Prostate cancer: A detailed review

We take an in-depth look at prostate cancer, the symptoms and how it is staged.

Age and screening

Screening, which includes a prostate specific antigen (PSA) blood test and a digital rectal exam (DRE), can help detect prostate cancer in the early stages when it can be cured. Early detection reduces the risk of dying by up to 56%.

Informed patient-based screening is recommended, by the Prostate Cancer Foundation, in men with a life expectancy of more than 10 years in the following situations:

• From the age of 40 in black African men and in men who have a family history of prostate and/or breast cancer in a first degree relative. 
• From the age of 45 years for all other men.
• In addition, patients with a history of lower urinary tract symptoms (LUTS) and/or clinical suspicion of prostate cancer, regardless of age group, should have their PSA tested.

Symptoms

There are generally no symptoms of prostate cancer in the early stages of the disease which is why screening is so important. Some of the symptoms are the same as the symptoms for an enlarged prostate (benign prostatic hyperplasia). This condition is also common in older men. 

1. Early (localised) prostate cancer

Localised prostate cancer is when the cancer is contained within the prostate. There are generally no symptoms at this stage which is why screening is important. 

2. Locally advanced prostate cancer

At this stage, the cancer tumour may have spread to areas surrounding the prostate, such as the bladder, the pelvic nerves, the urethra and the seminal vesicles. The tubes carrying the urine can be blocked. 

The following symptoms can occur:

• A need to urinate frequently, especially at night (also a symptom of an enlarged prostate)
• An urgent need to urinate
• Difficulty in starting urination or holding it in (also a symptom of an enlarged prostate)
• Weak or interrupted flow of urine (also a symptom of an enlarged prostate)
• Painful urination
• Blood in the urine or semen
• Erectile dysfunction
• Loin pain
• Very little or no urine

When the tumour enlarges, it can push against the rectum which sits behind the prostate causing constipation, cramping and rectal bleeding.

3. Advanced (metastatic) prostate cancer 

When prostate cancer spreads to other body parts it may cause: 

• Bone pain particularly in the pelvis and lower spine due to bone metastases and sciatica
• Bone fractures 
• Spinal cord compression causing a loss of feeling in the limbs
• Lymph node enlargements
• Loin pain due to a blockage in the tubes carrying urine from the kidneys to the bladder

Other symptoms that can occur when the cancer spreads widely throughout the body can include:

• Lack of energy from iron loss (anaemia) 
• Weight loss with muscle wasting and loss of appetite

What does staging mean?

Clinical staging

After a prostate biopsy, your urologist will estimate the stage of your prostate cancer as this determines what treatment options are available to you. This is clinical staging and it’s based on the results of your DRE, your PSA score, Gleason score and biopsy results. If any other investigations like an MRI, X-rays, bone scans, CT and PET scans have been done, these will help with staging.

Pathologic staging

If you have surgery to remove the prostate (a radical prostatectomy), the prostate, seminal vesicles and surrounding tissue removed during surgery are sent to a laboratory for analysis. The pathologist will use the results to restage the cancer. 

This is more accurate than clinical staging. Pathologic staging is indicated by a ‘P.’

The most common method to stage prostate cancer is the TNM method:

T – indicates the tumour size and how far it has spread

N – describes regional lymph node involvement

M – indicates whether the cancer has spread (metastasised) to bones or other organs.