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Prostate Cancer

Introduction

Each year, more than 120,000 new cases of prostate cancer occurs in USA and more than 30,000 deaths are caused annually by this disease. Approximately, one out of every 10 men will develop this form of cancer – it is second only to lung cancer as the leading cause of death in men – and the likelihood of developing it increases with age.  An estimated 232,090 cases of prostate cancer will be diagnosed in U.S. men in 2005.

Every man over the age of 50 should know that he is at risk for prostate cancer. African Americans have the highest risk of developing this disease. Having a father or brother with prostate cancer also greatly increases a man’s likelihood of developing it. In addition, studies have shown that a diet high in fat may contribute to the development of this cancer.

Most prostate cancers begin in the outer part of the prostate. The cancer must grow fairly large before it presses on the urethra and interferes with the urination. In the early stages, prostate cancer is curable. With prompt treatment the percentage of men who survive longer than 10 years is roughly equal to that of men who have never had prostate cancer.

If prostate cancer is allowed to develop without treatment, it may spread to other organs, causing disability and sometimes death. Advanced prostate cancer is more likely to cause symptoms, which may lead a man to see a doctor for diagnosis. Unfortunately, by the time prostate cancer has reached this stage, it is less responsive to treatment.

If the results of DRE suggest the presence of cancer, your urologist may recommend that other test be performed which help detect prostate cancer or indicate the extent of the cancer’s growth. To confirm the presence of cancer, the urologist may perform a biopsy obtaining a small sample of the suspected cancer for examination under a microscope by a pathologist.

If a diagnosis of prostate cancer is made, the urologist will generally recommend treatment. How prostate cancer is treated depends upon the stages of cancer, the aggressive nature of the cancer, the age of the patient, the patient’s overall health and side effects of different treatments. Because so many different options exists, the treatment of prostate cancer should be carefully weighed by you and your urologist.  One of the treatment options, no matte what the stage is “watchful waiting”.

Since the prostate cancer grows slowly, symptoms may not appear for years. Men generally develop this disease late in life, so a period of watchful waiting (period of observation) may be a choice. But studies have shown that after the age of 40, there is no fixed rule for cancer of prostate to develop.

Various treatment options are employed: these include surgery, radiation therapy, hormonal therapy and occasionally chemotherapy. The urologist will advise on the treatment most appropriate for each particular case depending upon the stage of disease.

Prostate cancer occurs when cells within the prostate grow uncontrollably, creating small tumors. Most cells in the body are constantly dividing, maturing, and then dying in a tightly controlled process.  Unlike normal cells, the growth of cancer cells is no longer well regulated. Instead of dying, as they should, cancers cells outlive normal cells and continue to form new, abnormal cells. The term “primary tumor” refers to the original tumor; secondary tumors are caused when the original cancer spreads to other locations in the body.  Prostate cancer typically is comprised of multiple very small, primary tumors within the prostate.  At this stage, the disease is often curable (rates of 90% or better) with standard interventions such as surgery or radiation that aim to remove or kill all cancerous cells in the prostate.  Unfortunately, at this stage the cancer produces few or no symptoms and can be difficult to detect.

Metastatic prostate cancer

 If untreated and allowed to grow, the cells from these tumors can spread in a process called metastasis.  In this process, prostate cancer cells are transported through the lymphatic system and the bloodstream to other parts of the body, where they lodge and grow secondary tumors.  Once the cancer has spread beyond the prostate, cure rates drop dramatically

 The major known risk factors for prostate cancer are

• Age
  The chance of having prostate cancer increases rapidly after age 50.  In fact, about 80% of all prostate cancers are diagnosed in men over the age of 65.
• Race:
  More African-American men develop prostate cancer than Caucasian-American men. Asian men living in Asia have the lowest incidence.
• Family history:
  Approximately 25% of men with prostate cancer have a history of the disease within their family.
• It is believed that only 9% of all prostate cancers are purely hereditary.
• Obesity:
  Recent studies have shown that men who are overweight or obese are at significantly higher risk for developing prostate cancer.
  
  
  

Some risk factors – such as race, family history or age -cannot be modified, while others, especially diet and weight, can be controlled. 
The Prostate Cancer Foundation suggests that men wanting to reduce their risk of prostate cancer

• Eat fewer red meats and high-fat dairy products,
• Eat five or more servings of vegetables and fruits each day,
• Exercise regularly and
• Maintain a normal weight.
  
  

Screening & Diagnosis

Screening for prostate cancer can be performed quickly and easily in a physician’s office using two simple tests:

1. The Prostate Specific Antigen (PSA) blood test, and the
2. Digital Rectal Exam (DRE).
   
   

PSA

A PSA level above 4.0 ng per milliliter of serum may trigger a prostate biopsy to search for cancer.

The Digital Rectal Exam

	>	>
Normal	Tenderness	Symmetrical Enlargement (BPH)
Asymmetry	Induction	Nodularity

The digital rectal exam should be performed along with the PSA test.  A physician who will insert a gloved finger into the rectum to feel the peripheral zone of the prostate where most prostate cancers occur performs the DRE.  The physician will be checking for hardness of the prostate or for irregular shapes or bumps extending from the prostate – all of which may indicate a problem.  The DRE is particularly useful because the PSA test may miss up to 25% of cancers, and the DRE may catch some of these.

Symptoms

Often, early stages of prostate cancer do not cause symptoms.  However, in some cases, men with prostate cancer may experience any of these problems:

• A need to urinate frequently, especially at night;
• Difficulty starting urination or holding back urine;
• Weak or interrupted flow of urine;
• Painful or burning urination;
• Difficulty in having an erection;
• Painful ejaculation;
• Blood in urine or semen; or
• Frequent pain or stiffness in the lower back, hips, or upper thighs.
  
  

Investigation

• Digital Rectal Examination (DRE)
• Prostate Specific Antigen (PSA) Test
• Transrectal Ultrasonograpy (TRUS) of the prostate
• Prostate Needle Biopsy (PNB)
• X-ray chest  P.A.view
• Bone scan

Bone scan

After a bone is damaged by tumor, new bone tissues grows. A bone scan can detect this new growth may show that cancer has spread into the bone. Bone scan is done to see for the spread of the cancer to the bone.

Learning about prostate cancer

Your treatment about will depend on:

• PSA test result
• What the cancer cell look like (their grade)?
• Where they’re located (their grading)?

Your age, lifestyle, general health will also help you and your doctor to choose the best treatment.

Grading cancer

The pathologist grade cancer cell removed during biopsies

Low grade look more like normal cells

High grade, cell may vary in size and shape

Cell from two biopsy site are graded using Gleason score of between 2 –10. The higher the score, the more likely cancer cells will grow faster and spread. The pathologist will give your doctor a report about biopsy.

Staging cancer

Base on results from your test, your urologist will stage the cancer. This shows how much the cancer has grown and spread.

Lower stage tumors are likely to be confined to prostate.

Higher stage tumor may have spread from prostate to the seminal vesicles, lymph nodes, bones, lungs and other part of body.

Stage 1	Stage 2	Stage 3	Stage 4

You should speak with your doctor immediately if you have experienced any of the above symptoms or if you are a man over 50 who have not had a recent prostate cancer screening.  If you have a family history of prostate cancer, or are an African-American male, you should consider screening at age 45.

Bone scan is done to see for the spread of the cancer to the bone.

Treatment for prostate cancer.

Various treatment options are employed:

• Surgery
• Radiation therapy.
• Hormonal therapy.
• Chemotherapy.
  
  

Treatment of prostate cancer in early stage:

In early stages, when the prostate cancer is localized (confined to prostate), treatment options generally would include:

1.Prostatectomy:

This is surgical removal of the prostate gland. The idea is to remove the cancerous growth of the prostate by removing the entire prostate gland.

• Side effect include
• Impotence
• Incontinence
  
  

2.Radiation therapy:

This therapy helps to shrink the tumor by:

• Directing radiation from outside the body directly on the tumor within prostate.
• Implanting tiny radioactive seeds directly into prostate.

Radiation has its own complication but with proper planning and linear accelerator, side effects can be minimized.

Radical retropubic prostatectomy and radical perineal prostatectomy are the two most common types of radical prostatectomy procedures. The entire prostate gland, attached seminal vesicles, and some nearby tissue are removed during these surgeries.

• A radical retropubic prostatectomy involves a surgical cut in the lower abdomen. The surgeon can then remove the cancer through this skin incision. The entire prostate and attached seminal vesicles are removed, along with a small part of the bladder next to the prostate.
  
  
• If necessary, a pelvic lymphadenectomy is performed to remove nearby pelvic lymph nodes
  
  
• Recent developments in surgery have led to a newer version of this technique, called nerve-sparing radical retropubic prostatectomy. This allows the surgeon to identify the nerves on either side of the prostate so that they can be left alone, if possible. In general, there is a lower risk of certain adverse effects if the nerve-sparing technique can be used.
  
  
• Radical perineal prostatectomy is similar to radical retro pubic prostatectomy except that the cancer is removed through an incision in the perineum. A surgical cut is made in the area between the scrotum and the anus. The entire prostate is removed along with any nearby cancer.
  
  

Laparoscopic Robotic

Advantages:

 Prostatectomy is a one-time procedure that may optimally treat prostate cancer in its early stages and may help extend life in the later stages. Surgery avoids some of the problems seen with radiation therapy. These problems are discussed in the next section.

Disadvantages:

Prostatectomy is a major operation that requires hospitalization and can produce side effects. The possible side effects include impotence, urinary incontinence, and narrowing of the urethra that can make urination difficult.
Although impotence can occur in a large number of patients, the chance of impotence is lower with the newer nerve-sparing technique. Urinary incontinence occurs in only a small percentage of patients.

3.Radiation therapy:

Radiation therapy uses high-energy x-ray to kill cancer cells. There are two methods of radiotherapy

• Radiation may come from out side the prostate (external radiation).
  As treatment begins cancer cells are damaged and later die. Some normal cells are damaged too. More cancer cells die with more treatment. Cells continue to die for 12-18 months after treatment.
• During each dose of external beam radiotherapy, radiation comes from a machine outside your body is beamed into the cancer. Each dose damages more and more cancerous cells.
• Your radiation oncologist designs your treatment plan based on the cancer’s grade, stage and your overall health.
• Radiation therapist positions patients on tablet o help protect normal cells. Radiation is aimed at the tumor from different angle.
• Each treatment last few minutes. Treatment occurs once a day, 5 days a week for 5-7 weeks.
  
  

• Radiation comes from material placed inside the prostate (interstitial brachytherapy).
  targeting cells from inside the prostate. During interstitial brachytherapy, “seeds” (tiny plastic tubes containing radioactive material) are implanted into your prostate through needles using the perineal approach. This occurs when you are under anesthesia. The seeds releases decreasing amount of radiation for about a year. The implant can be temporary or permanent. Healthy tissue near the seeds may also be affected. This may cause some side effect

• Frequent urination, possibly with a burning feeling.
• Erectile dysfunction.
• Bleeding and inflammation of bladder and rectum.
• Incontinence.

Treatment of advanced prostate cancer:

Advanced cancer of the prostate may not be present with the symptoms. The aim of treating advanced prostate cancer is to slow further growth of the disease, even before the symptoms begin.

Hormonal therapy is usually used for the slowing the spread of cancer

All male hormones “feed” prostate cancer. Hence, the idea is to shut off the supply of testosterone to prostate. This would prevent or slow down the spread of prostate cancer. This testosterone is manufactured in testis.

Partial Hormonal Therapy

Modern drugs provide various ways to reduce the flow of testosterone, the primary source of tumor growth. The following  are the examples of partial hormonal therapy:

Estrogen:

Estrogen (DES), a female hormone is used in the treatment of prostate cancer. In men, intake of estrogen leads to fall of testosterone. However, its use is not widely accepted due to many side effects. It is usually prescribed as a single dose per day but it may cause nausea, vomiting, breast tenderness or enlargement, serious heart or blood vessel problems (such as stroke, clots, and fluid retention) and lower sex drive.

Orchidetcomy:

It means surgical removal of testicles, it is also known as surgical castration. In the absence of testis, the main source of male hormones, testosterone, is absent. This slows the growth of the tumor. Side effects may include impotence and hot flashes. The surgery can be performed as a day care.

Medical Castration: Testosterone production from testicles can also be blocked by medicines. Medical castration shuts off the supply of testosterone by the testicle and achieves almost the same results as surgical castration. Medical castration involves monthly injection of Lupron Depot (Leuprolide) or Zoladex (Goserelin). These medications are also known as LHRH agonists. A LHRH agonist help reduce the amout of testosterone similar to surgical procedure. Side effects usually include hot flashes, impotence, breast enlargement and tenderness, loss of sex drive and nausea.

Complete Hormonal Therapy

Although testicles are the main source of male hormones, they are not the only one. The adrenal glands also make male hormones.

While castration stops the testicles from making testosterone, a drug called Flutamide can help prevent the male hormone produced by the adrenal glands from reaching the prostate. Flutamide is referred to as an antiandrogen.

The combination of LHRH agonist (Lupron or Zoladex), or castration plus Flutamide are called complete hormonal therapy. Complete hormonal theapy virtually shuts off the body’s supply of male hormones and slows the growth of the tumor.