Prostate cancer

What is prostate cancer?

Consultant urologist, Jonathan Aning, talks you through what prostate cancer is, the main types, risk factors, stages and common treatments available to you.

Prostate cancer starts in the cells of the prostate. The prostate is a small gland that is just below the bladder and in front of the rectum (back passage).

Prostate cancer is a common cancer. In the UK about 48,600 men are diagnosed with it each year. Prostate cancer is more common over the age of 65. It can happen at a younger age but it is uncommon under 50. You have a higher risk of prostate cancer at a younger age if you are Black or have a strong family history of prostate cancer.

There are different types of prostate cancer

early prostate cancer (or localised prostate cancer) – the cancer is only inside the prostate gland.
locally-advanced prostate cancer – the cancer has spread through the capsule surrounding the prostate gland and may have started to spread into tissue or organs close by.
advanced prostate cancer (or metastatic prostate cancer) – the cancer has spread to other parts of the body, such as the bones..

If you are a trans woman or are non-binary assigned male at birth, you also need to be aware of prostate cancer.

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Symptoms of prostate cancer

Prostate cancer symptoms only happen when the cancer is large enough to press on the tube that carries the urine from the bladder (urethra). If the cancer is in the early stage it may not cause any symptoms.

The prostate gland can also become enlarged due to a prostate condition called benign prostatic hyperplasia (BPH), which is non-cancerous.

The symptoms of benign (non-cancerous) prostate conditions and prostate cancer are similar. They can include:

needing to pee more often than usual, especially at night
difficulty peeing – for example, a weak flow or having to strain to start peeing
feeling like you have not completely emptied your bladder
an urgent need to pee
blood in your urine or semen
rarely, pain when peeing or ejaculating.

If you have any of these symptoms, it is important to have them checked by your doctor. Your GP can do tests (see Diagnosis of prostate cancer below) to find out if you need a referral to a specialist doctor.

If prostate cancer spreads, it usually goes to the bones. It may cause pain in the bones, such as in the back. This is called advanced prostate cancer (or metastatic prostate cancer).

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Do I have cancer?

Risk factors of prostate cancer

Certain things called risk factors may increase the risk of developing prostate cancer. If you are black, you have a much higher risk of developing prostate cancer. You are also more likely to develop it at a younger age. Having a strong family history of prostate cancer is also a risk factor.

We have more information about the risk factors of prostate cancer.

Diagnosis of prostate cancer

You usually start by seeing your GP to have your symptoms checked. Your GP usually arranges some tests. The first tests used to diagnose prostate cancer are:

Rectal Examination

The doctor gently inserts a gloved finger (using lubricating gel) into your back passage (rectum). The rectum is close to the prostate gland so your doctor can feel for anything unusual in the prostate. A rectal examination test is quick and it should not be painful. It is also sometimes called Digital Rectal Examination (DRE).
PSA test

The PSA test is a blood test to measure the level of prostate-specific antigen (PSA) in your blood. Prostate cancer often causes a raised level of PSA. But different things such as non-cancerous prostate conditions and getting older can also increase your PSA.

If your PSA level is raised or your rectal examination is unusual your GP refers you to a specialist doctor (urologist). Your GP may test your PSA level again if it is raised but your prostate feels normal.

At the hospital

A specialist doctor or nurse asks about your symptoms and any other medical conditions. They check if you have any risk factors for prostate cancer. The doctor may do another rectal examination and arrange another PSA test. They will talk to you about further tests you may have. These may include:

A multi-parametric MRI scan

You may have this specialised scan to help your doctor decide if you need to have a prostate biopsy. A multi-parametric MRI scan gives a more detailed picture of the prostate gland and surrounding area than a standard MRI scan.
Trans-rectal ultrasound (TRUS) biopsy

You may have a TRUS biopsy if tests show you may have prostate cancer. They use a fine needle to remove samples of prostate tissue to examine for cancer cells. This is done through an ultrasound probe your doctor passes into your back passage. You have an injection of local anaesthetic to numb the area first.
Trans-Perineal (TP) biopsy

You may have a Trans-Perineal biopsy instead of a TRUS biopsy. The doctor takes samples of the prostate gland through the area between the scrotum and the back passage (called the perineum). It can be done under a general anaesthetic or using local anaesthetic to numb the area first.

Further tests after diagnosis

Whether you have any further tests will depend on the risk of the cancer growing quickly. Doctors work out your risk by looking at the PSA level, the stage, and the grade of the cancer.

To help diagnose or stage prostate cancer, you may have staging tests:

an MRI (magnetic resonance imaging) scan
a bone scan
a CT scan
more blood tests.

Booklets and resources

Staging and grading of prostate cancer

Knowing the stage, grade and risk group of the cancer helps you and your doctor to decide on the best treatment for you.

The stage

The stage of prostate cancer describes its size and how far it has spread, based on your test results. Doctors often use the TNM staging system or a number staging system.

The grade

Your doctor decides the grade by how the prostate cancer cells (from your biopsy) look under the microscope. This tells them how quickly the cancer might grow or spread. Doctors use a combination of 2 systems to grade prostate cancer:

Gleason score - examines the pattern of cells in the prostate tissues and grades them from 1 to 5. The most common and highest grades are added to give your Gleason score
Grade Group - grades the cancer between 1 and 5 based on your Gleason score.

Risk group

Prostate cancer is also divided into risk groups. Your treatment options will depend on the risk group the cancer is in.

Your doctor looks at the stage of the cancer, your PSA level and your Gleason score to work out the risk group. They use a system called the Cambridge Prognostic Group (CPG). It divides prostate cancer risk into 5 different groups.

Treatment of prostate cancer

A team of specialists meet to discuss the best possible treatment for you. This is called a multidisciplinary team (MDT). There are different treatments. Your treatment will depend on:

your general health
your age
the Gleason score, cancer grade
the stage of the cancer
the risk group of the cancer
your preferences.

Your doctor and nurse will talk to you about the different things to think about when making treatment decisions. They will explain the different benefits and disadvantages of each treatment. You and your doctor can then decide on the best treatment for you.

Treatment for early or locally advanced prostate cancer may include one or more of the following:

Radiotherapy

Radiotherapy uses high energy rays to destroy cancer cells. It can be given from outside the body (external beam radiotherapy) and also from inside the body (brachytherapy). In early prostate cancer sometimes brachytherapy is given as the only treatment.

If you have locally advanced prostate cancer you usually have a combination of external radiotherapy and brachytherapy.
Surgery or radical prostatectomy

Surgery to remove the prostate gland is called a prostatectomy. If you have early prostate cancer you may be asked to decide between having a prostatectomy and radiotherapy. Prostatectomy is not often done in locally advanced prostate cancer.
Monitoring
Active surveillance
Active surveillance involves having regular tests to monitor early prostate cancer. It can help to avoid unnecessary treatment or to delay treatment and its side effects.

Watchful waiting
During watchful waiting, you will not have as many tests as with active surveillance. You see your doctor regularly to check if the cancer is causing symptoms. If you have symptoms or there are signs the cancer is growing you can have treatment, usually with hormonal therapy.

Find out more about monitoring prostate cancer.
Hormonal therapy

Prostate cancer needs the hormone testosterone to grow. Hormonal therapies reduce the amount of testosterone in the body. You may have hormonal therapy as tablets or injections. It may be given with radiotherapy and for some time afterwards. Hormonal therapy is sometimes given on its own.
Chemotherapy

Chemotherapy uses anti-cancer (cytotoxic) drugs to destroy cancer cells.

Chemotherapy is sometimes used for locally advanced prostate cancer that has a higher risk of coming back. It is more commonly used to treat advanced prostate cancer.
Other treatments

Other treatments may sometimes be used to treat early prostate cancer. Cryotherapy uses cold to freeze and destroy prostate cancer cells. HIFU uses heat delivered through an ultrasound to destroy prostate cancer cells. These treatments may not be widely available on the NHS.

Advanced (metastatic) prostate cancer is usually treated with hormonal therapy and chemotherapy.

We have more information about prostate cancer treatments, including treatment options for early prostate cancer and locally advanced prostate cancer.

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After prostate cancer treatment

You will have regular follow-up appointments after treatment for prostate cancer.

You may get anxious between appointments. This is natural. It may help to get support from family, friends or a support organisation such as Prostate Cancer UK.

Macmillan is also here to support you. If you would like to talk, you can:

Call the Macmillan Support Line on 0808 808 00 00.
Chat online to our specialists online.
Visit our prostate cancer forum to talk with people who have been affected by prostate cancer, share your experience, and ask an expert your questions.

Sex, relationships and fertility

Prostate cancer treatments can affect your sex life. They can reduce your sex drive (libido) and cause difficulties getting an erection. This is called erectile dysfunction or ED. This may be very worrying for you. There are different treatments and support available to improve sexual difficulties.

Talk to your doctor or nurse about sexual difficulties or concerns. They will be used to talking about these issues. You may want to involve a partner in these discussions.

Fertility

Prostate cancer treatments can affect your fertility. If this is a concern for you, talk to your doctor or nurse. You may be able to store sperm before treatment starts.

Well-being and recovery

Even if you already have a healthy lifestyle, you may choose to make some positive lifestyle changes after treatment.

Small changes to the way you live such as eating well and keeping active can improve your health and well-being and help your body recover.

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About our information

References

Below is a sample of the sources used in our prostate cancer information. If you would like more information about the sources we use, please contact us at cancerinformationteam@macmillan.org.uk

C. Parker, E. Castro, K. Fizazi, et al. Prostate cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology, 2020, Volume 31, Issue 9, p1119-1134. Available from www.esmo.org/guidelines/genitourinary-cancers/prostate-cancer

National Institute for Health and Care Excellence (2019) Prostate cancer: diagnosis and management (NICE guideline NG131). Last updated December 2021 to include Risk stratification for localised or locally advanced prostate cancer. Available at www.nice.org.uk/guidance/ng131

Reviewers

This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer. It has been approved by Senior Medical Editors, Dr Jim Barber, Consultant Clinical Oncologist and Dr Ursula McGovern, Consultant Medical Oncologist.

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