Prostate Cancer

DISCLAIMER: This is a summary of information regarding prostate cancer treatment. This is not a replacement for medical advice or a diagnosis tool. If you are sick or think you may have prostate cancer please reach out to your doctor as they are best equipped to diagnose you and help you seek treatment. Never ignore advice from your doctor or delay seeing them because of this information. 

Overview

Prostate cancer is a cancer that occurs in the prostate which is a small walnut shaped gland in men that produces the fluid that nourishes and transports sperm. Generally prostate cancer will grow slowly and is confined to the prostate gland initially where it may not cause serious damage. However, while some kinds of prostate cancer progress slowly and may require low or no treatment, other types are very aggressive and spread quickly.  

When prostate cancer is detected early (when it’s still confined to the prostate gland) has a better chance of being successfully treated. 

Symptoms

Prostate cancer can cause no signs or symptoms in the early stages. 

More advanced prostate cancer may result in the following symptoms: 

  • Blood in semen
  • Bone pain
  • Trouble urinating
  • Decreased force in the stream of urine
  • Erectile dysfunction
  • Discomfort in the pelvic area

Causes

The cause of prostate cancer is unclear. 

Doctors know that prostate cancer starts when cells in your prostate become abnormal. DNA mutations to the abnormal cells cause these cells to grow and divide more rapidly than normal cells do. The abnormal cells continue living when other cells would normally die. The accumulation of abnormal cells results form a tumor that may grow and invade nearby tissue. Some abnormal cells might also break off and spread to other parts of the body. 

Risk factors

Factors that may increase your risk of prostate cancer include: 

  • Race. For reasons not yet determined it has been found that black men carry a greater risk of prostate cancer than other men. Black men are also more likely to have advanced or aggressive prostate cancer. 
  • Age. The risk of prostate cancer becomes greater as you age. 
  • Obesity. Obese men with prostate cancer are more likely to have advanced prostate cancer that is more difficult to treat. 
  • Family History. If prostate cancer is common in men in your family, your risk may be increased. As well, if your family history has genes that increase the risk of breast cancer (BRCA1 or BRCA2) or there is a strong family history of breast cancer, you may have an increased risk of prostate cancer. 

Diagnosis

Screening for prostate cancer

Whether or not to test otherwise healthy men who are not experiencing symptoms for prostate cancer is controversial. Medical organizations are not in agreement on the issue of screening and whether it gives benefit. 

There are some medical organizations that recommend men consider screening for prostate cancer in their 50s, or if they have risk factors, sooner. 

Discuss your situation and the risks and benefits of screening with your doctor. Together you can make a decision in your best interests. 

Prostate screening tests might include:

  • Digital rectal exam (DRE). During a DRE, the doctor will insert a gloved and lubricated finger into your rectum in order to examine your prostate. If your doctor finds abnormalities in the shape, texture, or size of the gland you may need to undergo further testing. 
  • Prostate-specific antigen (PSA) test. A blood sample gets drawn from an arm vein and analyzed for PSA, a substance naturally produced by the prostate gland. It’s normal for there to be a small amount of PSA in the bloodstream. However, if there is a higher than normal level, it could indicate prostate enlargement, infection, cancer, or inflammation. 

DRE and PSA testing combined helps to identify prostate cancer at the earliest stages. 

Diagnosing prostate cancer

If an abnormality is detected during a PSA or DRE, your doctor will likely recommend further tests to determine whether you have prostate cancer such as: 

  • Ultrasound. If other tests raise concerns, your doctor may want to further evaluate your prostate using a transrectal ultrasound. A small probe (about the shape and size of a cigar) is inserted into your rectum. The probe creates a picture of your prostate gland using sound waves. 
  • Collecting a sample of prostate tissue. If the initial test results suggest prostate cancer, your doctor could recommend a procedure to collect cell samples from your prostate (prostate biopsy). A prostate biopsy is done using a thin needle that gets inserted into the prostate to collect tissue. The tissue sample is analyzed in a lab in order to figure out whether cancer cells are present. 
  • MRI fusion. While it’s still being developed worldwide, MRI fusion to assist in prostate diagnosis and biopsy is being used more and more often. 

Determining whether prostate cancer is aggressive

When prostate cancer is confirmed by biopsy, the next step will be to determine the grade of the cancer cells (a measure of the aggressiveness). A laboratory pathologist will determine how much the cancer cells differ from the healthy cells by examining a sample of the cancer cells. A higher grade indicates an aggressive cancer that is more liable to spread. 

The Gleason score is the most common scale used to evaluate the grade of prostate cancer cells. Gleason scoring combines two numbers that range from 2 (nonaggressive) to 10 (very aggressive), though the lower part of this range is not often used. 

Most Gleason scores that are used to assess prostate biopsy samples range from 6-10. Six indicates low-grade prostate cancer. A 7 indicates a medium-grade, and scores from 8-10 indicate high-grade cancers. 

In addition, genomic testing is being used more and more often to accurately assess the risk and detect aggressive prostate cancer. 

Determining how far the cancer has spread

After you’ve been diagnosed with prostate cancer, your doctor will try to determine the stage of your cancer. If your doctor suspects the cancer may have spread beyond just the prostate, one or more of the following imaging tests may be suggested: 

  • Ultrasound
  • Computerized tomography (CT) scan
  • Positron emission tomography (PET) scan
  • Bone scan
  • Magnetic resonance imaging (MRI) 

Not every person should have every single test. Your doctor will decide which tests are needed for your personal case. 

Your doctor will then use the information from the tests to assign a stage to your cancer. Prostate cancer stages get named using Roman numerals ranging from I to IV. The lowest stages mean the cancer is just in the prostate. By stage IV, the cancer has spread beyond the prostate and could have spread to other areas of the body. 

The cancer staging system is constantly evolving and is getting more complex as cancer treatment and diagnosis are improved. Your doctor will use your cancer stage to help select the treatments that are right for you. 

Treatment

Prostate cancer treatment options will depend on several factors, such as how fast your cancer is growing, how much it’s spread, and your health overall, as well as the benefits or side effects of treatment. 

Immediate treatment may not be necessary

For men with low-risk cancer, prostate cancer treatment may not be immediately necessary. Some men may never need treatment. Instead, doctors will recommend active surveillance. 

Active surveillance involves regular follow-up blood tests, rectal exams, and sometimes biopsies to monitor the progression of your cancer. If tests show that your prostate cancer is progressing, you may opt for a prostate cancer treatment. 

Active surveillance can be an option for cancer that doesn’t cause symptoms, is expected to grow slowly and stay confined to a small area of the prostate. Active surveillance may also get considered if someone has another serious health condition or is older which makes prostate cancer treatment more difficult. 

Active surveillance comes with the risk that the cancer can grow and spread  between checkups, making the cancer less likely to be cured. 

Surgery to remove the prostate

Surgery for prostate cancer treatment involves removing the prostate gland, some surrounding tissue, and a few lymph nodes. Radical prostatectomy can be performed in a few ways: 

  • Using a robot to assist with surgery. During surgery assisted by robots, the instruments get attached to a robot and are inserted into your abdomen through several small incisions. The surgeon then sits at a console and uses hand controls to guide the robot in surgery. This allows the surgeon to make more precise movements with the surgical tools than is normally possible with a traditional minimally invasive surgery. 
  • Making an incision in your abdomen. In retropubic surgery an incision is made in your lower abdomen and the prostate is taken out. 

Talk to your doctor about what surgery is best for your situation. 

Radical prostatectomy has a risk of erectile dysfunction and urinary incontinence. Talk to your doctor about the risks you face based on your situation, your age, the procedure you select, your overall health, and your body type. 

Radiation therapy

In radiation therapy, high-powered energy is used to kill off cancer cells. Prostate cancer radiation therapy can be delivered two ways: 

  • External radiation (external beam radiation). During external beam radiation therapy, you will lie down on a table while a machine moves around your body. It directs high-powered energy beams such as protons or x-rays, to your prostate cancer. You will typically undergo this prostate cancer treatment for five days a week for several weeks. 
  • Radiation placed inside the body (brachytherapy). Brachytherapy is where many rice-sized radioactive seeds are placed in your prostate tissue. The radioactive seeds will deliver a low dose of radiation over a lengthy period of time. Your doctor will implant the radioactive seeds in the prostate using a needle guided by images from an ultrasound. The implanted seeds will stop emitting radiation eventually and do not need removal. 

The side effects of radiation therapy may include: urgent, frequent or painful urination, pain while passing stools, or loose stools, as well as erectile dysfunction. 

Hormone therapy

Hormone therapy is a treatment with the goal of stopping your body from producing testosterone. Prostate cancer cells rely heavily on testosterone to help their growth. If you cut off the testosterone supply, it can cause cancer cells to slow their growth or die. 

Hormone therapy options for prostate cancer treatment include: 

  • Medications to stop your body from producing testosterone. Medications called luteinizing hormone-releasing hormone (LH-RH) agonists prevent the testicles from receiving messages to make more testosterone. Drugs typically involved in this prostate cancer treatment include: Lupron, Vantas, Zytiga, Terlatar, and Zoladex. 
  • Surgery to remove the testicles (orchiectomy). Completely removing your testicles reduces testosterone levels
  • Medications that block testosterone from getting to cancer cells. Medications called anti-androgens prevent the testosterone from getting to your cancer cells. Examples of medications involved in this prostate cancer treatment include: Nilandron, Xtandi, and Casodex

Hormone therapy gets used for men with advanced prostate cancer. The goal of this prostate cancer treatment is to shrink the cancer and slow tumor growth. For men with early-stage cancer, hormone therapy can be used to shrink tumors prior to radiation therapy, which can increase the success chances of radiation therapy. 

Freezing prostate tissue

Cryoablation or cryosurgery involves freezing tissue in order to kill cancer cells. 

During cryosurgery for prostate cancer, ultrasound images guide the insertion of small needles into the prostate. A very cold gas gets placed in the needles which causes the surrounding tissue to freeze. Then another gas is placed in the needles to warm the tissue. The cycle of freezing and thawing kills the cancer cells as well as some surrounding healthy tissue. 

Initial attempts to use cryosurgery for prostate cancer treatment resulted in unacceptable side effects and high complication rates. However, newer technology lowers complication rates, makes the procedure easier to tolerate, and improved cancer control. Cryosurgery is frequently used as a salvage therapy for people who haven’t been helped by radiation therapy. 

Chemotherapy

Chemotherapy is a prostate cancer treatment where drugs are used to kill rapidly growing cells, including cancer cells. Chemotherapy may be administered in pill form, through a vein in your arm, or both. 

Chemotherapy may be a prostate cancer treatment option for people with prostate cancer that has spread across the body. It can also be an option if your cancer hasn’t responded to hormone therapy. 

Biological therapy

Biological therapy (also called immunotherapy) is a prostate cancer treatment that involves using your body’s immune system to fight cancer cells. One type of immunotherapy called sipuleucel-T (Provenge) was developed to treat advanced, recurrent prostate cancer. 

This prostate cancer treatment takes some of your own immune cells and genetically engineers them in a laboratory to fight prostate cancer. Then the cells are injected back into your body through a vein. Some people respond to this therapy with some improvements in their cancer, but the treatment is expensive and requires multiple treatments.