Localised prostate cancer is prostate cancer that is contained within the prostate gland. You may also hear it called early or organ-confined prostate cancer.

Prostate cancer can behave in different ways. Many localised cancers are not aggressive and grow too slowly to cause any problems in your lifetime.¹ However, some cancers may grow more quickly and spread to other parts of the body.

The tests used to diagnose your cancer help to give your doctor an idea of how the cancer will behave and what treatment options may be suitable for you.

If you are not sure whether your prostate cancer is localised, speak to your doctor or nurse. They can explain your test results and talk to you about your treatment options.

If you have been diagnosed with localised prostate cancer, you may have had some or all of the following tests.

• A PSA test
  This test measures the level of a protein called prostate specific antigen (PSA) in your blood. PSA is produced by healthy prostate cells and also by prostate cancer cells.
• A digital rectal examination (DRE)
  The doctor or nurse feels the surface of the prostate gland through the wall of the back passage (rectum). They are feeling for any hard or irregular areas that may be a sign of cancer.
• A prostate biopsy
  Small amounts of tissue are removed from different areas of the prostate gland using thin needles. The tissue samples are sent to a laboratory to be looked at under a microscope to check for any cancer.

You may be offered other tests such as a bone scan, a magnetic resonance imaging (MRI) scan or a computerised tomography (CT) scan to find out if the cancer has spread outside of the prostate. However you may not need these tests if the results of the other tests show your cancer is unlikely to have spread.

Sometimes, prostate cancer is found following an operation called a transurethral resection of the prostate (TURP) which is used to treat an enlarged prostate. The prostate tissue removed during the operation is sent to a laboratory where it is checked to see if there is any cancer.

The results of all of your tests help to give your doctor an overall picture of your cancer. They can use the results to get an idea of how quickly your cancer may grow and how far it has spread. This will help them to decide which treatment options will be suitable for you.

All men have some PSA in their blood. A raised PSA level may show that there is a problem with your prostate but it does not necessarily mean you have prostate cancer. You may have had a PSA test which showed that you had a raised PSA level, and then had further tests which diagnosed your prostate cancer.

If you have been diagnosed with localised prostate cancer, your PSA level can help to decide which treatment options will be most suitable for you.

The PSA test is also used, alongside other tests, to monitor your prostate cancer if you decide not to have treatment straight away (see below). If you do have treatment, it is used to check how successful your treatment has been. You will have regular PSA tests after treatment. A continuous rise in your PSA level may suggest that your treatment has not been successful or the cancer has returned.

After your biopsy, a pathologist looks at the samples of your prostate tissue under a microscope. The pathologist looks at the patterns made by the cancer cells and gives them a grade from 1 to 5. This is called the 'Gleason grade'.

The pathologist may see more than one grade of cancer in the biopsy samples. The grades of the most common pattern and the pattern with the highest grade are added together to give a 'Gleason score'.

For example, if the biopsy shows that:

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

Most men with prostate cancer will have a Gleason score between 6 and 10.² The higher the Gleason score, the more likely the cancer is to spread.

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

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 measures the tumour.
• The N stage measures whether cancer has spread to the lymph nodes.
• The M stage measures whether the cancer has spread (metastasised) to other parts of the body.

T stage
The T stage shows how far the cancer has spread in and around the prostate. This is measured by a DRE. You may also have an MRI scan to confirm your T stage.

T1 The cancer cannot be felt or seen on scans and can only be found by looking under a microscope - localised prostate cancer.

T2 The cancer can be felt but it is contained within the prostate gland - localised prostate cancer.

• T2a The cancer can be felt in half of one side (lobe) of the prostate gland, or less.
• T2b The cancer can be felt in more than half of one of the lobes, but not in both lobes of the prostate gland.
• T2c The cancer can be felt in both lobes but is still inside the prostate gland.

T3 The cancer can be felt breaking through the capsule of the prostate gland - locally advanced prostate cancer.

• T3a The cancer has broken through the capsule but has not spread to the seminal vesicles. The seminal vesicles are two glands situated behind the prostate.
• T3b The cancer has spread to the seminal vesicles.

T4 The tumour has spread to nearby organs, such as the bladder neck, back passage or pelvic wall - locally advanced prostate cancer.

If your cancer is staged T1 or T2, you will be diagnosed with localised prostate cancer. The diagrams below give an example of a T1 and T2 prostate cancer.

N stage
The N stage shows whether the cancer has spread to the lymph nodes near the prostate. The lymph nodes are part of the immune system. There are lymph nodes in the groin and pelvic area, near the prostate, which can be a common place for prostate cancer to spread to.

The N stage is measured using an MRI or CT scan . You may be offered an MRI or CT scan if you are thinking about having a treatment such as radiotherapy or surgery and there is a risk that your cancer has spread to your lymph nodes.

NX The lymph nodes were not looked at.
N0 The lymph nodes do not appear to contain cancer cells.
N1 The lymph nodes appear to contain cancer cells.

M stage
The M stage shows whether the cancer has spread (metastasised) to other parts of the body. The majority of men diagnosed with localised prostate cancer will not need to have this stage measured as, if tests show that your cancer is localised, it is unlikely that it will have spread. A bone, MRI or CT scan may be used to check whether the cancer has spread to other parts of the body. If your cancer has spread (M1), you will be diagnosed with advanced prostate cancer.

MX The spread of the cancer was not looked at.
M0 The cancer has not spread to other parts of the body.
M1 The cancer has spread to other parts of the body.

An example of staging for localised prostate cancer

If your cancer is described as T2, N0, M0 it is likely that your cancer:

• is contained completely within the prostate gland
• has not spread to your lymph nodes, and
• has not spread to other parts of your body.

Clinical trials

Clinical trials are a type of medical research study that aims to find new improved ways of preventing, diagnosing and treating illnesses. If you would like to find out about taking part in a prostate cancer clinical trial ask your doctor or specialist nurse.

Talk to your doctor or specialist nurse if you have any questions about the tests you have had or your diagnosis.

Doctors often divide localised prostate cancers into risk groups. This is the risk of the cancer coming back after treatment.^{3, 4} This can be used to help decide which treatment options are suitable for you. To work out your risk group, your doctor will look at your PSA level, your Gleason score and the stage of your cancer.

Low risk
Your cancer may be described as low risk if:

• your PSA level is 10 ng/ml or less, and
• your Gleason score is 6 or less, and
• the stage of your cancer is T1 to T2a.

Medium risk
Your cancer may be described as medium risk if:

• your PSA level is between 10 and 20 ng/ml, or
• your Gleason score is 7, or
• the stage of your cancer is T2b or T2c.

High risk
Your cancer may be described as high risk if:

• your PSA level is 20 ng/ml or higher, or
• your Gleason score is 8 or higher, or
• the stage of your cancer is T3 or T4.

The main treatment options for localised prostate cancer are:

• active surveillance
• watchful waiting
• surgery (radical prostatectomy)
• external beam radiotherapy (EBRT)
• brachytherapy.

You may also be offered high intensity focused ultrasound (HIFU) or cryotherapy. They are not widely available in the UK and researchers are studying better ways of carrying out these treatments. They may be available in specialist centres or as part of a clinical trial. They are more commonly used to treat prostate cancer that has started to grow again after radiotherapy.

There may be more than one treatment that is suitable for you. Your choice of treatment will depend on your test results, personal preferences and a number of other factors.

Clinical Trials

Clinical trials are a type of medical research study that aims to find new improved ways of preventing, diagnosing and treating illnesses. If you would like to find out about taking part in a prostate cancer clinical trial ask your doctor or specialist nurse.

There are several treatment options available for localised prostate cancer. Your doctor or nurse will explain all your treatment options and help you choose the right treatment for you. It is up to you how much you want to be involved in choosing your treatment, but your personal preference can be an important factor in deciding your treatment.

If you have been diagnosed with localised prostate cancer this means your test results suggest your cancer has not spread outside of the prostate gland. Because of this, most treatment options for localised prostate cancer aim to get rid of the cancer.

There is no overall best treatment and each treatment has its own advantages and disadvantages. Each treatment has side effects. Treatments will affect each man differently, and you may not get all of the side effects. It is important that you think about the side effects and how you would cope with them when deciding on a treatment.

It can be hard to take everything in, especially when you have just been diagnosed with prostate cancer. In most cases there is no urgency to decide which treatment to have, and your doctor may suggest you take time to think things through before coming to a decision. It can be a good idea to write down any questions you might want to ask at your next appointment. If you need more time to think about the treatment options, just ask. You might find it useful to have someone with you at the consultation, or make notes that you can read in your own time. You can also discuss the treatments with your partner or family to help you decide.

If you would like to discuss your treatment options, you can also speak to one of our Specialist Nurses.

Which treatment you choose may depend on several things. You might like to discuss some of the following factors with your doctor or nurse:

• how the cancer is behaving and whether your cancer is low, medium or high risk
• your general health and age, for example, if you have any other medical conditions such as heart disease
• what the treatment involves
• the possible side effects of each treatment
• the advantages and disadvantages of the treatment, including practical things such as how often you would need to go to hospital, or how far away your nearest hospital is
• your personal views about different treatments, for example some men prefer to have their prostate gland removed, while others may not like the idea of surgery.

Many prostate cancers grow very slowly and may never cause symptoms or harm in a man's lifetime. In other words, many men with prostate cancer will never need treatment.

Treatments for prostate cancer can cause side effects. If you have slow growing cancer, the side effects may be worse than any problems that might be caused by the cancer.

You may therefore prefer to avoid or delay treatment and any side effects, by having your cancer monitored. It is not always possible to tell how quickly your cancer will grow, but if it is monitored your doctor can check for any changes.

The two different options for monitoring prostate cancer are active surveillance and watchful waiting.

If you are given the option of having your cancer monitored, there are a few things you may wish to think about. For example, what will monitoring involve, how will you know if you need treatment, and how you would feel about living with prostate cancer that has not yet been treated. Some men are not comfortable with this and prefer to have treatment straight away.

If you do decide to have your cancer monitored but then change your mind, talk to your doctor or nurse about what treatments are available for you.

The main treatment options for localised prostate cancer are shown in the diagram below.

Your doctor and nurse will monitor your response to your treatment to check how well it is working and whether you are experiencing any side effects. You will have regular PSA tests and appointments with your doctor or nurse. How often this happens will depend on the treatment you have had, so ask them about this. It is important to let them know about any side effects you are experiencing and how you are coping with these. There are usually ways of managing side effects.

You should be given the details of someone to contact between appointments if you have any concerns or develop any new symptoms or side effects.

After a diagnosis of localised prostate cancer, many men will want to know how successful their treatment is likely to be and what chance there is of curing their cancer. This is sometimes called your outlook or prognosis. No one will be able to tell you exactly what your outlook will be. Each cancer is different and it will depend on many things, such as the grade and stage of your cancer, and how quickly it is growing.

For many men with localised prostate cancer, treatment will get rid of the cancer. However, for some men treatment will be less successful, and the cancer may come back again. But there are further treatments available if your cancer does come back. You can read more about these in our booklet, Recurrent prostate cancer: a guide to treatment and support.

Not everyone will want to know about their outlook, but if you do, speak to your doctor. They will be able to talk to you about your individual situation.

If you have been recently diagnosed with prostate cancer and are facing decisions about treatment, there is support available. It can be an overwhelming time and you may experience a range of emotions. Your family may also find it difficult so this section may be helpful to them.

You will be given a main contact at the hospital, sometimes called a key worker. This might be a specialist nurse or another member of the team looking after you. They should be able to answer any questions or concerns you might have, as well as providing support. You and those close to you can also speak to one of our specialist nurses. They can help you to understand your diagnosis, treatment options and the emotional effects of cancer.

You and your family may find that talking to someone with similar experiences helps. Our support volunteers are all men and women personally affected by prostate cancer, either as a man with prostate cancer or a family member. They are trained to listen and offer support over the telephone.

You and your family can join also our online community. You can share your experiences with other men and their families. There are also prostate cancer support groups across the country, where you and your family can meet other people affected by prostate cancer.

If you have been diagnosed with prostate cancer, you may be worried about practical issues such as work and money. There is support available, and you can read more about this in our booklet, Living with and after prostate cancer: A guide to physical, emotional and practical issues.

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

What is my grade and stage?

Which of the treatment options in this fact sheet are suitable for me and why?

What does each treatment involve?

Are all of the treatments available at my local hospital? If not, how could I have these treatments?

What are the side effects of each treatment?

What are the advantages and disadvantages of each treatment?

If I decide to have my cancer monitored, what will this involve?

Are there any clinical trials that would be suitable for me?

How successful are the treatments available to me likely to be?

When do I need to make a decision by?

After treatment, how will I be monitored and often will this be?

If I have a question, who should I contact?

British Association for Counselling and Psychotherapy
www.itsgoodtotalk.org.uk
Telephone: 01455 883300
Provides information about counselling and details of therapists in your area.

Cancer Black Care
www.cancerblackcare.org.uk
Telephone: 020 8961 4151
Provides information and support to all people affected by cancer and raises awareness of cancer in black and minority ethnic communities.

CancerHelp UK
http://cancerhelp.cancerresearchuk.org/
Freephone: 0808 800 4040 (9am-5pm, Mon-Fri)
Part of Cancer Research UK, Cancer Help provides information about all types of cancer and a database of cancer clinical trials.

Healthtalkonline
www.healthtalkonline.org
Watch, listen to, or read personal experiences of men with prostate cancer and other medical conditions.

Macmillan Cancer Support
www.macmillan.org.uk
Freephone: 0808 808 00 00 (9am-8pm, Mon-Fri)
Provides practical, financial and emotional support for people with cancer, their family and friends.

Maggie's Cancer Caring Centres
www.maggiescentres.org
Telephone: 0300 123 1801
Provides cancer information and support centres throughout the UK where people affected by cancer can drop in to access information and support services.

NHS Choices
www.nhs.uk
Provides information and advice about medical conditions, and information on NHS health services in your area.

UK Prostate Link
www.prostate-link.org.uk
Guide to reliable sources of prostate cancer information.

Reviewed by:
Bev Baxter, Urology Oncology Nurse Specialist, The Royal Derby Hospital, Derby
Mr Simon Brewster, Consultant Urological Surgeon, Churchill Hospital, Oxford
Ben Challacombe, Consultant Urological Surgeon and Honorary Senior Lecturer, Guy's Hospital & Kings College London
Janette Kinsella, Prostate Clinical Nurse Specialist, Guys Hospital, London
Evelyn Pearson, Urology Nurse Specialist, Stepping Hill Hospital, Stockport
Prostate Cancer Voices
Prostate Cancer UK Specialist Nurses

Written and edited by:
Prostate Cancer UK's Information Team

1. Albertson PC, Hanley JA, Fine J. 20-year outcomes following conservative management of clinically localised prostate cancer. JAMA 2005; 293 (17): 2095-2101
2. Berney, D M (2007). The case for modifying the Gleason grading system. BJU Int, 100 (4), p.725-726
3. National Institute for Health and Clinical Excellence. 2008. Prostate cancer: diagnosis and treatment. full guideline. 2008
4. D'Amico AV, Whittington R, Malkowicz SB, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA. 1998;280:11.