Prostate cancer

The prostate is a small gland, about the size of a walnut, sitting under the bladder and wrapped around the tube that carries urine out. Cancer arising in it is the commonest malignant tumour in men and at the same time one of the quietest: it usually grows slowly, over years, and a good proportion of men reach old age carrying one without ever knowing. Two things follow at once. There is no cause for panic. And there is no cause for putting things off either: found while it is still inside the gland, this cancer is treated with a cure in mind.

Why the tumour stays silent so long

Cancer usually starts in the outer part of the gland — exactly where the gland is not pressing on the urinary passage. So an early tumour does not interfere with passing urine and gives nothing else away. Symptoms appear once it has grown enough to press from within, or once cells have moved beyond the gland.

Hence a very common confusion. A man in his fifties gets up at night, the stream has weakened, it is harder to start — and he thinks of cancer. In fact it is nearly always benign enlargement of the prostate: the gland grows with age in most men, squeezes the passage and produces precisely those complaints. That is not a reason to reassure yourself on your own, though. Only a doctor can tell the two apart, and urinary trouble is reason enough to go.

Signs not to blame on age

See a doctor if any of the following appears:

• the stream has weakened, it is hard to start, you have to strain, the flow stops and starts;
• you need to pass urine more often or more urgently, and you are up several times a night;
• afterwards it feels as though the bladder has not emptied;
• blood in the urine or in the semen, even once;
• pain in the lower back, pelvis, hips or ribs lasting weeks, worse at night and unrelated to exertion;
• erections have weakened or stopped;
• weight is falling without trying and tiredness has become constant.

The last few deserve a word of their own. Bone pain, weight loss and exhaustion already suggest the tumour may have spread, and with those the visit is not postponed. One more thing: there is nothing here to be embarrassed about. Talking about passing urine and about erections is routine for a doctor, who does it several times a day.

When help is needed urgently

Three situations are not measured in weeks.

Pressure on the spinal cord. Prostate cancer spreads above all to the spine, and growth inside a vertebra can compress the cord. The signs are: new severe pain in the back or neck, often band-like, worse lying flat and on coughing; weakness, numbness or pins and needles in the legs; unsteady walking; numbness around the perineum and inner thighs; loss of control of the bladder or bowels, or conversely an inability to pass urine at all. This is not a matter for an appointment: call an ambulance or go to hospital straight away (112 in Spain, Italy, Portugal, Poland and Ukraine). Whether treatment starts within hours decides whether the person keeps walking.

Complete inability to pass urine. Nothing comes at all, the lower abdomen is tight and painful and the bladder can be felt above the pubic bone. This is not something to sit out: it needs emergency care and a catheter to drain it.

Fever after a biopsy. If in the days following the biopsy a fever appears, with shivering rigors, marked weakness or confusion, that may be infection in the bloodstream. Ambulance, without waiting.

Who is at greater risk

No exact cause can be named, but what raises the odds is known.

• Age. The dominant factor. Below fifty prostate cancer is uncommon; after that the likelihood climbs with every decade.
• Ancestry. In men of African and Caribbean background the disease occurs roughly twice as often, starts earlier and behaves more aggressively.
• Family. A father or brother with prostate cancer roughly doubles the risk, particularly if theirs was found young.
• Inherited gene faults. Breast or ovarian cancer in close female relatives is not a coincidence: some cases trace back to the same genes, above all BRCA2. It is worth mentioning at the appointment.
• Excess weight. The link with developing a tumour at all is unclear, but the link with a more aggressive course is not.

If any of this applies to you, discuss monitoring with a doctor before symptoms arrive. The age at which checks are worth starting differs between countries — it is set by the national programme, and your doctor will advise on yours.

PSA: what the test can and cannot tell you

PSA is a protein made by the prostate; some of it passes into the blood, where it can be measured. The test is simple, but it has to be read properly.

A raised PSA does not mean cancer. It is pushed up by benign enlargement, by prostatitis, by a urine infection, by recent ejaculation, by cycling, by a catheter and sometimes by an examination the day before. That is why the test is usually repeated and always judged alongside the examination rather than on its own. The reverse holds too: a normal PSA does not entirely rule cancer out.

The test also has a downside the doctor should set out beforehand. Some of the tumours it finds would never have declared themselves, and a tumour once found is hard to leave alone: biopsy and treatment, with their complications, follow the diagnosis. So the decision whether to have a PSA is made together with a doctor after a conversation about what the result would actually change in your case. That is not a formality or a legal precaution — it is the heart of the matter.

How a suspicion is investigated

It all starts with the conversation and the examination. The doctor will ask about passing urine, about pain, about weight, and about cancer in the family, including breast and ovarian cancer. Then they will offer a rectal examination: wearing a glove, with gel, they feel the back surface of the gland and judge its size, firmness and irregularity. It takes under a minute and is hardly ever painful. You can ask for someone else to be in the room.

If needed, you are referred to a urologist. The current order is this: an MRI scan of the pelvis first, and only then, if the scan shows a suspicious area, a biopsy, in which cores of tissue are taken with a needle guided by ultrasound. That sequence lets some men avoid a biopsy altogether.

The tissue is examined under the microscope and graded by how far the cells have departed from normal; that is what tells you how dangerous the tumour is. If cancer is confirmed, scans follow to find out whether it has left the gland — a CT scan, a bone scan or a specialised study using a tracer. Waiting for results is hard; ask in advance when and how you will be told.

Treatment, and why watching is sometimes better

The choice depends on how aggressive the cells are, on whether the tumour has left the gland, on age and on other illnesses. There are several routes, and each has its price.

• Active surveillance. With a small, low-grade tumour, treatment is deferred and the gland is watched: regular PSA tests, repeat scans and repeat biopsies. This is not "doing nothing", it is a deliberate choice: while the tumour behaves itself, treating it would do more harm than good. If it starts to grow, treatment begins, and the moment will not have been missed.
• Surgery. The whole gland is removed. It suits a tumour that has not left the gland, in someone with enough years ahead to justify the risk of complications.
• Radiotherapy. A course of external beams, or sources implanted inside the gland. For localised disease the results compare with surgery; the set of side effects is different.
• Hormone therapy. The tumour grows under the influence of testosterone, and treatment takes that influence away. On its own it does not cure, but it holds the disease back for years, and combined with radiotherapy it is used with cure in mind.
• Chemotherapy and newer drugs come in once the tumour has spread.

Side effects and what to do about them

These need to be known before treatment starts rather than after: some of the decisions are made precisely because of them.

After the gland is removed almost everyone leaks urine for a while. In most men it settles over weeks and months, and pelvic floor exercises speed it up — better started before the operation than after. Erection problems are common after both surgery and radiotherapy; there is plenty that helps, from tablets to vacuum devices, and this is for discussing with a doctor rather than accepting in silence. Orgasm survives removal of the gland but becomes "dry": no semen is produced and natural conception is no longer possible. If children are in the plans, sperm should be stored before treatment begins.

Radiotherapy can bring frequent and uncomfortable passing of urine, looser bowels and bleeding from the back passage, usually temporary. Hormone therapy brings hot flushes, loss of libido, weight gain, mood swings and loss of bone density — which is why bone is monitored during it and resistance exercise, vitamin D and calcium are advised.

Online consultation

A rectal examination and a biopsy cannot be done online, but most of the road to the diagnosis, and of the road after it, is conversation — and conversation works perfectly well at a distance.

An online appointment fits for working out whether a PSA test is right for you and what the result would change; for making sense of a test already done when the figure is high and it is unclear what happens next; for going through a biopsy report and translating grade and stage into plain language; for weighing surgery, radiotherapy and surveillance before the urology appointment; and for dealing with side effects of treatment that many men find hard to raise face to face.

Have to hand every previous PSA result with its date — the trend says more than a single figure — along with scan and biopsy reports and a list of your medicines. Write down what exactly is worrying you and since when, and do not leave out cancer in the family, including in the women.

This material is for information only and does not replace medical advice.