Prostate Cancer: Symptoms and Treatment Options

The prostate is a gland sitting just below the bladder and surrounding the urinary channel. Cancer most often begins in the OUTER part of the gland, away from that channel. That is why, early on, it does not compress the urinary passage and causes no complaints at all.

In practice this means two things: a man with no symptoms can have prostate cancer, and in a man who does have urinary symptoms the cause is usually NOT cancer but benign enlargement. Treating urinary symptoms as a warning sign of cancer is as wrong as being reassured by their absence.

Early detection is a decision about screening, and that decision is personal: your age, a family history of prostate cancer, your general health and your life expectancy are weighed together. Discuss plainly with your doctor whether screening is right for you.

A weakening stream, hesitancy, frequency and waking at night are the commonest urinary symptoms. They are not specific to cancer; the same symptoms occur with benign enlargement.

THESE FINDINGS, HOWEVER, SHOULD BE ASSESSED WITHOUT DELAY: blood in the urine or semen, new bone pain that does not settle (particularly in the back or hips), unexplained weight loss, weakness or loss of sensation in the legs.

Blood in the urine can be PAINLESS; the absence of pain does not make it unimportant. Painless blood in the urine is investigated at any age.

PSA (prostate-specific antigen) is a protein produced by prostate tissue. It is measured in the blood and tells you something about the prostate — but it IS NOT A CANCER TEST.

PSA can rise with benign enlargement, with urinary infection, with inflammation of the prostate, after catheterisation and sometimes after cycling or intercourse. A high PSA does not mean "there is cancer", and a normal PSA does not entirely exclude it.

A POINT VERY OFTEN MISSED: drugs that shrink the prostate (5-alpha reductase inhibitors) roughly HALVE the PSA value. If you do not say that you take one, a value that actually warrants attention can be read as normal. Give this information at every PSA measurement.

A single PSA value is usually not enough. Its trend over time, its ratio to the prostate volume and the examination finding are considered together.

Where the PSA is raised or the examination is suspicious, the first step is now usually not a biopsy but a multiparametric MRI of the prostate. The scan shows whether there is a suspicious area and, if so, where the biopsy should be directed.

That order has two benefits: an unnecessary biopsy can be avoided, and where a biopsy is needed it is taken from the right place. "MRI first" protects the patient from random needling.

If a biopsy is needed, the urine culture must be clear beforehand. Blood in the urine and semen for a while afterwards is expected; fever and shivering are not, and require immediate contact.

If cancer is found, the pathologist reports how far the cells have changed, as a grade (the Gleason score and the corresponding ISUP grade group). That grade indicates how actively the disease tends to behave.

Low-grade disease in a few cores with a low PSA is not the same picture as high-grade disease, and it is not treated the same way. "Prostate cancer" should therefore not be spoken of as a single illness.

If you do not understand your report, ask for it to be explained. You cannot compare treatment options without knowing which grade you are in.

ACTIVE SURVEILLANCE is a legitimate option in low-risk disease and is not "refusing treatment". The disease is followed closely with regular PSA, examination, MRI and, where needed, repeat biopsy; treatment begins if there are signs of progression. The aim is to avoid the side effects of surgery or radiotherapy where they are not needed.

SURGERY (radical prostatectomy) removes the whole prostate and is today often performed with robotic assistance. The removed tissue goes to pathology, which is how the true extent of the disease becomes visible.

RADIOTHERAPY aims at a similar goal to surgery in selected patients and may be combined with hormone therapy.

HORMONE THERAPY is not a curative method on its own; it is used in advanced disease or added to radiotherapy.

Which approach is chosen depends on the grade and extent of the disease, your age, your other conditions and your own priorities. No method is "best" for everyone.

After prostate surgery semen no longer passes outwards, and fathering a child naturally is not possible. If you wish to have children, say so BEFORE surgery.

Erectile function may not return reliably even where the nerves are preserved; recovery can take months and depends on your function before surgery.

Leakage of urine is common in the first weeks and lessens markedly over months in most men. Learning pelvic floor exercises BEFORE surgery makes that period easier.

THE PATHOLOGY RESULT CAN BE WORSE THAN EXPECTED. Needing further treatment (radiotherapy or hormones) after surgery does not mean the operation failed; it follows from the fact that the true extent of the disease can only be seen in the removed tissue.

What is the grade and risk group of my disease? Is active surveillance an option for me, and if not, why not?

What is the specific advantage of the approach you propose for me, and why do the other options fall behind?

If I have surgery, what is my individual expectation regarding continence and erections, and on what is that expectation based?

What is the chance that I will need further treatment after surgery, and how will that be monitored?

What is my follow-up plan: which test, how often, and who interprets it?

"My PSA is normal, so I do not have cancer." Not true. A normal PSA does not entirely exclude cancer; the examination finding and your risk factors are assessed as well.

"My PSA is high, so I must have cancer." Also not true. Infection, benign enlargement and inflammation of the prostate all raise PSA. The first step is usually to repeat the measurement and reassess.

"A biopsy spreads cancer." This worry is often voiced, but there is no evidence that biopsy spreads the disease. The real risk is not having the biopsy that was needed.

"Once I have surgery it is all over." In prostate cancer follow-up continues after surgery. PSA is measured regularly; that is not mistrust but proper management of the disease.

"Active surveillance means doing nothing." No. Active surveillance is a programme: PSA at set intervals, examination, imaging and, where needed, biopsy. If you will not attend follow-up, active surveillance is not right for you.

This article is for general information and does not replace medical advice. Prostate cancer is not a single disease; decisions are individual and require examination by a doctor.

Fever with flank pain, inability to pass urine, or weakness or loss of sensation in the legs require URGENT assessment.