Prostate Cancer

Prostate Cancer

Prostate cancer is the most commonly diagnosed cancer in men. Estimates indicate that it is found in as many as half of all men over the age of 70 and in almost all men over the age of 90 in America. Since the discovery of the blood test for Prostate Specific Antigen (PSA) in the 1980's, prostate cancer can now be detected at a much earlier stage. While most men may eventually develope prostate cancer, most don't need treatment.

In fact, survival rates for prostate cancer have been improving for the last 20 years. For this reason, more than 2 million men in the US count themselves as prostate cancer survivors. So, whether you’re worried about developing prostate cancer, making decisions about your treatment, or trying to stay well after treatment, Dr. Nelson can provide answers, explain treatment options, and offer you peace of mind.
 

General Information

The prostate is the walnut shaped gland in men located between the bladder and the urethra that is involved in production of part of the ejaculate. The gland is made up of secretory cells with a surrounding muscular and connective tissue stroma. Prostate cancer is the transformation of these secretory cells into malignant cells that have the potential to grow more rapidly and spread outside of the prostate.

Prostate cancer starts localized in the prostate, but can then spread into adjacent tissue structures, lymph nodes and bones if not detected early. The most common site of metastatic disease is the bone, but it can also spread to the lung, liver and other organs.
 

Risk Factors

It is largely unknown as to what causes prostate cancer. It is thought, as with other cancers, to be a combination of environmental risk factors in conjunction with a genetic predisposition. Risk factors are not "causes," but are factors that make you statistically more likely than others in the general population to have a certain condition. The following is list are some of the more well-known and accepted risk factors for the development of prostate cancer.

  • Age

  • Family History

  • Race

  • Dietary Fat

  • Hormones

  • Cadmium

  • Vitamin A & D

Advanced age, family history and race are the three most important factors. It is for this reason that men begin screening for prostate cancer at the age of 50, unless they are African American or have a family history, then screening is to begin at the age of 40.

Approximately 9% of all prostate cancers are termed "familial." This is a form of cancer that is genetically passed on in an autosomal dominant fashion. This tends to cause prostate cancer in younger individuals (less than age 55).
 

Symptoms

Localized prostate cancer does not cause any symptoms. Until the development of the PSA blood test, detection of localized prostate cancer could only occur if the cancer grew to the point where it was able to be felt via a digital rectal examination or if it was found incidentally during transurethral resection of the prostate for obstructive symptoms.

Prostate cancer that has metastasized may cause pain, especially from spread to the bones. Weakness from anemia may occur if prostate cancer has affected multiple areas of the bone marrow, limiting the body's ability to produce red blood cells. In advanced cases, malignant enlargement of the prostate can obstruct urine flow, resulting in backup of urine into the kidneys (hydronephrosis) with possible kidney failure if this process affects both kidneys.

Locally advanced prostate cancers may obstruct urinary flow and/or cause severe irritation in the bladder region when the cancer extends from the prostate into the base of the bladder. Treatment of this locally advanced cancer can be very difficult. Obstruction to urinary flow may be opened by transurethral resection of the prostate, but there is a delicate balance between opening the urethra adequately to void and opening the urine passage too much, resulting in incontinence.
 

Early Detection

Dr. Nelson and Dr. Masson consider the use of a number of tests to look for warning signs of prostate cancer. The most common of these is the PSA blood test and is described below. Others detection tests include:

  • Percent-free PSA

  • PSA velocity

  • PSA density

  • Age-specific PSA ranges

  • Digital rectal exam (DRE)

  • Transrectal ultrasound (TRUS)

  • Prostate MRI

  • Genetic Testing

These early detection tests can’t tell for sure whether or not cancer is present. If the results of one or more of these tests are abnormal, you may need a prostate biopsy to determine if you have cancer.
 

PSA Blood Test

Prostate-specific antigen (PSA) is a substance made by cells in prostate gland (it is made by both normal cells and cancer cells). Although PSA is mostly found in semen, a small amount is also found in the blood. Most healthy men have levels under 4 nanograms per milliliter (ng/mL) of blood. The chance of having prostate cancer goes up as the PSA level goes up.

When prostate cancer develops, the PSA level usually goes above 4. Still, a level below 4 does not mean that cancer isn't present -- about 15% of men with a PSA below 4 will have prostate cancer on biopsy. Men with a PSA level in the borderline range between 4 and 10 have about a 1 in 4 chance of having prostate cancer. If the PSA is more than 10, the chance of having prostate cancer is over 50%.

The PSA level can also be increased by a number of factors other than prostate cancer, such as:
 

  • An enlarged prostate, such as with benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate that many men get as they grow older.

  • Age: PSA levels will also normally go up slowly as you get older, even if you have no prostate abnormality.

  • Infection or inflammation of the prostate gland (prostatitis)

  • Ejaculation can cause the PSA to go up for a short time, and then go down again. This is why some doctors will suggest that men abstain from ejaculation for 3 days before testing.

  • Riding a bicycle

  • Certain urologic procedures

 

There are also factors that can cause PSA levels to go down, even when cancer is present. The PeeDocs will discuss these with you.

Prostate Cancer Stages

Since the widespread use of PSA testing, the majority of patients have non-metastatic disease at presentation. Below are several staging systems to categorize the levels of prostate cancer.

Stage I - (T1) - Tumor remains confined to the prostate and is too small to be detected on DRE. This is an incidentally found cancer either by an elevated PSA or found after a transurethral resection of the prostate.

Stage II - (T2) - Tumor is still confined to the prostate, but is now large enough to be felt on a digital rectal exam [DRE].

Stage III - (T3) - The prostate cancer has spread through the prostatic capsule and may involve locally surrounding tissues such as the seminal vesicles.

Stage IV - (T4) - Locally advanced (T4) or metastatic (Stage IV) prostate cancer in which the cancer involves the bladder, lymph nodes or bony sites or other organs such as the liver or lungs.
 

Treatment Options

The following is a list of possible treatment options. The PeeDocs will recommend a course of treatment that offers the greatest chance of success for you. These are only brief descriptions of each.  Prostate cancer may be divided, based on its clinical presentation into localized or advanced disease. For men with clinical T1-T2 prostate cancer, curative therapy or observation are options.


Cryosurgery:
This is a relatively new modality for the treatment of prostate cancer. It involves placing several percutaneous probes into the prostate and the prostate is then frozen, thawed and then frozen again.

Robotic Prostatectomy:
This is fast becoming the most common treatment of prostate cancer. It involves using a surgical robot to remove the cancer with minimal discomfort and blood loss.

Hormonal Ablation Therapy:
Prostate cancer grows in response to testosterone. Testosterone is produced in the testicles and the adrenal gland. Testosterone production can be stopped medically and surgically.

Metastatic Prostate Cancer and Chemotherapy:
For patients who have hormone-resistant prostate cancer growth, several options including investigational treatments are available. Most patients who are treated with hormone-resistant prostate cancer have symptomatic disease.

Observation:

Patients who are followed expectantly should have regular physical examinations,  serial PSA levels, and occasional biopsies. Progression of the disease would be an indication to change plans and treatment modality.

Radiation Therapy:
Radiotherapy, the use of ionizing radiation to destroy cancer cells, has been proven to be effective in the treatment of many cancers.

Radical Prostatectomy:
Radical prostatectomy implies the complete removal of the prostate gland along with the pelvic lymph nodes. Radical prostatectomy may be performed by robotic, retropubic or perineal approach.

 

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