Page modified at: 02/01/2010
What is the prostate?
The prostate is a small gland in men. It is part of the male reproductive system.
The prostate is about the size and shape of a walnut. It sits low in the pelvis, below the bladder and just in front of the rectum. The prostate helps make semen, the milky fluid that carries sperm from the testicles through the penis when a man ejaculates.
The prostate surrounds part of the urethra, a tube that carries urine out of the bladder and through the penis. How does the prostate change as you get older?
Because the prostate gland tends to grow larger with age, it may squeeze the urethra and cause problems in passing urine. Sometimes men in their 30s and 40s may begin to have these urinary symptoms and need medical attention. For others, symptoms aren't noticed until much later in life. An infection or a tumor can also make the prostate larger. Be sure to tell your doctor if you have any of the urinary symptoms listed below. Tell your doctor if you have these urinary symptoms:
Are passing urine more during the day
Have an urgent need to pass urine
Have less urine flow
Feel burning when you pass urine
Need to get up many times during the night to pass urine What prostate changes should you be aware of?
Growing older raises your risk of prostate problems. The three most common prostate problems are:
Enlarged prostate (BPH, or benign prostatic hyperplasia)
One change does not lead to another. For example, having prostatitis or an enlarged prostate does not increase your risk of prostate cancer. It is also possible for you to have more than one condition at the same time.
Most prostate changes are not cancer. Prostate Cancer Cells
Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.
Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor.
Prostate growths can be benign (not cancer) or malignant (cancer). Benign prostatic hyperplasia (BPH) is a benign growth of prostate cells. It is not cancer. The prostate grows larger and squeezes the urethra. This prevents the normal flow of urine. BPH is a very common problem. In the United States, most men over the age of 50 have symptoms of BPH. For some men, the symptoms may be severe enough to need treatment. Benign growths are not as harmful as malignant growths: Benign growths (such as BPH):
Benign growths are rarely a threat to life , can be removed and probably won't grow back , don't invade the tissues around them and don't spread to other parts of the body Malignant tumors:
Malignant tumours may be a threat to life , often can be removed, but sometimes grow back , can invade and damage nearby tissues and organs , can spread to other parts of the body Detection and Diagnosis
Your doctor can check for prostate cancer before you have any symptoms. During an office visit, your doctor will ask about your personal and family medical history. You'll have a physical exam. You may also have one or both of the following tests: Digital rectal exam:
Your doctor inserts a lubricated, gloved finger into the rectum and feels your prostate through the rectal wall. Your prostate is checked for hard or lumpy areas. Blood test for prostate-specific antigen (PSA):
A lab checks the level of PSA in your blood sample. The prostate makes PSA. A high PSA level is commonly caused by BPH or prostatitis (inflammation of the prostate). Prostate cancer may also cause a high PSA level. The digital rectal exam and PSA test
are being studied in clinical trials to learn whether finding prostate cancer early can lower the number of deaths from this disease. The digital rectal exam and PSA test can detect a problem in the prostate. However, they can't show whether the problem is cancer or a less serious condition. If you have abnormal test results, your doctor may suggest other tests to make a diagnosis. For example, your visit may include other lab tests, such as a urine test to check for blood or infection. Your doctor may order other procedures: Transrectal ultrasound:
The doctor inserts a probe into the rectum to check your prostate for abnormal areas. The probe sends out sound waves that people cannot hear (ultrasound). The waves bounce off the prostate. A computer uses the echoes to create a picture called a sonogram.
Transrectal biopsy: A biopsy is the removal of tissue to look for cancer cells. It's the only sure way to diagnose prostate cancer. The doctor inserts needles through the rectum into the prostate. The doctor removes small tissue samples (called cores) from many areas of the prostate. Transrectal ultrasound is usually used to guide the insertion of the needles. A pathologist checks the tissue samples for cancer cells. What are the Pros and Cons of Screening with the PSA Blood Test?
The PSA test shows the amount in the blood of a protein produced by prostate cells. If the level of PSA is higher than normal it could be due to a prostate cancer but there are other causes of raised PSA, such as infection, a non cancerous enlarged prostate and even exercise and sex. So if you have a raised PSA level you will need to have more medical tests to find the cause.
If you have your PSA checked, your doctor will do a rectal examination as well as the blood test. Rectal examination is also called DRE (digital rectal examination). The doctor puts a gloved finger into your back passage to feel your prostate. This helps the doctor to decide whether your PSA reading is likely to indicate a cancer or not. If you have an abnormal PSA and your doctor thinks your prostate feels unusual, it is more likely to be a cancer than if you have an abnormal PSA but your prostate feels normal.
Generally speaking, the higher the PSA level, the more likely it is that there is a cancer in the prostate. But in early prostate cancer, PSA levels are usually relatively low. It is not possible to pick out a particular PSA reading and say “people above this level have cancer and those below do not”. The level of PSA varies from man to man. It naturally gets higher as men get older.
If you have a normal PSA test result, the current thinking amongst experts is that you do not need to have another test for at least 2 years. If you have a result that your doctor considers borderline, you should have a repeat test in 1 to 3 months to see if the level is going up or is stable. What Do Different Countries Do About PSA Testing?
PSA testing is used in the USA to screen men for prostate cancer. The American Cancer Society support screening with a PSA blood test and rectal examination for men over 50 and at the age of 45 for men thought to be at high risk of prostate cancer (African American men and men with a family history of prostate cancer). The National Comprehensive Cancer Network supports screening for men from the age of 40.
In the UK, there is no national screening programme for prostate cancer because trials have not yet shown clear evidence that screening will reduce deaths from this disease. Also, many men diagnosed with prostate cancer have very slowly growing cancers that will never cause any symptoms or problems in their lifetime. If the cancer is diagnosed and treated, the treatment can cause side effects for some men that may greatly reduce their quality of life. Possible side effects include erection problems (impotence) and inability to completely control urine (incontinence). So at the moment there is no clear benefit in diagnosing prostate cancer early and it may actually cause harm for some men.
In the UK and other European countries, PSA testing is not recommended for screening because Some men with prostate cancer do not have a raised PSA level
2 out of 3 men with a raised PSA do not have prostate cancer
There is uncertainty about the best way to treat early prostate cancer
The treatments can cause unpleasant side effects
If PSA was used as a screening test, some men who did have prostate cancer would be told that they didn’t. Two thirds of men with a raised PSA level would go on to have other tests such as a needle biopsy and rectal ultrasound when they did not actually have a cancer. These tests can be uncomfortable and many men find them embarrassing. They also have risks. Some men who have a needle biopsy will have infection or persistent bleeding afterwards.
If prostate cancer screening was introduced, some men would have their cancer detected early and may live longer than if they did not have screening. But this is likely to help very small numbers of men because prostate cancer is not usually a quickly growing disease. Most men with early prostate cancer don't have symptoms. The cancer can grow very slowly in many men and they are unlikely to die from it. These men don't really need treatment. The treatment has side effects and could cause more problems than the cancer.
Some men have faster growing cancers and do need treatment. But, unfortunately, doctors cannot always tell with any accuracy which prostate cancers are likely to grow quickly and need treatment and which can safely be left alone. What would happen if PSA Testing was introduced? Some men with cancer would be missed
Other men without cancer would be given tests they did not need
Some men with very slow growing cancers would be given treatment they did not need
There is still a lot of discussion worldwide about prostate cancer screening. It is not clear whether the risks outweigh the benefits It is also not clear whether a screening programme using the current tests will reduce deaths from prostate cancer. Is there any Research on PSA Testing?
A UK based trial called ProtecT
has been looking into treatment for prostate cancer for some years. It aims to find the best way of dealing with early prostate cancer. Now, Cancer Research UK and the Department of Health are funding an extension to this trial. The extension will compare the outcomes for men who weren't screened for prostate cancer with those who had PSA testing within the ProtecT trial. This trial has closed and it will be a few years before we know the results.
Two large international trials are looking into prostate cancer screening. In Europe the large ERSPC trial
has stopped recruiting patients. In the USA the PLCO trial
has closed and men taking part are now being followed up. The PCLO study compared 2 groups of men. One group had screening every year with the PSA test and rectal examination. The other group did not have screening as part of the study. The researchers found that screening did not reduce the number of deaths from prostate cancer after 11 years of follow up. The number of deaths was small in both groups. But the results are not clear, because some men in the trial group who were not supposed to have screening had PSA tests from their own doctors.
The ERSPC study is being carried out in 7 European countries. It compared men who had screening for prostate cancer with a PSA test every 4 years to men who had no screening. The early results show that PSA tests can detect very early prostate cancer and may reduce the number of deaths from the disease. But the men in the study need to be followed up for longer to be sure. So the men in the study will carry on being followed up over the next few years to see whether screening reduces the number who die due to prostate cancer
How do I Decide about PSA Testing?
There is now an online decision tool (PROSDEX)
which is designed to help men evaluate the pros and cons of PSA Testing so they can make an informed choice about screening. What If Cancer Is Not Found
If cancer cells are not found in the biopsy sample, ask your doctor how often you should have checkups. What If Cancer Is Found
There are 35,000 new cases every year in the UK, and around 10,000 deaths. If cancer cells are found, the pathologist studies tissue samples from the prostate under a microscope to report the grade of the tumor. The grade tells how much the tumor tissue differs from normal prostate tissue. It suggests how fast the tumor is likely to grow. Tumors with higher grades tend to grow faster than those with lower grades. They are also more likely to spread. Doctors use tumor grade along with your age and other factors to suggest treatment options. Treatment
Men with prostate cancer have many treatment options. The treatment that's best for one man may not be best for another. The options include active surveillance (also called watchful waiting), surgery, radiation therapy, hormone therapy, and chemotherapy. You may have a combination of treatments.
The treatment that's right for you depends mainly on your age, the grade of the tumor (the Gleason score), the number of biopsy tissue samples that contain cancer cells, the stage of the cancer, your symptoms, and your general health. Your doctor can describe your treatment choices, the expected results of each, and the possible side effects. You and your doctor can work together to develop a treatment plan that meets your medical and personal needs..
Your doctor may refer you to a specialist, or you may ask for a referral. You may want to see a urologist, a surgeon who specializes in treating problems in the urinary or male sex organs. Other specialists who treat prostate cancer include urologic oncologists, medical oncologists, and radiation oncologists. Your health care team may also include an oncology nurse and a registered dietitian.
Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. For example, you may want to discuss with your doctor the possible effects on sexual activity
At any stage of the disease, supportive care is available to relieve the side effects of treatment, to control pain and other symptoms, and to help you cope with the feelings that a diagnosis of cancer can bring