Prostate cancer 

Doctors will use the results of your prostate examination, biopsy and scans to identify the ‘stage’ of your prostate cancer (how far the cancer has spread). The stage of the cancer will determine which types of treatments will be necessary. It is a relatively complex system, reflecting the many varieties of prostate cancers.

Doctors identify the stage of prostate cancer by using the TNM system (Tumour, Nodes, Metastases):

• ‘T’ describes the tumour: whether it can be felt on DRE, how much cancer was found when the biopsy was done (Gleason score), and if it has spread from the prostate gland into nearby tissues.
• ‘N’ shows whether your cancer has spread to your lymph nodes where the body fluid lymph is filtered and where cancers often spread first.
• ‘M’ shows whether your cancer has spread (metastasised) to other parts of your body.

Want to know more?

• Cancer Research UK: the stages of prostate cancer
• Macmillan: grading and staging of prostate cancer

If the cancer is in its early stages and is causing no symptoms, you may decide to delay any treatment, and wait to see if any symptoms of progressive cancer develop. This is often recommended for older men when it is unlikely that the cancer will affect their natural life span.

Active surveillance aims to avoid unnecessary treatment of harmless cancers, while still providing timely treatment for men who need it. 

When they are diagnosed, we know that around half of men with low-risk prostate cancer do not need any treatment. We just don’t know which half. Surveillance provides a period of observation to gather extra information to help men decide whether or not to have treatment.

Active surveillance involves you having regular PSA tests and biopsies to ensure that any signs of progression are found as early as possible. If these tests reveal that the cancer is likely to spread beyond the prostate, you can then make a decision about further treatment.

Many men who undergo surveillance (perhaps 30-40%) will later have treatment. This does not mean that they made the wrong initial decision. Provided that delayed treatment is as effective as immediate treatment, they will not have been harmed. They will have delayed any treatment side effects, and they will be reassured that their treatment was actually necessary. 

A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing localised prostate cancer and locally-advanced prostate cancer.

Like any operation, this surgery carries some risks, and there may be some side effects. These are outlined below.

• Some men have problems with urinary incontinence. This can range from leaking small drips of urine, to leaking larger amounts. However, for most men, this often clears up within 3-6 months of the operation. Less than 5% of men have long-term problems requiring the use of pads.
• Some men have problems getting an erection (erectile dysfunction). For some men, this improves with time. But around half of men will have long-term problems.
• In extremely rare cases, problems arising after surgery can be fatal. For example, 0.1% of men under 65 years old and 0.5% of men over 65 will die following a radical prostatectomy.

For many men, having a radical prostatectomy will get rid of the cancer cells. However, for around one in three men, the cancer cells may not be fully removed, and the cancer cells may return some time after the operation.

Want to know more?

• Macmillan: surgery for early prostate cancer

Radiotherapy involves using radiation to kill cancerous cells. This treatment is an option for curing localised prostate cancer and locally-advanced prostate cancer. Radiotherapy can also be used to slow the progression of metastatic prostate cancer and relieve symptoms.

The levels of radiation are safe but they can cause side effects (see below).

Radiotherapy is normally given as an outpatient at a hospital near you. It is done in short sessions for five days a week, for four to eight weeks. There are short-term and long-term side effects associated with radiotherapy.

Short-term effects of radiotherapy can include:

• discomfort around the rectum and anus (the opening through which stools pass out of your body)
• diarrhoea
• loss of pubic hair
• tiredness
• cystitis – an inflammation of the bladder lining, which can cause you to urinate frequently; urination may be painful.

Possible long-term side effects can include:

• an inability to obtain an erection – this affects 30 to 50% of men
• urinary incontinence (less than 1%)

As with radical prostatectomy, there is a one-in-three chance that the cancer will return.

Want to know more?

• Macmillan: radiotherapy for early prostate cancer

Brachytherapy is a form of radiotherapy where a number of tiny radioactive seeds are surgically implanted into the tumour. It is also known as internal radiotherapy.

This method has the advantage of delivering a high dose of radiation to the prostate, while minimising damage to other tissues. However, the risk of sexual dysfunction and urinary problems is the same as with radiotherapy, but the risk of bowel problems is lower.

Hormone therapy is often used in combination with radiotherapy. For example, you may receive hormone therapy before undergoing radiotherapy in order to increase the chance of a successful treatment. Or hormone therapy may be recommended after radiotherapy to reduce the chances of cancerous cells returning.

Hormone therapy alone should not normally be used to treat localised prostate cancer. Hormone therapy can be used to slow the progression of advanced prostate cancer and relieve symptoms.

Hormones control the growth of cells in the prostate. In particular, prostate cancer needs the hormone testosterone to grow. The purpose of hormone therapy is to block the effects of testosterone, either by stopping its production or by stopping your body being able to use testosterone.

There are three ways to give hormone therapy:

• Injections to stop your body making testosterone, called luteinising hormone-releasing hormone (LHRH) agonists.
• Tablets to block the effects or reduce the production of testosterone, called anti-androgen treatment.
• Combined LHRH and anti-androgen treatment.

The main side effects of hormone treatment are caused by their effects on testosterone. They usually go away when treatment stops. They include loss of sex drive and impotence (this is more common with LHRH agonists than anti-androgens).

Other possible side effects include:

• hot flushes
• sweating
• tiredness
• weight gain
• swelling of the breasts

A surgical alternative to hormone therapy is to surgically remove the testicles, called orchidectomy. The operation does not cure prostate cancer, but by removing the testosterone it controls the growth of the cancer and its symptoms. However, many men prefer to have hormone treatment to block the effects of testosterone.

Want to know more?

• Cancer Research UK: hormone therapy for prostate cancer

This is a surgical procedure similar to a TURP biopsy, except a larger piece of your prostate gland is removed. This is done to relieve pressure from the urethra in order to treat any problematic symptoms you may have with urination.

HIFU is sometimes used to treat men with localised prostate cancer that has not spread beyond their prostate. HIFU treatment is still going through clinical trials for prostate cancer. It is not widely available.

An ultrasound probe put into the rectum releases high-frequency sound waves (which cannot be heard by humans) through the wall of the rectum. These sound waves kill cancer cells in the prostate gland by heating them to a high temperature.

The side effects of HIFU can include impotence, urinary symptoms or fistula – an abnormal connection (fistula) between the urinary system and rectum. In a small number of men (about 1–3%), an abnormal connection occurs between the rectum and the urethra (which carries the urine down to the penis).

Want to know more?

• Cancer Research UK: high intensity focused ultrasound (HIFU) for prostate cancer

Cryotherapy is a method of killing cancer cells by freezing them. It is still undergoing clinical trials for prostate cancer. It is sometimes used to treat men with localised prostate cancer that has not spread beyond their prostate gland.

Tiny probes called cryoneedles are inserted into the prostate gland through the wall of the rectum. They freeze the prostate gland and kill the cancer cells, but some normal cells also die. The aim is to kill cancer cells while causing as little damage as possible to healthy cells. The side effects of cryotherapy can include impotence, urinary symptoms and rectal problems.

If the cancer has reached an advanced stage, it is no longer possible to cure it. But it may be possible to slow its progression, prolong life and relieve symptoms.

Treatment options include:

• radiotherapy
• hormone treatment
• chemotherapy

Chemotherapy is mainly used to treat prostate cancer that has spread to other parts of the body (metastatic prostate cancer) and which is not responding to hormone therapy.

Chemotherapy destroys cancer cells by interfering with the way in which they multiply. Chemotherapy does not cure prostate cancer, but it can keep it under control and reduce symptoms (such as pain) so that everyday life is less affected.

The main side effects of chemotherapy are caused by their effects on healthy cells, such as immune cells. They include infections, tiredness, hair loss, sore mouth, loss of appetite, nausea and vomiting. Many of these side effects can be prevented or controlled with other medicines, which your doctor can prescribe for you.

Steroid tablets are used when hormone therapy no longer works because the cancer is resistant to it. This is called hormone-refractory cancer. Steroids can be used to try to shrink the tumour and stop it from growing. The most effective steroid treatment is dexamethasone.

As many of the treatments above have unpleasant side effects that can affect your quality of life, you may decide against treatment. Especially if you are at an age when you feel that treating the cancer is unlikely to significantly extend your life expectancy.

This is entirely your decision, and your MDT will respect it.

If you decide not to have treatment, your GP will still give you support and pain relief. This is called palliative care. Support is also available for your family and friends.

Want to know more?

• End of life care