Localized prostate cancer

Localized prostate cancer doesn't cause any symptoms. It normally first becomes noticeable when it reaches a more advanced stage. Then it can lead to symptoms such as an increased urge to urinate (pee) or a weaker flow of urine. In most cases, though, problems urinating aren’t caused by cancer, but by a benign enlarged prostate. This is very common in men over the age of 50. In rare cases, blood in urine or in semen can also be a sign of prostate cancer.

Very advanced prostate cancer may also spread to other parts of the body (like the bones) through the lymphatic system or the blood vessels. This can lead to symptoms such as bone pain.

The exact causes of prostate cancer aren’t known. Certain factors can increase the risk of prostate cancer somewhat. The main ones include:

• Age: The risk of prostate cancer increases with age. This is the biggest risk factor.
• Close relatives: Men who have a father or brother who developed prostate cancer are at a somewhat higher risk themselves. If several close relatives have (had) prostate cancer, your risk is even higher.
• Ethnicity : Men with dark skin are somewhat more likely to develop prostate cancer.
• Vitamin E: Dietary supplements that have a lot of vitamin E in them have been proven to increase the risk of prostate cancer if taken over many years.

Certain types of food, such as red meat or tomatoes, are often associated with cancer. No high-quality studies have shown that men can influence their risk of getting prostate cancer or affect the course of the disease by following a specific diet.

The risk of prostate cancer increases with age. It is very rare in men younger than 50.

The following tables show how likely it is that a man of a certain age will be diagnosed with prostate cancer within the next ten years and how likely it is that he will die of it. These numbers are averages: A man’s individual risk will also depend on whether he has risk factors and – if so – which risk factors.

Whether and how prostate cancer continues to grow will vary from person to person. It is hard to accurately predict how prostate cancer will continue to develop in a specific man. The prognosis depends on things like the stage of the tumor and how aggressive it is. The following table shows how tumor stage and aggressiveness influence how likely it is that someone will die of prostate cancer.

Tissue samples (biopsies) and other examinations can be used to find out whether the cancer tends to grow quickly or only very slowly. The probability that the cancer will grow is called its risk of progression.

If it’s thought that a man might have prostate cancer, the doctor will first ask about his symptoms to get a rough idea of the problem and figure out what might be causing it (anamnesis). After that, one or more of the following examinations may be done:

• Palpation (feeling): Here the doctor gently inserts a finger into the anus to feel the size, hardness and surface of the prostate (digital rectal exam, or DRE).
• PSA test: The PSA test is a blood test that looks for a certain protein known as “prostate-specific antigen.” This protein is produced inside the prostate. Small amounts of it enter the bloodstream. Having high levels of PSA might – but doesn’t necessarily – mean that someone has prostate cancer. Other things can lead to an increase in PSA levels too.
• Transrectal ultrasound (TRUS): Ultrasound is used to check the size and shape of the prostate gland. This involves gently inserting an ultrasound device about as wide as a finger into the rectum (the end part of the bowel).
• Tissue sample (biopsy): The only way to find out whether there actually is cancerous tissue in the prostate is by taking a tissue sample. Ten to twelve tissue samples are usually taken to be examined under a microscope. The most commonly used approach is called fine needle aspiration. This also involves inserting an ultrasound device into the rectum. The device has a fine hollow needle that can puncture the prostate through the wall of the rectum in order to take a sample of the prostate tissue. This procedure is done using a local anesthetic, or – in some rare cases – a brief general anesthetic.
• Magnetic resonance imaging (MRI): Sometimes MRI is used in addition to taking tissue samples.

Doctors can use the results of these examinations to ma ke an educated guess about whether the cancer will grow and how fast (risk of progression).

Two of the methods used for diagnosing prostate cancer can also be used to screen for it:

• In Germany, statutory health insurers cover the palpation of the prostate. But it doesn’t have any proven benefits. There is no proof that men are less likely to die of prostate cancer if they regularly have the palpation examination.
• The benefits of PSA tests in prostate cancer screening have been investigated in large studies. The results show that, together with the advantages, there are also some serious disadvantages such as overdiagnosis. Before deciding whether to have a PSA test, it is worth carefully considering the pros and cons.

Transrectal ultrasound isn’t suitable for the detection of prostate cancer. So medical societies advise against using this examination for screening purposes.

The possible treatment options for prostate cancer will depend on various factors. They include the following:

• How much the cancer has spread (tumor stage)
• The likely course of the disease (risk of progression)
• Individual factors such as general health, and how important the pros and cons are to you

Depending on the situation, you can choose one of the following options:

• Active surveillance: The prostate is checked at regular intervals. The cancer is treated only if the tumor starts growing. This strategy is an option for what is known as "low-risk" prostate cancer. It is based on the fact that low-risk prostate cancer usually grows very slowly or doesn't grow at all. This type of cancer often doesn't progress even years after it was diagnosed. The advantage: Many men can avoid the side effects of treatment. The disadvantage: If the cancer does progress, that is sometimes discovered too late. Many men find the checks to be distressing as well.
• External radiotherapy: The cancer is exposed to radiation from outside of the body (through the skin) in order to destroy the cancer cells. The most common side effects include erection problems and bowel trouble such as diarrhea, unintentional bowel movements and blood in the stool (poo).
• Internal radiotherapy (brachytherapy): The cancer is exposed to radiation from slightly radioactive "seeds" that are implanted inside the body. The side effects of brachytherapy are similar to those of external radiotherapy. Bowel problems are a little less common. There may also be problems with urination (peeing) in the first 1 to 2 years.
• Removal of the prostate gland (prostatectomy): The prostate and cancer are surgically removed. Common side effects include urinary incontinence, erection problems and impotence.

If the prostate cancer has reached a more advanced stage, there are several kinds of hormonal treatments and chemotherapies that aim to slow its growth.

The strategy that you choose will mainly depend on his personal preferences and values. Some will feel it is more important to avoid side effects like impotence or incontinence as much as possible. Others will want to be as sure as possible that the cancer has been removed, so they are willing to accept the risks associated with treatment.

In older men who may have other medical conditions as well, the risks and stress associated with surgery or radiotherapy could outweigh the possible benefits of this treatment. Then "watchful waiting" is an option. In this approach, only the possible symptoms are treated, rather than the cancer itself ("palliative" treatment). Unlike "active surveillance," this allows you to avoid the distressing check-up examinations.

You will find more information about prostate cancer and the various treatment options (in German) on the website of the German Cancer Information Service (Krebsinformationsdienst ) or in the patient information accompanying the German clinical practice guidelines.

You can also read about how to find the right doctor, how to prepare for the appointment and what to remember.