General information about prostate cancer
The information below is provided courtesy of the Prostate Cancer Foundation.
The prostate is a walnut-sized gland located between the bladder and the penis and in front of the rectum. The urethra, the tube which carries urine from the bladder and out of the body through the penis, passes through the center of the prostate. The microscopic nerves that control erection are attached to both sides of the prostate as they extend to the penis. The prostate is not a vital organ; however, it is surrounded with lots of small and sensitive nerves and blood vessels that can be damaged as a result of the disease and its treatment. In some ways, it functions as “Grand Central Station” for the male reproductive and urinary systems where urine and semen must pass through the prostate to leave the body. Its importance is less related to what it does than to the problems that it creates when something goes awry.
The term “primary tumor” refers to the original tumor; secondary tumors are caused when the original cancer spreads to other locations in the body. Prostate cancer typically is comprised of multiple very small, primary tumors within the prostate. At this stage, the disease is often curable (rates of 90% or better) with standard interventions such as surgery or radiation that aim to remove or kill all cancerous cells in the prostate. Unfortunately, at this stage the cancer produces few or no symptoms and can be difficult to detect.
Only rarely does early-stage prostate cancer show any symptom at all. However, men may experience some of these prostate problems as they mature:
- A need to urinate frequently, especially at night;
- Difficulty starting urination or holding back urine;
- Weak or interrupted flow of urine;
- Painful or burning urination;
- Difficulty in having an erection;
- Painful ejaculation;
- Blood in urine or semen; or
- Frequent pain or stiffness in the lower back, hips, or upper thighs.
You should speak with your doctor if you have any of the above symptoms. They are usually caused by non-cancerous conditions that are treatable. But the only reliable way to find PC at an early stage, with an excellent chance of cure, is through screening.
A few broad-scope public health organizations proclaim that age 50 is soon enough to begin testing for PC. However, the American Urological Association Foundation (the organization of doctors most aware of the nature of the disease) as well as almost all PC survivor organizations consider a delay to that age to be risky. They, the Georgia Prostate Cancer Coalition, and the National Alliance of State Prostate Cancer Coalitions strongly support early detection of prostate cancer. We recommend that men, by age 40 (age 35 for African-Americans and men with a family history of prostate cancer), obtain a baseline prostate specific antigen (PSA) blood test along with a digital rectal exam (DRE). Continue testing regularly thereafter. These tests can be performed quickly and easily in a physician’s office, clinic, or other medical facility. Free testing is available in a number of Georgia facilities.
PSA readings which increase over time may be more important than the PSA score of one test. You should keep track of all your scores and discuss them with your physician. The results of these screens could lead to a recommendation for a biopsy of prostate tissue. If cancer is found, it is analyzed for the degree of aggressiveness. The degree of aggressiveness is portrayed by a Gleason Score or grade, which will be an important factor in your treatment decision.
About The PSA Test
PSA is an enzyme produced in the prostate that is found in the seminal fluid and the bloodstream. An elevated PSA level in the bloodstream does not necessarily indicate prostate cancer, since PSA can also be raised by infection or other prostate conditions such as BPH (benign prostate hyperplasia). Many men with an elevated PSA do not have prostate cancer.
It is important to note that the PSA test is an imperfect screening tool. A man can have prostate cancer and still have a PSA level in the “normal” range. Approximately 25% of men who are diagnosed with prostate cancer have a PSA level below 4.0. In addition, only 25% of men with a PSA level of 4–10 are found to have prostate cancer. With a PSA level exceeding 10, this rate jumps to approximately 65%.
About The Digital Rectal Exam
The digital rectal exam should be performed along with the PSA test. The DRE is performed by a physician who will insert a gloved finger into the rectum to feel the peripheral zone of the prostate where most prostate cancers occur. The physician will be checking for hardness of the prostate or for irregular shapes or bumps extending from the prostate–all of which may indicate a problem. The DRE is particularly useful because the PSA test may miss up to 25% of cancers, and the DRE may catch some of these.
The Gleason Grade refers to the degree of aggressiveness of a particular tumor based on the appearance of the tissue under a microscope. The Gleason grading system assigns a numerical score to each of the two largest areas of cancer in the tissue samples. The lowest possible combined Gleason Grade is 2, and the highest possible Gleason Grade is 10.
How Is It Determined/Calculated?
The Gleason grading process assigns a number ranging from 1–5 based on the degree of “cell differentiation” within the tissue sample from very well differentiated (i.e., least cancerous, most normal looking [grade 1] to very poorly differentiated and most cancerous [grade 5]).
Gleason Grades 1 and 2 closely resemble normal prostate tissue – in which the cells appear round, orderly and with defined borders. In grade 2, the cells are more loosely aggregated.
In Gleason Grade 3 cells are beginning to lose their defined borders and are starting to group together into clumps.
Gleason Grade 4 is identified by loss of normal cell structure and a more pronounced clumping together of cancerous cells.
Gleason Grade 5 means that the cells have lost most or all of their normal characteristics are very poorly differentiated and have essentially merged together into cancerous islands of cells.
Since prostate cancers often have areas with different grades, a grade is assigned to the 2 areas that make up most of the cancer. These 2 grades are added to yield the Gleason score (also called the Gleason sum). More information is available at cancer.org.
Treating prostate cancer
Over the years, a wide array of treatments for prostate cancer have been developed. A partial list of treatments includes surgery, radiation, hormone deprivation therapy, chemotherapy, proton therapy, high intensity focused ultrasound (HIFU), and focal laser ablation (FLA). In addition, there are dietary changes and the use of various herbal supplements.
Which treatment is right for you?
Since there is no “one size fits all” treatment, each man must learn as much as he can about various treatment options and, in conjunction with his physician, make his own decision about what is best for him. Most prostate cancers (92%) are found when the disease is confined to the prostate and nearby organs. This is referred to as the local or regional stage. The 5-year survival rate tells you what percent of men live at least 5 years after the cancer is found. The 5-year survival rate for most men with prostate cancer is 99%. Ninety-eight percent are alive after 10 years, and 95% live for at least 15 years. For men diagnosed with prostate cancer that has spread to other parts of the body, the 5-year survival rate drops to 28%. (See http://www.cancer.net/cancer-types/prostate-cancer/statistics, 2016, for more information.) A variety of factors that must be considered and evaluated before deciding on a treatment plan (or no treatment at all) include the stage of the prostate cancer, age, other health issues and the patient’s willingness to undergo certain procedures or therapies – some of which may have side effects.
The key is to collect as much information as possible before making a final decision – and if you are being encouraged to pursue one particular treatment by your physician, it may be valuable to get a second or third opinion, just to be sure that you have received a balanced view of your particular situation. Keep in mind that second and third opinions can sometimes be confusing because you may receive conflicting advice or opinions. That is why it is important to gather as much information about your particular cancer and the various treatment options as possible, so you can make an informed decision about which treatment is best for you.
Making a decision regarding treatment can be helped by talking with a spouse, friends, family and other men who have prostate cancer. When speaking with other men with prostate cancer, however, it is important to remember that their circumstances (including the grade and stage of their cancer) may be very different from yours. The treatment decisions that they have made may not be appropriate for you.
1. Active surveillance/watchful waiting
5. Hormonal therapy
6. Proton therapy
7. High intensity focused ultrasound (HIFU)
8. Focal laser ablation (FLA)
Choosing the best treatment for localized prostate cancer is generally based on the man’s age, the stage and grade of the cancer, the man’s general health and the man’s evaluation of the risks and benefits of each therapy option.
While there have been many studies of this, no local treatment option has been shown to have a distinct survival advantage for all patients. However, physicians may prefer a specific treatment depending on their specialty. One study found that 93% of urologists recommended surgery (also known as “radical prostatectomy”); and 72% of radiation oncologists recommended radiation. Patients should always seek a second opinion or the opinion of different specialists (e.g., urologists, radiation oncologists and medical oncologists) if they are uncertain about which treatment to pursue. Additionally, watchful waiting, in which PSA levels are monitored but no treatment is performed, may be an option for some men.
A program of active surveillance has two goals:
- To provide definitive treatment for men with localized cancers that are likely to progress; and,
- To reduce the risk of treatment-related, quality-of-life side effects such as incontinence and impotence for men with cancers that are not likely to progress.
Active surveillance is not appropriate for every prostate cancer patient. You are typically a good candidate if you are a patient with a lower grade localized prostate cancer, a low PSA level, a low Gleason Score, and an appropriate clinical stage. Additional factors that you need to consider are your age, general health, life expectancy, psychological makeup and your family’s expectations
A typical program of active surveillance may include the following: a review of the candidate criteria described above; a discussion with your urologist regarding all possible treatment options; and, if appropriate, an active surveillance plan customized to your specific situation. The plan would typically include periodic physical exams and PSA testing as well as periodic biopsies as appropriate.
Your goal is to be able to react quickly to seek additional treatment promptly if a worsening of the cancer occurs.
A radical prostatectomy is the surgical removal of the entire prostate gland. Many experts tend to recommend surgery when the cancer is thought to be contained within the prostate, such as in stage T1 and T2 cancers, and when the man is relatively young and healthy. During surgery, the entire prostate gland plus some surrounding tissue is removed. The surgery is almost always performed under general anesthesia. It is important to note that the experience and skill of the surgeon can be a major factor in the success of the surgery. This is true in all surgical procedures, but is particularly true with a radical prostatectomy because of the challenging location of the prostate and the critical anatomy near the prostate.
If you choose surgery, be sure that you know the experience level and skill of the surgeon. Ask about the surgeon’s training and how many prostatectomies he or she performs on a regular basis. A skilled and experienced surgeon will have performed hundreds of prostatectomies and will typically perform multiple prostatectomies each week. Also, know the hospital.
Radiation involves the killing of cancer cells and surrounding tissues with radioactive material. Radiation therapy can be particularly appealing for men who are not good candidates for surgery because of their age, ill health or advanced disease stage. However, even for those who qualify for surgery, there may be distinct reasons why radiation is the best treatment option. After evaluating the benefits, risks and potential side effects of various local treatment options, some men may decide that some form of radiation therapy is the best treatment option for them.
There are two major categories of radiation therapy:
- External beam radiation, which is a non-invasive procedure in which high-intensity beams of radiation are directed at the target area; and
- Brachytherapy, which involves the implantation of radioactive metal seeds or pellets into the prostate either permanently or temporarily.
Based on the most recent data, cure rates appear to be similar to those of radical prostatectomy in patients with low-grade and low-stage localized prostate cancer. In more advanced disease, radiation is sometimes used to treat a wider area surrounding the prostate and to include irradiation of regional lymph nodes, to destroy locally advanced cancer.
Cryotherapy involves the destruction of the prostate tissue by a freezing process in which the entire prostate is turned into an “iceball.” Probes containing liquid nitrogen or freezing argon gas are inserted into the prostate, causing cancer cells within the prostate to be destroyed as they thaw. Ultrasound imaging is used to ensure that the entire prostate has been frozen. The urethra is heated during the process so that it won’t be destroyed during the freezing process.
Cryotherapy requires less time in the hospital than some other treatments and is less invasive than radical prostatectomy. However, erectile dysfunction, urinary problems and rectal damage may occur. There is not a large volume of data on the long-term effectiveness of cryotherapy.
Most prostate cancer cells thrive on male hormones (androgens) such as testosterone. Androgens provide fuel to the fire of prostate cancer cell growth. Hormonal (or hormone-suppression) therapy is designed to turn off the production of the male hormones, or androgens.
If prostate cancer is diagnosed at an advanced stage (when it has spread beyond the prostate) or if the cancer returns after localized therapy such as surgery or radiation, additional treatment with hormonal therapy is typically initiated.
Recent studies have also shown that hormonal therapy, initiated prior to and following radiation therapy, may be more beneficial than radiation alone.