What is Locally Advanced Prostate Cancer?
Locally-advanced prostate cancer means that the cancer has spread just outside the prostate through the capsule that surrounds the prostate or into the seminal vesicles. The seminal vesicles are glands that lie behind the prostate and supply some of the fluid in semen.
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.
Not all men will show any symptoms and a lot of men may have this condition without it leading to any problems. It may be found if they are offered a PSA test from their GP or health provider or possibly undergo a digital rectal examination for another condition, either of which may highlight a problem.
Other men may experience lower urinary tract symptoms like those occurring with benign growths in the prostate gland, which may lead to tests being done to rule out potential prostate cancer. These urinary symptoms 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 urinate – having to get to the toilet fast
- Poor emptying – a feeling of not quite emptying the bladder
Sometimes men may 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 determine the stage of the cancer.
There are a number of factors affecting men’s likelihood of developing prostate cancer – age, family history and, potentially, diet.
- Age is an important factor in that prostate cancer rarely occurs in men under 40, but its incidence increases in men aged 45 to 64 to a point where it is the most common cancer amongst men in Scotland.
- 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 affect.
- Men who have had close family members (fathers/brothers) diagnosed at a young age (under 55) can be at increased risk, with studies showing that the risk of developing prostate cancer can be as much as 3 times greater if a man has a first degree relative with the disease.
- In addition, some men can be at increased risk due to inherited genes which are faulty, such as BRCA2, which also has a role to play in breast cancer (and there may be a link between a family history of breast cancer and propensity to develop prostate cancer).
- Studies have also shown that the ethnic origin of men may be a factor, with men of Afro-Caribbean origin having higher risk and those of East-Asian origin, particularly Chinese and Japanese men, having a lower risk.
- There may also be a dietary link, as studies have shown that Japanese men when moving to the US have a higher risk than when they live in Japan. This may be connected with the fact that Western diets are high in red meat and saturated fat and that obesity may have a role in cancer. Some studies have shown that diets rich in Vitamins D and E, as well as lycopene (usually found in tomatoes) can help to protect against prostate cancer.
- Men who have an increased family risk of prostate cancer, such as brothers or fathers affected by the disease, may wish to consider screening once they are over the age of 40 or 50 to monitor against the potential onset of the disease.
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. These tests are listed below.
If you have symptoms you will probably be offered a digital rectal examination (DRE) and a blood test for prostate specific antigen (PSA). If these suggest that you may have a risk of prostate cancer, you will probably be offered a trans-rectal ultrasound (TRUS) guided prostate biopsy.
If your PSA is very high, your doctor may decide that rather than giving you a biopsy, they will offer you a bone scan and treat you on the basis of this result and your PSA. Although the combination of a DRE and a PSA test will pick up most tumours that are likely to cause any harm, no test is 100% accurate.
Below is a list of the main tests that may be carried out, although not all tests may be undertaken, depending on the person’s situation. In addition, some of the tests for BPH such as a urine flow study may be carried out or have been carried out to initially rule this disease in or out.
This test is done to allow the doctor to feel the outer surface of the prostate gland where the majority of tumours are located. The prostate lies very close to the rectum (back passage) which is why this method is used to feel the gland. It allows the doctor to feel if there are any obvious areas of cancer and estimate how large the prostate gland is, which may influence what treatment is recommended, whether this is for benign or malignant (cancerous) disease (although some very small prostate cancers may be initially difficult to detect through a DRE. DREs are rarely painful, although may be uncomfortable.
PSA is a protein that comes from prostatic tissue and its level can be checked via a blood test. It 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 for monitoring treatment for prostate cancer.
A PSA test may detect prostate cancer at an early stage when it can be detected by no other means and even when there are no other symptoms at all. Conversely, not all men who have a raised PSA level will have prostate cancer. If prostate cancer is diagnosed, the PSA test can be very valuable in monitoring the condition as well as the response to all forms of treatment.
The test works by measuring the amount of the protein in the blood. The level of PSA in the blood can be raised by PSA finding its way out of the prostate into the blood stream, through the prostate walls becoming weakened through diseases, particularly prostate cancer. The greater the leakage, the greater the amount of PSA can reach the bloodstream. An elevated level, however, can be for a number of reasons rather than always necessarily being an indicator of prostate cancer. The level can go up due to a number of different conditions including:
- Benign prostate growths
- Malignant prostate growths
- Urinary tract infections (water infections, see prostatitis risk factors)
- Biopsies of the prostate
- Inspections of the bladder using cystoscopes
- Significant levels of cycling (more than 10 miles/day on a regular basis)
The last 5 only raise PSA for a short period of time and it will go back to its more normal level when the infection is treated or after a period of abstinence. As PSA goes up with age, most doctors now use age-specific PSA ranges, as a PSA that is elevated in a 45 year old man may be normal in a 75 year old man.
The normal PSA levels are:
- Age 40-49 years ~ 2.5 ngms/ml
- Age 50-59 years ~ 3.0 ngms/ml
- Age 60 – 69 years ~ 4.0 ngms/ml
- Age 70+ years ~ 5.0 ngms/ml
PSA circulates in 2 forms in the blood. One type is linked to a second protein, while the other is ‘free’. As part of the PSA test, the amount of ‘free’ PSA, which is not linked, may also be measured. This is because a lower amount of ‘free’ PSA may indicate prostate cancer and a higher amount is more likely to indicate benign prostate growth. A percentage level of ‘free’ PSA below 18 is more likely to indicate prostate cancer.
If your doctor is concerned that you may have prostate cancer, they will arrange for you to have a trans-rectal ultrasound guided prostate biopsy (TRUS). This is a common procedure, usually performed as a day case in a hospital under local anaesthetic.
An ultrasound probe is placed into the back passage using some lubricating jelly. This is moved around whilst the doctor or nurse scans through your prostate to measure its size and to see if there are any abnormal areas. Local anaesthetic is then injected around the gland – this does not hurt, but might give the sensation that you want to pass water. Then the biopsies (small samples of tissue) are taken with a spring-loaded instrument that makes a loud noise. This is not painful but the noise can sometimes be a little frightening. Usually 10 biopsies are taken, unless you have had previous biopsies in which case more may be taken.
After the biopsy, it is very normal to see blood in the water and from the back passage. This usually passes after a day or so. It is also very normal to see blood in the ejaculate (semen), which can last for weeks and depends how often you are sexually active. Infection is a risk with these biopsies so you will be given antibiotics to try to prevent this.
What happens if I have no back passage? If your back passage has been removed from previous surgery, biopsies are usually taken transperineally. This means using an ultrasound probe from the front and the needle to take the biopsies is passed through the skin behind the scrotum in front of the area where your back passage would have been (perineum). The after effects are similar to a biopsy taken via the back passage.
Once prostate cancer has broken through the prostate capsule or wall and has spread to the seminal vesicles a treatment is needed that tackles all the prostate cancer cells. The most common way to do this is through hormone therapy that ‘switches off’ or removes the male hormone testosterone. Prostate cancer cells need testosterone to grow. So, by reducing the amount of testosterone, cancer cells shrink or don’t grow as fast. Hormone therapy can keep prostate cancer in check for many months and in some cases years. For more information about hormone therapy see to Spotlight on Hormone therapy for prostate cancer
Testosterone production is switched off by having an injection. Depending on the injection used it may be administered just under the skin, usually in the tummy area, or into the buttock. The injection may be given once a month, once every 3 months or once every 6 months. You will most likely be given the injection by your GP or nurse at your local clinic.
By taking a tablet, testosterone can be blocked from going into the cancer cells. This may be given for a week or two before starting injections and may be continued for a week or so after your injections have started.
A small number of men may be on tablets alone (monotherapy).
Because hormone therapy blocks testosterone, there may be some side-effects including: not being able to get and keep an erection,( see Spotlight on Prostate conditions and erectile dysfunction) lack of sexual desire, hot flushes, heart problems, changes in your mood, thinning of the bones and breast swelling or tenderness.
If any of these side-effects have an impact on your quality of life, let theoncologist or CNS know as there may be some treatments that they can give to help.
EBRT can be used to treat locally advanced prostate cancer using high energy x-ray beams from a special machine called a linear accelerator. The beams are accurately shaped to your body frame and pelvis and are then very carefully and accurately aimed at the cancer in the prostate.
The treatment can also cover a small area around the gland, including the seminal vesicles and lymph nodes in the pelvis.
Some men may be given hormone treatment for several months before radiotherapy treatment with the aim of shrinking the cancer so that radiotherapy has a higher/better chance of working and this may continue after radiotherapy treatment. For more information about EBRT see the Spotlight on external beam radiotherapy-for-prostate-cancer
If the man is not fit enough or has other health problems then radical treatment is not an option and your urologist may suggest ‘watchful waiting’ for some men with locally advanced prostate cancer. It’s a way of keeping a careful check on the cancer through monitoring or watching what is happening with it. Watching and waiting might be suitable if your cancer is not causing any symptoms or problems right now or if other treatments aren’t suitable for you because of additional health problems. For further information about Watchful waiting see the Early Prostate Cancer Explained Booklet
Surgery to remove the prostate
This is called a radical prostatectomy. Although this is rarely used to treat locally advanced prostate cancer, in certain cases, your doctor may discuss surgery to remove your prostate, seminal vesicles and lymph nodes in your pelvis. See more in the Guide to minimal access surgery to remove the prostate and also in the Early Prostate Cancer Explained Booklet
A TURP is completely different from the radical prostatectomy mentioned above. The purpose of a TURP is not to remove the prostate and is not a cure for prostate cancer. It is surgery done when part of the tumour in your prostate is blocking or squeezing on the urethra. A TURP ‘trims off’ the part of the tumour pressing on the urethra which may make it easier for you to pass urine and so help ease one of the potential side-effects of locally advanced prostate cancer. For more information about TURPs see the Spotlight on treatment for an enlarged prostate
For more information about locally Advanced Prostate Cancer see the Early Prostate Cancer Explained Booklet