Prostate cancer is the most common cancer in men in the UK, with over 40,000 new cases diagnosed every year.
The prostate is a small gland in the pelvis found only in men. It's located between the penis and the bladder and surrounds the urethra. The main function of the prostate is to help in the production of semen.
The causes of prostate cancer are largely unknown. However, certain things can increase your risk of developing the condition. The chances of developing prostate cancer increase as you get older. Most cases develop in men aged 50 or older.
For reasons not yet understood, prostate cancer is more common in men of African-Caribbean or African descent, and less common in men of Asian descent. Men who have first degree male relatives (such as a father or brother) affected by prostate cancer are also at slightly increased risk.
Some prostate cancers develop slowly, so there may be no signs you have it for many years, whilst others grow more rapidly. Symptoms often only become apparent when your prostate gland is large enough to affect the urethra (the tube that carries urine from the bladder to the penis). When this happens, you may notice things like an increased need to urinate, straining while urinating and a feeling that your bladder has not fully emptied. Although these symptoms shouldn’t be ignored, they do not mean that you definitely have prostate cancer. It is more likely that they are caused by something else, such as benign prostatic hyperplasia (also known as BPH or prostate enlargement).
If you have been referred to Aneurin Bevan University Health Board, it is likely that you have had a prostate specific antigen (PSA) blood test at your GP surgery. PSA is a protein produced by the prostate gland. Prostate cancer can increase the production of PSA, and so a PSA test looks for raised levels of PSA in the blood that may be a sign of the condition in its early stages. It is likely that at your first appointment this test will be repeated, along with an examination of your prostate gland via the back passage (your rectum).
A magnetic resonance imaging (MRI) scan will be requested by the team. This is a specialised type of imaging, where a series of pictures is taken and fed into a computer to build up a detailed picture.
The Royal Gwent Hospital (ABUHB) uses the multiparametric-magnetic resonance imaging (mp-MRI) scan, which combines up to four different types of image. These images give your doctor information about whether or not there is any cancer inside your prostate, and how quickly any cancer is likely to grow.
CT (Computerised Tomography) scan is a specialised type of X-ray. A series of pictures is taken and fed into a computer to build up a detailed picture of the inside of the body. The scan can show whether or not the cancer has spread to other parts of the body. It is painless and takes between 10 to 30 minutes.
An isotope bone scan – this can tell if the cancer has spread to your bones. A small amount of radiation dye is injected into the vein and collects in parts of the bone where there are any abnormalities.
It may be necessary to perform a trans-perineal ultrasound-guided biopsy (TRUS). The multiparametric-magnetic resonance imaging (mp-MRI) scan is used to help target the biopsy.
A Trans Perineal Biopsy involves putting an ultrasound probe into your rectum (back passage) to scan your prostate. Guided by ultrasound, biopsies are taken from your prostate through your perineum (the skin between your scrotum and rectum) The procedure can be uncomfortable, so you may be given a local anaesthetic to minimise any discomfort. As with any procedure, there may be complications, including bleeding and infection. These will be discussed with you in more detail by the team.
Your test results tell your doctors more about the size of the tumour and if it has spread outside the prostate. Doctors often use the TNM staging system. It gives information about the tumour, if it has spread to any lymph nodes, or to another part of the body (metastasis).
Early prostate cancer is contained to the prostate. It has not spread to lymph nodes or other parts of the body.
Early prostate cancer is also divided into risk groups. This looks at the T stage of the cancer, its grade and your PSA level. The grade tells how quickly the cancer cells may grow.
The Gleason system is the most commonly used grading system. It looks at the patterns of the cancer cells in the prostate.
Risk groups are divided into low risk, intermediate and high risk. Knowing the stage and risk group of the cancer helps you and your doctors decide on the best treatment for you.
Your treatment for prostate cancer will depend on your individual circumstances. For many men with prostate cancer, no treatment will be necessary. When treatment is necessary, the aim is to cure or control the disease so it doesn't shorten life expectancy and affects everyday life as little as possible.
Sometimes, if the cancer has already spread, the aim is not to cure it, but to prolong life and delay symptoms. One or more of the following treatments may be an option for you:
Active surveillance
Active surveillance aims to avoid unnecessary treatment of harmless cancers, while still providing timely treatment for men who need it. Surveillance is a safe strategy that provides a period of observation to gather extra information over time to see whether the disease is changing.
Active surveillance involves you having regular PSA tests and often several biopsies to ensure any signs of progression are found as early as possible. Sometimes, MRI scans may also be carried out. If these tests reveal the cancer is changing or progressing, you can then make a decision about further treatment. About one in three men who undergo surveillance will later have treatment.
Watchful waiting
Watchful waiting is often recommended for older men when it is unlikely that the cancer will affect your natural life span. If the cancer is in its early stages and not causing symptoms, you may decide to delay treatment, and wait to see if any symptoms of progressive cancer develop. If this happens, pain medication and hormone medication (see below) to control prostate cancer are usually used. Watchful waiting may also be recommended for people with a higher risk of prostate cancer if:
In this case, hormone treatment may be started if there are symptoms caused by the prostate cancer.
Radical prostatectomy
A radical prostatectomy is performed under general anaesthetic and consists of the surgical removal of your prostate gland, seminal vesicles (tube-like glands which make semen) and occasionally lymph nodes. It can be undertaken using the ‘Da Vinci’ robotic technique, which is surgery performed laparoscopically (key-hole surgery) or open surgery. This treatment is an option to attempt to cure localised and locally-advanced prostate cancer. During the multi- disciplinary meeting and pre- surgery assessments, the surgeon and anaesthetic will choose which surgical option is best for you.
The Health Board is one of the few hospitals in the UK that can perform the prostectomy using the ‘Da Vinci’ robotic surgical system. The da Vinci system provides the surgeon with controlled and precise movements mimicking the human hand and wrist. The surgeon is in full control of the system at all times and can operate in highly magnified 3D. It has been have found that patients benefit from a reduced recovery time, reduced pain following the procedure and from far less visible scarring.
Hormone therapy
Hormone therapy is often used in combination with radiotherapy. For example, you may receive hormone therapy before undergoing radiotherapy to increase the chance of a successful treatment. Hormone therapy may also be recommended after radiotherapy to reduce the chances of cancerous cells returning. It can also e used to slow the progression of advanced prostate cancer and relieve symptoms.
Hormones control the growth of cells in the prostate. In particular, prostate cancer needs the hormone testosterone to grow. The purpose of hormone therapy is to block the effects of testosterone, either by stopping its production or by stopping your body being able to use testosterone.
Hormone therapy can be given as:
The main side effects of hormone treatment are caused by their effects on testosterone. They include loss of sex drive and erectile dysfunction (this is more common with LHRH agonists than anti-androgens and hot flushes.
Radiotherapy
Radiotherapy involves using radiation to kill cancerous cells. This treatment is an option to attempt to cure localised and locally-advanced prostate cancer. Radiotherapy can also be used to slow the progression of metastatic prostate cancer and relieve symptoms.
High energy X-rays are directed at the area of the cancer by using a special machine. The number of treatments will depend on the type and size of the cancer, but the whole course of treatment for early cancer will usually last up to six weeks. Your doctor will discuss the treatment and possible side effects with you.
External radiotherapy is not painful, but you do have to lie still for a few minutes while your treatment is being given. The treatment will not make you radioactive and it is perfectly safe for you to be with other people, including children, after your treatment.
You may receive hormone therapy before undergoing radiotherapy to increase the chance of successful treatment. Hormone therapy may also be recommended after radiotherapy to reduce the chances of cancerous cells returning.
There are short-term and long-term side effects associated with radiotherapy. Short-term effects of radiotherapy can include discomfort around the rectum and anus, diarrhoea, tiredness and cystitis (an inflammation of the bladder lining, which can cause painful urination). Possible long-term side effects can include erectile dysfunction, urinary incontinence and back passage problems (diarrhoea, bleeding, and discomfort).
Chemotherapy
Chemotherapy is mainly used to treat prostate cancer that has spread to other parts of the body (metastatic prostate cancer) and which is not responding to hormone therapy.
Chemotherapy destroys cancer cells by interfering with the way they multiply. Chemotherapy does not cure prostate cancer, but can keep it under control and reduce symptoms (such as pain) so everyday life is less affected. The main side effects of chemotherapy are caused by their effects on healthy cells, such as immune cells. They include infections, tiredness, hair loss, sore mouth, loss of appetite, nausea and vomiting. Many of these side effects can be prevented or controlled with other medicines, which your doctor can prescribe for you.
Radiotherapy and chemotherapy carries their own risks and benefits. An oncologist will be able to discuss this treatment with you in more depth. In ABUHB, a referral will be made by your clinical team to Velindre Cancer Centre, Cardiff for a consultation.
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