Early prostate cancer can cause problems with passing urine with reduce urinary flow rate, urinary frequency and getting up more at night to pass urine. Prostate cancer can also cause blood in the urine and blood in the ejaculate. More advanced prostate cancer can cause other symptoms such as fatigue, bone pain especially back pain and anaemia.
Prostate cancer is most often diagnosed on the basis of a raised PSA. PSA is a blood test that looks at the level of prostate specific antigen in the blood. PSA is an enzyme made by the prostate and therefore is present in all man who have not had their prostate removed. The problem is that PSA is not specific to prostate cancer and can be raised for other reasons such as benign prostate enlargement or infection and inflammation. PSA also goes up as we get older and therefore PSA must be related to age and also to the size of your prostate. The variations on PSA which make it more accurate or useful to interpret such as PSA density and free to total PSA ratios. If you do have a raised PSA you will need further investigations. In the first place, you would need a prostate rectal examination by your doctor. Following on from this, if there is felt to be concern about prostate cancer these days you are most likely to undergo a multi-parametric MRI scan of the prostate (MPMRI). The MRI scan cannot diagnose prostate cancer but can look at the whole prostate gland to see areas of abnormality which should then be biopsied. If there are no areas of abnormality then this is very reassuring. Unfortunately, neither PSA or MRI are fool proof and can still miss some cancers. If the MRI highlights some areas of concern then you will need to undergo a prostate biopsy to make a diagnosis. Biopsies are performed using small needles that take samples from the prostate. These can either be done through a trans-rectal approach where the needles are put through your back passage or through a trans-perineal approach where the needles are put through the perineum. Trans-rectal biopsy can be done under local anaesthetic and are therefore quicker and easier but trans-perineal biopsies have a lower risk of infection. More and more these days we are moving to MRI fusion biopsies of the prostate which involves combining the MRI images on to the ultrasound screen and allowing targeted biopsies of the specific abnormal areas of the prostate. This is usually done using fewer biopsies through the trans-rectal route.
The biopsy tissue is then looked at under the microscope by a pathologist who is able to see if there are cancerous cells present or, if there are cancerous cells present the pathologist will grade the cancer using the Gleason grading system. The Gleason grading system gives a score which allows an understanding of the aggressiveness of a cancer. The scoring system means that a score of six is a low-grade cancer and a score of ten is a very high-grade cancer. High-grade cancers are more aggressive. The pathologist will also comment on the amount of cancer present and how many biopsy cores were effected.
Staging – the MRI scan will also allow staging of the cancer if it is present. This means we can say whether the prostate cancer is confined to the prostate or has spread elsewhere or if it has grown outside of the prostate. This is important information both for the prognosis and for deciding which treatment to have.
Treatments depend on the stage of the prostate cancer and whether it is confined to the prostate or not. For early organ confined prostate cancer the main treatment options are radical surgery to remove the entire prostate (the standard operation is now a robotic assisted radical prostatectomy). Other treatments include radiotherapy – external beam radiotherapy or brachytherapy (radioactive seed implants). There are also newer focal treatments such HIFU or cryotherapy. These are attractive in that they have fewer side effects but at the moment they still remain unproven as there is little long-term data to support them.
It is important to remember that most prostate cancers are slow growing and in fact many early prostate cancers will have a ten-year life expectancy without treatment. Some lower risk cancers do not require any treatment other than monitoring. More significant cancers can be cured by surgery or radiotherapy. Even for advanced prostate cancers there is often a very good response to hormone treatment or chemotherapy.