Symptoms and diagnosis of prostate cancer
Symptoms of prostate cancer
Early prostate cancer doesn’t normally cause any symptoms. Prostate cancer usually only causes symptoms when it has grown large enough to disturb your bladder or press on the tube that drains urine, causing problems passing urine. These symptoms are called prostate urinary symptoms.
Having prostate urinary symptoms can be a sign of prostate cancer but more often they are caused by a harmless enlargement of the prostate, which is common as you get older.
Prostate urinary problems:
A slow flow of urine.
Trouble starting or stopping the flow.
Passing urine more often, especially at night.
Pain when passing urine.
Blood in the urine or semen.
Feeling of not emptying your bladder fully.
It is important to visit your GP if you have any worries or if you have any of these symptoms so that they can be discussed and assessed.
Most prostate cancers are found when they are early, many are slow growing, and symptoms may not happen for many years if they happen at all. Remember that men with early prostate cancer are unlikely to have any symptoms.
Because early prostate cancer does not usually cause any symptoms, it is often identified through prostate cancer screening. This involves your GP checking for the possibility of prostate cancer when you have no symptoms. The screening involves an examination of the prostate gland and a special blood test called the PSA blood test.
Advanced prostate cancer may cause some or all of the prostate urinary symptoms. A small number of men may experience other symptoms such as unexplained tiredness, low energy or poor appetite.
If prostate cancer has spread to the bone you may experience aches and pains in the bone, which might require pain killers for pain relief.
How is prostate cancer diagnosed?
Men who have urinary symptoms will usually begin by seeing their GP. The first tests for assessing the prostate gland are the PSA blood test and a digital rectal examination (DRE). Your GP will also examine you and ask you about your general health, your symptoms and any family history of prostate cancer. You may also have these tests when you have no symptoms, as part of prostate cancer screening.
PSA blood test
This is a blood test which measures a protein made by the prostate gland called prostate specific antigen (PSA). The level of PSA in the blood stream can rise if you have prostate cancer but it can rise for other reasons as well, so a raised PSA does not necessarily mean you have prostate cancer. The normal level of PSA changes as you get older. If the PSA level is raised above normal for your age range it will need to be repeated after six weeks to see if it remains raised. Your GP will also examine your prostate (called a digital rectal exam, or DRE) to see if it feels abnormal, as this can help to diagnose prostate cancer.
The PSA test can only indicate a prostate problem - it doesn’t specifically diagnose prostate cancer.
A raised PSA can only indicate that a man may have a problem with his prostate gland that needs further investigation. Two out of three men with a raised PSA who do proceed to prosate biopsy do not have prostate cancer , and some men with prostate cancer do not have a raised PSA level.
If your PSA is high your doctor will look further at your prostate with other tests to see why.
Digital rectal exam (DRE)
This involves your doctor putting a gloved finger into your back passage to feel the size and texture of your prostate. The test may be a little uncomfortable or embarrassing, but it is quick. Your GP will be looking for any abnormalities like an area of hardening or a lump on the prostate or if the prostate feels large.
If the prostate gland feels abnormal your GP will refer you to a urology department for further tests, even if your PSA blood test is normal.
Further tests for prostate cancer for many men are often done at Rapid Access Prostate Clinics, which are special clinics set up to reduce waiting times for prostate cancer testing.
Your doctor will consider your PSA level along with your DRE result, any risk factors or other health problems you have as well as any previous biopsy results before discussing the next step with you.
Your GP may refer you to a urology department, often through one of the eight Rapid Access Prostate Clinics. Here further tests may take place like a repeat Digital Rectal Examination (DRE) along with a Trans-rectal Ultrasound Scan (TRUS) of the prostate gland and a Trans-rectal Needle Biopsy of the prostate gland.
For more information on the symptoms and diagnosis of prostate cancer, please see our booklet Understanding the PSA test.
Tests at the hospital
Trans-rectal ultrasound scan (TRUS)
This type of scan is used to measure the size of the prostate. It uses sound waves to build up a picture of the prostate gland inside your body. To scan the prostate gland, a small device called a probe is passed into your back passage and an image of the prostate appears on a computer screen. The scan may be uncomfortable but only takes a few minutes.
Trans-rectal needle biopsy of the prostate
The only way to make sure a diagnosis of prostate cancer is correct is by taking samples of the prostate gland. It is usually done at the same time as a prostate ultrasound (TRUS).
A trans-rectal needle biopsy involves putting a plastic probe into your back passage and giving you a local anesthetic injection around the area of the prostate gland to help numb it. Then a needle is passed through the wall of your back passage to take usually up to 12 samples (cores) from the prostate gland. These samples will then be sent to the laboratory where they will be looked at under the microscope by a doctor.
The test itself is uncomfortable and normally takes 10-15 minutes. It is important to drink plenty of fluids in the twenty four hours afterwards. It is normal to expect some blood in your urine and bowel motions for a week or two afterwards and in your semen for longer.
You will be given a short course of antibiotics to take before and after the biopsy in order to reduce the small risk of developing an infection afterwards. It is important to finish the course prescribed.
It is important to contact your GP or attend your local A & E department if you experience the following symptoms after a prostate biopsy, even if you are still taking the antibiotics:
- A high temperature.
- Flu-like symptoms.
- Burning sensation when passing urine.
- Difficulty passing urine.
Researchers have been investigating other tests which may prove useful in diagnosing prostate cancer. Some tests are still being measured as to their usefulness in practice and not all are widely available yet. Ask your urologist or nurse for more information.
This test is a different way of measuring the PSA in the blood. It is useful for men who have a PSA between 4 and 10ng/ml and a normal DRE examination.
The PSA is carried in the blood stream in two different ways: ‘free’ PSA, which is not bound to blood proteins, and PSA that can bind to blood proteins.
The percentage of free PSA tends to be lower in men who may have prostate cancer. Results from this type of test can be useful in helping the urologist to decide how to treat men with a normal biopsy result. It is important to remember that other factors, like the size of the prostate, may influence the measurement.
The doctor will take this into consideration too when deciding the next step.
This is a measure of how fast the PSA level rises over time. Normally the PSA rises very slowly as you get older. If the PSA level rises by 0.5ng/ml (per year) in a younger man or 0.75ng/ml (per year) in a man over 60 years of age it may increase the suspicion of prostate cancer.
PCA3 urine test
This test checks urine for the presence of a gene secreted by the prostate cells which is in higher quantities in the presence of prostate cancer. The test is done after the prostate gland has been massaged and may be used to decide if a repeat biopsy is necessary. A PCA3 test cannot say for certain if you have prostate cancer, but it can show how likely it is. This is a relatively new test and currently is only available privately in Ireland at a cost of approximately €450.
Waiting for results
It can take a week or two before the results of a prostate biopsy are available. Waiting for results can feel like a worrying time.
If you are feeling anxious or have any concerns or questions please contact us on the Cancer Nurseline Freephone 1800 200 700 or by email where you can talk in confidence to a specialist cancer nurse.
When getting the results of a biopsy, it can be helpful to have a second person with you for support and also so that they can hear the information with you. In this way you can clarify what you have heard with them afterwards It is also very useful to write down any questions or anxieties you might have for the doctor before your visit and to bring these questions with you.
What if the biopsy comes back normal?
A normal biopsy result is good news. It means that there is no evidence of cancer in the samples that were taken. It does not give you an absolute guarantee that there is no prostate cancer. Occasionally, if the cancer is very small it may be that it has been missed by the needle, despite many samples being taken.
Your doctor may wish to continue to monitor your PSA levels and do other DRE examinations over the coming months. If your PSA level remains raised or continues to climb they may then suggest doing a repeat prostate biopsy.
What if the biopsy comes back with prostate cancer present?
When the biopsy results are through the urologist will have been given a laboratory report with the biopsy results which will describe what was seen down the microscope.
The report will have details like how many cores (samples) have cancer present in them and how much is present on each core. The cancer will be graded using the Gleason score, which is a means of estimating how active the cancer appears by looking at how the cancer cells look under the microscope and if they are dividing in a slow or fast rate.
The doctor will want to stage the cancer. This means finding the size of the tumour and if it has spread to other parts of the body. This is done with other tests and investigations.
Coping with a prostate cancer diagnosis
Receiving a diagnosis of prostate cancer may feel shocking for you.
You may find it difficult to remember all the information given to you by the doctor or to understand the meaning of it. You may also find it hard to think about what important questions need to be asked in the moment. It can be useful to record the details of your biopsy result and suitable treatment options and to keep them safe for future reference.
You could record them in the dedicated tracking chart available on page 22 of the Understanding Early Prostate Cancer booklet.
It is normal to need plenty of time to allow yourself to absorb the information. Most men need to have a number of discussions in order to understand the various treatment options and their possible side-effects.
If you would like to read more please see the section Treatment for Early Prostate Cancer.
See the booklet Understanding Early Prostate Cancer for more information about treatment choices in early prostate cancer.
If you would like to read more about locally advanced prostate cancer or advanced prostate cancer (metastatic) you can download or order our free booklet Understanding locally advanced and advanced prostate cancer. All booklets can be ordered by calling our Cancer Nurseline on Freephone 1800 200 700.
Prostate Cancer Patient’s Charter
As part of the Irish Cancer Society’s ongoing commitment to achieving world-class cancer services in Ireland we have written a Prostate Cancer Patient’s Charter, which was launched in November 2011.
This charter outlines the standard of services that men with prostate cancer in Ireland should be entitled to from the time of diagnosis and treatment, through to learning to live with the potential effects of the illness or its treatment. For more information on the Prostate Cancer Patient’s Charter please see our information leaflet Prostate Cancer Patient’s Charter.
Speak with a volunteer
Talking to another man who has dealt with a diagnosis of prostate cancer can be helpful when you are deciding on treatment. Contact the Cancer Nurseline on 1800 200 700 and we can put you in contact with a trained Survivors Supporting Survivors peer volunteer who has dealt with a prostate cancer diagnosis themselves and knows what you are going through.
Please call our Cancer Nurseline on Freephone 1800 200 700 if you would like to speak with a cancer nurse in confidence or if you want copies of any of our booklets.
Questions to ask your doctor
Here is a list of questions that you may wish to ask. Never be shy about asking questions. It is always better to ask than to worry.
What tests do I need?
Will the tests definitely show if I have cancer or not?
How long will I have to wait before the tests?
How is prostate cancer confirmed?
Do I need treatment straight away? If not, how will you know when I should have treatment?
If I need treatment, what are my treatment choices?
How successful is this treatment for my cancer?
If my treatment is not successful, can I still have other treatments?
Do some treatments have more side-effects than others?
Will I need hormone therapy and radiotherapy? If yes, for how long?
Are the side-effects of treatment short or long term?
Will I have problems with urinary incontinence after my treatment?
Will treatment affect my fertility? Will I develop erectile dysfunction?
Why is follow-up so important? Why do I need regular blood tests?
If the tests show that you have prostate cancer, you may need other tests. This is called staging and can help your doctor to decide on the right treatment for you.
Possible tests are:
Prostate cancer screening
Checking for prostate cancer when you have no symptoms is called prostate screening.
Deciding to have prostate cancer screening done is a personal decision and should be based upon having a full discussion with your GP beforehand in order to weigh up the pros and cons of undertaking the test. This way you will have a greater understanding of what the test involves, and an understanding that it could lead you to having to make further important decisions which might affect your life now, and perhaps in the future.
For more information about PSA testing you can read our booklet Understanding the PSA Test.
Ireland and other European countries do not offer a routine PSA screening programme. It is not known for sure if routine PSA screening can reduce the number of deaths from prostate cancer.
A national screening program could increase the numbers of men having unnecessary treatment for very slow growing prostate cancer, which could lead to many men experiencing worse side-effects as a result of treatment than they would from the cancer.
Who should consider having a PSA test?
Discuss how you feel about having a PSA test with your GP. Men over 50 should be aware of the risk factors for prostate cancer and consider the following questions:
Am I at risk of prostate cancer?
Do I have any urinary or prostate problems?
What would I choose to do if my PSA is raised?
What would I do if I were diagnosed with early prostate cancer?
If you have a family history of prostate cancer or are in another high-risk group you could discuss with your GP the option of having a PSA test from the age of 40. If you have no family history and are not in a high-risk group, many doctors feel it is best to discuss the possibility of a PSA test from the age of 50.
After having the first test done some men, in particular those men who are in a high-risk group, may decide to have this test repeated regularly. How often this test needs to be repeated can be discussed with your doctor, as the frequency may be influenced by the PSA level, your age and the degree of risk.
Routine PSA testing in men over 70-75 is not advised due to the slow-growing nature of prostate cancer. However, it may be necessary if the prostate gland is felt abnormal on examination by the GP or if you are having prostate urinary problems.
Where do I have a PSA blood test?
If you are considering having a PSA test it should be done with your GP after full discussion with you about the pros and cons of the PSA test. Your GP will send the blood sample to a hospital for measurement. It may take a week or two before your GP gets the result.
Home PSA test kits are available, but prostate problems are best diagnosed by your GP, who can take your medical history and carry out a physical examination, as well as doing the PSA test. By attending your GP you can also discuss prostate cancer risk factors and talk about any concerns you may have about the test and its results when they are available.
How reliable is the PSA test?
The PSA blood test is not reliable to diagnose prostate cancer. The PSA can be raised for other non-cancerous reasons like recent urinary tract infection, prostatitis (infection in the prostate) or an enlarged prostate as a result of ageing.
The higher the PSA level, the more likely you are to have prostate cancer, but in early prostate cancer the PSA level may be only slightly raised.
It is also important to know that a small number of men could have prostate cancer and have a normal PSA level.
What are normal PSA levels?
PSA is measured in nanograms. PSA levels can range from less than 1ng/ml up to 100 ng/ml and beyond.
In Ireland most hospitals have an age-related reference range.
How the normal PSA changes with age:
|40-49||up to 2.5ng/ml|
|50-59||up to 3.5ng/ml|
|60-69||up to 4.5ng/ml|
|70-79||up to 6.5ng/ml|
Some drugs such as finasteride (Proscar ®) and dutasteride (Avodart ®), which are taken for an enlarged prostate, can make the PSA appear lower than it is. Doctors usually allow for this by doubling your PSA result if you are on these medications.