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Prostate Cancer

Prostate cancer occurs when cells in the prostate (a gland in the male reproductive system found below the bladder in front of the rectum) grow and multiply uncontrollably, damaging surrounding tissue and interfering with the normal function of the prostate. The cells can then spread to other parts of the body. Mostly occurring in older men, prostate cancer is the most common form of male cancer, with approximately 186,320 new cases diagnosed in 2008. Your best chance for surviving prostate cancer is detecting it early. When found early, there is nearly a 100% chance for cure.

SYMPTOMS

Men with prostate cancer may have one or more of these symptoms:

  • Painful or burning urination
  • Inability to urinate or difficulty in starting to urinate
  • Frequent or urgent need to urinate
  • Trouble emptying the bladder completely
  • Blood in the urine or semen
  • Continual pain in the lower back, pelvis or thighs

None of these symptoms are specific for cancer, and most men with prostate cancer have none of them. However, they may point to other health problems. Their presence should prompt men to seek medical evaluation, including a digital rectal exam (DRE) of the prostate and serum PSA, from a urologist or other physician.

RISK FACTORS

Many factors may influence the development of prostate cancer, including:

Age: Men 50 or older are at the greatest risk. Age is the most influential risk factor.

Family history: Your risk is higher with a family history (especially father, brother, son) of prostate cancer.

Race: African Americans have nearly twice the prostate cancer incidence of white men. The disease is less common among Asian and American Indian men.

Diet: A high-fat diet, particularly animal fats, may increase your risk of developing prostate cancer. Diets high in fruits and vegetables are thought to decrease your risk.

SCREENING & TESTS

Cancer screenings are medical tests performed when a person has no symptoms. Prostate cancer screening should begin at age 50 for most men, and at age 45 for African American men or men with a family history (father, brother, son) of prostate cancer.

Digital Rectal Exam (DRE)

The simplest and oldest screening test for prostate cancer is the digital rectal exam, or DRE. The urologist gently inserts a gloved forefinger into the rectum in order to feel the prostate gland for enlargement or other obvious abnormalities, such as a lump. Of course, the DRE is not a definitive cancer test, but regular exams help the urologist detect any changes in the prostate over time that might signal pre-cancerous conditions. DREs are recommended as part of a man's annual physical exam beginning at age 50.

PSA Test

Prostate-specific antigen (PSA) is a glycoprotein produced by the epithelial cells of the prostate gland. A blood test measures the amount of PSA circulating in the blood, expressed in nanograms per milliliter (ng/mL). The resulting PSA level is used to assess cancer risk:

PSA LevelProbability of Cancer
0-2 ng/mL 1%
2-4 ng/mL 15%
4-10 ng/mL 25%
>10 ng/mL >50%

However, there is no simple correlation between PSA level and disease stage, and elevated PSA can also indicate non-cancerous conditions such as infection or benign prostatic hyperplasia (enlarged prostate). Additionally, low PSA levels don't always mean there's no cancer. PSA is not specific to cancer, but rather to prostate tissue.

Despite its limitations, PSA testing has helped detect cancer in countless individuals. In 1984, before PSA testing was available, the chance of finding localized prostate cancer was about 50%, either incidentally or during other procedures. In 1993, after PSA testing became widely used, that figure jumped to over 90%.

As with all cancers, early detection is the best hope for a cure. Routine PSA screening is recommended starting at age 50 for Caucasian men, and age 45 for African-American men or others at high risk for prostate cancer.

Researchers at MD Anderson are searching for new "markers" that correlate to tumors rather than prostate tissue, with the ultimate goal of a more accurate prostate cancer screening tool.

Prostate Biopsy

A biopsy, or sampling of prostate tissue, is currently the only definitive method of diagnosing prostate cancer. A biopsy is performed on all men with a strong suspicion of cancer based on PSA test results and other factors.

A biopsy takes about 35 minutes to perform and is done as an outpatient procedure. Biopsies are generally well-tolerated with minimal pain and bleeding. Before the biopsy, the patient undergoes an enema and is given an antibiotic. Lidocaine is used to deaden the nerves that lie alongside the prostate gland to make the procedure more comfortable.

A transrectal ultrasound (TRUS) probe is inserted into the rectum so the oncologist can view the prostate, which takes about 10 minutes. Then, a fine-gauge, spring-loaded biopsy needle is used to remove six to 10 tiny “core” samples of tissue from specific, predetermined areas on the prostate gland. The biopsy specimens take about three to seven days to process.

Gleason Grading System

Prostate cancers contain several types of cells that appear differently under a microscope. The Gleason grading system uses the numbers 1– 5 to “grade” the most common (primary) and next most common (secondary) cell types found in a tissue sample. Together, the sum of these two numbers is the Gleason score, ranging from 2–10 at MD Anderson, and tells the physician how aggressive the tumor appears under the microscope. The higher the Gleason score, the more aggressive the cancer. The Gleason score is considered along with other factors to help select the most appropriate treatment for the patient.

TREATMENTS

Prostate Surgery

Prostatectomy (surgical prostate removal) is the most common treatment for prostate cancer. Innovative surgical techniques have provided more options for men who desire complete cancer control with minimal impact on quality of life.

There are two types of "open" prostatectomy:

Retropubic: An incision is made between the navel and pubic bone. The surgeon removes the prostate and any affected lymph nodes and then sews the urethra and bladder back together. Retropubic prostatectomy provides the best chance of sparing the urethra to preserve urinary continence, as well as the neurovascular bundles responsible for erection. The procedure takes 2.5 to 3 hours if nerves are not spared; 3.5 to 4 hours if nerves are spared. It is the most common type of prostatectomy.

Perineal: The incision is made between the scrotum and rectum, and the prostate is approached from the bottom. Perineal surgery is less invasive than retropubic, with a faster recovery time and fewer days on a catheter, but it is seldom used today and few surgeons are trained on this approach. Perineal prostatectomies are best for low-grade and/or early stage tumors with no lymph node involvement, or for very obese patients.

Nerve-Sparing Surgery

Nerve-sparing surgery is performed during a prostatectomy in order to preserve the two neurovascular bundles next to the prostate that are responsible for erections. Before 1980, these nerves were routinely taken to make sure all cancer cells were removed, but the unfortunate result was sexual impotence.

Today, surgical and diagnostic advances have allowed MD Anderson surgeons to spare one or both nerves in about 75% of prostatectomies, giving the patient a better chance of retaining sexual function. If both nerves are spared (bilateral), the patient has an 80% chance of maintaining sexual potency; if one nerve is spared (unilateral), the potency rate is about 30%.

The decision for nerve-sparing surgery is largely up to the patient, but controlling the cancer is the surgeon's primary goal. The best candidates for nerve-sparing surgery are men with:

  • Localized tumors
  • A PSA level of 10 or less
  • A Gleason score of 6 to 7 or less
  • No prior use of erectile dysfunction (ED) drugs

Nerve-sparing surgery is not recommended for men with large tumors or high-grade disease, or for those who have pre-existing erectile dysfunction unrelated to cancer treatment.

Sural Nerve Graft

This surgery is generally performed on patients who are not eligible for nerve-sparing, but had normal erections before surgery. The sural nerve, which is located in the calf, is removed and then used to replace either one or both of the nerve bundles alongside the prostate.

Sural nerve graft was developed in the late 1990s and is still considered experimental. Its role in preserving sexual function has diminished as nerve-sparing techniques have improved. However, for young, potent men with locally advanced disease, this may be an option. MD Anderson performs about 30-40 sural nerve grafts a year.

An MD Anderson study of 30 sural nerve graft patients indicates that 50% can achieve erection when both nerves are replaced. A clinical trial that combines sural nerve graft with unilateral nerve-sparing surgery hopes to achieve the same outcome as bilateral nerve-sparing.

Laparoscopic Radical Prostatectomy (LRP)

Minimally invasive surgery is quickly becoming an alternative to standard "open" surgery for treating prostate cancer. A laparoscopic radical prostatectomy (LRP) involves the use of a laparoscope, which is a thin tube with a tiny camera. An incision less than an inch long is made at the navel and the laparoscope is inserted so that surgeons can view the treatment area on a monitor. Four other tiny incisions are made for miniature surgical instruments that can remove the entire prostate.

Although LRP is more complicated than traditional surgery and may take longer, there are many benefits for the patient:

  • Less blood loss during surgery
  • Shorter hospital stay
  • Decreased recovery time
  • Decreased reliance on narcotic pain medications
  • Less fluid buildup
  • Fewer days with a urinary catheter

Other benefits may include a decreased risk of post-surgery bladder and bowel continence. Outcomes appear to be similar to standard surgery.

The best candidates for LRP are men with low to intermediate grade prostate cancer who have no prior pelvic radiation or surgery. Age is not a factor, but generally, surgery is not offered to men over age 70.

Side effects of prostatectomy: Urinary incontinence (stress and total), erectile dysfunction (ED), typical post-operative complications.

Radiation Therapy

Radiation therapy is a primary treatment option for both localized and locally advanced prostate cancer. For early-stage disease, patients often have a choice between surgery and radiation, with similar outcomes. For larger or more aggressive tumors, radiation therapy may be used in combination with hormone therapy.

There are four types of radiation therapy used for prostate cancer:

External Beam Radiation is the most commonly used radiation therapy for prostate cancer. Pre-treatment planning with a CT scan determines the treatment field and where radiation beams will be aimed. The patient lies on a special bed designed to keep him immobile during treatment, and the radiation machine, or gantry, moves around the bed to deliver beams from eight different angles.

Proton Therapy is a powerful treatment that precisely targets even the most difficult to treat and reach cancers, often allowing higher doses of radiation to be delivered to the prostate without complications. Because the radiation beam can be precisely directed to a prescribed depth in tissue in the prostate, it spares healthy surrounding tissues, such as the bladder and rectum. This often results in fewer side effects.

Intensity Modulated Radiation Therapy (IMRT), an advanced form of external beam radiation, is used to further focus radiation beams, with the goal of increasing the dose to the prostate while sparing normal tissue. IMRT has 80-100 tiny lead "leaves" on each side of the beam that are moved in or out to define the treatment field with pinpoint accuracy.

Radiation treatment involves 40 daily sessions (Monday through Friday) over the course of eight weeks. Sessions last about 30 minutes. Ultrasound is performed before each session to ensure that the prostate has not shifted between treatments.

Brachytherapy involves the use of tiny radioactive seeds implanted directly in the prostate, delivering a constant dose of radiation.

Treatment side effects can be similar for all forms of radiation therapy, although many patients report fewer side effects with proton therapy treatment. Side effects may be more intense for brachytherapy. Overall, most patients will experience some side effects, but they generally are not severe and go away after treatment ends. The rectum and bladder are most likely to be affected in prostate cancer patients.

Possible side effects include:

  • Irritation of the bladder, urethra and/or rectum
  • Frequent urination, burning on urination, stronger urges to urinate
  • Rectum soreness (may be accompanied by slight bleeding)
  • More frequent bowel movements

Chemotherapy

Chemotherapy generally is not a standard treatment for prostate cancer. Since most tumors are slow-growing and occur in older men, the side effects from chemotherapy usually outweigh any benefit that treatment may provide.

However, chemotherapy may be an option for men with advanced or recurrent prostate cancer, or who have not responded to other treatments. Mitoxantrone and prednisone, two drugs used in combination, have had some effect in easing pain and improving quality of life in patients whose cancer has metastasized (spread) to bone, but with no significant change in overall survival.

Hormone Therapy

The majority of prostate cancers are hormone-sensitive, which means they depend on the male hormone (testosterone) as fuel for tumor growth. men diagnosed with prostate cancer require hormone therapy, which removes all traces of testosterone from the body in an effort to reduce the tumor size.

Hormone therapies work best on early-stage, high-grade tumors (Gleason score of 8 or higher). However, there is disagreement over the length and timing of hormone therapy. Most studies have shown that suppression of testosterone at an earlier stage has a significant effect on patient survival. There are differing opinions on length of therapy,

There are three types of hormone therapies for prostate cancer:

Androgen ablation blocks the ability of cancer cells to interact with testosterone at the cellular level. Flutamide and Casodex® are two types of androgen ablation drugs. They are taken orally on a daily basis for up to three years. Their effects are permanent in most patients.

The standard of care for early-stage, high-grade disease is androgen ablation given at least two months before radiation therapy. The drugs make the tumor more responsive to radiation treatment, and reduce the number of cancer cells to be treated.

LHRH agonists work by overstimulating the pituitary gland to release luteinizing hormone-releasing hormone (LHRH), which signals the testicles to suppress testosterone production. Zoladex and Leuprolide are LHRH agonist drugs, administered by regular injections ranging from once a month to once a year. A disadvantage of this therapy is that it causes a short spike in testosterone levels before suppression takes effect. However, its effects are not permanent, so patients who cannot cope with treatment side effects can be taken off the drug and can resume testosterone production.

Orchiectomy (surgical removal of the testicles) used to be the standard hormone therapy for prostate cancer. Because orchiectomy is an efficient, cost-effective and convenient method of reducing testosterone, it is still an option for certain patients, particularly elderly men.

Side effects of hormone therapies include:

  • Impotency, loss of sex drive
  • Loss of muscle mass, weakness
  • Decreased bone mass (osteoporosis)
  • Shrunken testicles
  • Depression
  • Loss of self-esteem, aggressiveness/alertness and higher cognitive functions such as prioritizing or rationalization

The severity of side effects increases with the length of hormone therapy. MD Anderson researchers are exploring other alternatives to minimize side effects, including earlier administration of hormone therapy before the disease has advanced, or using it intermittently to achieve similar results to continuous therapy.

Advanced Disease

For men with advanced or metastatic prostate cancer, hormone therapies provide relief from pain and other cancer-related symptoms. In these patients, the symptoms of advancing cancer outweigh the side effects of hormone therapy.

Watchful Waiting

Because not all prostate cancers will progress to threaten patients’ lives, MD Anderson does consider watchful waiting as a treatment option for very carefully selected patients with low-grade prostate cancer. These patients fall into two general categories:

For patients who believe the side effects of treatment (impotence, urinary incontinence) are excessive, watchful waiting would be considered for these men if they:

  • Recognize there is no validated screening method for early detection of disease progression
  • Have a low Gleason score
  • Have low-volume disease
  • Have a PSA level within the normal range (or accounted for by an enlarged prostate)
  • Are willing to submit to follow-up with annual biopsies and quarterly PSA tests

For patients who believe the risk for cancer is less than the risk from unrelated, co-existing health conditions, watchful waiting would be considered acceptable if:

  • Patients have a less than 10-year expected survival
  • The Gleason score is low
  • Patients have low-volume disease
  • The PSA level is within the normal range
  • Patients have an estimated survival of less than five years and a cancer judged not to be at risk during that time
  • Patients are willing to submit to follow-up with quarterly PSA tests and annual biopsies

The challenge of watchful waiting is that oncologists still cannot anticipate progression of the disease in a timely enough fashion to avoid risky treatment delays, and there are still no reliable methods to select patients in whom cancer is unlikely to spread. As the ability to predict prostate cancer progression improves, the risks of watchful waiting can be minimized.

Post-Prostatectomy Erectile Dysfunction

While outstanding surgical techniques clearly play a large role in preventing post-prostatectomy ED, early counseling for the patient and his partner about realistic expectations and treatment possibilities is critical.

The ultimate goal in treating prostatectomy-related ED in men who are potent prior to surgery is the return of spontaneous erections sufficient for sexual intercourse. Although this is probably not achievable in every patient, it is possible to predict whether erectile function will be recovered on the basis of certain factors. Men most likely to recover erectile function:

  • Are less than 60 years old
  • Do not have diabetes, hypertension, coronary artery disease and/or elevated cholesterol
  • Are non-smokers
  • Have undergone ideal nerve-sparing surgery
  • Had low-stage disease before surgery
  • Have a motivated partner

An assessment of a patient’s erectile function is essential when counseling patients prior to surgery, so they are appropriately informed of their risk for ED. This is particularly important for men who use phosphodiesterase type 5 inhibitors such as Viagra®, Levitra® or Cialis®, which place them at risk of worsening ED after surgery. Using a validated questionnaire such as the International Index of Erectile Function (IIEF) may help determine the severity of the patient’s preoperative ED during the initial patient assessment.

Post-Prostatectomy Penile Rehabilitation

Treatment to restore erectile function should be a part of every patient’s recovery plan following prostatectomy, but early return of erectile function is not always possible. MD Anderson physicians are committed to a program of early penile rehabilitation for patients after radical prostatectomy. This includes frequent use of a vacuum erection device and early use of oral therapy. For men who do not recover erections early, physicians may recommend penile injection therapy, as studies have consistently shown that without some intervention, spontaneous erections sufficient for intercourse are unlikely to begin more than one year after surgery.

Current and future studies of post-prostatectomy ED are focusing on improving penile rehabilitation, enhancing nerve regeneration and preserving penile length. In addition, researchers are developing drugs to help protect the nerves spared during prostatectomy, a novel approach that may help prevent post-prostatectomy ED.

SUPPORT

Cancer is a journey that no one needs to take alone. There are many forms of support to help you through every stage: diagnosis, treatment and survivorship. Whether you meet with other cancer survivors like yourself, use complementary therapies or individual coping mechanisms, help is available in many forms. Listed below are just some of the ways to find help...and hope.

Support Groups

Getting together with other cancer patients in a support group is a valuable coping tool. Support groups are usually focused on a single disease or topic, such as breast cancer survivors or people coping with life-changing side effects from their cancer or cancer therapy. These groups allow participants to meet others like themselves and seek strength from each other. Most major cities and cancer hospitals offer support groups that meet weekly or monthly. There are also dozens of online support web sites or message boards for those who may not have access to a traditional meeting.

Complementary Therapies

Complementary therapies are used in conjunction with cancer treatment, in an effort to reduce treatment side effects, ease depression and anxiety and help cancer patients take their mind off the negative aspects of their situation. Complementary therapies may include mind-body exercises like yoga, tai chi and Qi gong; visualization or guided imagery; using art or music as therapy and self-expression; and traditional Eastern medicine such as acupuncture.

Physical Activity

Staying physically active as much as possible during cancer treatment has many positive benefits. Physical activity stimulates the release of endorphins, a hormone that helps elevate mood, as well as decreasing feelings of fatigue.

Exercises for cancer patients can range from simple stretches done in the bed or chair, to more active pursuits such as walking or light gardening work. However, it’s important not to push yourself too hard. Check with your doctor before attempting any physical activity to make sure you are up to it.

Journaling/Blogging

Many people find it helpful to keep a journal of their cancer treatment experience. It may be as simple as recording symptoms and side effects into a notebook, or may include personal emotions and opinions about what they may be going through. Journals can be private, like a diary, or shared with loved ones and even strangers.

Increasingly, people are turning to the Internet to share their cancer journey with the world at large and to seek out others with similar experiences. Many cancer patients have begun their own web log, or “blog” to publicize their battle with cancer. Twitter, a mini-blogging technology that limits posts to 140 characters, has also proven to be a helpful tool for cancer patients to keep friends updated and reach out to others.

 

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St. Gregorios Medical Mission Hospital was started in 1975, and was registered under the Travancore — Cochin Literacy, Scientific and Charitable Act with Reg No. A334/78. The Institution is owned and controlled by the society of the Malankara Orthodox Syrian Church, the head of which is His Holiness Baselious Marthoma Paulose II, Read more

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