Prostate Cancer

Symptoms, diagnosis and treatment of Prostate Cancer

What is Prostate Cancer?

Cancer begins in cells which are the building blocks that make up all tissues and organs of the body. Normal cells in the prostate and other parts of the body grow and divide to form new cells as they are needed. When normal cells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when the body doesn’t need them, and old or damaged cells don’t die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor. Growths in the prostate can be benign (not cancer) or malignant (cancer):

  • Benign growths (such as benign prostatic hyperplasia):   Rarely a threat to life. Major morbidity is bleeding, infection, inability to urinate and chronic kidney failure.
  • Malignant growths (prostate cancer): often a threat to one’s life and quality of life.  Can invade nearby organs and tissues (such as the bladder or rectum) Can spread to other parts of the body Often can be removed but sometimes grow back.  Prostate cancer cells can spread by breaking away from a prostate tumor. They can travel through blood vessels or lymph vessels to reach other parts of the body. After spreading, cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues.

When prostate cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary (original) tumor. For example, if prostate cancer spreads to the bones, the cancer cells in the bones are actually prostate cancer cells. The disease is metastatic prostate cancer, not bone cancer. For that reason, it’s treated as prostate cancer, not bone cancer.

Tests to Determine Treatment

After you learn that you have prostate cancer, you may need other tests to help with making decisions about treatment.

Tumor Grade Test with Prostate Tissue

The prostate tissue that was removed during your biopsy procedure can be used in lab tests. The pathologist studies prostate tissue samples under a microscope to determine the grade of the tumor. The grade tells how different the tumor tissue is from normal prostate tissue.

Tumors with higher grades tend to grow faster than those with lower grades. They are also more likely to spread. Doctors use tumor grade along with your age, overall health and other factors to suggest treatment options.

The most commonly used system for grading prostate cancer is the Gleason score. Gleason scores range from 2 to 10.

To come up with the Gleason score, the pathologist looks at the patterns of cells in the prostate tissue samples. The most common pattern of cells is given a grade of 1 (most like normal prostate tissue) to 5 (most abnormal). If there is a second most common pattern, the pathologist gives it a grade of 1 to 5 and then adds the grades for the two most common patterns together to make the Gleason score (e.g.3 + 4 = 7). If only one pattern is seen, the pathologist counts it twice (5 + 5 = 10).

A high Gleason score (such as 10) means a high-grade prostate tumor. High-grade tumors are more likely than low-grade tumors to grow quickly and spread.

Staging Tests

Staging tests can show the stage (extent) of prostate cancer, such as whether cancer cells have spread to other parts of the body. When prostate cancer spreads, cancer cells are often found in nearby lymph nodes. If cancer has reached these lymph nodes, it may have also spread to other lymph nodes, the bones, or other organs.

Your doctor needs to learn the stage of the prostate cancer to help make the best decision about treatment. Staging tests may include:

Physical exam (digital rectal exam): If the tumor in the prostate is large enough to be felt, your doctor may be able to examine it. With a gloved and lubricated finger, your doctor feels the prostate and surrounding tissues from the rectum. Hard or lumpy areas may suggest the presence of one or more tumors. Your doctor may also be able to tell whether it’s likely that the tumor has grown outside the prostate.

Bone scan: A small amount of a radioactive substance will be injected into a blood vessel. The radioactive substance travels through your bloodstream and collects in the bones. A machine called a scanner makes pictures of your bones. Because higher amounts of the radioactive substance collect in areas where there is cancer, the pictures can show cancer that has spread to the bones.

CT scan: A radiographic machine linked to a computer takes a series of detailed pictures of your lower abdomen or other parts of your body. You may receive contrast material by injection into a blood vessel in your arm or hand, or by enema. The contrast material makes it easier to see abnormal areas. The pictures from a CT scan can show cancer that has spread to the lymph nodes or other areas.

MRI: A strong magnet linked to a computer is used to make detailed pictures of your lower abdomen. An MRI can show whether cancer has spread to lymph nodes or other areas. Sometimes contrast material is used to make abnormal areas show up more clearly on the picture.

Stages of Prostate Cancer

Doctors describe the stages of prostate cancer using the Roman numerals I, II, III, and IV. A cancer that is Stage I is early-stage cancer, and a cancer that is Stage IV is advanced cancer that has spread to other parts of the body. The clinical stage and aggressiveness of prostate cancer depends mainly on.

  • whether the tumor has invaded nearby tissue, such as the bladder or rectum
  • whether prostate cancer cells have spread to lymph nodes or other parts of the body, such as the bones
  • grade (Gleason score) of the prostate tumor
  • psa level

Stage I:  The cancer is only in the prostate. It  cannot be felt during a digital rectal exam. It is usually discovered following an elevated psa determination or in the prostatic tissue following a transurethral resection of the prostate.

Stage II:  The tumor is palpable but does not extend beyond the prostate.

Stage III:  The tumor extends beyond the prostate into the surrounding local tissues. The tumor may have invaded a seminal vesicle, but cancer cells haven’t spread to lymph nodes.

Stage IV:  The tumor may have invaded the bladder, rectum, or nearby structures (beyond the seminal vesicles). It may have spread to lymph nodes, bones, or other parts of the body.

Treatment Options

Men with prostate cancer have many treatment options. Treatment options include:

  • Active surveillance
  • Surgery
  • Radiation therapy
  • Hormone therapy
  • Chemotherapy
  • Immunotherapy

You may receive more than one type of treatment. The treatment that’s optimal for one man may not be optimal for another. The treatment that’s right for you depends mainly on:

  • Your age
  • Gleason score (grade) of the tumor
  • Stage of prostate cancer
  • Your symptoms
  • Your general health

Active Surveillance

Your doctor may suggest active surveillance if you’re diagnosed with early-stage prostate cancer that seems to be growing slowly. Your doctor may also offer this option if you are older or have other health problems.

Active surveillance is putting off treatment until test results imply that your prostate cancer is growing or changing. If you and your doctor agree that active surveillance is a good idea, your doctor will check you regularly (such as every 3 to 6 months, at first). You’ll get digital rectal exams and PSA tests. After about a year, your doctor may order another prostate biopsy to check the Gleason score. Your doctor may suggest treatment if your Gleason score rises, your PSA level starts to increase, or you develop symptoms. Your doctor may suggest surgery, radiation therapy, or another type of treatment.

By choosing active surveillance, you’re putting off the side effects of surgery, radiation therapy, or other treatments. However, the risk for some men is that waiting to start treatment may reduce the chance to control cancer before it spreads. Having regular checkups reduces this risk.

For some men, it’s stressful to live with an untreated prostate cancer. If you choose active surveillance but grow concerned later, you should discuss your feelings with your doctor. You can change your mind and have treatment at any time.

Surgery

Surgery is an option for men with early-stage cancer that is found only in the prostate. It’s sometimes also an option for men with advanced prostate cancer to relieve symptoms.

There are several kinds of surgery to treat prostate cancer. Usually, the surgeon will remove the entire prostate and sometimes the nearby lymph nodes. Your surgeon can describe each kind of surgery, compare the benefits and risks, and help you decide which kind might be best for you.

The entire prostate can be removed in several ways:

  • Through an incision in the abdomen: The surgeon removes the prostate through an incision in the abdomen below the belly button. This is called a radical retropubic prostatectomy  also called an open prostatectomy.
  • Through small incisions (ports) in the abdomen: The surgeon makes several small cuts in the abdomen, and surgery tools are inserted through the small cuts. A long, thin tube (a laparoscope) with a light and a camera on the end helps the surgeon see the prostate while removing it. This is called a laparoscopic prostatectomy.
    With a robot: The surgeon may use a robot to remove the prostate through small incisions in the abdomen. The surgeon uses handles below a computer display to control the robot’s arms.
  • Through an incision between the scrotum and anus: The surgeon removes the prostate through an incision between the scrotum and anus. This is called a radical perineal prostatectomy. It’s a type of open prostatectomy that is rarely used anymore.

Other therapeutic options for treating prostate cancer or relieving its symptoms are:

  • Freezing: For some men, cryosurgery is an option. The surgeon inserts needle probes between the scrotum and anus. The probe freezes and ablates prostate tissue.
  • Heating (not FDA approved-investigational) : Doctors are testing high-intensity focused ultrasound therapy in men with prostate cancer. A probe is placed in the rectum. The probe gives off high-intensity ultrasound waves that heat up and kill the prostate tumor. This is investigational at the present time.
  • TURP: A man with localized prostate cancer may choose transurethral resection of the prostate (TURP) to relieve urinary symptoms of obstruction. The surgeon inserts a long, thin scope through the urethra. A cutting tool at the end of the scope removes tissue from the inside of the prostate. TURP may not remove all of the cancer, but it can remove tissue that blocks the flow of urine.

Radiation Therapy

Men with prostate cancer may choose radiation therapy instead of surgery. It may also be used after surgery to destroy any cancer cells that remain in the area. In men with advanced prostate cancer, radiation therapy may be used to help relieve pain.

Radiation therapy uses high-energy rays to kill cancer cells. It affects cells only in the part of the body that is treated. Doctors use two types of radiation therapy to treat prostate cancer. Some men receive both types:

External: machine outside the body: The radiation comes from a large machine outside the body. The radiation beam has to travel through your bladder and your rectum to get to your prostate. Because of this, some men experience urinary frequency and burning and some diarrhea for a few months. Computers are used to more closely target the prostate. Some such as intensity-modulated radiation therapy, proton radiation therapy, and 3-dimensional conformal radiation therapy are types of radiation delivery systems that use computers to limit damage to healthy tissue. Treatments are usually 5 days a week for 8 to 9 weeks although cyber knife lasts only 5-8 days.

Radioactive material inside the body (brachytherapy): This method places multiple radioactive seeds inside needles, and the needles are inserted into the prostate. When the needles are removed, the seeds are left behind.

The seeds give off radiation for months. The seeds do not need to be removed once the radiation is dissipated. This too is an ambulatory procedure. Side effects depend on whether or not there is any post procedure restriction to urine flow.

Hormone Therapy

Men with advanced prostate cancer usually receive hormone therapy. In addition, a man with early-stage prostate cancer may have hormone therapy before, during, and after radiation therapy. Hormone therapy may also be used after surgery. Hormone therapy interrupts prostate cells from responding to male hormones (androgens such as testosterone). Male sex hormones can cause prostate cancers to grow.

Types of hormone therapy include:

  • A drug that can prevent the testicles from making testosterone (LH-RH agonist)
  • A drug that can block the action of male hormones (anti-androgen)
  • Surgery to remove the testicles, which are the body’s main source of testosterone
  • A drug that can prevent the adrenal glands from making testosterone

Your doctor can help you decide which type of hormone therapy or which combination is best for you.

The side effects of hormone therapy depend on the type used. The most common side effects are erectile dysfunction, hot flashes, and loss of sexual desire. Other possible side effects include breast growth, an increase in body fat around the waist, and an increase in sugar level in your blood. Also, hormone therapy can weaken your bones. Your doctor can suggest medicines that may reduce your risk of breaking a bone.

An LH-RH agonist may make pain and other symptoms worse at first. This temporary problem is called a flare. To prevent a flare, your doctor may give you an anti-androgen before receiving the LH-RH agonist.

Although the side effects of hormone therapy may be upsetting, your health care team can suggest ways to manage them.

Chemotherapy may be used for men with advanced prostate cancer. Chemotherapy uses drugs to kill cancer cells. The drugs for prostate cancer are usually given directly into a vein (intravenously). You may receive chemotherapy in a clinic, at the doctor’s office, or at home. Men rarely need to stay in the hospital during treatment.

The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:

Immunotherapy

Immunotherapy may be used for men with advanced prostate cancer who are not helped by hormone therapy. Immunotherapy stimulates the immune system to kill cancer cells.

Nutrition

Eating well is important before, during, and after cancer treatment. You need the right amount of calories to maintain a good weight. You also need enough protein to keep up your strength. Eating well may help you feel better and have more energy.

Sometimes, especially during or soon after treatment, you may not feel like eating. You may be uncomfortable or tired. You may find that foods don’t taste as good as they used to. In addition, poor appetite, nausea, vomiting, mouth blisters, and other side effects of treatment can make it hard for you to eat.

Your doctor, a registered dietitian, or another health care provider can suggest ways to help you meet your nutrition needs.

Follow-up Care

You’ll need regular checkups (such as every 3-6 months) after treatment for prostate cancer. Checkups help ensure that any changes in your health are noted and treated if needed. If you have any health problems between checkups, contact your doctor.

Prostate cancer may come back after treatment. Your doctor will check for the return of cancer. Checkups also help detect health problems that can result from cancer treatment.

Checkups may include a digital rectal exam and a PSA test. A rise in PSA level can mean that cancer has returned after treatment. Your doctor may also order a biopsy, a bone scan, CT scans, an MRI, or other tests.

Cancer Treatment Research

Cancer research has led to real progress in prostate cancer detection, treatment, and supportive care. Because of research, men with prostate cancer can look forward to a better quality of life and less chance of dying from the disease. Continuing research offers hope that, in the future, even more men with this disease will be treated successfully.

Doctors continue to search for new and better ways to treat prostate cancer. All over the world, doctors are conducting many types of cancer treatment research studies (clinical trials).

Even if a man who takes part in a clinical trial doesn’t benefit directly from the treatment under study, he may still make an important contribution by helping doctors learn more about prostate cancer and how to control it. Although clinical trials may pose some risks, researchers do all they can to protect their patients.

If you’re interested in being part of a clinical trial, talk with your doctor.

(source: National Cancer Institute)