Early prostate cancer doesn’t normally carry symptoms. Photo / 123RF
One of the most common forms of cancer in men is also one of the least understood.
Opening up about their below-the-belt health is not a conversation every man wants to have with his doctor, let alone his nearest and dearest – but the fact remains that every 45 minutes one man dies from prostate cancer in the UK. It may be an awkward discussion, but one worth having.
One of the most common forms of cancer in men – with more than 52,000 cases diagnosed every year – it is also one of the least understood. How it affects a man’s life, and what can be done to treat it is far from straightforward. But from the age of 50 onwards it cannot be ignored.
“Most people assume that if they’ve got cancer, they will know they will feel unwell. They’ll feel the lumps, the bumps, all of the normal cancer messaging, but that just doesn’t apply to most men with prostate cancer,” says Amy Rylance, head of improving care at Prostate Cancer UK.
We’ve consulted the experts, at the cutting edge of research into the causes and treatments of prostate cancer, to answer the questions you might be afraid to ask.
“We often hear prostate cancer described as a ‘good’ cancer to get, or that men die with it, not of it,” says Rylance, “but it is something many men with prostate cancer find quite offensive.” The truth is more startling, with more than 12,000 a year dying of the disease, out of 52,000 diagnosed annually – and one in eight men diagnosed with it in their lifetime. “And even for those men who are successfully treated for prostate cancer, there can be a significant burden of side effects for men who are diagnosed late.”
These side effects, often as a result of invasive surgery or radiotherapy, range from urinary incontinence and erectile dysfunction to depression and fatigue. “Hopefully for most men, these will be relatively short term, and will get better over time, but for some, they could last for the rest of their lives,” says Rylance.
Early prostate cancer, the treatable kind, doesn’t normally carry symptoms – and only a third of men realise this, according to a survey carried out by Prostate Cancer UK, who work closely with the NHS on new research and treatments.
“It’s what makes prostate cancer really tricky to diagnose,” says Rylance. “And it’s why it is crucial to understand your risk factors [below], rather than waiting for symptoms to appear.”
Three quarters of the men surveyed did not know what the prostate – a gland around the size of a walnut which helps to produce semen – does, and nearly half did not know where it was in their body, sitting under the bladder.
Usually, difficulty urinating is likely to be a sign of a common non-cancerous problem such as an enlarged prostate – unless the cancer grows near the urethra (the tube you pee through) – but the disease usually starts in the outer part of the prostate, which doesn’t press on the urethra or wreak havoc with your morning micturition.
If men do display symptoms at the later stages, when the cancer breaks out of the prostate, these might include: blood in the urine or semen, unexplained weight loss and general urinary symptoms, although these could also be signs of other health problems.
The likelihood of having the disease increases from 50 onwards; black men are at double the risk (advised to be checked from the age of 45), and the threat also doubles if your father or brother has had prostate cancer.
Not all prostate cancers are genetic, but there are more than 20 genetic mutations that can increase your chances of it, says Rylance. One of the most well known is the BRCA gene mutation: this can affect the chances of developing breast cancer, but what is less known is that it also increases a man’s risk of prostate cancer.
The risk is also higher if your relative was diagnosed at a younger age, say less than 60, or if they have died of cancer at a young age, adds Rylance. “It’s vital to be very clear about your family history with your doctor.”
First of all, get tested. The PSA blood test (prostate-specific antigen) – which measures for high levels of protein in the blood – is the first, if far from infallible, step in checking for prostate cancer. It is available to any man over the age of 50 who requests it.
Up until a few years ago, men with a high level of PSA in their blood were sent straight for a biopsy, which came with a risk of serious infection and could sometimes miss the cancer, leading to repeated biopsies or unnecessary radical treatments, the charity found.
Two new techniques available since 2019 have meant that screening is now much safer than before. The multiparametric MRI scan (mpMRI), is a special type of MRI scan which produces a detailed picture of the prostate gland and can assess tumours more accurately. The transperineal guided biopsies – where the needle passes through the perineum – is less likely to lead to infection.
Because of MRI the experts know where to look, and exactly where to put the needle. “We can know if we are finding aggressive cancers and treat aggressively, or a low-risk cancer and try other options,” says Rylance.
“Not all prostate cancer is the same; some grow very, very slowly,” says Rylance. Because it is diagnosed, typically, in men over the age of 50, if it is growing very slowly, “one of the lazy cancers that isn’t going anywhere, it is not going to do you any harm in your lifetime,” she says.
Because treatments can have major side effects, the NHS recommends, for men with low-risk cancers who are not experiencing any symptoms, to instead monitor the cancer – an “active surveillance”. This might involve regular blood tests, to check for whether there’s more of the protein that the cancer releases in the blood, and repeat MRI scans, or targeted biopsies to check for any changes.
In the largest study of its kind, presented in March this year, funded by the National Institute for Health and Care Research, active monitoring of prostate cancer was shown to have had the same high survival rates after 15 years as radiotherapy or surgery.
The ProtecT trial followed 1,643 men ages 50-69 to measure the effectiveness of conventional treatments for localised prostate cancer, which had not spread to other parts of the body. The men were randomly assigned to the three major treatment options: active monitoring, surgery or radiotherapy.
About a quarter of men in the study at the end of 15 years had not had radical treatment and had managed 15 years without intervention and were alive and well – the other men had needed treatment as the cancer had progressed.
The results made it “clear that, unlike many other cancers, a diagnosis of prostate cancer should not be a cause for panic or rushed decision-making,” said lead investigator Professor Freddie Hamdy from the University of Oxford.
“Patients and clinicians should take their time to weigh up the benefits and possible harms of different treatments,” said Hamdy.
Active surveillance reduces side effects and allows for the best possible quality of life, adds Rylance, although she concedes that one major side effect is psychological – with the anxiety of living with cancer weighing on the mind.
“It does not mean you would never treat the cancer,” she says. “If the cancer does start to move, and looks like it’s becoming more aggressive, it should be treated, either with surgery or radiotherapy.”
Professor Hing Leung is consultant urological surgeon and senior research group leader at the Cancer Research UK Beatson Institute. He uses cryotherapy – applying extreme cold to freeze and destroy cancer cells – on patients across the whole of Scotland, “but only for those who have had previous primary treatment, such as radiotherapy, or if the cancer has recurred. This is a second line of treatment,” he says.
“The newer options such as cryotherapy and HIFU – high intensity focused ultrasound – are considered local, ablative [minimally invasive procedures] treatment options,” says Prof Leung, “but they are not as robust as prostatectomy [the surgical removal of the prostate] or radiation-based therapy.
“They have yet to be proven as long-lasting in terms of how many years the cancer is being cured.”
There is currently no long-term research on the success or side effects of these approaches. Cryotherapy and HIFU are available on the NHS in some centres, but are not appropriate for all men, or all stages of advanced or aggressive cancer.
Immunotherapy is used to “wake up the immune cells and get them to fight the cancer,” says Prof Leung. This has been successful for treating melanoma and other tumour types, but has not the same effect yet with prostate cancer.
“A lot of research is being done to understand why the cancer of the prostate manages to escape being noticed by the immune cells – it’s a hot topic,” says Prof Leung.
There have been clinical trials with different immunotherapy approaches with cancer, so experts believe there could be immune-targeting drugs for prostate cancer within the next five years.
“We are starting to see the first precision medicines for treating prostate cancer,” says Dr Matthew Hobbs, director of research at Prostate Cancer UK.
The olaparib drug, approved in April this year, for men with advanced prostate cancer, works by blocking the protein cancer cells need to live and grow. It means that, for the first time, men across the UK can receive treatment based on the genetic make-up of their cancer. In patients whose cancer has spread, it could extend their lives by an average of six to 18 months.
Coming in a more futuristic form, from the United States, is another “precision medicine” tool, but for men with localised, early-stage disease, which is working its magic via Artificial Intelligence technology. The AI can analyse prostate cancer scans through a complex set of algorithms, potentially able to predict if a patient will benefit from a specific treatment.
“It is probably the first use of AI that has been convincing in having the potential to spare thousands of men from the side effects of hormone therapy,” says Hobbs, “without reducing the likelihood of them surviving their cancer.”
Men had their biopsy sample taken when diagnosed, put on a slide, scanned and made into a digital image, then fed into the AI tool which predicts whether they would benefit or not from hormone therapy, “much better than anything used previously,” says Hobbs.
Many in the high-risk category receive 18 months of hormone therapy, removing their testosterone, alongside their surgery or radiotherapy – which can cause weight gain, cognitive decline and compromise their sex lives.
“For men who need hormone therapy it is absolutely essential and controls their cancer – but for those who don’t, we really do need to spare them from that,” says Hobbs.
“The exciting thing is that the AI is taking data that is clearly there, how multiple features combine, but that we currently can’t see – which is beyond human capability. We don’t actually know what it is looking at, we just know that it is working at the moment.”
The conflict, as with all cancer treatment, remains between curing the disease and maintaining a decent quality of life.
“We need to use new treatments to reduce the number of men dying,” says Hobbs, “but we also need to reduce the number of men suffering by having just enough treatment to control their cancer – and no more than that.”
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