Prostate Cancer

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Factors that are most strongly linked to an increased chance of developing prostate cancer are:

• Age: Prostate cancer is an age-dependent disease, which means the chance of developing it increases with age. The risk of getting prostate cancer by the age of 75 is 1 in 7 men. By the age of 85, this increases to 1 in 5.
• Family history: If you have a first degree male relative with prostate cancer, you have a higher chance of developing it than men with no such history. The risk increases again if more than one male relative has prostate cancer. Risks are also higher for men whose male relatives were diagnosed when young.
• Genetics: Genes are found in every cell of the body. They control the way the cells in the body grow and behave. Every person has a set of many thousands of genes inherited from both parents. Changes to genes can increase the risk of prostate cancer being passed from parent to child. Although prostate cancer can’t be inherited, a man can inherit genes that can increase the risk.
• Diet: There is some evidence to suggest that eating a lot of processed meat or food that is high in fat can increase the risk of developing prostate cancer.
• Lifestyle: There is evidence to show that environment and lifestyle can affect the risk of developing prostate cancer.

The information above has been adapted from: the PCFA Prostate Cancer Resources &www.prostate.org.auThe study was carried out by researchers from Boston University School of Public Health, Harvard T.H. Chan School of Public Health, and Harvard Medical School, all in the US. It was funded by the National Cancer Institute and grants from the Prostate Cancer Foundation Young Investigator Award. The researchers concluded that "this large prospective study provides the strongest evidence to date of a beneficial role of ejaculation in prevention of prostate cancer".

In the early stages, there may be no symptoms. In the later stages, some symptoms of prostate cancer might include:

– Feeling the frequent or sudden need to urinate

– Finding it difficult to urinate (for example, trouble starting or not being able to urinate when the feeling is there or poor urine flow)

– Discomfort when urinating– Finding blood in urine or semen

– Pain in the lower back, upper thighs or hips.

These symptoms may not mean you have prostate cancer, but if you experience any of them, go and see your doctor.

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WHAT ARE THE RISK FACTORS?

Factors that are most strongly linked to an increased chance of developing prostate cancer:

– Age: Prostate cancer is an age-dependent disease, which means the chance of developing it increases with age. The risk of getting prostate cancer by the age of 75 is 1 in 7 men. By the age of 85, this increases to 1 in 5

.– Family history: If you have a first-degree male relative with prostate cancer, you have a higher chance of developing it than men with no such history. The risk increases again if more than one male relative has prostate cancer. Risks are also higher for men whose male relatives were diagnosed when young.

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OTHER FACTORS THAT MAY INCREASE THE RISK OF DEVELOPING PROSTATE CANCER:

Factors that are most strongly linked to an increased chance of developing prostate cancer:

– Genetics: Genes are found in every cell of the body. They control the way the cells in the body grow and behave. Every person has a set of many thousands of genes inherited from both parents. Changes to genes can increase the risk of prostate cancer being passed from parent to child. Although prostate cancer can’t be inherited, a man can inherit genes that can increase the risk.

– Diet: There is some evidence to suggest that eating a lot of processed meat or food that is high in fat can increase the risk of developing prostate cancer.

– Lifestyle: There is evidence to show that environment and lifestyle can affect the risk of developing prostate cancer.

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HOW IS PROSTATE CANCER DETECTED AND DIAGNOSED?

A doctor will usually do a blood test and/or physical examination to check the health of the prostate.

– Blood test (Prostate Specific Antigen (PSA) test): The result shows whether there is an increase in this specific protein. Depending on the result, you might need further investigation by a specialist. A high PSA test result does not necessarily mean cancer. Prostate diseases other than cancer can also cause a higher than normal PSA level.

– Digital Rectal Examination (DRE): Because of where the prostate is located, the doctor inserts a gloved, lubricated finger into the rectum to check the size of the prostate and assess if there are any abnormalities. A normal DRE result does not rule out prostate cancer.

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DIAGNOSIS

If your tests show you may be at risk of prostate cancer, the next stepis a biopsy. A biopsy is the only way a firm diagnosis of prostate cancer canbe made. A urologist removes small samples of tissue from your prostate, usingvery thin, hollow needles guided by an ultrasound. The prostate is eitheraccessed through the rectum (trans rectal) or the perineum (trans perineal),which is the area between the anus and the scrotum. A biopsy is usually done asan out-patient procedure and the doctor will likely advise a course ofantibiotics afterwards to reduce the chance of infection. The tissue is sent toa pathologist to identify whether the cells are malignant (cancerous) or benign(not cancerous).

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REDUCING THE RISK OF DEVELOPING PROSTATE CANCER

There is no evidence that the following protective factors can stop prostate cancer from developing, but they can improve your overall health and possibly reduce the risk of prostate cancer:

– Diet: Eat meals that are nutritious. Refer to the Australian Guide to Healthy Eating. What is good for the heart is good for the prostate.

– Physical activity/exercise: There is some evidence to show that physical activity and regular exercise can be protective factors for cancer. Try to exercise at least 30 minutes of a day.

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Adapted from:  http://www.prostate.org.au

In most cases the diagnosis of Prostate Cancer comes as a shock, and for most, this will be one of the greatest challenges that a man will face as an individual and as a partner. A Prostate Cancer diagnosis, or pre and post treatment can affect on the man’s work, family, relationship, social life and self-esteem.

Examples of the difficulties experience following a prostate cancer diagnosis (including after treatment) can include:

- Facing your mortality?

- Addressing the changes to sexual functioning and performance?

- How will you deal with your mates/friends having a healthy sex life?

- Who will you tell and what will you tell them?

- How will you fend off unwanted questions and/or comments?

- How will you relieve the stress?

- How will you keep your relationship strong?

- How will you deal with some of the potential side-effects of treatment?

- How will you find strength and strategies to plan ahead?

- Avoiding damage to self-esteem and self-confidence.

= Playing the wait and see game?

- Navigating your way through treatment options?

There are some practical things you can do to cope better with the experience of Prostate Cancer. This involves focusing on thoughts, feelings and behaviours that may be of concern, enabling you, as an individual or a couple, to gain a new perspective and understanding. You may learn to challenge old patterns of thinking, explore a wide range of alternatives and practice different ways of behaving.

Research indicates more and more that stress and anxiety can impact on the progression of a person’s health condition, so it is therefore vital to address concerns at an early stage, to maintain a balanced outlook and relationship despite treatment. The resulting stress of treatment, such as incontinence, erectile dysfunction, dry orgasm, etc, can impact on people in different ways and can greatly affect a person’s mood, daily functioning, and coping ability. Counselling provides an ongoing source of non-judgmental support at a time when you may feel highly vulnerable.

The journey through the prostate cancer diagnosis and treatment can take their toll both physical and emotional. Forming realistic expectations of outcomes, and how to prepare for and manage the roller coaster of emotions can be a challenge. It is common to fear that being counselled means there is something wrong with you or that it confirms a weakness and inability to handle treatment. However, nothing could be further from the truth! It takes strength to reach out for help. Dave Wells facilitated a prostate cancer support group for 6 years and his experience and sensitivity can help to equip you with the skills needed to manage emotions, cope better with day-to-day stresses, identify and adopt strategies to improve/maintain sexual and personal quality, and ultimately prevent long-term problems such as depression or anxiety.

All prostate cancer treatments, including 'surgery', 'radiation therapy' and 'hormone therapy' can affect your sexual function in a variety of ways. The following section will discuss the commonly used treatments for prostate cancer and the side effects that can occur.

'Prostate Cancer Surgery' – 'Radical Prostatectomy Surgery':

The side effects relate to physical changes to that area of your body after the prostate gland has been removed and learning about the possible side effects from surgery is particularly important because some side effects can be permanent. When your prostate gland is removed with a 'radical prostatectomy' (open, laparoscopic or robotic), a number of things occur during the surgical procedure that can impact on your sexual function. These include:

Changes during orgasm:

The removal of the prostate can cause changes during orgasm. Your entire prostate gland is removed along with the seminal vesicles. It is important to understand that after surgery you will have a ‘dry’ orgasm because semen is no longer produced. There is no ejaculate during orgasm but you will still feel the muscular spasms and pleasure that produce the orgasm. The lack of semen and sperm means that you will not be able to conceive children naturally in the future (see below). Other changes could include the following:

• Painful orgasm: Pain is felt during orgasm but little is known about its cause. This usually settles after a few orgasms.
• Leaking urine on orgasm: There may be some involuntary release of urine during orgasm.
• Men report different experiences with dry orgasm; some describe a more intense orgasm while others feel orgasm is not as pleasurable. Pain may be experienced in the short term but this generally improves as healing to the area occurs.

NOTE: Infertility occurs in all men after radical prostatectomy. If you plan to have children following treatment, discuss this with your healthcare team. If fertility is important to you, you could ask to be referred to a service that provides fertility- preserving options such as sperm banking (having some of your sperm stored) before you start treatment. That way, fathering a child using your stored sperm may be possible in the future.

Tips:

• Speak with a continence nurse or physiotherapist as they can offer you techniques to improve any problems you may have.
• Empty your bladder before intercourse or use condoms if you leak urine during orgasm.
• Talk with a health professional, such as a sex therapist/counsellor who can give you strategies to help you manage your feelings about, and reduce the impact of, any changes during orgasm.

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Erectile dysfunction:

It is likely you will have some difficulties getting and maintaining an erection after the surgery. How long this will last depends on a number of factors such as whether the erectile nerves were preserved at the time of surgery. The nerves that enable you to have an erection are on either side of the prostate. If cancer has not grown near the nerves, a nerve-sparing operation may be able to be performed when removing the prostate. This means the chance of you regaining the ability to have an erection naturally is increased. If these nerves are permanently damaged or removed, erectile difficulties may be ongoing. It is important that you know what treatments are available that can help. Members of your healthcare team can provide you with information appropriate to your needs.

In advanced prostate cancer, the cancer itself can also cause erectile dysfunction by invading the bundles of nerves that lie close to the prostate.

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Tips:

• Think about other ways that you could enjoy sex without penetration (e.g. oral sex, kissing, masturbation or mutual masturbation). Many men can still achieve orgasm without a full erection.
• Talk with your sexual partner(s) about what feels good for you and ask what feels good for them.
• Talk to your treating healthcare team about being referred to a professional (e.g. Sex Therapist) or service that specialises in sexuality matters.

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Change in penis size:

A possible side effect of a radical prostatectomy surgery is a reduced length and width of the penis, while erect and/or flaccid/soft. Many men report penile shortening and shrinkage following surgery. It is thought there are a number of factors that may contribute to this, including scar tissue formation, reconnecting of the urethra to the bladder, and damage or interruption to the blood supply of the nerves. The reasons for penile shortening and shrinkage are not yet fully understood.

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Tips:

• Talk with a health professional such as a sex therapist who can give you strategies to help you manage your feelings about changes to the appearance of your penis, if this does occur.

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Incontinence:

The removal of the prostate gland may affect your ability to control the flow of urine from the bladder. This is because the urethra (the tube that urine passes through as it leaves the bladder) runs through the prostate gland. The mechanisms for urinary control (the bladder neck and the urinary sphincter) are located very close to the prostate and can be affected during the surgery.

• Many men experience some degree of urinary incontinence in the short-term following surgery. This usually resolves over time.
• When the urinary sphincter is affected, people can experience stress urinary incontinence – losing control of the bladder during physical activities (e.g. exercising) or strain (e.g. coughing, sneezing).
• All men will have a temporary urinary catheter for a short period after surgery. This is a thin, soft plastic tube that runs from inside the bladder to a bag outside of your body to collect the urine.
• Men normally need a catheter for a week after surgery, but sometimes up to three weeks. After the catheter is removed, it is not unusual to have some mild urinary incontinence.
• Improvement can occur quickly, but if you are still troubled after 6 months, then further treatments can help. Talk to members of your healthcare team who are supporting you if you are concerned.
• Many men experience some degree of urinary incontinence in the short-term following surgery.

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Tips:

• Talk to a continence nurse who can offer suggestions about the best continence products for your needs. The Continence Aids Payment Scheme (CAPS) may provide financial assistance for continence products (see www.bladderbowel.gov.au/caps/capsfaq.htm).
• Talk with a continence nurse or physiotherapist for information on pelvic floor muscles training. Pelvic floor muscles are important for continence control (see www.bladderbowel.gov.au/adults/pelvicmen.htm), and are best learned and started before surgery, and continued afterwards.
• You can obtain more information about surgery from the Understanding surgery for prostate cancer resource available from PCFA (www.pcfa.org.au).

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'TURP' (Transurethral Resection 0f the Prostate):

A side effect is ‘retrograde ejaculation’, when semen is forced back into the bladder during ejaculation due to damage to the internal sphincter muscle (valve) located near the prostate. The valve cannot close shut, so semen flows back into the bladder. It is then passed out with urine the next time you go to the toilet; potentially giving your urine a cloudy appearance. This is a harmless effect which occurs in most men having this type of surgery.

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Radiation Therapy (External Beam Radiation Treatment or EBRT):

Generally people are having this treatment in a hospital setting daily, Monday to Friday, for 7-8 weeks. During your EBRT treatment, you can continue to do what you would normally if you’re able; however, the multiple hospital visits and side effects associated with treatment may interfere with some day-to-day activities.

• Inflammation to the surrounding areas can cause pain. A small leakage of urine on ejaculation can occur. This is generally a short-term side effect and improves as inflammation settles.
• Due to damage to the prostate cells that produce ejaculation fluid, you can notice a decreased amount of fluid or dry ejaculation.
• Unlike surgery, radiation therapy doesn’t usually have immediate effects on erectile function. Erectile problems typically occur in the longer term, commencing six months after treatment and progressing over the following years. Ageing and progressive damage to the blood vessels and nerves to the penis contribute to this.
• Radiotherapy will not affect your libido directly but the whole process may mean that you do not feel like having sex during the weeks of, or after, the treatment. There is no reason to avoid sex if you feel ready.
• If you wish to have children in the future, you will need to discuss alternatives such as having some of your sperm stored before treatment starts (this is called sperm banking). You can ask to speak with a fertility counsellor or be referred to a service that specialises in fertility issues.
• Hormone therapy is often used in conjunction with radiation therapy treatment, which can increase the impact on erectile function as well as libido.

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'Brachytherapy' (Low dose rate: LDR):

Note: There is a very small chance of passing a radioactive seed during sexual activity. A condom is recommended for use for the first two months after implantation. If your partner is pregnant, use condoms for the whole pregnancy as a precaution.

• Placement requires surgery that may take a few hours. You may have the treatment as a ‘day-only patient’ or have an overnight stay.
• Your semen may be discoloured or blood-stained for the first few weeks after placement, due to the bruising or bleeding from the prostate caused by treatment. This usually resolves with time.
• You may have pain on ejaculation as the prostate contracts with orgasm. This is a short-term side effect.

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High dose rate (HDR):

The procedure takes place at a hospital but may require a longer stay than LDR brachytherapy. HDR brachytherapy is generally a treatment option for men with intermediate risk or locally advanced prostate cancer and is often given in conjunction with EBRT.

• The side effects of high dose rate brachytherapy are similar to those of low dose rate brachytherapy.
• Often men have hormone (androgen deprivation) therapy or external beam radiation therapy in conjunction with high dose rate brachytherapy. Side effects from these treatments on sexual function may also be experienced.

You can obtain more information about brachytherapy from the Understanding brachytherapy for prostate cancer resource available from PCFA (www.pcfa.org.au).

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Hormone Therapy:

Prostate cancer is driven by hormones. By reducing these hormones, it is possible to slow the growth of the cancer. This is known as hormone therapy, also known as androgen deprivation therapy (ADT), and is the standard first treatment when prostate cancer has spread (metastatic prostate cancer).

There is also a surgical hormone treatment called ''orchiectomy', ', in which the testicles are surgically removed. The testicles are responsible for a high percentage of testosterone production, so removing them starves the prostate cancer cells of testosterone.

Testosterone is a male sex hormone (or androgen), which is produced by the testicles. It is vital in reproductive and sexual function. Hormone therapy reduces testosterone levels and can often keep the cancer under control for several years by shrinking it, delaying its growth and reducing symptoms. How well hormone therapy controls the cancer is different from one man to another. It depends on how aggressive the cancer is, and how far the cancer has spread when you start hormone therapy.

What to expect: Hormone therapy side effects can be difficult to predict. It is important that you tell your healthcare team about the side effects you’re having as they may be able to offer you ways to manage them (e.g. medications, techniques).

• Lowering testosterone levels may cause a reduction in sex drive and erectile difficulties.

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Tips:

• Work with a health professional (e.g. Sex Therapist) who specialises in sexuality matters.
• Explore ways of being intimate with your partner that are not related to sex.
• Erectile dysfunction (ED) is the inability to achieve or maintain an erection firm enough for penetration. ED can be variable, with some men still able to achieve erections but not for long periods or with the ability to reach orgasm.
• Medications: Some medications in tablet and injectable forms can be prescribed to manage erectile difficulties. Because these medications can have side effects, discuss with your healthcare team if they are suitable for you.
• Implants/devices: If you don’t want to use medications, devices that draw blood into the penis (e.g. vacuum erection device) or the use of penile implants (e.g. flexible rods or inflatable tubes) could be ways of getting an erection. Members of your healthcare team (e.g. urologist, nurse, sex therapist) can provide you with information about these.
• Other physical side effects of hormone therapy, such as loss of muscle, weight gain, hot flushes and growth in breast tissue can impact how you feel about yourself sexually. You can obtain more information about hormone treatment from the Understanding hormone therapy for prostate cancer resource available from PCFA.
• Prostate cancer is driven by hormones. By reducing these hormones, it is possible to slow the growth of the cancer.

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The information above has been adapted from: the PCFA Prostate Cancer Resources, & www.prostate.org.au