Metro Urology

Prostate Cancer: The Condition, its Causes and Effects

The prostate is a gland of the male reproductive system. This small, walnut-sized organ, located below the bladder and behind the base of the penis, produces semen. The prostate surrounds the urethra, the tube that carries urine from the bladder to the outside of the body and is the connecting point for the reproductive and urinary systems.

Prostate cancer is a major health concern among men age 50 and older. Prostate cancer is the second most common cancer (behind skin cancer) in American men and outnumbers breast cancer in the number of cases diagnosed each year1. In 2002, approximately 189,000 new cases of prostate cancer will be diagnosed and an estimated 30,200 men are expected to die of this disease, according to the American Cancer Society2. One out of every nine American men will develop prostate cancer at some time in life3. Since 1980, the incidence of prostate cancer has risen steadily to become the second most common cause of cancer-related deaths (13% of male cancer-related deaths4) among men, exceeded only by lung cancer5. This increase in prostate cancer cases has led to heightened awareness of the disease and improved diagnostic and treatment methods.

We don’t truly know the cause of prostate cancer but there are specific risk factors that can be identified. Men age 50, a history of prostate cancer in close relative, and African-American men6 are at the greatest risk. Men who eat diets high in saturated fat (meat, dairy fat) seem to have an increased risk of prostate cancer (and other diseases). Other risk factors such as environment, occupation, obesity, sun exposure, vasectomy, alcohol consumption, and smoking have —no consistent relationship to the development of prostate cancer.

If diagnosed early, prostate cancer is treatable and most often cured. Over all, 89% of men diagnosed with prostate cancer survive at least five years, and 63% survive at least 10 years7. The five-year relative survival rate for men with prostate cancer confined to the prostate is 100%.

Diagnosis

There are no symptoms of early-stage prostate cancer. A prostate-specific antigen (PSA) test and digital rectal exam (DRE) are commonly used by physicians to detect prostate cancer. PSA is a protein produced by prostate cells that reside in the blood. In general, a PSA level of 0 to 3 (ng/mL) is normal while a level of more than 10 (ng/mL) is high and a value between four and ten ng/mL is considered borderline8. However, because conditions such as benign prostatic hyperplasia (an enlarged prostate) can contribute to elevated PSA levels, additional tests are necessary. During a DRE, a doctor inserts a gloved, lubricated finger into the patient’s rectum to feel for any irregular or abnormally firm area that might be cancerous. To ensure early detection, men age 50 years and over should receive an annual prostate check, including a digital rectal exam (DRE) and a prostate-specific antigen (PSA) blood test.

If either a DRE or PSA is abnormal, an ultrasound and biopsy is the next step in making a diagnosis. During this procedure, an ultrasound probe is placed into the rectum and pictures are taken of the prostate and the prostate is examined carefully to look for abnormalities that would suggest a cancer. Biopsies are taken of all areas of the prostate.. The biopsies are taken by placing a small needle through the ultrasound and the rectal wall directly into the prostate. The tissue samples obtained are sent to the pathologist who reviews the tissue under a microscope looking for cancerous cells.

Men with advanced prostate cancer may experience symptoms such as a weak or interrupted urine flow, increased frequency, pain or burning during urination, blood in the urine, or dull, persistent pain in the back, hips or pelvis. Usually, men with advance disease will also have elevated PSA levels and abnormal findings on the rectal exam..

Grading

To give an estimate of how fast a cancer is growing, a grading system called the Gleason System is used by physicians. The Gleason score is determined by the pathologist when he views the cancerous cells under the microscope and is determined by how abnormal the individual cells appear and how groups of cancerous cells clump together. The more irregular the individual cells appear and the more irregularly they clump together, the higher the Gleason score will be. The Gleason score is rated on a 2-10 scale. Gleason scores of two through four are considered slow-growing, five and six are considered intermediate, and scores of seven to 10 are considered faster growing and more aggressive. The higher the score, the more likely the cancer will grow and spread rapidly9.

Staging

If a prostate biopsy finds cancer, an attempt is made to determine how far the cancer has advanced. Staging is a standardized method by which the extent of a tumor’s growth is defined. There are four categories, ranging from T1 (least severe) to T4 (most severe) used to describe the spread of a tumor. The stage of cancer is very important in determining the most appropriate treatment option.

• Stage 1 is when a cancer tumor that is not felt during a DRE but the PSA is elevated and cancer cells are found in a biopsy specimen.
• Stage 2 means that a doctor can feel a prostate abnormality on DRE and a biopsy proves there is cancer in the prostate. The cancer still lies completely within the prostate gland.
• Stage 3 is a cancer that has spread beyond the prostate to the fat around the prostate, the bladder, or the seminal vesicles.
• Stage 4 means that it has spread beyond the prostate10 to the lymph nodes, bone, liver, or other areas in the body.

The stage of tumor cannot be determined completely on DRE, PSA and biopsy alone, but the selection of further tests for determining stage is based on a patient’s PSA and DRE results and Gleason score11. Because prostate cancer is a slow growing tumor, many men with favorable findings do not need further testing to determine the stage but can be reassured that their cancers are very likely to still be contained to the prostate itself. Men with PSA >10, large and irregular prostates, and Gleason scores > 7 most likely will need further testing with an x-ray of the bones and possibly a CT scan to determine if the tumor has spread.

Treatment

Once a cancer is diagnosed, you and your physician will need to discuss treatment. Your surgeon will help you determine which treatment option will serve you best. The standard forms of treatment are listed here.

Watchful Waiting: If it has been determined that the cancer is in a very early stage, is expected to grow slowly and is not causing any symptoms, a “watch and wait” approach may be recommended. This method of monitoring the tumor’s growth allows the patient to defer treatment. This approach is most often used for elderly patients with slow-growing tumors. Treatment may become necessary, and most often hormonal treatment is then chosen. Some physicians may also recommend this for men whose medical condition may make it difficult for them to have other forms of treatment.

Read more about Watchful Waiting.

Hormonal Ablation: Hormones can be used to slow the growth of the cancer, and can be used as primary treatment or as a secondary treatment for men whose cancers have returned. Hormone treatment is also used in combination with other forms of treatment if necessary.

Read more about Hormonal Ablation.

Chemotherapy: This type of treatment is most often used for patients with very aggressive cancers or cancers that have returned after initial treatment. Chemotherapy is delivered by an Medical Oncologist.

Radical Prostatectomy: The most common prostate cancer treatment – the “gold standard” – is the radical prostatectomy. A radical prostatectomy surgically removes the entire prostate, seminal vesicles and some surrounding tissue. This surgical procedure is highly effective, but it is also the most invasive treatment. A standard “open” radical prostatectomy involves a hospital stay of several days and a recovery period of 6-12 weeks. A laparoscopic robot-assisted prostatectomy (DaVinci) allows a surgeon to use smaller incisions and may help decrease recovery time.

What to expect after a Radical Prostatectomy.

Radiation Therapy: Radiation therapy uses high-energy rays or permanent implantable radioactive “seeds” to destroy cancer cells. External beam radiation generally requires treatment five days a week for six to eight weeks. Brachytherapy involves implanting radioactive pellets into the prostate that give off radiation for several weeks to months.

Cryosurgery: Cryosurgery destroys cancer by freezing it. Under anesthesia, small probes are placed through the skin and into the prostate. A freezing agent is passed through the probes and the prostate is carefully frozen.

Read more about Cryosurgery.

References:

American Cancer Society Web site, “The Prostate Cancer Resource Center: Key Statistics” and “The Breast Cancer Resource Center: Key Statistics.” www.cancer.org. December 20, 1998.
American Cancer Society, “The Prostate Cancer Resource Center: Key Statistics.” www.cancer.org. December 20, 1998.
American Foundation for Urological Disease, “Treatment Options for Localized Prostate Cancer.” www.afud.org.
American Cancer Society, “The Prostate Cancer Resource Center: Key Statistics.” www.cancer.org. December 20, 1998.
American Cancer Society, “The Prostate Cancer Resource Center: Key Statistics.” www.cancer.org. December 20, 1998.
American Foundation for Urological Disease, “Treatment Options for Localized Prostate Cancer.” www.afud.org.
American Cancer Society, “The Prostate Cancer Resource Center: Key Statistics.” www.cancer.org. December 20, 1998.
American Cancer Society, “The Prostate Cancer Resource Center: Detection and Symptoms.” www.cancer.org. December 20, 1998.
American Cancer Society Web site, “Cancer Facts and Figures 1999: Selected Cancers” www.cancer.org. December 20, 1998.
American Cancer Society, “The Prostate Cancer Resource Center: Key Statistics.” www.cancer.org. December 20, 1998.
American Cancer Society, “The Prostate Cancer Resource Center: Detection and Symptoms.” www.cancer.org. December 20, 1998.

Helpful PDF downloads:

After Radical Postatectomy Surgery Instructions
Dietary Instructions for Radical Retropubic
Preparing for Radical Retropubic Prostatectomy
Prostate Radioactive Seed Implant