The prostate is approximately the same size as a chestnut. It is located directly underneath the urinary bladder and surrounds the urethra like a ring. The prostate’s main function is to produce part of the seminal fluid. This fluid is important for the mobility of sperm and therefore for the ability to reproduce. Together with the testicles, the prostate is part of the male reproductive organs.
The prostate changes in every second man over the age of 50. This includes a benign enlargement of the gland, so-called benign prostatic hyperplasia. It originates at the point where the prostate surrounds the urethra. As the disease progresses, the urethra is being pressed upon. Urinary flow becomes weaker and the urge to urinate increases.
In contrast to malignant changes, i.e. prostate cancer, the benign enlargement of the gland does not spread beyond the prostate.
Prostate cancer is a malignant tumour. It tends to spread beyond its own, limited capsule. As the tumour does not necessarily develop near the urethra, the malignant changes are often not noticed over a long period. Pressure on the urethra including problems urinating mostly only occurs when the tumour has already reached a considerable size and has spread. In many cases, physicians can feel the malignant tumour in an examination through the rectum.
If the cancer has not spread beyond the gland, it can be cured with surgery or radiation.
In Germany, prostate cancer is the most common cancer in men. Every year, around 63,000 new cases are diagnosed. The cancer is rare in men below the age of 50.
The median age when developing the disease is slightly above 70.
Risk factors for prostate cancer include advanced age, genetic disposition and diet.
Risk factor age
Age is the most important factor in prostate cancer. More than 80 per cent of all men diagnosed with prostate cancer are older than 60. The chance to develop prostate cancer rises 40-fold between the ages of 50 and 85.
Risk factor genetic disposition
Prostate cancer can at least partly be traced back to a genetic disposition. Disposition can be passed on in families.
Risk factor hormones
Hormones are a significant factor in the development of the disease. Prostate cancer cannot develop without the presence of the male sex hormone testosterone. Testosterone is necessary for the prostate to work. On the other hand it promotes the growth of prostate cancer cells.
Diet, lifestyle and possibly even workplace conditions can influence the development of prostate cancer. The following are beneficial for your health:
- A healthy weight
- Regular physical exercise
- A balanced diet, particularly if it is plant-based
- Low alcohol consumption
Screening is particularly important for an early diagnosis of prostate cancer as patients do not have typical symptoms at an early stage of the disease. Men over the age of 45 are offered annual screening as part of a state-sponsored initiative. Screening is free of charge. Physicians need to employ diagnostic procedures to determine with certainty whether any prostate changes are benign or malignant.
The earlier prostate cancer is diagnosed the better the prognosis for a complete cure.
New screening methods such as PSA testing show changes to the prostate in the early stages. This blood test, which incurs a fee, determines the concentration of a protein specific to the prostate, PSA is short for prostate-specific antigen. Increased PSA levels result in further examinations to explain the elevation.
Physicians can also extract a tissue sample through the rectum to make a certain diagnosis. This is usually done in combination with a transrectal ultrasound.
Magnetic resonance imaging (MRI) where cross sections of the body’s interior are taken without the use of radiation, is currently considered the best imaging technique for detecting tumours. If prostate cancer is suspected, the MRI can provide images of potentially tumour-invaded areas.
An MRI cannot, however replace the need for a biopsy. In some cases, an MRI can help physicians decide whether surgery is an option and if so, to what extent.
If bone metastasis is suspected, a bone scan is performed. During a bone scan, a radioactive substance is injected into the bloodstream so that it is transported with the blood throughout the whole body. The radioactive particles accumulate in the affected bones. A special camera visualises these accumulations.
Once the prostate cancer diagnosis is certain and the extent and stage of the disease have been determined, physicians and patients will discuss the treatment options.
The following therapy options are available for prostate cancer:
- Radiation therapy
- Hormone therapy
- Active monitoring
- Wait and see
In early stage tumours limited to the prostate, surgery and radiation therapy are treatment options. During surgery, the prostate is removed completely.
The main goal is to resect the tumour tissue completely and thus achieve remission. At the same time as the prostate, the seminal vesicles and possibly the pelvic lymph nodes are also removed. This prevents the tumour cells spreading by the lymphatic system.
An alternative to surgery is radiation therapy. This is the first treatment choice when surgery is not possible or wanted. During radiation, radioactive rays are aimed directly at the tumour. The nuclei of the cancer cells are damaged so greatly in this procedure that the cancer cells can no longer divide and die as a result. There are two types of radiation. External radiation, also called percutaneous radiation therapy, and internal radiation, also known as brachytherapy.
If the cancer has not spread beyond the gland, it can be cured with surgery or radiation.
If the tumour has already spread to surrounding tissue at the time of diagnosis and formed metastasis in lymph nodes, hormone therapy is the treatment of choice. It is effective in the whole body. This therapy inhibits the production and effect of the male sex hormone testosterone. Alternatively, only the effect of testosterone can be suppressed and thus its stimulating effect on the prostate cancer cells. During this blocking of hormones the body continues to produce testosterone which then retains its mostly positive effects on the male organism. Through this intervention in hormone production, the tumour’s growth can be halted for an extended period.
During chemotherapy medicinal products called cytostatics are used, which inhibit the growth of cancer cells and destroy them. The cytostatics spread throughout the entire body and thus manage to reach tumour cells that have already spread to other body regions. This treatment does not effect a cure but it can slow down the progression of the disease significantly.
If the tumour has already formed bone metastasis hormone therapy and chemotherapy are used in combination with radiation therapy. This can help bring pain relief and stop the tumour from spreading.
In patients with less aggressive tumours, it may be possible to not initiate treatment at first. During the active monitoring approach, regular check-ups ascertain whether the tumour is even growing. If this is the case, treatment can be initiated straightaway.
Active monitoring can be an option for very elderly patients for whom therapy would be very taxing. Patients are monitored in the long term and, once symptoms appear that have been caused by the cancer, only those symptoms are treated and not the cancer itself.
As in other tumours, prostate cancer is staged according to the TNM classification, where T is for tumour, N is for lymph nodes and M is for metastasis. In accordance with the WHO classification, the cancer stages are given as T1-2 and T3-4. This is a coded way of expressing how far the cancer has spread within the prostate (see table below).
Pathologists further classify prostate cancer according to the pattern of its growth. This results in the so-called Gleason score with numbers between 2 and 10; the higher the number the poorer the diagnosis.
Primary tumour cannot be assessed
No evidence of primary tumour
Clinically inapparent tumour, neither palpable nor visible by imaging
Tumour incidental histological finding in 5% or less of tissue resected
Tumour incidental histological finding in more than 5% of tissue resected
Tumour identified by needle biopsy (e.g. because of elevated PSA)
Tumour confined within prostate
Tumour involves one-half of one lobe or less
Tumour involves more than one-half of one lobe
Tumour involves both lobes
|T3||Tumour extends through the prostatic capsule|
Notes: Invasion into the apex of the prostate or into the prostatic capsule (but not through it) is classified as T2 (not T3)
|T3a||Extracapsular extension (unilateral or bilateral) including microscopic bladder neck involvement|
Tumour involved seminal vesicle(s)
Tumour is fixed or invades adjacent structures other than seminal vesicles (bladder neck, external sphincter, rectum, levator muscles, pelvic wall)
Regional lymph nodes cannot be assessed
No regional lymph node metastasis
Regional lymph nodes metastasis
No distant metastases
Non-regional lymph nodes affected
(TNM 7th edition 2009 – German edition 2010)