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Frequently Asked Questions about Prostate Cancer


How reliable is the PSA test?

It is not a perfect test, but it is the best we have at present and is considered extremely useful by most urologists, especially if it is expertly evaluated, and taken together with a digital rectal examination (DRE).  All men have small amounts of prostate specific antigen (PSA) in the bloodstream and this level can increase with age or if there is any infection or inflammation in the prostate. This can cause falsely high  PSA readings,  which can be alarming.  A raised PSA can be an important sign of prostate cancer and in this setting it can save lives.  The Department of Health has recently sanctioned PSA tests in informed men aged 50–70 and your GP will be able to discuss this with you.

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What is the PCA3 test?

The PCA3 test is a new molecular test that measures the extent to which the PCA3 gene is expressed in cells derived from the prostate.  It does not require a biopsy, but instead a prostatic massage is performed and the first 10–20cc of urine is collected and the specimen sent to a specialised laboratory to be analysed.  A value above 35 suggests that there is an increased risk of cancer being present if a biopsy is performed.  The higher the PCA3 value the greater the probability of a positive biopsy.  Unlike PSA, PCA3 values do not increase as the prostate enlarges.  There is now some evidence that PCA3 is more positive in larger more aggressive cancers, and less so in smaller clinically insignificant tumours, so there is great interest in this test.

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What is a prostate biopsy, why is it necessary and how is it performed?

A prostate biopsy is a procedure to remove some very small samples of prostate tissue from the prostate gland.
Consultants ordinarily recommend a biopsy to see what degree of cancer may be present if the PSA level is raised above the norm (greater than 4 ng/ml).
A very fine hollow needle is pressed into the prostate so that the tissue becomes a 'core' in the interior of the needle which is then withdrawn.  The process is usually performed under ultrasound control which provides the urologist with an image of the prostate so that he can guide the needle to the best position.  A probe, covered by a condom, and the size of two fingers is introduced into the rectum and the ultrasound image is used to direct the biopsy needle towards the required part of the gland.  Under local anaesthetic and antibiotic cover, 12 or so cores are taken and then sent to a pathology laboratory for analysis.  Each one is assessed for the presence or absence of cancer.

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I am told this can be very painful and unpleasant. Is this true?

Biopsies are not exactly thrilling or agreeable to experience; they can vary from just uncomfortable to very uncomfortable or, at worst, rather painful.  They can also cause rectal bleeding and blood in the ejaculate, but this has been likened to having a nosebleed, and it will stop after a few days.  Nowadays, doctors taking biopsies from the prostate, via the rectum, will usually use a local anaesthetic.  You will also be treated with antibiotics to help prevent any associated infections.  If you do develop a temperature or shaking attacks after a biopsy please let your doctor know immediately.  These are usually due to an E coli infection secondary to the biopsy and will need to be treated, often with intravenous antibiotics.

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What is the Gleason score?

The biopsy results give very important information about the extent of the cancer within the prostate and also the level of aggressiveness.  The pathologist will give any cancer cells a grade called the Gleason Grade.  Prostate cancers range from slow growing tumours which are unlikely to spread and cause any problems to fast growing tumours which can spread quickly.  The Gleason Grade is a scoring system between 6 and 10. The higher the score, the more aggressive the cancer is thought to be.  These results in combination with the stage of the cancer and the original PSA will be important in deciding the best treatment option.

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Can I have my biopsy done under a general anaesthetic??

Yes, biopsies can be done under light anaesthesia in which case they are painless.  Recently, a template biopsy technique is being used which allows biopsies to be taken more precisely through the perineal skin, rather than the rectum.  This reduces the risk of infection and allows more samples to be taken, thereby increasing the accuracy of the technique.

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Consultants sometimes want you to have a bone scan, CT scan or MRI scan before they will deliberate on the best course of treatment.  Why is this?

These tests will show if the cancer has spread outside the prostate and again are very important in deciding the best treatment options.  It is common to have a CT or MRI scan which will give information about whether the cancer has spread outside the prostate to the immediate surrounding areas or to the local lymph nodes.  A bone scan may also be arranged to see if any cancer cells have escaped and spread to the bones.  These scans along with the information from feeling the prostate at DRE will enable the doctors to stage the cancer.  There are basically three different stages with different treatment options:

Localised or early prostate cancer is when the tumour is contained within the prostate gland and has not spread to any other parts of the body.  These early tumours can usually be treated with surgery, radiotherapy or sometimes active surveillance (see above).  The stage of the tumour will be considered in combination with the Gleason Grade (above) determined from the biopsies and the PSA results.  Some men have normal scans but a high Gleason Grade or PSA and this can be an indicator that there could be a risk of tiny microscopic prostate cells that have spread to other places in the body that are too small to be seen on a scan.  In this situation it is common to offer both local treatment, (usually with radiotherapy) and also hormone therapy which has been shown to help prevent or delay the cancer developing in other places in the body.

Locally Advance prostate cancer is when the cancer is seen or felt to have spread just outside the capsule of the prostate into the immediate surrounding tissues or local lymph nodes within the pelvis.  Men with locally advanced prostate cancer have a higher risk that microscopic cancer cells may have already spread (as above).  In this situation treatment is usually with radiotherapy to include the surrounding structures (as well as the prostate) in combination with hormone therapy as this can delay or prevent the cancer coming back in other places and is given by tablets or injections.  Some men with locally advanced prostate cancer are treated with hormone therapy alone.  The choice depends on factors that you will discuss with your doctor.

Advanced or Metastatic prostate cancer is diagnosed when the scans show that the cancer has spread to distant sites usually the bones.  This is usually treated with hormone injections initially but there are many other therapies that can be added later if necessary to keep the cancer under control.

So staging scans, as well as biopsies, and the original PSA value, are vitally important for making treatment decisions.

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If cancer is diagnosed, should I have radiotherapy, brachytherapy, surgery, or active surveillance?

There is no right and wrong answer in the treatment of early prostate cancer and treatment approaches can vary with many different factors.  The options can be between active surveillance, radical radiotherapy with either external beam treatment or brachytherapy or radical prostatectomy.  The treatment choices that you are offered will depend on some factors related to the tumour itself.  These include the stage of the prostate cancer (how much cancer can be seen and felt in the prostate), the grade (the level of aggressiveness of the biopsies) and the level of presenting PSA.  Some men have other medical conditions that may make certain treatments more difficult or more likely to cause certain side effects and this will also need to be considered.  When there is a choice between several treatment options, it is important that you are able to discuss these therapies with all the relevant doctors and nurses and make a decision as to which treatment best suits your individual needs and circumstances.  The choice can sometimes be influenced by where you live and the how the different side effects of treatment may affect you individually.

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What is Active Surveillance ?

Following the increase in testing for prostate cancer by the PSA (prostate specific antigen) test and subsequent prostatic biopsy, the number of patients diagnosed with prostate cancer continues to rise.  The problem then is to distinguish the potentially life-threatening “tiger” cancers from the less dangerous “pussy cat” cancers that pose little or no threat to life, provided that they are carefully monitored.  Active surveillance may be an option for some men with early localised prostate cancer.  Suitable patients are those who would be fit for radical treatment (surgery or radiotherapy) and have low risk localised disease (usually Gleason ≤ 6 and PSA ≤ 10 ng/ml).  Men are monitored with regular PSA checks, MRI scans and repeat prostate biopsies.  If the disease becomes more active (rising PSA or more aggressive disease on scan or biopsy) they can then have radical treatment with surgery or radiotherapy.  Although it can sometimes be difficult for patients and their partners and families to come to terms with living with cancer rather than opting for initial active treatment with surgery or radiotherapy, there is mounting evidence that for a subset of men diagnosed with early prostate cancer this can be an option.  Provided that follow up is meticulous and that speedy treatment is employed if there is clear evidence of prostate cancer progression, there is little reason to suspect that overall outcomes are jeopardised.  And many men following this protocol will in fact avoid the need for radiation or surgery altogether, thereby maintaining their full quality of life, with little jeopardy to their sexual and urinary function.  It is however only one option and some men may elect to have immediate radical therapy for their early disease after considering all the options.

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Why are certain patients ineligible for brachytherapy?

Low dose rate (LDR) permanent seed brachytherapy can also be an effective alternative in some men with early prostate cancer.  It involves ‘radioactive seeds’ being implanted in the prostate under anaesthetic.  The seeds are left in the prostate permanently where they slowly lose their radioactivity and treat the prostate cancer over several months.  This type of brachytherapy is most suitable for men with early localised prostate cancers that are growing slowly (Gleason grade 6).  It is not usually suitable for men with high grade or more extensive tumours.  There needs to be a careful assessment of prostate size before treatment as men with large prostates can have an increased risk of urinary side effects with this treatment and this can be another reason why some men are not suitable for seed brachytherapy.  If TURP has been performed previously, the radioactive seeds cannot be sited correctly in the gland.  Pre-treatment with prostate-shrinking drugs such as LHRH analogues can sometimes make brachytherapy suitable for men with large glands.

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What are the commonest side-effects of radiotherapy?

Most men experience some side-effects during radiotherapy but the severity varies from person to person.  Side effects can occur during treatment (acute) and are usually temporary or later after the treatment has finished and these can be permanent.  You should however be able to continue normal activities during the radiotherapy.  Acute or Short Term side effects are temporary and usually occur in the last three or four weeks of treatment and start to get better a few weeks after the treatment is over.  You will be given advice about diet and skin care before the treatment starts.  Your doctor will prescribe creams and medicines if you need help with any of these problems.  The common temporary side effects are tiredness, frequency and stinging when passing urine, diarrhoea and soreness in the rectum.  There can be occasionally be some bleeding or mucous (slime) form the rectum.  There may be some darkening and soreness of the skin in the area being treated especially between the legs and around the anus.  Other side-effects can occur many months after the radiotherapy has finished and these can be permanent.  These include loss of erections, long term change in bowel habit with diarrhoea or urgency to have the bowels open and occasionally some bleeding from the rectum.

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If I go for surgery, is the aftermath of the operation painful?

Not really, because any pain is expertly controlled.  This can be achieved, for example, through the use of epidural anaesthetics and of drugs given to you post operatively.  The side effects of the surgery and what to expect afterwards will be discussed with you before the operation.  These days more and more operations aimed at removing the whole prostate (radical prostatectomy) are done through keyhole incisions, with or without robotic assistance.  Keyhole surgery causes a lot less post-operative discomfort than traditional open surgery because the wounds are much smaller.

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Is there much loss of blood?

No, not normally.  Only a small proportion (less than 5%) of patients undergoing radical prostatectomy nowadays require a blood transfusion, possibly about two pints — not a particularly significant quantity.

The new approaches of removing the prostate with either keyhole (laparoscopic) surgery or robotic assisted keyhole surgery have been shown to reduce blood loss even further so that blood transfusion after these types of operation are now very uncommon.

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Do I need to have some of my own blood taken beforehand?

No, unless it will buy you peace of mind, but if there are no exceptional circumstances there is no need.  Use of your own (autologous) blood is more common in the USA, where there is possibly a higher risk of infection from regular blood transfusion.  It is not advised in the UK.

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I have heard that you see traces of blood in the urine after the operation.  Is this true and why is it?

It is true, but normally it is only a trace, and just while the catheter is draining urine immediately after the operation, or perhaps for a while longer while the re-routed ‘plumbing’ inside is healing.  It normally clears after a week or two at most.  Drinking extra fluids is helpful, as is taking laxatives, whole wheat cereal, prune juice and fruit to keep the bowels regular.

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Is there any risk that I will die during or shortly after the operation?

There is always such a risk with any operation (around 1 in 1000), but we do not often hear of it happening.  Do not be afraid to ask your surgeon what his own mortality rate is.  Ask him or her when the last major complication occurred and what was the outcome.

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What about unsightly scars as a result of the operation?

This need be the least of your concerns.  To gain access to the prostate, many surgeons perform an 8—10 cm lateral or vertical incision above the pubic bone, with a small drain hole beside it.  Clips are more commonly used than stitches these days, and the healing process is quick.  Indeed after a few months the scar is almost, but not quite, invisible.  New recent developments include Laparoscopic (keyhole) and Robotic (robot assisted keyhole) radical prostatectomy.
These techniques involve making 4 to 6 very small cuts and the surgeon removes the prostate using tiny instruments under magnification through a telescope.
The surgeon views the operation on a video screen.  This has the advantage of reducing blood loss and shortening the recovery time after the operation.
The very latest development is the use of a robot to assist keyhole surgery.  This involves the surgeon conducting the surgery via a robot.  The surgeon sits at a console and his/her movements are replicated by the robot with extreme precision beyond the capabilities of the human hand.  This again allows reduced blood loss and better preservation of the tiny nerve bundles that are important for achieving erections.  This new technique looks set to increase in the future as cancer excision rates are high with less incontinence and better preservation of sexual function.

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How long will I be in hospital?

Between 4 and 7 days, often including a 12—24 hour period in a progressive care ward where you will be monitored for bleeding, signs of respiratory infection, or any heart rate instability.  About a fortnight after the operation, your catheter will be removed and you will be watched closely for 24 hours to make sure the new ‘plumbing’ is in order (for example, your fluid intake will be checked against your urine output). The newer keyhole operations have the advantage of a shorter recovery time and a reduced stay in hospital often only 2 or 3 days. Also the catheter only needs to stay in 1 week as the join between the bladder and the urethra (the tube through which urine passes out of the body) can be performed more accurately.

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When will I know if the surgeon has successfully excised the cancer?

He or she will usually tell you what he thinks within 24 hours, but he has to wait for a few days for the laboratory report on the removed prostate to be sure what has been achieved.  If the report is such that some cells are thought to have escaped from the prostate into the surrounding tissue, a so-called ‘positive margin’ then the surgeon may recommend some ‘mop-up’ radiation, which is usually very successful.  The radiation therapy does not have that much to do compared with clearing the whole prostate of cancer (as is necessary if surgery is not performed).  Side-effects are not usually too troublesome, although some rectal irritation and minor bleeding may occur.

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Will the PSA have dropped out of sight after the operation?

Yes, it should have dropped to about 0.6 ng/ml or thereabouts immediately after the operation, and then gradually reduce further to an ideal of below 0.1 ng/ml where, in successful cases, it should remain for the rest of your life.  But remember to have it checked every 3 months for at least a year, and at the same laboratory too, otherwise you may get a variation in results that could alarm you.  In other words, one laboratory may have machines that only read as low as 0.5 whereas another might read down to 0.1, or even 0.01.  In essence the result, as far as you are concerned, is the same.  If the PSA begins to increase months or years after the surgery you may need some mop up radiotherapy at that stage and your surgeon and oncologist will advise you about this.

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How many years do I have to have these tests?

You will need to have PSA tests for many years but these will be less and less as time goes on.  It is important to note that after surgery we aim for the PSA to be less than 0.1ng/ml to 0.2ng/ml but after radiotherapy the PSA levels will be higher due to the fact that the normal prostate tissue can secrete small amounts of PSA.  The current definition of good response to radiotherapy is a PSA that remains below 2 to 3 ng/ml.  Also if hormone treatments are given in combination with the radiotherapy, the PSA will increase a little after the hormones are stopped as the normal prostate tissue recovers from the therapy.

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Are there any special things I need to remember when I am in hospital?

Yes.  Don’t encourage too many visitors; don’t worry about breaking wind (nurses love wind because it shows things are beginning to sort themselves out in the bowel, which will have been a bit disturbed during the operation): don’t eat too heavy a diet because you don’t want to get constipated through lack of exercise and too many heavy meals: drink as much as you can — at least 8 pints of water or soft drinks, like cranberry juice, every day for a couple of weeks if you can stand that (it helps to flush the system through after your internal plumbing has been re-routed); and, most importantly, just look forward to the new future that the surgeon will have given you.

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Is it true that my penis will be shorter after the operation?

Well, yes, some men have noticed a detectable change in length, but not circumference, when the penis is at rest once everything has settled down.  But it’s somewhat relative.  It rather depends upon how well endowed (as the expression goes) you were to begin with.  If there is a noticeable difference, it is very slight.  It is because the newly organized and re-routed urethra has been necessarily shortened and therefore had the effect of ‘pulling back’ the penis into the body just a little.  After a few months, the urethra will stretch to accommodate most of the change.  On erection, the difference is usually of little or no consequence.

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I have heard that after the operation my scrotum and possibly my penis will be very badly swollen and look severely bruised.  What will they have done to them and why is this?

This is seldom mentioned before the operation because it is of no long-term significance, but yes, there can be some rather alarming–looking swelling — more often associated with the scrotum, which can occasionally swell to the size of a small orange — but it subsides quite quickly, doesn't hurt, and is neither damaging nor even particularly inconvenient or uncomfortable.  The penis can appear a bit bruised also, and this has to do with inevitable disturbance (during the operation) of the blood vessels and nerve endings serving the scrotum.  But it really is a very short-term problem and is soon history.  Scrotal and penile swelling is less common after laparoscopic or robotic surgery than traditional open operations.

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Do I need any special nursing care when I first go home?

Not normally, though you may need some help getting up from deep armchairs, or getting into and out of bed during the first few days at home.  And it is advisable to wear loose clothes like tracksuit bottoms because your lower tummy will be a bit swollen, and getting zips done up can be a problem for a while.  Also you need a spare urine collection leg bag, which the hospital can give you, or you can buy them easily from chemists.  You need to keep yourself scrupulously clean to reduce the risks of any infection while the catheter is still in place.  Some patients like to have sleeping tablets to help them get off to sleep when they are at home with a catheter in place.

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Is it painful to have the catheter removed?

Not normally, because catheters are much slimmer these days.  Usually it only takes a moment and it's gone, but they can occasionally get a little stuck because of a tight fit.  But a modern catheter getting severely stuck is unusual, and you would have to be unlucky to experience it.

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Will I feel tired and washed out after the operation?

Yes, you may, as this is a normal protective mechanism to allow healing.  Some men feel a tremendous loss of energy, and have days when they think they will never regain their original verve, but gradually the energy level returns and the post-operative tiredness and lassitude are soon forgotten.  In others the effect is minimal. Fatigue is less after keyhole (including robotic) surgery than traditional open surgery and patients are back to normal activities quicker, but heavy lifting should be avoided.

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How long should I be off work?

Between 6 and 8 weeks is recommended, although reading, telephone calls, and stress-free activity are all fine.  Every single patient with whom we have spoken who has returned to work a bit early has really regretted it, and his recovery has taken longer.  Remember, nobody is indispensable, and it will probably do your colleagues the world of good to shoulder some of your responsibilities while you are away!  Even if you are retired, take it easy, and handle one day at a time.  You can't really drive comfortably for a few weeks, anyway, so get somebody to drive you!

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Can I exercise after the operation?

Yes, but listen to your body: it will tell you how much is sensible and when to rest.  But avoid heavy lifting, such as weight training.

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Will I lose my continence control?

Not unless you are very unlucky.  Most patients now recover control almost as soon as the catheter is taken away, but it is true that for some it can take a few hours, a few days, a few weeks, and even a few months, and you might need to wear some padding for a while if leakage is a bit of a problem.  As explained earlier, many surgeons ask you to stay in hospital overnight after the removal of the catheter, measuring fluid intake and outflow to see that the plumbing is working as it should and that there are no internal leaks.  To some extent, regaining continence control depends upon individual muscle tone (and you will be taught exercises to strengthen the pelvic muscles), the skill of the surgeon who will have done all he can to spare the nerves that affect continence, and a certain amount of incalculable individual luck.  The good news is that things almost always dry up sooner rather than later, and you should have a urine stream like when you were a teenager.  If the urinary stream does deteriorate, alert your urologist.  You may be developing a bladder neck contracture, which requires gentle stretching under light anaesthetic.

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Is sexual dysfunction a problem?

Yes, for nearly everyone, whatever they claim.  However, some ability and sensation, albeit with a dry orgasm (because the seminal vesicles have been removed as part of the operation) can return after a few months, or sooner for a few lucky ones.  Normal penetrative sex is a problem because however careful the surgeon was to avoid damaging the nerves during the operation, achieving a sustainable firm erection is more difficult for most patients, although some men say they can manage reasonably satisfactorily.  Having a successful radical prostatectomy is unquestionably a trade-off because if the alternative is to die of prostate cancer, then it has to be remembered that so far as we know there is not a great deal of sex in the graveyard.  (Although a local vicar, who incidentally has undergone a radical prostatectomy, told us that there is rather too much in his!)  Sexual dysfunction is also quite common after radiotherapy.

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Are there things I can do to help me get back my erections?

Yes, there is a lot that can be done to help restore erections.  These days an active programme of rehabilitation is advised.  Tablets such as Viagra, Cialis and Levitra can all help as can the use of a vacuum device to achieve an artificial erection.  Injections of prostaglandin E1 in the form of Caverject almost always are effective.  Penile suppositories of prostaglandin (known as MUSE) are available, but are quite expensive.  They do work, though, and are favoured by some patients.  In a few cases there are silicone implants (for those who wish to afford them privately, or individuals who can persuade the NHS to help), and these either work rather like a bendy toy, in the sense that you bend it up when you want that, and down when you don't, or are available in an inflatable form, which quite closely simulate a normal erection.
Other drugs such as Uprima (apomorphine) can be helpful.  Successors to Viagra, known as Cialis (tadalafil) and vardenafil, may act more quickly and stay effective for longer.

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How will my partner be affected?

Nobody can ‘catch’ prostate cancer from you, but your partner will certainly be affected if impotence is the result.  Frank discussion is vital before and after the operation, particularly if you go for a radical prostatectomy, and the partner must understand the implications along with you.  The ‘prostate cancer journey’ can be a lonely one so take your partner with you and allow them to help and support you along the way.

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Should I tell my family and friends I have, or have had, a cancer?

It’s up to you of course, but why should there be a need for secrecy and shame, and why not become an advocate for regular check-ups and possibly save a life in the process?  This is particularly true if you have sons or brothers who have yet to reach their 40s and 50s when a check-up would be wise, unless by then medical science has beaten this disease completely.  Prostate cancer does run in some families so it is important that you share information with them candidly.

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Will the cancer come back?

Well, yes, this has been known, with any of the treatments.  The doctors will determine the risks of your individual case and do everything to try and prevent any recurrence of the cancer as early as possible.  This can sometimes mean that you will need a course mop up radiotherapy after surgery.  This can be given as a planned procedure after the operation if the surgeon and pathologist feel there is some cancer left behind in the bed of the prostate.  Sometimes a small rise in PSA months or years after the surgery can be an early warning sign that the cancer could be active again and radiotherapy can also be given successfully at this stage.  If there is a risk that there could be tiny microscopic tumour cells in other parts of the body, your doctor may advise a period of preventative hormone therapy with either tablets or injections as this has been shown to prevent or significantly delay any cancer recurrence.  If the cancer does come back there are many other effective treatments including different hormone drugs that can be used in sequence.  Chemotherapy with taxotere has recently been shown to be effective in prostate cancer if and when some of the cancer cells stop responding to hormone therapy.  There are also many new and very promising new drugs that are being developed and are currently being tried out in clinical studies.

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Was there anything I could have done to prevent the cancer in the first place?

Not really, because nobody knows for certain why anyone is affected by it.  There are plenty of theories.  Some say it is all to do with diet (ranging from eating too much saturated fat, especially red meat); others believe it is a genetic disease (and there is much research going on in that direction); yet others say it is connected with a multifarious and largely unidentifiable mix of factors, including having had a vasectomy.  Nobody has a monopoly of wisdom on the subject.  The latest research has found that men who carry a damaged version of a mutant gene are four to five times more likely to suffer from prostate cancer than those who do not have this faulty gene.  It’s a case of ‘watch this space’.

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And what about the future in terms of treatments?

There is much research going on which may one day find a solution for prostate cancer, through a vaccine, gene or stem cell therapy to achieve a more certain cure without losing the gland, but we are presently years away from this happy circumstance.  And, inevitably, more money is needed to support research into the causes and possible cures of this very common disease.

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