Uro-oncology consultant at HMT Sancta Maria, Mr Neil Fenn, shares his frequently asked questions about the symptoms, diagnosis and treatment of prostate cancer, a cancer that effects nearly 3,000 men across Wales each year.
What is the prostate?
The prostate is a small gland, found only in men which sits below the bladder. It surrounds the urethra and has two main functions, protecting the urethra and facilitating fertility by supporting the ejaculated sperm.
What are the common problems that occur with the prostate gland, which may cause symptoms?
- Age related benign (non-cancerous) enlargement of the prostate. This is the main cause of urinary symptoms such as such as difficulty passing water and getting up at night. Symptoms which are common as men age. These symptoms are bothersome, and can impact on sleep patterns and daytime activities
- Inflammation of the prostate is also a well described problem causing pelvic symptoms including discomfort and pain.
- Prostate cancer occurs when you get uncontrolled & abnormal growth of the prostate. Initially the cancer is confined to the prostate, however if left unchecked, cancer cells can spread directly out of the prostate, into lymph glands or to other parts of the body particularly the bones.
What are the different types of prostate cancer?
Although there are several different types of prostate cancer, the majority fall into the group that we would call a ‘prostate adenocarcinoma’. Even though prostate cancer is currently the commonest cancer in men, many patients may not require active treatment. When treatment, however, is required, recent advances in surgery, radiotherapy, and oncological drugs, have resulted in excellent outcomes. 90% of men diagnosed with the disease, are alive and well five years after diagnosis.
What are the risk factors associated with the development of prostate cancer?
Advancing age is the most significant risk factor, with over ¾ of cases occurring in men over the age of 65-years. Most men over the age of 80, should we look, will have a small prostate cancers, however these are rarely life threatening and don’t generally require treatment.
The most significant other risk factor is a family history, particularly in a close relative such as father, brother, or uncle. The risks will change depending on the age of the relative at his diagnosis with younger relatives increasing the risk. It is thought that approximately 5%-10% of prostate cancers may have a genetic link.
Ethnicity is also a well described risk factor with Afro-Caribbean men having a higher risk of prostate cancer compared with Caucasian men, whilst Asian or Chinese men have a lower risk.
It is important to lead a healthy lifestyle, for, as in other cancers, being overweight or obese are risk factors for prostate cancer.
What are the common symptoms of prostate cancer?
Symptoms may include difficulty passing urine such as hesitancy, poor flow and dribbling as well as the feeling of wanting to go more frequently with urgently during the day and night. Some patients describe incontinence. These symptoms, however, are not specific for cancer and can occur as a result of many causes of a large prostate.
Pain on urination, or blood in the urine or ejaculate may also occur. Should the disease have spread, some patients may present with more general symptoms such as loss of appetite, fatigue, weight loss and bone pain. One must remember, however, that these are common symptoms which can be as result of other conditions and don’t always mean a cancer.
Many cases of prostate cancer are now detected before symptoms start through an opportunistic blood testing or prostate examination.
What if I start experiencing symptoms or am worried about prostate cancer, what next?
If concerned, then then your GP will be able to advise you. They will ask you specific questions and will examine you, which may include a digital rectal examination (DRE) of the prostate gland. They will discuss things with you and may organise some additional blood and urine tests.
If the prostate examination is abnormal or a blood test known as Prostate Specific Antigen (PSA) is elevated, they would generally ask for a second PSA test, four weeks after the first. Should the PSA remain elevated then you will be referred to the local urology department for additional tests.
What diagnostic pathways are available at HMT Sancta Maria Hospital?
When first seen, a specialist consultant urologist will assess you, similar to the way to the GP assessed you. They will listen to your concerns, examine you again and review the results of tests already performed.
If PSA or DRE are abnormal, in line with national guidelines, patients will be offered a special prostate scan called a multiparametric (mp) MRI. This particular MRI scan is able to locate areas of concern within the prostate. Should any abnormality be found, a radiological scoring system helps stratify a patient’s individual risk of having a possible underlying cancer. Many men who have a marginally elevated PSA will have a normal mpMRI and can be reassured that nothing further needs to be done. Men who have a significant abnormality on the MRI will be called for further tests
What is the next phase of diagnostics if there is obvious abnormality?
This will normally involve a prostate biopsy where small pieces of tissue are taken from areas of concern identified by the MRI. The samples are then sent off to the laboratory for testing. These tests will determine whether there is a cancer present and the extent of the cancer. This is vital to help guide further treatment. Patients will normally receive the results within 5-10 working days. Depending on the result of the biopsy certain patients, may undergo additional tests such as a bone scan, a CT or a PET scan may be required.
What are the treatment options?
Treatment options will vary greatly depending on the age of the patient, other illnesses, and the stage of the cancer at presentation. Prostate cancer may be confined to the prostate (localised), extending out of the prostate (locally advanced) or may have spread to other parts of the body (advanced).
Should the prostate cancer be diagnosed early and is confined to the prostate, often the treatment is with active surveillance. You will be monitored regularly and undergo regular PSA’s, DRE, and scans. Treatment will only be offered if tests suggest that the cancer is growing. In elderly patients this surveillance is often termed ‘watchful waiting’ and will involve just regular blood tests.
Larger volume localised disease will offered treatment with radical surgery, external beam radiotherapy or brachytherapy at the outset.
Locally advanced cancers tend to be treated with external beam radiotherapy which may be combined with by the use of ‘hormone therapy’. Both works together well as the hormone therapy lowers the testosterone level which controls the cancer and makes it more sensitive to radiotherapy.
The management of advanced disease has changed significantly over the last five years. This now includes multimodal therapy in which radiotherapy, hormone therapy, newer oral therapies, and chemotherapy, are combined. These have significantly improved success rates.
Can you live normally with age related prostate cancer?
Yes. Many age-related cancers are asymptomatic and slow growing. These are unlikely to affect life expectancy. This is often referred to as ‘dying with your prostate cancer, not as a result of it’.
Where can I find additional information and support?
There are many websites that are an extremely supportive for men wanting further advice and guidance on their prostate cancer and its management. These include www.prostatecymru.com or www.prostatecanceruk.org
How can HMT Sancta Maria Hospital help me?
In addition to prostate cancer management, Sancta Maria offers a full men’s health service including the assessment and treatment of benign prostate cancer, erectile dysfunction, scrotal and penile problems.