Prostate Cancer.

know the signs and symptoms

Written 23th Nov 2015                                

Prostate cancer usually affects men over 50 years of age. It is the commonest cancer among men. Compared to other cancers it is usually slow growing with no symptoms for 10-20 years.

 

What is the prostate?

The prostate is the small circular mass just below the bladder. I have drawn it in the colour purple.

The prostate is often called the prostate gland.  It is the size and shape of a walnut, and sits at the opening of the bladder. A tube from the bladder passes through the prostate to the penis, allowing urine to flow. A good example of another gland is the lymph gland or lymph node which release substances into the blood to help us fight infection. As a gland, the prostate also releases a substance which mixes with sperm from the testicles during ejaculation, to produce semen. Although the prostate acts as a gland, it is also important to think of it as a muscle.  During ejaculation it contracts to force the semen from the prostate outwards through the penis.

 

 

Is there anything that makes me more likely to get prostate cancer?

  • Age over 50

  • African-Caribbean heritage*

  • Genetic i.e someone in your family has or had prostate cancer

  • Sexually transmitted infections like chlamydia or syphilis

  • Smoking

  • Geographic- often related to soil deficient in selenium or genetic factors

  • Vasectomy

  • Diet low in tomatoes or oily fish

*(2 to 3 times increased risk compared to non African-Caribbean man)

Unclear risk factors

  • Diet-some studies have associated a western style diet high in sugars, processed carbohydrates, processed meats, and low in vegetables with increased rates of prostate cancer. In countries where selenium ( an essential nutrient) is low in the soil, such as New Zealand, more men have prostate cancer. There are hundreds of studies on Selenium. In 2014 a review of the best studies, stated that there was no clear evidence that selenium supplements can reduce the risk of prostate cancer. If you decide to take a supplement it is important to remember that too much selenium in the blood has also been associated with prostate cancer. There are lots of foods rich in selenium so it may be better to look at what you are eating and improve your diet.

  • Obesity and metabolic syndrome- both of these conditions increase the risk of heart disease. Men who have heart disease are at increased risk of prostate cancer. See advice on lifestyle to help reduce this risk.

  • Low vitamin D and not enough safe sunlight exposure. There is a geographical relationship between low exposure to sunlight and increase rates of prostate cancer. Patients with Prostate cancer have been found to have low vitamin D levels, but there is no evidence that taking a vitamin D supplement helps treat prostate cancer.

  • Animal fats-There are mixed results from observational studies that associate animal fats in milk and red meat with higher rates of prostate cancer. These results are controversial.

 

ask your doctor: how do i know that i have prostate cancer?

What are the symptoms?

If you're not sure if you have any symptoms of prostate disease then speak to your doctor

  • Problems passing urine (see below)

  • Infection in urine

  • Difficulty having an erection

  • Difficulty ejaculating

  • Blood in the urine or sperm

  • Unable to pass urine

  • Pain in testicles or around the anus

  • Constipation

Examples of problems passing urine:

  • You need to get up during the night to pass urine (This can be normal-but get it checked out with your doctor)

  • You have difficulty or pain starting the stream

  • Urine stops mid stream

  • There is dribbling at the end of passing urine

  • You have to urgently pass urine

  • You are incontinent of urine

Other symptoms sometimes associated with spread of the cancer:

  • Feeling sick

  • loosing weight

  • No appetite

  • Persistent pain in the bones-lower back or pelvis

  • Bleeding from the rectum/anus

 

What will my doctor do?

Your doctor will ask you about your 'water-works' to see if you have any difficulty passing urine or an infection. He or she will ask you about your bowels to know if you are constipated. The doctor will want to know if you have any of the risk factors mentioned earlier e.g has someone in your family had prostate cancer?

He or she will also about how you are feeling: if you are tired, feeling sick and if you any prolonged pain in the bones that cannot be explained by arthritis.

If you have any of the symptoms above the doctor will

  • Ask you for a urine sample

  • Examine the prostate

  • Arrange an appointment for blood tests

The urine sample

You can bring this with you. It should be taken that morning and collected in the middle of the stream i.e. not at the start of the start or end of passing urine

It’s worth remembering that urine infections in men are rare, compared to women. So if you have an infection you doctor will want to do further tests. Don’t treat this yourself and don’t start an antibiotic unless your doctor has prescribed it.

The prostate examination

The prostate can be felt through the rectum. It is sometimes called a “PR’ examination which means ‘per rectum’ (via the rectum) or DRE which stand for Digital Rectal Examination, because the finger (digit) is used to feel the gland.

This is an important examination as your doctor will be able to feel if the prostate has any lumps on it or if it is hard or enlarged.  This procedure can pick up some cancers but not all.  It is only performed if you have any of the symptoms above.

PSA Blood test

A lot of men have heard about a test called PSA (Prostate Specific Antigen). In the united Kingdom your doctor will check the PSA test if:

  • You have any of the symptoms above: difficulty passing urine, urine infection, blood in the urine, new constipation or a lump on the prostate felt during rectal examination.

  • If you are concerned that you are at risk of prostate cancer and over 50 years of age.

There are special requirements for doing the test.  It must be done:

  • greater than 48 hours after vigorous exercise e.g Cycling can increase PSA

  • greater than 7 days after digital rectal examination

  • greater than 48hours after last ejaculation

  • greater than 4-8 weeks after urine infection has cleared

  • greater than 6 weeks after prostate biopsy.

So, your doctor will usually ask you to come back after at least one week for the PSA blood test, or after 8 weeks if you have a urine infection.

What if you are under 50 years of age with no symptoms of prostate cancer but want to have the PSA blood test?

Your doctor will ask you questions to see if you have any risk factors for prostate cancer. He or she will also ask you if the worry of not doing the blood test is causing you a lot of anxiety.

  • If you are at increased risk of prostate cancer and have associated anxiety your GP will perform the test.

  • If you have no risk factors and no symptoms then you may have to pay for the blood test- discuss this with your doctor.

Remember that a slightly raised PSA test cannot make the diagnosis of prostate cancer and you will have to be referred to a Urology doctor. The urology doctor will discuss with you whether you need a scan and biopsy of the prostate gland which is preformed via the rectum.More information on when to do the PSA test can be found at the Department of Public Health England.

 

In the UK PSA test is not routinely used to screen for prostate cancer in men under 50 years of age- why is that?

This remains a controversial area. But there are good reasons why we do not screen all men for prostate cancer.

  • The PSA test can be positive in men who do not have prostate cancer. This positive result usually leads to a needle biopsy of the prostate gland to see if there really are cancer cells. There is 2% chance that the biopsy will cause side-effects such as blood in the urine or sperm, and in some cases pain that can persist for a week. Having a positive PSA result cause undue worry in a lot of men who turn out to have a normal biopsy.

  • The PSA test can also be normal in a man with early prostate cancer. So a negative result can mean that there are some cancer cells present

So the PSA test is not always correct at predicting prostate cancer, which means at present, it is not a cost-effective means for screening for this disease in the UK.  More information on PSA can be found at from the Department of Public Health England.

Other investigations

If your PSA test is positive or if your doctor has felt a lump on the prostate or if you have problems with your 'urinary track', your doctor will refer you to see a urology doctor. He or she will examine the prostate again by PR examination and decide if you need an ultra sound scan and biopsy. There are two new blood tests now available called 'PCA3 assay and the Prostate Health Index (PHI)' which can be used in men who have a normal or uncertain biopsy result but in whom prostate cancer is suspected. 

Sometimes the urologist will order a more detailed scan called an MRI. You will also have some other blood tests taken either with your own doctor or in the hospital.  All of these results will be used to decide if you have prostate cancer and what stage it is at.  More information on all investigations can found here.

Treatments

Treatment depends on:

  • The stage of the cancer, which means how big it is and whether it has spread to other parts of the body.

  • Your age

  • Past and current medical history i.e fit for surgery

  • Your understanding of the complications or side side-effects of surgery

  • Your own personal preference

If you have a partner it is important to discuss your options and side-effects with them. You will also see an oncology doctor to discuss your options and will have time to discuss any concerns.

Treatment may involve:

  • Watch and wait surveillance. You will have regular PSA tests, rectal examination and repeat biopsy.

  • Surgery to remove the prostate

  • Radiotherapy

  • Hormone therapy

  • Alpha blockers ( Also used to treat enlarged prostate)

  • Lifestyle changes i.e. your diet, exercise and weight loss.

Detailed information on treatments can be found on the Prostate Cancer UK website.

Lifestyle

  • Stop smoking. Smoking is linked to a lot of cancers, so if possible see you doctor or practice nurse about help with stopping, or speak to someone you know who has already given up smoking.

  • Drink 2-3 litres of water a day. This will help keep you hydrated and, as you get older, reduce the chance of infection in the bladder.

  • Decrease alcohol and sugar intake.

  • Eat cooked tomatoes and a variety of fresh vegetables every day.

  • Eat sustainable oily fish such as line caught mackerel, salmon, anchovies, and arctic char twice a week to increase your omega-3 intake.( These recommendations will change, so it's important to check which fish are safe to eat)

  • Eat 1-2 Brazil nuts every day. This will provide your daily amount of selenium.

  • Try drinking a cup of green tea each day. Like red wine, it contains polyphenols. There is also some evidence for pomegranate polphenols.

  • Exercise- keep your heart, body and mind healthy. Try a ten minute walk and build it up to 30 minutes a day.

  • Reduce infections transmitted by sexual intercourse. The use of barrier contraception such as condoms can reduce the chance of getting an infection. Remember all sexually transmitted infection can have lasting effects for both men and women.

  • If you're overweight have a look at my suggestions on finding motivation to get fit. You can also try out my ten-minute exercise work-out to get started at home. It's a good idea to seek personal professional help if you're struggling on your own.

  • Sleep well. There are some studies that associate good sleep patterns with a decrease risk of getting prostate cancer.

  • Eating more cruciferous vegetables (cauliflower, broccoli), drinking soy milk and eating pomegranates may reduce prostate cancer.

Summary

If you are over 50 years of age and have any symptoms of urine infection, blood in the urine, problems passing urine, getting up at night to pass urine, or difficulty with erections see your doctor to have a rectal examination to feel the prostate (PR), and a PSA blood test.

Remember the biggest threat to a man's life is heart disease, so if you smoke ask your doctor for some help to give up. If you have a poor diet or don't exercise read my prostate newsletter on how to change these habits. Guidelines on exercise can be found on NHS choices website. More information about the PSA test can also be found here.

If you are over 50 with no symptoms and no risk factors then now is the time to keep your body healthy with a good diet high in omega-3 and exercise.  More information on prostate cancer can be found at the NHS choices website.

Remember, If you're not sure if you have any of the symptoms above or think you might be at risk, always speak to your doctor.

References:

  • Dragan Ilic et al. (March 2011) Lycopene for the prevention of prostate cancer.A review by The Cochrane Library 2011, Issue 11http://www.thecochranelibrary.com

  • NHS Cancer Screening Programmes (2010) Prostate Cancer Risk Management Programme Information for primary care; PSA testing in asymptomatic men. Evidence document.

  • NICE Guidelines (January 2014). Prostate cancer: diagnosis and treatment.

  • Catalona WJ et al.(1991) Measurement of prostate-specific antigen in serum as a screening test for prostate cancer.New England Journal Medicine ; 324: 1156-61

  • R. S. Kirby (Roger S.)& Manish I Patel;Prostate cancer. Inc.Abingdon : Health Press 7th ed. 2012

  • Marco Vinceti et al.(March 2014) Selenium for preventing cancer. Cochrane Database Systematic Review. ( Updated from Dennert 2011)

  • R.J. Ablin & M.R. Haythorn. (2009) Screening for prostate cancer: Controversy? What controversy? Editorial Current Oncology:Volume 16, number 3

  • Sara Arranz et al.(2012) Wine, Beer, Alcohol and Polyphenols on Cardiovascular Disease and Cancer Nutrients , 4, 759-781

  • Brooks JD et al.(2001)Plasma selenium level before diagnosis and the risk of prostate cancer development. J Urol ; 166:2034-8.

  • Lippmani SM et al.(2009) Effect of selenium and vitamin E on risk of prostate cancer and other cancers: the Selenium and Vitamin E Cancer Prevention Trial (SELECT). JAMA ;301:39-51.

  • Baillargeon J et al.(2005) The association of body mass index and prostate-specific antigen in a population-based study. Cancer;103: 1092-5.

  • Bul M & Schroder FH. (2011) Screening for prostate cancer-the controversy continues, but can it be resolved? Acta Oncol ;50(suppl 1):4-11.

  • Miller EC et al.(2002) Tomato products, lycopene, and prostate cancer risk. Urol Clin North Am ;29:83-93.

  • M.Diana van Die et al.(May 2014) Soy and soy isoflavones in prostate cancer: a systematic review and meta-analysis of randomized controlled trials. BJU International Special Issue: Focus on Urological Oncology Volume 113, Issue 5b, pages E119–E130.

  • Kushi LH et al. (2012) American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. CA Cancer J Clin 62: 30–67

  • Liu Y et al. (2011) Does physical activity reduce the risk of prostate cancer? A systematic review and meta-analysis. Eur Urol 60: 1029–1044

  • Clarke G & Whittemore AS.(May 2014) Prostate cancer risk in relation to anthropometry and physical activity: The National Health and Nutrition Examination Survey I Epidemiological Follow-Up Study. Cancer Epidemiol Biomarkers Prev;9:875-881

  • Liu Y, et al. (2011) Does physical activity reduce the risk of prostate cancer? A systematic review and meta-analysis. Eur Urol 60: 1029–1044

  • Mejak SL, Bayliss J, Hanks SD (2013) Long Distance Bicycle Riding Causes Prostate-Specific Antigen to Increase in Men Aged 50 Years and Over. PLoS ONE 8(2): e56030. doi:10.1371/journal.pone.0056030

  • D Jiandani et al (September 2015) The effect of bicycling on PSA levels: a systematic review and meta-analysis. Prostate Cancer and Prostatic Diseases 18, 208-212

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