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According to the Irish Cancer Society, around 4,000 men are diagnosed with prostate cancer each year in this country, and about 500 men die from prostate cancer annually. The majority of prostate cancers are slow-growing, however, and most men who get a prostate cancer diagnosis will not die from the disease. The prostate, a gland found only in men, lies below the bladder, in front of the rectum, with the urethra running through it. It increases in size as a man ages and its primary functions are the production of seminal fluid and the regulation of urinary flow. “Prostate cancer is a malignancy that commences in the prostate,” explains professor David Galvin, consultant urologist at St Vincent’s and the Mater hospitals. Nine out of 10 men diagnosed with prostate cancer in Ireland will have no symptoms whatsoever, he says, and the causes are largely unknown. Genetics is of key importance: “If a first-degree relative had or is diagnosed with prostate cancer, that dramatically increases your risk [of developing it] to about a one in two or one in three chance.” John Wall was aware his grandfather had had prostate cancer, but for the 54-year-old, who lives in Lahinch, Co Clare, “it never crossed my mind for a moment that prostate cancer might have been an issue”. Prior to his own diagnosis, Wall was getting up at night to urinate and had a slight pain in his right leg; he also had a series of high PSA readings. A PSA test measures the amount of prostate-specific antigen (PSA) in the blood, and a high level can indicate that further investigation is warranted. Due to Wall’s relative youth — he was in his mid-40s at this time — it was initially thought that he had prostatitis, inflammation of the prostate gland. When he was eventually referred to a urologist, a follow-up MRI and biopsy revealed he had an “extremely aggressive” cancer. Wall’s cancer was so far advanced that he was initially offered palliative chemotherapy, but through his urologist, he accessed surgery in Belgium and underwent a 17-hour operation involving a radical prostatectomy and the removal of 71 lymph nodes. While recovery was “tough”, he eventually returned to “a relatively normal life”, although incontinence remains an issue that he manages “on a day-to-day basis”. He also suffers from lymphedema, body tissue swelling caused by issues with lymphatic drainage, which is managed at a dedicated HSE pilot project clinic in Ennis. “[The therapists there] have given me a quality of life that far exceeds anything I ever thought I would have.” He’s had extensive radiation treatment, which, six years on, is causing bowel frequency, but that is, he says, “very easily managed”. Wall’s cancer impacted his marriage, and the father of three is now separated. “Prostate cancer is one of those cancers that, depending on the stage you are at, has significant repercussions for you, for your partner,” he says. “When I was diagnosed, I had nobody to talk to. I had our family, but I didn’t know anybody or how to access anybody who was going through something similar.” Dealing with side effects Men diagnosed with prostate cancer face significant mental health challenges, with studies showing elevated rates of depression, anxiety, and emotional distress. In a large Irish study of more than 3,000 prostate cancer survivors, 14.4% reported clinically significant depression. Mental health impacts are often more severe in men with advanced or metastatic prostate cancer. For John Foley (61), it took getting to breaking point before he looked for help. A retired civil servant, who lives in Tullamore, Co Offaly, he was 56 when he was diagnosed with aggressive prostate cancer in 2020. His GP noted a series of rising PSA results and referred him to a urologist. An MRI and biopsy revealed cancer, and testing after Foley’s prostatectomy showed cancer in the lymph nodes. He was put on hormone therapy and had chemotherapy. Tumours have since appeared on his pelvis, ribs, and most recently on the opposite side of his pelvis. Radiotherapy successfully treated the first two tumours, and Foley is currently hoping for a similar result with the most recent one, which appeared within a year of him stopping hormone therapy. He’s now resumed hormone therapy and is also on an additional medication that further suppresses his testosterone. A father of two adult sons, Foley says his wife Tracey has been “absolutely brilliant” throughout, but he lacked peer support in dealing with the multiple difficult side effects from treatment and surgery, one of which was severe incontinence. He came away from surgery “with a complete misunderstanding of this side effect” and unaware he had options. After three years, having “got to a point where I felt ‘I can’t manage this much longer on my own’. I couldn’t manage the mental side of it”, he contacted the Irish Cancer Society, where a nurse put him in touch with ARC Cancer Support. He joined its prostate cancer peer support group, and during one of their monthly Zoom chats, discovered that there were treatments for severe incontinence. He has since been fitted with a device and now has full control of his bladder again, “which has been brilliant”. In the hope of helping other men avoid being in the dark about their options, Foley is currently putting together a submission to the HSE’s national cancer control programme to request that, going forward, patients receive a much more in-depth consent form than the current one. Screening is key Surgery for prostate cancer comes with side effects, with sexual and urinary function impacted. For some men, either or both may return to their pre-operative state, but for others, the changes can be permanent and range from mild to severe. For others who have a diagnosis of low-grade prostate cancer, active surveillance can be a viable alternative to surgery or can delay it for a significant period. Screening is key to early diagnosis and best outcomes. “The best and most effective form [of screening] is to have an organised national screening protocol with regular testing offered to every man,” Galvin says. Such a pilot programme is currently underway in the form of Praise-U, a European prostate cancer screening pilot project, aimed at improving early detection and diagnosis of prostate cancer through carefully designed, risk-based screening programmes. Ireland is one of four countries participating. Urine leakage is “universal” in men after prostate surgery, explains Galvin, and is managed by wearing pads. He says most men’s urinary function returns to normal within eight to 12 weeks. Four out of five stop leaking within about three months; 10% may still be leaking at six months post-op, while 5% will still be leaking after a year. Anxiety and social isolation can occur in men who struggle to cope. Radiotherapy doesn’t cause leaking, but it can cause urinary urgency and bleeding issues. “About 30% of men who go for radiotherapy end up having to undergo treatment for bleeding from their bowel,” he says. Hormone changes Impaired sexual function is common post-op, with Galvin noting that 70% of men report “moderate to major problems with their sexual function after treatment”. Nerve-sparing surgery is now the norm, but nerves can still be stretched or injured during the operation and temporary or permanent erectile dysfunction is common afterwards. With radiotherapy, sexual function often isn’t impacted until months or even a year after treatment. Sexual dysfunction — an umbrella term for a range of issues including erectile problems, difficulty with orgasm, loss of libido — can have profound effects on a man’s sense of self. “I was told, but it didn’t resonate with me, the part of me that I would lose as a result of my prostate being removed,” Wall says. Various medications and devices, such as penile pumps, can help remedy erectile dysfunction, but with hormone therapy, especially, libido is affected. The side effects of hormone therapy, the main treatment for metastatic prostate cancer, can be very challenging. Physical side effects include hot flushes and weight gain, while psychological effects such as mood changes and depression are common. “The most difficult part of the whole diagnosis for me has been the hormone treatment,” says Wall, who wishes, when he was diagnosed, that he had been able to speak to others on that treatment about how they coped with the side effects. “I found it extraordinarily difficult … It’s like chemical castration. I put on weight. My boobs were absolutely massive.” Gynecomastia is a common side effect of hormone therapy, and it made Wall feel so self-conscious that he initially wore a compression garment. Three years ago, against his oncologist’s advice, Wall stopped hormone therapy. “I just said, ‘I need a break from this’,” he recalls. “I got a very long time off it, and I got ‘me’ back again. A me that I had forgotten about, a part of me that felt like a man again. I got that person back.” His PSA levels have recently begun to rise, and he faces resuming the three-monthly hormone injections. Foley found hormone therapy equally challenging and also took a break. He was profoundly fatigued, mentally and physically: “I wouldn’t be able to do anything, but I didn’t want to do anything.” He stopped it in March 2024, but resumed it months later when a third tumour was detected: “There’s too high a risk now to take me off the treatment again”. Foley’s PSA has dropped to a low level, and he’s hoping it will be undetectable at his next check-up, which will mean the tumour has been successfully treated and the cancer cells in his system are once again inactive. Foley stresses the importance of support and early detection. “There’s no way you can do this on your own,” Foley says. “As soon as I was first diagnosed, I should have reached out … my support group have been absolutely wonderful.” Support services
