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.
There are several known risk factors for prostate cancer, of which age is the most important one. Prostate cancer is rare in men younger than 40 and mostly develops in men over the age of 65. A family history of prostate cancer can increase the risk.
This type of cancer is most commonly diagnosed in men of African descent, and least in Asian men. It is still unknown what causes these differences. Eating more meat and dairy products could increase the risk of prostate cancer, but this is still being researched.
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:
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.
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).
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.
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.
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:
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 localised 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.
Besides surgery, radiation, and conservative management there is also ablation therapy (also referred to as focal therapy) as treatment option for localised prostate cancer, such as:
Because the tumour cells are targeted directly, there is not much damage to other tissue in the prostate or the lower urinary tract.
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.
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 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 realis 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.
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.
Castration-resistant prostate cancer can be managed with:
Because castration-resistant prostate cancer still responds to androgens, your doctor will recommend to continue hormonal treatment to keep the levels of testosterone low.
Bones that are affected by tumours fracture more easily. If you are at risk of bone fractures, your doctor may recommend drugs to stabilize your bones. The most common drugs are bisphosphonates and denosumab. These drugs will help postpone the complications caused by bone metastases. Bone metastases can also be treated with radiation therapy.
Bisphosphonates are administered with an IV every 4 weeks. They increase your bone mass, and can postpone the complications caused by bone metastases. The most effective bisphosphonate in prostate cancer is zoledronic acid. This drug can cause kidney damage.
Denosumab is administered under the skin every 4 weeks. It also increases bone mass but generally causes fewer side effects than bisphosphonates. Denosumab may cause low calcium levels in the blood.
Because these drugs can damage your jaws, your doctor will advise you to see a dentist before you start treatment.
Bone metastases from prostate cancer can be managed with radiation therapy. The treatment will help to relieve pain and may allow you to live longer.
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.
If you have been treated with experimental techniques, discuss with your doctor which treatment option is best for you.
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.