Prostate Cancer

Prostate cancer is one of the most common cancers affecting men worldwide, but many cases grow slowly and can be successfully managed with modern treatments and careful monitoring.

Table of contents

• What is Prostate Cancer?
• The Prostate Gland
• Who Gets Prostate Cancer?
• Symptoms
• How Prostate Cancer is Diagnosed
• Types of Prostate Cancer
• Treatment Options
• Monitoring Without Immediate Treatment
• Living with Prostate Cancer
• Prevention and Risk Reduction

What is Prostate Cancer?

Prostate cancer is a disease in which cells in the prostate gland grow out of control^[1][4]. It is cancer that develops in the prostate, a small, walnut-shaped gland located below the bladder and in front of the rectum in males^[3].

Prostate cancer is the most commonly diagnosed malignancy in men globally and the fifth leading cause of cancer-related deaths in men^[5]. In 2020, there were 1,414,249 newly diagnosed cases and 375,000 deaths worldwide annually due to this disease^[5]. In the United States, about one out of eight men will be diagnosed with prostate cancer during their lifetime^[10].

Fortunately, most prostate cancers tend to grow slowly and are low-grade with relatively low risk and limited aggressiveness^[5]. Many men with prostate cancer, especially those with tumors that have not spread beyond the prostate, die of other causes without ever having any symptoms from the cancer^[8].

The Prostate Gland

• Bladder
• Rectum
• Urethra
• Seminal vesicles
• Penis
• Testicles

The prostate is a part of the male reproductive system, which includes the penis, prostate, seminal vesicles, and testicles^[4]. The prostate is located just below the bladder and in front of the rectum. It is about the size of a walnut and surrounds the urethra, which is the tube that empties urine from the bladder^[4].

This tiny gland secretes fluid that mixes with semen, keeping sperm healthy for conception and pregnancy^[3]. The prostate produces fluid that makes up a part of semen^[4].

As a man ages, the prostate tends to increase in size. This can cause the urethra to narrow and decrease urine flow. This is called benign prostatic hyperplasia (a noncancerous enlargement of the prostate), and it is not the same as prostate cancer^[4].

Who Gets Prostate Cancer?

Prostate cancer affects one in seven men, making it the second most common cancer among men worldwide^[1]. For every 100 males, 13 will develop prostate cancer at some point in their lives^[3].

Your risk increases as you get older. You’re more likely to get diagnosed if you’re over 50, and about 60% of prostate cancers occur in people older than 65^[3].

Several factors can increase your risk of prostate cancer:

• Race and ethnicity: Your risk is higher if you’re Black or of African ancestry, especially for aggressive cancers and those diagnosed before age 50^[3]. African-American men are more likely to get prostate cancer than other men, are more than twice as likely to die from prostate cancer, get prostate cancer at a younger age, tend to have more advanced disease when it is found, and tend to have a more severe type of prostate cancer^[8].
• Family history: You’re two to three times more likely to get prostate cancer if a close family member has it^[3]. You may have an increased risk if you have more than one first-degree relative (father, son, or brother) who had prostate cancer, including relatives in three generations on your mother’s or father’s side of the family^[8].
• Genetics: You’re at a greater risk if you have Lynch syndrome or if you inherited mutated (changed) genes associated with increased breast cancer risk (BRCA1 and BRCA2)^[3].
• Age at diagnosis: You were diagnosed with prostate cancer when you were 55 years old or younger^[8].

Some studies have identified other potential risk factors, but the evidence is mixed. Other potential risk factors include smoking, prostatitis (inflammation of the prostate), having a BMI greater than 30 (having obesity), sexually transmitted infections, and exposure to Agent Orange^[3].

Symptoms

Early-stage prostate cancer rarely causes symptoms^[3]. There are no initial or early symptoms in most cases^[5]. Many men do not have symptoms at all^[8].

But as prostate cancer progresses, you may start to notice changes. If you have any of the following symptoms, be sure to see your doctor right away^[8]:

• Frequent, sometimes urgent, need to pee, especially at night^[3]
• Weak urine flow or flow that starts and stops^[3]
• Difficulty starting urination^[8]
• Difficulty emptying the bladder completely^[8]
• Pain or burning when you pee^[3]
• Loss of bladder control^[3]
• Loss of bowel control^[3]
• Painful ejaculation and erectile dysfunction^[3]
• Blood in semen or pee^[3]
• Pain in your low back, hip or chest^[3]
• Pain in the back, hips, or pelvis that doesn’t go away^[8]

Keep in mind that these symptoms may be caused by conditions other than prostate cancer^[8]. Other conditions may cause the same symptoms. As men age, the prostate may get bigger and block the urethra or bladder. This may cause trouble urinating or sexual problems. The condition is called benign prostatic hyperplasia, and although it is not cancer, surgery may be needed^[10].

When prostate cancer is detected in an advanced stage, late symptoms may include fatigue due to anemia, bone pain, paralysis from spinal metastases, and renal failure from bilateral ureteral obstruction^[5].

How Prostate Cancer is Diagnosed

Doctors use screening tests, physical exams, scans and, sometimes, a biopsy to diagnose prostate cancer^[3]. Most people start screening at age 55, or earlier if they’re at a higher risk. Screening usually stops after age 70^[3].

Diagnosis is primarily based on prostate-specific antigen testing and transrectal ultrasound-guided prostate tissue biopsies, although prostate-specific antigen testing for screening remains controversial^[5].

In addition to asking about your personal and family health history and doing a physical exam, your doctor may perform the following tests and procedures^[10]:

• Digital rectal exam (DRE): An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the rectum and feels the prostate through the rectal wall for lumps or abnormal areas^[10].
• Prostate-specific antigen (PSA) test: A blood test that measures the level of PSA in the blood. PSA is a substance made by the prostate that may be found in higher than normal amounts in the blood of men who have prostate cancer. The PSA level may also be elevated in other conditions that affect the prostate^[10]. As a rule, the higher the PSA level in the blood, the more likely a prostate problem is present. But many factors, such as age and race, can affect PSA levels. Some prostate glands make more PSA than others^[8].
• MRI scan: Magnetic resonance imaging scans may be used to help visualize the prostate and surrounding structures^[5].
• Prostate biopsy: A biopsy is done to diagnose prostate cancer and find out the grade of the cancer (Gleason score)^[10].
• PSMA PET scan: An imaging procedure that is used to help find prostate cancer cells that have spread outside of the prostate, into bone, lymph nodes, or other organs^[10].

Newer diagnostic modalities include free and total PSA levels, PCA3 urine testing, Prostate Health Index (PHI) scoring, the 4K test, exosome testing, genomic analysis, magnetic resonance imaging, Prostate Imaging-Reporting and Data System (PI-RADS) scoring, and MRI-TRUS fusion-guided biopsies^[5].

Types of Prostate Cancer

If you’re diagnosed with prostate cancer, it’s most likely an adenocarcinoma (a cancer that starts in the cells of glands that secrete fluid, like your prostate)^[3]. Rarely, prostate cancer forms from other types of cells.

Less common types of prostate cancers include^[3]:

• Small cell carcinomas
• Transitional cell carcinomas
• Neuroendocrine tumors
• Sarcomas

When the cancer is limited to the prostate, it is considered localized and potentially curable^[5]. If the disease has spread outside the prostate, treatment options may vary^[5].

Treatment Options

Treatment options might include surgery or radiotherapy^[14]. Different types of treatment are available for prostate cancer, and you and your doctor will decide which treatment is right for you^[11].

Some common treatments for prostate cancer are^[11]:

• Surgery: Surgery for prostate cancer involves removing your prostate gland (radical prostatectomy)^[14]. Radical prostatectomy removes the prostate as well as the seminal vesicles (glands that produce the fluids that will turn into semen)^[11].
• Radiation therapy: Using high-energy rays (similar to x-rays) to kill the cancer. There are two types of radiation therapy: External radiation therapy, where a machine outside the body directs radiation at the cancer cells, and internal radiation therapy (brachytherapy), where radioactive seeds or pellets are surgically placed into or near the cancer to destroy the cancer cells^[11].
• Hormone therapy: Prostate cancer usually depends on testosterone to grow. Hormone therapy blocks or lowers the amount of testosterone in the body^[14]. This is also called androgen deprivation therapy^[11].
• Chemotherapy: Using special drugs to shrink or kill the cancer after it has spread to other parts of the body. The drugs can be pills you take or medicines given through your veins, or, sometimes, both^[11]. Chemotherapy is a common treatment for metastatic prostate cancer. The most common type is docetaxel. You usually have it together with hormone therapy^[14].

Other therapies may be used, depending on whether the prostate cancer has spread^[11]:

• Cryotherapy: Placing a special probe inside or near the prostate cancer to freeze and kill the cancer cells. This is a less common treatment^[11]. Cryotherapy uses extreme cold to destroy cancer cells. It isn’t a common treatment for prostate cancer and is only available in the UK in specific centres or as part of a clinical trial^[14].
• Biological therapy: Works with your body’s immune system to help it fight cancer or to control side effects from other cancer treatments^[11].
• High-intensity focused ultrasound (HIFU): This therapy directs high-energy sound waves (ultrasound) at the cancer to kill cancer cells. This is a less common treatment^[11]. HIFU uses high frequency sound waves to destroy prostate cancer cells. It isn’t a common treatment for prostate cancer. It is only available in specific centres or as part of a clinical trial^[14].
• Targeted therapy: Using drugs that attack cancer cells while minimizing damage to healthy cells. Targeted therapy is used to treat prostate cancer that has spread to other parts of the body and is no longer responding to hormone therapy^[11].

Your specialist doctor discusses whether you need treatment, and what your treatment options are^[14]. Talk to your cancer doctor about the treatment options available for your type and stage of cancer. Your doctor can explain the risks and benefits of each treatment and their side effects^[11].

Monitoring Without Immediate Treatment

Prostate cancer does not always need treatment. If the cancer has not spread, your care team may suggest monitoring your cancer to see if it is growing or not^[14]. If your doctor thinks your prostate cancer is unlikely to grow quickly, he or she may recommend that you don’t treat the cancer right away^[11].

If your cancer is small and not causing any symptoms, it may just be monitored at first. This is because prostate cancer often grows slowly and may never cause problems. Treatments for prostate cancer can also cause side effects, which can be serious and long-lasting^[16].

If your care team recommends monitoring your cancer, they may suggest either^[16]:

• Watchful waiting: Having regular check-ups and blood tests at your GP surgery. No tests are done. Your doctor treats any symptoms when they develop. This is usually recommended for men who are not expected to live for more than 10 more years^[11].
• Active surveillance: Closely monitoring the prostate cancer by performing prostate specific antigen (PSA) tests and prostate biopsies regularly, and treating the cancer only if it grows or causes symptoms^[11]. Having regular tests and scans in hospital^[16].

If the cancer grows or starts to cause symptoms, your care team will talk to you about your treatment options^[16].

Living with Prostate Cancer

Life goes on after a prostate cancer diagnosis, and often for a very long time^[18]. Getting practical and emotional support can help you to cope with a diagnosis of prostate cancer. It can also help you with life during and after treatment^[19].

During treatment, your care team can help you cope with and manage any physical and emotional issues. The support of your family and friends can help, too^[21]. You might also find it helps to talk with others who are dealing with the same issues. Ask your care team about in-person or online support programs^[21].

Learning to live with the inevitable uncertainty about treatment outcomes is a challenge for anyone^[17]. Although there are no guarantees that you’ve achieved a cure, you may actually live your full natural life span. Your PSA level should be checked at appropriate intervals for the rest of your life^[17].

Some men experience “PSA anxiety” around the time they’re due for testing, but many manage to live without obsessive worry about recurrence^[17]. Some changes to expect after treatment include^[21]:

• Changes in sexual function: Treatment for prostate cancer often affects your sexual function. This includes your interest in sex or sex drive. And it also includes erectile dysfunction, which is when you have trouble getting or keeping an erection. In most cases, these problems can be treated^[21]. Sex will be a little different if you have surgery to remove your prostate gland. It means you won’t ejaculate, though you can still have an orgasm. Trouble getting erections or having orgasms is also a risk after an operation or if you have radiation therapy^[18].
• Bladder problems: After surgery or radiotherapy, you might have problems with your bladder. These can include leaking urine, bladder inflammation and difficulty passing urine^[19]. You might feel the urge to go to the bathroom all the time, not be able to go when you want to, have a weak stream, or leak in between trips to the toilet^[18]. These side effects may go away soon after treatment, or they might linger for a while^[18].

You can work with your doctor to cut those risks. Start by asking about “nerve-sparing” surgery and more precise radiation therapy^[18]. If you do end up having problems after treatment, you’re not out of luck. Keep in mind that for many men, the problems go away on their own once the body has time to heal^[18].

You can live a long time with prostate cancer. If you catch and treat it early, you might even be able to cure it. Staying as healthy as possible plays an important role. Follow these tips^[18]:

• Stay informed. Ask your doctor how likely the cancer is to come back or to get worse, when it might happen, and signs you should watch for.
• Continue follow-up care. This means getting the tests your doctor suggests and keeping all your medical appointments. You’re more likely to notice troubling signs before they become serious.
• Exercise regularly. Some research suggests those who exercise after prostate cancer treatment live longer than those who don’t. More studies are needed. Even so, exercise has several known benefits and is an important part of your overall health.
• Eat healthy foods. Lots of fruits and vegetables help keep your immune system strong and lower your risk of cancer.
• Keep your weight under control. Studies show being overweight lowers your chances of getting better after treatment. More research is needed to know if losing weight helps, but maintaining a healthy weight is also an important part of your overall health.
• Manage stress.

After treatment for prostate cancer, you have regular check ups. This includes tests to check your PSA level^[14]. You’ll have regular check-ups during and after any treatments. You may also have tests and scans^[14].

Prevention and Risk Reduction

There’s no proven prevention strategy for prostate cancer^[20]. Prevention may have little effect on disease-related mortality^[12]. But you may reduce your risk of prostate cancer by making healthy choices, such as exercising and eating a healthy diet^[20].

Researchers haven’t found a sure way to prevent prostate cancer. Study results often conflict with each other. And most studies aren’t designed to prove whether something can prevent prostate cancer. But healthcare professionals suggest that people with an average risk of prostate cancer make healthy lifestyle choices for prostate cancer prevention^[20].

Some things you can do^[20]:

• Choose low-fat foods: In some studies, those who ate the highest amount of fat each day had an increased risk of prostate cancer. This doesn’t prove that eating excess fat causes prostate cancer. Other studies haven’t found this link. But cutting the amount of fat you eat each day has other plusses. For instance, cutting fat can help you control your weight and improve heart health.
• Eat more fruits and vegetables each day: Fruits and vegetables are full of vitamins and nutrients that are thought to cut the risk of prostate cancer, but research hasn’t proved that any nutrient cuts your risk.
• Maintain a healthy weight: Studies show being overweight lowers your chances of getting better after treatment.
• Exercise regularly: A healthy lifestyle with 30 minutes of exercise a day has shown to be protective^[9].

There isn’t any strong evidence that you should eat or avoid particular foods when you have prostate cancer. But you should try to have a healthy diet and stay within the government guidelines for drinking alcohol^[19].

A support group can help both you and your loved ones before, during and after treatment. Studies have shown the value of support groups in aiding decision-making, enhancing quality of life and possibly even in prolonging life. Talking with other men whose prostate cancer was successfully treated can be tremendously reassuring^[17].