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Prostate

​This information should not be used for self-diagnosis or in place of a qualified physician's care.

Reviewed 2015

The basics
  • Guidelines for treating this cancer have been developed by the Genitourinary Tumour Group.
  • For health professional information on treating this cancer, please see our Cancer Management Guidelines.
  • The prostate gland is found only in men. It produces a milky fluid that is a large portion of semen.
  • The prostate is located under the bladder and it wraps around the urethra. The urethra is the tube that carries urine from the bladder through the penis.
  • After age of 40, the prostate gland is at risk for a number of non-cancerous conditions including benign enlargement.
  • Cancer of the prostate is rare in younger men.
  • It is the most common form of cancer among Canadian and American men.
  • Most prostate cancers are very slow growing, but some can grow and spread quickly. Research is being done to see how to detect the difference between slow and fast growing prostate cancers.
  • If the cancer is discovered before it spreads beyond the prostate gland it is potentially curable.

What causes it and who gets it?

Some of the known risk factors for this cancer are listed below. Not all of the risk factors below may cause this cancer, but they may be contributing factors.

  • The exact cause of prostate cancer is unknown.
  • Prostate cancer is very unusual under the age of 50. As men age, their risk increases, and most prostate cancers are diagnosed after age 70. The risk of prostate cancer rises more rapidly with age than any other cancer.
  • The risk of this cancer is twice as high in black men as in white men. North American Asian men have a lower risk than white men.
  • Family history can play a role in prostate cancer. If a number of male relatives on one side of your family have prostate cancer, especially if they were younger when they got it, you may be at higher risk for prostate cancer. Testing for hereditary risk for prostate cancer is not yet available.
  • High levels of testosterone may increase risk.
  • In the past, questions have been asked about a possible relationship between vasectomy and prostate cancer. The evidence suggests this is coincidence and that vasectomy is not a risk factor for prostate cancer.
  • Statistics

Can I help to prevent it?

  • Researchers suspect that diet may be associated with the development of prostate cancer. The American Institute for Cancer Research has published information that pulls together the evidence.
  • Eat a wide variety of fruits and vegetables each day.
  • Be physically active.
  • Maintain a healthy weight.

Screening for this cancer

  • No effective screening program exists for this cancer yet.
  • Digital rectal examination by a doctor during routine physical check-ups are a common way to check for these cancers.
  • There has been interest in the PSA (prostate specific antigen) test as a screening tool. The BC Cancer Agency has produced a pamphlet which discusses the issues, called the Pros and Cons of PSA Screening for Prostate Cancer.

Information about the PSA Test and its use in Prostate Cancer from the BC Cancer Agency By R. Gallagher, Genitourinary Tumour Group, BC Cancer Agency

The PSA test is a blood test that measures a substance produced by the prostate calledprostate specific antigen (PSA). There are 3 potential uses for PSA:
  1. PSA may be used for monitoring of established prostate cancer and metastatic disease (spread of prostate cancer) or detection of early recurrence of prostate cancer, where prostate cancer is already known.
  2. PSA may be used as a diagnostic adjunct in combination with other tests for early detection of prostate cancer in symptomatic men.
  3. As a screening tool.
Two randomized clinical trials, the 'gold standard' for evaluating screening tests have recently been published. One, the American PLCO trial shows no reduction in mortality from prostate cancer with screening. However, there are a number of potential problems with this trial. The European trial (ERSPC) shows a 20% reduction in prostate cancer mortality with screening. However, the authors have noted that the use of PSA screening results in over-treatment of many cancers which might not have otherwise been problematic. Because of the potential for both over-treatment of otherwise clinically non-significant tumours, and quality of life issues associated with the test the authors recommend that these issues be resolved before organized screening programs are contemplated.

Fit men, age 50-70 (men with at least 10 years life expectancy) should be made aware of the potential benefits and risks of early detection so that they can make an informed decision as to whether to have the test performed.

Additional Information about PSA:

PSA levels of less than 4 are generally considered normal, however a prostate cancer may exist even though levels are normal. The upper limit of normal depends on age and race, so for example, the 'normal' for a 50 year old man is 2.5

PSA levels higher than normal may indicate benign disease or prostate cancer. The higher the level, the more likely the presence of cancer. Refinements of the PSA test such as the percent free ratio, or the PSA velocity may increase its sensitivity for prostate cancer detection.

If a PSA level is elevated, further investigation and referral to a urologist is indicated.

If healthy men with no symptoms want a PSA test, they should speak to their family physician about the possible advantages and disadvantages of being tested. The cost is approximately $35.00. The PSA test may be covered by the medical plan if a physician has reason to suspect the patient may have cancer and feels the test is necessary due to suspicious symptoms.

Many prostate tumours can be felt with a rectal exam. However, small localized tumours are more likely to be detected by a combination of PSA and DRE (digital rectal exam).


Signs and symptoms

  • In the early stages, there may be no symptoms.
  • Sometimes prostate cancer is found coincidentally after surgery for benign (non-cancerous) prostate enlargement.
  • Prostate cancer is usually found during a routine physical examination.
  • As men age, the prostate can become enlarged for a number of reasons. Enlargement of the prostate can lead to difficulties with urination (peeing). These symptoms don't mean that cancer is present, but they should be checked with a physician.
    • starting or stopping urination is a problem
    • slow stream
    • painful urination or ejaculation
    • dribbling
    • frequent urination
    • loss of urinary control
    • blood in urine or ejaculate
    • night-time voiding
  • In advanced cases of prostate cancer, symptoms can include:
    • Weight loss
    • Fatigue
    • Backache or sciatica-like pain, or swelling of the legs that doesn't go away
Diagnosis & staging

Diagnosis

These are tests that may be used to diagnose this type of cancer.
  • Digital rectal examination (DRE) – a physician inserts a finger into the patient's anus to examine the prostate by touch.
  • PSA blood test – measures the levels of prostate specific antigen. Normal levels of PSA are considered between 4 - 7.
  • Transrectal ultrasound (TRUS) – can be used to see if there is a mass that may indicate a tumour.
  • Biopsy - uses ultrasound to guide a needle to the prostate, where tiny bits of the prostate are taken out to check for cancer.
  • If cancer is found, then more tests are needed to see if the cancer has spread:
    • If the PSA score is greater than 10, or if a high grade of prostate cancer is found in the biopsy, a bone scan may be performed to discover if the cancer has spread.
    • A CT scan can be useful in some cases.
  • Transurethral Resection of Prostate (TURP, also known as TUPR)
    • TURP can be used to obtain tissue for diagnosis in the case of cancer and/or for the removal of obstructions in benign prostate enlargement.
    • With TURP, there is no incision. A resectoscope is inserted through the penis and layers of the prostate are removed with an electric wire loop. Each layer of dead cells is then removed by a washing process. Bleeding is controlled using an electric current. A catheter may remain in place to help with urination.
For more information on tests used to diagnose cancer, see our Recommended Websites, Diagnostic Tests section.

Types and Stages

Types
  • More than 95% of prostate cancers are adenocarcinomas. The following treatment section refers only to this type.
Stages
Staging describes the extent of a cancer. The TNM classification system is used as the standard around the world. In general a lower number in each category means a better prognosis. The stage of the cancer is used to plan the treatment.
  • T describes the site and size of the main tumour (primary)
  • N describes involvement of lymph nodes
  • M relates to whether the cancer has spread (presence or absence of distant metastases)
The ABCD Staging numbers in parentheses refer to the older Whitmore-Jewett system.
  • T1
    Can't feel the tumour during a digital rectal exam (A)
  • T2
    A nodule that can be felt on rectal examination (B)
  • T2a
    The tumour is small, on one side of the prostate only (B1)
  • T2b
    On both sides but confined to prostate (B2)
  • T3
    Extends through the capsule of the prostate (C)
  • T4 or N+
    Tumour is touching or attached to other organs, or cancer has escaped to lymph nodes or beyond (D-1)
  • M+
    Metastatic (spread) to other organs, e.g. bone (D2)
Gleason Score
  • Prostate cancer tissue from the biopsy is viewed and given a score from 2 - 10. The score indicates how aggressive the cancer is, and how likely it is that the cancer will spread. The Gleason score assists the oncologists in choosing the best possible treatment options.
Risk Group*
  • Low risk
    • stage T1c, T2a
    • PSA level <=10 ng/mL
    • Gleason score <= 6
  • Intermediate risk (neither high nor low risk)
    • stage <= T2b
    • PSA level >10 and <=20 ng/mL
    • Gleason score of 7
  • High risk
    • stage T2c
    • PSA level >20 ng/mL
    • Gleason score >= 8
*adapted from: D'Amico AV, et al. JAMA. 1998;280:969-974.
Treatment

Treatment

Cancer therapies can be highly individualized – your treatment may differ from what is described below.

  • Standard treatment for prostate cancer can include surgery, radiation, hormone therapy or a combination. Some prostate cancers do not require active therapy. The type of treatment is influenced by the patient's age, medical condition and personal desires. For treatment options in localized prostate cancer, see below.
    • What's a man to do? This Canadian Family Physician article describes the choices men face in making a treatment decision for localized prostate cancer.
Active Surveillance
  • This is sometimes called watchful waiting, but it is more accurate to refer to it as active surveillance.
  • Patients who are in the low and minimal risk category and who have no active treatment have a more than 99% survival rate at 10 years. It is uncertain if treatment affects the survival rate beyond 10 years.
  • Because the side effects of treatment for prostate cancer can be considerable, active surveillance should always be considered for low risk patients.
  • Sexual function is maintained during active surveillance.
  • Active surveillance can be an option if:
    • the cancer appears late in life.
    • the prostate cancer is small and slow growing.
    • treatment is not possible due to other health considerations.
  • Active surveillance consists of careful monitoring of the patient and testing on a regular basis. For more information, see our Active Surveillance Guidelines.
Radiotherapy
  • If the cancer is localized (Stage T1 - T3), radiotherapy is given with the intent to cure the cancer.
  • Prostate radiation that is intended to cure may temporarily cause diarrhea and aggravation of hemorrhoids.
  • Radiation treatment can be given in several different ways. The most common ways are described below.
  • External beam radiation can also be used to relieve symptoms caused by metastases (cancer spread). In those cases, a single treatment may be used.
  • More advanced cancers may use radiation therapy to control the cancer, without the intent to cure.
External Beam Radiotherapy
  • External beam radiation may be used at any stage of cancer.
  • Sometimes standard external beam radiotherapy is the best choice for radiation therapy.
  • Radiation treatment that is intended to cure usually takes seven weeks of Monday to Friday radiation. The appointments don't take much time, each is approximately twenty minutes.
  • For T1 and T2 cancers, survival rates for radiation may be equivalent to prostatectomy, although no direct comparison has been done. Risk of recurrence is between 5-50%.
Brachytherapy
  • Brachytherapy is a method of giving internal radiotherapy. Radioactive seeds are placed inside the prostate. They can be placed very near to the tumour. The seed implants are permanent, but they lose their radioactivity over time.
  • The side effects of brachytherapy can be less than surgery or external beam radiation therapy.
  • About 2/3 of newly diagnosed prostate cancer patients are considered good candidates for brachytherapy.
  • For more information, see our Brachytherapy Guidelines.
Intensity Modulated Radiation Therapy / RapidArc
  • IMRT is a specific way of delivering external beam radiation therapy that allows the beam to better define the area being radiated.
    • Uses 5 stationary beams at a time.
    • Using IMRT, the prostate receives a higher dose of radiation but the bladder and rectum receive less radiation with this method. This can minimize side effects.
  • The BC Cancer Agency developed traditional IMRT further, resulting in RapidArc.
    • Prior to treatment, 3 gold seeds are inserted into the prostate, which allows the most accurate positioning of the patient for treatment.
    • RapidArc uses one continuously moving beam of radiation, using IMRT technology.
    • RapidArc is as effective as IMRT, but it takes less time.
    • Side effects are equal to IMRT.
    • RapidArc has increased the efficiency of dose delivery.
Surgery

Radical Prostatectomy
  • This surgery is used for localized cancer (stages T1-T2). It is also called "total prostatectomy."
  • In a retropubic prostatectomy, the incision is below the navel. This is the most common type of prostatectomy. Surgery may also be done through the perineum (called a radical perineal prostatectomy).
  • The first step in this surgery is to remove some pelvic lymph nodes (also called a lymphadenectomy) and have a pathologist check to see if they are cancerous. If cancer is found in the lymph nodes, the procedure stops because continuing the surgery is not useful at this point (with some exceptions). If cancer is not found in the lymph nodes, the surgeon continues and removes the prostate.
  • All total prostatectomies remove the prostate gland and seminal vesicles.
  • A catheter is left in place for 10 - 21 days after surgery.
  • The pain levels are considered moderate and can be controlled with medication.
  • One month's convalescence is required.
  • Men may lose their ability to have an erection after surgery, but recent surgical advances allow a proportion of patients to retain their sexual function. Questions about this side effect should be discussed with the surgeon. Erections may also be regained by using injections or a vacuum pump device.
  • Incontinence is losing the ability to control urination (peeing). This may be a side effect of the surgery. Leaking often subsides after 6 to 12 months. Incontinence is nearly always treatable by using external appliances, medication or surgical implants.
Hormone Therapy
  • Prostate cancers are mostly 'androgen dependent.' Androgens are male hormones. By lowering the hormone levels in men, symptoms can be relieved and tumour growth can be reversed.
  • There are 2 different ways that the levels of male hormones can be decreased; surgically or by using hormone therapy:
    • Surgical castration (orchiectomy) means removing the testes. They are the glands which produce the hormones.
    • Medical castration means that the patient takes hormone medication. It is as effective as surgical castration. The hormones can be taken by injection or as pills.
  • Both medical and surgical castration result in impotence and loss of sex drive. Medical castration is reversible if the patient stops taking the hormones.
  • There are different drugs for hormone therapy. They can act by blocking the production of hormones, the release of hormones or by blocking the effects of hormones.
  • Hormone therapy may be added to radiation therapy to improve its effectiveness for localized cancer. Typically it is used for a few months before radiation and for a year or two after radiation.
  • Remissions with hormone therapy are temporary, lasting on average 2 to 3 years, with occasional patients enjoying a long-term remission.
Chemotherapy
  • Chemotherapy is used to relieve symptoms of advanced cancer but will not lead to a cure.
  • It can also provide a temporary remission in some patients.
Other Treatments
  • These treatments are not in use in B.C. They are experimental (not yet proven to be better) or they are not useful, but as patients frequently request information about these procedures, we include this information here.
Cryosurgery
  • Cryosurgery uses freezing to treat the prostate cancer. It is still experimental.
High Intensity Focused Ultrasound (HIFU)

Follow-up after treatment

  • Guidelines for follow-up after treatment are covered on our website. There are separate follow-up pages for radiotherapy or surgery.
  • You will be returned to the care of your family doctor or specialist for regular follow-up. If you do not have a family physician, please discuss this with your BC Cancer Agency oncologist or nurse.
  • Follow-up testing is based on your type of cancer and your individual circumstances.
  • Life after Cancer focuses on the issues that cancer survivors can face.
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