Prostate Cancer: Symptoms, Diagnosis & Treatment Options

What Is Prostate Cancer?

Prostate cancer is a malignant tumor that develops in the prostate gland, a walnut-sized organ located below the bladder in men. It is the most common cancer in men worldwide, with approximately 1 in 8 men being diagnosed during their lifetime. The disease typically grows slowly and often remains confined to the prostate for many years.

The prostate is a gland that surrounds the urethra, the tube that carries urine from the bladder out of the body. The prostate produces fluid that nourishes and transports sperm. Prostate cancer usually develops in the outer parts of the prostate, furthest from the urethra, which is why early-stage cancer often causes no noticeable symptoms.

Understanding how prostate cancer develops is essential for appreciating why early detection matters so much. Cancer begins when cells in the prostate gland start to grow uncontrollably. Unlike normal cells, which grow, divide, and die in an orderly fashion, cancer cells continue to grow and divide, eventually forming a tumor. In prostate cancer, this process typically occurs very slowly, often taking 10 to 15 years before the tumor grows large enough to cause symptoms or be detected during a physical examination.

The slow growth rate of most prostate cancers is both a blessing and a challenge. On one hand, it means that many men live with prostate cancer without ever knowing it, and some will never need treatment because the cancer grows so slowly that other health conditions become more significant. On the other hand, this slow progression can make early detection difficult without regular screening, as symptoms may not appear until the disease has advanced.

How Does Prostate Cancer Spread?

If prostate cancer continues to develop without treatment, it can eventually spread beyond the prostate gland. The cancer typically spreads first to nearby tissues, including the seminal vesicles (glands that produce semen) and the lymph nodes in the pelvis. This is called locally advanced prostate cancer.

In more advanced stages, prostate cancer can spread through the bloodstream to distant organs. The most common site for prostate cancer metastases (secondary tumors) is the bones, particularly the spine, pelvis, and hip bones. Bone metastases can cause significant pain and increase the risk of fractures. In very advanced cases, prostate cancer may also spread to the liver, lungs, and other organs.

Who Is at Risk for Prostate Cancer?

Prostate cancer can develop in anyone born with male reproductive organs, including individuals who have undergone gender-affirming surgery. However, certain factors significantly increase the risk of developing this disease.

Age is the most significant risk factor. Prostate cancer is rare before age 50, but the risk increases dramatically with age. Approximately half of all prostate cancer diagnoses occur in men over 70 years old. After age 50, the risk continues to increase, with most men having some cancer cells in their prostate by age 80, although many will never cause clinical problems.

Family history plays an important role. If your father or brother has been diagnosed with prostate cancer, your risk is approximately twice that of a man with no family history. The risk is even higher if the relative was diagnosed at a young age or if multiple family members have been affected. About 5-10% of prostate cancers are considered hereditary, caused by inherited genetic mutations.

Genetic factors contribute to prostate cancer risk. Mutations in the BRCA1 and BRCA2 genes, more commonly associated with breast and ovarian cancer, also increase prostate cancer risk. Men with Lynch syndrome (hereditary nonpolyposis colorectal cancer) also have an elevated risk.

What Are the Symptoms of Prostate Cancer?

Early prostate cancer often has no symptoms because tumors typically develop in the outer regions of the prostate, away from the urethra. When symptoms do occur, they may include frequent urination (especially at night), weak or interrupted urine flow, difficulty starting or stopping urination, blood in urine or semen, and pain in the lower back, hips, or pelvis. However, these symptoms can also indicate benign conditions.

One of the most challenging aspects of prostate cancer is that it frequently develops silently. Because prostate tumors usually begin in the peripheral (outer) zone of the prostate gland, they can grow for years without pressing on the urethra or causing any noticeable changes in urination. This is fundamentally different from benign prostatic hyperplasia (BPH), or enlarged prostate, which typically grows in the central part of the gland and causes urinary symptoms much earlier.

When prostate cancer does cause symptoms, they often appear gradually and may be attributed to aging or other conditions. It's important to understand that urinary symptoms are extremely common in older men and are more often caused by benign conditions than by cancer. However, any persistent changes in urination should be evaluated by a healthcare provider.

Urinary Symptoms

The following urinary symptoms may occur when prostate cancer grows large enough to affect the urethra:

• Frequent urination: Needing to urinate more often than usual, particularly at night (nocturia)
• Hesitancy: Difficulty starting urination, or a delay before the urine stream begins
• Weak stream: A weaker-than-normal urine flow
• Intermittent stream: Urine flow that stops and starts during urination
• Incomplete emptying: The sensation that the bladder hasn't fully emptied after urination
• Urgency: A sudden, compelling need to urinate
• Blood in urine: This is less common but can occur (hematuria)

Other Symptoms

Prostate cancer may cause additional symptoms, particularly when the disease has become more advanced:

• Blood in semen: A symptom that should always be evaluated, though it can have many causes
• Erectile dysfunction: New difficulty achieving or maintaining an erection
• Pain during ejaculation: Discomfort or pain during orgasm
• Unexplained weight loss: Losing weight without trying
• Fatigue: Persistent tiredness not explained by activity level
• Loss of appetite: Decreased interest in eating

Symptoms of Advanced Disease

When prostate cancer has spread to the bones or other parts of the body, additional symptoms may develop:

• Bone pain: Persistent pain in the back, hips, pelvis, or thighs, which may worsen at night
• Weakness or numbness: In the legs or feet if cancer affects the spine
• Loss of bowel or bladder control: If cancer presses on spinal nerves
• Swelling in legs: If lymph nodes are affected

When Should You Seek Medical Care?

Seek medical evaluation if you experience persistent urinary symptoms, blood in urine or semen, unexplained bone pain, or if you have risk factors for prostate cancer and want to discuss screening. Men without symptoms but with concerns about prostate cancer risk should discuss PSA testing with their healthcare provider starting at age 50 (or earlier if at high risk).

Deciding when to seek medical care for potential prostate-related concerns requires balancing the need for early detection against unnecessary worry. Because prostate cancer usually develops slowly and early-stage disease rarely causes symptoms, the decision to pursue screening is often more complex than simply responding to symptoms.

For men with symptoms, medical evaluation is recommended if you notice:

• Blood in your urine, especially if it persists
• New or worsening difficulty urinating that affects your quality of life
• Pain in your bones, particularly in the lower back, hips, or pelvis, that doesn't improve with rest
• Unexplained weight loss accompanied by fatigue

For men without symptoms, the decision to pursue prostate cancer screening should be made in consultation with a healthcare provider. This is called shared decision-making, and it involves discussing the potential benefits and risks of testing based on your individual circumstances.

How Is Prostate Cancer Diagnosed?

Prostate cancer is diagnosed through a combination of PSA blood tests, digital rectal examination (DRE), MRI imaging, and prostate biopsy. The PSA test measures prostate-specific antigen levels in the blood, while biopsy provides tissue samples that confirm whether cancer is present and determines its Gleason score, which indicates how aggressive the cancer is.

The diagnostic process for prostate cancer typically begins with screening tests, followed by more detailed evaluations if initial results suggest the possibility of cancer. Understanding each step in this process can help reduce anxiety and prepare you for what to expect.

PSA Blood Test

The prostate-specific antigen (PSA) test is a blood test that measures the level of PSA, a protein produced by the prostate gland. While PSA is present in small amounts in all men with a prostate, elevated levels can indicate prostate cancer. However, PSA can also be elevated due to benign conditions such as enlarged prostate (BPH) or prostatitis (prostate infection).

Generally, a PSA level below 4 ng/mL is considered normal, but interpretation depends on several factors including age, prostate size, and trends over time. Some men with PSA levels below 4 ng/mL have prostate cancer, while many men with higher levels do not. This is why PSA testing is just one part of the diagnostic process.

Digital Rectal Examination (DRE)

During a digital rectal examination, a healthcare provider inserts a gloved, lubricated finger into the rectum to feel the prostate gland. The examination takes only a few seconds and, while it may be uncomfortable, should not be painful. The provider checks for any hard areas, lumps, or abnormalities in the prostate's shape or size.

MRI Imaging

If PSA levels are elevated, multiparametric MRI (mpMRI) is typically performed before biopsy. MRI can identify suspicious areas in the prostate that might be cancer and helps guide biopsy needles to the most concerning regions. MRI has significantly improved the accuracy of prostate cancer diagnosis by reducing the number of unnecessary biopsies and improving detection of clinically significant cancers.

Prostate Biopsy

A prostate biopsy is the only way to definitively diagnose prostate cancer. During this procedure, small samples of prostate tissue are removed using thin needles. Modern approaches use MRI-fusion biopsy, which combines MRI images with real-time ultrasound to target suspicious areas more precisely.

The tissue samples are examined by a pathologist who determines whether cancer cells are present. If cancer is found, the pathologist assigns a Gleason score, which indicates how aggressive the cancer appears under the microscope.

Additional Staging Tests

If prostate cancer is diagnosed, additional tests may be needed to determine whether the cancer has spread:

• CT scan or PET scan: To check for spread to lymph nodes or organs
• Bone scan (skeletal scintigraphy): To detect whether cancer has spread to the bones
• PSMA PET scan: A newer imaging technique that can detect prostate cancer cells throughout the body

What Are the Treatment Options for Prostate Cancer?

Treatment options for prostate cancer depend on the cancer's stage, grade (Gleason score), PSA level, patient age, overall health, and personal preferences. Options include active surveillance (monitoring without immediate treatment), surgery (radical prostatectomy), radiation therapy, hormone therapy (androgen deprivation therapy), chemotherapy, and newer targeted treatments. For localized cancer, surgery and radiation offer similar cure rates.

Choosing the right treatment for prostate cancer is one of the most important decisions you'll make. Unlike some cancers where immediate treatment is always necessary, prostate cancer often grows slowly enough that there's time to carefully consider all options. The best treatment depends on many factors, and there's rarely one "right" answer for everyone.

Active Surveillance

Active surveillance involves closely monitoring prostate cancer without immediate treatment, with the intention to treat if the cancer shows signs of progressing. This approach is most appropriate for men with low-risk prostate cancer (Gleason score 6, low PSA, small tumor).

During active surveillance, you'll have regular PSA tests (typically every 3-6 months), periodic digital rectal examinations, and repeat biopsies or MRIs at scheduled intervals. If testing shows that the cancer is becoming more aggressive, treatment can be initiated. Studies have shown that active surveillance is safe for appropriately selected patients, with the vast majority not experiencing cancer progression during 10-15 years of follow-up.

The main advantage of active surveillance is avoiding or delaying treatment side effects while maintaining quality of life. The potential drawback is the psychological burden of living with untreated cancer and the small risk that cancer could progress.

Surgery: Radical Prostatectomy

Radical prostatectomy involves surgical removal of the entire prostate gland along with surrounding tissue and seminal vesicles. This is a potentially curative treatment for cancer that hasn't spread beyond the prostate.

Modern prostatectomy is most commonly performed using robotic-assisted laparoscopic surgery, which offers advantages including smaller incisions, less blood loss, and faster recovery compared to traditional open surgery. During surgery, the surgeon aims to preserve the nerve bundles adjacent to the prostate that control erectile function, when oncologically safe to do so.

After prostatectomy, PSA levels should drop to undetectable levels (less than 0.1 ng/mL) since the prostate, which produces PSA, has been removed. If PSA remains detectable or rises later, this indicates either residual cancer or recurrence.

Radiation Therapy

Radiation therapy uses high-energy beams to destroy cancer cells. It can be delivered externally (from a machine outside the body) or internally (brachytherapy). Radiation therapy offers cure rates similar to surgery for localized prostate cancer.

External beam radiation therapy (EBRT) is typically delivered in daily sessions over several weeks. Modern techniques like intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) allow precise targeting of the prostate while minimizing radiation exposure to surrounding tissues.

Brachytherapy (internal radiation) involves placing radioactive seeds directly into the prostate. This can be done as permanent seed implantation (low-dose-rate brachytherapy) or temporary high-dose-rate brachytherapy. Brachytherapy may be used alone for low-risk cancer or combined with external radiation for higher-risk disease.

Hormone Therapy

Hormone therapy (also called androgen deprivation therapy or ADT) reduces levels of testosterone and other male hormones that prostate cancer cells need to grow. Hormone therapy doesn't cure prostate cancer but can significantly slow its growth and shrink tumors.

Hormone therapy is used in several situations:

• Combined with radiation therapy to improve effectiveness in intermediate- and high-risk localized cancer
• As primary treatment for cancer that has spread beyond the prostate
• When cancer returns after surgery or radiation
• To shrink large tumors before radiation therapy

Hormone therapy can be delivered as injections (given monthly, quarterly, or every six months), oral medications, or rarely through surgical removal of the testicles. Most men receive hormone therapy as injections combined with oral anti-androgens.

Chemotherapy

Chemotherapy uses drugs to kill rapidly dividing cells throughout the body. It's primarily used for prostate cancer that has spread to other parts of the body (metastatic cancer) and no longer responds to hormone therapy.

The most commonly used chemotherapy drug for prostate cancer is docetaxel, typically given as an intravenous infusion every three weeks. Chemotherapy can extend survival and reduce symptoms in advanced prostate cancer, though it does cause side effects including fatigue, nausea, and increased susceptibility to infections.

What Are the Side Effects of Prostate Cancer Treatment?

The main side effects of prostate cancer treatment include urinary incontinence (leaking urine), erectile dysfunction, and bowel problems. Side effects vary by treatment type: surgery causes more immediate urinary issues that improve over time, while radiation may cause bowel irritation. Hormone therapy causes fatigue, hot flashes, and sexual side effects. Many side effects can be managed and often improve with time.

Understanding potential side effects is crucial for making informed treatment decisions. While treatments for prostate cancer are effective, they can affect urinary function, sexual function, and bowel function. The good news is that many side effects improve over time, and there are treatments available to help manage them.

Urinary Side Effects

Urinary incontinence (involuntary urine leakage) is common after prostate surgery. In the weeks immediately following radical prostatectomy, most men experience some degree of incontinence because the sphincter muscle that controls urine flow needs time to strengthen and compensate for the removal of the prostate.

For most men, urinary control improves significantly over the first year after surgery. By one year, approximately 80-90% of men have good urinary control, though some may experience occasional leakage with physical activity (stress incontinence). Pelvic floor exercises (Kegel exercises) can help speed recovery.

Radiation therapy can also affect urinary function, causing symptoms like frequent urination, urgency, and burning during urination. These symptoms are usually temporary and improve within a few months of completing treatment, though they can occasionally persist or develop years later.

Sexual Side Effects

Erectile dysfunction is a common side effect of all prostate cancer treatments. After surgery, erectile function depends largely on whether the nerves adjacent to the prostate (nerve-sparing surgery) could be preserved. Even with optimal nerve-sparing, most men experience some degree of erectile dysfunction immediately after surgery, with gradual improvement over 1-2 years.

Radiation therapy can also cause erectile dysfunction, though it typically develops more gradually than after surgery. About 50-70% of men who had normal erectile function before radiation will experience some degree of erectile dysfunction within 3-5 years.

Hormone therapy has significant effects on sexual function, causing decreased libido (sex drive) and erectile dysfunction in most men. These effects typically resolve after hormone therapy is stopped, though this may take several months.

There are effective treatments for erectile dysfunction, including oral medications (PDE5 inhibitors like sildenafil), vacuum devices, penile injections, and penile implants for severe cases. Many men are able to maintain satisfying sexual relationships with appropriate treatment.

Bowel Side Effects

Bowel problems are more common after radiation therapy than surgery. Radiation to the prostate can affect the nearby rectum, causing symptoms such as:

• Increased frequency of bowel movements
• Diarrhea
• Rectal bleeding
• Fecal urgency or incontinence (less common)

Most bowel symptoms from radiation improve within a few months, though some men experience chronic changes. Dietary modifications and medications can help manage persistent symptoms.

Side Effects of Hormone Therapy

Hormone therapy causes distinct side effects related to testosterone deprivation:

• Hot flashes: Similar to those experienced by women during menopause
• Fatigue: Decreased energy levels
• Loss of muscle mass: And increase in body fat
• Bone loss: Increased risk of osteoporosis
• Mood changes: Including depression and difficulty concentrating
• Breast enlargement: And tenderness (gynecomastia)
• Metabolic changes: Increased risk of diabetes and heart disease

Regular exercise, a healthy diet, and monitoring for bone loss can help manage hormone therapy side effects. Some men receive preventive radiation to the breast tissue before starting hormone therapy to prevent gynecomastia.

How Can Life Be Affected by Prostate Cancer?

Living with prostate cancer affects quality of life in various ways depending on the stage of disease and treatment received. Many men experience emotional challenges including anxiety and depression, alongside physical effects on urinary and sexual function. Support from healthcare teams, family, and support groups can help manage these challenges. Most men with localized prostate cancer live normal lifespans.

A prostate cancer diagnosis affects more than just physical health. The emotional, psychological, and social impacts can be significant, affecting relationships, work, and daily activities. Understanding what to expect and knowing that help is available can make living with prostate cancer more manageable.

Emotional and Psychological Impact

Receiving a cancer diagnosis naturally causes anxiety and concern. Many men experience a range of emotions including fear, anger, sadness, and uncertainty. These feelings are normal and may come and go throughout treatment and recovery.

For some men, anxiety about the cancer itself or worry about recurrence can persist long after treatment ends. The changes in body function that may result from treatment, particularly urinary and sexual changes, can affect self-image and confidence. It's important to recognize these challenges and seek support when needed.

Depression is more common in men with prostate cancer than in the general population. Signs include persistent sadness, loss of interest in activities, changes in sleep or appetite, and difficulty concentrating. If you experience these symptoms, speak with your healthcare team, as effective treatments are available.

Impact on Relationships

Prostate cancer and its treatment can affect intimate relationships. Open communication with partners about physical and emotional changes is essential. Many couples find that their relationship actually strengthens through facing cancer together, though this requires effort and sometimes professional guidance.

Sexual intimacy may need to adapt to changes in erectile function. Many couples discover that physical intimacy can remain satisfying even when sexual function changes. Couples counseling or sex therapy can help partners navigate these adjustments.

Maintaining Quality of Life

There is much you can do to maintain and improve quality of life during and after prostate cancer treatment:

• Stay physically active: Exercise has been shown to reduce fatigue, improve mood, maintain muscle mass (especially important during hormone therapy), and potentially improve cancer outcomes
• Eat a healthy diet: A diet rich in vegetables, fruits, whole grains, and lean proteins supports overall health and may help manage treatment side effects
• Practice pelvic floor exercises: These can help improve urinary control after treatment
• Seek support: Whether from family, friends, support groups, or mental health professionals, connecting with others helps manage the emotional burden
• Stay engaged: Continue activities you enjoy and maintain social connections

Long-term Follow-up

After treatment, you'll need regular follow-up appointments to monitor for recurrence and manage any ongoing side effects. Initially, these visits typically occur every few months, then become less frequent over time. Most follow-up involves PSA blood tests, which can detect cancer recurrence early.

If cancer recurs, there are often additional treatment options available. Many men live for many years with recurrent prostate cancer, particularly if it's detected early through regular monitoring.