Introduction
The prostate is a gland found in men that is located at the base of the bladder. Its function is to secrete fluid that makes up part of the semen (sperm fluid).
How common is prostate cancer?
Prostate cancer is the second leading cause of cancer deaths in Australian men, after lung cancer. One in 11 men will be diagnosed with prostate cancer by the age of 75. Each year in Australia, over 11,200 men are diagnosed with prostate cancer and over 2,700 will die of it.
What causes prostate cancer?
About 10% of prostate cancers run in the family. The risk increases by over 2-fold when a first-degree relative (father or brother) has prostate cancer. The likelihood of being diagnosed with prostate cancer increases with age (>65). Certain racial background also increases the risk of prostate cancer; the risk is high in African Americans, moderate in Caucasians and low in Asians.
Are all prostate cancers potentially fatal?
Most prostate cancers do not cause death (<10% of those with prostate cancer will die from it). Each man is different; an older 75-year-old man with prostate cancer is more likely to die from other causes (e.g., heart disease, other cancers) than a younger 50-year-old man, who has a high chance of dying from it. A lot would also depend on the characteristics of the prostate cancer when it is diagnosed – meaning the stage (has the cancer spread beyond the prostate?) and the grade (how aggressive the prostate cells look under the microscope).
What are the symptoms?
Most early prostate cancers do not cause any symptoms. Often, it is detected by either an abnormal prostate examination or a raised PSA.
Some patients would develop urinary symptoms secondary to enlargement of the prostate (which can be benign, cancerous or both). These urinary symptoms are covered here (see prostate related bladder symptoms) in more details.
In advanced prostate cancer, men can present with blood in the urine (haematuria), urinary obstruction, kidney obstruction, and bone pain from spread of cancer to the bone. Rarely if a secondary bone tumour in the spine causes compression of the spinal cord, the patient may end up with paraplegia.
How is prostate cancer diagnosed?
A PSA test and a prostate examination must be done to assess the overall risks of having prostate cancer. A raised PSA is not specific to prostate cancer; other benign diseases can cause it too. The PSA only gives us an indication of the probability of having cancer. The absolute PSA level, PSA velocity (how fast the PSA rises over time), PSA density (PSA divided by prostate volume) and free-to-total PSA ratio are all tools to help assess if the PSA is abnormal.
A prostate examination or digital rectal examination (DRE) involves a lubricated, gloved finger in the rectum, with the patient either lying on his left side all curled up or bent over in a standing position. DRE can tell us about the size, consistency, and symmetry of the prostate gland. Prostate cancer would often feel hard, nodular, craggy, or asymmetrical.
The chances of having prostate cancer if a raised PSA or a prostate examination is the only abnormality, are about 30% each. If both PSA and the prostate examination are abnormal, the chance of having cancer is about 50%.
A multiparametric MRI scan of the prostate can be done to guide the urologist about a patient’s likelihood of having prostate cancer. This has been MBS listed in Australia since July 2018. However, the MRI is not a replacement for a prostate biopsy.
The definitive method of diagnosing prostate cancer is by a prostate biopsy. Click on the link for further information on a prostate biopsy.
What is next after prostate cancer is diagnosed?
Once the diagnosis of prostate cancer is made, the cancer must be graded and staged, to determine if the cancer is localised (confined to the prostate) or advanced (spread beyond the prostate), before deciding the next step.
Grading
The prostate biopsy specimens are looked at by a pathologist under a microscope for cancer cells. The most and second-most predominant cancer patterns seen under low-power microscopy are given a grade each (1 to 5). These two numbers are then added together to get a Gleason score. For example, if the most common cancer pattern was grade 4 and the next most common cancer pattern was grade 3, then the Gleason score would be 4+3 = 7. A Gleason score of 6 or below is considered a low grade, a score of 7 is a moderate grade, and a score of 8 to 10 is considered a high grade. This grading system gives an indication of the prognosis of the prostate cancer.
Staging
Staging refers to further investigations done to determine if the cancer has spread beyond the prostate gland. A CT scan of the abdomen and pelvis and a bone scan are the two tests usually done for staging of prostate cancer. The CT scan can look for cancer spread to adjacent or distant organs in the abdomen (e.g., lymph nodes, rectum) and the bone scan looks for the spread of cancer to the bones.
A PSMA PET / CT scan can also be used to detect cancer that has spread to other organs. Australia is leading the world in this technology and it has been listed on MBS since July 2022.
What are the treatments?
Once the prostate cancer is categorised into localised or advanced, the treatment options can be considered. Every patient is different. There are many treatment options available, each with its own pros and cons. Some patients may need combination therapy. A detailed discussion with your urologist is imperative and often a decision needs to be made in conjunction with the patient’s family. The general treatment options for localised and advanced prostate cancer are as follows:
Localised prostate cancer
The primary treatment options for localised prostate cancer are:
Radical prostatectomy
This is the surgical removal of the prostate gland, sometimes together with the pelvic lymph nodes.
There are different approaches to doing this operation – open, laparoscopic (keyhole), and robotic-assisted. All three approaches have similar long-term success rates.
Complications and side effects include:
- Erectile dysfunction (impotence).
- Happens in 40% to 80% of patients.
- In some patients, it is possible to do a ‘nerve-sparing’ radical prostatectomy, which will increase the chances of potency after surgery.
- Post-prostatectomy urinary incontinence.
- Bladder neck contracture (scarring).
- Bleeding.
- Infection.
- Leg swelling (if lymph nodes are removed).
- Injury to surrounding organs (rare) e.g., rectum, ureters, obturator nerve (causes numbness in the inner leg and some weakness in pulling the legs together).
Radiotherapy
Comes in the form of external beam radiotherapy and brachytherapy (radioactive seed implants).
Side effects include bladder irritation, rectal irritation, urinary incontinence, rectal bleeding, and impotence.
Careful observation (watchful waiting and active surveillance)
This can be divided into watchful waiting and active surveillance.
Watchful waiting means to observe the cancer and see what happens in an older man with significant medical problems and a life expectancy of < 10 years. The prostate cancer in this case, is unlikely to cause significant problems.
Active surveillance applies to the younger patients who have early, low-grade prostate cancer, and may want to defer treatment. For these patients, definitive treatment would mean that they must live with the side effects (impotence, incontinence etc.) when their disease may not have been significant enough initially to cause problems. These patients are observed closely and repeat prostate biopsies may be necessary. They are given the option of definitive treatment if there is any disease progression.
Advanced prostate cancer
When the cancer has spread to other organs, the aim of treatment shifts from trying to cure, to keeping the cancer under control. This is done with hormone suppression therapy (androgen deprivation therapy).
Hormone suppression therapy
Prostate cancer cells need the male hormone, testosterone to grow. By suppressing testosterone to very low levels, the cancer can be controlled. There are medications (e.g., Androcur, Cosudex) that block testosterone from reaching the cancer cells, as well as implants (e.g., Zoladex, Lucrin, Eligard) that reduce the body’s production of testosterone. Other drugs (e.g., Abiretarone, Enzalutamide) work via different pathways. These drugs can be given alone or in combination and they can be used intermittently or continuously. Sometimes instead of medications, the urologist may recommend surgical removal of the testicles (orchidectomy), which can lower the testosterone levels faster.
Side effects include:
- Low sex drive.
- Fatigue.
- Depression or mood swings.
- Impotence.
- Breast swelling or tenderness.
- Worsening of mental function e.g., memory.
- Hot flushes.
- Thinning of the bones (osteoporosis).
Chemotherapy
Some advanced prostate cancer becomes resistant to hormone suppression therapy in the late stages. At this point, the patient is assessed to see if he is suitable for chemotherapy. In some advanced cases, this can also be considered as an initial treatment in combination with androgen deprivation therapy. Chemotherapy is usually administered by a medical oncologist (cancer specialist).
Related information
View lifestyle and dietary advice for Men’s Health.
Read A/Prof Gani’s publication:
Download Active surveillance failure for prostate cancer does the delay in treatment increase the risk of urinary incontinence - PDF (157 Kb)
Read A/Prof Gani’s publication:
Download Do patients know their nerve sparing status after radical prostatectomy - PDF (115 Kb)
Read A/Prof Gani’s publication:
Download Long term complications in men who have early or late radiotherapy after radical prostatectomy - PDF (4000 Kb)