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. On average, men most commonly get prostate cancer at the age of 71.
• A genetic predisposition: Men who have a father or brother who developed prostate cancer are at a 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 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 a higher or lower risk of 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: Your individual risk will also depend on whether you have risk factors and – if so – which risk ones.

The course of prostate cancer varies from person to person. It usually grows slowly and doesn't cause any problems for a long time. But it can also grow quickly and spread to other organs. It is hard to accurately predict how prostate cancer will continue to develop in any particular person. The prognosis depends on things like the stage of the tumor and how aggressive it is.

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 (digital rectal exam, DRE): The doctor feels the prostate with their finger through the rectum. That makes it possible to find out about the prostate gland's size, firmness and surface. This test is not very accurate, though, and it can't tell us anything about the cause of a possible enlargement.
• 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).
• Magnetic resonance imaging (MRI): MRI can be used to assess whether and where cancerous tissue is visible. This allows that specific tissue to be removed. A method called multiparametric MRI (mpMRI) is usually offered. Unlike other kinds of MRI scans, a contrast agent is injected into a vein. This makes it easier to see your blood vessels and other tissue structures inside the body. MRI can also be used to view nearby lymph nodes.
• 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 or more tissue samples are usually taken to be examined under a microscope. The tissue is removed using a thin hollow needle that is inserted through the wall of the rectum or the skin between the rectum and testicles. The procedure itself can be painful and is usually done under local anesthesia. You might also experience pain after the procedure.

Doctors can use the results of these tests to make an educated guess about whether the cancer will grow and how fast.

In Germany, the costs of these tests will be covered by public health insurers if doctors suspect that you might have prostate cancer. One exception is mpMRI, which is not normally covered by health insurance. That is because there are still some unanswered questions about the benefits and harms of this type of MRI. An mpMRI scan typically costs several hundred euros.

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

• In Germany, palpation (DRE) is covered by public health insurers. It is unclear whether prostate palpation is useful for screening, though. That is because early-stage prostate cancer is often not detected during palpation. So it is no longer recommended by doctors.
• The benefits of PSA tests in prostate cancer screening have been investigated in large studies., and the results show the following: By using PSA testing, fewer men die of prostate cancer. But in addition to this advantage, PSA testing alone also has serious disadvantages – such as overdiagnosis or false alarms. Before deciding whether to have a PSA test, it is worth carefully considering the pros and cons. PSA tests for prostate cancer screening are not covered by public health insurers.
• The medical associations in Germany recommend a combination of PSA testing and MRI. An MRI scan of the prostate is performed if the PSA value is abnormal multiple times. This is done as an extra measure of precaution after the PSA testing. But it is still not clear if this combination testing is better than no prostate cancer screening. Public health insurers typically don't pay for this combination. But coverage in the future is now being considered.

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:

• How much the cancer has spread (tumor stage)
• The likely course of the disease (risk of progression)
• Individual factors like age and general health
• What you think of the possible advantages and disadvantages

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 or is causing problems. This strategy is suitable for low-risk prostate cancer – cancer that mostly grows very slowly or not at all. Often the cancer hasn't spread even years after diagnosis. The advantage of this strategy: 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. Active monitoring of low-risk prostate cancer is recommended by the medical associations in Germany.
• 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 one to two 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, then several kinds of hormonal treatments and chemotherapies are considered. There are also radioactive drugs that slow the growth of the cancer. Various treatments can be combined.

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.

For low-risk prostate cancer, the treatment strategy is largely an individual choice: 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.

Deciding on whether or not to have a certain treatment is a personal matter. Having enough information on all the options helps to make it easier. You can also see a specialist again. Doctors are obligated to inform you of your right to a free second opinion.

You can find more information on prostate cancer and the various treatment options at the Cancer Information Services provided by the German Cancer Research Center.

Information about health care in Germany can help you to navigate the German healthcare system and find a suitable doctor. You can use this list of questions to prepare for your appointment.

When people are ill or need medical advice, they usually go to see their family doctor first. You can also see a urologist about prostate problems.