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Prostate Cancer

Definition

The prostate is a walnut-sized gland that sits below the bladder and surrounds the urethra, the tube that runs from the bladder to the outside of the body. The prostate is part of the male reproductive system and creates fluid that makes up part of the semen.

Prostate cancer is the second most common form of cancer in men, after skin cancer. About 233,000 new cases, or one in five men, will be diagnosed this year and nearly 29,400 men will die of the disease.

Risk Factors

  • Prostate cancer typically develops in older men; almost 70 percent of those diagnosed are over 65. It rarely occurs in men under 40.
  • Men with a family history of the disease, specifically a father or brother, are twice as likely to develop prostate cancer.
  • African American men have a 60 percent higher chance of getting the disease and twice as likely to die from it.
  • Obese men, those with a body mass index over 32.5, are 33 percent more likely to die from prostate cancer.
Symptoms

There are typically no symptoms of prostate cancer in its early stages.

Once the disease has advanced, men may experience the following:
  • Frequent or sudden urge to urinate, or a weak or interrupted flow of urine.
  • Trouble starting to urinate or difficulty emptying the bladder completely.
  • Pain or burning while urinating.
  • Blood in the urine or semen.
  • Pain in the back, hips, or pelvis that doesn't stop.
  • Shortness of breath, fatigue, fast heartbeat, dizziness, or pale skin.
Tests

Prostate-specific antigen (PSA)

Is a substance made by the prostate. It is typically found in increased levels when prostate cancer develops and a blood test can determine if the level is elevated. But other conditions such as an enlarged or inflamed prostate can also raise the level so further testing will be needed.

A digital rectal exam (DRE)

Allows a physician to feel the prostate by inserting a lubricated gloved finger into the rectum and touching it through the rectal wall for lumps or abnormal areas.

AA transrectal ultrasound

Is used when a biopsy is needed, to help guide where samples of tissues should be taken. The procedure involves inserting a probe about the size of a finger into the rectum to bounce high-energy sound waves off internal tissues to make echoes. These echoes form a sonogram, which is reviewed by an urologist to determine where a needle should remove tissue for sampling.

During a biopsy, about 12 to 14 tissue samples are removed with a thin needle inserted into the prostate. The patient may either be put under anesthesia or receive a local numbing medication prior to the procedure and the ultrasound is used to ensure all suspected abnormalities are sampled. Prostate biopsies are typically performed on an outpatient basis.
Treatment Options

The type of treatment used to fight prostate cancer depends on a number of factors, including the age of the patient, how aggressive the tumor is and if the cancer has spread outside the prostate. Among the options are surveillance, radiation, surgery, chemotherapy, and hormone therapy.

Surveillance

In some cases, physicians may recommend surveillance, or watchful waiting, if the patient is older or the tumor is determined to be very slow growing. Active treatment may not be necessary.

Radiation

Radiation therapy is used to treat all stages of prostate cancer. It can be used alone or in conjunction with other treatments. It is frequently combined with surgery if the cancer is aggressive, has spread or recurred.

Procedure

Radiation therapy can be delivered via external or internal methods. These two methods may occasionally be combined very effectively.

  • External radiation therapy (EBRT) uses a machine outside the body to target radiation beams at the cancer. A highly sophisticated technology, known as intensity-modulated radiation therapy (IMRT), combined with a hands-on delivery technique, known as image-guided radiation therapy (IGRT) uses real-time imaging to ensure that the radiation beams are sculpted to the contours of the tumor, while avoiding unnecessary radiation going to normal healthy body organs. Multiple, dynamically shaped beams are directed at the prostate from different directions to achieve the desired effect. Treatment is typically given five days a week for nine weeks.
  • Internal radiation therapy, also known as brachytherapy, involves putting radiation directly into the tumor.

    High-dose-rate brachytherapy delivers high doses of radiation through catheters inserted in or near the tumor. A wire containing a radiation pellet or "source" at its tip is fed through the catheters into the prostate. This wire is connected to a machine that is computer-controlled to determine exactly where and for how long the radiation source should pause to release its radiation. Each treatment-delivery procedure typically takes several minutes. Occasionally, a second treatment is given the following day, which would then require an overnight hospital stay.

Learn more about brachytherapy



Risks

Radiation therapy may cause impotence, incontinence, and fatigue, which is usually temporary. It also may pose a slight eventual risk of bladder and gastrointestinal cancer.



Surgery

A radical prostatectomy is the surgical removal of the prostate gland and seminal vesicles, the pair of tube-like glands found behind the bladder that make up about 70 percent of the seminal fluid. Often, regional lymph nodes are also taken out.

A radical prostatectomy is frequently done when cancer has not spread outside the prostate. It is usually done as a robotic-assisted laparoscopic procedure as opposed to an "open" surgery and is known for reduced pain, less blood loss and often its nerve-sparing technique that helps prevent long-term side effects such as incontinence and erectile dysfunction.

Procedure

The surgeon makes several small incisions, less than 1 cm, in the lower abdomen using lighted, magnified scopes and a camera. The prostate, seminal vesicles and lymph nodes are removed in a small bag through an incision made in the navel, which is enlarged to about 2 or 3 cm.

Two small bundles of nerves located on both sides of the prostate control erections and if cancer is not growing into or very near these bundles, they are spared during the procedure.

Recovery

A radical prostatectomy usually requires only an overnight hospital stay. Drains that have been put in place during the surgery will be removed prior to discharge from the hospital.

A catheter also inserted during surgery to drain urine from the bladder into a bag is removed in a physician's office between five and six days following discharge from the hospital. Clips or staples used to close the incisions are removed at the same time as the catheter.

Side Effects

One of the major side effects that may occur from a prostatectomy is urinary incontinence.

Urinary incontinence, typically in the form of stress incontinence - when the patient coughs, laughs, sneezes or exercises - is the most common side effect of a prostatectomy. It is typically a result of damage to the sphincter, the muscle that keeps urine in the bladder, or the nerves that control this muscle. Often, the condition is not permanent and normal bladder activity can return immediately or as long as three months after surgery.

Erectile dysfunction (ED) is also a side effect that may occur after a radical prostatectomy. Other factors may affect whether a patient experiences ED after surgery, including whether there were ED problems prior to the radical prostatectomy, such as those caused by diabetes and hypertension. Older men are typically affected by ED much more than younger ones. But the ability to have erections after surgery often returns, slowly, sometimes taking as long as two years.

If potency is intact the patient should still be able to have an orgasm, though it will be dry because there is no ejaculation of semen since the prostate and seminal vesicles have been removed.

Hormone therapy

Definition

In treating prostate cancer, hormone therapy is used to decrease testosterone production in the testicles. Testosterone helps cancer cells grow so preventing its production causes these cells to die or grow more slowly.

Hormone therapy doesn't cure prostate cancer but it can put the disease in a dormant stage, thereby slowing the progress of the illness for months or years.

When it is used

  • Hormone therapy is often prescribed for metastatic or recurring prostate cancer.
  • It is sometimes used in combination with external radiation, making that treatment more effective in men with locally advanced cancer.
  • Hormone therapy may also be prescribed intermittently, stopped once the PSA levels are undetectable and the cancer is under control. It can then be used again if the disease progresses or recurs.

Procedure

The medication is injected under the skin into a muscle once a month or every three or six months.

Side Effects

Side effects include hot flashes, fatigue, osteoporosis or weakened bones, erectile dysfunction and loss of muscle mass. It may occasionally cause the growth of breast tissue. The longer medication is taken, the higher the risk of side effects.



Chemotherapy

Chemotherapy is only used for prostate cancer when the disease has spread or if it doesn't respond to other treatments, including hormone therapy.

Other Procedures

Cryosurgery

Cryosurgery is a procedure that freezes and destroys cancer cells. It is used when the cancer has not spread beyond the prostate.

Physicians use ultrasound to find the cancer cells and then a hollow tube is inserted into the tumor. Liquid nitrogen or argon gas is pushed through the tube, which forms ice crystals on the edge and freezes nearby cells. When the frozen tissue thaws it is naturally absorbed by the body.

Cryosurgery may obstruct urine flow or cause incontinence and impotence.
Stages of Prostate Cancer

The process used to see whether cancer has spread within or outside the prostate to the blood and other tissues or organs is called clinical staging. The stage of the cancer dictates the treatment plan.

In addition to determining if cancer has spread beyond the gland, prostate cancer is also staged using a patient's PSA and his Gleason score. A Gleason score is a grade assigned to the cancer cells based on how the abnormal cells are organized in the tissue. The closer the cancer cells resemble normal cells, the lower the grade. Since cells vary widely, most tumors have more than one cancer grade. Pathologists assign the tumor two grades and then add those numbers together to get a Gleason score between 6 and 10.

Stage 1

Cancer is found only in the prostate, specifically in only one area. It is usually detected through a needle biopsy or during surgery for benign diseases. It cannot be felt by a digital rectal exam or by imaging screenings. The PSA is lower than 10 and the Gleason score is six or lower.

Stage 2

The cancer is still only within the prostate and can't be felt in a rectal exam but it is more advanced. Stage 2 is typically divided between 2A and 2B, differentiated by the number of cancer cells and the parts of the prostate affected. The Gleason score is usually seven or lower.

Stage 3

The cancer has spread beyond the prostate and may be in the seminal vesicles. The PSA and Gleason scores can be at any level.

Stage 4

The cancer has spread beyond the prostate and seminal vesicles to other tissues, lymph nodes, or bones.