Prostate cancer and BRCA gene changes: risk, testing and what it means

BRCA1 and BRCA2 are genes everyone carries. Cancer Research UK explains that people who inherit a faulty version of BRCA2 have an increased risk of several different cancers. Most prostate cancers are not linked to an inherited faulty gene, and Cancer Research UK stresses that these inherited genes are rare and account for only a small number of cancers.

For prostate cancer the evidence is strongest for BRCA2. Cancer Research UK says there is strong evidence that men with BRCA2 gene changes are more likely to develop fast-growing prostate cancer, with research estimating a risk between 2 and 5 times higher than in the general population. It adds that the risk may also increase with faulty BRCA1 genes, but that more research is needed to understand the link.

A BRCA change is an inherited trait, so it can be passed down in families from either parent. Men and women can carry and pass on the same change, which is why a family history of breast or ovarian cancer on either side can be relevant to a man.

The NHS lists several things that can raise the chance of prostate cancer: being over 50, being from a Black African or African Caribbean ethnic background, and having a family history of prostate cancer. It also names a close relative who has had pancreatic, breast or ovarian cancer, particularly at a young age, because prostate cancer is sometimes caused by the same inherited genes, including a faulty version of BRCA2.

Cancer Research UK also notes that your risk is higher if you have a close relative who has had prostate cancer. If you recognise a pattern like this in your family, it is worth writing down who was affected, which cancer they had and roughly how old they were, then raising it with your GP. A GP can discuss whether a referral for genetic assessment is appropriate under local NHS criteria.

The NHS says prostate cancer often has no symptoms at first. When symptoms occur they can include difficulty starting to pee or straining, a weak flow, stop-start peeing, needing to go urgently or often, feeling that your bladder has not emptied and needing to pee at night. Other possible symptoms include erection problems, blood in urine or semen, and lower back pain or weight loss without trying, which may point to advanced cancer. These symptoms do not always mean prostate cancer, because an enlarged prostate can cause similar problems.

The NHS advises seeing a GP if you have trouble peeing or other symptoms, if you are worried about your risk, or if you are over 40 and genetic tests have shown that you have a faulty BRCA2 gene. It also says PSA blood tests are not routinely offered if you do not have symptoms or have not had genetic tests that show a faulty BRCA2 gene, which means a known BRCA2 result is one of the situations where a conversation about PSA testing is appropriate.

At a GP appointment the NHS says you may be asked about your health and family history of prostate, pancreatic, ovarian or breast cancer, and the GP may offer a rectal examination and a PSA blood test. The NHS explains that a PSA test cannot tell you whether you have prostate cancer, but can show if there is a problem with the prostate. Results usually take 1 to 2 weeks, and a higher than normal result leads to further tests.

If you are referred to a specialist, the NHS says you will have an MRI scan, and may be offered a biopsy, where a small needle takes a tissue sample to check for cancer cells. Results can take a few weeks, and if you are still waiting after 2 weeks you can call the hospital or your GP. Further scans such as CT, MRI, PET or a bone scan may follow to work out how far the cancer has spread.

The NHS says prostate cancer does not always need treatment, and that options include monitoring (watchful waiting or active surveillance), surgery to remove the prostate, radiotherapy, hormone therapy and, if the cancer has spread, chemotherapy. The choice depends on how the cancer is behaving and on your own priorities and health.

Because BRCA2 is linked to faster-growing cancer, doctors may take the genetic result into account when discussing monitoring and treatment. For advanced disease, both Cancer Research UK and Prostate Cancer UK name olaparib, a targeted cancer drug, among the options that can be used when hormone therapy stops working so well. Whether it is suitable for you is a decision for your oncology team.

If a BRCA change is found in one person, relatives may wish to find out whether they carry it too. The NHS suggests speaking to a GP if you are worried about your risk, even if you have no symptoms, and notes that symptoms of prostate cancer do not always appear until the cancer has grown or spread. Cancer Research UK also lists ways of reducing risk in its risks and causes page, and these apply to everyone whether or not a gene change is present.

Clinical genetics services in the NHS decide who is eligible for gene testing, so family members should ask their GP rather than seek tests directly. Some people choose to pay privately for genetic testing; if you consider this, ask what the result would mean, who will interpret it and what follow-up you would get.

For most people the route runs from GP to an urgent specialist referral, MRI and possibly biopsy, then a multidisciplinary team that agrees the plan. Some people choose a private urologist or oncologist for speed or a second opinion. Whichever route is used, the genetic result, the grade and stage of the cancer and your wishes should shape the plan, and it can help to ask for results to be shared between teams.