 | Prostate Cancer |
| Overview | |
| Prostate cancer is the most commonly diagnosed malignancy, in men. In 1998, over 184,00 cases were diagnosed. In addition, over 1 million new cases of prostate cancer were reported between 1992 and 1997. Obviously, there are a lot of men with this problem. It is estimated that close to 40,000 men will die of the disease this year. Since the chance of developing prostate cancer increases as men age, most urologists recommend routine screening for prostate cancer starting at age 50 (age 40 in black men or those men with a strong family history of prostate cancer). | |
| Symptoms | |
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In its early stages, prostate cancer has no symptoms. It is common for men to develop some difficulties urinating as they age. However, these symptoms are signs of an enlarged prostate, not necessarily prostate cancer. In advanced stages, prostate cancer can cause voiding difficulties as the prostate enlarges and squeezes the channel (urethra) through which the urine passes. With prostate cancer, these symptoms usually develop more rapidly. Symptoms are reported to appear in weeks to months, whereas in benign conditions of the prostate that produce similar symptoms, these systems are more likely to develop over a period of years.
Advanced prostate cancer may also cause blood in the urine and irritative voiding symptoms such as frequency, urgency and dysuria (painful urination). When cancer spreads outside of the prostate, it will commonly spread to the bones causing pain and possible fractures. If prostate cancer presents for the first time in the advanced stages, it may become evident as a consequence of symptoms associated with pathological long bone fractures. | |
| Diagnosis | |
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Screening for prostate cancer is usually performed starting
at age 50 (age 40 in black men or those with a family history of
prostate cancer). Screening requires a yearly digital rectal
examination and PSA (prostatic specific antigen). The rectal
examination allows the physician to feel the prostate and determine
if any palpably abnormal areas are present. PSA is a blood test that
potentially aids the physician in diagnosing prostate cancer even when
no abnormalities are felt on rectal examination. For proper screening,
both tests are necessary since prostate cancer may exist when either the
rectal examination or the PSA are normal.
Once any abnormality is discovered, a prostate biopsy must be performed in order to diagnose prostate cancer. Since some benign conditions of the prostate can cause abnormalities of PSA or rectal exam, only a prostate biopsy can diagnose prostate cancer. A recent enhancement in the utility of the PSA value is the ability to measure the level of Free PSA (sometimes called PSA II). This test is most commonly useful when the PSA is between 4 and 10. Since a normal PSA is between 0 and 4, Free PSA is sometimes helpful to determine whether or not an abnormal PSA is due to benign or malignant conditions. The Free PSA test does not take the place of a prostate biopsy but may be help some patients avoid additional biopsies, if the initial biopsy reveals no evidence of prostate cancer. Unfortunately, a negative prostate biopsy does not guarantee that there is actually no prostate cancer present in the prostate gland, nor that prostate cancer will not subsequently develop. A prostate biopsy may be performed in either a urologist's office or hospital. The procedure is commonly done with the guidance of transrectal ultrasound (TRUS). Transrectal ultrasound allows the urologist to systematically biopsy the prostate in more than one area. The TRUS may also radiologically detect abnormalities in the prostate that may actually represent prostate cancer and therefore improve the sensitivity of the TRUS procedure. Since TRUS will not detect all cancers and since many abnormalities detected by ultrasound will not be cancer, the TRUS by itself has not proven to be as useful for detecting prostate cancer as had been once hoped. Once prostate cancer is detected by biopsy, a Gleason score will be determined by the pathologist. "Gleason score" is a measure of the degree of aggressiveness of an individual prostate tumor. A "Gleason score" is the sum of two individual numbers called the "Gleason grade". The Gleason grade is a number between 1 and 5, with 1 representing the least aggressive and 5 representing the most aggressive tumor. Since the "Gleason score" is the sum of two "Gleason grades", the Gleason score can range between 2 and 10. A Gleason score of 2 indicates a tumor with a low level of aggressiveness and a Gleason score of 10 indicates a very aggressive tumor.
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| Staging | |||||||||||||||||||||||||||||||
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Once prostate cancer is diagnosed by biopsy, proper
staging must be performed to determine whether or not the cancer is localized
to the prostate. Once the cancer spreads outside of the prostate gland, the treatment
choices may change. The necessity for staging will depend upon the size and extent
of the tumor based on physical examination, the PSA level, and the Gleason score.
Commonly used staging modalities may include:
Prostate cancer may be localized to the prostate at the time of diagnosis. At this stage, an individual patient may be a candidate for all treatments. If the tumor is found locally outside of the prostate, or found in the regional lymph nodes or in other organs, at the time of diagnosis, the options for treatments will be dramatically different. In general, prostate cancer is staged as follows:
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| Treatment | |
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More than any other urologic tumor, the treatment of prostate cancer
should be specifically individualized. Treatment for prostate cancer not
only depends upon the characteristics of the tumor, but it also depends upon
the patient's age, medical condition and anticipated lifespan.
The recommended treatment for prostate cancer can only be determined after consultation with your urologist. Although treatment options will be reviewed, patients must discuss these options with their urologist prior to determining what is the best treatment option. Radical prostatectomy For younger patients without significant medical problems, surgical removal of the prostate offers the best option for long-term survival. Radical surgery is a treatment option for those patients with localized disease who have a life expectancy of at least 15 - 20 years. Surgery also has significant risks. Risks of radical prostatectomy include, but are not limited to, significant blood loss (possibly requiring blood transfusion), infection, heart attack during or after surgery, blood clots in the legs (which may travel to the lungs), or even death. Aside from these more serious risks, surgical removal of the prostate also may permanently affect sexual functioning and urinary control. At least 50% of patients will no longer be able to achieve spontaneous erections following radical prostatectomy. Although new surgical techniques have allowed surgeons to preserve the nerves that are responsible for normal erectile function, at least 50% of men may become impotent after the surgery. Also, many patients experience some degree of incontinence (leakage of urine) after radical prostatectomy. Although less than 5% of patients will have significant long-term incontinence, many men may need to wear pads or garments to remain completely dry. Treatments are available for managing complications associated with the surgical approach to clinically localized prostate cancer. These treatments are designed to minimize the impact of surgical complications on quality-of-life issues. |
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Radiation therapy
There are currently several forms of radiation therapy available for treatment of prostate cancer:
External beam radiation External beam radiation therapy is considered an effective means of curing prostate cancer and is commonly used as an alternative to radical prostatectomy. External beam radiation therapy also has its own risks. Since organs surrounding the prostate are also affected by radiation, patients may develop some (all) of the following symptoms:
Radioactive seed implantation (brachytherapy) In 1998, there were reports of excellent outcomes for patients treated with radioactive seed implantation. This procedure requires that small radioactive pellets be permanently implanted directly into the prostate. The procedure is either performed on an outpatient basis or the patient maybe admitted to the hospital overnight. In general, there are less side effects from radiation seeds than external beam radiation therapy. Although the radiation is placed directly into the prostate, with significantly higher dosages of radiation reaching the cancer cells, less radiation affects the surrounding tissues and thereby decreasing the toxicity of this treatment option. However, care must be taken in determining which patients are best suited for radiation seeds. In general, those patients with small tumor volume, low PSA (< 10.0), and low Gleason score (< 7), make the best candidates. A history of prior transurethral resection of the prostate (usually for symptoms of benign prostatic blockage), is generally a contraindication for permanent brachytherapy, even when performed many years earlier. Hormonal therapy Although not intended to "cure" prostate cancer, hormonal therapy may be used to control prostate cancer. At times, hormones are also used to shrink large prostate tumors prior to treatment with radiation. Prostate cancer needs the male hormone testosterone to proliferate. If the body is deprived of testosterone, the prostate tumor can not grow and may even regress in size. However, hormonal deprivation is a therapy utilized to control the cancer since it does not kill all of the cancer cells. In fact, most prostate tumors will eventually grow locally and spread in spite of hormonal treatment.
Hormonal deprivation may also be accomplished by surgical castration i.e. removal of the testicles. Watchful waiting In certain patients, the best treatment option may be to defer treatment at the time of cancer diagnosis. This option is usually reserved for older patients, patients with multiple other medical problems, tumors with low Gleason scores, or any patient in whom the risks of treatment outweigh the benefits. Sometimes it may be pertinent to complete an extent of disease evaluation, before a final decision is made regarding the appropriateness of this approach. | |||
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