Cancer of the prostate

What is it?

An enlargement of the prostate gland caused by a tumour. If left untreated, the cancer may spread to other parts of the body.

What are the main symptoms?

Prostate cancer is often symptomless in the early stages.

If the tumour starts to press on the urethra it can cause urinary problems such as

• difficulty in passing urine
• passing urine more frequently, especially at night
• pain on passing urine
• blood in the urine

Prostate cancer cells may eventually break away to form new tumours elsewhere. Symptoms then might include:

• weight loss
• pain in the bones of the pelvis, legs and especially the lower back 

What's the risk?

• Rare in men under 45, but the risks rise with age.
• Nearly three out of four men in their 80s have tiny specks of prostate cancer. But only a few of these will develop any symptoms.
• Certain genes may make you more susceptible. Your risk is greater if you have a father or brother with prostate cancer, particularly if they developed prostate cancer at an early age.

What causes it?

• No one knows exactly.
• Age, race and heredity are recognised risk factors.
• A Western lifestyle — with a diet high in fat and low in vegetables — may also be implicated. 

How can I prevent it?

• Cut right down on red meat, animal fats, milk and dairy produce.
• Increase your daily intake of fruit and vegetables — especially tomatoes. These contain antioxidants, natural cancer-fighters, and other substances which may have a protective effect.
• The minerals zinc and selenium are also important for prostate health.

Should I see a doctor?

• Yes, if you have symptoms. He will want to carry out some tests and investigations - perhaps a DRE or PSA test or ultrasound or all three. Please be aware that having "waterworks" symptoms does NOT automatically mean you have prostate cancer — it's more likely that you have a benign growth of the prostate pressing on the urethra.
• PSA test can give an early indication of cancer. PSA is a protein made by the prostate and raised levels may indicate cancer. However, other conditions such as enlarged prostate or urinary infection, can also increase PSA levels so the test is not very specific. Also some cancers do not lead to raised PSA. There is currently no national screening programme for prostate cancer using the PSA test. You can however, ask your doctor for a PSA test if you want one. This is a matter for informed choice to be discussed with a doctor/practice nurse. Currently, there's no hard evidence that PSA testing saves lives through earlier diagnosis of prostate cancer. However trials are under way (although results won't be available for a few years). A national screening programme may be introduced in the future depending on the results of this research.

What are the main treatments?

Treatment depends on your age, general health, and the type, size and spread of the cancer. A combination of treatments may be used for the best results.

• If your cancer is localised (confined to the prostate), watchful waiting may be recommended. Or you may be offered radiotherapy or surgery.
• If your cancer is locally advanced (spread quite widely into surrounding tissue) you may be offered hormonal therapy and/or radiotherapy.
• If your cancer is advanced (spread to the bones or elsewhere in the body) you will be offered hormonal therapy.
  • Unfortunately these tumours usually begin to grow again after a period of time. Doctors call this hormone escape.
  • Treatment for patients who have reached this point is aimed mainly at controlling the symptoms. Radiotherapy can be an effective way of helping to reduce pain.

Watchful waiting

• As treatment for prostate cancer has side-effects, watchful waiting may be the best option for older men, or men with other illnesses which limit life expectancy. Treatments such as radiotherapy or surgery are usually only considered for men with a life expectancy of at least 15 years. For other men watchful waiting may be a better option as it will minimise the side effects at little risk to the man.
• You will need regular check-ups and PSA tests, so that treatment can be considered if the cancer appears to be progressing.
• Let your doctor know at once if your condition changes, rather than waiting for your next appointment.

Radiotherapy

• The prostate is bombarded with carefully calculated doses of radiation to kill cancer cells while harming normal cells as little as possible.
• Radiotherapy is not painful but can cause diarrhoea, bleeding and rectal discomfort, as well as problems with erections and continence.
• Conformal radiotherapy — where the radiation beams are shaped to fit the irregular outline of the tumour — reduces the risk of side-effects.
• Internal radiotherapy, or brachytherapy, can be as effective as surgery and side-effects are minimal. Small, radioactive beads are inserted into the tumour to release radiation slowly over a period of time.

Surgery

• If the cancer is confined to the prostate, surgically removing the entire gland (a radical prostatectomy) offers a good prospect of a cure.
• This complex operation is carried out less often in the UK than in the US, and is usually only considered for younger men.
• It carries a high risk of impotence and a lesser one of incontinence, although improvements in surgical techniques mean that these complications are less common than they used to be.

Hormonal therapy

• If you reduce the amount of testosterone your body produces, you may halt, or even reverse, the disease's progression.
• One way of doing this is by removing the inner part of the testicles surgically.
• The other is by having a monthly injection of LHRH agonists such as Zoladex or Prostap [LHRH stands for luteinising hormone-releasing hormone.] These are often used with anti-androgens to create a maximum androgen blockade
• Treatment often allows men to get back to virtually normal lives, but the drugs can produce unpleasant side-effects such as impotence and hot flushes.
• All of these hormone treatments are equally effective and the choice is left up to the man himself. The operation to remove the inner part of the testicles needs a general anaesthetic, but after that no other treatments may be required for a long time. Tablets are easy to take but need to be taken three times daily for a long while. Injections of LHRH agonists represent a compromise, as they only need to be given every 28 days (or with the newer longer-acting preparations, every three months).

How can I help myself?

• Eat less animal fat and more fresh fruit, vegetables and fish.
• A diet high in soya phytoestrogens may slow down the growth of prostate tumours.
• Stop smoking — smoking doesn't cause prostate cancer but may cause it to spread more quickly.
• Learn to relax — take up a new hobby, join a support group, consider complementary therapies.

What's the outlook?

It's better the earlier the cancer is caught. It's very difficult to generalise about prostate cancer because some cancers are very aggressive while others develop very slowly and cause relatively few problems. Indeed, many men die of another condition before they die of their prostate cancer.