Cancer of the prostate gland is one of the most common types of cancer detected in men. Prevalence of prostate cancer is higher in the older age groups and is more common after the age of 65. The cause of prostate cancer is unknown, although it is known to be hormone related, and a family history is often present. It is also more common in African-Americans and Caucasians than in Asians. There may not be any noticeable symptoms in the early stages and often cancer of the prostate gland is detected incidentally or during a routine screening such as digital rectal examination (DRE) or blood test for prostate-specific antigen (PSA). Early detection gives better treatment results hence routine screening for prostate cancer is very important, especially for those considered as high risk.
How do you know if you have prostate cancer?
Signs and Symptoms of Prostate Cancer
In the early stages of the disease, prostate cancer may not produce any signs or symptoms and therefore goes undetected. It may only come to notice while undergoing routine screening such as digital rectal examination (DRE) or blood test for prostate specific antigen (PSA).
Urinary problems may be present in the early stages, although it is rare, and can be due to pressure by the prostate tumor on the bladder or urethra. In the later stages, symptoms depend on the spread of the cancer. Some signs and symptoms of prostate cancer include :
- Frequent starting and stopping during urination.
- Difficulty in passing urine.
- Weak urine stream.
- Hematuria (blood in the urine).
- Blood in the semen.
- Swelling of the legs and discomfort in the pelvic region may be caused by spread of cancer to the lymph nodes in the pelvis.
- Bone pain, fractures, and compression of the spine may occur due to bone metastasis (spread of cancer to the bones).
These symptoms must be differentiated from other possible causes like an enlarged prostate (BPH or benign prostatic hyperplasia)/
What causes prostate cancer?
Prostate Cancer Causes
The cause of prostate cancer is not known but various factors may be implicated, such as :
- Age – prostate cancer is more common in older men, especially in those over 65 years of age.
- Hereditary – a family history of prostate cancer increases the risk of developing the same.
- Ethnicity – African-Americans and Caucasians have more chances of developing prostate cancer than Asians.
- Obesity and a high-fat diet may increase the risk of prostate cancer.
- Hormones – the growth of cancer of the prostate is hormone related. High levels of testosterone, especially in those undergoing testosterone therapy is implicated in the development of prostate cancer.
- Occupation – men working in the rubber industry or those exposed to cadmium are more at risk.
How is prostate cancer detected?
Diagnosis of Prostate Cancer
Since prostate cancer in the early stages rarely produce any symptoms, routine screening for prostate cancer is advisable for all men over the age of 50, and those men at higher risk should get routine screening done from the age of 40.
- Digital rectal examination (DRE) to detect any variation in shape, size or consistency of the prostate gland from the norm, which may merit further testing
- Prostate-specific antigen (PSA) test – a small amount of PSA is present in the blood, but higher levels may indicate prostatitis, benign prostatic hyperplasia (BPH) or prostate cancer.
Further tests may be done if there is cause for concern after doing the above tests.
- Transrectal ultrasound (TRUS) may be conducted to estimate the size of the prostate gland and may help to diagnose prostate cancer.
- Prostate biopsy may be done in suspected cases of cancer of the prostate. Fine needle aspiration of prostate tissue from the suspected area is sent for microscopic examination to determine if the cells are cancerous.
More tests may determine the extent of spread of prostate cancer.
- Ultrasound – to evaluate whether the cancer has spread to nearby tissues.
- Bone scan – to determine spread of cancer or metastasis to the bones.
- Imaging techniques such as computerized tomography (CT) scan and magnetic resonance imaging (MRI) may help to detect spread of cancer to the bones, lymph nodes and other tissues.
- Lymph node biopsy – of enlarged lymph nodes may reveal infiltration of the lymph nodes by cancer cells.
How is prostate cancer graded?
Grading of Prostate Cancer
Grading is done to evaluate the aggressiveness of the cancer cells, which will determine how quickly they are likely to grow and spread. After confirmation of cancer by biopsy, the cancer cells are compared with normal healthy prostate cells to determine their aggressiveness, depending on how different they are from the healthy cells. The prostate cancer cells are graded as per the Gleason score, with the score ranging from 2 (nonaggressive cancer) to 10 (very aggressive cancer).
What are the stages of prostate cancer?
Staging of Prostate Cancer
Based on if and how far the cancer has spread, staging of prostate cancer is done.
- Stage 1 – very early cancer, which cannot be detected except under the microscope.
- Stage 2 – the cancer may be felt by the examining finger but it is confined within the prostate gland.
- Stage 3 – the cancer has spread beyond the prostate gland to the surrounding tissues and seminal vesicles.
- Stage 4 – the cancer has spread widely, to the lymph nodes, bones, lungs, or other organs.
What are the complications of prostate cancer?
Prostate Cancer Complications
Complications of prostate cancer may occur either due to the cancer or as a result of its treatment.
- Spread of cancer – the cancer can spread to the nearby organs or tissues or may spread to the bones, lungs or other organs. Treatment may be done by hormone therapy, radiotherapy, and chemotherapy.
- Pain – spread of cancer to the bones may cause severe bone pain. Pain relievers may help and some relief is also produced by treatment of the cancer itself.
- Fractures and spinal compression – may occur due to spread of disease to the bones and spine.
- Urinary incontinence – may be due to prostate cancer as well as its treatment. Management will depend upon the severity and type of incontinence.
- Impotence or erectile dysfunction (ED) – prostate cancer or its treatment may be the cause. Side effects of surgery, radiation or hormone treatment may be the cause of impotence but medications such as sildenafil, tadalafil and vardenafil may help to combat this problem.
- Depression – this is normal after a diagnosis of cancer, and treatment such as counseling and antidepressants may be required.
How is prostate cancer treated?
Prostate Cancer Treatment Options
Treatment of prostate cancer depends on several factors, such as
- Age of the patient
- Life expectancy
- Stage or spread of the cancer
- Grade or aggressiveness of the cancer
- Benefits or side effects of the type of treatment to be undertaken.
Combination treatments, such as radiation following surgery or radiation along with hormone therapy give good results in most cases.
The types of treatment available for prostate cancer are :
External beam radiation therapy (EBRT)
High powered x-rays are used to kill the cancer cells effectively, but during this procedure some healthy surrounding tissue may be damaged too. Treatment may need to be given five days a week for eight weeks, the duration of each radiation being about a minute. Mild side effects such as urgency, frequent urination, loose motions, bleeding from the rectum, or discomfort while passing stool may occur during radiation therapy but they normally disappear on completion of treatment.
Radioactive seed implants
About 40 to 100 tiny rice-sized radioactive seeds, containing one of several radioactive isotopes such as iodine or palladium, are implanted into the prostate by means of ultrasound-guided needles. This procedure is done under general anesthesia and may take one to two hours, but overnight hospital stay is not necessary. Hormone therapy may need to be done for a few months previously to reduce the size of the prostate. The implants deliver high dose of radiation over a longer period of time, as it takes about a year for the radiation inside the implants to be exhausted. This form of therapy is effective in patients with small or moderate sized prostate and with low grade prostate cancer. Side effects may include frequent and painful urination, discomfort while passing stool, loose motions, and impotence.
Hormone therapy
Since the male sex hormone testosterone is thought to be involved in stimulating growth of cancer cells in prostate cancer, drugs are used either to decrease the production of testosterone or to block the body’s ability to use this hormone. In advanced cases, hormone therapy can help to reduce the size of the prostate and also slow down the growth of the tumor. In early cases, hormone therapy may be used to reduce the size of the prostate so that subsequent surgery or radiation is made easier. Hormone therapy may also be used in combination with surgery or radiation therapy for treatment of prostate cancer. Hormone injections of leuprolide or goserelin can be injected into a muscle or under the skin every three to four months, or drugs such as bicalutamide or nilutamide may be taken in oral form.
Surgery to remove the testes, which produce most of the testosterone in the body, may be taken as another form of hormone therapy, and can be done under local anesthesia as an out-patient procedure.
Side effects of hormone therapy may include :
- Enlargement of breast (gynecomastia)
- Impotence or erectile dysfunction
- Weight gain
- Hot flushes
- Reduced sex drive
- Nausea
- Excessive tiredness
- Diarrhea
- Liver damage
- Increased risk of heart attack
Radical prostatectomy
If the cancer is detected while it is still confined within the prostate gland, radical prostatectomy may be done, which involves removal of the prostate gland along with the nearby lymph nodes. Two methods of approach are available for this type of surgery :
- Retropubic surgery – the prostate gland is removed through an incision in the lower abdomen, just below the umbilicus. This method is ideal since it gives easy access to the prostate, as well as allowing removal of the lymph nodes through the same incision.
- Perineal surgery – in this method, the incision is given in the perineal region between the anus and the scrotum. Although there is less bleeding and early recovery with this type of surgery, the lymph nodes cannot be removed with this type of incision.
Side effects of radical prostatectomy may include urinary incontinence and erectile dysfunction.
Robot-assisted laparoscopic radical prostatectomy (RALRP)
In this procedure, five small incisions are made in the abdomen through which a laparoscope (a long tube with a camera at the end) and other instruments which are attached to a mechanical device are inserted into the abdomen. The camera gives a magnified view of the surgical field to enable the surgeon to perform the operation by guiding the instruments precisely.
This form of surgery is relatively new so long term effects of treatment are yet to be monitored.
Expectant therapy
Expectant therapy or watchful waiting is an option for treatment where actually no active treatment is done – neither medication, surgery nor hormone therapy is initiated. Regular blood tests for PSA, digital rectal examination (DRE), and biopsies may be done to note any progress of the prostate cancer. Also called observation or deferred therapy, watchful waiting is preferred by some men in whom routine PSA test detected very early prostate cancer, where there are no symptoms, and the cancer is confined to a very small area with very slow expected growth. Expectant therapy may be indicated in elderly patients with very poor health.
Chemotherapy
Use of chemicals to destroy the cancer cells is an effective means of treatment, but due to its numerous side effects, chemotherapy is used only in cases of hormone-resistant prostate cancer with metastasis to other parts of the body.
Cryotherapy
The method of treatment is to destroy the cancer cells by freezing the tissue. More studies are necessary to evaluate the success of cryotherapy as a treatment for cancer of the prostate.
Gene therapy and immune therapy
These forms of therapy are still in the experimental stage and are limited to only a few centers, but they hold promise for treatment of prostate cancer in the future.
What is the prognosis for prostate cancer patients?
Prostate Cancer Prognosis
Prognosis of prostate cancer is strongly dependent upon the grade of the tumor and seminal vesicle involvement is an important indicator for prognosis. Always consult with your doctor about your options and prognosis. For further information on prostate cancer, support and new developments on the fight against prostate cancer, visit the Prostate Cancer Foundation website.
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