The prostate
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.
View an image of the prostate gland.
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. Based on 2006 figures, one in seven men in NSW will develop prostate cancer by the age of 75 years, and one in five men will be affected by the age of 85. This is about 6,000 new cases every year.
It is less common in men under 50 unless they have a family history of prostate cancer.
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 cancer.
In 5-10% of men with prostate cancer, their family medical history may indicate they have an inherited gene that contributed to the cancer's development. You may have an inherited prostate cancer gene if you have:
- multiple relatives with prostate cancer or breast cancer on the same side of the family (either the mother's or father's side)
- younger male relatives (under 50) with prostate cancer.
If you are concerned about your family history of prostate cancer, you may wish to ask your doctor for a referral to a family cancer clinic or a urologist to 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 urine or semen
- pain in the lower back, hips or upper thighs.
These symptoms are common to many conditions and may not be a sign of advanced prostate cancer. If you are concerned, see your doctor.
Diagnosis
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. Your body makes more PSA as you age, but other factors can increase PSA levels in your blood, such as:
- inflammation in the prostate
- benign prostate enlargement
- prostate cancer.
This is not a definitive test, so a PSA test 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 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.
Biopsy
- A biopsy is done if the PSA test or digital rectal examination are abnormal.
- Small pieces of tissue is removed for examination under a microscope to see if there are any cancer cells.
- Between six 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.
Further test
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
A standardised international system called TNM is used to stage prostate cancer, which shows how far the cancer has spread.
- T (tumour) indicates the size and depth of tumour invasion.
- N (nodes) indicates whether the lymph nodes (glands) are affected.
- M (metastasis) indicates whether the cancer has spread.
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.
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 between 3 and 5. These two grades are added together to get a final score out of 10.
- A low Gleason score (6) indicates a slow-growing (less 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 less aggressive treatment.
Prognosis
Prognosis means the expected outcome of a disease.
You need to discuss your prognosis for prostate cancer with your urologist. Only someone who knows your medical history can tell you what to expect and the treatment options that are best for you, but it is not possible for any doctor to predict the exact course of your illness.
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.
With surgery, the prognosis is good, but side effects can occur long term and reduce quality of life. With other treatments, the tumour may shrink or stop growing, resulting in a remission, which means the cancer has been controlled. Even if the prostate gland is not removed, the cancer cells can still be killed.
Most men usually return to normal or near normal good health.
Deciding on treatment
Your urologist will advise you on the best treatment after considering your age, general health, how fast the prostate cancer is growing (the grade) and whether it has spread (the stage). The side effects you are prepared to accept is also important.
The treatments for localised prostate cancer include surgery and radiotherapy. If the cancer has spread beyond the prostate, hormone therapy may be used. You may have one of these treatments or a combination.
Active surveillance
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
- men are over 70, as the cancer is unlikely to grow fast enough to cause any problems during their lifetime
- the possible treatment side effects 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.
Surgery
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.
Radical prostatectomy
- Involves removal of the whole prostate gland, part of the urethra, and the seminal vesicles, which are nearby glands that store semen.
- Usually done through a 10-12 cm cut in your lower abdomen.
- After the prostate is removed, the urethra is rejoined to the bladder.
Nerve-sparing surgery
Nerve-sparing surgery involves the removal of the prostate and the preservation of the nerves controlling erections. These nerves can only be saved if the cancer has not spread along them and there were no problems with the nerves prior to surgery. This surgery works best with men who had good quality erections before the operation. Problems with erections are common after nerve-sparing surgery, but there are ways to manage them.
Keyhole surgery
An alternative to open surgery for some men is to remove the prostate via keyhole surgery. This is called a laparoscopic prostatectomy or robot-assisted laparoscopic prostatectomy.
- Several small cuts are made in the skin, and a small tube is passed into the abdomen.
- A very small telescope with a camera attached (the laparoscope) is passed through the tube to allow the surgeon to see inside the abdomen.
- The prostate is cut away and removed through the tube.
Transurethral resection (TURP)
- Removes blockages in the urinary tract to help with symptoms of more advanced cancer, such as frequent urination.
- Does not cure cancer.
- Is also used to treat benign prostate enlargement.
- You will have a general or spinal anaesthetic.
- A telescope-like instrument is passed through the opening in the penis and up the urethra to remove the blockage
- The operation only takes about an hour but usually requires a couple of days in hospital.
External beam radiotherapy
- External beam radiotherapy uses x-rays to kill cancer cells or injure them so they cannot multiply.
- It may be used instead of surgery or in combination with it.
- You may have it if you have early cancer and you are otherwise in good health.
- The x-rays are aimed at the cancer in your prostate from an external machine.
- Treatment aims to do as little harm as possible to your normal tissue. Modern machines are more accurate and are able to limit radiation to surrounding healthy tissue.
- You will probably have treatment each weekday for up to eight weeks. Usually you can stay at home and go to the radiotherapy centre each day during this time.
- Each treatment only takes a few minutes once started, but it can take 1-3 hours to set up the machine, see the radiation oncologist and have blood tests.
Brachytherapy
- A type of internal radiotherapy where the radiation source is placed directly within a tumour.
- This allows higher doses of radiation to be given with minimal effect on nearby tissues such as the rectum.
- 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.
Permanent radioactive seeds
- Low-dose radiotherapy is implanted in the prostate in the form of tiny seeds, about the size of a rice grain.
- 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 level over time.
- This procedure takes several hours and is done under local anaesthetic. It usually requires an overnight stay in hospital, but it allows a quicker convalescence.
Temporary needle implants
- Hollow needles are placed in the prostate under general anaesthetic and high-dose radioactive material is passed down them.
- After a few treatments over 36 hours, the needles are removed.
- The procedure usually requires a couple of nights in hospital.
Hormone treatment
- 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. This is called hormone treatment or androgen deprivation therapy (ADT).
- This does not cure cancer but can help with symptoms such as pain caused by the cancer spreading.
- Hormone treatment 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.
Hormone injections
- Injections of luteinising hormone-releasing hormone (LHRH) are control the production of testosterone.
- LHRH is given as a monthly or three-monthly injection.
- It will not cure the cancer but will often slow its growth for years.
Hormone treatment by surgery
- Two operations can reduce testosterone levels:
- The removal of the testes is known as an orchidectomy. After surgery, a plastic prosthesis can be put into the scrotum to keep its shape and appearance.
- The removal of only the inner part of the testes is called a subcapsular orchidectomy. This operation does not require a prosthesis.
- Most men choose LHRH injections over surgery. Removal of the testes is uncommon, but it offers a permanent solution.
Palliative treatment
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:
- urologist – surgeon who specialises in treating diseases of the urinary system
- radiation oncologist – prescribes and co-ordinates the course of radiotherapy
- medical oncologist – prescribes chemotherapy in more advanced cases
- nurses – give the course of treatment and support and assist you through all stages of your treatment
- cancer nurse coordinator – supports patients throughout treatment and liaises with other care providers
- continence nurses – nurses who have expertise in continence (urinary) issues
- dietician – recommends the best eating plan to follow while you are in treatment and recovery
- social worker, physiotherapist and occupational therapist – talk to you about support services and help you resume normal activities.