Prostate cancer

The prostate gland is part of the male reproductive system. It produces some of the fluid that makes up semen.

Prostate cancer is the most common cancer in Australia, affecting one in five Australian men. Around 6,300 Victorian men alone are diagnosed with prostate cancer every year.

Every person's body is different, so it is good to know what is normal for your body. This information is relevant for all people who have a prostate gland.

Risks and causes of prostate cancer

The exact causes of prostate cancer are unknown. However, there are some risk factors we know about, including:

• Getting older – your risk of prostate cancer increases as you get older.
• Family history – having a family history of prostate cancer. If your father was diagnosed with prostate cancer before the age of 65 or your brother has been diagnosed with prostate cancer, your risk is at least double .
• Black Sub-Saharan ancestry – there is evidence that men with Black Sub-Saharan ancestry have a higher risk of prostate cancer and are more likely to be diagnosed at a younger age.
• Confirmed BRCA2 gene mutations - men with BRCA2 gene mutations are at higher risk of prostate cancer, particularly aggressive prostate cancer.
• Family history of breast and ovarian cancer and Lynch Syndrome – There is increasing evidence that men from families with hereditary breast and ovarian cancer and Lynch Syndrome may also be at higher risk of prostate cancer

Symptoms of prostate cancer

Early prostate cancer usually causes no symptoms. When symptoms do occur, they may include:

• difficulties starting and stopping urination
• pain or a burning sensation when passing urine
• urinating more often than usual, particularly at night
• the feeling that the bladder can't be fully emptied
• dribbling urine
• blood in the urine or semen
• pain during ejaculation.
• Pain in the lower back, upper thighs or legs
• Bone pain
• Unexpected weight loss.

Many of these symptoms can also be caused by conditions usually less serious than prostate cancer. Most enlargements of the prostate are benign, which means they are not cancer and can be easily treated. You should discuss any symptoms with your doctor.

Diagnosis of prostate cancer

Prostate cancer is diagnosed using a number of tests. To start with, your doctor will organise a Prostate-specific antigen (PSA) test – the prostate makes a protein called PSA. This is a simple blood test. Large quantities of PSA in the blood, or a rising PSA, can indicate prostate cancer or other prostate problems. If your PSA levels indicate a problem, your doctor will refer you for further investigation. From there, tests may include:

• Digital rectal examination (DRE) – a urologist may perform a DRE as part of their investigations if required. Using a gloved finger in the rectum, the specialist will feel for enlargement and irregularities of the prostate.
• Multiparametric Magnetic Resonance Imaging (mpMRI) - is a scan to assess the prostate size and look for any abnormal areas. It is used to determine the likelihood that cancer is present, determine the area affected and if a biopsy is necessary..
• PSMA PET/CT – is a newer technology that is a very sensitive and accurate way to see and find prostate cancer wherever it is in the body.
• Biopsy – tissue samples are taken from the prostate and examined in a laboratory for the presence of cancer cells.

Test results can take a few days to come back. It is very natural to feel anxious while waiting to get your results. It can help to talk to a close friend or relative about how you are feeling. You can also speak with a Prostate Cancer Foundation of Australia Specialist Nurse on Tel. 1800 22 00 99.

Treatment for prostate cancer

Prostate cancer treatment depends on a range of factors such as the man’s age, physical condition, the stage of his prostate cancer and his personal preference. Prostate cancer can be treated in a variety of ways, so carefully discuss treatment options with your doctor and seek referral to other specialists to discuss each of your treatment options

If you prostate cancer is contained within the prostate treatment may include:

• Active surveillance – if immediate treatment is not needed, you may instead go on active surveillance. This means you will have regular PSA and DRE tests, MRI prostate scans and repeat biopsies to monitor if anything changes. If it does, your doctor will discuss other treatment options.
• Surgery –removal of the prostate is called a radical prostatectomy. The operation can be performed by open surgery (the traditional way), or by a ‘keyhole’ (laparoscopic) approach. You can also have another type of keyhole surgery called ‘robotic surgery’. This is only available in some cancer centres where they have surgeons trained to perform this technique. Depending on whether the surgery is open or ‘keyhole’, the hospital stay is between 1 and 10 days.
• Transurethral resection of the prostate (TURP) –TURP surgery may be performed to remove blockages in the prostate to relieve urination problems but is not designed to remove all the cancer. TURP is sometimes used before radiotherapy.
• Radiation therapy uses high energy X-ray beams directed at the cancer. This delivers a controlled dose of radiation to damage and kill cancer cells. It is sometimes referred to as radiotherapy. Radiation therapy works by damaging the DNA in cancer cells. When the DNA is damaged beyond repair, the cells stop dividing and eventually die. It can take several treatments before DNA is damaged enough for cancer cells to die. For this reason, radiation therapy is often given as a course of treatment over several days or weeks.
• Internal radiation therapy (brachytherapy): radioactive material is inserted directly into the prostate. It is given at either at a low dose rate (LDR) or high dose rate (HDR):
  • LDR: Given by implanting permanent radioactive seeds directly into the prostate. The seeds give off concentrated amounts of radiation over a number of months to the prostate with the aim of killing the cancer cells and curing prostate cancer. They are placed in a surgical procedure that may take a few hours, and you may have to stay in hospital overnight.
  • HDR: Given by inserting radioactive material directly into the prostate. Unlike LDR seeds, the material is only placed temporarily and for shorter periods. The procedure takes place in hospital and may require a longer stay than LDR.
  • Not all radiation therapy techniques are suitable for all men. A radiation oncologist can advise you which options suit you best.
• Watchful waiting is a way of monitoring prostate cancer symptoms and side effects and treating them as they arise. Treatment is for the purpose of symptom relief and slowing the cancer growth, not to cure the cancer. You may be offered Watchful Waiting if you are older or in poor health and the cancer is not likely to progress and cause a problem in your lifetime. It may also be offered to you if you have other health problems as well as prostate cancer. Watchful Waiting involves fewer tests than Active Surveillance. You may have regular PSA tests. If the level rises or you experience troublesome symptoms, you may also need imaging scans.

If your cancer is not contained within the prostate at diagnosis, or if your cancer spreads outside the prostate, your treatments may include:

• Hormone therapy – Prostate cancer is driven by male sex hormones (androgens) like testosterone. By reducing testosterone, it is possible to slow the growth of the cancer wherever it might be in the body. This systemic treatment is known as hormone therapy or androgen deprivation therapy (ADT). You may be offered hormone therapy if your cancer is higher risk, has spread outside the prostate or if it has metastasised, or to prevent and relieve symptoms, such as in watchful waiting. It may be used in bursts for a short period of time, for a period of 1 to 3 years, or indefinitely. Previously, hormone therapy involved surgical removal of the testicles (orchidectomy). But nowadays it is usually given as either injections, tablets or a combination of the two.
• Radiation therapy – For advanced or metastatic prostate cancer, radiation therapy may be offered:
  • to treat the cancer growing in the prostate gland to slow its growth and extend your life
  • to treat cancer that has spread to your bones to reduce pain (this is called palliative radiation therapy)
• Chemotherapy – This uses anti-cancer medication to destroy cancer cells. It cannot eradicate prostate cancer, but it can shrink it and slow its growth. It is commonly used to improve survival when prostate cancer has spread beyond the prostate and is given in combination with hormone therapy and can be given either when prostate cancer has spread at diagnosis or has become resistant to hormone therapy.
• Targeted therapies - PARP inhibitors prevent cancer cells from repairing their DNA so that cancer stops growing. PARP inhibitors may work in those diagnosed with a BRCA 1 or BRCA2 gene mutation.
• Radioisotope Therapy - Lutetium PSMA therapy is a new type of radioisotope therapy that can specifically target prostate cancer calls in any part of the body. It involves injecting radioactive molecules into the bloodstream. The molecules move through the blood to find prostate cancer cells and kill them. Lutetium PSMA therapy is not widely available and is mainly available through private providers and clinical trials.
• Clinical Trials Medical research into the use of medications and new therapies for the treatment of advanced prostate cancer is essential to finding better ways of treating and potentially curing this disease. If a new treatment looks promising, researchers will conduct clinical trials, which are often the only way to get access to new and promising treatments. Always consider asking if there is a clinical trial available that might be suitable for you. More information about clinical trials can be found on the Victorian Cancer Trials site.
• Watchful Waiting - Occasionally, men choose watchful waiting instead of active treatment for advanced prostate cancer. This means that the cancer is not being treated right now, as it is not always necessary or right for you to have immediate treatment. The purpose of treatment for advanced prostate cancer is to relieve symptoms and slow the cancer growth, not to cure the cancer. If you choose watchful waiting, you will be monitored for any prostate cancer symptoms and they will be treated at some point in the future if necessary. Watchful waiting for advanced prostate cancer involves reviews with your doctor to see how you are going. It might also involve PSA tests or imaging scans, particularly if the PSA level is rising rapidly or if you are developing symptoms from the cancer.
• Complementary and alternative therapies – It’s common for people with cancer to seek out complementary or alternative treatments. When used alongside your conventional cancer treatment, some of these therapies can make you feel better and improve quality of life. Others may not be so helpful and in some cases may be harmful. Visit Cancer Council’s website for more information about Understanding complementary therapies.

Side effects of prostate cancer treatment

The side effects of treatment vary depending on several factors, and they can be distressing. You should talk through options and concerns with your doctor before deciding which treatment to use for your prostate cancer.

Some common side effects of types of treatment include:

Surgery

• Incontinence: Most men will have some degree of urinary leakage (incontinence) after the catheter is removed. This can be managed by wearing pads. For most men, incontinence improves quickly within 2 to 12 weeks. But for some men it can take longer (3 to 12 months). Occasionally, it can become a permanent and chronic problem. In this case, further surgery may be performed to improve continence. In general, continence comes back more quickly in younger men and in men who have done pelvic floor exercises before surgery.
• Erection problems (also called erectile dysfunction) are a common side effect of surgery for prostate cancer. Erectile dysfunction is when you cannot achieve or maintain an erection firm enough for sexual activity or penetration. It may be temporary or permanent. It is common to lose the ability to have an erection in the short term. Erections may improve over a period of 18-24 months after surgery. The timeframe and likelihood you will return to having erections depends on your situation and the extent of surgery. You should discuss this with your urologist or healthcare team.
• Loss of fertility: After surgery you will be unable to father a child naturally. If this is a concern you can speak with your doctor about options for sperm banking.

Radiotherapy

During treatment:

• urinary problems such as frequency, urgency and/or burning/discomfort when you urinate
• bowel problems such as frequency, urgency and/or discomfort when you open your bowels
• fatigue (tiredness).

After treatment:

• urinary problems such as frequency, poor flow and bleeding (short term or long term)
• bowel problems such as frequency, urgency and/or bleeding (short term or long term)
• erection and ejaculation problems (short term or long term)
• loss of fertility - you will not be able to father a child naturally

Brachytherapy

Erectile dysfunction and bowel problems can occur. Some men may experience painful urination and irritation of the bladder for several months after therapy. Urinary incontinence is not usually a problem.

Hormone therapy

Side effects may include nausea, changes with sexual function including effects on fertility, erectile dysfunction genital shrinkage and loss of sex drive, tiredness, mood changes, hot flushes, weight gain, breast swelling and tenderness, changes with memory and concentration, loss of muscle strength and bone density.

Chemotherapy

Side effects may include fatigue, changes in appetite, nausea and vomiting, constipation or diarrhoea, temporary hair loss, sore mouth or throat, nerve changes causing numbness or tingling in your toes or fingers, skin and nail changes, low red blood cells (anaemia) and low white blood cells (neutropenia)

Coping with some of these side effects can be very difficult. It is important that you discuss possible side effects with your specialist before treatment. If you do experience these side effects, there are ways to manage and reduce the impact on your quality of life. Support is available from Prostate Cancer Foundation of Australia.

Sexuality and prostate cancer

Most treatments for prostate cancer cause side effects that can affect your sex life, some more than others. This can have a huge effect on your mood, self-esteem and body image. It is important to discuss your concerns with your specialist before treatment starts, so that you are aware of any potential problems and how you can manage and limit their impact.

If you are having problems with your sex life after your treatment is over, ask your doctor or nurse for help. If you have a partner, it also helps to be as open as possible with them about how you are feeling. Prostate Cancer Foundation of Australia’s booklet called Understanding Sexual Issues following prostate cancer treatment may be helpful to read.

Caring for someone with prostate cancer

Caring for someone with cancer can be a difficult and emotional time. If you or someone you know is caring for someone with prostate cancer, there is support available. Prostate Cancer Foundation of Australia’s booklet Understanding Prostate cancer for partners and families may also be helpful to read.

When treatments for advanced prostate cancer fail

Most men with advanced prostate cancer can live for a long time because of the treatments available. During this time, men will receive palliative care and/or end of life care.

The purpose of palliative care is to quickly identify and treat physical symptoms of the disease and side effects of treatment, as well as to help the person manage the effects of the disease on their emotional, social and spiritual wellbeing. Research suggests that palliative care reduces pain and distress, improves comfort, mood and feelings of wellbeing, and may also help to extend survival times.

Palliative care also helps partners, family and friends who love and care for the man with prostate cancer to better manage the impact of the disease. Studies have shown that it benefits not only the person with cancer, but the whole family.

Prostate Cancer Foundation of Australia Understanding Advanced Prostate Cancer may be helpful to read.

Where to get help

• Your GP (doctor)
• Cancer Council Victoria, Information and Support Service Tel. 13 11 20
• Multilingual Cancer Information Line, Victoria Tel. 13 14 50
• WeCan website helps people affected by cancer find the information, resources and support services they may need following a diagnosis of cancer.
• Prostate Cancer Foundation of Australia Tel. 1800 22 00 99
• Prostate Cancer Specialist Nurses
• Healthy Male
• Continence Foundation of Australia Tel. 1800 33 00 66