Prostate cancer – early detection, symptoms and treatment

Prostate cancer is the most commonly diagnosed cancer in men in Europe. It develops slowly, often over years, and in its early stages it almost never causes any complaints. That is why many cases are found at a check-up rather than because of symptoms.

The word “cancer” is frightening, but here the facts are encouraging. When it is found while it is still confined to the gland, prostate cancer is treated successfully in most men, and many low-risk tumours do not need immediate treatment, only careful monitoring. Below you will find calm, clear information – who is at risk, how the disease is detected in time and what the treatment options are.

What is prostate cancer

The prostate is a gland below the bladder that produces part of the semen. In cancer, some of its cells start to divide uncontrollably, most often in the peripheral zone – the part that can be felt during a rectal examination. Almost all cases are adenocarcinomas.

Tumours differ widely in how they behave. Their aggressiveness is determined under the microscope using the Gleason scale and summarised in five grade groups – from 1 (slow-growing) to 5 (fast-growing tumour). The stage shows whether the cancer is confined to the prostate, has spread beyond its capsule or has reached the lymph nodes and bones. The combination of PSA, grade and stage places patients into low-, intermediate- and high-risk groups, which are treated differently.

Symptoms

In the early stage there are usually no symptoms. When they do appear, they are often due to an enlarged prostate at the same time, but they always deserve to be checked:

• a weak or interrupted stream, straining, passing urine often and getting up at night;
• blood in the urine or in the semen;
• pain or burning when passing urine and on ejaculation;
• erection problems that have appeared over a short period.

In advanced disease there may also be constant pain in the lower back, pelvis or thighs, unexplained tiredness and weight loss, and swelling of the legs.

Blood in the urine, especially if it is painless, needs to be checked within the next few days rather than watched at home. Suddenly being unable to pass urine with a full bladder is an emergency – go to an emergency department or call 112 (the European emergency number).

Causes and risk factors

The exact cause is not known, but the risk clearly increases with:

• age – the disease is rare before 50 and becomes more common after that;
• family history – a father or brother with prostate cancer roughly doubles the risk, and inherited mutations that are also linked to breast cancer in the family raise it further;
• ethnic background – men of African descent are affected more often;
• being overweight and inactive, which are linked to more aggressive forms.

An enlarged prostate and prostatitis do not cause cancer, but they produce similar complaints and raise PSA, so telling them apart is the urologist’s job.

Diagnosis

Early detection rests on two simple steps – a PSA blood test and a rectal examination. The European Association of Urology (EAU) recommends that these be discussed with a well-informed man from around the age of 50, and from 45 if there is a family history; Dr Penev decides how often to follow up on an individual basis, depending on the first value and your age.

During a prostate check at the practice in Plovdiv or Karlovo, Dr Penev feels the gland for hard areas and asymmetry and performs an ultrasound to assess its volume, the urine left in the bladder and the condition of the kidneys. If the PSA is raised or rising, or there is a suspicious finding, the next step is a multiparametric MRI scan of the prostate, which outlines the suspicious areas and guides the biopsy precisely to them, and when the picture is clear it allows a biopsy to be avoided in some cases.

The diagnosis can only be confirmed with a biopsy – taking thin cores of tissue from the gland under ultrasound guidance, with anaesthetic and, if needed, a preventive antibiotic. If cancer is confirmed, staging tests are ordered depending on the grade and the PSA – a CT scan, a bone scan or modern nuclear medicine methods, which show whether the disease has spread beyond the prostate.

Treatment

There is no single right treatment – the choice depends on the risk group, your age, other illnesses and your priorities. The decision is made by a team of a urologist, an oncologist and a radiation oncologist, and Dr Penev explains the benefits and side effects of each option to you.

• Active surveillance – for low-risk tumours: regular PSA tests, periodic MRI scans and repeat biopsies, with treatment only if there are signs of progression. This avoids unnecessary side effects.
• Radical prostatectomy – removal of the whole prostate together with the seminal vesicles and, if needed, the pelvic lymph nodes. Today it is often done laparoscopically or with robotic assistance, with less blood loss and faster recovery, and in suitable cases the nerves for erection are spared. Laparoscopic uro-oncology surgery is performed at the Department of Urology at Kaspela University Hospital (UMBAL Kaspela), Plovdiv.
• Radiotherapy – external beam radiotherapy or brachytherapy (radioactive sources placed inside the gland), with results comparable to surgery for localised disease, often combined with hormone treatment.
• Hormone therapy – suppresses testosterone, on which the tumour depends; it is used for advanced disease or together with radiotherapy.
• Systemic treatment – chemotherapy, newer hormonal and targeted medicines for disease that has spread, prescribed by an oncologist.

The main side effects – incontinence, most often temporary, and changes in erections – are discussed beforehand and can be treated, which is part of the follow-up.

When to see a urologist

Book a check-up if you are over 50 and have never had a PSA test, if you are over 45 and have prostate cancer in the family, if you have blood in your urine or semen, new problems with passing urine, or a raised PSA from a test done for another reason. The examination is short and gives you peace of mind.

Prevention

There is no sure way to prevent it, but a healthy weight, regular exercise, a diet with more vegetables and less processed meat, and not smoking are linked to a lower risk of aggressive forms. The most important measure is still a timely check-up after the age of 40–50.

Prostate cancer found in time has a very good outlook and a choice of several effective treatments. If you are in the at-risk age group or have complaints, book an appointment with Dr Penev in Plovdiv or Karlovo – one calm examination gives you clarity for years to come.