Information on the diagnosis & treatment of prostate cancer

Find out about prostate cancer, its symptoms, diagnosis, treatment and other information.

What is the prostate?

The prostate is a gland which forms part of the male reproductive system and when healthy is about the size and shape of a walnut. It is found between the pubic bone and rectum and surrounds the upper part of the urethra (the tube that carries urine out of the bladder). The prostate produces part of the seminal fluid which helps transport sperm out of the man’s body during ejaculation.

Men over the age of 50 should go for an annual prostate check-up.

Men with a family history of prostate cancer should go for an annual checkup from the age of 40.

Growth of the prostate

Male hormones (androgens) make the prostate grow. At birth the prostate is normally the size of a pea and at puberty it grows to its adult size which is about the size of a walnut.

When men reach their 40’s to 50’s the prostate gland can begin to grow under the influence of testosterone. If the prostate grows too large, it squeezes the urethra. This may slow or stop the outflow of urine from the bladder.

The symptoms of prostate problems such as BPH are similar to those of prostate cancer.

Benign Prostatic Hyperlasia (BPH)
An abnormal increase in the numbers of non-cancerous cells in the central part of the prostate

OR

Benign Prostatic Hypertrophy (BPH)
An abnormal increase in the size of non-cancerous cells in the central part of the prostate

Understanding prostate cancer

Understanding cancer

Cancer begins in the body’s cells which are the building bocks that make up our tissues. Our tissues make up the organs of our bodies.

Under normal circumstances, cells grow and divide to create new cells as the body needs them. When the cells grow old, these old cells die. New ones then take their place.

At times this process is upset and for some reason extra cells are created to form a mass of tissue or a tumour.

Tumours can be benign (non-cancerous) or malignant (cancerous).

What is prostate cancer?

Prostate cancer is a disease in which cancer develops in the tissues of the prostate gland. The cancer occurs when cells of the prostate begin to multiply out of control. These cells may spread, which in medical terms is known as metastasis.

Metastasis means that the cells spread from the prostate to other parts of the body, especially the lymph nodes and the bones. Even when the disease has spread to other parts of the body, it is still known and treated as prostate cancer, as that is the primary source of the cancer. Doctors also call the new or metastasized tumor, “distant” disease.

Prostate cancer is a slow growing cancer compared with other cancers.

Incidence and epidemiology of prostate cancer

In medical terms “incidence” refers to the frequency with which a disease appears in a particular population or area. Epidemiology deals with the study of the causes, distribution, and control of disease in populations.

Populations

In the USA it is estimated that 1 in 6 men will be diagnosed with prostate cancer during their lifetime. It is the most commonly diagnosed solid organ cancer in South African men. According to the South African National Cancer Registry (1999), the incidence of prostate cancer in South Africa is increasing at approximately 3% every year.
Rates of prostate cancer vary widely across the world. It is least common in parts of Asia, more common in Europe, and most common in the United States.

Incidence

Prostate cancer is rare in men under the age of 40,.After the age of 50 the incidence rises steeply, and by the age of 80 almost 80% of men will have prostate cancer, even if it is only a small focus of cancer cells in some. Generally the peak age incidence is around 65, however but this also depends on the life expectancy, which varies among race groups.

Rates of prostate cancer vary widely across the world. It is least common in parts of Asia, more common in Europe, and most common in the United States. A non smoking man is more likely to develop prostate cancer than colon, bladder, melanoma, lymphoma and kidney cancer combined. Men are 35% more likely to be diagnosed with prostate cancer than women are to be diagnosed with breast cancer

While one man in six may develop prostate cancer during his lifetime, only one man in 34 will die of this disease. This is because prostate cancer is not as aggressive as other cancers, and because it occurs most often in elderly men who may have other diseases that are more likely to cause their death.

Risk factors

The cause of prostate cancer, as in most cancers in general, is not entirely known. There are however, some risk factors that can be taken into consideration which are thought to increase the chances of developing prostate cancer. Studies have identified the following areas as risk factors:

Age:
The older you are, the more likely you are to be diagnosed with prostate cancer. The disease is less common in men younger than 40 years of age. If you are 50 or older your risk increases.

Race:
There are racial differences across the globe which could be due to social and geographical influences. The lowest incidence rates are seen in Asia, Africa, Central and South America. In the USA, prostate cancer is twice as common among African-American men as among white men. The apparently lower incidence rates in Africa are most probably due to the disease not being diagnosed or reported. In South Africa, prostate cancer appears to be equally common in men of all race groups.

Diet:
Studies have shown that certain foods may protect against prostate cancer, including tomatoes which contain lycopene. Vitamin E, selenium, soy and Omega-6 fatty acids are also thought to have benefits. Dietary factors which may increase the risk of prostate cancer include saturated fat and red or grilled meat.

Family history:
A man’s risk is higher if a family member such as a father or brother has had prostate cancer. Studies show that men with a family history of prostate cancer are likely to present with the cancer 6–7 years earlier than patients without a family history.

Men with single first degree relatives i.e. a father, brother or son, with a history of prostate cancer are twice as likely to develop the disease, while those with two or more relatives have a nearly four times greater chance of being diagnosed. The risk is increased further if the family member is diagnosed before the age of 65.

Lifestyle:
Doctors suggest that maintaining a healthy weight and participating in regular physical activity reduces the risk of developing prostate cancer.

Symptoms

It is important to remember that many symptoms listed here may not necessarily mean you have prostate cancer. They could be due to Benign Prostatic Hyperplasia (BPH), an infection (prostatitis), or other health problems. However, it is also important to know that, in its early stages, prostate cancer usually does not cause any symptoms at all. Consult a doctor as soon as possible and do not wait for the onset of symptoms.

When symptoms of Benign Prostatic Hyperplasia or malignant prostate cancer occur, they may include:

• A need to urinate frequently, especially at night.
• Difficulty in starting to urinate or holding back urine.
• Inability to urinate.
• Weak or interrupted flow of urine.
• Painful or burning urination.
• Painful ejaculation.
• Blood in urine or semen.

• Frequent pain in the lower back.

What causes these symptoms?

These symptoms are usually caused because the tumour is blocking the flow of urine by pressing on the urethra.

Diagnosis and screening

Thoughts of a cancer diagnosis can be quite stressful. Fear of the unknown can add to this stress. You will feel more at ease about your doctor’s appointment and what to expect by educating yourself about the various tests available to screen for prostate cancer.

An initial prostate examination will most likely begin with your doctor asking about your personal and medical history, followed by a physical examination and blood tests which may include:

• Digital rectal exam (DRE)
• Urine test to check for blood/infection
• Blood tests

DRE
The doctor inserts a gloved, lubricated finger into the rectum and feels the prostate through the rectal wall to check for hard or lumpy areas.

PSA Blood test
The PSA test measures the blood level of prostate-specific antigen (PSA), a protein produced by the prostate and released in small amounts into the blood. In normal circumstances, very little PSA should be found in the blood. Rising levels of PSA in the blood indicate a problem with the prostate, which could be cancer but could also be an enlarged prostate (BPH) or infection (prostatitis).

If you have previously been diagnosed and treated with prostate cancer your doctor will monitor your PSA on a regular basis.

The PSA test together with a DRE is the best option for early detection.

Additional PSA terminology your doctor may use:
PSA density: determined by dividing the PSA level by the size or volume of the prostate.

PSA doubling time: refers to the time during which PSA measured in blood doubles.

PSA velocity measures how quickly the PSA level rises over a period of time.
If the PSA velocity is increased, it means there is a higher risk of developing prostate cancer.

How good is the PSA blood test?
The PSA test indicates the risk that you may have prostate cancer. This is helpful for your doctor as it can guide him/her in their decision about whether you should have further tests.

PAP
The PAP test measures the Prostatic Acid Phosphatase (PAP) in the blood. The PAP level usually rises only after the cancer has metastasized (spread to other parts of the body).

Other Tests

• Transrectal ultrasound (TRUS)
In this procedure, an ultrasound (sonar) probe is inserted into the rectum to check for abnormal areas. The probe sends out sound waves at ultra-high frequency, hence the name ultrasound. The waves bounce off the prostate and the echoes are used to create a picture called a sonogram.

• Cystoscopy
In this procedure a thin, lighted tube is used to look into the urethra and bladder.

• Transrectal biopsy
This test is normally used to guide a prostate biopsy so that a pathologist can examine the removed cells or tissues to check for cancer cells. It is the most accurate way to diagnose prostate cancer. While the patient is anaesthetized a needle is inserted through the rectum into the prostate. A small tissue sample is taken from many areas of the prostate. Ultrasound may be used to guide the needle.

Staging

Staging is the process where doctors determine and evaluate how far the cancer has spread. It is important for your doctor to know the stage of the cancer as it will assist in determining the type of treatment you will receive. Doctors will predominantly talk about your cancer in three categories – localised, locally advanced or metastatic. Generally speaking, there are four stages of prostate cancer which fall into these three categories.
Localised prostate cancer

• Stage I:
The cancer is in a very early stage and cannot be felt with a digital rectal exam (DRE). The tumour is usually found because of an elevated PSA level, or when surgery is performed for a BPH diagnosis. The cancer is only in the prostate.

• Stage II:
The cancer can be felt during DRE and is more advanced, but has not spread outside the prostate.

Locally advanced prostate cancer

• Stage III:
The cancer has spread outside the prostate. It may be in the seminal vesicles. It has not spread to the lymph nodes.

Metastatic prostate cancer

• Stage IV:
The cancer may have spread to nearby muscles and organs and possibly to the lymph nodes. It may have spread to other parts of the body such as the bones.

• Recurrence
When treatment is finished and the cancer can no longer be detected, the cancer could come back or recur. This could happen in the prostate or any other part of the body.

Grading

Grading measures how abnormal the cancer cells appear when a biopsy is looked at under the microscope. When your biopsy is sent to a pathology laboratory, a pathologist looks closely at the difference in the definition or shape of the healthy cells compared to the cancerous cells.
The healthier cells are well defined and fairly uniform in shape while the cancer cells are more irregular looking. A grade is given to these cells.
The grade indicates how quickly the cancer can spread or metastasize. There are two grades to consider, low-grade and high-grade.

• Low-grade cancer cells are only slightly abnormal in appearance, and grow slowly.
• High-grade cells usually vary in size and shape. Without treatment they spread quickly.

Treatment

A prostate cancer diagnosis may bring an onset of fear, panic or distressing thoughts. However since this is a slow growing cancer, there is no need to rush into making quick decisions about your treatment.

To ensure that you receive the most effective treatment for your prostate cancer, your doctor will take the stage and grade of the cancer into consideration, along with your age and other health factors. The more precise your diagnosis the more specific your treatment will be. Armed with this information, you and your doctor can make the right decisions about your treatment.

Prostate cancer will usually follow the path of surgery, radiotherapy, hormonal therapy and sometimes chemotherapy, however each patient is different and your doctor will determine what is best for you.

Ablatherm HIFU (High Intensity Focused Ultrasound) treatment

Ablatherm HIFU treatment destroys the prostate by ‘cooking’ it with focused ultrasound. Ablatherm HIFU is an effective, non-invasive (incisionless) treatment that preserves the patients quality of life. Ablatherm HIFU treatment (or ablation) treats prostate cancer by focusing high-intensity ultrasound waves on the affected area, causing localized heating that destroys the cells in the gland without damaging the surrounding tissue. Focused ultrasound works in the same way as rays of sunlight that pass through a magnifying glass and are concentrated at a single point, causing a significant temperature rise around the focal point. Thermal ablation is a non-invasive treatment that has been used in humans since 1993. There have been more than 22 000 treatments performed using Ablatherm HIFU around the world and the treatment is recognized by urology specialists in several countries including South Africa.

Watchful waiting
Watchful waiting means that your doctor will not treat your disease immediately. Instead, your condition will be monitored by your doctor very closely through regular DRE’s and PSA tests. Should your symptoms increase or change your doctor may decide that treatment is necessary.
This approach may seem inappropriate to many prostate cancer patients and their families, however it may be the best and most sensible option, particularly if you are older or have serious health problems. Watchful waiting can also delay side effects from surgery or radiation.
Your doctor may also suggest watchful waiting if you are diagnosed with an early stage and slow growing prostate cancer.

Surgery
Surgery is the most common treatment for prostate caner and can be used to remove all or part of the prostate. Removal of the prostate is known as a prostatectomy.

Surgery for early stage disease will usually include a radical prostatectomy which involves the surgical removal of the entire prostate gland including some surrounding tissue. There are a number of surgical and prostectomy procedures for prostate cancer.

• Radical retropubic prostatectomy:

The removal of the entire prostate and seminal vesicles through an incision or cut in the lower abdomen. Sometimes the nearby lymph nodes are also removed (pelvic lymph node dissection). After the prostate has been removed, the urethra is stitched directly to the bladder so urine is able to flow.

• Radical perineal prostatectomy:

The removal of the entire prostate through a cut in the perineum, or the space between the scrotum and the anus. Nearby lymph nodes may be removed through a separate cut in the abdomen.

• Laparoscopic prostatectomy:

The removal of the entire prostate through several (3 to 5) small incisions, through which a thin, lighted tube (a laparoscope) and other instruments are placed to remove the prostate.

• Transurethral resection of the prostate (TURP):

The doctor removes the central part of the prostate with a long, thin device that is inserted through the bladder tube (urethra). The outside (peripheral) part of the prostate is not removed. TURP may not remove all of the cancer, which usually occurs in the outside part of the prostate, but it can remove tissue that blocks the flow of urine.

• Cryosurgery:

The prostate cancer is placed under sub zero temperatures (frozen) with probes inserted through the perineum.

• Pelvic lymphadenectomy:

This is sometimes done during prostatectomy. The doctor removes lymph nodes in the pelvis to see if cancer has spread to them. If there are cancer cells in the lymph nodes, the disease may have spread to other parts of the body. In this case, the doctor may suggest other types of treatment however most patients selected for radical prostatectomy these days have such a low risk of pelvic metastases that lymph node dissection can be omitted..
Radiation therapy

Radiation therapy, also known as radiotherapy, is commonly used in prostate cancer treatment and uses radiation to kill the prostate cancer cells. Two different kinds of radiation therapy are used in prostate cancer treatment: radiation therapy and brachytherapy.

Radiation therapy (external radiation)

This is a standard form of radiation therapy that uses a machine to aim high-energy rays at the cancer.

Brachytherapy (internal radiation)

Brachytherapy for prostate cancer is given using small radioactive rods called “seeds” implanted directly into the tumour. Each “seed” is smaller than a grain of rice and is precisely placed into the prostate via needles that enter through the skin behind the testicles.
These “seeds” are basically small amounts of radiation that affect a small area of the prostate. Over a period of months the “seeds” give off radiation to the surrounding area which kills the prostate cancer. By the end of one year, the radioactive material degrades and the remaining radioactive “seeds” become harmless.

Hormonal therapy

The male hormones (androgens) stimulate the normal prostate (and also prostate cancer) to grow. The most abundant androgen is testosterone. Stopping the production of testosterone, or blocking its action on the cells, prevents the cancer cells or tumour from growing.

There are several types of hormonal therapy:
• Antiandrogens
Antiandrogens are drugs which block the action of testosterone on the cancer cells by blocking the hormone receptors. .

• LH-RH Agonists
LH-RH stands for luteinizing hormone-releasing hormone.
LR-RH agonists are drugs which stop the testicles from producing testosterone.

• Orchiectomy

Testicles make most of the body’s testosterone. An orchiectomy is when surgery takes place to remove the testicles in order for the testosterone levels to drop.

PSA blood test during Hormone Therapy
If you are receiving hormone therapy for prostate cancer your PSA levels should be low. Your doctor will explain your PSA levels to you and how your treatment can affect these levels.

Chemotherapy
Chemotherapy refers to drugs which can kill cancer cells. It cannot be focused to any particular area of the body and is primarily used to treat prostate cancer when the disease has become resistant to hormones. Prostate cancer chemotherapy is almost always used for advanced prostate cancer.

Chemotherapy in prostate cancer has advanced greatly over the past three years with the creation and of new and more effective chemotherapy drugs. In some men, the earlier use of chemotherapy has been helpful in slowing the advancement of the disease.

Talk to your doctor about chemotherapy options which are best suited to your disease.

Palliative care
Palliative care or treatment reduces the severity of cancer symptoms or slows down the cancer’s progress. This type of treatment is not aimed at cure but rather at improving quality of life by reducing pain and easing physical and psychological problems. Palliative care also supports the partners and family of patients.

Bisphosphonate treatment

Bone disease
In advanced cancer, the disease often spreads to the bones, causing bones to weaken. Bisphosphonates can help reduce the risk of your bones weakening and therefore reduce the risk of fractures and other complications.

Bone pain

Bisphosphonates can also assist in reducing cancer related bone pain and reduce the levels of calcium in your blood which can occur when bones are damaged.

Talk to your doctor about a bisphosphonate treatment that will help reduce your bone complications from your prostate cancer and allow you to get on with your normal activities as much as possible.

Side Effects

Side effects of Surgery

Impotence

The nerves that cause erection of the penis run very close to the outside of the prostate. Damage to these nerves during radical prostatectomy can cause loss of erections (impotence). If the cancer is not very large, these nerves can be spared during surgery, thus reducing the risk of erectile dysfunction. Pills and injections are available in South Africa to treat impotence.

Incontinence

Normally there are two closure mechanisms (sphincters) that prevent leakage of urine from the bladder (incontinence). With radical prostatectomy one of these sphincters (the internal one) is removed, so if the other (external) sphincter is not strong, or is damaged during surgery, there is a risk of incontinence.

Blocked outflow of urine

The prostate has a rich blood supply therefore blood transfusion may be necessary. Sometimes scar tissue may develop where the prostate has been removed, thus blocking the outflow of urine.

Side effects of Radiation therapy
As your treatment continues, you may feel ongoing tiredness.
External radiation may cause:
• Bowel dysfunction – diarrhea or frequent stools; faecal incontinence or the inability to control bowel movements and rectal bleeding
• Bladder dysfunction – passing urine more frequently, inability to hold back the urine, discomfort or difficulty in passing urine, or blood in the urine – this is usually transient, and long-term bladder problems are rare
• Erectile dysfunction (impotence) – if this does occur, it usually does so a few years after the radiotherapy
• Skin – may become dry, red and tender
• Hair loss – only in the pelvic area, but may not necessarily occur

Side Effects of Hormone Therapy
Because Hormone therapy affects the testosterone levels, it is important to discus the potential side effects with your doctor prior to treatment. Ask you doctor for advice about how to adjust your lifestyle after hormone therapy.
Some side effects experienced include:
• Decreased sexual desire and erectile dysfunction
• Hot flushes
• Anemia
• Fatigue
• Weight loss
• Weight gain

Side effects of Chemotherapy
These side effects depend on the type of chemotherapy administered, but can include tiredness, nausea and vomiting, hair loss, loss of appetite, fatigue and weight loss. Don’t be afraid to talk about your side effects with your nurse or doctor. There are many supportive care treatments available to help treat side effects.

Maintaining your Health

Looking after your health during treatment is important and will assist with your recovery. Take the time to understand your disease and treatment and don’t be afraid to ask questions.

Regular Check-ups and appointment
Protect your health by having regular check-ups and scheduling appointments with your doctor to follow up and monitor your health. Expect to have further tests and examinations to evaluate your health to ensure that you are responding well to treatment.

Nutrition
Good nutrition is important. Eating well will ensure you feel better and have more energy. It also means you will get enough calories to prevent weight loss, regain strength, and rebuild normal tissue.

You may find it difficult to eat during treatment or even lose your appetite. Talk to a dietician who can give you advice for healthy eating during your treatment or ask your nurse or doctor for advice in this area.

Exercise

Regular, gentle exercise such as walking or swimming can help keep your energy levels up and also reduce pain levels. Don’t forget to inform your doctor of any exercise you are doing and if you feel unwell during exercise let your nurse or doctor know.

Quality of Life
Most men with prostate cancer can live a productive lifestyle and enjoy a good quality of life. Because every person is different and responds differently to treatment, the outcome of your treatment cannot be guaranteed, however, by working together with your doctor you should be able to control your disease and live life to its fullest.

Questions to ask your doctor before surgery or treatment

• What tests are going to be done for an accurate diagnosis?
• How long will the biopsy take? Will I be awake? Will it hurt?
• How long will it take to get the biopsy results?
• If I do have cancer, what will happen next?
• Has the cancer spread to any other areas?
• What stage of prostate cancer do I have?
• What type of treatment do you recommend?
• What are the risks from the chemotherapy, from radiation, and from surgery?
• How will I feel during treatment?
• What are the side effects of my treatment?
• When will my treatment start? How often will I have treatments? When will the treatment end?
• What is the survival rate with or without treatment?
• What effects will this condition have on sexual activity? On urinary continence?
• How long will it be before I can return to my normal activities?
• How will my prostate cancer be monitored after treatment? How often will I need check-ups?

Anatomy and Function of the prostate

Compiled July 2018

What is it?

The prostate is a small gland about the size and shape of a walnut. It is part of a man’s internal sex organs. All the sex organs play a role in reproduction. The prostate generally increases in size as men age.

Where is it?

It is situated under the bladder and surrounds the urethra which is the tube that transports urine from the bladder to the penis where the urine is released through the ureter. This why problems with the prostate often affect the ability to urinate, causing what doctors call (urinary symptoms). The rectum sits directly behind the prostate. This means that a part of the prostate can be felt if a finger is inserted up the rectum. (digital rectal examination) or the “finger” test. The tube that carries the semen from the testicles feeds into the ejaculatory ducts which then connect to the seminal vesicles which are just above the prostate. When prostate cancer spreads it often spreads first into these structures that surround the prostate. The prostate has gland tissue and smooth muscles fibres which help it to contract when a man ejaculates. The prostate is surrounded by a loose capsule which is connected to sheaths of pelvic muscles. Before 1981 surgeons were not aware of the nerve bundles towards the back and sides of the prostate that play an important role in erections. The identification of these nerves led to the first “nerve sparing” prostatectomy in 1982. Knowing where these nerves are situated has made a big difference to minimising erectile dysfunction in men who have had a prostatectomy.

Until a few years ago, doctors described the different parts or areas of the prostate as lobes (see illustration below). One method of staging prostate cancer was to determine which lobes had been affected by cancer cells.

A more up-to-date way of describing the different areas of the prostate is the Zonal System.   (See illustration below). 80 to 85% of prostate cancers start in the peripheral zone.

What does it do?

The prostate gland produces prostatic fluid which makes up about 15 to 30% of the semen or ejaculate. The average amount of semen ejaculated is 3.4ml which is less than a teaspoon full. Sperm make-up only 1 to 5% of the total volume of the ejaculate.  The secretions from the seminal vesicles make-up the majority of the ejaculate. The secretions from the various glands that help to produce semen all assist with nourishing and protecting the sperm so that they can survive and impregnate an egg in the process of reproduction.

References

(1) Nicholas J., Primer on Prostate Cancer-2014, Springer Healthcare 2014.

(2) William K, Hurwitz M, D’Amico AV, et al. Biology of Prostate Cancer. Holland-Frei Cancer Medicine. 6th edition. Hamilton (ON): BC Decker; 2003. Available from: https://www.ncbi.nlm.nih.gov/books/NBK13217/

(3) Owen DH., Katz DF. A Review of the Physical and Chemical Properties of Human Semen and the Formulation of a Semen Simulant. J Androl 2005;26:459–469.