PROSTATE CANCER

Prostate cancer is the abnormal growth of cells in a man's prostate gland. The prostate sits just below the bladder. In young men, the prostate is about the size of a walnut, but usually grows larger as one grows older. The function of the prostate is to store and secrete a slightly alkaline fluid, milky or white in appearance, that usually constitutes 20-30% of the volume of the semen along with spermatozoa and seminal vesicle fluid. The alkalinity of semen helps neutralize the acidity of the vaginal tract, prolonging the lifespan of sperm. Prostate cancer is common in men older than 65. It usually grows slowly and can take years to grow large enough to cause any problems.

Prostate cancer is the most common cancer in American men other than skin cancers. About 1 man in 6 will be diagnosed with prostate cancer during his lifetime. Prostate cancer comprises about 27% of all cancers diagnosed in men. This cancer is the second leading cause of cancer death in American men, behind only lung cancer. The American Cancer Society estimates that for the United States in 2010, about 217,730 new cases of prostate cancer were diagnosed and that about 32,050 men died of prostate cancer.

Prostate cancer tends to develop in men over the age of fifty and although it is one of the most prevalent types of cancer in men, many never have symptoms, undergo no therapy, and eventually die of other causes. This is because cancer of the prostate is, in most cases, slow-growing, symptom-free, and since men with the condition are older they often die of causes unrelated to the prostate cancer, such as heart/circulatory disease, pneumonia, other unconnected cancers, or old age. About 2/3 of cases are slow growing, the other third more aggressive and fast developing.

Early prostate cancer usually causes no symptoms. Often it is diagnosed by an elevated prostate-specific antigen (PSA) noticed during a routine checkup. Sometimes, however, prostate cancer does cause symptoms, often similar to those of diseases such as benign prostatic hyperplasia. These include frequent urination, nocturia (increased urination at night), difficulty starting and maintaining a steady stream of urine, hematuria (blood in the urine), and dysuria (painful urination). A nodule in the prostate gland may be felt by a medical practitioner during a rectal examination.

In the later stages, prostate cancer can spread locally into the surrounding tissue or the nearby lymph nodes, called the pelvic nodes. The cancer then can spread even farther (metastasize) to other areas of the body. Symptoms of metastatic disease include fatigue, malaise, and weight loss. The doctor during a rectal examination can sometimes detect local spread into the surrounding tissues. That is, the physician can feel a hard, fixed (not moveable) tumor extending from and beyond the gland. Prostate cancer usually metastasizes first to the lower spine or the pelvic bones (the bones connecting the lower spine to the hips), thereby causing back or pelvic pain. The cancer can then spread to the liver and lungs. Metastases (areas to which the cancer has spread) to the liver can cause pain in the abdomen and jaundice (yellow color of the skin) in rare instances. Metastases to the lungs can cause chest pain and coughing.

The cause of prostate cancer is unknown, but the cancer is not thought to be related to benign prostatic hyperplasia (BPH). The risk (predisposing) factors for prostate cancer include advancing age, genetics (heredity), hormonal influences, and such environmental factors as toxins, chemicals, and industrial products. The chances of developing prostate cancer increase with age. Thus, prostate cancer under age 40 is extremely rare, while it is common in men older than 80 years of age. As a matter of fact, some studies have suggested that among men over 80 years of age, 50%-80% of them may have prostate cancer. More than 80% of prostate cancers are diagnosed in men older than 65 years of age.

African-American men are 1.6 times more likely than white men to develop prostate cancer. They are also 2.4 times more likely to die from their disease as compared to white men of a similar age. These differences in diagnosis and death rates are, however, more likely to reflect a difference in factors such as environmental exposure, diet, lifestyle, and health-seeking behavior rather than any racial susceptibility to prostate cancer. Recent studies indicate that this disparity is progressively decreasing with chances of complete cure in men undergoing treatment for organ-confined prostate cancer (cancer that is limited to within the prostate without spread outside the confines of the prostate gland), irrespective of race.

Genetics (heredity), as just mentioned, plays a role in the risk of developing a prostate cancer. Prostate cancer is more common among family members of individuals with prostate cancer. This risk may be two to three times greater than the risk for men without a family history of the disease. Earlier age at diagnosis (<60 years) in a first-degree relative (father or brother) and disease affecting more than one relative also increases the risk for developing prostate cancer.

Testosterone, the male hormone produced by the testicles, directly stimulates the growth of both normal prostate tissue and prostate cancer cells. Not surprisingly, therefore, this hormone is thought to be involved in the development and growth of prostate cancer. The important implication of the role of this hormone is that decreasing the level of testosterone should be (and usually is) effective in inhibiting the growth of prostate cancer.

Recent evidence has suggested that sexually transmitted infections are risk factors for developing prostate cancer. Men with a history of sexually transmitted infections have a 1.4 times greater chance of developing prostate cancer as compared men without this history.

Although still unproven, environmental factors, such as cigarette smoking and diets that are high in saturated fat, seem to increase the risk of prostate cancer. There is also a suggestion that obesity leads to an increased risk of having more aggressive, larger prostate cancer, which results in a poorer outcome after treatment. Additional substances or toxins in the environment or from industrial sources might also promote the development of prostate cancer, but these have not yet been clearly identified. Geographical influences also seem to play a role in the development of prostate cancer with men living in the Scandinavian and North American countries being at a higher risk for the disease as compared to those residing in Asian countries.

There is no proven relationship between the frequency of sexual activity and the chances of developing prostate cancer. In fact some studies suggest that regular sexual activity may decrease the chances of developing prostate cancer.

The most commonly-used screening tests for prostate cancer are the digital rectal examination and prostate-specific antigen (PSA) blood test. Prostate cancer usually is suspected initially because of an abnormality of one or both of these two screening tests. The PSA level is usually higher than 4ng/mL in people with prostate cancer, whereas lower levels are found in persons without the cancer. Large prostate size, infection and inflammation are other reasons why the PSA may be elevated. The PSA, therefore, is valuable as a screening test for prostate cancer but other tests are needed to confirm the diagnosis.

The American Urological Association (AUA) issued their latest guidelines for prostate cancer in 2009. According to these, men at the age of 40 should be offered a baseline PSA test and a prostate exam (digital rectal exam) to ascertain the risk of prostate cancer. Subsequent screening and tests may be performed according to the findings on this initial evaluation and an individual's risk of getting the disease on the basis of other factors such as race, ethnicity, and family history of prostate cancer.

In interpreting the PSA test results, one of the important factors that need to be considered is the rate at which the PSA value has increased over time on repeated measurements (PSA velocity). Results between 4 and 10 are considered borderline. These borderline values are interpreted in the context of the patient's age, symptoms, signs, family history, and changes in the PSA levels over time. Results higher than 10 are considered abnormal, suggesting the possibility of prostate cancer. It has been shown that the higher the PSA value, the more likely the diagnosis of prostate cancer. Moreover, the level of PSA tends to increase when the cancer has progressed from organ-confined prostate cancer to local spread to distant (metastatic) spread. Very high values, such as 30 or 40 and over, are usually caused by prostate cancer.

Prostate cancer is diagnosed from the results of a biopsy of the prostate gland. If the digital rectal exam of the prostate or the PSA blood test is abnormal, a prostate cancer is suspected. A biopsy of the prostate is usually then recommended. The biopsy is done from the rectum (trans-rectally) and is guided by ultrasound images of the area. Multiple pieces are taken by sampling the base, apex, and mid gland on each side of the gland. More cores may be sampled to increase the yield, especially in larger glands. An important assessment that the pathologist makes form the specimen is the grade (Gleason's score) of the tumor. This indicates how different the cancer cells are from normal prostate tissue. Grade gives an indication of how fast a cancer is likely to grow and has very important implications on the treatment plan and the chances of cure after treatment. A Gleason score of 6 is supposed to indicate low-grade (less aggressive) disease while that of 8-10 demonstrates high grade (more aggressive) cancer; 7 is regarded as somewhere in between these two.

The staging of a cancer refers to determining the extent of the disease (where in the body have the prostate cancer cells spread). Once a prostate cancer is diagnosed on a biopsy, additional tests are done to assess whether the cancer has spread beyond the gland.

Radionuclide bone scans can determine if there is a spread of the tumor to the bones. The radioactive substance highlights areas where the cancer has affected the bones. This test is usually reserved for men with prostate cancer who have deep bone pain or a fracture or who have biopsy findings and high PSA values (>10-20 ng/ml) suggestive of advanced or aggressive disease.

Additionally, CT scans  and MRIs (magnetic resonance imaging) can determine if the cancer has spread to adjacent tissues or organs such as the bladder or rectum or to other parts of the body such as the liver or lungs. Newer scanning using a method called PET scan can sometimes help to detect hidden locations of cancer that has spread to various areas of the body.

Cystoscopy is usually performed in selected situations. A thin, flexible, lighted tube with a tiny camera on the end is inserted through the urethra to the bladder. The camera transmits images to a video monitor. This may show whether the cancer has spread to the urethra or bladder and may be utilized to take a biopsy from these organs.

The stages of prostate cancer are categorized as follows:

Stage I (or A): The cancer cannot be felt on a digital rectal exam, and there is no evidence that it has spread outside the prostate. These are often found incidentally after surgery for an enlarged prostate

Stage II (or B): The tumor is larger than a stage I and can be felt on a digital rectal exam. There is no evidence that the cancer has spread outside the prostate. These are usually found on a biopsy when a man has an elevated PSA level

Stage III (or C): The cancer has invaded other tissues neighboring the prostate

Stage IV (or D): The cancer has spread to lymph nodes or to other organs

For men diagnosed with a very early stage prostate cancer, treatment may not be necessary right away. Some men may never need treatment. Instead, doctors sometimes recommend watchful waiting, which is sometimes called active surveillance. In watchful waiting, regular follow-up blood tests, rectal exams and possibly biopsies may be performed to monitor progression of your cancer.

If tests show your cancer is progressing, you may opt for a prostate cancer treatment such as surgery or radiation. Watchful waiting may be an option for cancer that isn't causing symptoms, is expected to grow very slowly and is confined to a small area of the prostate. Watchful waiting may also be considered for a man who has another serious health condition or an advanced age that makes cancer treatment more difficult. Watchful waiting carries a risk that the cancer may grow and spread between checkups, making it more difficult to treat.

Radiation therapy

Radiation therapy uses high-powered energy to kill cancer cells. Prostate cancer radiation therapy can be delivered in two ways:

Radiation that comes from outside of your body (external beam radiation). During external beam radiation therapy, you lie on a table while a machine moves around your body, directing high-powered energy beams, such as X-rays, to your prostate cancer. You typically undergo external beam radiation treatments five days a week for several weeks.

Radiation placed inside your body (brachytherapy). Brachytherapy involves placing many rice-sized radioactive seeds in your prostate tissue. The radioactive seeds deliver a low dose of radiation over a long period of time. Your doctor implants the radioactive seeds in your prostate using a needle guided by ultrasound images. The implanted seeds eventually stop giving off radiation and don't need to be removed.

Side effects of radiation therapy can include painful urination, frequent urination and urgent urination, as well as rectal symptoms, such as loose stools or pain when passing stools. Erectile dysfunction can also occur.

Hormone therapy

Hormone therapy is treatment to stop your body from producing the male hormone testosterone. Prostate cancer cells rely on testosterone to help them grow. Cutting off the supply of hormones may cause cancer cells to die or to grow more slowly. Hormone therapy options include:

Medications that stop your body from producing testosterone. Medications known as luteinizing hormone-releasing hormone (LH-RH) agonists prevent the testicles from receiving messages to make testosterone. Drugs typically used in this type of hormone therapy include leuprolide (Lupron, Eligard,), goserelin (Zoladex), triptorelin (Trelstar), histrelin (Vantas) and degarelix (Firmagon).

Medications that block testosterone from reaching cancer cells. Medications known as anti-androgens prevent testosterone from reaching your cancer cells. Examples include bicalutamide (Casodex), flutamide, and nilutamide (Nilandron). These drugs typically are given along with an LH-RH agonist or given before taking an LH-RH agonist.

Surgery to remove the testicles (orchiectomy)

Removing your testicles reduces testosterone levels in your body. The effectiveness of orchiectomy in lowering testosterone levels is similar to that of hormone therapy medications, but orchiectomy may lower testosterone levels more quickly.

Hormone therapy is used in men with advanced prostate cancer to shrink the cancer and slow the growth of tumors. In men with early-stage prostate cancer, hormone therapy may be used to shrink tumors before radiation therapy. This can make it more likely that radiation therapy will be successful. Hormone therapy is sometimes used after surgery or radiation therapy to slow the growth of any cancer cells left behind.

Side effects of hormone therapy may include erectile dysfunction, hot flashes, loss of muscle and bone mass, reduced sex drive, and weight gain. Hormone therapy also increases the risk of heart disease and heart attack. Doctors believe long-term use of hormone therapy and the low hormone levels that result may lead to cardiovascular problems.

Surgery to remove the prostate

Surgery for prostate cancer involves removing the prostate gland (radical prostatectomy), some surrounding tissue and a few lymph nodes. Ways the radical prostatectomy procedure can be performed include:

Making an incision in your abdomen. During retropubic surgery, the prostate gland is taken out through an incision in your lower abdomen. Compared with other types of prostate surgery, retropubic prostate surgery may carry a lower risk of nerve damage, which can lead to problems with bladder control and erections.

Making an incision between your anus and scrotum. Perineal surgery involves making an incision between your anus and scrotum in order to access your prostate. The perineal approach to surgery may allow for quicker recovery times, but this technique makes removing the nearby lymph nodes and avoiding nerve damage more difficult.

Laparoscopic prostatectomy. During a laparoscopic radical prostatectomy, several small incisions are made in the abdomen. The doctor inserts special surgical tools through the incisions, including a long, slender tube with a small camera on the end (laparoscope). The laparoscope sends images to a monitor in the operating room. The surgeon watches the monitor as he or she guides the instruments. Laparoscopic surgery may offer a shorter hospital stay and quicker recovery than traditional surgery.

Using a robot to assist with surgery. During robotic laparoscopic surgery, the instruments are attached to a mechanical device (robot). The surgeon sits at a console and uses hand controls to guide the robot to move the instruments. Using a robot during laparoscopic surgery may allow the surgeon to make more precise movements with surgical tools than is possible with traditional laparoscopic surgery.

Radical prostatectomy carries a risk of urinary incontinence and erectile dysfunction. Ask your doctor to explain the risks you may face based on your situation, the type of procedure you select, your age, your body type and your overall health.

Freezing prostate tissue

Cryosurgery or cryoablation involves freezing tissue to kill cancer cells. During cryosurgery for prostate cancer, small needles are inserted in the prostate using ultrasound images as guidance. A very cold gas is placed in the needles, which causes the surrounding tissue to freeze. A second gas is then placed in the needles to reheat the tissue. The cycles of freezing and thawing kill the cancer cells and some surrounding healthy tissue. Original attempts to use cryosurgery for prostate cancer resulted in unacceptable side effects. Doctors hope newer technologies will make cryosurgery safer.

Heating prostate tissue using ultrasound

High-intensity focused ultrasound treatment uses powerful sound waves to heat prostate tissue, causing cancer cells to die. High-intensity focused ultrasound is done by inserting a small probe in your rectum. The probe focuses ultrasound energy at precise points in your prostate. High-intensity focused ultrasound treatments are being studied in clinical trials. More study is needed to understand the benefits and risks of this treatment.

Chemotherapy
Chemotherapy uses drugs to kill rapidly growing cells, including cancer cells. Chemotherapy can be administered through a vein in your arm, in pill form or both. Chemotherapy may be a treatment option for men with prostate cancer that has spread to distant areas of their bodies. Chemotherapy may also be an option for cancers that don't respond to hormone therapy. Doctors are studying whether chemotherapy is helpful when combined with radiation therapy or surgery.

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