Download Having Prostate cancer tests

A practical guide to tests
and treatments
Having
tests for
Prostate
cancer
Contents
Contents
About this booklet
3
The prostate gland 5
Prostate symptoms 6
What is cancer? 7
The lymphatic system
8
Prostate cancer
11
How prostate cancer is diagnosed
12
Waiting for test results
19
Your test results 21
If you are diagnosed with prostate cancer
22
Staging and grading
27
Talking to healthcare staff
29
Asking questions
32
If you are a relative or friend
37
How we can help you
38
Other useful organisations
43
Further resources
50
TNM staging
54
1
Having tests for prostate cancer
2
About this booklet
About this booklet
This booklet is for men who may be having tests
for prostate cancer.
Tests for prostate cancer can be divided into two groups:
• Diagnostic tests These are carried out to find out if you
have prostate cancer.
• Staging tests These are done if you’re diagnosed with
prostate cancer. The results of staging tests help doctors
decide which treatment is most suitable for you.
This booklet gives information about the tests that fall into the
two groups above. We hope it answers some of your questions
and helps you deal with some of the feelings you may have.
We have separate information for men who have been
diagnosed with prostate cancer and already know what stage
their cancer is:
• Understanding early (localised) prostate cancer
• Understanding locally advanced prostate cancer
• Understanding advanced (metastatic) prostate cancer.
We can’t advise you about the best treatment for you.
This information can only come from your doctor, who knows
your full medical history.
If you’d like to discuss this information, call the Macmillan
Support Line free on 0808 808 00 00, Monday–Friday,
3
Having tests for prostate cancer
9am–8pm. If you’re hard of hearing you can use textphone
0808 808 0121, or Text Relay. For non-English speakers,
interpreters are available. Alternatively, visit macmillan.org.uk
Turn to pages 43–53 for some useful addresses and websites.
If you find this booklet helpful, you could pass it on to your
family and friends. They may also want information to help
them support you.
4
The prostate gland
The prostate gland
The prostate is a small gland only found in men. It’s about the
size of a walnut and gets a little bigger with age. It surrounds
the first part of the tube (urethra) that carries urine from the
bladder along the penis.
Spine
Pubic bone
Bladder
Vas deferens
Seminal
vesicle
Prostate
gland
Rectum
Penis
Urethra
Scrotum
The male sex organs and surrounding structures
The prostate produces a thick white fluid called semen that
mixes with the sperm produced by the testicles. It also produces
a protein called prostate-specific antigen (PSA) that turns the
semen into liquid.
5
Having tests for prostate cancer
The prostate gland is surrounded by a sheet of muscle and a
fibrous capsule.
The growth of prostate cells and the way the prostate gland
works is dependent on the male sex hormone testosterone,
which is produced in the testicles.
Prostate symptoms
In men over 50, the prostate gland often gets larger due to a
non-cancerous condition called benign prostatic hyperplasia
(BPH), which is sometimes called hypertrophy.
Cancer of the prostate is often slow-growing and symptoms
may not occur for many years. Men with early prostate cancer
are unlikely to have any symptoms, as these only occur when
the cancer is large enough to put pressure on the urethra.
The symptoms of both benign enlargement of the prostate
gland and prostate cancer are similar, and can include any
of the following:
• difficulty passing urine
• passing urine more frequently than usual, especially at night
• blood in the urine (this is uncommon).
If you have any of these symptoms, it’s important to
have them checked by your doctor.
6
What is cancer?
What is cancer?
The organs and tissues of the body are made up of tiny
building blocks called cells. Cancer is a disease of these cells.
Cancer is not a single disease with a single cause and a single
type of treatment. There are more than 200 different types of
cancer, each with its own name and treatment.
Although cells in different parts of the body may look and work
differently, most repair and reproduce themselves in the same
way. Normally, cells divide in an orderly and controlled way.
But if for some reason the process gets out of control, the cells
carry on dividing and develop into a lump called a tumour.
Tumours are either benign (non-cancerous) or malignant
(cancerous). Doctors can tell if a tumour is benign or malignant
by removing a piece of tissue (biopsy) and examining a small
sample of cells under a microscope.
Normal cells
Cells forming a tumour
In a benign tumour, the cells do not spread to other parts of
the body and so are not cancerous. However, they may carry
on growing at the original site, and may cause a problem by
pressing on surrounding organs.
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Having tests for prostate cancer
In a malignant tumour, the cancer cells have the ability to
spread beyond the original area of the body. If the tumour
is left untreated, it may spread into surrounding tissue.
Sometimes cells break away from the original (primary) cancer.
They may spread to other organs in the body through the
bloodstream or lymphatic system.
When the cancer cells reach a new area they may go
on dividing and form a new tumour. This is known as a
secondary cancer or a metastasis.
The lymphatic system
The lymphatic system is part of the immune system – the body’s
natural defence against infection and disease. It’s made up
of organs such as bone marrow, the thymus, the spleen,
and lymph nodes. The lymph nodes throughout the body
are connected by a network of tiny lymphatic tubes (ducts).
The lymphatic system has two main roles: it helps to protect
the body from infection and it drains fluid from the tissues.
Lymph nodes are small glands, each about the size of a baked
bean. They can be found in many different places in the body,
including near the prostate.
8
The lymphatic system
Neck (cervical)
lymph nodes
Thymus
Armpit
(axillary)
lymph nodes
Spleen
Groin
(inguinal)
lymph nodes
The lymphatic system
9
Having tests for prostate cancer
10
Prostate cancer
Prostate cancer
Prostate cancer generally affects men over 50, and is rare in
younger men. It’s the most common type of cancer in men.
Around 37,000 men in the UK are diagnosed with prostate
cancer each year.
It differs from most other cancers in the body, in that small
areas of cancer within the prostate are very common and may
stay dormant (inactive) for many years.
Around half of all men in their fifties have some cancer cells
within their prostate, and 8 out of 10 men (80%) over the age
of 80 have a small area of prostate cancer. Most of these
cancers grow very slowly and so, particularly in elderly men,
will never cause any problems.
In a small number of men, prostate cancer can grow more
quickly and in some cases may spread to other parts of the
body, particularly the bones.
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Having tests for prostate cancer
How prostate cancer
is diagnosed
Men who have symptoms usually start by seeing their GP.
Your GP will examine you and ask about your general health.
The first tests used to diagnose prostate cancer are a digital
rectal examination and a PSA test.
Digital rectal examination (DRE)
As the rectum (back passage) is close to the prostate gland,
your doctor can feel for any abnormalities in the prostate
by gently inserting a gloved finger (with lubrication) into the
rectum. This may be uncomfortable but should not be painful.
If there’s cancer in the prostate gland it may feel hard
and knobbly, whereas with benign prostatic hyperplasia
(see page 6), the prostate usually feels enlarged, firm and
smooth. However, the prostate may feel normal, even when
cancer cells are present.
PSA (prostate-specific antigen) test
A sample of blood is taken to check for PSA (prostate-specific
antigen). PSA is a protein produced by the prostate, and a
small amount of it is normally found in the blood. Men with
cancer of the prostate tend to have a high level of PSA in
their blood.
12
How prostate cancer is diagnosed
However, this test isn’t always reliable and some men who have
prostate cancer will have a normal PSA level. The PSA level can
also be raised by:
• urine infections or infection of the prostate (prostatitis)
• recent prostate biopsies
• having a urinary catheter (a tube to drain urine)
• prostate or bladder surgery
• prostate massage (see page 15).
PSA levels also rise as men get older:
• In men aged 50–59, a PSA of 3 nanograms per millilitre
(ng/ml) of blood or lower is considered normal.
• In men aged 60–69, a PSA of 4 ng/ml or lower is
considered normal.
• In men aged 70 and over, a PSA of 5 ng/ml is
considered normal.
Men with a PSA level that is considered high for their age are
usually referred for further tests.
As a general rule, the higher the level of PSA, the more likely it
is to be cancer. Once the cancer has been treated, the level of
PSA will fall. So, measuring PSA levels can be a helpful way of
assessing the cancer and the effectiveness of treatment.
If your PSA level is raised, or if your GP feels any abnormalities
during the digital rectal examination, they will refer you to
hospital for a discussion about further tests.
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Having tests for prostate cancer
Why is the PSA test not used for screening?
PSA is a protein produced by the prostate as well as by prostate
cancer cells. The PSA test may help to detect early prostate
cancer. However, men in the UK are not always offered PSA
tests to screen for prostate cancer. There are many reasons
for this:
• The PSA test alone is not completely reliable for detecting
cancer. For every 100 men with a raised PSA level, only
about 30 will have prostate cancer detected in a biopsy
(see page 16). Also, about 15% of men with a normal PSA
level will have prostate cancer. The amount of PSA in the
blood can be high for reasons other than prostate cancer
(see page 13).
• If the PSA level is high, a man may need further tests such
as a biopsy. A biopsy can usually show whether cancer
is present in the prostate, but for a small number of men
(5–10%), the biopsy will not show cancer, even if a cancer
is present. Some men find having a biopsy of the prostate
painful and uncomfortable. There is also a small risk of
bleeding into the urine, semen or bowel motions, as well as
a small risk of infection. Very rarely, if you get an infection
you may need to go into hospital for treatment.
• Many small prostate cancers detected by a PSA test would
never grow enough to cause any symptoms or problems at
all during a man’s lifetime.
• Many prostate cancers grow very slowly and the side effects
from treatment (radiotherapy or surgery) may be worse than
the effects of the prostate cancer.
Research hasn’t yet shown whether or not finding and treating
prostate cancer early gives an improved chance of survival.
This can make it difficult to decide whether to have a test or
14
How prostate cancer is diagnosed
treatment if cancer is found. Your doctors and nurses will be
aware of this and can discuss it with you.
If you don’t have prostate symptoms but would like to have a
PSA test, you should discuss this with your GP, who can give you
information and arrange the test if you’d like to go ahead.
Our booklet Understanding the PSA test has
more information. We also have a video about
the PSA test on our website. You can watch this
at macmillan.org.uk/diagnosis/PSAtesting
PCA3 (prostate cancer antigen 3) test
This is a new test for prostate cancer that’s still being researched.
PCA3 is a protein that’s made by normal prostate cells.
When prostate cancer is present, much more of this protein
is made than usual. If a man has high levels of this protein,
it can be found in the urine. Before providing a urine sample,
you will have a digital rectal examination (see page 12).
During the procedure, the doctor massages the prostate,
which helps PCA3 to be detected in the urine afterwards.
Studies have shown that this test may be helpful in diagnosing
prostate cancer, but more research is needed. Like the PSA
test, PCA3 can’t diagnose cancer on its own, but it might help
doctors decide which men should have a biopsy (see page 16).
This would mean that men who are very unlikely to have
prostate cancer could avoid the possible risks and side effects
of having a prostate biopsy.
PCA3 is not available on the NHS at the moment, but is being
offered by some private hospitals. It can be expensive, so it’s
important to have as much information as possible about the
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Having tests for prostate cancer
test beforehand. Your doctor or specialist nurse will be able to
talk to you about how helpful it might be in your situation.
Trans-rectal ultrasound scan (TRUS)
Ultrasound scans use sound waves to build up a picture of the
prostate gland. During this scan, a small, lubricated probe
is passed gently into the back passage and an image of the
prostate appears on a screen. This type of scan is used to
measure the size and thickness of the prostate.
A sample of cells (biopsy) is often taken at the same time for
examination under the microscope by a pathologist (see below).
The scan may be uncomfortable but it only takes a few minutes.
Biopsy
If the initial tests (digital rectal examination, PSA or TRUS) show
there is a possibility of cancer, you may have a biopsy. This is
when several small samples of tissue (usually around 10) are
taken from the prostate to be looked at under a microscope.
The biopsy is normally done at the same time as an ultrasound
(see above). The ultrasound probe is used to guide the needle
through the wall of the back passage (rectum) and into the
prostate. The test is often uncomfortable, and can sometimes
be painful. You may be given a local anaesthetic to reduce
the discomfort. Antibiotics are also given to reduce the risk
of infection.
For 24 hours after this test, it’s important to drink plenty of
fluids. For up to a few weeks afterwards, you may notice
blood in your semen during sex. You may also notice a small
amount of blood in your urine or when opening your bowels.
16
How prostate cancer is diagnosed
If these symptoms persist, speak to your doctor.
Unfortunately, even if there is cancer in the prostate it may not
be found by a biopsy. This happens in around 1 in 10 or 20
men (5–10%). If a biopsy is negative it may need to be repeated,
which may pick up a cancer that was missed the first time.
Sometimes, PSA levels may be measured again after a few
months and the biopsy repeated if the PSA level starts to rise.
The repeat biopsy is sometimes carried out by saturation
biopsy (also known as template biopsy). This is done under
a general anaesthetic. A needle will be passed through the skin
between the scrotum (the skin that covers the testicles) and the
anus. This type of biopsy uses a special needle, which is able
to take many small tissue samples from different areas of the
prostate, all at the same time. It’s usually only used if previous
biopsies have not shown cancer but your doctor still thinks there
may be a high risk you have cancer.
Your doctor can give you more information about biopsies
and discuss whether saturation biopsy might be helpful in
your situation.
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Having tests for prostate cancer
18
Waiting for test results
Waiting for test results
It can take from a few days to a few weeks for test results
to be ready, and many people feel anxious during this
time. Although it’s normal to feel this way, you may feel
overwhelmed by the anxiety while waiting for your results.
You may feel that you have no control over what’s going
to happen to you. The waiting period might also feel
unreasonably long and the future may feel very uncertain.
There is no right or wrong way to deal with these feelings.
Some people find it helps to carry on with normal activities as
much as possible. Continuing with everyday life, such as going
to work, can be a welcome distraction from worrying. Others
may feel they simply cannot concentrate on anything else.
It might be helpful to divide your day into different activities,
for example, you could meet a friend for lunch or do one of
your favourite things, such as going to the cinema or visiting
a museum. This can provide a distraction from thoughts around
a possible cancer diagnosis, make you feel more in control,
and reduce feelings of uncertainty.
Some men look for more information about prostate cancer
during this time. Searching for information can help you feel
more in control while you wait for your results. However, if you’re
not certain of the diagnosis, some information can be confusing
and upsetting. It may be more helpful to wait until a diagnosis
is made before looking for more information. However, if you
decide to find out more, it’s a good idea to make sure the
information is from a reliable source. There are some useful
websites with reliable, user-friendly information listed on
pages 51–53.
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Having tests for prostate cancer
Try talking to a family member or close friend. Many people
find that their fears and worries are reduced simply by telling
someone else about them. ‘Offloading’ in this way can be
a relief and you may find that you feel better afterwards.
Some people prefer to talk to someone outside their circle
of family and friends. You may find it helpful to speak to one
of our cancer support specialists on 0808 808 00 00.
If you struggle to sleep during this time, simple breathing
and relaxation exercises may be useful in reducing anxiety,
stress and any muscle tension you have. Many people find
this relaxing, and experience a sense of calm when using
these simple methods. Almost everyone can learn relaxation
techniques; you could do this at home using a CD or podcast.
20
Your test results
Your test results
Once the test results are back you will have an appointment with
your specialist to discuss them. Some men will be told they don’t
have cancer, but their specialist might discuss any treatment
needed for their symptoms. Others won’t need any treatment.
Some men will be told they have cancer, which may mean
they need to have some further tests (see pages 22–26).
The results from these tests will help the doctors plan treatment.
Other men won’t need these tests, so instead their specialist
will discuss what treatment is best for them.
During the appointment your doctor will outline the different
treatment options, what they involve and any potential side
effects. It may be helpful to take someone with you to this
appointment to help you remember the discussion. You might
also like to write down any questions you have. Pages 32–34
give some examples of questions you may want to ask.
There’s also space for you to write down your own questions,
or for you to make notes from the discussion to refer to later.
Some men with prostate cancer are given a choice of two or
more treatments. This is because sometimes treatments are
thought to be equally effective and there is no clear benefit of
having one treatment over another. In this situation, doctors
offer men a choice of treatments. This is because some men
with prostate cancer may have a preference over which
treatment they want in terms of what the treatment involves
and the possible side effects.
You may find our free booklet Making treatment
decisions helpful. Call 0808 808 00 00 to order a copy.
21
Having tests for prostate cancer
If you are diagnosed
with prostate cancer
If your specialists are certain you have cancer, they may want
to carry out further tests to find out more about the stage and
grade of your cancer (see pages 27–28).
The stage gives information about the size and extent of the
cancer. The grade gives information about whether the cancer
is a slow- or fast-growing type. Knowing the stage and grade
of the cancer helps doctors plan the best treatment for you.
Further tests
Although the following tests can be used to help diagnose,
stage or grade prostate cancer, you may not need to have
all of them. The advantages and disadvantages of each test
should be explained to you before you agree to have any of
them. Your doctor will be able to tell you how and when you
will get the results.
The tests may include more blood tests, as well as any of
the following:
Isotope bone scan
The bones are the most common place for prostate cancer to
spread to. A bone scan can show up abnormal areas of bone.
A very small amount of a mildly radioactive liquid is injected
into a vein, usually in your arm. A scan is then taken of the
whole body. Abnormal bone absorbs more of the radioactive
22
If you are diagnosed with prostate cancer
substance than the normal bone does, and shows up on the
scan as highlighted areas called hot spots.
After the injection you’ll have to wait for up to three hours
before the scan can be taken, so it’s a good idea to take a
book or magazine with you.
The level of radioactivity that is used is very small and doesn’t
cause any harm. However, you may be asked to avoid long
periods of close contact with children or pregnant women for a
while after the scan. This is usually a requirement for 2–3 days,
but the staff at the hospital will give you more information.
This scan can also detect other conditions affecting the bones,
such as arthritis. This means that further tests, such as an
x-ray of the abnormal area, may be necessary to confirm that
it is cancer.
X-rays
A chest x-ray and x-rays of the bones are sometimes taken to
check your general health, and to see if the cancer has spread
to other parts of the body.
MRI (magnetic resonance imaging) scan
This test uses magnetism to build up a detailed picture of areas
of your body. An MRI scan may show whether the cancer has
spread into the tissues around the prostate gland or into the
lymph nodes near the prostate (see pages 8–9).
The scanner is a powerful magnet, so you may be asked to
complete and sign a checklist to make sure it’s safe for you.
The checklist asks about any metal implants you may have,
for example a pacemaker, surgical clips or bone pins.
23
Having tests for prostate cancer
You should also tell your doctor if you’ve ever worked with
metal or in the metal industry, as very tiny fragments of metal
can sometimes lodge in the body. If you do have any metal in
your body it’s likely that you won’t be able to have an MRI scan.
In this situation another type of scan can be used.
Before the scan, you’ll be asked to remove any metal
belongings including jewellery. Some people are given an
injection of dye into a vein in the arm, which doesn’t usually
cause discomfort. This is called a contrast medium and can
help the images from the scan to show up more clearly.
During the test you’ll lie very still on a couch inside a long
cylinder (tube) for about 30 minutes. It’s painless but can
be slightly uncomfortable, and some people feel a bit
claustrophobic. It’s also noisy, but you’ll be given earplugs
or headphones. You can hear, and speak to, the person
operating the scanner.
MRI scans can also sometimes be used to help men decide
whether to have a repeat biopsy. This usually happens when
biopsies have been negative for cancer, but other factors,
such as a high PSA level or particular symptoms, suggest that
there may still be a risk of prostate cancer.
The MRI scan can guide doctors to areas of the prostate that
may have cancer in them so they can take biopsies more
precisely. This is sometimes known as prostate mapping and
is not widely available on the NHS or across the UK. You can
speak to your doctor or nurse about whether prostate mapping
might be helpful for you.
24
If you are diagnosed with prostate cancer
25
Having tests for prostate cancer
CT (computerised tomography) scan
A CT scan takes a series of x-rays, which build up a
three-dimensional picture of the inside of the body. The scan
takes 10–30 minutes and is painless. It uses a small amount of
radiation, which is very unlikely to harm you and will not harm
anyone you come into contact with. You will be asked not to eat
or drink for at least four hours before the scan.
Someone having a CT scan
You may be given a drink or injection of a dye, which allows
particular areas to be seen more clearly. This may make you
feel hot all over for a few minutes. It’s important to let your
doctor know if you are allergic to iodine or have asthma,
because you could have a more serious reaction to the injection.
You’ll probably be able to go home as soon as the scan is over.
26
Staging and grading
Staging and grading
Staging
The stage of a cancer is a term used to describe its size and
whether it has spread. There are a few different staging systems
for prostate cancer. Two of the most commonly used systems are
a numbered staging system and the TNM staging system.
A simplified numbered staging system is described below:
• Stage 1 The cancer is very small and confined within the
prostate. It can’t be felt during a rectal examination.
• Stage 2 The cancer can be felt as a hard lump during a
rectal examination but is still within the prostate gland.
• Stage 3 The cancer has started to break through the outer
capsule of the prostate gland and may be in the nearby
tubes that transport semen (seminal vesicles).
• Stage 4 The cancer has spread beyond the prostate gland
to nearby structures such as the bladder or back passage
(rectum), or to more distant organs such as the bones or liver.
Using the numbered staging system described above, stages 1
and 2 are known as early (localised) prostate cancer. Stage 3
is known as locally advanced prostate cancer, and stage 4
is known as advanced (metastatic) prostate cancer.
The TNM staging system is more complicated than
the number staging system. We have more detailed
information about TNM staging at the back of this
booklet if you’d like to know more – see pages 54–57.
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Having tests for prostate cancer
Grading
The grade of a cancer gives an idea of how quickly it might
grow. Prostate cancer is graded according to the appearance
of the cancer cells when the biopsy sample is looked at under
the microscope.
There are several grading systems, but the Gleason system
is the most commonly used. This system can help doctors
decide which treatment might be best, as it gives them more
information about the cancer.
The Gleason system looks at the pattern of cancer cells within
the prostate. There are five patterns, which are graded from
1–5. 1 appears very similar to normal prostate tissue, whereas
5 appears very different to normal tissue.
The biopsy samples are each graded and then the two most
commonly occurring patterns are added together to get a
Gleason score of between 2–10. The lower the Gleason
score, the lower the grade of the cancer. Low-grade cancers
(6 or under) are usually slow-growing and less likely to spread.
A score of 7 is a moderate grade. High-grade tumours (8–10)
are likely to grow more quickly and are more likely to spread.
High-grade tumours are sometimes called aggressive tumours.
Prostate biopsies graded 1 or 2 are rare. It’s more common to
get scores from 6–10.
28
Talking to healthcare staff
Talking to healthcare staff
Having an appointment with a doctor about cancer treatment
can feel overwhelming. Many people find that after this
appointment they can remember very little about what was said.
Others find they have more questions once they’ve had some
time to think about things. This is common and you may like to
get in touch with your doctor or nurse to go over things again.
Most conversations with your doctors and nurses will probably
go smoothly. However, some people occasionally feel as
though they’re not getting the information they need.
Here are some tips for talking to healthcare staff:
• Ask your doctors and nurses to use simple language and
to explain medical terms. If they use words you don’t
understand, ask them to explain them to you. Sometimes
they may forget that you’re not as familiar with medical
terms as they are.
• Use your own words. Although your doctors or nurses
may use medical terms, you don’t have to. It’s okay to use
your own words to describe the problem. In fact, using
medical terms that you only partly understand might cause
problems, as the healthcare professionals may think you
know more than you do.
• If you’re embarrassed, say so. We all find certain medical
symptoms and problems embarrassing and they’re often
the kind of personal matter we don’t want to talk about with
someone else. So when you do start talking about something
you find embarrassing, you could say something like,
‘I’m sorry, this is a bit embarrassing to talk about, but ...’
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Having tests for prostate cancer
30
Talking to healthcare staff
• Try to think of the most important questions you definitely
want to ask before you meet with your doctor.
• Write down the important points on a piece of paper that
you can take with you. Every healthcare professional knows
how difficult it is to understand and remember information,
particularly when it’s serious and about you. Nobody will
mind you writing things down or making a list of questions
you want to ask beforehand. Some people are happy for
you to record the discussion, so that you can listen to it
later. You can also ask your medical team for a copy of any
letters summarising the details of your discussion with them.
• Make sure you understand what’s been said. Once your
doctor or nurse has answered your questions, it’s a good
idea to summarise their answers and say something like,
‘So you’re saying that ...’ or, ‘If I’ve got that right, you mean
that ...’ This makes it clear what you’ve understood,
and can encourage your doctor or nurse to explain
things more clearly if necessary.
• Ask for simple explanations. If you don’t understand what
you’ve been told, it’s fine to ask the person to explain again
more simply.
• Remember, you’ll have other chances to ask questions.
You can always make another appointment to ask your
questions if you don’t cover everything in the first discussion,
or if you’re given surprising news that changes the questions
you wanted to ask. You may also be given a phone number
for a specialist nurse you can phone if you’ve forgotten to
ask a question, or if you don’t understand something.
31
Having tests for prostate cancer
Asking questions
Here are some suggested questions you may want to ask
your healthcare team. There’s also some spare note paper
on pages 34–35.
1. What tests do I need?
2. When will I get the test results?
3. Do I have prostate cancer?
4. Do I need more tests?
5. Do I need to see any other doctors?
6. What are the treatment options?
32
Asking questions
7. What are the risks and benefits of each treatment?
8. What does the treatment involve?
9. What are the side effects of treatment?
10. How will you know if the treatment has worked?
11. What are the chances of the cancer coming back?
12. If my cancer does come back, can I have more treatment?
13. Will I come back for check-ups and, if so, how frequently?
14. What can I do to help myself?
33
Having tests for prostate cancer
15. Who should I call if I need help between appointments?
16. What will happen if I decide not to have treatment?
Other notes
34
Other notes
35
Having tests for prostate cancer
36
If you are a relative or friend
If you are a relative or friend
Some families find it difficult to talk or share their feelings.
You might think it’s best to pretend everything is fine, and carry
on as normal. You might not want to worry the person who’s
having tests for cancer, or you might feel you’re letting them
down if you admit to being afraid. Unfortunately, denying strong
emotions like this can make it even harder to talk, and may lead
to the person having these tests feeling very isolated.
Partners, relatives and friends can help by listening carefully to
what their loved one wants to say. Don’t rush into talking about
the illness. Often it’s enough just to listen and let that person
talk when they are ready.
37
Having tests for prostate cancer
How we can help you
Cancer is the toughest fight most of us will
ever face. But you don’t have to go through it
alone. The Macmillan team is with you every
step of the way.
Get in touch
Macmillan Support Line
Our free, confidential phone
Macmillan Cancer Support line is open Monday–Friday,
89 Albert Embankment,
9am–8pm. Our cancer
London SE1 7UQ
support specialists provide
Questions about cancer?
clinical, financial, emotional
Call free on 0808 808 00 00 and practical information and
(Mon–Fri, 9am–8pm)
support to anyone affected by
www.macmillan.org.uk
cancer. Call us on 0808 808
Hard of hearing?
00 00 or email us via our
Use textphone
website, macmillan.org.uk/
0808 808 0121 or Text Relay. talktous
Non-English speaker?
Interpreters are available.
Information centres
Our information and support
Clear, reliable information centres are based in hospitals,
about cancer
libraries and mobile centres,
and offer you the opportunity
We can help you by phone,
to speak with someone
email, via our website and
face-to-face. Find your nearest
publications or in person.
one at macmillan.org.uk/
And our information is free to informationcentres
everyone affected by cancer.
38
How we can help you
Publications
We provide expert, up-to-date
information about different
types of cancer, tests and
treatments, and information
about living with and after
cancer. We can send you free
information in a variety of
formats, including booklets,
leaflets, fact sheets, and audio
CDs. We can also provide
our information in Braille
and large print.
Need out-of-hours support?
You can find a lot of
information on our website,
macmillan.org.uk
For medical attention out of
hours, please contact your GP
for their out-of-hours service.
Someone to talk to
When you or someone you
know has cancer, it can be
difficult to talk about how
you’re feeling. You can call
our cancer support specialists
You can find all of our
information, along with several to talk about how you feel and
what’s worrying you.
videos, online at macmillan.
org.uk/cancerinformation
We can also help you find
support in your local area,
Review our information
so you can speak face-to-face
Help us make our resources
even better for people affected with people who understand
what you’re going through.
by cancer. Being one of our
reviewers gives you the chance
to comment on a variety of
information including booklets,
fact sheets, leaflets, videos,
illustrations and website text.
39
Having tests for prostate cancer
Professional help
Support for each other
Our Macmillan nurses, doctors
and other healthcare and
social care professionals offer
expert treatment and care.
They help individuals and
families deal with cancer from
diagnosis onwards, until they
no longer need this help.
No one knows more about
the impact cancer has on a
person’s life than those who
have been affected by it
themselves. That’s why we
help to bring people with
cancer and carers together in
their communities and online.
You can ask your GP, hospital
consultant, district nurse
or hospital ward sister if
there are any Macmillan
professionals available
in your area, or call us.
Support groups
You can find out about support
groups in your area by calling
us or by visiting macmillan.
org.uk/selfhelpandsupport
40
Online community
You can also share your
experiences, ask questions,
get and give support to others
in our online community
at macmillan.org.uk/
community
How we can help you
Financial and
work-related support
Find out more about the
financial and work-related
support we can offer
Having cancer can bring extra at macmillan.org.uk/
costs, such as hospital parking, financialsupport
travel fares and higher heating
Learning about cancer
bills. Some people may have
to stop working.
You may find it useful to learn
If you’ve been affected in this more about cancer and how
to manage the impact it can
way, we can help. Call the
have on your life.
Macmillan Support Line and
one of our cancer support
You can do this online on our
specialists will tell you about
the benefits and other financial Learn Zone – macmillan.org.
uk/learnzone – which offers
help you may be entitled to.
a variety of e-learning courses
and workshops. There’s
We can also give you
information about your rights also a section dedicated to
supporting people with cancer
at work as an employee, and
help you find further support. – ideal for people who want
to learn more about what
Macmillan Grants
their relative or friend is
Money worries are the last
going through.
thing you need when you have
cancer. A Macmillan Grant is
a one-off payment for people
with cancer, to cover a variety
of practical needs including
heating bills, extra clothing,
or a much-needed break.
41
Having tests for prostate cancer
42
Other useful organisations
Other useful organisations
Prostate cancer
support organisations
Bladder and
Bowel Foundation
SATRA Innovation Park,
Rockingham Road,
Kettering NN16 9JH
Helpline 0845 345 0165
Email info@bladderandbowel
foundation.org
www.bladderandbowel
foundation.org
Provides information and
advice on a range of
symptoms and conditions
related to the bladder
and bowel, including
incontinence, constipation
and diverticular disease.
Orchid
St Bartholomew’s Hospital,
London EC1A 7BE
Tel 0203 465 5766
(Mon–Fri, 9am–5.30pm)
Email
[email protected]
www.orchid-cancer.org.uk
Funds research into men’s
cancers, their diagnosis,
prevention and treatment.
Offers free information leaflets
and fact sheets, and runs an
enquiry service supported
by Orchid Male Cancer
Information Nurses.
Prostate Action
6 Crescent Stables,
139 Upper Richmond Road,
London SW15 2TN
Tel 020 8788 7720
Email
[email protected]
www.prostateaction.org.uk
Funds research and education
into all three prostate diseases:
benign prostatic hyperplasia
(BPH), prostate cancer and
prostatitis. Has information
about these conditions on
the website.
43
Having tests for prostate cancer
The Prostate
Cancer Charity
Cambridge House,
100 Cambridge Grove,
London W6 0LE
Helpline 0800 074 8383
(Mon–Fri, 10am–4pm,
Wed, 7–9pm)
Email
[email protected]
www.prostate-cancer.
org.uk
Provides information and
support to men with prostate
cancer, and their families.
A confidential helpline
is available for anyone
concerned or affected by
prostate cancer.
The Prostate Cancer
Support Federation
Mansion House Chambers,
22 High Street,
Stockport SK1 1EG
Helpline 0845 601 0766
Email info@prostatecancer
federation.org.uk
www.prostatecancer
federation.org.uk
An organisation of UK
patient-led prostate cancer
support groups.
44
Prostate Cancer
Support Scotland
Gf2, 21–23 Hill Street,
Edinburgh EH2 3JP
Tel 0131 226 8157
Email
[email protected]
www.prostatescotland.
org.uk
A Scottish charity set up to
provide information, advice
and help on prostate health
and diseases of the prostate.
You can watch videos online
and download free leaflets
and booklets.
The Sexual
Advice Association
Suite 301, Emblem House,
London Bridge Hospital,
27 Tooley Street,
London SE1 2PR
Tel 020 7486 7262
Email info@
sexualadviceassociation.co.uk
www.sda.uk.net
Aims to improve the sexual
health and well-being of
men and women, and to
raise awareness of how
sexual conditions affect
the general population.
Other useful organisations
General cancer
support organisations
Cancer Black Care
79 Acton Lane,
London NW10 8UT
Tel 020 8961 4151
(Mon–Fri, 9.30am–4.30pm)
Email
[email protected]
www.cancerblackcare.
org.uk
Offers a variety of information
and support for people
with cancer from ethnic
communities, their families,
carers and friends.
Welcomes people from
different ethnic groups
including African, Asian,
Turkish and AfricanCaribbean communities.
Cancer Support
Scotland (Tak Tent)
Flat 5, 30 Shelley Court,
Gartnavel Complex,
Glasgow G12 0YN
Tel 0141 211 0122
Email info@
cancersupportscotland.org
www.cancersupport
scotland.org
Offers information and
support to people with
cancer, families, friends,
and healthcare professionals.
Runs a network of support
groups across Scotland.
Irish Cancer Society
43–45 Northumberland Road,
Dublin 4, Ireland
Cancer Helpline
1800 200 700 (Mon–Thurs,
9am–7pm, Fri, 9am–5pm)
Email [email protected]
www.cancer.ie
Operates Ireland’s only
freephone cancer helpline,
which is staffed by nurses
trained in cancer care.
Maggie’s Cancer
Caring Centres
8 Newton Place,
Glasgow G3 7PR
Tel 0300 123 1801
Email enquiries@
maggiescentres.org
www.maggiescentres.org
Maggie’s Centres offer free,
comprehensive support for
anyone affected by cancer.
You can access information,
benefits advice, and emotional
or psychological support.
45
Having tests for prostate cancer
Tenovus
9th Floor, Gleider House,
Ty Glas Road, Llanishen,
Cardiff CF14 5BD
Freephone helpline
0808 808 1010
Tel 029 2076 8850
Email [email protected]
www.tenovus.org.uk
Provides a variety of
services to people with
cancer and their families,
including counselling and
a freephone cancer helpline.
The Ulster
Cancer Foundation
40–44 Eglantine Avenue,
Belfast BT9 6DX
Freephone helpline
0800 783 3339
Helpline email
[email protected]
Tel 028 9066 3281
Email [email protected]
www.ulstercancer.org
Provides a variety of services
for people with cancer and
their families, including a free
telephone helpline, which is
staffed by specially trained
nurses with experience in
cancer care.
46
Counselling and
emotional support
British Association
for Counselling and
Psychotherapy (BACP)
BACP House,
15 St John’s Business Park,
Lutterworth LE17 4HB
Tel 01455 883 300
Email [email protected]
www.bacp.co.uk and
www.itsgoodtotalk.org.uk
Promotes awareness and
availability of counselling,
and signposts people to
appropriate services.
You can search for a
counsellor on the website.
Other useful organisations
Financial or legal advice
and information
Benefit Enquiry Line
Warbreck House, Warbreck
Hill Road, Blackpool FY2 0YE
Freephone 0800 882 200
Free textphone
0800 243 355
Email [email protected]
www.direct.gov.uk/
disabilitymoney
Provides advice about benefits
and can also help people
complete some disabilityrelated claim packs.
Citizens Advice
Provides free, confidential,
independent advice on a
variety of issues including
financial, legal, housing and
employment. Find contact
details for your local office
in the phone book or at
citizensadvice.org.uk
Find advice for the UK online,
in a variety of languages,
at adviceguide.org.uk
The Law Society
113 Chancery Lane,
London WC2A 1PL
Tel 020 7242 1222
Email info.services@
lawsociety.org.uk
www.lawsociety.org.uk
Represents solicitors in
England and Wales
and can provide details
of local solicitors.
Law Society of Scotland
26 Drumsheugh Gardens,
Edinburgh EH3 7YR
Tel 0131 226 7411
Email
[email protected]
www.lawscot.org.uk
Law Society of
Northern Ireland
96 Victoria Street,
Belfast BT1 3GN
Tel 028 9023 1614
Email [email protected]
www.lawsoc-ni.org
Citizens Advice Scotland
www.cas.org.uk
47
Having tests for prostate cancer
National Debtline
(England, Wales
and Scotland)
Tricorn House,
51–53 Hagley Road,
Edgbaston,
Birmingham B16 8TP
Freephone 0808 808 4000
(Mon–Fri, 9am–9pm,
Sat, 9.30am–1pm)
Email from the website
www.nationaldebtline.co.uk
A national helpline for people
with debt problems. The
service is free, confidential
and independent, and the call
handlers also distribute free
self-help materials.
Personal Finance Society –
‘Find an Adviser’ service
42–48 High Road, South
Woodford, London E18 2JP
Tel 020 8530 0852
Email from the website
www.findanadviser.org
The UK’s largest professional
body for independent financial
advisers. Use the ‘Find an
Adviser’ website to find
qualified financial advisers
in your area.
48
Turn2Us
Hythe House, 200 Shepherd’s
Bush Road, London W6 7NL
Helpline 0808 802 2000
(Mon–Fri, 8am–8pm)
Email [email protected]
www.turn2us.org.uk
Provides an online service to
help people in financial need
in the UK. Its website has
information about the benefits
and grants available from
both statutory and voluntary
organisations. You can often
apply for support directly from
the website.
Unbiased Ltd
117 Farringdon Road,
London EC1R 3BX
Email
[email protected]
www.unbiased.co.uk
Helps people search for details
of local member independent
financial advisers online at
unbiased.co.uk
Other useful organisations
Support for carers
Carers UK
20 Great Dover Street,
London SE1 4LX
Tel 020 7378 4999
Advice line 0808 808 7777
(Wed and Thurs,
10am–12pm and 2–4pm)
Email [email protected]
www.carersuk.org
Offers information and
support to carers. Can put
people in contact with local
support groups. Has national
offices for Scotland, Wales
and Northern Ireland:
Carers Scotland
The Cottage, 21 Pearce
Street, Glasgow G51 3UT
Tel 0141 445 3070
Email
[email protected]
www.carersuk.org/
scotland
Carers Wales
River House, Ynsbridge
Court, Gwaelod-y-Garth,
Cardiff CF15 9SS
Tel 029 2081 1370
Email [email protected]
www.carersuk.org/wales
Carers Northern Ireland
58 Howard Street,
Belfast BT1 6PJ
Tel 028 9043 9843
Email [email protected]
www.carersuk.org/
northernireland
Equipment and advice
on living with disability
Assist UK
Redbank House,
1 Portland Street,
Manchester M1 3BE
Tel 0161 238 8776
Email
[email protected]
www.assist-uk.org
An independent voluntary
organisation with a network
of disabled living centres
throughout the UK. Centres
offer advice and a range
of products and equipment
designed to make life easier
for people who have difficulty
with daily activities.
49
Having tests for prostate cancer
The Blue Badge Scheme
(Department for Transport)
www.direct.gov.uk/
en/DisabledPeople/
MotoringAndTransport/
Bluebadgescheme
Allows drivers of passengers
with severe mobility problems
to park close to where they
need to go. The scheme
is administered by local
authorities that deal with
applications and issue badges.
Applications can be made
through the website and are
sent to your local authority
for a decision.
British Red Cross
44 Moorfields,
London EC2Y 9AL
Tel 0844 871 11 11
Email
[email protected]
www.redcross.org.uk
Provides short-term support
for vulnerable people in the
UK, including therapeutic
care, a medical equipment
loan service and a transport
service. Has offices throughout
the UK.
50
Further
resources
Related Macmillan
information
We hope this booklet has
helped you understand more
about tests for prostate cancer.
If you’ve been diagnosed
with prostate cancer and
need more information
and support, we have the
following booklets:
• Making treatment decisions
• Understanding early
(localised) prostate cancer
• Understanding locally
advanced prostate cancer
• Understanding advanced
(metastatic) prostate cancer
Your doctor or specialist nurse
can advise which of these
would be most useful for you.
We also have information on
different treatments and all
aspects of living with cancer.
Further resources
Visit our website at
macmillan.org.uk or call
the Macmillan Support Line
on 0808 808 00 00 for
more information.
Audio resources
Our high-quality audio
materials, based on our
variety of booklets, include
information about cancer
types, different treatments
and about living with cancer.
To order your free CD,
visit be.macmillan.org.uk
or call 0808 808 00 00.
Useful websites
A lot of information about
cancer is available on the
internet. Some websites
are excellent; others have
misleading or out-of-date
information.
The sites listed here are
considered by nurses
and doctors to contain
accurate information and
are regularly updated.
Macmillan Cancer Support
www.macmillan.org.uk
Find out more about living
with the practical, emotional
and financial effects of
cancer. Our website contains
expert, accurate, up-to-date
information about cancer and
its treatments, including:
• all the information from
our 100+ booklets and
350+ fact sheets
• videos featuring
real-life stories from
people affected by cancer
and information from
medical professionals
• how Macmillan can help,
the services we offer and
where to get support
• how to contact our cancer
support specialists,
including an email form
to send your questions
• local support groups
search, links to other
cancer organisations
and a directory of
information materials
51
Having tests for prostate cancer
• a huge online community
of people affected by
cancer sharing their
experiences, advice
and support.
www.healthtalkonline.org
www.youthhealthtalk.org
(site for young people)
Both websites contain
information about some
cancers and have video and
www.cancer.gov
audio clips of people talking
(National Cancer
about their experiences of
Institute – National Institute
cancer and its treatments.
of Health – USA)
Gives comprehensive
www.macmillan.org.uk/
information on cancer
cancervoices
and treatments.
(Macmillan Cancer Voices)
A UK-wide network that
www.cancer.org
enables people who have or
(American Cancer Society)
have had cancer, and those
Nationwide community-based
close to them such as family
health organisation dedicated
and carers, to speak out about
to eliminating cancer. It aims
their experience of cancer.
to do this through research,
education and advocacy.
www.nhs.uk
(NHS Choices)
www.cancerhelp.org.uk
NHS Choices is the online
(Cancer Research UK)
‘front door’ to the NHS. It is
Contains patient information
the country’s biggest health
on all types of cancer and
website and gives all the
has a clinical trials database.
information you need to make
decisions about your health.
52
Further resources
www.nhsdirect.nhs.uk
(NHS Direct Online)
NHS health information
site for England – covers
all aspects of health,
illness and treatments.
www.nhs24.com
(NHS 24 in Scotland)
www.nhsdirect.wales.nhs.
uk (NHS Direct Wales)
www.n-i.nhs.uk
(Health and Social Care
in Northern Ireland)
www.patient.co.uk
(Patient UK)
Provides people in the UK
with good-quality information
about health and disease.
Includes evidence-based
information leaflets on a wide
variety of medical and health
topics. Also reviews and links
to many health and illnessrelated websites.
www.riprap.org.uk
(Riprap)
Developed especially
for teenagers who have
a parent with cancer.
53
Having tests for prostate cancer
TNM staging
Two of the most commonly used staging systems
are a numbered staging system (see page 27)
and the TNM staging system. The TNM system is
more detailed and is described below.
T stands for Tumour
Doctors put a number next to the ‘T’ to describe the size and
spread of the cancer.
T1 – The tumour is within the prostate gland. It is too small to
be detected during a rectal examination, but may be picked
up through tests such as a PSA test, a biopsy or a transurethral
resection of the prostate gland (TURP) – an operation to make
passing urine easier by removing part of the prostate gland.
There are generally no symptoms with T1 tumours.
T2 – The tumour is still within the prostate gland but is large
enough to be felt during a digital rectal examination, or it
shows up on an ultrasound scan. Often there are no symptoms.
The T2 stage is divided into three further parts:
T2a – The tumour is only in one half of one of the two lobes
that make up the prostate gland.
T2b – The tumour is in more than one half of one of the
lobes in the prostate gland.
T2c – The tumour is in both lobes of the prostate gland.
54
TNM staging
T1 and T2 tumours are known as early (localised)
prostate cancer.
T3 – The cancer has begun to spread through the capsule that
surrounds the prostate gland. The T3 stage is divided into two
further parts:
T3a – The tumour has broken through the capsule but is not affecting the surrounding structures.
T3b – The tumour has spread into the glands that produce semen (seminal vesicles). These are very close to the prostate gland and sit just underneath the bladder.
Bladder
T3 tumour
T2 tumour
Prostate gland
T1 tumour
This diagram compares the size of
T1, T2 and T3 tumours in the prostate gland
55
Having tests for prostate cancer
T4 – The tumour has started to spread into nearby parts of the
body such as the bladder or rectum.
T3 and T4 tumours are known as locally advanced
prostate cancer because the cancer has started to
spread outside the prostate gland and may be invading
surrounding structures.
If the cancer has spread to other parts of the body, it’s known
as metastatic, secondary, or advanced prostate cancer.
Bladder
Prostate
gland
Rectum
Seminal
vesicle
T4 tumour
This diagram shows a T4 tumour that has started to
spread from the prostate gland into surrounding structures
56
TNM staging
At the hospital you might also see the letters ‘N’ and ‘M’.
N stands for Nodes
This describes whether there are any lymph nodes near the
prostate gland that have cancer in them. The ‘N’ may have an
‘X’ or a number written next to it, which gives extra information
about the nodes that were examined:
NX – The lymph nodes were not examined.
N0 – The lymph nodes were examined but no cancer was found.
N1 – Cancer was found in the lymph nodes.
M stands for Metastasis
A metastasis means that the cancer has spread to other parts
of the body, such as the bones.
The ‘M’ may have a number written next to it, which gives extra
information about where the cancer has spread to:
M0 – The cancer has not spread to other parts of the body.
M1 – The cancer has spread to another part of the body,
such as the bones, lung or liver.
Our cancer support specialists on 0808 808 00 00
can tell you more about TNM staging. It’s also
important to talk to your doctor for detailed
information about your situation.
57
Having tests for prostate cancer
Disclaimer
We make every effort to ensure that the information we provide is accurate but it
should not be relied upon to reflect the current state of medical research, which is
constantly changing. If you are concerned about your health, you should consult
a doctor. Macmillan cannot accept liability for any loss or damage resulting from
any inaccuracy in this information or third-party information, such as information
on websites to which we link. We feature real-life stories in all of our articles.
Some photographs are of models.
Thanks
This booklet has been written, revised and edited by Macmillan Cancer Support’s
Cancer Information Development team. It has been approved by our medical
editor, Dr Terry Priestman, Consultant Clinical Oncologist.
With thanks to: Professor Mark Emberton, Professor of Interventional Oncology;
Debra Gray, Uro-oncology Nurse Specialist; Anne Jackson, Macmillan Urology
Nurse Specialist; Professor Jonathon Waxman, Consultant Oncologist;
and the people affected by cancer who reviewed this edition.
Sources
Cancer Research UK. www.cancerresearchuk.org (accessed July 2011).
UpToDate. www.uptodate.com (accessed July 2011).
Hogle W. Prostate Cancer. 2009. Oncology Nursing Society.
Pagana K, Pagana T. Mosby’s Manual of Diagnostic and Lab Tests. Mosby Elsevier.
Transperineal template biopsy and mapping of the prostate. October 2010.
National Institute for Health and Clinical Excellence (NICE).
Vlaeminck-Guillem V, et al. Urinary Prostate Cancer 3 Test: Towards the age of
reason? 2010. Urology. 75: 2.
National Institute for Health and Clinical Excellence (NICE). Prostate cancer:
Diagnosis and treatment. www.nice.org.uk (accessed February 2008).
58
Can you do something to help?
We hope this booklet has been useful to you. It’s just one of our
many publications that are available free to anyone affected by
cancer. They’re produced by our cancer information specialists
who, along with our nurses, benefits advisers, campaigners and
volunteers, are part of the Macmillan team. When people are
facing the toughest fight of their lives, we’re there to support
them every step of the way.
We want to make sure no one has to go through cancer alone,
so we need more people to help us. When the time is right for you,
here are some ways in which you can become a part of our team.
5 ways
you can someone
hElP with
cAncer
Share your cancer experience
Support people living with cancer by telling your story,
online, in the media or face to face.
Campaign for change
We need your help to make sure everyone gets the right support.
Take an action, big or small, for better cancer care.
Help someone in your community
A lift to an appointment. Help with the shopping.
Or just a cup of tea and a chat. Could you lend a hand?
Raise money
Whatever you like doing you can raise money to help.
Take part in one of our events or create your own.
Give money
Big or small, every penny helps.
To make a one-off donation see over.
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Please cut out this form and return it in an envelope (no stamp required) to:
Supporter Donations, Macmillan Cancer Support, FREEPOST LON15851,
89 Albert Embankment, London SE1 7UQ 27530
Cancer is the toughest fight most of us
will ever face. If you or a loved one has
been diagnosed, you need a team of
people in your corner, supporting you
every step of the way. That’s who we are.
We are the nurses and therapists helping you through
treatment. The experts on the end of the phone.
The advisers telling you which benefits you’re entitled to.
The volunteers giving you a hand with the everyday
things. The campaigners improving cancer care.
The community supporting you online, any time.
The fundraisers who make it all possible.
You don’t have to face cancer alone.
We can give you the strength to get through it.
We are Macmillan Cancer Support.
Questions about living with cancer?
Call free on 0808 808 00 00 (Mon–Fri, 9am–8pm)
Alternatively, visit macmillan.org.uk
Hard of hearing? Use textphone
0808 808 0121, or Text Relay.
Non-English speaker? Interpreters available.
© Macmillan Cancer Support, 2012. 1st edition. MAC13704.
Next planned review 2014. Macmillan Cancer Support, registered
charity in England and Wales (261017), Scotland (SC039907) and
the Isle of Man (604).
Printed using sustainable material. Please recycle.