Introduction 

Prostate cancer is a terrifying diagnosis to receive and it comes with a lot of daunting questions. From what prostate cancer is to what treatment options may be available, this article will help answer all the frequently asked questions you and many others have on prostate cancer. 

What is the prostate and what does it do?

The prostate is part of the reproductive system in people assigned male at birth (AMAB). It is a small gland, about the size of a walnut, located between the penis and the bladder (the balloon-like organ where your urine is stored), surrounding the urethra (the tube that carries urine) in that area. 

The prostate contains both connective and glandular tissue. This gland adds thick fluids to semen, mixing with sperm produced by the testicles. The prostate muscle also helps push semen through the urethra during orgasm.¹

What is prostate cancer?

Prostate cancer is one of the most commonly diagnosed cancers in AMAB individuals. It is also the fifth leading cause of cancer death in this population.² 

By definition, cancer is a disease where certain cells in your body grow and divide uncontrollably due to changes in their DNA. These "transformed" cells multiply rapidly, forming tumours and competing with normal cells. They also evolve and adapt, becoming stronger and more aggressive over time, which may lead to spreading to other body parts such as the bones. The process of cancer spreading to other parts of the body is known as metastasis).³

Prostate cancer occurs when this process of uncontrollable cell growth and division happens in the prostate cells. Fortunately, most cases of prostate cancer grow slowly and are low-grade, making them low-risk with limited aggressiveness. 

These are some risk factors for developing prostate cancer:² 

• Old age - incidence rates are highest in people AMAB aged 75-79
• Family history of prostate cancer 
• Obesity 
• Hypertension 
• Lack of exercise 
• Ethnicity  - incidence rates are higher among those of black ethnicity
• Elevated testosterone levels 

What happens when a man has prostate cancer?

As prostate cancer tends to grow slowly, it usually doesn't cause any problems in its early stages. When symptoms begin to occur, the most common complaints are trouble urinating and the presence of blood in the urine. Patients may present to the doctor with a group of symptoms called lower urinary tract symptoms (LUTS), which include:

• Weak or poor flow of urine
• A urine stream that starts and stops several times during urination
• Difficulty starting to uninate, even when you feel the need to go
• Straining to urinate (needing to push and strain to begin or continue)
• Increased frequency of urination
• Waking up at night several times to urinate
• Sometimes feeling a sudden urge to urinate immediately, with involuntary loss of urine after the urge
• Feeling unsatisfied or incomplete after urinating
• Leakage of urine after finishing urinating

Some advanced prostate cancer symptoms include:

• Weight loss 
• Constant fatigue 
• Difficulty getting an erection
• Painful ejaculation 
• Urinary and faecal incontinence
• Bone pain, which may indicate that cancer has spread to the bones (metastasis)⁴

How does the doctor find out if I have prostate cancer?

When you present with prostate symptoms or have lower urinary tract symptoms in general and risk factors of prostate cancer, the healthcare provider will examine you and order some necessary tests. 

Tests that may be done include a digital rectal examination (DRE), urine sample, prostate-specific antigen (PSA) testing, prostate biopsy and diagnostic imaging. DRE and PSA testing are the mainstays of diagnostic testing for prostate cancer.⁵

Digital rectal examination (DRE) 

During a digital rectal examination, the doctor will insert a gloved and lubricated finger into your rectum to examine your prostate. They will evaluate if there are any bumps, hard spots, or abnormal areas. They will also examine the wall of the rectum and nearby structures. You may feel discomfort or mild pain during this exam.

Urine sample

By ordering a urine sample, the doctor will be checking for a possible infection.

Prostate-specific antigen (PSA) testing

Prostate-specific antigen (PSA) is a protein produced by prostate cells. The healthcare provider may measure the level of PSA in your blood to determine if it is within the normal range or elevated. The chance of having prostate cancer increases as PSA levels rise; however, there is no definitive cut-off point in PSA levels to determine if a person has prostate cancer. An elevated PSA level may indicate prostate cancer but it can also be a sign of other conditions, such as:

• An enlarged prostate
• A prostate infection
• A urinary tract infection 

If the PSA level is elevated, you may need further tests to confirm whether or not it’s prostate cancer.

Prostate biopsy

A biopsy is a procedure where a needle is used to remove small tissue samples to be examined under a microscope. During a prostate biopsy, a small part of your prostate will be taken to check for cancer cells and, if cancer is present, determine the grade of the cancer. The biopsy can be done using two techniques: 

• The first is through the rectal wall using an ultrasound probe (transrectal biopsy)
• The second is through the skin between the scrotum and anus (transperineal biopsy)

The doctor typically injects a local anaesthetic before the procedure to minimise discomfort.

Imaging

There are several types of diagnostic imaging techniques that may be used to determine the presence of prostate cancer:^2,5

• Transrectal ultrasound 
• Magnetic resonance imaging (MRI)
• Bone scan - this can help identify whether prostate cancer has spread (metastasised) to nearby bones of the pelvis
• CT scan

How treatable is prostate cancer?

The prognosis for prostate cancer varies based on several factors including the extent of the tumour, histology, patient age and health and PSA levels.^2,6

The extent of the tumour

• Confined to prostate: The prognosis is generally good when the tumour is confined to the prostate gland
• Locally advanced tumours: These tumours are usually not curable, but have a good 5-year survival rate
• Distant metastasis: When cancer has spread to distant organs, it is not curable and the survival rate is typically 1-3 years

Histology of cancer 

Poorly differentiated tumours have a higher likelihood of metastasis before diagnosis and are associated with a poorer outcome.

Patient’s age and health 

Younger and healthier patients may benefit from curative therapies such as radical prostatectomy, which is often considered for those with a life expectancy of more than 10 years.

PSA level 

Elevated PSA levels are often associated with a higher risk of metastasis and disease progression. However, PSA is an imprecise risk marker and should be interpreted in the context of other factors.

What are the treatment options for prostate cancer?

Treatment for prostate cancer depends on each patient’s circumstances. Doctors will consider factors like the type and size of the cancer, the grade, overall health condition of the patient and whether the cancer has spread to other body parts. Risk groups based on Gleason score, PSA level and tumour stage also help determine treatment approaches.

Approaches to treatment include:

• watchful waiting
• active surveillance
• radical prostatectomy
• radiotherapy
• and hormone therapy

Watchful waiting

• The approach of watchful waiting is usually recommended for older patients when cancer is less likely to affect their life expectancy 
• Watchful waiting involves monitoring the cancer, usually in its early stage or slow-growing form
• If the cancer is not causing any symptoms, treatment might be delayed, and the patient waits to see if any progressive cancer symptoms appear
• This approach is also considered if the patient's overall health does not permit treatment

Active surveillance

• If adopting the approach of active surveillance, doctors will monitor the patient via
  • Regular blood tests
  • PSA level
  • MRI imaging 
  • Biopsies 
• These tests are for detecting any signs of cancer progression and this approach aims to avoid unnecessary treatment

Radical prostatectomy 

• Radical prostatectomy is a surgical procedure to remove the prostate gland and surrounding tissue and is usually considered for prostate cancer that has not spread beyond the prostate gland 
• This surgery can be carried out via one of two techniques:
  • Laparoscopic: A small incision in the abdomen is made, through which a device is inserted and controlled by the surgeon's hand to guide the instruments
  • Open retropubic surgery: A long incision in the lower abdomen is made to remove the prostate gland
• Like some other medical procedures, this surgery also has its own risks. These include erectile dysfunction and urinary incontinence

Radiotherapy 

• Radiotherapy uses radiation to kill transformed cancer cells and is typically used for prostate cancer that has not yet spread beyond the gland 
• It also aims to slow the progression of the cancer 
• Side effects may include:
  • Discomfort around the buttocks 
  • Diarrhoea 
  • Loss of pubic hair 
  • Inflammation in the bladder 
  • Tiredness 
  • Impotence 
• Sessions usually take place five days a week for a period of 4-8 weeks

Hormone therapy 

• Hormone therapy for prostate cancer aims to stop the body from producing or using testosterone, which fuels cancer growth, and is often combined with radiotherapy 
• Side effects may include:
  • Hot flashes 
  • Sweating 
  • Breast tenderness
  • Weight gain

Other therapies

• Chemotherapy 
• Cryotherapy 
• Immunotherapy
• Steroids^2,7

What should I expect living with prostate cancer? 

In most cases, prostate cancer progression is relatively slow. You may even live for a long time without experiencing symptoms or needing treatment. However, at some point, it may begin to affect your life, both physically and mentally. Discomfort, especially related to urinary symptoms and cancer pain, treatment side effects, and impacts on mental well-being can be significant. 

Living with prostate cancer can be challenging, so having a supportive network of family and friends is very beneficial. You can always talk to your healthcare provider, discuss your condition, and gain reassurance. Lastly, don’t forget to maintain a healthy diet and lifestyle.⁸

Summary

• Prostate cancer occurs when there is an abnormal growth of prostate cells due to changes in the cells' DNA. Over time, these transformed cells adapt and compete with normal cells, potentially spreading to distant parts of the body
• People with prostate cancer may experience lower urinary tract symptoms such as poor urine flow, the need to strain when urinating, increased frequency of urination, feeling unsatisfied after urinating, and urine leakage. Blood in the urine may also be present 
• Other advanced symptoms can include weight loss, constant fatigue, difficulty getting an erection, painful ejaculation, urinary and faecal incontinence and bone pain
• To confirm prostate cancer and determine its stage, doctors may order several tests, including a PSA level test, biopsy and diagnostic imaging
• Treatment options for prostate cancer include watchful waiting, active surveillance, radical prostatectomy, radiotherapy and hormone therapy, among others
• The prognosis of this disease depends on the extent of the tumour, the age and general health of the patient, the PSA level and the cancer cell type