This information explains the advice about prostate cancer that is set out in NICE clinical guideline 175.

Transcription

1 Information for the public Published: 1 January 2014 nice.org.uk About this information NICE clinical guidelines advise the NHS on caring for people with specific conditions or diseases and the treatments they should receive. e. The information applies to people using the NHS in England and Wales. This information explains the advice about prostate cancer that is set out in NICE clinical guideline 175. All of the treatment and care that NICE recommends is in line with the NHS Constitution ( NICE has also produced advice on improving the experience of care for adults using the NHS. For more information see 'About care in the NHS' on our website ( This is an update of advice on prostate cancer that NICE produced in Does this information apply to me? Yes, if your GP has referred you or someone you care for to a specialist because of suspected or diagnosed prostate cancer. No, if: you have no symptoms and your GP has not referred you to a specialist NICE All rights reserved. Page 1 of 14

2 you have a cancer that started elsewhere in your body and has spread to your prostate you have a rare type of prostate cancer. Prostate cancer Prostate cancer is one of the most common cancers in men and is more likely to occur in older men. Prostate cancer tends to grow slowly, sometimes over many years. Sometimes prostate cancer never affects a man's general health, but other times it can be life-threatening. The prostate is a small gland near a man's bladder. It produces a fluid that carries the man's sperm when he ejaculates. When a man has prostate cancer, the cells in the prostate gland grow in an uncontrolled way and form lumps (also known as tumours). Your healthcare team The various types of treatment described are provided by a team of healthcare professionals who specialise in different treatments. These could include oncologists and urologists (doctors who diagnose and treat prostate cancer), radiologists (doctors who examine scans of the body), pathologists (doctors who examine tissue samples), specialist nurses and specialist surgeons. A member of your healthcare team should discuss prostate cancer with you and explain the tests and treatments for it in detail. You should have the opportunity to ask any questions you have there is a list of questions you might like to ask to help you with this. Involving you in decisions You should be given information about your diagnosis and treatment throughout your care, if you would like it, to help you make decisions. There are decision aids you can use, for example aids that predict how well a particular treatment might work see Sources of advice and support. If you are offered any decision aids a member of your healthcare team should explain how they work and how reliable they are. The information you are given should be tailored to your own needs. It may be written, such as in a pamphlet, or in a slide set or DVD. A member of your healthcare team should explain how to get information and support from websites, local and national cancer organisations and cancer support groups. NICE All rights reserved. Page 2 of 14

3 If you are offered a biopsy you should have the opportunity to discuss the risks and benefits with a member of your healthcare team. There is more information about this in Deciding whether to have a prostate biopsy. If you are diagnosed with prostate cancer a member of your healthcare team should tell you about all the different treatment options that might be suitable for you. They should discuss the benefits and risks of each treatment with you. They should tell you if there is not much evidence that a particular treatment works well. Symptoms of prostate cancer Symptoms of prostate cancer can include problems with urination such as needing to urinate more frequently. However, these symptoms are often caused by something other than cancer and do not mean that you have prostate cancer. Many men with prostate cancer have no symptoms. Diagnosis first steps Seeing your GP If you have symptoms or are concerned about prostate cancer your GP may offer to check your prostate and take a sample of your blood for testing. This is to help find out how likely it is that you have prostate cancer. Checking your prostate Your GP may offer you a digital rectal examination (or DRE for short). The GP will feel inside your rectum with a finger to check for anything unusual on the surface of the prostate. Having a blood test Your GP may also offer to take a sample of your blood to measure the level of a protein called prostate-specific antigen (or PSA for short) in your blood. The PSA level in the blood is often higher in men with prostate cancer, although a higher PSA level does not necessarily mean you have prostate cancer. NICE All rights reserved. Page 3 of 14

4 Diagnosis next steps Seeing a specialist If your GP thinks you might have prostate cancer they may refer you to a specialist. The specialist may offer you a test called a prostate biopsy. After you have had the results of the biopsy they may also offer you a type of scan called magnetic resonance imaging (or MRI for short). Having a prostate biopsy A prostate biopsy involves taking small samples of your prostate and checking them for cancer under a microscope. The biopsy helps the specialist to find out whether a man has prostate cancer and whether the cancer is likely to cause him harm. If the result of your biopsy is negative, your specialist should tell you that there is still a risk that you may have prostate cancer. They should tell you that the risk is slightly higher if the biopsy showed particular abnormalities. Deciding whether to have a prostate biopsy Your specialist should talk with you about whether a prostate biopsy is appropriate for you. To help you make a decision about a biopsy, your specialist should discuss with you the risks and benefits of having a biopsy. This should include discussion of the results of your previous tests (including the digital rectal examination, blood test and any previous biopsy results). They should also discuss with you factors that could increase your risk, such as increasing age or whether you are from a black African or black Caribbean ethnic background. Your specialist should explain the benefits and risks of having a prostate biopsy, including what it will mean for you if it turns out that the biopsy shows cancer of the prostate that is not likely to cause problems. You should be given as much support, time and information as you need to help you make the decision. NICE All rights reserved. Page 4 of 14

5 Having an MRI scan If your biopsy result is negative you may be offered a type of scan known as magnetic resonance imaging (or MRI for short) to help your specialist decide whether you need another biopsy. The MRI scan gives the specialist a detailed picture of your prostate. If the result of your MRI scan is negative you should not be offered another biopsy unless your first biopsy showed particular abnormalities. Stages of prostate cancer If you are diagnosed with prostate cancer you may be offered an MRI scan or a scan called computed tomography (or CT for short) to find out whether the cancer has spread outside your prostate. This is called staging. The NICE guideline divides prostate cancer into 3 stages, depending on whether and how far it has spread from the prostate to other parts of the body. Localised prostate cancer Localised prostate cancer is only in the prostate and has not spread anywhere else in the body. If you have localised prostate cancer your healthcare team should use your PSA measurement and biopsy results to determine whether your future risk is low, intermediate or high. Locally advanced prostate cancer Locally advanced prostate cancer is in the prostate and has spread from the prostate to the surrounding tissues. Metastatic prostate cancer Metastatic prostate cancer has spread further from the prostate, to the lymph nodes (glands that help fight infection), the bones or other parts of the body. Treatment options Some treatments described may not be suitable for you, depending on your exact circumstances. If you think that your treatment or care does not match this advice, talk to your healthcare team. NICE All rights reserved. Page 5 of 14

6 The treatment options you should be offered for prostate cancer depend on the stage of your cancer and, if you have localised prostate cancer, your level of future risk. You may be offered one or more of the following treatment options. Active treatments Radical prostatectomy surgery to remove the prostate. Radical radiotherapy radiation treatment to destroy the cancer cells. Hormone therapy drugs that reduce or stop the production or block the effect of hormones that help cancer cells to grow. Brachytherapy radiation treatment directed at the cancer from inside the prostate. A substance that gives off radiation is placed in the prostate to destroy the cancer cells. Pelvic radiotherapy radiation treatment for men with locally advanced prostate cancer. It destroys cancer cells that have spread outside the prostate. Orchidectomy surgery for men with metastatic prostate cancer. The part of the testicles that produces the hormone testosterone, which helps cancer cells to grow, is removed. No treatment Active surveillance Active surveillance involves regular PSA measurement and digital rectal examinations but no treatment unless there is a change in your results. You should be offered active surveillance as an option if: you have localised prostate cancer and radiotherapy or prostatectomy are suitable for you and your future risk has been assessed as low. You may be offered active surveillance if: you have localised prostate cancer and your future risk has been assessed as intermediate and NICE All rights reserved. Page 6 of 14

7 you do not wish to have active treatment straight away. Watchful waiting Some men choose not to have treatment and not to have regular digital rectal examinations. This is called watchful waiting. If you have chosen watchful waiting your PSA should be measured once a year. If you develop signs or symptoms that your cancer might be growing, such as bone pain or a sudden rise in your PSA level, your healthcare team should check you again. Palliative care Palliative care helps to relieve some of the symptoms of cancer but does not cure it. It includes pain relief and practical support to help you deal with the symptoms of your cancer. If you have metastatic prostate cancer your preferences for palliative care should be discussed with you as soon as possible. You should be offered care from a specialist palliative care team whenever you need it. Dealing with the side effects of treatment Some types of prostate cancer treatment cause side effects, either during the treatment or afterwards. You may be offered additional treatments to help stop or reduce the side effects of your prostate cancer treatment. A member of your healthcare team should discuss these with you. Problems with erections If your treatment causes problems with erections you should be offered access to a specialist erectile dysfunction service. You should be offered a drug called a PDE5 inhibitor to improve your chance of having spontaneous erections. If the PDE5 inhibitor doesn't work well enough, you should be offered a vacuum device, intraurethral insert, penile injection or penile prosthesis. Loss of fertility Some treatments for prostate cancer can affect a man's ability to father children. If you are concerned about losing your fertility you should be offered sperm storage before you have treatment. NICE All rights reserved. Page 7 of 14

8 Problems with urination It can be harder to control urination after treatment for prostate cancer. A member of your healthcare team should discuss this with you. If you are having problems with urination you should be referred to a specialist service that deals with this type of problem. Bowel problems Radiotherapy for prostate cancer can cause bowel problems. If you develop signs or symptoms of a bowel problem you should be offered treatment from a healthcare team who are experienced in treating bowel problems caused by radiotherapy. Hot flushes If you have troublesome hot flushes from hormone therapy you should be offered a drug called medroxyprogesterone to help relieve them. A member of your healthcare team should tell you that there is no good-quality evidence for the use of complementary therapies to treat hot flushes. Osteoporosis Hormone therapy for prostate cancer can cause osteoporosis, when the bones become fragile and break easily (known as fragility fractures). A member of your healthcare team may assess your risk of having a fragility fracture. See Other NICE guidance for details of our guidance on assessing the risk of fragility fractures. If you have osteoporosis and you are having hormone therapy, you should be offered a type of drug called a bisphosphonate to treat your osteoporosis. If you cannot take bisphosphonates you may be offered a drug called denosumab. You should not usually be offered a bisphosphonate to prevent osteoporosis. Enlarged breasts Hormone therapy with a drug called bicalutamide for more than 6 months can cause the breasts to become enlarged. If you are having bicalutamide therapy for 6 months or more, you should be offered radiotherapy to both breast buds within the first month to prevent them from becoming enlarged. If the radiotherapy doesn't work well enough you may be offered a drug called tamoxifen. NICE All rights reserved. Page 8 of 14

9 Fatigue A member of your healthcare team should explain that fatigue is a common side effect of hormone therapy and is not necessarily a symptom of your cancer. They should offer you a 12-week programme of supervised resistance and aerobic exercise, done at least twice a week, to reduce your fatigue and improve your quality of life. Follow-up A member of your healthcare team should talk to you and, if you wish, your partner or carer, about when and where your follow-up appointments will take place. They should also explain the purpose of the follow-up appointments. If you have had treatment for your prostate cancer, your PSA level should be checked 6 weeks afterwards. It should be checked again every 6 months for 2 years, and once a year after that. Questions to ask about prostate cancer These questions may help you discuss prostate cancer or the tests and treatments you have been offered with your healthcare team. Digital rectal examinations and blood tests Will the digital rectal examination hurt? How long will it take? What will it tell you? When can I have the blood test and when will you know the PSA measurement? How accurate is this test? Biopsies and scans How is a prostate biopsy done? Will the biopsy be painful? Are there any risks or side effects from the biopsy? NICE All rights reserved. Page 9 of 14

10 Where and when will the biopsy be done? Do I need to do anything to prepare for the biopsy? Will I be in any pain or discomfort after the biopsy? Will I need to take time off work to recover? When will you have the result of the biopsy? Will I need to have another biopsy? What are the risks if I decide not to have a biopsy? Where will my scan be done? How long will it take to get the results of the scan? Do I need to do anything to prepare for the scan? Information about prostate cancer Can you tell me more about prostate cancer? Can you recommend any websites or reading materials? Are there any support organisations in my local area? Can you provide any information for my family, partner or carers? For family members, partners or carers Drugs What can I/we do to help and support the man with prostate cancer? Is there any additional support that I/we as carer(s) might benefit from or be entitled to? Why have you decided to offer me this drug? How long will I need to take the drug for? What side effects might I get from this drug? Are there any long-term side effects? NICE All rights reserved. Page 10 of 14

11 Can anything be done to reduce the side effects? What might happen if I decide not to take this drug? What are my other options for treatment? Surgery Why have you decided to offer me this operation? When and where can I have the operation? What will happen during the operation? How long will I need to stay in hospital? How long will it take to recover? Do I need to do anything to prepare for the operation? Will I have any short-term or long-term side effects from the operation? Can anything be done to reduce the side effects? What might happen if I decide not to have the operation? What are my other options for treatment? Radiotherapy Why have you decided to offer me radiotherapy? What happens when a person has radiotherapy? When and where can I have the radiotherapy? How long will I have the radiotherapy for? Will the radiotherapy damage any healthy parts of my body? Are there any types of radiotherapy that reduce damage to healthy parts of my body? What are the side effects? Can anything be done to reduce the side effects? NICE All rights reserved. Page 11 of 14

12 Will I need to take time off work to recover? What might happen if I decide not to have radiotherapy? What are my other options for treatment? Side effects of treatment What should I do if I get side effects from my treatment? (For example, should I call you, or my GP, or go to the emergency department at a hospital?) Would I feel less tired if I made some changes to my lifestyle, such as becoming more physically active? No treatment Why have you decided to offer me the option to have no treatment? When will I be checked again? How often will I be checked? Will I need to have treatment later? What happens if my PSA level goes up? What should I do if I get symptoms? Can I change my mind about having treatment? What are my other options? Following up on your treatment When will I know whether the treatment has worked? When will I be checked again? Who will check me from now on? Is there anything I can do to speed up my recovery? Will the cancer come back? NICE All rights reserved. Page 12 of 14

13 How will I know if it has come back? What should I look out for? What should I do if I think I have symptoms again? If the cancer comes back what treatment will I need? How likely is it to work? Will I need to have regular tests from now on? Is there anything I can do to reduce the chance of the cancer coming back? Sources of advice and support Prostate Cancer Support Federation, Prostate Cancer UK, CancerHelp the patient information website of Cancer Research UK, Macmillan Cancer Support, You can also go to NHS Choices ( for more information. You can find an example of a decision aid for localised prostate cancer at NHS shared decision making ( NICE is not responsible for the quality or accuracy of any information or advice provided by these organisations. Other NICE guidance Osteoporosis: assessing the risk of fragility fracture. NICE clinical guideline 146 (2012). See ISBN: NICE All rights reserved. Page 13 of 14