What is locally advanced prostate cancer?

Locally advanced prostate cancer is cancer that has started to break out of the prostate, or has spread to the area just outside the prostate. It may have spread to the seminal vesicles, pelvic lymph nodes, neck of the bladder or back passage (rectum).

Watch our animation to find out more about prostate cancer:

The seminal vesicles are two glands that sit behind your prostate. They produce and store some of the fluid in semen. Lymph nodes are part of your immune system and are found throughout your body. The pelvic lymph nodes are near the prostate and are a common place for prostate cancer to spread to.

Different doctors may use the term ‘locally advanced prostate cancer’ to mean slightly different things, so ask your doctor or nurse to explain exactly what they mean. They can explain your test results and the treatment options available. Or you could call our Specialist Nurses for more information and support.

Find out more about prostate cancer.

Diagram of where the prostate is

How is locally advanced prostate cancer diagnosed?

If you’ve been diagnosed with locally advanced prostate cancer, you will have had some or all of the following tests.

Prostate specific antigen (PSA) test

This measures the amount of PSA in your blood. PSA is a protein produced by normal cells in the prostate and also by prostate cancer cells. Read more about the PSA test.

Digital rectal examination (DRE)

The doctor or nurse feels the prostate through the wall of the back passage (rectum). They feel for hard or irregular areas that might be a sign of cancer. Read more about having a DRE.

Prostate biopsy

Thin needles are used to take small samples of tissue from the prostate. The samples are looked at under a microscope to check for cancer. Read more about having a prostate biopsy.

Magnetic resonance imaging (MRI) scan or computerised tomography (CT) scan

These scans take images of your body to see whether the cancer has spread outside the prostate, for example to the lymph nodes or nearby bones. Read more about having a scan.

Bone scan

This can show whether any cancer cells have spread to the bones. This is a common place for prostate cancer to spread to. You might not need a bone scan if the result is unlikely to affect your treatment options. Read more about having a scan.

 

What do my test results mean?

Your doctor will look at all your test results to get an idea of how quickly your cancer might grow and whether it has spread. This will help you to discuss which treatments might be suitable for you.

PSA level

It’s normal to have a small amount of PSA in your blood, and the amount rises as you get older. Other things can also affect your PSA level. You may have had a PSA test that showed your PSA was raised, and then had other tests to diagnose your prostate cancer.

After you’ve been diagnosed, you will have regular PSA tests. If you have treatment, this is a useful way to check how well your treatment has worked. If your PSA level falls this usually suggests your treatment is working.

If you decide not to have treatment straight away, you will have regular PSA tests to check if your cancer might be growing.

Gleason grade and Gleason score

Your doctor may talk about your Gleason grade and Gleason score after your biopsy.

Gleason grade

Prostate cancer cells in your biopsy samples are given a Gleason grade. This tells you how aggressive the cancer is – in other words, how likely it is to grow and spread outside the prostate.

When cancer cells are seen under the microscope, they have different patterns, depending on how quickly they’re likely to grow. The pattern is given a grade from 1 to 5. This is called the Gleason grade. If a grade is given, it will usually be 3 or higher, as grades 1 and 2 are not cancer.

Gleason score

There may be more than one grade of cancer in the biopsy sample. An overall Gleason score is worked out by adding together two Gleason grades.

The first is the most common grade in all the samples. The second is the highest grade of what’s left. When these two grades are added together, the total is called the Gleason score.

Gleason score = the most common grade + the highest other grade in the samples.

For example, if the biopsy samples show that:

  • most of the cancer seen is grade 3 and
  • the highest grade of any other cancer seen is grade 4, then
  • the Gleason score will be 7 (3+4).

A Gleason score of 4+3 shows that the cancer is slightly more aggressive than a score of 3+4, as there is more grade 4 cancer.

If you have prostate cancer, your combined Gleason score will be between 6 (3+3) and 10 (5+5). You might only be told your total Gleason score, and not your Gleason grades.

What does the Gleason score mean?

The higher the Gleason score, the more aggressive the cancer, and the more likely it is to spread.

  • A Gleason score of 6 suggests the cancer is slow-growing.
  • A Gleason score of 7 suggests the cancer may grow at a moderate rate.
  • A Gleason score of 8, 9 or 10 suggests the cancer may grow more quickly

Staging

Staging is a way of recording how far the cancer has spread. The most common method is the TNM (Tumour-Nodes-Metastases) system.

  • The T stage shows the size of the cancer in the prostate.
  • The N stage shows whether the cancer has spread to the lymph nodes.
  • The M stage shows whether the cancer has spread to other parts of the body.

You might not be told your N stage or your M stage – your doctor may just tell you whether your cancer has spread to the lymph nodes or to other parts of your body.

T stage

The T stage shows how far the cancer has spread in and around the prostate. A digital rectal examination (DRE) is usually used to find out the T stage. You might also have an MRI scan or a CT scan to confirm your T stage.

If your T stage is T3 or T4, you’ll be diagnosed with locally advanced prostate cancer.

T1 and T2 prostate cancer

  • T1 - the cancer is completely contained inside the prostate and can only be seen under a microscope.
  • T2 - the cancer is completely contained inside the prostate, but can be felt or seen on scans.

T1 and T2 are both localised prostate cancer.

T3 prostate cancer

The cancer can be felt or seen breaking through the capsule of the prostate.

  • T3a - the cancer has broken through the capsule of the prostate, but has not spread to the seminal vesicles.
  • T3b - the cancer has spread to the seminal vesicles.

T4 prostate cancer

The cancer has spread to nearby organs, such as the neck of the bladder, back passage, pelvic wall or lymph nodes.

N stage

The N stage shows whether the cancer has spread to the lymph nodes near the prostate. This is a common place for prostate cancer to spread to. An MRI scan or a CT scan is used to find out the N stage.

The possible N stages are:

  • NX - the lymph nodes were not looked at, or the scans were unclear.
  • N0 - no cancer can be seen in the lymph nodes.
  • N1 - the lymph nodes contain cancer.

If your scans suggest that your cancer has spread to the lymph nodes (N1), it may be treated as either locally advanced or advanced prostate cancer. This will depend on several things, such as which lymph nodes are affected and whether the cancer has spread to other parts of the body.

M stage

The M stage shows whether the cancer has spread (metastasised) to other parts of the body, such as the bones. A bone scan is usually used to find out the M stage.

The possible M stages are:

  • MX - the spread of the cancer wasn’t looked at, or the scans were unclear.
  • M0 - the cancer hasn’t spread to other parts of the body.
  • M1 - the cancer has spread to other parts of the body.

You may not need to have a bone scan if the results are unlikely to affect your treatment options. If you do have a bone scan and your cancer has spread (M1), you will be diagnosed with advanced prostate cancer.

For example, if your cancer is described as T3b, N0, M0, it is likely that your cancer:

  • has spread to the seminal vesicles
  • has not spread to your lymph nodes
  • has not spread to other parts of your body.

If your cancer is described as T4, N1, M0 it is likely that your cancer:

  • has spread to nearby organs
  • has spread to nearby lymph nodes
  • has not spread to other parts of your body.

Both of these examples are locally advanced prostate cancer.

Ask your doctor or nurse to explain your test results if you don’t understand them. You can also call our Specialist Nurses.

What are my treatment options?

The treatment options for locally advanced prostate cancer are:

  • external beam radiotherapy (EBRT) with hormone therapy (and sometimes with high dose-rate brachytherapy)
  • hormone therapy alone
  • watchful waiting.
  • surgery (radical prostatectomy) - a small number of men with locally advanced prostate cancer may be offered surgery. This isn’t very common and is usually only offered as part of a clinical trial.

Some of the treatments might not be suitable for you, so ask your doctor or nurse about your own treatment options.

External beam radiotherapy (EBRT) with hormone therapy

EBRT with hormone therapy is the standard treatment for locally advanced prostate cancer. This aims to get rid of the cancer.

EBRT uses high-energy X-ray beams to destroy cancer cells from outside the body. Whether or not you’re offered EBRT will depend on how far your cancer has spread. It can be used to treat cancer in the prostate, seminal vesicles and pelvic lymph nodes.

You will be offered hormone therapy (see below) with your radiotherapy. This can help shrink the prostate and make the treatment more effective. You may be offered hormone therapy for up to six months before the radiotherapy. And you may continue to have hormone therapy during your radiotherapy, and for up to three years after it’s finished.

Read more about EBRT and hormone therapy.

High dose-rate brachytherapy

You might be offered high dose-rate (HDR) brachytherapy (sometimes called temporary brachytherapy) at the same time as EBRT. HDR brachytherapy is a type of internal radiotherapy. It involves putting a source of radiation into the prostate for a few minutes at a time.

HDR brachytherapy can be used together with EBRT to give higher doses of radiation to the whole prostate, as well as the area just outside it.

You may also have hormone therapy for several months before starting HDR brachytherapy. This can help to shrink the prostate and may make the treatment more effective. Some men also have hormone therapy for up to three years after HDR brachytherapy.

HDR brachytherapy isn’t available in all hospitals. If your hospital doesn’t offer brachytherapy, your doctor may be able to refer you to one that does.

Read more about HDR brachytherapy.

Hormone therapy

Hormone therapy is usually used with EBRT for locally advanced prostate cancer. But some men might have hormone therapy on its own if radiotherapy isn’t suitable for them.

Prostate cancer needs the male hormone testosterone to grow. Hormone therapy works by stopping testosterone from reaching prostate cancer cells. This causes the cancer cells to shrink, wherever they are in the body.

Hormone therapy won’t cure your cancer, but it can often keep it under control, sometimes for several years.

  • There are three main types of hormone therapy for prostate cancer:
  • injections or implants to stop the production of testosterone
  • surgery (orchidectomy) to remove the testicles or just the parts that make testosterone – this won’t be an option if you’re having EBRT
  • tablets to block the effects of testosterone.

Read more about hormone therapy.

Watchful waiting

Watchful waiting is a way of monitoring prostate cancer that isn’t causing any symptoms or problems.

The aim is to keep an eye on the cancer and avoid treatment unless you get symptoms. This means you will avoid or delay the side effects of treatment. If you do get symptoms, you’ll be offered hormone therapy to control the cancer and help manage symptoms.

Watchful waiting isn’t usually recommended for men with locally advanced prostate cancer. But it may be an option for men with other health problems who may not be fit enough for treatments such as radiotherapy.

If you’d prefer to be monitored instead or having treatment, speak to your doctor. They can help you think about the pros and cons of watchful waiting.

Read more about watchful waiting.

Surgery (radical prostatectomy)

This is an operation to remove the prostate and the cancer inside it. Your surgeon may also remove the nearby lymph nodes if there is a risk that the cancer has spread there.

Surgery isn’t usually recommended for locally advanced prostate cancer, but it may be an option for some men. This will depend on how far the cancer has spread outside the prostate. In some cases, it might not be possible to remove all of the cancer, and other treatments might be more suitable.

We don’t know how effective surgery is for men with locally advanced prostate cancer, so it’s usually only offered as part of a clinical trial.

You might also be offered hormone therapy or radiotherapy after surgery. All of these treatments have their own side effects, so speak to your doctor or nurse about this when thinking about your treatment options.

Read more about surgery.

Clinical trials

A clinical trial is a type of medical research. Clinical trials aim to find new and improved ways of preventing, diagnosing, treating and controlling illnesses. You can ask your doctor or nurse if there are any clinical trials you could take part in, or call our Specialist Nurses. 

Read more about clinical trials.

Choosing a treatment

Depending on how far your cancer has spread, you may have a choice of treatments. If so, your doctor or nurse will talk you through your treatment options and help you choose the right treatment for you. You might not be able to have all of the treatments listed above. Ask your doctor or nurse which ones are suitable for you.

What will affect my treatment choice?

If you have a choice of treatments, which treatment you choose may depend on several things, including:

  • how far the cancer has spread (its stage) and how quickly it may be growing
  • your age and general health – for example, if you have any other health problems such as heart disease
  • what each treatment involves
  • the possible side effects of each treatment
  • the advantages and disadvantages of each treatment, including practical things such as how often you would need to go to hospital, how far away your nearest hospital is, and how easy it is to get there
  • your own thoughts about different treatments.

Each treatment has its own advantages and disadvantages. All treatments have side effects, such as urinary problems, problems getting and keeping an erection, and fatigue. The type of side effects you get will depend on the treatment you choose.

Treatments will affect each man differently. Although you might not get all of the possible side effects, it’s important that you think about how you would cope with them when choosing a treatment.

It can be hard to take everything in, especially when you’ve just been diagnosed with prostate cancer. Make sure you have all the information you need, and give yourself time to think about what is right for you.

Your doctor or nurse can help you think about the pros and cons. It can be helpful to write down any questions you might want to ask at your next appointment.

You might also want someone to go to the appointment with you, such as your partner, friend or family member. You can talk about what was said at the appointment with them afterwards. You might find it helps to write down what’s said to help you remember it.

What will happen after my treatment?

You will have regular check-ups during and after your treatment to check how well it is working. You’ll have regular PSA blood tests – ask your doctor or nurse how often you’ll have these.

Tell your doctor or nurse about any side effects from your treatment. There are usually ways of managing side effects.

Make sure you have the details of someone to contact if you have any questions or concerns between check-ups. This might be your specialist nurse or key worker. You can also speak to our Specialist Nurses.

Find out what to expect from your follow-up appointments.

What is my outlook?

You may be concerned about the future and how a diagnosis of prostate cancer will affect your life and your loved ones. It can be difficult and stressful trying to make a decision about your treatment.

Many men will want to know how successful their treatment is likely to be. This is sometimes called your outlook or prognosis.

No one can tell you exactly what your outlook will be, as it will depend on many things, including the stage of your prostate cancer and how quickly it might be growing. Your age, general health and any other health problems will also affect how long you will live. Speak to your doctor about your own situation. There are also other people you can talk to and ways of getting support.

It’s normal to worry about dying if you’ve just been told you have cancer. But many men with locally advanced prostate cancer have treatment that aims to get rid of their cancer. So a diagnosis of prostate cancer doesn’t necessarily mean that you’ll die from it. But for some men, treatment may be less successful and the cancer may come back again. If this happens, you might need further treatment.

If you have hormone therapy on its own, it can keep the cancer under control, usually for several years. And there are other treatments available after hormone therapy.

Speak to your doctor or nursabout your own situation.

Questions to ask your doctor or nurse

You may find it helpful to keep a note of any questions you have to take to your next appointment.

  • What is my Gleason score?
  • How far has my cancer spread?
  • What treatments are suitable for me?
  • What do they involve?
  • What are the advantages and disadvantages of each treatment, including their possible side effects?
  • How effective is my treatment likely to be?
  • Is the aim to keep my prostate cancer under control, or to get rid of it completely?
  • Are all of the treatments available at my local hospital? If not, how could I have them?
  • Can I join any clinical trials?
  • How quickly do I need to make a decision?
  • After treatment, how often will I have check-ups and what will this involve?
  • If I have any questions or get any new symptoms, who should I contact?
  • Where is my nearest support group?

Dealing with prostate cancer

Some men say being diagnosed with prostate cancer changes the way they think and feel about life. If you are dealing with prostate cancer you might feel scared, worried, stressed, helpless or even angry.

At times, lots of men with prostate cancer get these kinds of thoughts and feelings. But there’s no ‘right’ way that you’re supposed to feel and everyone reacts in their own way.

Find out what you can do to help yourself and who can help.

References

Updated: August 2014 | Due for Review: July 2016

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