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Symptoms & diagnosis

Symptoms of prostate cancer

Cancer of the prostate is often slow-growing and symptoms may not occur for many years.

Men with early prostate cancer are unlikely to have any symptoms, as these only occur when the cancer is large enough to put pressure on the urethra (the tube that drains urine from the bladder). In men over the age of 50, the prostate gland often gets larger due to a non-cancerous condition called benign prostatic hyperplasia or hypertrophy (BPH).

The symptoms of both benign enlargement of the prostate gland and malignant tumours (cancer) are similar and can include any of the following:

  • difficulty passing urine
  • passing urine more frequently than usual, especially at night
  • pain when passing urine
  • blood in the urine (this is not common).

If you have any of these symptoms it's important to get them checked by your doctor. But remember, most enlargements of the prostate are not cancer.

Symptoms of advanced prostate cancer

The symptoms of advanced prostate cancer include those symptoms mentioned above.

The symptoms due to secondary cancer will depend on which part of the body is affected, although there are a few general symptoms which some men have. These include being more tired than usual, generally feeling unwell, and having less of an appetite than usual.

Secondary cancer in the bones

The first sign of a secondary cancer in the bones is usually a nagging ache in the affected bone. This can become painful, making it difficult to sleep at night, or to move around without taking painkillers. The pain is generally present both day and night, whereas pain from arthritis, for example, is often worse early in the morning and is not there all the time.

A secondary cancer in the bone may gradually make it weaker. Pain and weakness can make getting around difficult, and a bone that is very weak may break (fracture) more easily.

If the bones in the spine are affected this can sometimes lead to weakness and tingling or numbness in the legs, due to the cancer causing pressure on the spinal cord. This is known as malignant spinal cord compression. It's important to let your doctors know straight away if you have this symptom. We can send you information about spinal cord compression.

When bones are affected by cancer cells, extra calcium may be released into the blood. This is called hypercalcaemia. It can cause symptoms such as tiredness, feeling sick, constipation, thirst, poor appetite and confusion.

Secondary cancer in the bone marrow

Sometimes prostate cancer can spread to the bone marrow. The bone marrow is the spongy material that fills the bones and produces blood cells. The different types of blood cells are:

  • red cells, which carry oxygen around the body
  • white cells, which help to fight infection
  • platelets, which help the blood to clot and prevent bleeding.

If the bone marrow is unable to produce enough blood cells you may become anaemic. You may also be more likely to get infections or to have bruising or bleeding.

Other symptoms

Occasionally prostate cancer can affect other parts of the body such as the lungs, lymph nodes, brain or liver.

If you notice any new symptoms that last for a couple of weeks or more you should discuss them with your specialist. It's important to remember that any of these symptoms can be caused by conditions other than cancer.

PSA testing for prostate cancer

Prostate-specific antigen (PSA) is a protein produced by prostate cancer cells. A blood test, the PSA test, measures the level of PSA and may help to detect early prostate cancer.

Men in the UK are not routinely offered PSA tests to screen for prostate cancer. There are many reasons for this:

  • The PSA test is not completely reliable. For every 100 men with a raised PSA level, only about 30 will have prostate cancer detected in a biopsy. This is called a false-positive result. Also, approximately 15% of men with a normal PSA level will have prostate cancer. This is known as a false negative result.
  • The amount of PSA in the blood can be high for reasons other than prostate cancer.
  • If the PSA level is high a man may need further tests such as a biopsy, which can be painful and lead to blood in the urine, the semen or bowel motions. In a few men the biopsy can lead to infection of the prostate gland, which can be difficult to get rid of. In 5- 10% of men the biopsy will not show cancer even if it is present.
  • Many small prostate cancers detected by PSA screening would never grow enough to cause any symptoms at all during a man's lifetime.
  • Many prostate cancers grow very slowly and the side effects from treatment (radiotherapy or surgery) may be worse than the effects of the prostate cancer. If the tests show there is an early cancer it can be difficult to decide whether or not to have treatment.

Research hasn't yet shown whether finding and treating prostate cancer early gives an improvement in survival. This can make it difficult to decide whether to have a test. Your doctors and nurses will be aware of this difficulty and can discuss it with you.

Men who don't have symptoms but would like to have a PSA test should discuss it with their GP, who can give them all the necessary information and arrange the blood test if they would still like to have it.

In most men with advanced prostate cancer the PSA level will be raised. Once the cancer has been treated the level of PSA will fall.

How prostate cancer is diagnosed

Men who have symptoms will usually begin by seeing their GP. They will examine you and ask you about your general health.

The first tests for diagnosing cancer of the prostate are a digital rectal examination (DRE) and a PSA blood test.

Digital rectal examination (DRE)

The rectum (back passage) is close to the prostate gland, so your doctor can feel for any abnormalities in the prostate by inserting a gloved finger into the rectum. This may be uncomfortable but should not be painful.

If cancer is present in the prostate gland it may feel hard and knobbly, whereas with benign prostatic hyperplasia (BPH - see symptoms) it'is usually enlarged, firm and smooth. However, often the prostate may feel normal, even when cancer cells are present.

PSA Test

A sample of blood is taken to check for PSA (prostate-specific antigen). PSA is a protein produced by the prostate and a small amount is normally found in the blood. Men with cancer of the prostate tend to have more PSA in their blood. However, the PSA test is not always reliable and some men who have prostate cancer will have a normal PSA. The PSA level can also be raised by:

  • urine infections
  • recent prostate biopsies
  • having a urinary catheter (a tube to drain urine)
  • prostate or bladder surgery
  • prostatic massage.

The PSA level will also get higher as men get older.

  • In men aged 50-59, a PSA of 3 nanograms per millilitre (ng/ml) of blood or lower is considered normal.
  • In men aged 60-69, a PSA of 4 ng/ml or lower is considered normal.
  • In men of 70 and over, a PSA of about 5 ng/ml is considered normal.

PSA levels higher than this could be due to a prostate cancer and a biopsy may be recommended. Men with levels of 5 ng/ml or above are usually referred for further tests.

As a general rule, the higher the level of PSA the more likely it is to be cancer. In most men with advanced prostate cancer the PSA level will be raised. Once the cancer has been treated, the level of PSA will fall. Measuring PSA levels can, therefore, be a helpful way of assessing the cancer and the effectiveness of treatment.

At the hospital

The following tests can be used to help diagnose cancer of the prostate, but you may not need to have all of them. The advantages and disadvantages of each method should be explained to you before you agree to any of them. Your doctor will be able to tell you how and when you will get the results.

Trans-rectal ultrasound scan (TRUS)

Ultrasound scans use sound waves to build up a picture of part of the inside of the body. To scan the prostate gland, a small probe is passed into the back passage and an image of the prostate appears on a screen. This type of scan is used to measure the size and density of the prostate.

A sample of cells (biopsy) can be taken at the same time for examination under the microscope by a pathologist (see below). The scan may be uncomfortable but it only takes a few minutes.


If the initial tests (rectal examination, PSA or ultrasound) show that there is a possibility of cancer, you may be offered a biopsy, in which several samples of tissue (usually around 10) are taken from the prostate to be looked at under a microscope.

The biopsy is normally done at the same time as the ultrasound. A needle is passed through the wall of the back passage (rectum) and into the prostate. This test is often uncomfortable, and can sometimes be painful. You may be given a local anaesthetic to reduce the discomfort, and antibiotics are given to reduce the risk of infection.

In the 24 hours following this test it is important to drink plenty of fluids. For up to a few weeks you may notice bleeding when passing water, opening your bowels or in your semen after sex. This is quite normal.

Unfortunately, even if there is cancer in the prostate it may not be found by biopsy. This will happen in approximately 1 in 10-20 men tested (510%). If a biopsy is negative it may need to be repeated (this may detect a cancer that was missed first time). Sometimes the PSA may be measured again after a few months and the biopsy repeated if the PSA level starts to rise.

How advanced prostate cancer is diagnosed

If you have previously been diagnosed with early or locally advanced prostate cancer you may be attending the hospital or your GP for regular check-ups and blood tests. If you develop new symptoms, you will have tests to see if the cancer has spread. These will usually include a PSA test and a bone scan.

Other tests will depend on your symptoms. Some men are found to have prostate cancer after being investigated for bone pain. If you have bone pain but no other

symptoms, your GP may first arrange for you to have an x-ray or scan of the painful area. This may be an x-ray, isotope bone scan, CT scan or MRI scan.

If these suggest a secondary cancer in the bones, further tests will be done to find where the cancer started.

Further tests for prostate cancer

If the biopsy shows that a cancer is present, further tests may be needed to check whether the disease has spread beyond the prostate gland. These may include the following:

Isotope bone scan

The bone is the most common place for prostate cancer to spread to. A bone scan can show abnormal areas of bone. A very small amount of a mildly radioactive liquid is injected into a vein, usually in your arm.

A scan is then taken of the whole body. Abnormal bone absorbs more of the radioactive substance than normal bone and shows up on the scan as highlighted areas (known as 'hot spots').

After the injection you will have to wait for up to three hours before the scan can be taken, so it is a good idea to take a book or magazine with you.

The level of radioactivity that is used is very small and does not cause any harm. This scan can also detect other conditions affecting the bones, such as arthritis. This means that further tests, such as an x-ray of the abnormal area, may be necessary to confirm whether or not it is cancer.


A chest x-ray and x-rays of the bones are sometimes taken to check your general health and see if there has been any spread of the cancer to other parts of the body.

MRI (magnetic resonance imaging) scan

An MRI scan uses magnetism to build up cross-sectional pictures of your body. An MRI scan may show whether the cancer has spread into the tissues around the prostate gland or into the lymph nodes near the prostate.

Before the scan you may be asked to complete and sign a checklist. This is to make sure that it's safe for you to have an MRI scan, because the scanner is a powerful magnet. The checklist asks about any metal implants you may have, for example a pacemaker, surgical clips, bone pins etc.

You should also tell your doctor if you have ever worked with metal or in the metal industry as very tiny fragments of metal can sometimes lodge in the body. If you do have any metal in your body it's likely that you won't be able to have an MRI scan. In this situation another type of scan can be used.

Before having the scan, you'll be asked to remove any metal belongings including jewellery. Some people are given an injection of dye into a vein in the arm, which doesn't usually cause discomfort. This is called a contrast medium and can help the images from the scan to show up more clearly.

During the test you will lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It's painless but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. It's also noisy, but you'll be given earplugs or headphones. You can hear, and speak to, the person operating the scanner.

CT (computerised tomography) scan

A CT scan may be used as an alternative to an MRI scan.

The scan takes a series of x-rays, which builds up a three-dimensional picture of the inside of the body. The scan is painless but takes 10-30 minutes. CT scans use a small amount of radiation, which is very unlikely to harm you and will not harm anyone you come into contact with. You'll be asked not to eat or drink for at least four hours before the scan.

You may be given a drink or injection of a dye which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand.

You will probably be able to go home as soon as the scan is over.

Waiting for your test results

It can take from a few days to a couple of weeks for the results of the tests to be ready. The results will show the grade and the stage of the prostate cancer. This information will be used by the doctors to decide on the best treatment for you.

Waiting for the results can be a difficult time and you may need support from your family or a helpful organisation.

Grading and staging of prostate cancer


Grading refers to the appearance of the cancer cells when the biopsy sample is looked at under the microscope. The grade gives an idea of how quickly the cancer may develop.

There are several grading systems, but the Gleason system is the most commonly used. This system looks at the pattern of cancer cells within the prostate. There are 5 patterns, graded 1-5 (1 being the least aggressive and 5 being the most aggressive). The biopsy samples are each graded and then the two most commonly occurring patterns are added together to get a Gleason score of between 2 and 10. The lower the Gleason score, the lower the grade of the cancer.

With prostate biopsies, the samples are usually too small to show grades 1 and 2, so it is most common to get scores from 6-10.

Low-grade cancers (6 or less) are usually slow-growing and less likely to spread. A score of 7 is a moderate grade. High-grade tumours (8-10) are likely to grow more quickly and are more likely to spread.


The stage of a cancer is a term used to describe its size and whether it has spread beyond its original area of the body.

Knowing the stage of the cancer and the grade helps the doctors decide on the most appropriate treatment. There are a few different staging systems for prostate cancer, and one is described below:

  • T1 the tumour is within the prostate gland and is too small to be detected during a rectal examination, but may be detected through tests such as a PSA test, a biopsy or a transurethral resection of the prostate gland (TURP). TURP is an operation to make passing urine easier, by removing a part of the prostate gland . At T1 stage there are generally no symptoms.
  • T2 the tumour is still within the prostate gland but is large enough to be felt during a digital rectal examination or show up on ultrasound. At T2 stage there are often no symptoms. T1 and T2 tumours are known as early (localised) prostate cancer.
  • T3/T4 the cancer has spread beyond the prostate gland into the surrounding tissues. T3 and T4 are known as locally-advanced prostate cancer.

If the cancer has spread to other parts of the body this is known as metastatic, secondary, or advanced prostate cancer.

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