If I have prostate cancer, how should I feel?

I have prostate cancer but I am not feeling anything. Is that normal?

Most men with early prostate cancer don’t experience any signs.  Typically, prostate cancer tends to start growing in the outer part of the gland, so there is no pressure on the water pipe that leads to symptoms experienced by men with advanced prostate cancer.

Change in your water habit is more likely to be an issue from the prostate that has grown (medically, this is called benign prostatic hyperplasia – BPH). If you are experiencing the following, you still need to go to your NHS urologist or private urologist;

• taking a long time to start emptying your bladder
• a poor flow / intermittent stream of urine
• you remain in doubt if you have emptied your bladder completely
• waking at night to empty the bladder
• an urge to urinate or increased frequency of urinating

If prostate cancer progresses and breaches the capsule of prostates or spreads to different areas of the body, it can cause a person to complain of:

• bone pain (typically back pain)
• changes in your erections
• tiredness
• loss of appetite
• blood urine
• blood in ejaculate or semen
• loss of weight with no apparent reason.

Do I have prostate cancer? How is a prostate cancer diagnosis made?

The only way to know is to visit your doctor for a prostate exam and a blood test called PSA. If an abnormality is detected on these, you will be referred to an NHS urologist or private urologist who will guide further tests, typically an MRI plus minus biopsy.

Should all men get checked?

Every country has a different viewpoint on this. Data has shown that screening for prostate cancer has a role. If you have any of the following;

• are  aged 50 or over
• have a direct relative like a father or brother who had prostate cancer
• you are of black and afro Caribbean origin
• have a family history of breast or colon cancer

it is best to visit your doctor and kick-start your investigations.

What is PSA?

Prostate Specific Antigen (PSA) is a blood test that shows how active your prostate is. It can be high due to different reasons (recent ejaculation, infection, inflammation, prostate cancer, enlarged prostate, recent instrumentation like catheter insertion, intense exercise) so one needs to interpret it with caution.

Is there a normal PSA?

Historically, a PSA cut-off of 4 was considered the threshold. The argument is more complicated, and different thresholds have been utilised throughout the years.

There is no ‘normal’ PSA.

A PSA of 4 means 27% per cent risk of prostate cancer, and a PSA of 3 means 24%.  You can have men with a PSA of 1 who develop prostate cancer (very rare).

This means that a PSA as a standalone test is not suitable. One needs to analyse the trajectory of the numbers and combine it with other important elements like the medical, family history and clinical examination.

If PSA is unreliable, then how come it is quite reliable after radical prostatectomy?

PSA post-radical treatment, like robotic prostate removal or radical radiotherapy, is highly reliable as any detected PSA raises the suspicion of cancer recurrence. So your NHS urologist / private urologist is correct in their statements.

What is my next step if I have a high PSA and a normal rectal exam?

If there is no contraindication (pacemaker/metalwork/extreme claustrophobia), your next step is an MRI scan of your prostate.

In the old days, patients were immediately directed for a biopsy; however, nowadays, we perform an MRI scan of the prostate. If you have not been offered this, make sure to be referred to do one before having the biopsy done.

What are the benefits of an MRI scan?

• Gives information on the prostate size and characteristics and can give an idea through a specific score of the likelihood of the presence of an aggressive cancer
• low-risk cancers are typically not picked up, which means you are less likely to have a biopsy and be over-treated, with a detriment to your quality of life.
• Allows preplanning of your biopsies to be directed in the areas of interest rather than blindly.
• It can show if the disease has spread

What does an MRI scan involve?

Before the scan, a healthcare professional will go through questions about your health to ensure it is safe to go ahead for an MRI scan.

You will lie very still on a table, which will move slowly into a tunnel-shaped scanner shaped like a long tunnel. Ear plugs/headphones are given as the sound generated by the machine can be annoying.

If you are claustrophobic, you can do the scan feet first, the GP can prescribe an anxiolytic to take an hour before the test to calm down, and if available, some scanners are larger than others, and if you inform the team before, it may be an option to explore.

There are open MRI scans; however, the detail obtained by these is not of good quality.

A dye is typically given in a cannula introduced in your vein.

The scan takes 30 to 40 minutes to be completed. Afterwards, drinking plenty of fluids is recommended to flush out the dye from your system.

How is the MRI scored?

The scoring system typically used is the PI-RADS (Prostate Imaging – Reporting and Data System) score. There is a Likert score, but the PI-RADS is the most commonly used. This ranges from 1 to 5, with

PIRADS 1 and 2 benign changes, no need to worry.

PIRADS 3 the images are equivocal, neither here nor there.

PIRADS 4 suspicious of prostate cancer.

PIRADS 5 is strongly suspicious.

Can an MRI miss significant prostate cancer?

15 to 20% of the MRI scans may miss significant prostate cancer. Your NHS consultant or private urologist should interpret the MRI scan with your medical and family history, PSA and rectal exam.

If my MRI scan is suspicious, what will I be offered?

Your urologist will discuss the scans and refer you for a prostate biopsy. There are different ways biopsies are done, but the gold standard is transperineal template biopsies, which are now done under local anaesthesia.

What lifestyle changes do men use to prevent prostate cancer?

Research is controversial as some foods have not shown a benefit, but in other studies, the same food types did show a lower risk.

As a prostate cancer clinical champion, I recommend that men to follow a balanced diet containing a variety of healthy food.