Early Prostate Cancer

What is Early 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.

Some tumours can be non-cancerous (benign) ie Benign Prostatic Hyperplasia (BPH) These non-cancerous cells tend to stick together where they have grown.

On the other hand, tumours can be cancerous (malignant) and when this happens in the prostate it is called prostate cancer. Most prostate cancers grow slowly. At the moment, it’s not known why some prostate cancers grow more slowly and others grow more quickly

Prostate cancer may be:

• Early or localised where it is still inside the prostate and has not spread to other parts of the body;
• Locally advanced where it has spread just outside through the prostate capsule (covering) or into the seminal vesicles that lie just behind the prostate;
• Advanced where the cancer cells have spread away from the prostate through the bloodstream or lymph channels. On reaching a new site(s) the cancer cells may start to grow causing another growth or tumour. These are called secondary cancers (secondaries) or metastases.

For more information on prostate cancer please see the sections below. There is also additional information available in our booklets:

A start to help you understand prostate cancer

Early prostate cancer explained

Early prostate cancer explained – deciding on treatment

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

Not all men will show any symptoms in the early stages and some men may have this condition in their later years without it leading to any problems. However, the earlier symptoms are recognised, a diagnosis made and treatment started the better the outcome is likely to be.

A prostate specific antigen (PSA) test from a GP or health provider or a digital rectal examination for another condition maybe ways of highlighting a problem that may lead to tests to diagnose if a man may have prostate cancer.

Other men may have symptoms that can include:

• Poor stream – the urine flow is weaker and it takes longer to empty the bladder;
• Hesitancy – having to wait for a while before the urine starts to flow;
• Dribbling – after finishing, a bit more urine may trickle out and stain underpants;
• Frequency – having to pass urine more often, most irritatingly at night. Getting up several times a night is common and is called ‘nocturia’;
• Urgency – to pass urine and having to get to the toilet fast;
• Poor emptying – a feeling of not quite emptying the bladder;
• Blood in the urine and/ or semen;
• Difficulties in achieving and maintaining an erection;
• Pain or stiffness in the lower back, hips or thighs.

Sometimes men go to their doctor with symptoms related to cancer cells that have spread away from the prostate gland (metastases) such as back pain or pain in the bones that doesn’t change or go away with simple pain killers. Tests can be carried out to find out the stage of the cancer.

Risk factors

There are a number of factors affecting men’s likelihood of developing prostate cancer – age, family history and family background.

• A man’s age is the strongest risk factor. Prostate cancer is very uncommon in men under 40. After the age of 50, the chance of a man getting prostate cancer increases. It’s thought that by the age of 80, about 80% of men will have some cancerous cells in their prostate. With 1 in 10 men in Scotland likely to develop prostate cancer, it is the most common cancer for men in Scotland;
• It has been found that prostate cancer can run in families. Men who have close family members (father, grandfather, brothers or uncle) diagnosed at a young age (under 55) can be at increased risk.  If a father has/had prostate cancer then the son is about 2 times more at risk of developing prostate cancer.  If a brother has/had prostate cancer then the man is 2-3 times more at risk of developing prostate cancer. Men who are at increased risk of prostate cancer because of their family history may be best to make an appointment with their GP to chat over their family history and risk. Because of family history, the GP may ask the man to have a PSA test. Alternatively, the man may ask the GP for a PSA test. A man with a family history of prostate cancer may want to consider asking his GP for a PSA test around the age of 45;
• In addition, some men can be at increased risk due to inherited genes which are faulty. If there’s a strong family history of certain types of breast cancer due to BRCA 1 and BRCA 2 especially before the age of 50, then close male relatives are almost 4-9 times more at risk of developing prostate cancer;
• Men from an African/Caribbean background are 3 times more at risk of getting prostate cancer and up to 5 years earlier than other ethnic groups;
• There may also be a hormonal link to prostate cancer, given that the hormone testosterone seems to have an active role in promoting or triggering it, whereas the hormone oestrogen appears to have the reverse effect;

For more information on risk factors, please see our leaflet: Prostate Cancer – Is it in the family?

Investigations and tests

There are a number of tests which may be carried out to determine if you may have prostate cancer, depending on your symptoms. A brief summary of these tests is listed below.

With your GP

• Your GP will most likely ask about any symptoms and be particularly interested in any urinary symptoms;
• Ask about any medicines or herbal supplements that you are taking;
• The GP may test for any signs of infection or for glucose in your urine;
• A blood test may be done to check if your kidneys are working properly;
• You may be asked about your family history ie if any male relatives have or have had prostate cancer or if any close female relatives have breast cancer of a specific type ie BRCA 1 and BRCA 2;
• PSA blood test. This is a simple blood test and measures your PSA level. The doctor will take into account the PSA blood level along with other tests to help him/her with diagnosis. For more information on the PSA blood test see below as well as the leaflet The PSA Test: get the knowledge
• Digital Rectal Examination (DRE). Your GP will most likely do a physical examination of your prostate called a DRE. This will be to physically check on the shape, size and condition of the prostate. See below for further information.

Prostate Specific Antigen (PSA) test
PSA is a protein that is made in the prostate. It’s normal to find PSA in a man’s blood as some PSA ‘leaks’ naturally leaks out of the prostate. The level of PSA in the blood can be raised by more PSA finding its way out of the prostate into the blood stream, if the prostate walls becoming weakened or damaged by a disease in the prostate. The greater the leakage, the higher the PSA level is likely to be in the man’s blood.  The PSA level can be checked by having a simple blood test.

A raised PSA level however, can be for a number of reasons and doesn’t necessarily mean the man has prostate cancer.

The man’s PSA level is useful in telling doctors which treatments may benefit patients with benign and malignant prostate diseases, who needs to be examined further for prostate cancer, and also for monitoring treatment for prostate disease and prostate cancer.

Below is a list of the main tests that may be carried out, although not all tests may be undertaken, depending on the man’s circumstances. In addition, some of the tests for BPH such as a urine flow study may be carried out or may already have been carried out to initially rule this disease in or out.

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.

What happens next?
The GP will look at the PSA result and consider what he/she found during the DRE.  Depending on the results, a referral may be made to the urologist at the local hospital for a biopsy or a scan or perhaps the GP may refer the man directly to the hospital to have a biopsy.

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.  Biopsy means that tiny samples of prostate tissue are taken to be examined in a laboratory.  There are 3 types of biopsy and it’s important to be aware that you may not be offered or are suitable for all 3 types of biopsy and some types of biopsy may not be available in your area.

Trans rectal ultrasound biopsy
An ultrasound probe is gently placed into the back passage using some lubricating jelly. This is gently moved around whilst the urologist or clinical nurse specialist (CNS) scans through to see your prostate on a screen.  This gives a better idea of the condition of the prostate and the urologist or CNS can identify any areas of concern which they can then target with the special biopsy needle. For further information please see the booklet Spotlight on Prostate Biopsy

Transperineal prostate biopsy 

Again, this is to take tiny samples of prostate tissue.  Instead of going through the wall of the back passage the samples are taken through the skin of the perineum.  (The perineum is the area between the scrotum and the back passage).  As this is a surgical operation, it will involve having a general or spinal anaesthetic.

This type of biopsy may be undertaken if the cancer is thought to be at the front of the prostate and cannot be easily reached from the back passage, if there has been previous surgery to the back passage or if the back passage has previously been removed.  For further information please see  the booklet Spotlight on Prostate Biopsy

MRI fusion guided biopsy
This can be done either as a TRUS biopsy or Trans-perineal biopsy.  The difference being that a recently taken MRI high definition picture is overlaid or fused onto the current or live images of the prostate from the ultrasound scan on the screen.  Once these 2 types (ultrasound scan and MRI scan) of specialist diagnostic techniques are fused together using special computer software, they provide a detailed 360°, 3D picture of the prostate.  The biopsy needle can very accurately be targeted to specific areas in the prostate. For further information please see  the booklet Spotlight on Prostate Biopsy

Side-effects
After any type of biopsy, it’s quite common to see:

• Blood in the urine which should clear in about a week;
• Blood from the back passage when passing a motion which should clear in a few days;
• Blood in the ejaculate (semen), which can last for around 4-6 weeks and depends on how often you are sexually active.
• There may be a dull ache in the area between the scrotum and back passage.

After a biopsy, a small number of men may be at risk of developing an infection. To try to prevent this, antibiotics will most likely be given; it’s important to finish all the tablets.

However, if a large number of blood clots are passed, there is a problem passing urine, a fever with a high temperature this could be the sign of an infection.  Contact should be made with the GP or NHS 24 (dial 111) or hospital if they provided a contact number.

What happens next
The biopsy samples are sent to a laboratory to be examined in great detail for any signs of prostate cancer so the results won’t be available straight away.  The results are generally sent to the urologist or GP in about 2-3 weeks’ time, although this time frame can vary.  After getting the results an appointment will most likely be made to see the consultant urologist and CNS at the hospital.

Test results and what they mean

Gleason score
A doctor, called a pathologist, will be sent the biopsy samples taken from your prostate. The samples are examined under a microscope to look at the cells. Normal healthy prostate cells are roughly the same size and shape. As cancer grows, the cells change and become unusual in shape and size. The more unusual or abnormal the cancer cells are, the more likely the cancer is to be aggressive or spread outside the prostate.

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.

What does the ‘N’ stage mean?
The ‘N’ stands for lymph nodes. Lymph nodes help fight infection. Prostate cancer can spread to lymph nodes near the prostate or to lymph nodes in other parts of the body.  So, the ‘N’ shows whether cancer has been found in the lymph nodes. This is measured during an MRI scan.

What does the ‘M’ stage mean?
The ‘M’ stands for metastasis (one other cancer site) or metastases (when there are several other cancer sites). This is the term used to measure the spread of the cancer in the body.

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.

As this scan has to be studied in depth by a specialist, you won’t get the results straight away.  The results will be sent to the doctor who referred you for the scan and it may take a few weeks.

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 or locally 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.

The MRI scan usually takes about 30-40 minutes and the results will be back in a few weeks.

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).

The CT scan usually takes about 30 minutes and the results will be back in about 1-2 weeks.

Treatments

The next step
As there is no clear cut answer on the best way to treat prostate cancer, a multi- disciplinary team (MDT), which includes specialists in urology and oncology, radiologists, pathologists, and CNS will discuss which treatment option(s) will be most suitable and appropriate for the man in his particular circumstances based on whether he has low, 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 or urologist with an appointment date to discuss the results of tests, his diagnosis and his treatment options. This can be a very worrying time for the man and his family hearing the diagnosis and then being faced with helping to decide which treatment option is right for him.  Although he will already be seeing the urologist, he may also be referred to the oncologist (cancer specialist).

What are the treatment options?
There are three main ways to treat early or localised prostate cancer. However, not all of the treatments will be available in all areas. For some treatments it may be necessary to travel to other areas.

With early or localised prostate cancer there are generally three main choices of treatment. The treatment choices take into account the man’s age, general health, the risk to you from your cancer and which treatment he might prefer.

The treatment choices are:

• Active surveillance or monitoring

• Surgery to remove the prostate

• Radiation treatment to kill the cancer cells – this may be by external radiotherapy or brachytherapy

• Hormone therapy may also be used in combination with radiotherapy or brachytherapy

There are videos from clinicians and men who have had those treatments  about each treatment to be found on each treatment page of this website.

There are also patient stories of men who have had treatments  to be found at the infopool 

Active surveillance or monitoring
What is active surveillance (AS)?
Active surveillance (sometimes called active monitoring) is a management option suitable for some men with prostate cancer. AS means that there won’t be any immediate treatment, as treatment is deferred or postponed until the urologist or CNS feels it necessary to treat the prostate cancer because of recent test results.

AS might be suggested:

• When cancer is found in the early stages, is still inside the prostate and is thought to be low-risk of progression or prognostic grade group 1. It may be an option for a small number of men with intermediate-risk prostate cancer or prognostic grade group 2;
• For men aged under 75 with a life expectancy of 10 years or more;
• For men over 70, as the cancer is unlikely to grow fast enough to cause problems during their lifetime;
• For younger men who have concerns that the side-effects of treatment will have a greater effect on their life than the cancer. They may prefer to put off the risk of side-effects for as long as possible (called deferred radical treatment).

There may be additional local guidelines you may have to meet to be considered for AS. Ask your consultant or CNS for more information.

For further information see the booklet Active Surveillance as a management for early prostate cancer

Surgery to remove the prostate
The operation to remove the prostate is called a radical prostatectomy. The aim is to remove the prostate, and so all the cancer inside it, and stop the cancer from spreading to other parts of the body. It is not a suitable option for all men who have prostate cancer.

Why might a radical prostatectomy be suggested?

• As a primary/main treatment for prostate cancer when the cancer is localised and contained within the prostate;
• When the cancer has not spread (metastasised) to other parts of the body;
• After a period of active surveillance if there are signs of the cancer growing;
• When the cancer is thought to require treatment rather than surveillance;
• For men who are expected to live for at least 10 years;
• For men who are otherwise healthy and are fit enough to have a general anaesthetic;
• If there has been previous treatment for prostate cancer, such as radiotherapy, and the cancer has not spread out-with the prostate but the cancer has recurred.

Follow up appointments
After a radical prostatectomy, most likely an appointment will be arranged to attend the urology outpatient department in about 6-8 weeks’ time (depending on availability). You will most likely be asked to have a PSA test done at your GP practice prior to your clinic appointment so the clinician or CNS has an up-to-date PSA level. At your clinic appointment, you will be asked how you are, hear about your results and have your wound examined.

How do I know if the treatment has worked?
The urologist or CNS will want to see how you are with regular check-ups. Your PSA level will be measured. After a radical prostatectomy, your PSA should drop quickly and should be practically undetectable*. If it does not drop this low or starts to rise then this suggests there may be cancer cells elsewhere in your body.

* In this case undetectable will mean at its’ lowest limit and will vary depending on the type of test used.  The CNS or urologist will chat over with you what undetectable means.

For more information see the booklet Minimal access radical prostatectomy for prostate cancer

External Beam Radiotherapy (EBRT)
EBRT means that high energy X-rays are used to treat prostate cancer. A special machine called a linear accelerator produces high energy x-ray beams which are then very carefully and accurately aimed at the prostate.  The treatment can also cover a small area around the prostate, including the seminal vesicles, in case the cancer has spread to these areas.

As all the organs inside the body lie quite close to each other, the beam is shaped to fit your anatomy and surrounding areas of prostate, bladder, back passage and hips. The beam is shaped by the use of multi-leaf collimators within the head of the linear accelerator.  By shaping the beam the prostate can be accurately targeted and reduce the dose to the healthy surrounding normal tissues of the bladder and bowel. These beams kill the cancer cells inside the prostate.

Why might EBRT be suggested?
EBRT can be used in the following ways:

1. As the primary/main treatment when the cancer is localised, contained within the prostate and has not spread (metastasised) to other parts of the body;

2. For men with low, intermediate and high-risk prostate cancer.

3. As a treatment, after a period of active surveillance. If there are signs of the cancer growing or progressing, then EBRT may be one of the treatment options offered to you;

4. For men who are expected to live for at least 10 years;

5. After radical prostatectomy (surgery to remove the prostate).  if there are high-risk features or if there are signs of the cancer growing again (shown by rising PSA after surgery);

6. For men who are fit enough to have treatment and do not have other significant medical conditions that may impact on survival and life expectancy;

7. In combination with hormone therapy  for prostate cancer for treatment of cancers that have spread out-with the prostate capsule or affected other organs nearby such as the seminal vesicle. Hormone treatment can be used on a short term basis (3-6 months) or long term basis (2-3 years);

8. Smaller doses of EBRT can also be used very effectively to treat bone pain in cases of cancer spread to the bones.

How do I know if the EBRT treatment has worked?
The PSA level will be measured and is a good indicator of whether treatment has been successful. After radiotherapy, PSA will drop slowly and it is variable when it reaches its lowest level.  If you have also had hormone treatment then your PSA may rise slightly when hormone treatment is stopped because there are still some normal (non-cancerous) prostate cells making PSA.

If your PSA level rises sharply, the doctor may want to do more tests to find out what might be causing this rise and if it might be due to the recurrence of prostate cancer.

For more information see the booklet Spotlight on external beam radiotherapy for prostate cancer

Brachytherapy treatment for prostate cancer
This is sometimes called LDR brachytherapy or low-dose rate brachytherapy or sometimes seed implants.

At the present time prostate brachytherapy is undertaken in 2 centres in Scotland – Edinburgh and Glasgow.  Brachytherapy is available to all men with prostate cancer (who are suitable for and select this treatment option) across Scotland. Eligible patients will be referred to the brachytherapy consultant in Edinburgh or Glasgow by their local hospital urology or oncology team and must be prepared to travel to Edinburgh or Glasgow.

Brachytherapy is a method of delivering a kind of radiotherapy where tiny metal seeds that emit radiation are placed or implanted into the prostate, working to kill cancer cells from inside the body. The ‘seeds’ are placed throughout the prostate to match the shape and size of the prostate. This is to try to make sure that the radiation reaches all the cancer cells.

About 60-120 seeds will be placed into the prostate with each seed being smaller than an uncooked grain of rice. The exact number of seeds used will vary according to the size of the prostate itself and where the cancer cells are.  The amount of radiation, and the effect it has on the cancer cells, is decided by the number of seeds implanted (put) into the prostate and by getting them into exactly the right place; the number of seeds and where they are placed will vary from patient to patient.

The seeds stay in the prostate, slowly giving out radiation for around 9 months, until they are no longer active. Because the seeds send out low level radiation, very little escapes from the prostate, and the patient wouldn’t be radioactive.  The seeds will remain in the prostate when they are no longer active.

Why might brachytherapy be suggested?

• When the cancer is contained within the prostate and is thought to be low or intermediate-risk;
• When your Gleason Score is 7 and below or Prognostic Grade Group 1, 2 or 3;
• When the prostate is measured and is not too bulky (less than 50 cc). Sometimes, hormone treatment is used to shrink prostate glands that are between 50 and 70 cc, so brachytherapy can be used;
• For men who are expected to live for at least 10 years;
• When the PSA level is below 20 ng/ml;
• For men who don’t have severe problems when passing urine; in other words have a strong flow of urine;
• For men who have not had external beam radiotherapy (EBRT) Radiotherapy to the pelvis;
• If the man has previously had a Transurethral Resection of the Prostate (TURP) then brachytherapy may be a less suitable treatment option. The oncologist or CNS responsible for care will give more advice on this.

Preparing for a brachytherapy

Why might hormone therapy be needed before brachytherapy? 

Some men may need hormone treatment.  If the prostate is measured and is too large for the seed implant, the oncologist may decide to start hormone treatment for around 3 – 6 months.  As the male hormone testosterone fuels the growth of prostate cancer, the aim of hormone therapy is to remove as much of this testosterone as possible. Reducing the amount of testosterone allows the prostate to shrink making brachytherapy possible.

How do I know if the treatment has worked?
To make sure that the treatment has worked, you will have a PSA blood test in about 3 months and then 3-6 monthly afterwards. The PSA level often gradually decreases over many years.

Occasionally, at around 2 years, some men may experience ‘bounce’ or ‘spike’ in the PSA level. This doesn’t necessarily mean that your treatment isn’t working and your oncologist or CNS will most likely want to chat over why this might happen.

For more information see the booklet Spotlight on Prostate Brachytherapy

Follow up appointments
After 4-6 weeks you will most likely go back to the hospital to have a CT scan to check that the dose and position of the seeds were correct.

 Your Brachytherapy Information Card (BIC card)
After your implant you will be given or sent an information card to carry and you should carry this card with you at all times. The card gives other doctors and nurses who may be treating you essential information that they need to know to keep them safe. You, the CNS or oncologist should fill in any blanks on the card with the information about your treatment. If you’re not given a card, it may be a good idea to ask for one.

It’s particularly important to carry this with you, if travelling away from home or going abroad. Some security monitors, such as at airports, are very sensitive and can detect low levels of radiation. To get over this difficulty, you can show your brachytherapy information card which gives details about your seed implants so you can confirm your treatment with security staff.