What is prostate cancer?
Prostate cancer is a malignant tumour in the prostate. Your treatment and experience will depend on a variety of factors including the specific characteristics of the tumour, your general health, your personal preferences and the advice of your medical team.
The sections in this series provide general information about prostate cancer, diagnosis, and various treatment options. Discuss with your healthcare team 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 cancers are now detected. Prostate cancer is the most common cancer in men in Europe. The survival rate for prostate cancer in Europe is relatively high and is still going up.
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 tissues such as the seminal vesicles, the bladder neck, or lymph nodes around the prostate. If the cancer has spread, either to distant lymph nodes or to other organs, it is called advanced or metastatic prostate cancer.
The role of hormones in the prostate
A tumour develops when cells begin to grow faster than normal. The growth of prostate cancer cells is driven by male sex hormones called androgens. Testosterone is the most important androgen. Androgens are almost exclusively produced in the testicles.
Symptoms of prostate cancer
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 that it is there. 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 may be causing any symptoms you notice.
The symptoms may include:
Urinary symptoms such as urinary frequency or a weak stream of urine
Blood in the urine
Loss of bowel control
Pain in the hips, back, chest, or legs
Bone pain could be a sign that the cancer has spread through the body. This is known as metastatic disease.
Diagnosis of prostate cancer
One of the most frequently used tools to diagnose prostate conditions is PSA testing, which is a blood test to check the level of prostate specific antigen (PSA). If the PSA level is too high, this may suggest that the cells in the prostate are behaving unusually. This could be because of a tumour in the prostate, but also because of prostate irritation (sports, intercourse, urinary catheter), an infection or a benign enlargement of the prostate.
Digital rectal examination
Your health care provider will do a rectal examination with a finger to feel the size, shape, and consistency of the prostate.
This test is known as a digital rectal examination (DRE).
In some cases, you may be advised to have a scan. 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, or to determine whether any cancer may have spread.
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. Biopsies can be taken through the wall of the rectum (trans-rectal biopsy) or through the skin between your testicles and anus (trans-perineal biopsy). The way the biopsy is taken will depend on techniques available in your area. During a biopsy, samples of prostate tissue are taken. If you take medication to prevent blood clotting, discuss with your doctor if you need to stop taking it before the procedure. Before the biopsy your doctor will give you antibiotics.
If your biopsy is done through the rectum, you will receive local anaesthesia. Trans-perineal biopsies may be done either under general or local anaesthesia, but again this will depend on where you live, as well as other factors. Then the doctor inserts a needle through your rectum or perineum and into the prostate. The samples are taken from different parts of the prostate gland. If you have had a scan, the biopsy may be directed more to the area of the prostate that showed a possible tumour. The tissue samples are analysed by a pathologist in order to help determine future treatment.
After a prostate biopsy you may have some blood in your urine or semen. If you develop a fever, you need to contact your doctor immediately.
Although a biopsy is a reliable diagnostic tool, it may be possible that a tumour in the prostate is missed.
Treatment of prostate cancer
Treatment of 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.
Treatment options for localised prostate cancer
If you are diagnosed with localised prostate cancer, your doctor may recommend treating the cancer with conservative management, radical prostatectomy, radiation therapy, or new experimental techniques, such as ablation therapy.
This section describes the different treatment options which you should discuss with your doctor.
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 may 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 few urinary symptoms.
New experimental techniques: Ablation therapy
Besides surgery, radiation, and conservative management you may be offered ablation therapy (also referred to as focal therapy) such as:
Cryosurgical ablation of the prostate (CSAP)
High Intensity Focussed Ultrasound (HIFU)
Because the tumour cells are targeted directly, there should not be much damage to other tissue in the prostate or the lower urinary tract. This technique is still being investigated.
Treatment of 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 (Fig. 3 and 4), 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.
Treatment options for 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. Each treatment has its own advantages and disadvantages. The choice depends on your individual situation.
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).
Treatment of metastatic prostate cancer
Prostate cancer can spread to other organs or lymph nodes outside the pelvic area. This is called metastatic disease (Fig. 5). 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 realise 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 prostate cancer metastasises, it usually spreads to the bones or the spine. At a later stage, prostate cancer may also spread to the lungs, the liver, distant lymph nodes, and the brain (Fig. 5). Most metastases cause a rise in the level of prostate-specific antigen (PSA) in your blood.
Metastases in the spine can cause symptoms like severe back pain, spontaneous fractures, or nerve or spinal cord compression. They can also be asymptomatic. In rare cases, lung metastases may cause a persistent cough.
Imaging can be used to detect metastases. Bone metastases can be seen on a bone scan. A CT scan may be recommended to get more detailed information about bone metastases, or to detect metastases in the liver, the lungs, or the brain.
Treatment options for metastatic prostate cancer
If you have metastatic prostate cancer, your doctor may 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. Your doctor may also recommend that you have a type of chemotherapy (called Docetaxel chemotherapy) when you start hormone therapy as this has been shown to help men live longer.
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. Drug therapy to stop the production of androgens is done with LHRH agonists or LHRH antagonistst. These drugs are available as long acting injections under the skin or into the muscle. Anti-androgens are drugs that block the action of androgens. Anti-androgens are tablets taken every day.
Lowering or blocking testosterone has physical and emotional consequences. The most common are hot flushes, lower sex drive, and erectile dysfunction. The effects of surgical removal of the testicles are permanent. If drugs are used, some of the symptoms may disappear after the treatment. Do not hesitate to discuss any concerns with your doctor.
If you have bone metastases which cause symptoms while you receive drug treatment, radiation therapy may help to relieve them and prevent fractures.
LHRH agonists are the most commonly recommended treatment for metastatic prostate cancer, but the choice of treatment is always based on your individual situation. These are some things your doctor will consider when planning your care pathway with you:
Your medical history
Where the cancer has spread to
The kind of treatment available at your hospital
Your personal preferences and values
The support network available to you
Treatment of castration-resistant prostate cancer
Castration-resistant prostate cancer is a type of prostate cancer that usually develops during treatment for metastatic disease.
Hormonal therapy either stops the production or blocks the action of androgens. This is known as castration. When effective, hormonal therapy stops the growth of the tumour. This effect will not last and leads to castration-resistant prostate cancer. This generally happens 2-3 years after hormonal treatment started. Castration-resistant prostate cancer cannot be cured.
Castration-resistant prostate tumours need much lower levels of androgens to progress. This means that even when your body produces almost no androgens, the tumour and metastases continue to grow. These cancers are called castration-resistant, because they no longer respond to hormonal castration treatment.
In this type of cancer, the level of prostate-specific antigen (PSA) in the blood rises again. The doctor will diagnose castration-resistant prostate cancer if repeated tests show an increase in the PSA level in your blood. It can also be diagnosed if you experience symptoms caused by the growing tumour or metastases.
Treatment options for 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:
New hormonal agents
Because castration-resistant prostate cancer still responds to androgens, your doctor will recommend to continue hormonal treatment to keep the levels of testosterone low.
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.
Treatment of bone metastases
Prostate cancer cells can spread to the bones, often to the spine, although other areas, such as ribs and legs, bones can also be commonly affected. The treatment of bone metastases can have severe side effects. Your doctor will help to prevent and treat possible complications and side effects.
Bone metastases can cause pain. Your doctor may prescribe painkillers to manage this. In some cases, your doctor may recommend a very strong painkiller, like morphine. Your doctor may also offer radiotherapy to the affected area to help with the pain.
When tumours in the spine grow, they may cause spinal cord compression. This is a rare complication, but it is an emergency situation because it can lead to paralysis of the legs.
The main signs of spinal cord compression are:
Pain in a specific spot in your spine that is different from your usual pain
New pain in the spine which gets worse and does not respond to painkillers
A tingling sensation down your spine, into your legs or arms
Pain in your spine which changes when you change position
Numbness in your legs
Stiffness or heaviness in your legs that make you lose your balance
Pain down your legs or arms
Weakness in your legs or arms
A sudden loss of control of your bladder or bowels
If you think your spinal cord may be compressed you should contact your medical team immediately.
Bones that are affected by tumours fracture more easily. If you are at risk of bone fractures, your doctor may recommend drugs to stabilise your bones. The most common are bisphosponates and denosumab. Your doctor may recommend a procedure to strengthen your bones by injecting material that helps harden your bone. This is known as cementoplasty. In rare cases, surgery is needed to stabilise your bones.
Bisphosphonates are administered through a drip every 4 weeks. They increase your bone mass, and can reduce pain and prevent fractures. Because bisphosphonates can damage your jaws, your doctor will advise you to see a dentist before you start treatment.
Denosumab is administered under the skin every 4 weeks. It also increases bone mass and generally causes fewer side effects than bisphosphonates. If the bone metastases cause symptoms while you receive drug treatment, radiation therapy may help to relieve them and prevent fractures. To keep your bones healthy you could exercise regularly, keep a healthy weight, stop smoking, and drink alcohol in moderation. The risk of bone complications increases with age. To prevent complications from bone metastases, you may need to take nutritional supplements like calcium or vitamin D3.
If prostate cancer cells have spread to the bones, but no other organs, your doctor may advise radium. This is an internal radiotherapy treatment given by injection. This may allow you to live longer and with fewer symptoms.
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 get older.
The medical term for a prostate that has grown in size is benign prostatic enlargement (BPE). Read more about this condition in EAU Patient Information on BPE.
Risk factors for prostate cancer
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 common 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.
Classification and risk stratification of prostate cancer
Classification of prostate cancer
Prostate tumours are classified according to where the tumour is (the stage) and the aggressiveness of the tumour cells (the grade). These two elements are the basis for how your cancer may be treated.
The doctor will carry out 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 stage of a prostate tumour is based on the TNM classification. The urologist looks at the size and location of the tumour (T) and determines how advanced it is, based on 4 stages. Your doctor will also assign an a, b, or c to the stage, depending on the size of the tumour.
The team will also assess whether any lymph nodes around the prostate are affected (N) or if the cancer has spread (or metastasized) to any other parts of your body (M). If prostate tumours spread, they generally spread to the bones, often the spine, or to the lungs, liver, or brain.
The other element of classification is the Gleason score which gives us the grade. The Gleason score is determined by the pathologist, based on the tissue taken during biopsy. This gives information about the aggressiveness of the tumour. Based on the pattern of the cancer cells, the pathologist can see how fast the tumour is likely to grow. Recently, prostate cancer aggressiveness has been stratified based on a slightly modified version of Gleason score into 5 groups, from 1/5 less aggressive, to 5/5 the most aggressive.
The Gleason score
The Gleason score ranges from 6 to 10. Tumours with a higher score are more aggressive and more difficult to cure.
The score is based on the pattern of the cancer cells. Each pattern gets a value between 1 and 5. The pathologist adds the scores of the two patterns that appear in most of the tissue samples.
For example: the most common pattern has a score of 3, and the second most common a score of 4. In this case, the Gleason score is 3 + 4 = 7.
Risk stratification of prostate cancer
To determine the potential risk your disease poses, the classification of the tumour is combined with your age, medical and family history, and general state of health.
Keep in mind that definitive classification of the tumour is only possible after you have had surgery to remove the entire prostate.
The multidisciplinary team
Urologist: a urologist specialises in health and diseases of the urinary tract, he or she is usually a surgeon
Medical oncologist: a medical oncologist specialises in all types of cancer and uses drugs to treat them
Onco-urologist: an onco-urologist specialises in urological cancers of, for instance, the bladder, kidney, prostate, or testicles
Radiation oncologist (or clinical oncologist): a radiation oncologist uses radiation therapy to treat cancer
Pathologist: a pathologist studies tissue, blood, or urine to understand the specific characteristics of diseases. In cancer treatment, the pathologist helps with the classification of tumours
Radiologist: a radiologist specialises in imaging techniques and analyses ultrasound, CT, MRI, or other scans done to diagnose or monitor a tumour
Specialist nurse: in some countries an experienced nurse may provide support and information, or even perform some of the tests to diagnose your cancer or see you after your treatment to monitor you.
Treatment of recurrence
It is possible that prostate cancer may come 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 treatment, you will be given radiotherapy in the area where the prostate was located. The aim is to kill any cancer cells that may have been left behind. If radiation therapy is not the best option for you, your doctor can recommend hormonal therapy to control any remaining cells.
If your cancer was treated with radiation therapy, your doctor may recommend to treat recurrence with radical prostatectomy. 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 you have been treated with experimental techniques, discuss with your doctor which treatment option is best for you.