Locally advanced prostate cancer is cancer that is starting to break out of the prostate, or has spread to the area just outside the prostate, and may also affect the seminal vesicles, pelvic lymph nodes, neck of the bladder or back passage.

The seminal vesicles are two glands situated behind the prostate which produce some of the fluid in semen. The lymph nodes are part of the immune system. There are lymph nodes in the groin and pelvic area, near the prostate called the pelvic lymph nodes.

Different doctors sometimes use the term 'locally advanced prostate cancer' in slightly different ways, so ask your doctor or nurse what it means in your case.

If you are not sure whether your prostate cancer is locally advanced, 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 locally advanced prostate cancer, you may have had some or all of the following tests.

A PSA test
This 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, wherever they are in the body.

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 samples of tissue are sent to a laboratory to be looked at under a microscope to check for any cancer.

A magnetic resonance imaging (MRI) or computerised tomography (CT) scan
These scans take pictures of the body to find out if the cancer has spread to the area around your prostate gland, lymph nodes or other parts of the body.

A bone scan
This scan checks whether the cancer has spread to your bones. You may only be offered a bone scan if the result is likely to affect your treatment options.

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 are 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.

The PSA test is used, alongside other tests, to monitor your prostate cancer after you have started treatment. It is also used to monitor your cancer if you decide not to have treatment straight away. You will have regular PSA tests after treatment. A continuous rise in your PSA level may suggest that your cancer is growing more quickly.

After your biopsy, a doctor called a pathologist looks at the samples of tissue taken from your prostate gland 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 sample. The grades of the two most common patterns of cancer 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 second most common pattern of cancer seen is grade 4, then
• the Gleason will be 3 + 4, and the Gleason score will be 7.

A Gleason of 4 + 3 also gives a Gleason score of 7, but shows that the cancer is slightly more aggressive. This is because the most common pattern found is graded first. So, a Gleason of 3 + 4 has more cancer graded as 3, whereas a Gleason of 4 + 3 has more cancer with the higher grade of 4.

Most men with prostate cancer will have a Gleason score between 6 and 10.¹ The higher the Gleason score, the more likely the cancer is to spread.

Staging is a way of finding out 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 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 gland. This is measured by a DRE. You may also be offered a 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.
• 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 of the prostate but has not spread to the seminal vesicles.
T3b The cancer has spread to the seminal vesicles.

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

If your cancer is T3 or T4, you will be diagnosed with locally advanced prostate cancer. The diagram below gives an example of a T3 and a T4 prostate cancer.

N stage
The N stage shows whether the cancer has spread to the nearby lymph nodes. This is measured using an MRI or CT scan.

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.

If the results of your MRI or CT scan suggest that your cancer has spread to your lymph nodes (N1), it may be treated as locally advanced prostate cancer or advanced prostate cancer. This will depend on a number of factors including the results of your M stage (see below) and which lymph nodes are affected.

Speak to your doctor or nurse about what treatments may be suitable for you if your cancer has spread to your lymph nodes.

M stage
The M stage shows whether the cancer has spread (metastasised) to other parts of the body. One of the most common places for prostate cancer to spread to is the bones. This is measured using a bone scan. 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 the results show that your cancer has spread to your bones (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.

Examples of staging for locally advanced prostate cancer
If your cancer is described as T3, N0, M0 it is likely that your cancer:

• can be felt breaking through the capsule of the prostate
• has not spread to your lymph nodes, and
• 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, but
• has not spread to other parts of your body.

If there is anything you are unsure about or if you have any questions about what your test results mean, ask your doctor or nurse to explain them. You could also speak to our Specialist Nurses.

Treatments for locally advanced prostate cancer aim to either get rid of the prostate cancer or to control it long term. This will depend on your test results and how far the cancer has spread.

The main treatment options for locally advanced prostate cancer are:
• hormone therapy
• external beam radiotherapy with hormone therapy, and
• watchful waiting.

Hormone therapy
Hormone therapy works by stopping the male hormone testosterone from reaching the cancer. Prostate cancer needs testosterone to grow. Hormone therapy can cause the cancer to shrink, and it will treat all prostate cancer cells, wherever they are in the body. Hormone therapy will not get rid of the cancer but it can usually keep it under control for several years.

If you are diagnosed with locally advanced prostate cancer, you may have hormone therapy on its own, or together with radiotherapy.

If you have recently been diagnosed with locally advanced prostate cancer, you will usually be offered either injections or an orchidectomy to begin with.

External beam radiotherapy (EBRT) with hormone therapy
You may be offered external beam radiotherapy (EBRT), but this will depend on how far the cancer has spread. EBRT uses high energy X-ray beams directed at the prostate, seminal vesicles and pelvic lymph nodes to kill the cancer cells.

You will be offered hormone therapy with your radiotherapy to help make the treatment more effective.² This can be started before the radiotherapy begins and continue for up to three years after you have finished your radiotherapy.³ Hormone therapy can shrink the prostate and so it may help to reduce the risk of side effects of the radiotherapy. However hormone therapy also has side effects.^{2, 4, 5, 6, 7, 8}

Watchful waiting
Watchful waiting is way of monitoring prostate cancer that is not causing any symptoms. It is generally suitable for men who have other health conditions and so may not be fit enough for treatment such as radiotherapy. It may also be suitable for older men whose cancer is unlikely to cause problems during their lifetime.⁵

If you choose watchful waiting, you will not start treatment unless you get symptoms, such as problems passing urine or bone pain. You may then be offered hormone therapy to control the cancer and the symptoms. The advantage of this is that you will not get any of the side effects that can be caused by treatment, while you are on watchful waiting. However, there is a risk that changes to your cancer may not be picked up immediately.

You may have PSA tests every four to twelve months to check whether your cancer is changing.

Less common treatments
Less common treatments for locally advanced prostate cancer, which may be suitable for some men include

• surgery (radical prostatectomy) and
• high dose rate brachytherapy (also known as temporary brachytherapy).

Surgery (radical prostatectomy)
This is an operation to remove the whole prostate gland.

Surgery may be an option for some men with locally advanced prostate cancer. This will depend on how far the cancer has spread outside the prostate. Surgery for locally advanced prostate cancer is less common as it may not be possible to remove all the cancer cells that have spread outside the prostate. Researchers are looking at how effective surgery is for men with locally advanced prostate cancer, and you may be offered it as part of a clinical trial.^{4, 8, 9}

You may have hormone therapy, and/or a course of radiotherapy following surgery. Alternatively, you may be offered either or both of these only if you PSA starts to rise after having surgery.^{5, 10} You may experience more side effects if you have surgery with radiotherapy or hormone therapy.

High dose rate brachytherapy
Some men with locally advanced prostate cancer may be able to have a type of internal radiotherapy called high dose rate brachytherapy. This involves inserting a source of radiation into the prostate gland for a few minutes at a time. It is used together with external beam radiotherapy to give higher doses of radiation to the whole gland as well as to the area just outside the prostate.¹¹ You may also be offered hormone therapy alongside brachytherapy.

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

Personal experience
'I joined a clinical trial when diagnosed. My research nurse helped me understand the treatment and side effects.'

Depending on how far your cancer has spread, you may have a choice of treatments. Your doctor or specialist nurse will explain all your treatment options and help you to choose the right treatment for you. Which treatments you can have may depend on your test results and how far the cancer has spread. 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 on your treatment.

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. 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 to make notes so that you can read them in your own time. You could also discuss the treatments with your partner or family to help you decide.

What will affect my treatment choice?
If you have a choice of treatments, which treatment you choose may depend on several things. You might like to discuss some of the following factors with your doctor or nurse.

• 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 general health and age, for example, if you have any other medical conditions
• such as heart disease
• your personal views about different treatments
• any clinical trials that might be available.

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 them.

It can be a good idea to write down any questions you might have before your appointment. You should also 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 locally advanced prostate cancer, many men will want to know how successful their treatment is likely to be in getting rid of their cancer or controlling it. 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.

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.

It can be very difficult living with the uncertainty of a diagnosis of cancer, but there is support available if you need it.

If you have been 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 - 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 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 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?
• What clinical trials are available in my local hospital or elsewhere?
• 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 how often will this be?
• If I have a question, who should I contact?

The following organisations may be able to offer you and your family further support and information.

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
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:
Peter Hoskin, Consultant Clinical Oncologist, Mount Vernon Cancer Centre, Middlesex
Peter Kirkbride, Consultant Clinical Oncologist, Weston Park Hospital, Sheffield
Patricia McClurey, Specialist Nurse Prostate Cancer, James Cook University Hospital, Middlesbrough
Ann Tull, Urology Oncology Clinical Nurse Specialist, Southend University Hospital, Essex
Prostate Cancer UK's Volunteers
Prostate Cancer UK's Specialist Nurses

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

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