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Saturday, 20 Oct 2018

Prostate cancer

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What is prostate cancer?

Prostate cancer is the growth of abnormal cells in the prostate gland. The prostate gland is part of a man's reproductive system. Normally, it’s a little bigger than a walnut. It is located between the base of the bladder and the beginning of the penis. It surrounds the upper part of the urethra, the tube that carries urine from the bladder out through the penis. The prostate makes the fluid that supports and carries sperm.

In the US, prostate cancer is the most commonly diagnosed cancer in men.

How does it occur?

The cause of prostate cancer is not known. Studies have found or suggested the following risk factors:

  • Age: Age is the main risk factor for prostate cancer. Prostate cancer is rarely found in men younger than 45. The chance of getting it gets higher as a man gets older. 
  • Heredity: A man's risk is 2 to 3 times higher if his father or brother had prostate cancer. 
  • Race: Prostate cancer is more common and more likely to be fatal in African-American men. 
  • Diet and obesity: Studies suggest that men who eat a diet high in red meat and saturated fat have a higher risk for prostate cancer. Men who are overweight may be more likely to develop aggressive forms and die from prostate cancer.

What are the symptoms?

Prostate cancer often has no symptoms, especially in the early stages. When symptoms do appear, they may include:

  • trouble starting or stopping the flow of urine 
  • frequent and urgent need to urinate 
  • blood in the urine or semen 
  • trouble obtaining an erection, or pain during ejaculation 
  • pain in the lower back, hips, or upper thighs (usually because of a spread of the cancer beyond the prostate gland to the skeleton).

These symptoms are not limited to prostate cancer and can be caused by infection or a non-cancerous enlargement of the prostate (BPH) or other causes. 

How is it diagnosed?

Because prostate cancer most often does not cause any signs or symptoms, it may be found just during a routine exam. A digital rectal exam and prostate-specific antigen (PSA) test may be done to screen for prostate cancer. For the digital rectal exam, the doctor puts a gloved finger in a man's rectum to feel the prostate gland. Prostate cancers feel very hard compared to normal prostate tissue. If your doctor feels something abnormal, then you may have another test to see if there is a cancer (Prostate Biopsy).

The PSA test is a blood test. Cancer can cause the prostate to make more PSA, increasing the level of PSA in the blood. A prostate biopsy may then be needed to determine the presence of cancer. However, like many cancer-screening tools, the PSA test is not perfect and can give misleading results. A normal result does not necessarily mean that there is no cancer in the prostate. And if the result is elevated, it may not be from cancer.

The benefits of the PSA test and the rectal digital exam for prostate cancer screening are not certain. The current recommendations are that men age 75 and older should not be screened for prostate cancer. Men younger than 75 should discuss the potential benefits and/or harms of screening with their doctor.

Prostate Biopsy is currently the Gold Standard for the diagnosis of prostate cancer and is performed with transrectal ultrasound (TRUS) guidance. The biopsy of the prostate is needed to evaluate the tissues pathologically and establish the presence or absence of prostate cancer. If a biopsy shows cancer cells, other tests may be needed, such as a bone scan, CT scan, or pelvic MRI to see if the cancer has advanced.

How is it treated?

Most prostate cancer grows slowly. Prostate cancer is often found when the cancer is at an early stage and can be treated successfully.

Treatment depends on tumor grade, whether it has spread to other parts of your body, symptoms, a man’s overall health, and age. Some of the treatments and their side effects are:

  • Surgery to remove the prostate (prostatectomy). The standard surgical treatment is called a radical prostatectomy. Nearby lymph nodes are also removed. The hospital stay is usually 2 to 3 days. For a short while after surgery men may experience discomfort and some loss of control of urine (incontinence). Most men are able to control their bladder again after a few weeks. Surgery may also cause erectile dysfunction (impotence). Nerve-sparing surgery may help to prevent this problem. Also, when the prostate is removed, semen will no longer be produced. However, most men will still experience orgasm. The procedure can be performed either open or with robotically assisted laparoscopy (DaVinci). 
  • Radiation therapy. This treatment uses high-energy rays to kill cancer cells. The radiation may be given externally or via seeds that are surgically implanted into the prostate. Either approach may cause erectile dysfunction and cause the urethra, bladder and rectum to become inflamed, resulting in some loss of bladder control. 
  • Hormone therapy. Prostate cancer cells need the male hormone testosterone to grow. The testicles make most of the testosterone in your body. Drugs may be used to block the production of testosterone or block the effects of testosterone on the cancer cells. Side effects of hormone therapy may include erectile dysfunction, hot flashes, loss of sexual desire, osteoporosis, breast tenderness or slight enlargement of the breasts.

Instead of treatment, your doctor may suggest Active Surveillance.  A major concern to patients is whether their prostate cancer needs treatment at all.  Are they harboring an indolent prostate cancer that can be watched?  When clinical, pathologic and biochemical parameters suggest an indolent prostate cancer, Active Surveillance is given careful consideration.

This approach may be chosen if:

  • Age is over 60 
  • Disease is Stage T1 (non-palpable) 
  • Gleason score is 6 or less 
  • PSA doubling time < 3 years 
  • PSA Density < 0.15 
  • Less than 2 cores are positive of at least 12 initial core biopsies, with no single core having >50% of tissue positive for cancer 
  • Free PSA > 15% 
  • Confirmatory biopsy is favorable (within approximately one year)