Prostate cancer

What is prostate cancer?

Prostate cancer is a malignant tumour in the prostate. There are several stages of prostate cancer. Your treatment and experience depend on the specific characteristics of the tumour and the expertise of your medical team.

The sections in this series provide general information about prostate cancer, diagnosis, and various treatment options. Discuss with your doctor what is best for your individual situation.

Most prostate cancers develop slowly and do not cause symptoms. Fast-growing prostate cancer is less common. The risk of getting prostate cancer increases with age. The average age for diagnosis of prostate cancer is 69.

Because of the development in diagnostic tools and longer life expectancy, more prostate cancer are now detected. Prostate cancer is the most common cancer in elderly men in Europe. The survival rate for prostate cancer in Europe is relatively high and is still going up.

Fig. 1a: A healthy prostate in the lower urinary tract.
Fig. 1a: A healthy prostate in the lower urinary tract.

Symptoms

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.

Diagnostics

PSA testing
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 (Fig. 1).

This test is known as digital rectal examination (DRE).

Fig. 2: Digital rectal examination to feel the size, shape, and consistency of the prostate.
Fig. 2: Digital rectal examination to feel the size, shape, and consistency of the prostate.

Imaging
In some cases your doctor may recommend to make a scan of the lower urinary tract. Different types of scans are available, such as ultrasound, CT scan, MRI scan, and bone scan.

None of these tools will provide a definite answer on whether or not you have prostate cancer. Your doctor will use the test results, together with your age and your family history, to estimate the risk of you having prostate cancer.

If the risk is high, you may need a biopsy of prostate tissue. This test is done to confirm if you have a tumour or not.

Classification

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.

Read more about classification

Treatment

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
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
Radical prostatectomy is a surgical treatment option for localized prostate cancer. The aim is to remove the entire prostate and the seminal vesicles.

Radiation therapy
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.

 

New experimental techniques: Ablation therapy

Besides surgery, radiation, and conservative management there is also ablation therapy (also referred to as focal therapy) as treatment option for localized prostate cancer, such as:

  • Cryosurgical ablation of the prostate (CSAP)
  • High Intensity Focussed Ultrasound (HIFU)

Because the tumour cells are targeted directly, there is not much damage to other tissue in the prostate or the lower urinary tract.

Fig. 5: In focal therapy the prostate tumour cells are targeted directly so there is not much damage to other tissue.

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.

Watchful waiting
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
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).

 

 

Fig. 3: A T3 prostate tumour which has spread to the seminal vesicles.
Fig. 3: A T3 prostate tumour which has spread to the seminal vesicles.
Fig. 4: A T4 prostate tumour which has spread to the bladder neck, urinary sphincter, and rectum.
Fig. 4: A T4 prostate tumour which has spread to the bladder neck, urinary sphincter, and rectum.

Metastatic Prostate Cancer

Prostate cancer can spread to other organs or lymph nodes outside the pelvic area. This is called metastatic disease. The tumours in other organs or lymph nodes are called metastases. Your doctor may recommend treating metastatic disease with hormonal therapy.

It is important to realize that metastatic disease cannot be cured. Instead, your doctor will try to slow the growth of the tumour and the metastases. This will give you the chance to live longer and have fewer symptoms.

Hormonal treatment
If you have metastatic prostate cancer, your doctor will recommend hormonal therapy. This is part of a palliative care approach. The treatment will slow the growth of the primary tumour and the metastases, and help to manage the symptoms.

Bone metastases

See castration-resistant prostate cancer

Fig. 5: Metastatic prostate cancer can spread to the bones, spine, lungs, liver, or brain.
Fig. 5: Metastatic prostate cancer can spread to the bones, spine, lungs, liver, or brain.

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.

Adrenolytic agents
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.

Oestrogen therapy
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
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.

Radiation therapy
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, MRIPET 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.

Palliative care

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.

This information was produced by the European Association of Urology (EAU).

 

Contributors:
  • Dr. Roderick van den Bergh, Utrecht (NL)
  • Prof. Dr. Zoran Culig, Innsbruck (AT)
  • Prof. Dr. Louis Denis, Antwerp (BE)
  • Prof. Bob Djavan, Vienna (AT)
  • Mr. Enzo Federico, Trieste (IT)
  • Mr. Günter Feick, Pohlheim (DE)
  • Dr. Pirus Ghadjar, Berlin (DE)
  • Dr. Alexander Kretschmer, Munich (DE)
  • Prof. Dr. Feliksas Jankevičius, Vilnius (LTU)
  • Prof. Dr. Nicolas Mottet, Saint-Étienne (FR)
  • Dr. Bernardo Rocco, Milan (IT)
  • Ms. Maria Russo, Orbassano (IT)