Prostate cancer pathway

Symptoms of prostate cancer include:

• difficulty passing urine such as a weak flow or having to strain to start urination
• needing to urinate more frequently than usually, especially at night-time
• feeling like you have not completely emptied your bladder after urinating
• an urgent need to urinate
• blood in urine or semen
• sometimes pain when urinating or ejaculating.

These symptoms may also be a sign of benign prostatic hyperplasia which is the most common cause of prostate enlargement and this is non-cancerous.

If you are experiencing any of the above symptoms, it is important to always get checked by your GP.

Your GP will probably examine your prostate gland using a gloved finger into your back passage.  You may also be asked to provide a urine sample. Certain changes in your prostate gland might make your GP think you need further investigation but this does not necessarily mean you have cancer. You may also have a Prostate specific antigen (PSA) test at your GP surgery.

Prostate specific antigen (PSA) test

A PSA test detects levels of Prostate specific antigen, a protein only made by prostate cells. Although most PSA is carried out of the body in semen, a very small amount escapes into the blood stream and the amount depends on the size and health of your prostate. The test measures your levels of prostate specific antigen in the blood. There are pros and cons to having this test where there are no symptoms as it does not always accurately confirm or disprove the presence of cancer in the prostate. However, where a patient has symptoms that may be suggestive of prostate cancer it is important to test for PSA levels.

NHS – should I have a PSA test?

If prostate cancer is suspected, the next step of the pathway is a referral to the hospital for further testing within two weeks. This is called a fast track referral.

Tests you may have following your fast track referral

Trans-rectal ultrasound scan (TRUS) biopsy

This is where a small ultrasound probe is passed gently into the rectum with the use of a lubricating gel. The ultrasound probe will show an image of the prostate which will assist the consultant to guide a needle into the prostate. The needle will take several samples of tissue which will be reviewed by a pathologist (a doctor who specialises in studying cells).

Template biopsy or Precision Point biopsy

Your urologist takes tissue samples by inserting an ultrasound probe into the back passage and accessing the prostate through the perineum (the area between the anus and the scrotum).

Template biopsy is performed under a general anaesthetic and Precision Point biopsy is performed under local anaesthetic.

Multi-parametric MRI scan

This type of scan is one of the best ways of detecting a prostate cancer. This type of scan gives more detailed images of the body.

Flow rate and ultrasound of residual urine volume

This is used to measure the rate at which urine is passed (flow rate) and the amount of urine left in the bladder (the residual).

Repeat PSA blood test

A PSA test detects levels of Prostate specific antigen, a protein which is produced by the prostate gland, and measures your levels of PSA in the blood.

You may have to wait up to a couple of weeks for your test results. However most prostate cancers are slow growing and it is unlikely the cancer would change during this time.

Staging tests may include

Magnetic resonance imaging scan or MRI

This is a type of scan which uses strong magnetic fields and radio waves to produce a detailed image of the inside of the body.

Bone scan

This is a type of nuclear imaging test which helps to diagnose and monitor several types of bone disease. It is a tool for detecting cancer that has spread to the bone from the tumour’s original location.

CT scan or computerised tomography scan

This type of scan uses x-rays and a computer to create images of the inside of the body.

Blood tests

This is when a sample of blood is taken and assessed to assist with diagnosis.

For more information about the staging and grading of prostate cancer
Macmillan Cancer Support

You may have a lot of questions at this stage and don’t know where to begin. Try writing down and preparing questions when meeting with your consultant.

You can also download questions to ask your cancer care team
Prostate Cancer UK

Multidisciplinary team

A multidisciplinary team (MDT) is a group of health care professionals who are from one or more clinical disciplines who make decisions together regarding the recommended treatment for individual patients.

The treatment you may be offered depends on:

• the stage of your cancer – whether it is early stages, locally advanced or advanced prostate cancer
• the grade of your cancer – a Gleason score is a grading system which helps evaluate the prognosis of men with a prostate cancer, using samples from a prostate biopsy
• your general health
• your age
• other medical conditions that you may have.

Managing prostate cancer

When immediate treatment is not required

Active surveillance

This is where your prostate cancer is closely monitored for a period of time to avoid the need for immediate treatment. The monitoring includes MRI scans, further biopsies and measuring your prostate specific antigen (PSA) level which could be between every three to six months. Active surveillance is an option for low risk cancers.

Watch and wait

This is used when immediate treatment is not required, but ongoing monitoring of the prostate specific antigen (PSA) is necessary to determine when the cancer becomes more active.  Treatment would be recommended if the PSA started to rise or you developed symptoms. This is usually an option for older men who do not have symptoms or when you have another medical condition which could make treatment difficult.

Surgery

Early prostate cancer

Surgery is a major operation to remove the whole prostate. It is called a radical prostatectomy and can often be curative.

Locally advanced prostate cancer

Surgery for locally advanced prostate cancer is uncommon as surgery may not be able to remove all the cancer cells that have spread outside of the prostate. If there are cancer cells remaining following a radical prostatectomy (surgical removal of all or part of the prostate gland), it is often necessary to also have radiotherapy to the area.

Advanced prostate cancer

Surgery for men to remove the prostate is not suitable if your cancer has spread beyond the prostate.

Radiotherapy

• External Beam Radiotherapy
  This is the use of high energy x-ray beams targeted at the prostate from outside the body.
• Brachytherapy
  This is radiotherapy which is given internally. Sometimes brachytherapy will be given on its own and sometimes with external radiotherapy.

Hormonal therapy

This is to reduce the amount of testosterone in the body because prostate cancer needs testosterone in order to grow. This can be given on its own or you may have this before, during or after radiotherapy.

Chemotherapy

Chemotherapy is the use of anti-cancer drugs to destroy cancer cells. This is given if your prostate cancer is first diagnosed as advanced. This can be given together with hormonal therapy or used for cancer that is no longer controlled by hormonal therapy. The most common chemotherapy drug used is Docetaxel.

Other treatments

You may also have High-intensity focused ultrasound (HIFU) treatment or Cryotherapy.

High-intensity focused ultrasound is a non-invasive treatment and highly precise in the destruction of small amounts of cancerous tissue within the prostate gland.

Cryotherapy is a treatment that uses extreme cold to destroy cancer cells.

For more information on all the above treatments
Prostate Cancer UK

Advanced/metastatic prostate cancer

This is prostate cancer which has spread from the prostate to other parts of the body. Prostate cancer can spread to any other part of the body but if it does spread it will more commonly spread to the bones and lymph nodes.

Although it is not possible to cure advanced prostate cancer, it is possible to manage the symptoms and keep it under control. This can often be for many years.

For more information about advanced prostate cancer
Prostate Cancer UK

Emotional impact

How you cope with your diagnosis and treatment will be specific to you. You may expect to feel relief once your hospital-based treatment ends but this is not always the case and it can be a difficult and emotional time.

Following treatment, you may have time to reflect on the impact of your diagnosis. It is completely normal to have a mixture of emotions if you are living with or affected by cancer. There are a lot of support services available to help you through. 400,000 men in the UK are living with and beyond prostate cancer, so it is important to remember you are not alone. 

You may benefit from:

• talking to friends and family
• communicating with others in the same situation
• talking therapies and counselling – your clinical nurse specialist can refer you
• moving forward courses
• local support groups
• health and wellbeing events.

For more information on dealing with your feelings and emotions
Prostate Cancer UK
Macmillan Cancer Support

For information for partners and family on how to support someone with a prostate cancer diagnosis
Prostate Cancer UK

You can also chat with specialist nurses and find support and information
Prostate Cancer UK

Local support groups
Directory of Services

Online support
You can get support on the internet via online support groups, social networking sites, forums, chat rooms and blogs for people who are affected by cancer.

For information about counselling services
British Association for Counselling and Psychotherapy

If you are feeling depressed or need to speak to someone immediately, please contact Samaritans 116 123

If you are struggling with how you are feeling emotionally, it is important to speak to your GP or your cancer care team, they will be able to provide you information on the treatments and support available to you.

Side effects and symptoms

Many men live with side effects following treatment for prostate cancer such as fatigue, erectile dysfunction and incontinence. You may experience emotional effects of having or living with prostate cancer and its treatment too. There are many ways in which both the physical and emotional effects can be managed.

For a range of publications and guides
Prostate Cancer UK

You can pick and choose the information which is helpful to you and your situation. The information on this site includes:

• booklet for partners and family
• fatigue and prostate cancer
• follow-up after prostate cancer treatment: what happens next?
• living with and after prostate cancer
• living with hormone therapy: a guide for men with prostate cancer
• managing pain in advanced prostate cancer
• prostate cancer and your sex life
• urinary problems after prostate cancer treatment
• travel and prostate cancer.

You can also speak to your cancer care team to discuss any symptoms or side effects you may be having.

Relationships and sex

Prostate cancer and its treatment can have an impact on your relationships and on your sex life. You may be worried about having sex, whether you are in a relationship or looking to start a new relationship.

Some treatments for prostate cancer can damage the nerves and bloods vessels needed for an erection. This is often called erectile dysfunction or impotence. Treatments such as surgery, external beam radiotherapy, brachytherapy, high intensity focused ultrasound, and cryotherapy can interfere with the ability to get an erection.  Your consultant can give you an idea how likely this is to happen before you have your treatment.

Hormone therapy can also reduce your desire to have sex.

There are several treatments available for erectile problems including:

• tablets
• vacuum pump
• injections
• pellets or cream
• implant
• testosterone therapy.

For more information on erectile dysfunction, details about these treatments, access to support and specialist nurses to talk to
Prostate Cancer UK

It can be difficult to talk about sex as often it can feel embarrassing but talking about it to either your GP or healthcare professional is key to getting treatment and support. Healthcare professionals can prescribe free treatments via the NHS for erection problems.

Maintaining a healthy lifestyle

Following your treatment, there are many things you can do that may help to reduce the risk of prostate cancer recurrence and prevent other health conditions.

You can take care of yourself by:

• stopping smoking – your cancer care team and your GP can help as well as the national stopping-smoking service.
  NHS UK – Quit smoking
  Live Well Dorset – Stop Smoking
• managing tiredness
  Your clinical nurse specialist can discuss this with you and perhaps how family and friends could support you with day to day tasks.
• getting more active
  Macmillan – Safefit
• eating well and maintaining a healthy weight
  NHS UK – The eatwell guide
• sticking to sensible drinking guidelines
  Drink Aware
• reducing stress.

For more information about lifestyle
Macmillan Cancer Support

Learn how you can improve your general health and manage the effects of prostate cancer and its treatment
Prostate Cancer UK

You can get in contact with your GP for further information regarding maintaining a healthy lifestyle and they will be able to offer you advice and support.

Talking about cancer

It can be difficult to tell people you have cancer, however talking to your closest friends and family can make you feel more supported and reassured that the feelings you may be experiencing are normal.

Everyone you tell may have a different reaction and it is important to be prepared for this. Some will be keen to support you but this may not always be the case as some people may find the conversation difficult and uncomfortable. This may be through lack of experience, fearing your reaction or they may go into denial.

View videos of people talking about their own experiences and coping with people’s reactions
healthtalk 

It can also help to talk to people who also have cancer as they may have a better understanding of what you are going through.

For more information on talking about cancer
Macmillan Cancer Support

Complementary therapies

Complementary therapies can be used alongside conventional prostate cancer treatments. These are not the same as alternative therapies which are used instead of conventional treatments, such as chemotherapy or radiotherapy.

Complementary therapies can give you comfort and help you feel more relaxed after treatment and diagnosis. Types of complementary therapies can include:

• activities that improve mindfulness
• acupuncture
• acupressure and shiatsu
• aromatherapy
• healing and energy therapies
• herbal therapies
• hypnotherapy
• massage
• meditation
• mindfulness
• reflexology
• special ‘cancer diets’ and dietary supplements
• yoga, Tai Chi and Chi Gung.

You can discuss what complementary therapies are available to you with your cancer care team or clinical nurse specialist.

For more information about complementary therapies
Macmillan Cancer Support