Diagnosis and Treatment
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PROSTATE Cancer
The prostate is a walnut-shaped gland that lies just below the urinary bladder. The prostate gland is one of three primary sex glands in men -- the other two are the testicles and the seminal vesicles. Together, these three glands produce the fluids that make up semen.
The prostate gland surrounds the upper part of the urethra - which is the tube that carries urine from the bladder and semen from the sex glands out through the penis.
As one of a man's sex glands, the prostate is affected by male sex hormones. These hormones stimulate the activity of the prostate and the replacement of the prostate cells as they wear out. The chief male hormone is testosterone, which is produced almost entirely by the testicles.
How is Prostate Cancer Diagnosed?
One of the problems with prostate cancer diagnosis is detection. When a cancerous prostate tumor is small and located only within the prostate itself, it may not cause any symptoms. In fact, a person may live many years with prostate cancer and never know he has it. The tumor may also be too small for a doctor to feel during a routine prostate examination, called a digital rectal examination, (DRE). A doctor performs this examination by inserting a finger into the rectum to feel the size and shape of the prostate.
Since the mid 1980's a test for prostate cancer has been available, called a prostate-specific antigen (PSA) test. PSA is a substance produced by the prostate. When a person has prostate cancer or some other prostate disease, the amount of PSA in the blood often increases, thus indicating a problem. However, this test does not always give a clear picture of what is going on. A person can have prostate cancer, and still have a "low" level of PSA in their blood; conversely, a person can have a "high" PSA level, and not have prostate cancer - as other prostate conditions can also cause it.
For these reasons, different organizations have varying recommendations about screening for prostate cancer. Two of the most well-know and respected are:
The American College of Physicians (ACP), which recommends that rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient's concerns; and then individualize the decision to screen. The College also strongly recommends that physicians help enroll men in ongoing studies that are looking at these issues. For more information from the ACP on prostate cancer screening, click here.
The American Cancer Society (ACS) recommends that beginning at age 50, a prostate examination including a digital rectal exam (DRE) and PSA test should be offered annually to men who have a life expectancy of at least 10 years, and to younger men who are at high risk. Information should be provided to patients about the benefits and risks of screening. The ACS emphasizes the benefits of beginning annual screening at age 45 in certain high-risk populations (e.g., African-American men and men with two or more first-degree relatives with prostate cancer). For more information on the ACS position, click here.
Discussing these recommendations with your doctor will help you understand which choice is best for you.
What Are Symptoms to Look For?
If a person has a prostate cancer tumor, as it grows, it may eventually begin to squeeze the urethra. This will cause difficulty urinating, usually the first symptom of prostate cancer. However, it is important to remember that difficulty urinating can also be caused by other, non-cancerous conditions of the prostate. Other potential warning signs men should be alert to include:
* Frequent urination, especially at night
* Weak or interrupted urine stream
* Pain or burning upon urination or ejaculation
* Presence of blood or pus in the urine or semen
* Discomfort in the lower back, pelvis or upper thighs
If you have such symptoms, it is best to see your doctor right away.
How Are the Stages of Prostate Cancer Determined?
To detect prostate cancer, and/or to determine the size and extent of the spread (or stage) of the disease, your doctor will perform tests that usually involve:
* Feeling the prostate
* Looking at internal parts of the body
* Measuring the level of certain substances in the blood
* Examining samples of prostate cells.
Diagnosis and staging tests/Examinations and visualizations
Digital rectal examination (DRE) Insertion of a gloved, lubricated finger into the rectum to feel the prostate
Chest x-ray - An image that can show whether cancer has spread to the lungs or other structures such as the ribs
Bone scan - A picture that can show whether cancer has spread to the bone
Transrectal ultrasonography (TRUS) - A picture of the prostate and nearby structures that is produced by sound waves directed at the prostate by an instrument inserted into the rectum
Computed tomography (CT) - A picture produced by a computer from x-rays, showing the prostate and other nearby parts of the body
Intravenous pyelogram (IVP) - An x-ray of the kidneys, ureters, and bladder that is taken after the patient had been injected with a special dye.
Magnetic resonance imaging (MRI) - A picture produced by a computer and a high-powered magnet that shows the prostate and other nearby parts of the body
Blood Tests - Prostate-specific antigen (PSA) A test useful both in diagnosis and follow-up of prostate cancer that detects a blood substance that often increases in cases of prostate cancer and other prostate diseases
Tissue samples - Prostate biopsy The removal and microscopic examination of a small sample of a prostate tumor to determine whether it contains cancer cells
Pelvic node dissection (also called lymphadenectomy) - A procedure used to help determine whether prostate cancer has spread--typically done during surgery to remove the prostate
How are Treatment Methods Chosen?
In developing a treatment plan, it is important for you and your doctor to discuss the advantages and disadvantages of each treatment. The benefits of treatment depend on the stage of your cancer, meaning how large the cancer mass is and how far the cancer may have spread. Only by knowing how the cancer is behaving and where it is in the body can you find the best possible treatment for it. Unfortunately, this can be difficult when dealing with prostate cancer. There are currently no tests that identify with absolute certainty the stage of the disease. Instead, your doctor and health care team will use the most current tests available, along with skill and experience, to determine as best they can what stage your cancer is in.
However, despite the difficulty in determining staging, the benefits of prostate cancer treatment can be considerable. If started in an early stage, some treatments may cure the disease. If treatment is started in a later stage, it can extend life and help relieve symptoms. As a result of new and improved procedures, men with prostate cancer are now living longer with less discomfort and fewer treatment-related side effects.
Prostate cancer can be treated by one or more of the following methods:
* "Watchful waiting"
* Surgery
* Radiation therapy
* Hormone therapy
* Chemotherapy
The method selected to treat prostate cancer depends on:
* The stage of the cancer
* The speed of growth of the cancer
* The age and general health of the man with prostate cancer
* How treatment side effects, such as inability to achieve erection or incontinence might affect quality of life and other aspects of health. Possible side effects of treatments should be discussed along with treatment benefits when a course of action is chosen.
All of these factors can and should be discussed thoroughly by you and your doctor before treatment is chosen. For further information, see the next section on questions to ask your doctor.
What Are the Stages of Prostate Cancer?
Below is a brief overview designed to familiarize you with the staging of prostate cancer, and the common treatment choices that accompany each one. (Please note: this chart uses the "TNM" staging system, where "T" refers to the size of the primary tumor, "N" refers to the extent of lymph node involvement, and "M" refers to the presence or absence of metastases. Because some doctors still use the older, "ABCD" system of staging, these equivalents are noted in parentheses.)
Stage of Prostate Cancer Common Treatment Choices
Stage T1 (Stage A)
In this stage, the tumor is located within the prostate only. It causes no symptoms and is too small to be felt during a DRE or to be seen on an imaging scan. These tumors are usually found by chance during surgery for some other prostate disease, or by following up on screening tests that measure PSA.
Sometimes surgery or radiation therapy. In other cases, no treatment at all may be needed. Instead the cancer is simply watched (watchful waiting) by your doctor using regular DRE's and blood tests. Treatment may be started later if necessary.
Stage T2 (Stage B)
The tumor is still located within the prostate but is large enough to be felt during a DRE. There are often no symptoms.
Surgery or radiation therapy. Hormone therapy may also be used in combination with radiation therapy. In some cases, a short course of hormone therapy may be used prior to surgery in order to reduce the size of the prostate and make removal easier.
Stage T3 (Stage C)
The tumor has spread from the prostate into the immediately surrounding tissue, possibly including the seminal vesicles.
Surgery, radiation therapy, or both. In addition, hormone therapy before and after surgery or radiation may be used.
Stage T4 (no equivalent in ABCD)
The tumor is still within the pelvic region but may have spread farther to areas of the bladder or rectum. Same as above.
Stage N+ (Stage D1)
Prostate cancer is described as N+ if prostate cancer cells are detected in the lymph nodes in the pelvic area.
Hormone therapy. Chemotherapy may be used later if hormone therapy is no longer working.
Stage M+ (Stage D2)
A tumor that is M+ has spread beyond the pelvic area to other parts of the body. Bone pain, weight loss, and tiredness are common symptoms. Same as above.
The Grading of Tumors
Your doctor may talk to you about the grade of your tumor. The term "grade" describes the way the cancer tissue looks when seen under a microscope. The most common system used in the USA to grade the appearance of prostate cancer tissue is called the Gleason grading system, after the physician who first described this system. The grade of prostate cancer tissue helps doctors understand how aggressive (that is, fast growing) the prostate cancer cells are, and hence how they can best be treated. For a detailed discussion of the Gleason grading system, click here.
How is Prostate Cancer Treated?
Prostate cancer can be treated in many ways. Each of the specific treatment methods is described below. Being aware of all of the options will help you make an informed choice in collaboration with your health care provider.
Again, the most common treatments are:
* "Watchful waiting"
* Surgery
* Radiation therapy
* Hormone therapy
* Chemotherapy
The goals of treatment are 1) to increase longevity of life and 2) ensure the best possible quality of life. Conversations with your doctor, your partner and/or family should revolve around the balances in these two goals and how they relate to you.
* Watchful Waiting - Don't let the term "watchful waiting" mislead you. It is important to realize that this is a form of treatment. During watchful waiting, your doctor will actively observe the indicators of your disease progression. In certain cases, this may be the best possible approach. Your doctor will order regular testing, such as PSA's and DRE's, as well as other tests, for example a transrectal ultrasonography. Generally, a doctor will prescribe watchful waiting because factors such as age or other health problems make the cancer progression less of a risk than treatment.
Advantages: Watchful waiting has no side effects and therefore avoids problems associated with more aggressive treatment, such as impact on quality of life, or expense. If it turns out the cancer is not especially fast-growing, then the patient has avoided risks of side effects while having little to no effect on life expectancy.
Disadvantages: There is a risk that the cancer will progress and become active, when it might have been cured if it had been removed when it was first found. For a more detailed discussion of "Watchful Waiting" prepared by a survivor of prostate cancer click here.
*Surgery - Surgery can often be used to remove cancer from the prostate and from nearby areas where it has spread. It is used primarily during the early stages (T1, T2) of prostate cancer, when the cancer is located only within the prostate, or immediate areas. Your doctor will probably conduct other tests first to make certain that the prostate cancer has not metastasized (or spread) too far. A common test to check this is a pelvic node dissection (also known as lymphadenectomy).
Surgery may also help prevent further spread of the cancer. If the cancer is small and located exclusively within the prostate, surgery may cure it. When your doctor talks with you about surgery, it may be helpful if you ask to speak with a radiation therapist also, in order to understand those treatment options as well.
A description of the most common surgical procedures follows, with possible advantages and disadvantages.
* Perineal prostatectomy involves removing the cancer through the perineum, the area between the scrotum and the anus. The entire prostate is removed, along with any nearby cancerous areas or tumors.
* Retropubic prostatectomy consists of removing the cancer through the lower abdomen. The entire prostate is removed, and if necessary, nearby pelvic lymph nodes are removed as well. The only difference between this and a perineal prostatectomy is the way the surgeon enters the body to reach the prostate.
* A transurethral resection of the prostate or TURP, involves removing benign tissue from the prostate by inserting an instrument through the urethra in the penis. Only a part of the prostate is removed by this technique. This is usually done to relieve symptoms and make urinating easier. This is a palliative technique, meant to relieve symptoms: it does not cure prostate cancer.
* Cryosurgery is a technique that is receiving new attention as a treatment for prostate cancer. It is a method of freezing the prostate and other affected nearby tissues to very low temperatures with liquid nitrogen. The idea behind this technique is to kill all the prostate cancer cells without having the risks of an invasive surgical procedure. It is a technique that is still being evaluated and researched, and should probably still be considered investigational. If this technique is one you wish to consider, you should find a doctor that has a great deal of experience with this procedure.
Advantages: A prostatectomy is a one-time procedure that may cure prostate cancer in its early stages and may help extend life in the later stages. Surgery avoids the side effects of radiation therapy, which will be discussed in the next section.
Disadvantages: A prostatectomy is, however, a major operation. It requires hospitalization and can produce side effects, including erectile dysfunction (loss of ability to have an erection), incontinence (loss of urinary control) and narrowing of the urethra, which can make urinating difficult. While incontinence occurs in a small percentage of patients, erectile dysfunction occurs in a high percentage of cases. In recent years, however, the percentage of men with having problems with erections following surgery has decreased, because of what is called "nerve-sparing" surgical technique. It is important to remember that a doctor cannot give you a guarantee ahead of time that it is possible to spare the nerves and remove all of the cancer.
*Radiation Therapy - Radiation therapy uses high-energy x-rays to kill prostate cancer cells, shrink tumors, or prevent cancer cells form dividing and spreading. Because the rays cannot be directed with 100% accuracy, they may also damage nearby healthy cells. If the dose of radiation is small and spread out over time, however, the healthy cells are able to recover and survive and the cancer cells eventually die.
Radiation therapy is usually used when prostate cancer has not spread beyond the prostate (Stages T1-T2). It can help prevent the cancer from spreading further. Like surgery, radiation therapy works best when the cancer is located in a small area. In early stages of prostate cancer, radiation therapy may cure the disease. Radiation therapy may also be used alone or in combination with hormone therapy when cancer cells have spread beyond the prostate to the pelvic area (Stages T3-T4), or for pain relief in prostate cancer that is no longer responding to hormone therapy and has spread to the bones (Stage M+). Radiation therapy is a treatment choice for a man who is not a good surgical candidate due to other health factors, or who decides he does not want surgery.
There are two ways in which radiation therapy can be delivered:
* External beam radiation therapy: In this procedure, the x-rays are delivered by a machine, and the radiation is given in brief sessions, usually one session each weekday for several weeks.
* Internal radiation therapy (brachytherapy, also called seed implantation): The rays come from tiny radioactive seeds inserted directly into the prostate. The seeds are inserted while the patient is under anesthesia; they are too small to cause discomfort. They give off rays continually for about a year and remain safely in place for the rest of a person's life. Internal radiation therapy does not make the patient radioactive.
Another method for delivering internal radiation is by injection. This is used to control bone pain in patients with metastasized (Stage M+) prostate cancer that no longer responds to hormone therapy. Radioactive compounds have been found that go directly to the bone and may give dramatic pain relief to many patients with discomfort.
Advantages: It avoids major surgery. Radiation therapy may cure prostate cancer in its early stages and may help extend life in later stages. It rarely causes loss of urinary control, and leads to erectile dysfunction less frequently than does surgery. New injectable radioactive compounds, such as those containing radioactive strontium, can provide pain relief from cancer that has spread to the bone. These new compounds have fewer side effects than do the radioactive phosphorous compounds that were used in the past.
Disadvantages: It can cause a variety of side effects. Most of these are minor and disappear after the therapy stops. These side effects include tiredness, skin reactions in the treated areas, frequent and painful urination, upset stomach, diarrhea, and rectal irritation or bleeding. When an external machine provides radiation therapy, it can cause later development of erectile dysfunction in some patients. Internal radiation therapy causes this problem less often, but may be associate with deceased white blood cell and platelet counts.
* Hormone Therapy - Hormone therapy is most commonly used to treat cancer that has spread (metastasized) outside the pelvic area (Stages N+ and M+). Hormone therapy cannot cure prostate cancer. Instead, it slows the cancer's growth and reduces the size of the tumor or tumors. It can also be used in combination with radiation therapy or surgery when the cancer is in an advanced stage and the disease has spread beyond the prostate (Stages T3-T4). This therapy helps extend life and relieve symptoms.
In patients with early stage cancer (Stage T2), hormone therapy may be used to compliment radiation therapy. A short course of hormone therapy can also be used prior to surgery to reduce the size of the prostate and make it easier to remove.
The goal of hormone therapy is to decrease the production of testosterone by the testicles. Removing male hormones has the effect of "starving" the prostate tumor. Regardless of the method of hormone therapy, however, the decrease in testosterone can result in certain side effects. These commonly include hot flashes, a loss of sexual desire, and inability to or difficulty in achieving an erection.
Methods used to reduce testosterone production or block the actions of testosterone and other male hormones are described below:
* Surgical Removal of the Testicles - An operation called orchiectomy removes the testicles, which produce 95% of the body's testosterone.
Advantages: This is an effective procedure that is relatively simple and performed only once. Often the patient is given a local anesthetic and is allowed to go home the same day as surgery.
Disadvantages: Orchiectomy is a surgical procedure and many patients prefer a nonsurgical option if it will work as well. Many men also find if difficult to accept this type of surgery. It can be compared with a mastectomy for a woman, in that the operation may make a man feel self-conscious about the loss of his testicles. Testicular implants may be an option to discuss with your doctor. Also, depending on the kind of anesthesia used, there may be special risks in certain types of patients. Orchiectomy may in some cases require hospitalization. It is not a reversible procedure.
* Estrogen Therapy - Another method for reducing testosterone, although no longer common, is to administer a female hormone such as estrogen. Female hormones reduce the production of testosterone by the testicles. The most commonly used estrogen in prostate cancer is diethylstilbestrol, or DES.
Advantages: Estrogen therapy is simple and involves taking a pill. Unlike orchiectomy, estrogen does not involve removal of the testicles, and its effects can be reversed.
Disadvantages: Estrogen therapy produces various side effects of its own. Estrogens can cause water retention, embarrassing breast growth and tenderness, and symptoms such as stomach upset, nausea and vomiting. In addition, even low doses of estrogen may significantly increase the risk of heart and blood vessel problems.
* LHRH Therapy - Another method consists of administering a drug called a luteinizing hormone-releasing hormone analogue (or LHRH analogue); this leads to a drop in the production of testosterone. Taking an LHRH analogue works just as well as removal of the testicles but does not involve surgery. Currently available LHRH analogues are Zoladexâ (goserelin acetate) and Lupronâ (leuprolide acetate).
Advantages: Administering LHRH analogue therapy is simple; it involves an injection every 28 days or every 12 weeks. Treatment with LHRH analogues is as effective as orchiectomy, but it does not require surgical removal of the testicles. It also avoids the side effects of estrogen therapy.
Disadvantages: In a small percentage of patients, LHRH analogue therapy may cause a brief rise in cancer symptoms, such as bone pain, before the testosterone level begins to fall. This pain may be eased by the use of a pain reliever (such as aspirin or acetaminophen) or an antiandrogen drug, which is discussed next.
* Antiandrogen Therapy - This therapy involves the use of a drug that blocks the action of male hormones. Such a drug is called an antiandrogen. Antiandrogen drugs are used in combination with LHRH analogue therapy. This combination therapy is commonly known as maximal androgen blockade (MAB) or combined androgen blockade (CAB). The currently available antiandrogens are Casodex® (bicalutamide) and Eulexin® (flutamide).
Advantages: Ongoing clinical trials suggest that men treated with MAB therapy live longer than men treated with LHRH analogue therapy alone. The combined use of an LHRH analogue and an antiandrogen can also be of benefit before or after prostate surgery or radiation therapy.
Disadvantages: Antiandrogens can cause diarrhea, nausea, vomiting and liver injury.
* Chemotherapy is the use of powerful drugs to attack cancer cells. The drugs circulate throughout the body in the bloodstream and, because they are toxic, kill rapidly growing cells. Because cancer cells are rapid growing, they are destroyed by the chemotherapy. Unfortunately, however, some healthy cells are also destroyed in this process. To destroy the most amounts of cancer cells, while minimizing the harm to healthy ones, the drugs are carefully controlled in dosage and frequency.
Because chemotherapy does not work well in many men with prostate cancer, it is generally reserved for patients with advanced stage disease (Stage M+) that no longer responds to hormonal therapy. There are many different chemotherapy drugs, each with its own strengths and weaknesses. Often the drugs are used in combination with one another. EmCyt® (estramustine phosphate) is a frequently used chemotherapy drug in prostate cancer.
Advantages: Chemotherapy drugs provide an additional means of relieving the symptoms of advanced prostate cancer.
Disadvantages: Because the drugs circulate widely throughout the body and affect healthy as well as cancerous cells, they produce many side effects. These include hair loss, nausea, vomiting, diarrhea, lowered blood counts, reduced ability of the blood to clot, and an increased risk of infection. Most of the side effects disappear when the drugs are stopped. (For example, hair usually grows back when chemotherapy is stopped.)