Prostate Cancer

What is the prostate gland?

The prostate is a small gland, walnut-shaped and is part of the male reproductive system. Production of prostate fluid is its primary function. This fluid adds to the semen volume and is crucial to fertility as it nourishes and transports sperm.

The prostate gland is located below the bladder. The water pipe (urethra) passes through the prostate and carries urine from the bladder or, during orgasm, carries the ejaculate.

The last part of the large bowel is called the rectum, which lies behind the prostate gland.

The prostate gland has a role in hormone production. It changes testosterone into a biologically active form called dihydrotestosterone (DHT) which is ten times more potent.

How common is prostate cancer?

It is the most common cancer in men; 1 in 8 men is affected.

143 men are newly diagnosed every day.

There is one death from prostate cancer every 45 minutes.

Prostate cancer is responsible for the death of 12,000 men every year

What are the risk factors for developing prostate cancer?

1. Family history of prostate cancer
2. Family history of breast cancer / ovarian cancer or colon cancer
3. Black men or Afro Caribbean origin or Afro-American origin
4. Old age

When should I check my prostate?

The European Health Union 2022 has updated their position and recommends testing men up to 70 years with a  prostate specific antigen (PSA). Those needing further investigations will be referred for a magnetic resonance imaging (MRI scan) of the prostate.

In the United Kingdom, there is no national screening programme, although data for this common cancer has shown solidly that screening for prostate cancer has a role. Instead, there is an informed choice programme, referred to as prostate cancer risk management, for healthy men aged 50 years or over who ask their general practitioner (GP), NHS consultant, or private urologist about the pros and cons of doing a PSA test.

What is a PSA blood test?

Prostate Specific Antigen (PSA) is a blood test showing your prostate’s activity.

One needs to interpret it with caution as it can be high due to different reasons;

• recent ejaculation,
• infection,
• inflammation,
• prostate cancer,
• enlarged prostate,
• recent instrumentation like urinary catheter insertion,
• intense exercise

What is a normal PSA?

Historically, a PSA cut-off of 4 ng/ml was considered the threshold. The argument is more complicated; the thresholds have been lowered throughout the years.

There is no such ‘normal’ PSA.

A PSA of 4 ng/ml means a 27% per cent risk of having prostate cancer, and a PSA of 3 ng/ml means 24%.  

This means that a PSA as a standalone test is not suitable. One needs to look at the trajectory of the PSA levels and combine the information with other essential elements like the medical, family history and digital rectal examination.

Should I check my PSA?

If you have any of the following;

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

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

What further tests are there apart from PSA?

If your PSA is high or the prostate examination is abnormal, doctors can order an MRI scan of your prostate. You will be asked to undergo a prostate biopsy if this is suspicious.

What are the prostate cancer symptoms? What should I feel?

Most men with early stages prostate cancer don’t feel anything.  

Typically prostate cancer starts growing in the outer part of the gland, so at the early stage, there is no pressure on the urethra that leads to waterwork changes experienced by men with advanced prostate cancer.

Difficulty emptying your bladder 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 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 (the covering of the prostate gland) 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 (impotence)
• tiredness
• loss of appetite
• bleeding in the urine or blood in the ejaculate
• loss of weight with no apparent reason.

What is the Cambridge prognostic group (CPG) system?

The National Institute for Health and Care Excellence (NICE) now recommends the CPG system over the traditional three-group system, classifying prostate cancer into low, intermediate or high risk.

The CPG helps men to form informed decisions about the management of prostate cancer.

How is the CPG divided?

CPG consists of five groups.

CPG 1

• a Gleason score of 6 (Gleason Group 1)
• and a PSA level of less than 10 ng/ml
• and a T stage of 1 or 2

CPG 2

• a Gleason score of 3 + 4 = 7 (Gleason Group 2)
• or a PSA level between 10 and 20 ng/ml
• and a T stage of 1 or 2

CPG 3

• a Gleason score of 3 + 4 = 7 (Gleason Group 2)
• and a PSA level between 10 ng/ml and 20 ng/ml
• and a T stage of 1 or 2

Or

• a Gleason score 4 + 3 = 7. (Gleason Group 3)
• and a T stage of 1 or 2

CPG 4

You have one of the following

• Gleason score of 8. (Gleason Group 4)
• PSA level higher than 20 ng/ml
• T stage of 3

CPG 5

You have two or more of the following

• Gleason score 8. (Gleason Group 4)
• PSA level higher than 20 ng/ml
• T stage of 3

Or

• Gleason score 9 to 10. (Gleason Group 5)

Or

• T stage of 4

How will CPG help in decision-making?

Your CPG is a risk checker and guides your NHS consultant or private urologist on the way forward. Treatment choice depends on other factors like:

• general health (biological age)
• your age (chronological age)
• your views on the treatment options

Your doctor may recommend close monitoring for CPG 1, 2 or 3. Depending on the situation, this can be either:

• active surveillance
• watchful waiting

Your doctor might recommend treatment if you are in the CPG 2, 3, 4 or 5 groups. This can be;

• Radical Prostatectomy  (Robotic Surgery or Open Surgery or Laparoscopic surgery)
• Radiation Therapy with hormone treatment
• Experimental treatment like high-intensity focused therapy (HIFU),  cryotherapy or NanoKnife IRE

What treatment options are there for metastatic prostate cancer

The following can be explored depending on your level of fitness;

• Chemotherapy
• Novel Antiandrogens (Abiraterone, Enzalutamide, Darolutamide)
• Hormonal Therapy
• Watchful waiting

Is prostate cancer very curable?

Prostate cancer care has evolved with encouraging results both for early stage and late stage as a result of continuous research.

More men are seeking to check themselves and get an earlier diagnosis. More treatments are available, which means that doctors and patients have to honestly discuss when to avoid unnecessary treatment and when not to delay treatment. Yet more needs to be done to provide the necessary support and address concerns as more men are living longer.

Charities like prostate cancer UK, Movember and others are raising more awareness, empowering men and support research.

How to prevent prostate cancer?

Things you can change: Eating habits and Lifestyle

Men with an increased risk for prostate cancer through age, race, or genetic factors seek natural ways to prevent prostate cancer by following a healthy diet and a regular exercise regimen. Studies show mixed results however many men explore these lifestyle changes.

How long do you live after prostate cancer?

For more precise prostate cancer survival data, the stage of the disease at diagnosis is the most critical factor.

Early prostate cancer carries a better prognosis than metastatic prostate cancer. Ask your NHS consultant, private urologist or cancer nurse specialist what stage you are in.

One-year net survival of prostate cancer by stage

• Stage 1 carry a survival rate of 100%
• Stage 2 carry a survival rate of 100%
• Stage 3 carry a survival rate of 100%
• Stage 4 carries only a survival rate of 88%.

Five-year net survival of prostate cancer by stage

• Stage 1 carry a survival rate of 100%
• Stage 2 carry a survival rate of 100%
• Stage 3 carry a survival rate of 95%
• Stage 4 carry a survival rate of 49%