most common tools to check the condition of your prostate are a PSA test and a digital rectal examination (DRE). Your doctor could recommend these tests if you have urinary symptoms. These may include the need to urinate more often than usual, a sudden need to urinate that is difficult to postpone, or involuntary loss or dribbling of urine into the underwear. Often these symptoms point to other conditions, most commonly benign prostatic enlargement (BPE). They could also be signs of advanced prostate cancer. This is why you may need to take several tests before the doctor can make a diagnosis.
Based on the results of these tests your doctor may recommend a prostate biopsy. Keep in mind that a prostate biopsy is the only test that can confirm a prostate cancer diagnosis.
Because prostate cancer is generally asymptomatic, your doctor might recommend regular PSA testing. Whether or not your doctor will suggest this depends on many factors, including the policy of your doctor or hospital, or the national health policies of your country. The most important factors are always your age and your family history.
If you are diagnosed with prostate cancer, the urologist needs to define the tumour stage. By analysing tumour tissue, received either during surgery or biopsy, the pathologist determines the characteristics of the tumour and whether or not it is an aggressive form. Together, the stage and aggressiveness of the tumour form the classification.
Classification of the tumour in the prostate is used to estimate your individual prognosis. Based on this individual prognosis your doctor will discuss the best treatment pathway for you.
This section offers general information which is not specified to your individual needs. Keep in mind that situations can vary in different countries.
Hormonal therapy locally-advanced prostate cancer
Hormonal therapy is a treatment option for locally-advanced prostate cancer. It aims to stop the growth of the tumour.
The growth of prostate cancer cells is dependent on male sex hormones called androgens. Testosterone is the most important androgen. Androgens are mainly produced in the testicles. Hormonal therapy either stops the production or blocks the action of androgens. This is known as castration.
Another name for hormonal therapy is androgen deprivation therapy (ADT). It can be performed surgically or with drug treatment. In surgical therapy, both testicles are removed in a procedure called bilateral orchiectomy. The surgery is generally done under local anaesthesia. Drug therapy to stop the production of androgens includes LHRH agonists and LHRH antagonists. These drugs are available as depot injections right under the skin or into the muscle. Anti-androgens are drugs that block the action of androgens. They come as a pill. All of these therapies cause castration.
Castration has physical and emotional consequences. The most common are hot flushes, lower sex drive, and erectile dysfunction. The effects of surgical castration are permanent. In chemical castration, some of the symptoms may disappear after the treatment. Do not hesitate to discuss any concerns with your doctor.
In locally-advanced prostate cancer the standard treatment to cure the disease is hormonal therapy in combination with radiation therapy.
Castration-resistant prostate cancer
If you have been diagnosed with castration-resistant prostate cancer, your doctor will recommend a care pathway to manage your symptoms and allow you to live longer. It is important to remember that castration-resistant prostate cancer cannot be cured.
Castration-resistant prostate cancer can be managed with:
Additional treatment with anti-androgen therapy
When you have been treated with either surgical or chemical castration, your doctor may recommend additional treatment with anti-androgen therapy. The most common anti-androgen drug to manage castration-resistant prostate cancer is bicalutamide. Treatment with this drug aims to slow down the growth of the tumour. It will not relieve your symptoms. Side effects may include swelling of the breasts and liver problems.
Stopping anti-androgen treatment
If you have been treated with LHRH agonists or antagonists in combination with anti-androgen therapy, your doctor may recommend to stop taking the anti-androgen drugs. This approach may lower the level of PSA in your blood for a few months. The effect will be seen 4-6 weeks after you stop taking the drugs.
After castration, the adrenal glands continue to produce small amounts of androgens. Adrenolytic agents stop the adrenal gland from producing the hormones. Side effects of these drugs are diarrhoea, itching and skin rashes, fatigue, erectile dysfunction, and liver damage. These drugs are not commonly used.
Drug therapy with the hormone oestrogen can slow down the growth of the tumour and lower the level of PSA in your blood, without affecting your bones. This treatment can cause cardiovascular disease, including blood clots and heart attacks. Because of these risks, oestrogen therapy is rarely recommended today.
New hormonal agents
Castration-resistant prostate cancer can be managed with two new hormonal agents: abiraterone acetate and enzalutamide.
They both work differently.
Abiretarerone acetate stops the production of testosterone and ezalutamide blocks androgen receptors.
Immunotherapy is a type of treatment that uses your own immune system to fight the tumour cells. In prostate cancer the drug Sipuleucel-T is used as immunotherapy. Because your own blood is used to prepare the drug, you need to get blood drawn before the procedure.
Chemotherapy with docetaxel
Your doctor may recommend the chemotherapy docetaxel to manage castration-resistant prostate cancer. The drug relieves pain caused by the tumour or metastases. If effective, it allows you live longer and with fewer symptoms and side effects.
Treatment after chemotherapy
After you have been treated with docetaxel, your doctor can recommend treatment with hormonal therapy or another chemotherapy drug. The main hormonal treatments are abiraterone acetate and enzalutamide. Cabazitaxel is the chemotherapy drug most commonly used in these cases. You could also receive a second course of docetaxel. Your doctor will discuss the different treatment options to find the best one for you.
Treatment after bone metastases
Prostate cancer cells can spread to the bones, generally to the spine. The treatment of bone metastases can have severe side effects. Your doctor will help to prevent and treat possible complications and side effects. This may allow you to live longer and with fewer symptoms.
Castration-resistant prostate cancer can be managed with radiation therapy. The radiation damages and kills cancer cells. The treatment will help to relieve pain and may allow you to live longer. Common side effects are a burning sensation when you urinate, urinary frequency, and anal irritation.
Treatment of recurrence
In localised prostate cancer or locally-advanced prostate cancer, it is possible that prostate cancer comes back after you have been treated. This is known as recurrence. The cancer may come back in the prostate, in tissue around the prostate or pelvic lymph nodes, or in other parts of the body. The follow-up treatment pathway depends on where the cancer is. Your doctor will recommend imaging tests such as CT, MRI, PET scan or bone scans to locate the tumour, identify its characteristics, and determine treatment.
If you have been treated with radical prostatectomy and the PSA level in your blood rises, this could be a sign of recurrence. Your doctor may recommend salvage radiation therapy. In this procedure, the area where the prostate was located will be radiated to kill cancer cells. If your cancer was treated with radiation therapy, your doctor may recommend to treat recurrence with radical prostatectomy.
Localised prostate cancer
If you have been treated with experimental techniques, disucss with your doctor which treatment option is best for you.
Locally advanced prostate cancer
If radiation therapy is not the best option for you, your doctor can recommend hormonal therapy.
If the PSA level rises quickly, or you have symptoms, hormonal therapy will be recommended. In some countries, brachytherapy is available to treat recurrence as an alternative to hormonal therapy.
If your tumour has spread to other organs or tissues (metastases), surgery is not a treatment option. At this point, treatment should reduce symptoms and maintain your quality of life. This is the main focus of palliative care. During palliative care, you and your loved ones are supported by a multidisciplinary team. Together you address physical, psychological, social, and spiritual issues. Palliative care includes controlling your symptoms and medical treatment for pain management.
The palliative care team can provide care in the hospital or at your home. Another option is hospice care. A hospice is an institution that provides care during the final phase of your life.