Prostate Cancer
Prostate cancer is the most common cancer affecting American men. It is estimated that in 2019, 174,650 men will be diagnosed and 31,620 men will die of prostate cancer. It is the second most common cause of cancer deaths. Prostate cancer, as a whole, is poorly understood because some prostate cancers are slow-growing and may not require treatment, and other prostate cancers are aggressive and can metastasize. If these are left untreated, they can lead to death.
How is Prostate Cancer Diagnosed?
For most patients, an abnormal prostate-specific antigen (PSA) and/or Digital Rectal Examination (DRE) prompts a transrectal prostate ultrasound and biopsy (TRUS biopsy). Under ultrasound guidance, the urologist takes small needle-cores of prostate tissue during a short outpatient procedure. A pathologist then reviews these samples.
Click to read more about the PSA Test
PSA is a protein that is made in the prostate gland and secreted into the bloodstream. The levels of PSA can be measured through a simple blood test. Coupled with a digital rectal examination (DRE), PSA is currently the best test for early prostate cancer detection.
Very little PSA enters the bloodstream in men with a healthy prostate. There are several conditions in which the amount of PSA released may be increased. These include benign enlargement of the prostate gland (called BPH), older age, infection or inflammation of the prostate gland (called prostatitis), UTI, instrumentation or surgery on the urinary tract (such as with cystoscopy, catheter placement), and prostate cancer. Ejaculation may also temporarily increase the PSA for 24-48 hours, so abstinence from ejaculation before PSA testing is recommended.
There is no “normal” or “abnormal” PSA level. This is different for each individual, and interpretation of a man’s PSA level needs to take into account his prostate size (often estimated through the DRE) his family history, any symptoms he might have, as well as the trend of prior PSA levels (called the PSA velocity).
The decision to screen for prostate cancer is an important one that each man should make in discussion with his physician after weighing the risks and benefits. The PSA test has been proven in several studies to save lives, and, as the American Urologic Association (AUA) has stated, “provides important information on the diagnosis, pre-treatment staging, risk assessment, and monitoring of prostate cancer patients.”
Talk to a CUC physician today regarding PSA testing, whether it is right for you, and what options exist in your specific situation.
What are Common Symptoms of Prostate Cancer?
Most men diagnosed with prostate cancer do not have any symptoms. Diagnosis occurs after a biopsy done for an abnormal PSA and/or DRE. Some symptoms that can occur include pain in the pelvis and/or hips, blood in the urine or semen, frequent urination, or trouble with urinary stream.
What are the Risk Factors for Prostate Cancer?
- Age: Prostate cancer is more common in older men and risk increases with age.
- Ethnicity: African American men are at much higher risk for prostate cancer than Caucasians, Asians or Hispanics. The reasons for this are not known.
- Positive family history: a family history of prostate cancer is estimated to increase one’s risk by 2-11 times.
- Diet/Lifestyle: There is some evidence that the Western lifestyle increases prostate cancer risk, though the specific reasons are not known. There is some thought that obesity, increased dietary fat, and excess refined sugars play a role, though exactly how is not clear.
Is Prostate Cancer Preventable?
There is controversy as to whether prostate cancer can truly be prevented. Some evidence shows that the alpha-reductase inhibitors (dutasteride [Avodart], finasteride [Proscar]) used in many men with BPH can prevent prostate cancer; randomized, controlled studies demonstrate that men on these drugs were diagnosed with prostate cancer less often. Until recently, Vitamin E and Selenium (ingredients found in many men’s health and prostate health supplements), were thought to be protective. A major study showed that these vitamins had no effect on reducing a man’s risk of prostate cancer. In fact, vitamin E caused a slightly higher risk of prostate cancer, and men on taking selenium had a slightly higher incidence of diabetes. Currently, the best advice is “what is healthy for your heart is healthy for your prostate.” Eat a well-balanced diet that is high in fruits and vegetables and low in saturated fats.
What is the Gleason’s Score?
The Gleason’s score is used in grading prostate cancer. The most common tumor pattern (when looked at under the microscope) is assigned a score from 1 to 5 and the second most common pattern is given a similar score. The total of the two is the Gleason’s score. This score has a positive correlation with the aggressiveness of the cancer. Gleason’s score 2 through 6 are considered mildly aggressive, Gleason’s 7 moderately aggressive, and 8 through 10 highly aggressive.
Prostate Cancer Stages
Like may other cancers, the TNM staging system is commonly used for prostate cancer. T is for the primary tumor, N for lymph node involvement, and M for metastases.
The primary tumor (T) is staged as follows:
- T1-physician cannot feel the tumor
- T1a-less than 5% of cancer found on TURP done for BPH
- T1b-greater than 5% of cancer found on TURP done for BPH
- T1c-cancer found on needle-biopsy done for elevated PSA
- T2-physician can feel a tumor on DRE but it feels confined to prostate
- T2a-cancer is felt in one half or less of one side of the prostate
- T2b-cancer is found in greater than one half of one side of the prostate
- T2c-cancer is felt in both sides of the prostate
- T3-cancer is felt to be outside of the prostate gland
- T3a-cancer extends outside the prostate capsule
- T3b-cancer extends to the seminal vesicles
- T4- cancer has spread to adjacent organs such as sphincter, rectal wall or bladder
Depending on the specific Gleason’s score, PSA level, and DRE findings, a CT scan and bone scan may be ordered to evaluate for metastases. Not every patient requires these.
What are Treatment Options for Prostate Cancer?
Not all prostate cancers are the same and the best treatment can be different for each individual. Current treatment options include active surveillance, radical prostatectomy, radiation therapy, cryotherapy, and androgen deprivation.
Active Surveillance
Some prostate cancers do not require immediate treatment and can be monitored. This involves regular PSA, DRE and prostate biopsies. This approach allows for a better quality of life when the cancer is slow growing, and when there is evidence that the cancer is progressing, a treatment is offered. Not all patients are candidates for this approach, and it typically requires a cancer diagnosed at a very early stage.
Prostatectomy
A prostatectomy involves removing the prostate gland, seminal vesicles, and associated tissues. A prostatectomy can be performed with the da Vinci robot or in an open procedure. The entire prostate gland most be removed because the cancer cells are often scattered throughout the gland in an unpredictable manner. When done robotically, patients typically have a shorter hospital stay, less postoperative pain, and faster return of urinary continence. The surgeons of CUC have performed over 1000 robotic prostatectomies with overall excellent results.
Radiation Therapy and Prostate Cancer
Radiation therapy uses high energy x-rays to kill cancer cells. This can be delivered in several different ways.
- Intensity Modulated Radiation Therapy and Image Guided Radiation Therapy (IMRT and IGRT): the radiation energy is conformed to the tumor and delivered five days per week for an eight week period. Each treatment is only minutes long. Daily imaging of the prostate and surrounding structures can allow for a more precise, focused treatment.
- Brachytherapy: this is short, outpatient surgical procedure in which small radioactive seeds are permanently implanted into the prostate to gradually release radiation and destroy the cancer cells.
- Proton therapy: a form of radiation therapy in which a different form of energy (not standard X-rays) are focused on the prostate.
Androgen Deprivation
Prostate cancer is stimulated by testosterone produced in the testicles. Androgen deprivation involves medications that lower or block the effects of testosterone, which causes the cancer to shrink or slow in its growth. These medications are typically given in injection form. Androgen deprivation cannot cure prostate cancer but it can extend a patient’s life. This treatment is used when a cancer recurs or, in some cases, to supplement radiation therapy.
Advanced Prostate Cancer Treatment
Despite advances in treatment for localized prostate cancer, some patients have their cancer recur or they present with disease that has already spread to other parts of the body. In most of these cases the likelihood of complete cure is low. The cancer can however be controlled through the use of multiple treatment modalities, in some cases, for many years.
Many patients with advanced prostate cancer are seen in our Champions Clinic. This is currently run out of our Lake Barrington facility. The Clinic helps organize patients’ treatment plans, monitor responses to treatments, monitor bone health, and assess for any complications.
Many of the latest advanced treatments for prostate cancer are offered, including androgen deprivation (Lupron and Firmagon), Provenge immunotherapy, Prolia, Xgeva, and Zytiga.
The Champions Clinic is a comprehensive cancer care program incorporating not only the recent medical, surgical and radiation treatments, but also providing resources addressing our patients health and wellness needs. Lifestyle counseling, weight management and exercise programs are available through the Champions clinic. Comprehensive Urologic Care maintains relationships with local palliative care, wellness, and hospice programs and makes referrals to these organizations when appropriate.
Which Prostate Cancer Treatment is Right for me?
Every patient and every cancer is unique. Treatment decisions need to factor in age, medical history, specifics the cancer grade and stage, and treatment goals. It is important to discuss your specific situation with your urologist. If you are interested in discussing prostate cancer and treatment options with a CUC urologist, please contact us to schedule a consultation.