Prostate Cancer

Prostate cancer is the most common type of cancer in men in the United States (other than skin cancer).

The Prostate

The prostate is a male sex gland. It produces a thick fluid that forms part of the semen. The prostate is about the size of a walnut. It is located below the bladder and in front of the rectum. The prostrate surrounds the upper part of the urethra, the tube that empties urine from the bladder.

The prostate needs male hormones to function. The main male hormone is testosterone, which is made mainly by the testicles. Some male hormones are produced in small amounts by the adrenal glands.

What is Cancer?

Cancer is a group of many different diseases that have some important things in common. They all affect cells, the body’s basic unit of life. To understand cancer, it is helpful to know about normal cells and about what happens when cells become cancerous.

The body is made up of many types of cells. Normally, cells grow and divide to produce more cells only when the body needs them. This orderly process helps keep the body healthy.

If the cells keep dividing when new cells are not needed, they form too much tissue. Excess tissue forms a mass, called a tumor. Excess tissue can be benign or malignant.

• Benign tissue is not cancer. The cells do not invade nearby tissue or spread to other parts of the body.
• Malignant tissue is cancer. The cancer cells divide out of control. They can invade and destroy nearby healthy tissue. Also, cancer cells can break away from the tumor they form and enter the bloodstream and lymphatic system. This is how cancer spreads from the original (primary) tumor to form new tumors in other parts of the body. The spread of cancer is called metastasis.

Benign prostatic hyperplasia

(BPH) is the abnormal growth of benign prostate cells. In BPH, the prostate grows larger and pushes against the urethra and bladder, blocking the normal flow of urine. More than half of the men in the United States between the ages of 60 and 70 and as many as 90 percent between the ages of 70 and 90 have symptoms of BPH. Although this condition is seldom a threat to life, it may require treatment to relieve the symptoms.

Most cancers are named for the type of cell or organ in which they begin. Cancer that begins in the prostate is called prostate cancer (or prostatic cancer). Prostate cancer may remain in the prostate gland, or it may spread to nearby lymph nodes. Prostate cancer may also spread to the bones, bladder, rectum and other organs.

When cancer spreads to other parts of the body, the new tumor has the same malignant cells and the same name as the primary tumor. For example, if prostate cancer spreads to the bones, the cancer cells in the new tumor are prostate cancer cells. The disease is metastatic prostate cancer, it is not bone cancer.

Symptoms

Early prostate cancer often does not cause symptoms. When symptoms of prostate cancer do occur, they may include some of the following problems:

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

Any of these symptoms may be caused by cancer or by other, less serious, health problems such as BPH or an infection. Only a doctor can tell the cause. A man who has symptoms like these should see his family doctor or a urologist (a doctor who specializes in treating diseases of the genitourinary system). Do not wait to feel pain; early prostate cancer does not cause pain.

Diagnosis

If symptoms occur, the doctor asks about the patient’s medical history, performs a physical exam, and may order laboratory tests. The exam and tests may include the following:

• Digital rectal exam—the doctor inserts a gloved, lubricated finger into the rectum and feels the prostate through the rectum wall to check for hard or lumpy areas.
• Blood tests—a lab measures the levels of prostate-specific antigen (PSA) and prostatic acid phosphatase (PAP) in the blood. The level of the PSA in the blood may rise in men who have prostate cancer, BPH, or an infection in the prostate. The level of PAP rises above normal in many prostate cancer patients, especially if the cancer has spread beyond the prostate. The doctor cannot diagnose prostate cancer with these tests alone because elevated PSA or PAP levels may also indicate other, non-cancerous problems. However, the doctor will take the results of these tests into account in deciding whether to check the patient further for signs of cancer.
• Urine test—a lab checks the urine for blood or infection. The doctor may order other tests to learn more about the cause of the symptoms and to help determine whether conditions of the prostate are benign or malignant, such as:
  • Transrectal ultrasonography—sound waves that cannot be heard by humans (ultrasound) are sent out by a probe into the rectum. The waves bounce off the prostate, and a computer uses the echoes to create a picture called a sonogram.
  • Intravenous pyelogram—a series of x-rays of the organs of the urinary tract.
  • Cystoscopy—a procedure in which the doctor looks into the urethra and bladder through a thin, lighted tube.

If test results suggest that cancer may be present, the patient will need to have a biopsy. A biopsy is the only sure way to know whether a problem is cancer. During a biopsy, the doctor removes a small amount of prostate tissue, usually with a needle. A pathologist looks at the tissue under a microscope to check for cancer cells. If cancer is present, the pathologist usually reports the grade of the tumor. The grade tells how closely the tumor resembles normal prostate tissue and suggests how fast the tumor is likely to grow. One way of grading prostate cancer, called the Gleason system, uses a scale of 2 to 10. Another system uses G1 through G4. Tumors with lower scores are less likely to grow or spread than tumors with higher scores.

If the physical exam and test results do not suggest cancer, the doctor may recommend medicine to reduce the symptoms caused by an enlarged prostate. Other options are therapies using microwave heat or radiofrequency energy to shrink enlarged prostate tissue that is pressing against the upper part of the urethra.

Staging

If cancer is found in the prostate, the doctor needs to know the stage or extent of the disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. The doctor may use various blood and imaging tests to learn the stage of the disease. Treatment decisions depend on these findings.

The results of staging tests help the doctor decide which stage best describes a patient’s disease:

• Stage I (A) - The cancer cannot be detected by rectal exam and causes no symptoms. The cancer is usually found during surgery to relieve problems with urination. Stage I tumors may be in more than one area of the prostate, but there is no evidence of spread outside the prostate.
• Stage II (B) -- The tumor is felt in a rectal examination or detected by a blood test, but there is no evidence that the cancer has spread outside the prostate.
• Stage III (C) --The cancer has spread outside the prostate to nearby tissues.
• Stage IV (D) - Cancer cells have spread to lymph nodes or to other parts of the body.

Treating Prostate Cancer

Getting a Second Opinion

Decisions about prostate cancer treatment are complex. It may be helpful to have the opinion of more than one doctor. Before starting treatment, men may want to have a second doctor review their diagnosis and treatment options. A short delay will not reduce the chance that treatment will be successful. Some health insurance companies require a second opinion; many others will cover a second opinion if the patient requests it. There are a number of ways to find a doctor for a second opinion:

• The doctor may be able to recommend a specialist. Doctors who specialize in treating prostate cancer are urologists, radiation oncologists, and medical oncologists.
• The Cancer Information Service, at 1-800-4-CANCER, can tell callers about treatment facilities, including cancer centers and other programs supported by the National Cancer Institute.
• People can get the names of doctors from their local medical society, a nearby hospital, or a medical school.
• The Directory of Medical Specialists lists doctors by state and specialty and gives information about their background. This resource is in most public libraries.

Preparing for Treatment

The doctor develops a treatment plan to fit each patient’s needs. Treatment for prostate cancer depends on the stages of the disease and the grade of the tumor (how fast the cells are likely to grow or spread to other organs). Other important factors in planning treatment are the man’s age and general health and his feelings about the treatments and their possible side effects.

When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for patients to think of everything they want to ask the doctor. Often it helps to make a list of questions. To help remember what the doctor says, people may take notes or ask whether they may use a tape recorder. Some patients also want to have a family member or friend with them when they talk to the doctor to take part in the discussion, to take notes, or just to listen.

Methods of Treatment

Many men whose prostate cancer is slow growing and found at an early stage may not need treatment. Also, treatment may not be advised for older men or men with other serious medical problems. For these men, the possible side effects and risks of treatment may outweigh the possible benefits of treatment; instead, the doctor may suggest "watchful waiting"—following the patient closely and treating the patient later for symptoms that may arise. Researchers are studying men with early stage prostate cancer to determine when and in whom treatment may be necessary and effective.

Treatment for prostate cancer may involve surgery, radiation therapy, or hormone therapy. Sometimes, patients receive a combination of these treatments. In addition, doctors are studying other methods of treatment to find out whether they are effective against the disease.

Surgery

is a common treatment for the early stages of prostate cancer. Surgery to remove the entire prostate is called radical prostatectomy. It is done in one of two ways. In retropubic prostatectomy, the prostate and nearby lymph nodes are removed through an incision in the abdomen. In perineal prostatectomy, the prostate is removed through an incision between the scrotum and the anus. Nearby lymph nodes are sometimes removed through a separate incision in the abdomen. If the pathologist finds cancer in the lymph nodes, it may mean that the disease has spread to other parts of the body.

Radiation Therapy

is another way to treat prostate cancer. In radiation therapy (also called radiotherapy), high-energy rays are used to damage cancer cells and stop them from growing and dividing. Like surgery, radiation therapy is a local therapy; it can affect only the cells in the treated area. In early stage prostate cancer, radiation can be used instead of surgery, or it may be used after surgery to destroy any cancer cells that may remain in the area. In advanced stages, it may be given to relieve pain or other problems.

Radiation may be directed at the body by a machine (external radiation), or it may come from a small container of radioactive material placed directly into or near the tumor (brachytherapy). Some patients receive both kinds of radiation therapy.

For external radiation therapy for prostate cancer, the patient is treated in an outpatient department of a hospital or clinic. Treatment generally is given 5 days a week for about 6 weeks. This schedule helps protect healthy tissues by spreading the total dose of radiation. The rays are aimed at the pelvic area. At the end of treatment, an extra "boost" of radiation is often directed at a smaller area, where the tumor developed.

Hormone therapy prevents the prostate cancer cells from getting the male hormones they need to grow. When a man undergoes hormone therapy, the level of male hormones is decreased. This drop in hormone level can affect all prostate cancer cells, even if they have spread to other parts of the body. For this reason, hormone therapy is called systemic therapy.

There are several forms of hormone therapy. One is surgery to remove the testicles. This operation called orchiectomy, eliminates the main source of male hormones.

The use of luteinizing hormone - releasing hormone (LHRH) agonist is another type of hormone therapy. LHRH agonists prevent the testicles from producing testosterone.

After orchiectomy or treatment with an LHRH agonist or estrogen, the body no longer gets testosterone from the testicles. However, the adrenal glands still produce small amounts of male hormones. Sometimes, the patient is also given an antiandrogen, a drug that blocks the effect of any remaining male hormones. This combination of treatment is known as a total androgen blockade.

Prostate cancer that has spread to other parts of the body usually can be controlled with hormone therapy for a period of time, often several years. Eventually, however, most prostate cancers are able to grow with little or no male hormones. When this happens, hormone therapy is no longer effective, and the doctor may suggest other forms of treatment that are under study.

If you would like more information on this topic, please contact us.

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