Prostate Cancer Symptoms and Risk Factors

Prostate cancer symptoms and risk factors follow a clear pattern. Early, organ-confined disease is usually silent and is found by a PSA (prostate-specific antigen) blood test; urinary symptoms, leg swelling and bone pain appear as the cancer spreads. Risk rises with age, particularly after 65, with family history, diet and genetics, and is highest in men of African descent.

Dr. Amit Goel, Senior Director & Unit Head - Urology, Kidney Transplant, Uro-oncology, Robotic Surgery, Max Hospital, Gurugram, India, calls prostate cancer one of the most difficult cancers to treat. The difficulty is not a shortage of options. It is the opposite: the disease can be watched, irradiated, frozen, removed, hormonally suppressed or treated with chemotherapy and targeted radioligands, and the right choice depends on a stack of variables that differ for every man. Dr. Goel has treated more than 3,500 urological cancers over a career of more than 23 years. His masterclass on prostate cancer moves from who gets the disease, through how it shows itself, to the decisions that follow a diagnosis.

This guide sets out that full arc. Three companion articles in this urology series go deeper into the clinical decisions: diagnosis and staging, treatment selection by risk and stage, and the surgery itself.

Who is at risk of prostate cancer?

Age and ancestry are the two major determinants of prostate cancer risk: incidence rises as men get older, and men of African descent carry the highest risk of any ethnic group.

Incidence also varies widely across the world. Dr. Goel noted that the highest rates are found in northern Europe and the lowest in south central Asia. Within every population, the disease becomes more common after the age of 65.

Ancestry was a point Dr. Goel emphasised. For clinicians whose patients are predominantly of African descent, the disease belongs near the top of the list whenever an older man presents with urinary complaints.

Lower incidence does not mean small numbers. Prostate cancer ranks among the leading cancers in Indian men, and Dr. Goel cited roughly 40,000 new cases reported in India in 2020.

The established risk factors

Dr. Goel grouped the risk factors into four:

• Increasing age.
• Family history of prostate cancer.
• African descent, which confers the highest ethnic risk.
• Dietary factors.

Genetics and diet

He also pointed to genetic correlations, citing aberrations at chromosome 1q24 as one marker of higher risk. Linkage studies of families with hereditary prostate cancer mapped the first susceptibility locus, HPC1, to the 1q24-25 region.

On diet, the evidence for protection is weaker than often assumed. Studies of foods such as soy and lycopene-rich tomato products have produced inconsistent results, and supplements of vitamin E and selenium do not prevent prostate cancer: in the large SELECT trial neither lowered risk, and vitamin E supplementation was associated with a modest increase.

What type of cancer is prostate cancer?

Most prostate cancers are adenocarcinomas, cancers of glandular tissue. They arise in the acini, the small sac-like glands at the ends of the prostatic ducts. A minority of tumours are rarer histological variants, and Dr. Goel listed them: small cell carcinoma, mucinous carcinoma, endometrioid carcinoma, transitional cell carcinoma, squamous cell carcinoma, signet ring cell carcinoma and neuroendocrine cancer.

Which part of the prostate is most vulnerable?

The peripheral zone is the part of the prostate most susceptible to cancer. The gland is divided anatomically into zones, and they are not equally vulnerable: the transition and central zones harbour cancer less often.

This anatomy has a direct clinical consequence. The peripheral zone is the part of the gland that a digital rectal examination can palpate, so the region most likely to harbour cancer is also the region a clinician's finger can reach, and a hard nodule found there carries real weight. How that finding is acted on is set out in the section on diagnosis below.

Prostate cancer symptoms by stage

Early prostate cancer usually causes no symptoms. Symptoms appear as the disease spreads: urinary obstruction when it extends locally, leg swelling when it reaches the pelvic lymph nodes, and bone pain, fractures or spinal cord compression when it reaches bone. Dr. Goel described this as a spectrum that tracks the extent of disease, and the further the cancer has travelled, the more likely it is to announce itself.

Early, organ-confined disease: usually silent

Most prostate cancers seen today are organ-confined and early-stage, meaning the cancer is still contained within the gland. That shift is a product of PSA screening, which detects cancer at this stage. In Dr. Goel's experience, most patients are asymptomatic at diagnosis, at least in Indian practice, and the disease is found because a PSA test was done, not because the man felt unwell.

The corollary for clinicians is that waiting for symptoms means finding the disease later than it needs to be found.

Locally advanced disease: urinary symptoms and bleeding

When cancer extends beyond the gland locally, it can obstruct the outflow of urine. Dr. Goel listed the obstructive voiding symptoms that follow:

• Hesitancy in starting the stream
• Intermittency of the urinary stream
• Reduced force of the stream

Blood in the urine or blood in the semen can also appear.

Spread to the pelvic lymph nodes: leg swelling

When the disease reaches the pelvic lymph nodes, patients may present with oedema (swelling) of the lower extremities, and sometimes with pelvic and perineal discomfort.

Metastatic disease: bone first

Bone is the most common site of distant spread, and bone metastasis is the most common presentation of metastatic prostate cancer. It can cause pathological fractures, breaks through bone weakened by disease, and spinal cord compression. Dr. Goel noted that such an event is sometimes what first leads to the diagnosis: a man presents with a vertebral fracture or cord compression, and investigation reveals that prostate cancer has already seeded the vertebral column.

Spread to other organs is less common. Metastases to the lungs, liver, pleural cavity, peritoneal cavity and central nervous system do occur, but in Dr. Goel's experience they are usually found later in the course of disease, after the patient has received hormone therapy.

Prostate cancer symptoms and risk factors at a glance

Read together, Dr. Goel's account gives clinicians a set of presentations that should each prompt the question of prostate cancer in an older man:

• Obstructive urinary symptoms, particularly with blood in the urine or semen.
• Unexplained swelling of the legs, or pelvic and perineal discomfort, pointing to nodal disease.
• Bone pain, a pathological fracture or spinal cord compression, which may be the first sign of disease that has already spread to the spine.

The higher the baseline risk, as in men of African descent and men over 65, the lower the threshold for acting on any of them.

How is prostate cancer diagnosed?

Prostate cancer is confirmed by biopsy, and Dr. Goel identified three routes by which men reach that point:

1. A raised PSA found on testing, in a man who usually has no symptoms.
2. A hard nodule on digital rectal examination, in which the clinician feels the prostate with a gloved finger in the rectum, found while examining a man who has come with urinary complaints.
3. Symptomatic disease, where obstructive voiding, pelvic pain, leg swelling or bone pain prompt investigation.

Whichever route raises suspicion, the confirmation is the same: a biopsy, graded by the Gleason system, followed by imaging to stage the disease. The guide to prostate cancer staging and the Gleason score covers PSA screening, rectal examination, biopsy technique, Gleason grading and TNM staging in detail.

How is prostate cancer treatment chosen?

Prostate cancer treatment is chosen by weighing several variables together, not by applying a single standard regimen. Dr. Goel's central message on management was that stage, age, life expectancy, Gleason score and the patient's other risk factors all bear on the choice. The menu they select from runs from active surveillance and watchful waiting, through radiotherapy, cryotherapy and surgery, to hormonal, chemotherapeutic and radioligand treatment for advanced disease. Formal risk scores impose order on that choice. The article on prostate cancer treatment options by risk group sets out how Dr. Goel uses them, what the comparative evidence shows for surgery against radiotherapy, and how metastatic and castration-resistant disease is managed.

Where cure is the goal in intermediate-risk and high-risk disease, Dr. Goel's position is that surgery is the first choice, often as part of a multimodal plan. His platform of choice is the robot, and his preferred technique is the Retzius-sparing approach. The comparison of robotic, laparoscopic and open prostatectomy walks through the evidence and the operation step by step, and gives his cost figure for robotic surgery.

A second masterclass on the disease, from Dr. Shafiq Ahmad, sets out the management of prostate cancer by stage, including surgery for locally advanced disease.

PSA follow-up after prostate cancer surgery

After surgery, Dr. Goel's protocol is constant follow-up with a PSA test every three to six months, so that any rise is detected and assessed early. Surgery is offered specifically to patients in whom the aim, after full investigation, is to cure the disease. But no surgeon can promise that a cancer will never come back.

Recurrence does happen, Dr. Goel said in the masterclass Live Discussion, and that possibility is precisely what the word cancer conveys.

For referring physicians, the practical point is that the follow-up plan is part of the treatment, not an afterthought. A man whose prostatectomy has gone well still needs a clinician who will order and interpret his PSA on that three-to-six-month schedule.