What is Advanced Prostate Cancer?

Cells are the building blocks that we are made from. These usually grow in a regulated and controlled way to form tissue. Over time old cells will die and be replaced by new cells (through a process of cell division) to carry on their specific role for the rest of the body. If these new cells do not receive the correct messages as to what they should do, they can start to grow faster than normal and in an uncontrolled way and swell to become growths or tumours.

We know that the male sex hormone, testosterone, plays a vital role in promoting the growth of both normal and abnormal prostate cells. Without testosterone (even at normal levels in the male body), growth of prostate cancer can be slowed and this factor is used in some treatments of the disease.

At the moment, no one really knows what causes prostate cancer or why some cancers are more aggressive than others. Advanced prostate cancer means that the cancer is no longer contained within the prostate and cancer cells have spread away from the prostate through the bloodstream or lymph channels. On reaching a new site or sites, the cancer cells then may start to grow causing another tumour or tumours.

These are called secondary cancers (secondaries) or metastases. These metastases are most often found in lymph nodes in the pelvis, or in bone but may appear in the bladder, bowel, lungs or liver.

For more information on prostate cancer, please see our booklets

What the medical words mean, abbreviations that you might hear and medical staff that you might meet.
When you have been diagnosed with any disease or condition, unavoidably, there will medical words and abbreviations that doctors, nurses and other medical staff will use that you have never heard of and will perhaps not know what they mean and prostate disease and prostate cancer are no different. A helpful list of terms you might come across is provided here in alphabetical order.

Symptoms

The symptoms of advanced or metastatic prostate cancer depend on the size and spread of the cancer. If the cancer hasn’t spread very much then you may not have many symptoms at all.

You may find problems with passing urine:

  • Need to pass urine more often than before and more often during the night
  • Find it difficult to start passing urine
  • Need to get to the toilet quickly
  • Take longer to empty your bladder
  • Stop and start when passing urine

How you might be feeling

  • More tired than usual
  • Generally feeling unwell
  • Losing weight
  • Loss of appetite

Other symptoms of advanced cancer will depend on where the other cancer or secondary is in your body. Advanced prostate cancer tends to spread first of all to the bones. With cancer that has spread to the bones you may have:

In bones

  • A niggling ache in the affected bone
  • Pain in the affected bone may make it difficult to move around or sleep at night and you may have to take painkillers
  • Pain or ache in the affected bone all the time
  • Deep pain or stiffness in the lower back, upper thighs or hips
  • Weakness in the bone, so it can break more easily

If you have a numb feeling, pins and needles, or weakness in your legs, arms or body you should tell your doctor immediately as this may need urgent treatment. You should also let your doctor know if you have had problems with constipation or not being able to control your bladder or bowel as the doctor will most likely want to find out what is causing this.

Investigations and tests

Prostate Specific Antigen or PSA blood test
PSA is a protein that is made within the prostate. It is normal for small amounts of PSA to leak out of the prostate into the bloodstream so the PSA level can be checked by a simple blood test. This is called your PSA level, which will usually be higher if there is disease in the prostate and is a useful test for monitoring diseases of the prostate such as prostate cancer. For more information see booklet on PSA Explanatory-booklet

Digital Rectal Examination (DRE)
This test is done to allow the doctor to feel the outer surface of the prostate. The man will be asked to lie on the bed on his side with knees bent up towards his chest. As the prostate lies very close to the rectum (back passage) the doctor gently slides a gloved, lubricated finger into the back passage to the prostate to check the shape, size, condition of the prostate and if there are any lumps or bumps. Although this examination may feel a bit uncomfortable or perhaps a bit embarrassing it shouldn’t hurt and it’s usually over very quickly. It’s much better for you and the doctor if you can manage to relax.

Prostate biopsy
If the doctor is concerned that it may be prostate cancer, they will arrange for the man to have a prostate biopsy at the hospital. In fact, to have been diagnosed with advanced prostate cancer, you may already have undergone this test. Biopsy means that tiny samples of prostate tissue are taken to be examined in a laboratory.

Bone Scan
This is a test performed in the nuclear medicine department of your hospital. It is to find out if there is any evidence of spread of cancer cells to the bones, which is one of the common sites for prostate cancer to spread to.

MRI scan
An MRI (magnetic resonance imaging) scan is to help determine if there is any spread of prostate cancer outside of the prostate to other organs or tissues.  (to see if the cancer is localised, locally advanced or advanced). It can also sometimes be used to look at the bones and the lymph nodes.  Some men may be offered an MRI scan prior to having a biopsy.

CT scan
A CT (computerised tomography), or CAT scan, is usually done to find out if there is any evidence of prostate cancer in the lymph nodes in the pelvis or the area around your prostate. Lymph nodes become swollen in infections, but also in response to spread from cancer cells. (The function of the lymph nodes is to clean the body fluids known as lymph to remove any problems).

This is done less often now and usually if you suffer from claustrophobia (fear of being in an enclosed space).

X-Ray
An x-ray may be done to check out normal wear and tear on bones and joints.

What the test results mean
A multi- disciplinary team (MDT), which includes specialists in urology, oncology, radiologists, pathologists, and CNS will discuss which treatment(s) will be most suitable and appropriate for the man in his particular circumstances based on whether he has intermediate or high-risk cancer. Any decisions made about treatment will also take into account the views of the man and his family.

The man will be sent an appointment or contacted by the CNS, urologist or oncologist with an appointment date to discuss the results of tests, diagnosis and treatment. This can be a very worrying time for the man and his family hearing the diagnosis.  As there is often a lot of information to take in, it is usually very helpful if your wife, partner, family member or friend sits in while you see the doctor as they can often ask questions, take notes or just listen.  If there is a support group in the area, some men find it very helpful to speak to other men who have been in the same situation.

Gleason score
A doctor, called a pathologist, will be sent the biopsy samples taken from your prostate and examines the cells under a microscope.

The doctor looking at the cells decides which type of cell is most common and which is second most common. Each of these two cell types is then given a grade from 1 to 5. A grade of 1 means these cells are the most normal looking or least aggressive, whilst cells given a grade of 5 are the most abnormal looking or most aggressive. These numbers are added together to give a final score out of 10. This is your Gleason score and it describes the grade of your cancer.

Because of modern biopsy techniques, grades of 1 and 2 are rarely used, so the lowest Gleason score likely to be reported is Gleason 6.

The Gleason Score reporting system will be phased out over the next few years as a newer prognostic grade group system is introduced.

Prognostic Grade Group
The pathologist will still be sent the samples taken from your prostate and these will be examined under a microscope to look at the cell pattern.  Using the new grading system guidelines, the pathologist will grade the prostate cancer by simply numbering the prostate cancer from Grade 1 to Grade 5 with each of the grades having a likely outcome. Grade 1 will be the least aggressive and least likely to spread out-with the prostate while Grade 5 will be the most aggressive grade of prostate cancer. This system has been designed to be a simpler, more accurate and understandable way of reporting, making it easier for men and their families to understand the likely aggressiveness of their cancer.

Staging the cancer
Once a cancer is scored as to how aggressive it is, it will then need to be assessed for how advanced it is i.e. the extent to which it has spread or not. This will help in deciding which treatment may be most effective. Prostate cancers are commonly given 4 stages (T1 to T4) depending on their development under a staging system known as TNM (tumour, nodes and metastases).

TNM is made up of:

  • The letter ‘T’ for tumour and a number
  • The letter ‘N’ for lymph nodes
  • The letter ‘M’ for metastasis or metastases

Treatments

The three goals in treating advanced prostate cancer are to:

  • Help you feel better generally, lead as full and enjoyable a life as possible;
  • Relieve any symptoms that you may be having and possibly make your quality of life better;
  • Slow down the rate that your cancer is developing.

Once prostate cancer has broken through the prostate wall and has spread to other parts of the body, a treatment is needed that tackles the cancer cells wherever they are in the body. As treatment pathways for prostate cancer are changing the specialists looking after your care will talk through the most appropriate treatment in your particular circumstances.

Hormone therapy
Hormone therapy (or treatment) alone is the standard (or primary) treatment for men with advanced prostate cancer and works well for most men often keeping their cancer in check for several, and in some cases, many years.  Recent studies suggest that starting hormone treatment early may be more effective than delaying the start of hormone treatment.  This is something you can talk over with your oncologist.

Hormones control the activity and growth of all normal cells and so are naturally present in the body.  Men produce a hormone in their testes, called testosterone.  Testosterone is responsible for many male characteristics.  In order to grow, prostate cancer needs this testosterone.  So, by reducing the amount of testosterone, cancer cells wherever they may be in the body, shrink or don’t grow as fast.  So the aim of hormone therapy is to remove as much of this testosterone as possible.

For more information see the booklet Spotlight on Hormone Therapy

Chemotherapy
Chemotherapy is used when the cancer has spread out-with the prostate into other parts of the body advanced prostate cancer or for some men with locally advanced prostate cancer. At this stage it isn’t possible to kill all the cancer cells so advanced prostate cancer can’t be cured but it can be controlled very successfully often for many years.

What is chemotherapy?
Chemotherapy uses certain drugs to kill cancer cells wherever they are in the body so it acts throughout the whole body and it isn’t limited to particular sites or areas (this is called systemic treatment).

Cancer cells in the body divide very quickly. Chemotherapy works by targeting, and killing rapidly growing cancer cells as they divide, wherever they are in your body.  Because cancer cells divide more quickly than healthy cells, chemotherapy drugs kill more cancer cells than healthy cells.  This should help shrink and slow down the growth of the cancer.

The benefits of chemotherapy may be that you are not in as much pain, make you feel better generally and may help you live longer with a better quality of life.

The drawbacks are that chemotherapy may also damage healthy cells in your body so you might have side-effects like losing hair, feeling sick and being very tired.

Is chemotherapy the right treatment?
Chemotherapy may not be the right treatment for all men though.  The oncologist looking after you will need to consider:

  • If you would benefit from having this type of treatment;
  • How the side-effects would affect your quality of life;
  • If you are fit enough to deal with any side-effects.

So, before starting this kind of treatment you will probably find that that the doctor will check on your general health by making sure that your heart, liver, lungs and kidneys are working properly.

You might also want to think about whether to start chemotherapy and talk this over with your family.  In some areas, there are prostate cancer support groups and it may help to talk to other men and their families who have been in similar circumstances.

For more information see our booklet Treatments for Advanced Prostate cancer

Clinical trials
At any point on your cancer journey you may be asked to take part in a clinical trial. You and your family may have very mixed feelings about what this means. Choosing to take part in a clinical trial is an important decision for you and your family to make, so take some time to think about it and make sure that you have all the information to help you decide.

Clinical trials or clinical studies are carried out to test new ways to treat prostate cancer. Men who have volunteered to take part in a clinical trial for prostate cancer may be involved in testing new treatments or existing treatments in combination e.g. a different way of giving treatment, before these are approved for wider use with other men.

For more information on clinical trials please see our booklet Clinical trials and New Therapies Explained