Prostate Cancer

What Is Prostate Cancer?

Prostate cancer is cancer of the prostate gland. The prostate, a gland found only in males, is located under the bladder and in front of the rectum. Cancer is a disease in which cells grow out of control within the body, invading and destroying tissues and organs.

The prostate gland surrounds the neck of the bladder and the urethra, which is the tube that drains the bladder. In an adult man, the prostate is about the size of a walnut.

The prostate is one of three glands necessary for reproduction. The prostate produces a sticky, milky fluid of acids and enzymes. This fluid makes up about 15 percent of the total volume of the semen and helps to sustain the sperm cells that are created in the testicles. The prostate is surrounded by muscle, which contracts to ejaculate this fluid.

Prostate cancer begins in the cells of the prostate gland and can spread to other parts of the body, including the bladder, colon, rectum, and bone.

Soon after prostate cancer is diagnosed, it must be determined:

• How much cancer has developed in the prostate
• Where it is located
• How quickly it is developing
• Whether it has spread beyond the prostate

The best chance at curing prostate cancer is to detect it early, before it metastasizes. Fortunately, a simple blood test and physical exam can help discover prostate cancer at its earliest stages.

What Causes Prostate Cancer?

The exact causes of prostate cancer are unknown. However, research aimed at understanding how cancer cells start to grow and spread may indicate some contributing factors. These factors include:

• Testosterone
• Age
• Heredity
• Genetics
• Diet

Testosterone

Testosterone, the male hormone, does not cause prostate cancer but is known to feed its growth. Therefore, prostate cancer treatments are aimed at blocking the body’s production of testosterone.

Age

Men over age 50 are at risk for prostate cancer and risk increases with age. As studies into aging continue, scientists may find that the aging process produces biochemical reactions that contribute to abnormal cell growth. This is an area of intense research.

Heredity

If a man’s father or an older sibling has had prostate cancer, he is at increased risk. Also, African American men are at increased risk.

Scientists are looking at genes that may be responsible for inherited prostate cancer. The genes under investigation are called Hereditary Prostate Cancer Genes 1 and 2 (HPC1, HPC2) and HPCX.

It is not yet known to what degree these genes are responsible for prostate cancer. It may be that genetically acquired prostate cancer develops differently than cancer from other causes, but more research into this theory is needed.

Genetics

Researchers are finding that genetic flaws are responsible for many cancers. Recent research has shown that a genetic defect may keep some men from developing a certain enzyme. This enzyme could mount a defense against cells vulnerable to cancer-causing agents in the environment.

Diet

Some studies have found that a diet high in animal fat may increase a man’s risk for developing prostate cancer, while a diet high in fruits and vegetables (especially tomato-based products) may decrease the risk.

What Are The Symptoms Of Prostate Cancer?

In its early stages, prostate cancer often does not cause symptoms. When symptoms do occur, they can include:

• A need to urinate frequently, especially at night
• Difficulty in starting urination or inability to urinate
• Weak or interrupted flow of urine
• Painful or burning urination
• Difficulty in having an erection
• Pain during ejaculation
• Blood in the urine or semen
• Pain or stiffness in the lower back, hips, or thighs.

How Is Prostate Cancer Diagnosed?

A variety of excellent tests are available to screen for and diagnose prostate cancer. They include:

• PSA test
• Digital rectal exam
• MRI scan
• Ultrasound
• CT scan
• Biopsy

PSA Test

The prostate-specific antigen (PSA) test is one of the best ways to screen for prostate cancer. This blood test measures a protein made by the prostate that normally is present in the blood. The amount of this protein in the blood will increase in men who have prostate cancer.

The PSA test is reported in nanograms per milliliter (ng/ml).

• A PSA count of 0 to 4 ng/ml is considered below normal (and in some men, 1.0 or 2.0) is normal.
• A PSA count of 4 to 10 ng/ml is considered slightly elevated.
• A PSA count of 10 to 20 ng/ml is considered moderately elevated.
• Anything above 20 ng/ml is considered highly elevated.

However, one abnormal PSA test does not necessarily mean that other diagnostic tests must be performed immediately. Factors other than cancer can cause PSA levels to fluctuate. In this case, the doctor may suggest repeating the PSA test a short time later to see if the level returns to normal. When PSA levels continue to rise over time, other tests may be indicated.

Digital Rectal Exam

In a digital rectal exam (DRE), a doctor inserts a gloved, lubricated finger into a man’s rectum in order to feel the prostate. If the doctor finds a roughness and irregular uneveness to the tissue, prostate cancer might be suspected. An enlarged prostate that is not cancerous will likely still feel smooth.

The DRE cannot diagnose prostate cancer. It is used to examine the size and surface of the prostate to determine if further investigation is needed. Experts recommend that all men over the age of 50 have a DRE yearly along with a PSA test.

MRI Scan

A magnetic resonance imaging (MRI) scan is a computerized picture made by magnetic fields that can show detailed, cross-sectional images of the inner body. MRI scans can create a clear picture of the prostate gland.

Ultrasound

Ultrasound uses high-frequency sound waves that bounce off organs and body structures and produce a computerized image. Ultrasound most often is performed by passing a sensor over the surface of the body.

The prostate can be examined through a type of ultrasound called transrectal ultrasonography. In this exam, a tube is inserted into the rectum that carries the sound waves to the nearby prostate, producing a better image.

CT Scan

A CT (computed tomography) scan is a sophisticated x-ray producedure that uses a computer and rotating x-ray beams to produce images of soft tissue, bone, and blood vessels. Areas of dense tissue, such as tumors, can be seen better than with one-dimensional x-rays.

Biopsy

A biopsy is a technique in which a small sample of tissue is taken through a fine needle and examined under a microscope to see if cells are malignant. Biopsy is a highly accurate way to tell if prostate cancer is present.

The way in which the biopsy is performed varies among doctors. Before having a biopsy, a man will want to ask his doctor about:

• What the procedure will involve
• Whether medication can be given to block any discomfort
• Any risks associated with the biopsy procedure

What Is Prostate Cancer Staging?

If you are diagnosed with prostate cancer, it is important to know just how far the disease has progressed. This is determined by evaluating the stage of the cancer.

Oncologists (physicians who specialize in the treatment of cancer) have developed several systems to classify the extent of the cancer. This is done by looking at its stage of development and the arrangement of cancer cells. By determining the stage of the cancer, doctors can come up with the most appropriate treatment plan.

• Stage A – In this earliest stage, cancer has just been identified by PSA tests and biopsy. No prognosis can be made until it is known how widely spread the cancer cells may be.
• Stage B – In this stage, it is known that cancer is in several places within the prostate.
• Stage C – In this stage, cancer has spread throughout the prostate and may have spread to nearby tissue or the bladder.
• Stage D – Cancer has spread beyond the prostate and nearby tissues. If the cancer is still only within the pelvic area, the stage is D1. If it has spread to the bone, it is stage D2.

Gleason Score

Oncologist have developed another set of staging criteria called the Gleason Score. The Gleason Score is based on the arrangement of cancer cells in tumors as seen under the microscope by the pathologist. The lower the score, the better.

• The lowest possible Gleason score is 2.
• Typical Gleason scores are between 5 and 7.
• Gleason scores between 7 and 10 are high.

TNM Staging

Physicians also stage prostate cancer by the TNM system, a universal scoring system that looks at how far the cancer has spread. To get the TNM staging the oncologist looks at:

• The tumor size (T staging)
• The lymph node involvement (N staging)
• The presence of cancer in other parts of the body, or its metastasis (M staging)

T staging goes from T1 to T4, with some sub-stages:

• T1 means the cancer cannot be seen or felt, but a biopsy has confirmed its presence.
  • T1a means cancer is present in 5 percent or less of the prostate tissue that has been examined.
  • T1b means cancer is present in more than 5 percent of the prostate tissue.
• T2 means the cancer is confined to the prostate.
  • T2a means that cancer is on one side of the prostate.
  • T2b means that cancer is on both sides.
• T3 means the cancer spread beyond the prostate to nearby tissues and organs.
  • T3a means cancer is not found in the seminal glands (which contribute toward the production of semen).
  • T3b means that it has spread to the seminal glands.
• T4 tumors have spread to other organs, such as the bladder or rectum.

N staging goes from N0 to N1:

• N0 means that cancer has not spread to the lymph nodes.
• N1 means that cancer has been found in the lymph nodes.

M staging goes from M0 to M1, with some sub-stages:

• M0 means that cancer has not spread to distant tissues.
• M1 means that cancer has been found in distant tissues.
  • M1a means it has been found in lymph nodes beyond the pelvic area.
  • M1b means it has been found in the bone.
  • M1c means it has been found in other sites.

How Is Prostate Cancer Treated?

There are many treatments for prostate cancer. With new knowledge about prostate cancer and new treatment techniques, cure is possible for a large percentage of men with the disease. Treatments include:

• Watchful waiting
• Radiation therapy
• Chemotherapy
• Cryotherapy
• Hormone therapy
• Prostate removal
• TURP

Watchful Waiting

In watchful waiting, the prostate cancer is carefully monitored but is not immediately treated. This approach does not ignore prostate cancer but acknowledges that prostate cancer is generally slow growing.

In some cases, the cancer is growing so slowly that it most likely will not affect the man over the course of his lifetime. Watchful waiting may be preferable to aggressive treatment for men with other health problems or men over age 80.

If symptoms should develop or if the cancer should begin to spread more quickly, other treatments may be considered.

Radiation Therapy

Radiation can kill fast-growing cells such as cancer cells.Radiation therapy can be performed either externally or internally.

• External radiation therapy uses a beam sent from outside the body toward the tumor. Radiation therapy is performed at a hospital or treatment center, usually five days a week for several weeks. Radiation therapy is painless but may produce side effects that include tiredness, nausea, hair loss, skin soreness, and loss of appetite.
• Brachytherapy is an internal radiation therapy in which radioactive seeds or pellets are surgically implanted in the prostate using thin needles. An ultrasound picture guides physicians in placing the seeds. Medication can be given to block discomfort from the procedure.

This procedure, also called radioactive seed implant, allows for a higher total dose of radiation to a smaller area than is possible with external treatment. Men may stay in the hospital for a short time for implant radiation. The length of time that the implant is left in place depends on the amount of radioactivity needed for effective treatment. Once the implant is removed, no radioactivity remains in the body.

For further information about radiation therapy, go to Radiation Therapy.

Chemotherapy

Chemotherapy uses chemicals to kill cancer cells. It is used only when the cancer has spread beyond the prostate, not for early prostate cancer. The drugs used in chemotherapy are administered on an outpatient basis and do not require a hospital stay. Side effects may include fatigue, nausea, and hair loss.

Cryotherapy

In cryotherapy, an ultrasound probe is inserted into the rectum to produce a picture that the physician will watch on a monitor. The physician will insert probes into the prostate through small incisions between the rectum and scrotum. These probes deliver liquid nitrogen to the prostate, which freezes the tissue and kills cancer cells.

Cryosurgery is an effective way to treat small areas of cancer. Risks of the procedure include injury to the bladder. Men also may experience temporary swelling in the penis and scrotum.

Hormone Therapy

Because prostate cancer feeds on the male hormone testosterone, reducing testosterone will slow the growth of cancer. There are several ways to do this:

• The female hormone, estrogen, may be taken as a pill to counteract the effects of testosterone. This may cause breast tenderness and the growth of breast tissue, which will subside when treatment is stopped.
• Luteinizing hormone-releasing hormone agonists (LH-RH agonistss) are drugs that reduce the production of testosterone. LH-RH agonists can stop the production of testosterone without some of the side effects of estrogen. LH-RH is often used with hormones called antiandrogens, which aim at stopping testosterone from interacting with cancer cells.
• The removal of the testicles prevents the production of testosterone, a hormone known to increase the growth rate of prostate cancer. This procedure is known as orchiectomy.

Prostate Removal

If cancer has not spread beyond the prostate, removing the prostate (prostatectomy) offers an excellent chance of cure. However, time may need to pass following surgery to be certain that the microscopic cancerous cells have not metastasized (spread).

• In a suprapubic prostatectomy, the prostate is removed through an incision in the abdomen.
• In a perineal prostatectomy, the prostate is removed through an incision between the scrotum and the anus. Nearby lymph nodes are sometimes removed through a separate incision in the abdomen.

The two main side effects of prostate removal are:

• The possibility of urinary incontinence because of damage to the muscles that control urine flow
• Impotence (the inability to have an erection)

However, techniques for performing a prostatectomy are improving, and more healthy tissue can now be preserved. Nerve-sparing surgical techniques can preserve the nerve endings that control erection and can help avoid impotence.

For further information about prostate removal, go to Prostate Removal.

TURP

A procedure called transurethral resection of the prostate (TURP) removes just a portion of the prostate, with an instrument that is inserted through the urethra. The cancer is removed from the prostate by electricity that passes through the end of this special instrument.

This procedure can be helpful for:

• Men who cannot have a prostatectomy because of health factors or other reasons
• Men who just need to have a freer urine flow because an enlarged or cancerous prostate is constricting the urethra

What Can I Expect After Treatment of Prostatet Cancer?

Following treatment for prostate cancer, some men may experience:

• Incontinence
• Impotence
• Physical discomfort

Incontinence

The inability to control urination affects about 10 percent of men who have been treated for prostate cancer. Incontinence may result from surgery or radiation. There are three kinds of incontinence:

• Stress incontinence – Urines leaks when you exercise, cough, or sneeze, because control muscles have been damaged in surgery.
• Overflow incontinence – This happens when the urine flow is temporarily blocked.
• Urge incontinence – Sudden strong urges to urinate that occur because the bladder has become very sensitive.

Normal bladder function often returns within weeks after surgery or after radiation treatments have stopped.

• Many men find help from special treatments to help urinary incontinence, including exercises to improve muscle control.
• Special disposable undergarments are available for men with incontinence.
• If incontinence continues to be a problem, surgery may be an option to help restore bladder control.

Impotence

Impotence, also known as erectile dysfunction, is the inability to have an erection. Impotence can result from surgery, radiation therapy, or hormone therapies.

After surgery, impotence may occur because of damage to the nerves that control an erection. In the months following surgery, some potency may return.

• Drugs such as sildenafil (Viagra) can help a man achieve an erection.
• Vacuum devices also assist in achieving an erection.
• Penile implants can be inserted surgically to help create an erection.

Physical Discomfort

Physical discomfort after treatment for prostate cancer may include:

• Fatigue caused by radiation therapy, chemotherapy, or hormone therapies
• Nausea and vomiting caused by radiation therapy or chemotherapy
• Hair loss from chemotherapy

Medications are available to relieve nausea and vomiting. Hair usually will grow back when chemotherapy treatment is finished.

Living With Prostate Cancer

Getting back to normal after treatment for prostate cancer may take time.

If the prostate was removed, semen can no longer be ejaculated. Whether or not a man can achieve an erection will depend on the degree to which nerves have been affected by the surgery. Many men can return to a degree of sexual function, especially with newer surgical techniques that can save nerves that control an erection.

If impotence (erectile dysfunction) is a side effect, medication may help. While there are many drugs in use, Viagra has become the most well-known. Only a physician should prescribe a drug for erectile dysfunction, however. Some of these drugs can cause low blood pressure, and heart-related side effects have been reported.

Men whose prostate was removed will no longer produce semen, but they can still have a dry orgasm, which is a sexual climax without the release of semen from the penis. Men who wish to father children may wish to consider having their sperm frozen for use in the future.

What Is The Long-Term Outlook?

For men whose cancer has not spread beyond the prostate, the five-year survival rate is close to 100 percent. The long-term outlook depends on:

• Age
• Stage of cancer
• Treatment

Most oncologists and urologists will say that treatment is essential for younger men. Yet, many of the therapies, such as radiation and chemotherapy, are not easy to endure. The long-term outlook and your expectations should be the subject of open and frank discussions with your care providers. Quality of life issues, especially for older men and those whose cancer has spread, become very important as part of the long-term outlook.

Can Prostate Cancer Be Prevented?

Because it is not clear what causes prostate cancer, there is no guarantee of prevention. However, experts believe that you can reduce your risk for many types of cancer by:

• Not smoking
• Eating a low-fat, high-fiber diet
• Getting plenty of exercise

Recent nutritional studies have suggested that:

• Men who eat large amounts of green leafy vegetables may develop prostate cancer less frequently.
• Men who eat tomato-based foods at least twice a week may be at lower risk for developing prostate cancer.

Studies into diet and its relationship to prostate cancer are inconclusive. However, a substance called lycopene, an antioxidant found in some fruits and vegetables, is being studied because it may offer some protection against prostate cancer. Scientists think antioxidants help protect protein in cells from damage. Vitamin C and vitamin E are antioxidants.

In July 2001, the largest prostate cancer prevention trial began enrolling participants. The trial’s name is SELECT, which stands for Selenium and Vitamin E Cancer Prevention Trial. The purpose is to determine whether these two dietary supplements can protect against prostate cancer. For more information on this trial, call the National Cancer Institute’s Cancer Information Service at 1-800-4CANCER, or visit their Web site. www.nci.nih.gov

Prostate Cancer: Frequently Asked Questions

Here are some frequently asked questions related to to prostate cancer.

Q: Is prostate enlargement the same as prostate cancer?

A: No. As a man ages, the prostate can increase in size many times without becoming cancerous. The medical term for noncancerous prostate enlargement is benign prostatic hyperplasia, or BPH. Prostate enlargement is not the same as prostate cancer, and BPH cannot “turn into” prostate cancer. However, BPH and prostate cancer can exist together. Even if cancer is not present, an enlarged prostate may cause other problems, such as interfering with a man’s ability to urinate.

For further information about prostate enlargement, go to Prostate Enlargement.

Q: Who needs radical prostate surgery?

A: Radical prostate surgery is usually performed on younger men, under the age of 70, when the cancer is in danger of metastasizing (spreading).

Q: Is “watchful waiting” dangerous?

A: Watchful waiting is likely to be a strategy in older men for whom radical surgery would be taxing and for whom radical surgery might not prolong life. It is often said that an older man is likely to die “with” prostate cancer rather than “from” prostate cancer.

Q: At what stage is prostate cancer “terminal”?

A: The chances of cure are smallest when the cancer cells have spread to other organs and to the bone. But even then, effective treatments are available.

Q: What is hospice care?

A: Hospice is a philosophy of end-of-life care that emphasizes dignity, quality of life, and pain relief.

Q: Should I worry about blood loss and safe transfusion during surgery?

A: Many patients are now “donating” their own blood before surgery. Any blood they lose during surgery can be replaced with their donated blood.

Q: Will hormone therapy cure prostate cancer?

A: Hormone therapy aims at slowing the growth of prostate cancer. For this reason, hormone therapy may be recommended for older men who might not be able to undergo radical surgery.

Q: Should I participate in a clinical trial?

A: Participation in a clinical trial generally guarantees good treatment and potentially the most advanced treatment available. However, clinical trials are designed so that one group receives an experimental treatment while another receives a standard treatment. Your outcome may vary depending on which group you are in. There are risks with experimental treatments, and standard treatment may not provide you with your optimal outcome. However, your participation helps medical science better understand and treat prostate cancer.

Q: What about “natural treatments,” with herbs, foods, and vitamins?

A: Alternative medicine is making its way into medical scientific circles, and there may benefits to herbal and vitamin treatments. While it is unlikely that they will cure cancer, they may help ease symptoms or side effects of treatment. If you decide to pursue alternative treatments, be certain to let your physician know. Some alternative treatments can interfere with or complicate conventional treatments.

Prostate Cancer: Putting It All Together

Here is a summary of the important facts and information related to prostate cancer.

• Prostate cancer generally does not produce symptoms until it is well-advanced. For this reason, annual screenings are important for men beginning at age 50 (or age 40 for men at higher risk).
• Regular digital rectal examination and PSA tests can detect prostate cancer in its earliest and most successfully treated stages.
• Treatment options include “watchful waiting” for early-stage prostate cancer, radiation therapy, chemotherapy, and surgery to remove the prostate.
• Two complications of prostate cancer treatment are urinary incontinence and impotence, both of which may be helped through medication and other means.
• Prostate cancer detected early is quite curable.
• Prostate cancer is generally slow growing and may need minimal treatment in older men; however, it requires aggressive treatment in younger men.

Prostate Cancer: Glossary

Here are definitions of medical terms related to to prostate cancer.

Antioxidants: Substances that can neutralize the effects that free radicals may have on the body. Free radicals are formed during the natural course of metabolism and have been linked to various types of tissue damage, including the development of cancer.

Benign: Not cancerous.

BPH (benign prostatic hyperplasia): The non-cancerous enlargement of the prostate, fairly common in men over age 50.

Biopsy: A specimen of tissue that is taken to be examined for the presence of cancer.

Carcinogen: A cancer-causing agent

Chemotherapy: Chemical treatments designed to kill cancer cells.

CT scan: Computed tomography, which uses rotating x-rays to create a picture of the body from many different angles.

Cryotherapy: Freezing cancer cells to kill them.

Digital rectal examination (DRE): An examination in which a health-care provider inserts a gloved, lubricated finger into a man’s rectum to feel the prostate.

Estrogen: A female hormone that can be given to a man to counteract the effects of testosterone, a male hormone.

Hormones: A chemical created by the body’s glands and secreted into the blood in order to have an effect on an organ.

Impotence: The inability to have or maintain an erection.

Lymph nodes: Small round or oval bodies connected by a network of vessels; they help remove bacteria and foreign particles from the circulation and play a role in the body’s immune defenses.

Malignant: Cancerous.

Metastasis: The spreading of cancer cells within the body.

MRI (Magnetic Resonance Imaging): A computerized picture made by magnetic fields that can show cross-sections of the inner body.

Oncologist: A physician who specializes in the treatment of cancer.

Orchiectomy: The surgical removal of the testicles to prevent the production of the hormone testosterone.

Percent-free PSA: A test measuring the percent of PSA that is free in the blood compared to the PSA that is bound to other proteins.

Prostatectomy (radical): The surgical removal of the prostate.

PSA test: Prostate-specific antigen test, a test to measure the level of a protein in the blood produced by the prostate, the amount of which increases if the prostate is cancerous.

PSA velocity: The measure of time and speed of rising PSA numbers.

Radiation therapy: The use of high-powered x-rays to kill cancer cells.

Semen: Fluid made up of sperm cells and fluid produced by the prostate and other sex glands; semen is passed through the urethra to the outside during ejactulation; semen is also called ejaculate.

Testosterone: The male hormone produced by the testicles; it is known to feed the spread of prostate cancer.

Transrectal ultrasound: A device that uses sound waves to get an image of the prostate; it involves inserting a thin ultrasound probe into the rectum.

TURP: Transurethral resection of the prostate; surgery to remove part of the prostate to free the urine flow.

Ultrasound: The use of sound waves to make a computerized picture of body parts and tissue.

Urethra: The tube that drains urine from the bladder and out of the body.

Urinary retention: A condition in which urine cannot pass out of the bladder because the urethra is blocked by an enlarged prostate.

Urologist: A physician who specializes in diseases of the urinary system.

Watchful waiting: A form of treatment in which a condition is monitored closely but no therapy is given; is often used in cases where disease is present but is advancing very slowly.

Prostate Cancer: Additional Sources of Information

Here are some reliable sources that can provide more information on prostate cancer.

American Cancer Society (ACS) 
Phone: (800) ACS-2345 (toll-free hotline)

www.cancer.org

National Cancer Institute (NCI), Cancer Information Service 
Phone: (800) 4-CANCER
Phone: 800-422-6237

www.nci.nih.gov

American Urological Association

http://www.auanet.org