Procedure

Prostate Cancer Treatment- Cancer/Oncology

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Prostate cancer is the second most deadly cancer in men (just after lung cancer). However much progress has been made, early diagnosis and treatment carry a favorable prognosis.

The prostate

The prostate is a gland found in men just below the urinary bladder, and it’s shaped like a walnut. It surrounds the bladder outlet and urethra (where urine is supposed to go out), so most problems in the prostate can cause urinary symptoms. The gland is responsible for producing the seminal fluid (or semen), which is a fluid that nourishes your sperm and helps it move. Testosterone plays an important role in regulating the prostate’s function. The prostate usually weighs around 30 grams and it gets larger with age, and that’s why most prostate problems happen in older men.

What’s prostate cancer?

Prostate cancer happens when abnormal cancerous cells start to multiply in the prostate and grow uncontrollably to become a tumor. It can remain localized in the prostate or, in more advanced cases, it can spread to other regions of the body (metastasis). Prostate cancer can have varying levels of aggressiveness in each individual, so doctors usually classify it as either aggressive (fast-growing) or non-aggressive (slow-growing) prostate cancer. Aggressive prostate cancer tends to grow very fast and spread to other regions of the body, like bones.

Symptoms

Depending on how aggressive the cancer is, you might experience a different range of symptoms. In men who have slow-growing cancer, there might not be any symptoms at all early on. Different symptoms that may accompany prostate cancer include:

  • Urinary problems: Since the prostate gland surrounds the urethra (the passage through which urine passes outside the body), many of the symptoms that occur when a tumor grows in the prostate are related to urination. These include:
    • Going to the bathroom too frequently
    • Waking up at night to pee (nocturia)
    • Straining when urinating
    • Blood in the urine (hematuria)
    • Dribbling after urination
    • Incontinence
  • Sexual problems: Since the prostate is a part of the man’s sexual physiology, and is anatomically in close proximity to the nerve bundles that affect sexual function, some men with prostate cancer might develop sexual problems. One of the problems is erectile dysfunction (or sexual impotence), which means that the man cannot develop or maintain an erection hard enough to complete a satisfactory sexual act. Another sex-related symptom is seeing blood in the semen (hematospermia).
  • Pain: If prostate cancer spreads to the bone it can cause significant pain in areas like the lower back, hip, pelvis, and chest.
  • Numbness: If cancerous cells metastasize to the spinal cord they might affect the nerves supplying your lower limbs and cause numbness in the legs and loss of bladder sensation.

In most cases, urinary problems are the earliest signs of prostate cancer. These symptoms are very similar to what men experience in non-cancerous prostate enlargement (Benign Prostatic Enlargement or BPH) or prostate inflammation (prostatitis). That’s why it is important to visit your urologist or general practitioner when you have any of the symptoms listed above.

Risk factors

Doctors have identified a few risk factors that make you more likely to develop prostate cancer:

  • Older ager
  • A family member with prostate cancer
  • African American ethnicity
  • Obesity
  • Certain genetic mutations
  • Smoking

Diagnosis

First, your doctor will ask about your symptoms, sexual health, and any urinary complaints to assess the possible risk of prostate cancer. If your doctor suspects that you might have prostate problems, or you both agree that you want to screen for prostate cancer, he/she might perform one or more of the following tests:

  • Digital rectal examination (DRE): This is usually a routine test performed by urologists on older men. In this test, your doctor inserts a gloved and lubricated finger into the rectum to try to feel the prostate. They will try to identify any lumps or nodules, assess how firm the gland is, and estimate its size. The test might be a little uncomfortable, however, it’s not painful and provides your doctor with very important information.
  • Prostate-specific antigen (PSA) testing: PSA is a molecule produced by the prostate gland and it helps doctors know if there are any prostate problems. PSA normally rises as men age and it can also be elevated in most prostate problems, like benign prostatic hyperplasia, prostatitis, and prostate cancer. An elevated PSA level might warrant further testing.
  • Transrectal prostate biopsy: If your doctor suspects that you might have prostate cancer based on the DRE and PSA level, he/she might order a prostate biopsy. The biopsy is taken using a thin catheter inserted through the rectum under ultrasound guidance and the tissue samples are then sent to the lab for testing. The pathologist will determine the “Gleason Score” of the tissue, which is a score based on the appearance and characteristics of the biopsied prostate cells. The Gleason score is correlated with your PSA level to determine how aggressive your prostate cancer is.
  • Imaging tests: Your doctor might order an MRI, CT, or bone scan to check the extension of your prostate cancer and see if there is any metastasis.

Screening

In most cases, prostate cancer is non-aggressive and grows very slowly, so screening is not usually mandatory, especially since PSA levels can indicate a wide range of prostate problems, or even non at all. This could lead to a higher likelihood of misdiagnosis and unnecessary treatment of prostate cancer. Therefore, most authorities recommend leaving the choice of whether to screen or not to the patient’s personal preference after discussing the risks and benefits of screening with their urologist.

Treatment

Once prostate cancer has been confirmed, your doctor will discuss a treatment plan with you, and it will mainly be based on your age, health, and Gleason score. In many cases where the prostate cancer is found to be non-aggressive, your doctor might recommend watchful waiting. This means that you will receive no treatment, and instead will come in regularly for check-ups to make sure that the cancer is not progressing. If at any point the prostate cancer is found to be progressing, your doctor will start you on a treatment plan. Prostate cancer treatment can involve one or more of the following:

  • Surgery: surgical removal of the prostate and surrounding lymph nodes can be done. The surgery is called “radical prostatectomy”. It can be performed by traditional surgery, laparoscopic surgery, or robot-assisted surgery.
  • Radiation therapy: In some cases, radiation therapy might be considered in addition to surgery. There are several forms that include external beam radiation, brachytherapy, and stereotactic radiotherapy.
  • Hormone therapy: Drugs that suppress testosterone might be prescribed and they can reduce the tumor size and slow its growing
  • Chemotherapy: Different pharmacological agents might be prescribed to treat prostate cancer
  • Immunotherapy: Drugs that stimulate the immune system to kill cancer cells

Outlook

In most cases, prostate cancer is slow-growing and not aggressive, however, it needs constant monitoring. If the cancer is detected early and proper treatment is initiated, the prognosis is usually favorable. If the diagnosis is delayed and the prostate cancer is aggressive, it might spread to other regions of the body, which might affect the treatment outcome. In any case, you should be aware of the symptoms of prostate cancer and never delay checking up with your physician if any concerning symptoms arise.

Sources:

  • cancer.org/cancer/prostatecancer/moreinformation/prostatecancerearlydetection/prostate-cancer-early-detection-acs-recommendations
  • uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate-cancer-screening1#consider
  • ajph.aphapublications.org/doi/abs/10.2105/AJPH.2008.150508
  • cancer.gov/cancertopics/types/prostate
  • screeningforprostatecancer.org/read-the-materials/
  • cancer.org/cancer/prostatecancer/detailedguide/prostate-cancer-diagnosis
About the Author:
Mersad Alimoradi is a medical doctor specializing in general surgery, with a big interest in academia. He is passionate about spreading medical knowledge and making it accessible to everyone. He has received his medical degree from the Lebanese University, in Beirut, and currently works as a physician and researcher in the country's university hospitals.
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