Prostate Cancer: Screening and Treatment

Prostate cancer is malignancy of the small, walnut-sized gland that produces semen, the fluid that nourishes and transports sperm. Prostate cancer is one of the most common types of cancer in men, affecting about one in six men in the United States. A diagnosis of prostate cancer can trigger anxiety, not only because prostate cancer can be life-threatening, but also because treatments can cause side effects such as bladder control problems and erectile dysfunction (impotence). Fortunately, both diagnostic methods and treatment techniques for prostate cancer have dramatically improved since the 1980's.

Prostate cancer usually grows slowly and initially remains confined to the prostate gland. While some types of prostate cancer may need minimal or no treatment, other types are aggressive and can spread quickly. If prostate cancer is detected early — when still confined to the prostate gland — the likelihood of successful treatment is excellent.

Signs & Symptoms

Prostate cancer usually does not produce any noticeable symptoms in its early stages. Consequently, some cases of prostate cancer are not detected until the cancer has spread beyond the prostate. Most often, prostate cancer is first detected during routine screening with a prostate-specific antigen (PSA) test or a digital rectal exam (DRE).

Early signs and symptoms of prostate cancer can include urinary problems, caused when the prostate tumor presses on the bladder or on the tube that carries urine from the bladder (urethra). However, urinary symptoms are much more commonly caused by benign prostate problems, such as an enlarged prostate (benign prostatic hyperplasia) or prostate infections. Less than 5 percent of cases of prostate cancer have urinary problems as the initial symptom. When urinary signs and symptoms do occur, they can include:

  • Trouble urinating
  • Starting and stopping while urinating
  • Decreased force of the urine stream
  • Blood in urine
  • Blood in semen

Prostate cancer that has spread to the lymph nodes in the pelvis may cause:

  • Swelling in the legs
  • Discomfort in the pelvic area
  • Blockage of the ureters (tubes draining urine from kidneys) causing kidney failure

Advanced prostate cancer that has spread to bones can cause:

  • Bone pain that does not go away
  • Bone fractures
  • Compression of the spine

Risk Factors for Developing Prostate Cancer

  • Age. After age 50 the incidence of prostate cancer increases.
  • Race or ethnicity. For reasons that are not well understood, black men have a higher risk of developing and dying of prostate cancer.
  • Family history. If a man’s father or brother has prostate cancer, his risk of the disease is greater than that of the average man.
  • Diet. A high-fat diet and obesity may increase the risk of prostate cancer. One theory is that fat increases production of the hormone testosterone, which may promote the development of prostate cancer cells. Other dietary factors are under active investigation.

Prevention

  • Eat well. High-fat diets have been linked to prostate cancer. Therefore, limiting one's intake of high-fat foods and emphasizing fruits, vegetables and whole fibers may help reduce risk. Foods rich in lycopene, an antioxidant, also may help lower prostate cancer risk. These foods include raw or cooked tomatoes, tomato products, grapefruit and watermelon. Garlic and some vegetables such as arugula, bok choy, broccoli, Brussels sprouts, cabbage and cauliflower also may help fight cancer.
  • A study has found that supplemental vitamin E and selenium do not reduce the risk of developing prostate cancer.
  • Get regular exercise. Regular exercise can help prevent a heart attack and conditions such as high blood pressure and high cholesterol. When it comes to cancer, the data aren't as clear-cut, but studies do indicate that regular exercise may reduce cancer risk, including prostate cancer. Exercise has been shown to strengthen the immune system, improve circulation and speed digestion — all of which may play a role in cancer prevention. Exercise also helps to prevent obesity, another potential risk factor for some cancers. Regular exercise may also minimize urinary symptoms and reduce the risk of prostate gland enlargement, or benign prostatic hyperplasia (BPH). Men who are physically active usually have less-severe symptoms than do men who get little exercise.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) might prevent prostate cancer. These drugs include ibuprofen (Advil, Motrin, others) and naproxen (Aleve). NSAIDs inhibit an enzyme called COX-2, which is found in prostate cancer cells. More studies are needed to confirm whether NSAID use actually results in lower rates of prostate cancer or reduced deaths from the disease.
  • 5 Alpha-reductase inhibitors. Research has shown that the drugs dutasteride (Avodart) and finasteride (Proscar) reduce the likelihood of developing prostate. These drugs are currently FDA-approved to control prostate gland enlargement. At this time, these drugs are not routinely prescribed to prevent prostate cancer.

Screening & Diagnosis of Prostate Cancer in PA

  • Digital rectal exam (DRE). During a DRE, the doctor inserts a gloved, lubricated finger into the rectum to examine the prostate, which is adjacent to the rectum. If your doctor finds any abnormalities in the texture, shape or size of your gland, more tests likely will be recommended.
  • Prostate-specific antigen (PSA) test. A blood sample is drawn from a vein and analyzed for PSA, a substance that's naturally produced by your prostate gland to help liquefy semen. It's normal for a small amount of PSA to enter your bloodstream. However, if a higher than normal level is found, it may be an indication of prostate infection, inflammation, enlargement or cancer. Screening with PSA and DRE can help identify cancer at an early stage.
  • Transrectal ultrasound. If other tests raise concerns, a transrectal ultrasound might be utilized to further evaluate the prostate gland. A small probe, about the size and shape of a cigar, is inserted into the rectum. The probe uses sound waves to image the prostate gland.
  • Prostate biopsy. If initial test results suggest prostate cancer, prostate biopsy will be recommended. Following application of local anesthesia, the ultrasound probe is inserted into the rectum. Guided by the ultrasound images, a spring-propelled needle is used to retrieve six to twelve thread-like pieces of prostate gland tissue. A pathologist evaluates the samples. The pathologist determines if cancer is present. If cancer is found, the pathologist grades the aggressiveness of the cancer with a Gleason score.

What If Prostate Cancer Is Found?

Determining how far the cancer has spread
Once a cancer diagnosis has been made, further tests will be obtained to determine if the cancer has spread. Some men don't require additional studies and can directly proceed with treatment based on the characteristics of their tumors and the results of their pre-biopsy PSA tests.

  • Bone scan. A bone scan evaluates the skeleton in order to determine whether cancer has spread to the bone.
  • Computerized tomography (CT) scan. A CT scan attempts to determine if the prostate cancer has spread to the tissues adjacent to the prostate gland, to the pelvic lymph nodes, to other organs or to the skeleton.
  • Magnetic resonance imaging (MRI). An MRI is an alternative to a CT scan.

Prostate Cancer Grading (The Gleason Score)
When a biopsy confirms the presence of cancer, the next step, called grading, is to determine how aggressive the cancer is. The tissue samples are studied, and the cancer cells are compared with healthy prostate cells. The more the cancer cells differ from the healthy cells, the more aggressive the cancer and the more likely it is to spread quickly.

The pathologist identifies the two most aggressive types of cancer cells when assigning a grade. The most common scale used to evaluate prostate cancer cells is called a Gleason score. Based on the microscopic appearance of cells, individual ratings from 1 to 5 are assigned to the two most common cancer patterns identified. These two numbers are then added together to determine your overall score. Scoring can range from 2 (nonaggressive cancer) to 10 (very aggressive cancer).

Staging
After the level of aggressiveness of your prostate cancer is known, the next step, called staging, determines if or how far the cancer has spread. Your cancer is assigned one of four stages, based on how far it has spread:

  • Stage T1. Signifies very early cancer that was suspected by PSA elevation but cannot be felt on finger examination of the prostate.
  • Stage T2. The cancer can be felt, but it remains confined to the prostate gland.
  • Stage T3. The cancer has spread beyond the prostate to the seminal vesicles or other nearby tissues.
  • Stage T4. Cancer has spread to neighboring structures such as the bladder
  • Stage N+. Cancer has spread to regional lymph nodes
  • Stage M+. Cancer has spread distantly (bones, liver).

Bucks County Prostate Cancer Treatment Options

Multiple options exist to treat prostate cancer. For some men a combination of treatments — such as surgery followed by radiation or radiation paired with hormone therapy — works best. The treatment that's best for each man depends on several factors. These include how fast the cancer is growing, how much it has spread, a man’s age and life expectancy, as well as the benefits and the potential side effects of the treatment. The most common treatments for prostate cancer include the following:

Watchful waiting/Active Surveillance
Prostate cancer is often diagnosed at a very early stage. This allows some men, particularly those over 70 years old, to choose watchful waiting as a treatment option. In watchful waiting (also known as observation, expectant therapy, deferred therapy or active surveillance), repeat PSA tests, rectal exams and periodic biopsies will be performed to monitor progression of the cancer.

Watchful waiting may be an option if prostate cancer isn't causing symptoms, is expected to grow very slowly, and is small and confined to one area of the prostate. Watchful waiting may be particularly appropriate for those who are elderly, in poor health or both. Many such men will live out their normal life spans without treatment and without the cancer spreading or causing other problems.

Hormone therapy

Prostate cancer cells are fueled by testosterone, the principal male hormone. Testosterone is manufactured mostly by the testicles. The brain sends a signal to the testicles to produce testosterone. By blocking the signal from the brain to the testicles, testosterone production is turned off. With dramatically reduced testosterone levels, prostate cancer cells go into remission.

Drugs commonly used in this type of hormone therapy known as LH-RH agonists, such as leuprolide (Lupron). Such agents are injected into a muscle or under the skin once every three or four months. They can be administered so that they act continuously or intermittently for a defined period or for the rest of a patient's life, depending on the specific situation.

Other drugs used in hormone therapy block the body's ability to use testosterone, known as anti-androgens. Examples of anti-androgens include bicalutamide (Casodex) and nilutamide (Nilandron). They are oral medications, taken daily. These drugs typically are given along with an LH-RH agonist.

In most men with advanced prostate cancer, hormone treatment is effective in helping both shrink the cancer and slow the growth of tumors. Sometimes doctors use hormone therapy in early-stage cancers to shrink large tumors so that surgery or radiation can remove or destroy them more easily. In some cases, hormone therapy is used in combination with radiation therapy or surgery. After these treatments, the drugs can slow the growth of any stray cancer cells left behind.

Depriving prostate cancer of testosterone usually does not kill all of the cancer cells. Within a few years, some cancer cells again begin to grow even without testosterone. Once this happens, hormone therapy is less effective. When cancer becomes "hormone-resistant" or "hormone-refractory", other options such as chemotherapy can be considered.

Side effects of hormone therapy can include:

  • Reduced sex drive
  • Erectile dysfunction
  • Hot flashes
  • Weight gain
  • Reduction in muscle and bone mass
  • Breast enlargement (gynecomastia)
  • Fatigue
  • Increased risk of diabetes or heart disease

External beam radiation therapy (EBRT) / Intensity-modulated radiation therapy (IMRT)
Radiation treatment uses high-powered X-rays to kill cancer cells. Radiation is effective at destroying cancerous cells, but it can also damage or scar adjacent, healthy tissues.

The first step in radiation therapy is to consult with a radiation oncologist, a physician who treats patients with radiation. Computer-imaging software helps your doctor find the best angles to aim the beams of radiation. Precisely focused radiation kills cancer in the prostate while limiting radiation exposure to surrounding tissues such as the rectum and bladder.

Treatments generally are given five days a week for eight weeks. Each treatment appointment takes approximately 10 minutes. However, much of this is preparation time — radiation is received for only about one minute. No anesthesia is required for external beam radiation, because the treatment cannot be felt at the time of radiation delivery.

A patient is asked to arrive for radiation therapy with a full bladder. This will push most of the bladder out of the path of the radiation beam. A body supporter holds the patient in the same position for each treatment. Small ink tattoos or internal gold markers are used to guide the radiation beam so that it hits the same targets each time. Custom-designed shields help protect nearby normal tissue, such as the bladder, erectile tissues, anus and rectal wall.

Pelvic radiation increases the likelihood of developing either bladder or rectal cancers. Radiation typically cannot be followed by surgery due to the qualitative alteration of the integrity of the tissues of the urinary tract.

Side effects of EBRT/IMRT can include:

  • Urinary problems. Radiation causes inflammation and irritation of the bladder and urethra in the short term. In the long term, the bladder and urethra often lose elasticity and resilience. The most common signs and symptoms are urgency to urinate and frequent urination. These problems usually are temporary and gradually diminish within a few weeks after completing treatment. A minority of patients experience chronic, long-term problems such as incontinence, frequency, nocturia, urgency or episodic blood in the urine. Urge-type urinary incontinence is the most common type of permanent of post-radiation incontinence. Hospitalization and surgery are sometimes required to address these complications.
  • Loose stools, rectal bleeding, discomfort during bowel movements or a sense of needing to have a bowel movement (rectal urgency) occur in some patients. In most cases these problems eventually resolve. Incontinence of stool occasionally occurs. For long-term rectal symptoms, medications can help. Rarely, men develop persistent bleeding or a rectal ulcer after radiation. Surgery may be necessary to alleviate these problems.
  • Sexual side effects. Radiation therapy doesn't usually cause immediate sexual side effects such as erectile dysfunction, but most men who have undergone radiation treatment experience sexual problems within two years of treatment.

Radioactive seed implants (Brachytherapy)
Radioactive seeds implanted into the prostate gained popularity in the 1990’s as a treatment for prostate cancer. The implants, also known as brachytherapy, deliver a higher dose of radiation than do external beams, delivered over the course of several months. The therapy is generally used in men with smaller or moderate-sized prostates with small-volume, and lower grade cancers.

During the procedure, between 40 and 100 rice-sized radioactive seeds are placed into the prostate through ultrasound-guided needles. The implant procedure typically lasts one to two hours and is done under general anesthesia. Most men can go home the day of the procedure. Sometimes, hormone therapy is used for a few months to shrink the size of the prostate before seeds are implanted. The seeds contain radioactive isotopes — either iodine or palladium. These seeds don't have to be removed after they stop emitting radiation. Iodine and palladium seeds generally emit radiation that extends only a few millimeters beyond their location. This type of radiation isn't likely to escape the body in significant doses. However, doctors recommend that for the first few months you stay at least six feet (1.83 meters) away from children and pregnant women, who are especially sensitive to radiation. All radiation inside the pellets is generally exhausted within a year.

Side effects of radioactive seed implants can include:

  • Urinary problems. Radiation causes inflammation and irritation of the bladder and urethra in the short term. In the long term, the bladder and urethra often lose elasticity and resilience. The most common signs and symptoms are urgency to urinate and frequent urination. Men can also experience slow and painful urination. Most men need medications and some men need to perform intermittent self-catheterization to help them urinate. Total urinary retention requiring long-term catheterization or surgery can occur. Urge-type urinary incontinence is the most common type of permanent of post-radiation incontinence.
  • Sexual problems. Most men eventually experience erectile dysfunction due to radioactive seed implants.
  • Rectal symptoms. Sometimes this treatment causes loose stools, discomfort during bowel movements or other rectal symptoms. However, rectal symptoms from radioactive seed implants are generally less severe than with external beam radiation.

Radical prostatectomy
Surgical removal of the prostate gland, called radical prostatectomy, is used to treat cancer that is confined to the prostate gland. During this procedure, the surgeon uses precise techniques to completely remove the prostate, gland, seminal vesicles and possibly lymph nodes. Three surgical approaches are available for prostatectomy — retropubic, perineal and robotic-assisted laparoscopic.

  • Retropubic surgery. The gland is taken out through an incision in the lower abdomen that typically runs from the navel to the pubic bone, just above the base of the penis. This surgical approach has largely been replaced by robotic-assisted laparoscopic prostatectomy.
  • Perineal surgery. An incision is made between the anus and scrotum. The perineal prostatectomy has been performed for 100 years, and is the most mature surgical approach. It provides the most direct access to the prostate gland. A perineal prostatectomy typically can be completed in less than two hours. Nerve-sparing can be readily accomplished by this approach. Preservation of urinary control (continence) is often best with the perineal approach due to less disruption of the supportive structures of the urethra and bladder. Bleeding and pain are usually modest. Hospitalization typically is two days. For men who have had previous pelvic surgeries or who are significantly overweight, the perineal approach is often the best. With this procedure, the surgeon isn't able to remove regional lymph nodes. The surgeons at Central Bucks Urology have collectively performed more that one thousand perineal prostatectomies.
  • Robot-assisted laparoscopic surgery. Robotic prostatectomy is the newest surgical approach. Since its introduction in 2001, robotic surgery has become the most popular technique. In robotic prostatectomy, five 1/3 to ½ inch laparoscopic ports are inserted into the abdomen. A high-definition, 3-D camera provides unparalleled, ten-fold magnified visualization. The Intuitive Surgical da Vinci Robotic Surgical System (www.davinciprostatectomy.com) is controlled by the operating surgeon. The advantages that the robotic system provides has led to its rapid adoption over the past few years, largely displacing standard, retropubic surgery as well a conventional laparoscopic prostate surgery; the majority of prostatectomies performed in the United States are now done utilizing the da Vinci robotic system. The surgeons at Central Bucks Urology have been operating with the da Vinci robotic system since 2008.

During any type of operation, a catheter is inserted into the bladder through the penis to drain urine from the bladder during recovery. The catheter remains in place for one to two weeks after the operation while the urinary tract heals.

Side effects of radical prostatectomy can include:

  • Bladder control problems (urinary incontinence). These symptoms can last for weeks or even months, but most men eventually regain bladder control. Many men experience stress incontinence, meaning they are unable to hold urine flow when their bladders are under increased pressure. This can happen during sneezing, coughing, laughing or lifting. In approximately 5% of men, urinary incontinence does not return completely.
  • Erectile dysfunction. This is a common side effect of radical prostatectomy, because nerves on both sides of the prostate that control erections may be disrupted or removed during surgery. Most men younger than age 50 who have nerve-sparing surgery are able to achieve erections afterward, and even some men in their 70s are able to maintain normal sexual functioning. Men who had trouble achieving or maintaining an erection before surgery have a higher risk of being impotent after the surgery.

Chemotherapy
This type of treatment uses chemicals that destroy rapidly growing cells. Chemotherapy can be effective in treating prostate cancer, but it is not yet capable of curing prostate cancer. Because it has more side effects than hormone therapy does, chemotherapy is reserved for men who have hormone-resistant prostate cancer that has spread to other parts of the body.

Cryotherapy
This treatment is used to destroy cells by freezing tissue. Cryotherapy involves inserting a probe into the prostate through the skin between the rectum and the scrotum (perineum). Using a specialized probe, the prostate is frozen in an attempt to destroy cancer cells. This method can damage the tissues of the urethra, bladder or rectum. Although progress continues, more time is needed to determine how successful cryotherapy may be as a treatment for prostate cancer.

Gene therapy and immune therapy
In the future, gene therapy or immune therapy may be successful in treating prostate cancer. Current technology limits the use of these experimental treatments to a small number of medical centers.


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