Prostate Cancer

Prostate cancer is the most common cancer among men, after skin cancer. The disease is almost always successfully treated when diagnosed before it spreads, or metastasizes, out of the prostate.

Those at greatest risk for developing prostate cancer include men over the age of 40 and especially African American men, and men with a family history of the disease.

Cancer of the prostate usually spreads very slowly with few, if any, symptoms before it reaches an advanced stage. It’s known to progress more rapidly in the 40 to70 age range as opposed to patients in the late 70 and older. Routine screenings significantly decrease a man’s risk of developing an untreatable prostate cancer.

If the disease is not diagnosed in an early stage, it may spread to the lymph nodes bones, bladder, rectum or other organs.

The prostate is a male sex gland. About the size of a walnut, it sits between the bladder and rectum and surrounds the proximal portion of the urethra. The prostate produces fluid that nourishes sperm and forms part of semen’s contents, which is expelled during ejaculation.

To function effectively, the prostate gland needs male hormones. The testicles produce testosterone, and small amounts of other male hormones are produced by the adrenal glands.

Symptoms of prostate cancer often mimic those of a variety of health problems, including benign prostate hyperplasia (BPH) and prostatitis.

BPH is an abnormal growth of benign prostate cells that results in an enlarged prostate. The condition is common in aging males and may produce symptoms similar to those of advanced prostate cancer, including urinary problems. It is a normally a harmless condition, and does not lead to prostate cancer.

Prostatitis, also a benign and treatable condition, is inflammation of the prostate caused typically by a bacterial infection. It can cause pain and urinary difficulties.

When a male has prostate cancer, he may experience a variety of urinary problems, as the growth blocks urine flow through the urethra leading to the following:

• Inability to urinate.
• Frequent urination, particularly at night.
• Difficulty starting urination or holding back urine.
• A weak urine stream.
• Painful or burning urination.

Other symptoms that can be caused by prostate cancer include the following:

• Blood in urine or semen.
• Painful ejaculation.
• Frequent pain or stiffness in the lower back, hips, pelvis, and upper thighs.
• Significant weight loss.

Patients with prostate cancer rarely develop symptoms in the early, most curable stages of the disease, which is why regular screening is so important.

Prostate cancer is often diagnosed via a routine screening before symptoms occur. These screening methods help detect the disease early and lead to treatment resulting in a complete cure.

As part of an annual exam, the doctor feels the prostate for hard or lumpy areas, which could indicate the presence of nodule, firmness or asymmetry of the prostate. If any abnormalities are found, the doctor will conduct further tests.

A blood test is typically used to screen for prostate cancer. Levels of the prostate-specific antigen (PSA) are measured. PSA is an enzyme, produced by prostate tissue, that dissolves the proteins that cause semen to clump. Elevated PSA levels may indicate prostate cancer, but they can also rise due to other factors like sexual activity, inflammation of the prostate and increased size. PSA screening does have some drawbacks, however, as false-positives (indicating cancer when there is none) and false-negatives (missing an existing cancer) do occur. Once cancer is diagnosed, PSA levels are closely monitored following treatment and are very useful in determining a prognosis for the patient.

Although PSA has the highest predictive value for prostate ca, use of this test alone without DRE may lead to a misdiagnosis of the ca in up to 25% of the cases.Thus the most effective way to detect early prostate ca is a combination of a PSA and DRE.

If either the DRE or the PSA test signal the possibility of prostate cancer, further tests are performed. These may include:

• Urine test to check for blood or infection.
• Transrectal ultrasound (TRUS) to examine any suspicious nodules.
• Biopsy – removal of prostate tissue samples for testing.
• Abdominal CAT scan and bone scan when PSA levels are higher than 10 and the Gleason score (measurement of cancer’s aggressiveness) is high.
• A cystoscopy to look into the urethra,prostate and bladder using a thin, lighted tube especially when blood in the urine or difficulties urinating are present.

African Americans and those with a family history of prostate cancer should consider beginning the screening process before age 40 and possibly twice a year. Others should have an annual PSA blood test after the age of 40.

Once prostate cancer is diagnosed, the doctor will determine its stage in order to advise the patient of treatment options and the prognosis.

Various blood and imaging tests are performed for this purpose.

• Stage refers to the tumor’s location and how far, if at all, the cancer has spread.

• Stage A or T1 tumors have not spread outside the prostate and cannot be felt during a physical exam or seen on an ultrasound.

• Stage B or T2 tumors are still localized in the prostate, but they are large enough to be felt and detected by a blood test.
• Stage B1N or T2a tumors involve half of a lobe or less.
• B1 or T2b tumor involves more than half of a lobe.but not both lobes.
• B2 or T2c tumor involves both lobes.
• Stage C1 or T3 tumors indicate the cancer has spread outside the prostate to nearby organs and tissues, e.g. seminal vesicles.
• T4 or C2 tumor is fixed or invades adjacent structures other than seminal vesicles.
• Stage D or N+ or M+ tumors indicate that the cancer has entered the bloods tream and lymph nodes (N+) and traveled to bones and other organs (M+).
• Grade refers to how malignant the cancer cells appear, which affects how fast they may grow and spread. Tumors are graded with a Gleason score based on the pattern of the tumor (1 to 10) A low Gleason score means a lower graded tumor that is less likely to spread quickly.Gleason total of 7 or greater is predictive of a poorer prognosis.
• Other factors that help determine a prognosis include:

• PSA levels. In cases where the man’s PSA levels are more than 20 mg/ml, there is a higher concern for metastasis. Those patients with PSA levels lower than 20 mg/ml typically are localized.Naturally a PSA of 0 after treatment has a good prognosis.
• Recurring cancer. Most cases of recurring cancer involve metastasized tumors that seem to be more aggressive than the initial tumors.

There are four main forms of treatment for prostate cancer. A doctor may recommend one or a combination of the following treatment options.

• Watchful Waiting. Because prostate cancer usually grows slowly – especially in the elderly – and aggressive treatment often involves risks and negative side effects, elderly men with localized tumors may not benefit from treatment.Watchful waiting is not recommended for young men or those with a long life expectancy. Aggressive treatment is usually recommended for younger otherwise healthy men (40 to 70). Prostate cancer seems to be more aggressive in younger patients, and life expectancy of the patient is often considered in determining the treatment approach.

• Surgery. If the cancer has not spread from the prostate, a prostatectomy – surgical removal of the prostate and nearby lymph nodes – may be recommended.

An incision is made in either the abdomen or perineum (between the scrotum and anus) to remove the prostate. Lymph nodes are typically removed via the abdomen.

• Side Effects

• A prostatectomy may cause impotence and sometimes causes urinary incontinence.
• With small tumors, nerve-sparing surgery can be performed to help minimize or eliminate these side effects.

• Radiation Therapy

Radiation therapy is a localized treatment to damage the cancer cells with radioactive rays so they stop growing and dividing. Radiation can be performed using two methods:

• External radiotherapy – radiation is administered via a machine aimed at the pelvic area.
• Brachytherapy – radioactive material is placed into or near the prostate tumor.

When prostate cancer is detected early and confined to the prostate, brachytherapy can be as effective as a prostatectomy although long term results are not available yet. In advanced stages – especially when bony metastasis has occurred – relief of bony pain is noted with external beam radiation.

• Side Effects

• Radiation may cause fatigue, diarrhea, and frequent or uncomfortable urination.
• With external radiotherapy treatment, the skin may become red, dry, and tender.
• Men may also experience hair loss in the pelvic area.
• In some cases, men suffer impotence.

• Hormone Therapy

Hormone therapy prevents the cancer cells from receiving the male hormones required to grow. This systemic treatment affects all prostate cancer cells, even those that have spread to other areas of the body.

• Orchiectomy, removal of the testicles, eliminates the body’s source of testosterone.
• A luteinizing hormone-releasing hormone (LHRH) agonist prevents the testicles from producing testosterone (Called a medical orchiectomy).
• Estrogen also stops the testicles from producing testosterone.
• Antiandrogens block the effect of any male hormones that the adrenal glands may produce.

Hormone therapy may causes several side effects, including:

• Decreased sexual desire.
• Impotence.
• Hot flashes.
• Swollen or tender breasts.

After being treated for prostate cancer, a man should continue seeing his doctor regularly. These follow-up visits will help determine if and when the prostate cancer returns or progresses. Follow-ups typically involve PSA tests and a DRE. If there is a concern for metastasis imaging studies are employeed.

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