Prostate Cancer: All You Need To Know

All men over the age of 50 are at a risk for prostate cancer. Although prostate cancer rarely occurs in young males, the disorder is primarily seen in older men and the risk of prostate cancer increases with age. More than 70% of men over the age of 65 are annually diagnosed with prostate cancer. Prostate cancer is the most common cancer of men in the United States. Each year close to 200,000 new cases of prostate cancer are discovered and close to 30,000 men die from the cancer annually.

The prostate is a small, walnut-shaped organ located in the rectal area. It surrounds the base of the bladder through which runs the urethra. The primary function of the prostate is to produce seminal fluid which provides nourishment and transports sperm.

Prostate cancer is generally a slow growing tumor and typically starts off in the periphery of the gland. In the early stages, prostate cancer causes no symptoms. However, if left untreated, it can grow and invade adjacent organs and spread to other parts of the body. What causes prostate cancer and why some subtypes behave differently remains unknown. It is believed that a multitude of factors such as heredity, ethnicity, hormones, diet and environment may play a role in the cause of prostate cancer.

Knowing the risk factors may help to prevent or delay the onset of prostate cancer. In addition, knowledge about risk factors may also help one undergo early screening. The risk factors identified to cause prostate cancer include:

- Age: As one gets old, the chances of having prostate cancer increase. It is recommended that after age 50, men should have regular prostate evaluation.

- Ethnicity: Of all ethnic groups, blacks have the highest risk of prostate cancer.

- Hereditary: If anyone in the family has prostate cancer, the chance of a family member developing the cancer are greatly increased

- Nutrition: A high-fat diet and obesity have been associated with an increase in prostate cancer. It is believed that fat stores are important for production of testosterone, and thus reduction in a fatty diet may reduce the risk of developing prostate cancer.

- Vasectomy: Although it has been suggested that vasectomy may be a risk factor for prostate cancer, there is no conclusive evidence to substantiate this fact.

- High levels of testosterone: Men who have high levels of testosterone are at high risk for prostate cancer. Long term testosterone treatment has been linked to benign prostate hypertrophy and there is a concern that these individuals should undergo regular screening for prostate cancer.

Symptoms

In the early stage of prostate cancer, most individuals have no symptoms. However, when the cancer grows or spreads, the following symptoms may occur:

• weak urine flow
• frequent urination (especially at night)
• difficulty starting urination
• inability to urinate
• pain or burning sensation when urinating
• blood in the urine
• persistent pain in lower back, hips, or thighs (bone pain)
• painful ejaculation
• difficulty having an erection

Unfortunately there are no early signs or symptoms of prostate cancer. The general advice is that if one is 50 or older, one should undergo prostate cancer screening. A blood test is also recommended to check for prostate-specific antigen (PSA) beginning at age 50, or earlier if one has risk factors for cancer. A digital rectal exam as early as age 40, is also advised in individuals with risk factors.

Since Prostate cancer does not cause symptoms in the early stage, the following screening tests are recommended and include:

• Digital rectal exam (DRE): A digital rectal exam is not fun but essential in examining the prostate. The digital exam can discover the presence of any abnormalities in the texture, shape or size of your gland.
• Prostate-specific antigen (PSA) test: This blood test analyzes the levels of a chemical released from the prostate. Higher levels are not always specific for prostate cancer because infection, inflammation or prostate enlargement may also cause an increase in this chemical.
• Transrectal ultrasound: If the above tests raise any suspicion of prostate cancer, a small probe is placed through the rectum and the gland is analyzed. The images can reveal the presence of any mass or deformity of the gland.

Prostate biopsy

If there is suspicion that a mass may be present, a prostate biopsy is the next step. The biopsy is done under ultrasound guidance. The ultrasound probe is placed through the rectum and will identify any abnormal areas. A fine needle is then inserted for a biopsy. There is minimal pain associated with the test. The tissue specimen is analyzed by the pathologist and the grade of the tumor is determined.

Cancer Spread

Once prostate cancer has been diagnosed, further testing is done to determine if spread has occurred. The majority of men do not require these additional investigations if no other symptoms are present. Treatment of the prostate cancer is then based on the needle biopsy results.

Test to determine spread of cancer

• Bone scan: Because prostate cancer usually spread to the bone,  a bone scan can rapidly identify the presence of any cancer anywhere in the body skeleton
• Ultrasound: Ultrasound is used to detect presence of cancer but is not a very sensitive test and this not widely used
• Computerized tomography (CT) scan: A CT scan of the abdomen and pelvis can rapidly identify the presence of spread to the liver, adjacent lymph nodes or adrenals.
• Magnetic resonance imaging (MRI): MRI is useful for identification of cancer spread into the adjacent soft tissues and bones
• Lymph node biopsy: When the CT scan or MRI identifies enlarged lymph nodes in the pelvis area, a biopsy may be required to determine if they are cancerous.

Grading

Whenever a cancer is diagnosed, the next step is to define the grade-which allows one to determine it aggressiveness. The degree of aggressiveness can be evaluated by looking at the degree of differentiation of the prostate cells. The degree of differentiation is then graded. With prostate cancer, a grading scale known as the Gleason score is used to define the degree of differentiation. The Gleason grading scale runs from 1 to 5, with 1 being the least aggressive form of cancer. The Gleason scores may be helpful in determining which is the best treatment option.

Staging

Once the grading of the cancer has been completed, the next step is to define the stage of the cancer. This basically determines if the cancer has spread and how far:

• Stage I:  This is very early cancer that' can only be identified on microcopy. There is no mass felt in the prostate.
• Stage II: In this stage the cancer can be felt but it remains confined to the prostate gland.
• Stage III: The cancer has spread beyond the prostate to the seminal vesicles or other adjacent tissues.
• Stage IV: The cancer has spread to lymph nodes, bones, lungs or other organs.

When prostate cancer is not treated, a whole host of complications can occur. The typical complications of untreated prostate cancer include:

• Spread of cancer: Prostate cancer can spread to nearby organs and bones and can be life-threatening.
• Pain: Although early-stage prostate cancer typically isn't painful, once it spreads to bones, it may produce severe pain. In most cases the pain is severe and requires some form of treatment. These treatments may include hormonal therapy, radiation therapy or chemotherapy. If these treatments aren't successful in relieving pain, a pain management consult is required. In most cases, narcotics are required to relieve the pain.
• Urinary incontinence:  Prostate cancer can cause incontinence. The treatment depends on the degree and type of incontinence. Treatments may include behavior modifications, exercises to strengthen pelvic muscles (Kegel exercises), drugs and catheters. If the above fail, complex surgery is required with no guarantee that it will work.
• Erectile dysfunction (ED) or impotence: Like incontinence, ED can be a result of prostate cancer. Various drugs and mechanical devices are available that may assist in achieving an erection. Current drugs include sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra). When all these fail, surgical penile implant is the last resort to help achieve an erection.
• Depression. Whenever a diagnosis of cancer is made, it is natural for all individuals to develop depression. The severity and duration of depression may determine the treatment. When depression affects one’s ability to manage life and family, treatment is recommended. Treatment may involve psychological counseling or drug therapy. In many cases, a combination of the two therapies often is successful.

Prostate cancer can be treated in more than one way. Depending on the rate of growth, age, life expectancy, stage and spread, combination therapy is often used. The most common treatments for prostate cancer include the following:

Radiation

One may either receive direct radiation therapy to the prostate or the surgeon may place small radioactive implants in the prostate. They both work by killing the cancer cells. Today, radiation therapy is applied in a very sophisticated way to prevent toxicity.  With precise focusing of radiation beams, greater doses of radiation can be given to decrease the frequency of complications. During the radiation therapy, all individuals are protected by custom-designed shields.

Radiation treatments are generally given over a 6-8 week period. The individual goes to a radiation center daily 5 times a week. The treatment is not painful and does not require anesthesia. The side effects of radiation therapy are not instant and one may gradually develop the following:

• Frequent urination
• impotence more common in elderly
• loose stools
• rectal bleeding
• urgency to defecate
• rectal ulcers
• rectal pain upon defecation

Once the radiation treatment course is complete, the majority of these side effects gradually disappear. However, a few unlucky men may continue to experience rectal pain/bleeding/ulcers. If these do not resolve with medical therapy, surgery may be required.

Radioactive seed implants.

Another radiation option is to implant radioactive seeds into the prostate gland. Implantation of these seeds is also known as brachytherapy. Unlike external beam radiation, these implanted seeds deliver a higher dose of localized radiation than do external beams over a much longer period of time.

The implantation of these radioactive seeds requires surgery under general anesthesia and takes about 1-3 hours. About 40-100 radioactive seeds measuring about 2 mm are implanted in the prostate with special needles. This therapy is generally used in men with small to moderate size low grade prostate cancers. The seeds may contain either iodine or palladium as the radioactive isotopes. After the seeds stop emitting radiation, they are not removed. The duration of radiation emission lasts about 12 months. Because the radiation exposure is limited to the prostate, there is no risk to others. However, pregnant females should limit exposure to individuals with these implants.

Because these seeds are placed into the prostate, the surrounding tissues are more affected from the radiation. In addition, the higher dose of localized radiation is also associated with slightly a higher incidence of complications.

The side effects include:

• slowed urination
• painful urination
• inability to pass urine requiring catheterization
• impotence
• Rectal pain

The urinary symptoms tend to be more severe and longer lasting with seed implants than with external-beam radiation. In addition, the side effects take a lot longer to subside.

Hormone therapy

Because testosterone is know to stimulate growth of prostate cancer cells, anti hormonal therapy is frequently used to treat prostate cancer. Hormone therapy either uses drugs to stop the production of the male sex hormones or the entire source of the hormone is surgically stopped by removing the testicle (orchidectomy). Occasionally, both types of treatment are used.

Hormonal therapy is most effective in men with advanced prostate cancer. The treatment does help to slow the growth and frequently shrinks the tumor. Because this therapy is effective in shrinking tumors, hormonal therapy is frequently used in the early stage of prostate cancer — often in combination with radiation and surgery. Once the tumor size is downsizes, surgery or radiation therapy can be used to destroy whatever tumor is left behind.

Also available are drugs which prevent the release of signals from the brain to manufacture testosterone (LH-RH agonists). These hormonal drugs include leuprolide (Lupron, Viadur) and goserelin (Zoladex). These longer acting drugs are injected every 2-3 months. The drugs can be continued for a prolonged time without undue side effects.

In the past decade, other anti testosterone drugs have become available in the treatment of prostate cancer. These medications include flutamide (Eulexin), bicalutamide (Casodex) and nilutamide (Nilandron). They can be taken orally and can be combined with an LH-RH agonists.

Drug therapy, however, is not ideal for the treatment of prostate cancer. After a few years, most cancer cells develop mechanisms to resist these drugs and develop alternative mechanisms for survival. To prevent the development of drug resistance, intermittent hormone therapy programs have been developed. The PSA levels are monitored and once the levels start to drop, the drugs are stopped. If the PSA levels rise, the drugs are re-started again.

Side effects of Drug therapy

Most men develop side effects from these hormonal based drug therapies. These include nausea, diarrhea, breast enlargement, decreased libido, impotence, hot flashes, weight gain and loss of muscle and bone mass. The liver function has to be regularly monitored because all these drugs have the potential to cause liver damage.

Orchidectomy

A few men elect to undergo an orchidectomy. The testes are a major source of testosterone and surgical removal of the testes eliminates the hormone. This mode of therapy is usually for individuals with advanced prostate cancer and is quite effective. The procedure is not as painful as it sounds. The surgery is done under general/local anesthesia and takes 30-45 minutes. Most patients are discharged home the same day.

Radical prostatectomy

Surgical removal of the prostate gland is another option for patients with prostate cancer. This is a major surgical procedure which removes the entire prostate and adjacent lymph nodes. The surgeon tries to preserve the nerves and muscles which control urination and sexual function. Two surgical approaches are available to remove the prostate. – Retropubic and perineal. Both have been designed to prevent the complication to the adjacent organs, however, a fair number of individuals continue to have complications

Many individual have loss of bladder control which may last for weeks to months after the surgery. The major complaint by most men is that whenever they cough, laugh or sneeze they lose control of their bladder. Generally, most men are able to control this incontinence but a fair number require a surgical procedure for correction of this troublesome problem.

Another major side effect of surgery is the inability to have an erection. This is mostly likely related to the nerve damage that occurs during surgery. Most young men were able to achieve normal erections before surgery, usually regain their erectile function. Those older individuals who had problems with erections before surgery, almost never regain their ability to regain this function.

Chemotherapy

Chemotherapy drugs are frequently used to treat prostate cancer. These toxic drugs kill the rapidly growing cancer cells. This form of therapy is not curative but can help control the spread. However, chemotherapy is associated with more side effects and is generally given to men who have prostate cancer which did not respond to hormonal therapy. Today, various combinations of chemotherapeutic drugs are used and may even be combined with hormones. Early results are positive but long term resulting are not available.

Future therapy

Current trials are evaluating use of stem cells, gene therapy and immune therapy in the treatment of prostate cancer which has already spread.  These newer treatments are currently only available at major cancer centers.

Cryotherapy

Cryotherapy involves use of freezing temperatures to destroy the cancer cells. Cryotherapy has been used to treat prostate cancer in the past. It involves the use of a probe placed through the rectum and freezes the prostate. The freezing action destroys the cancer cells. However, previous results were poor and associated with a number of complications including damage to surrounding structures such as the bladder and rectum. Bladder incontinence was a major complication of Cryotherapy.

Technologic advances have helped to make smaller probes for precise placement on the prostate. Although the complications have decreased, the long term results are unknown.

Observation

The PSA blood test can help detect prostate cancer at a very early stage. This allows many men to choose observation as a treatment option. With observation, one has to have regular follow-ups, frequent blood tests, repeat rectal exams and possibly biopsies to monitor the progression of the early cancer.

Observation is a viable option when the individual has:

• no symptoms
• the tumor is localized
• the grade of the tumor is low
• tumor growth is very slow
• individual is reliable and informed
• elderly male in poor health
• can accept the risks and understand the benefits

Unfortunately prostate cancer can’t be prevented but one can take measures to decrease the risks or slow its progression. The most important steps one can take to maintain good health is to well, be physically active and get regular check up from the doctor.

It is generally agreed that high fat diets should be avoided and more vegetables added to the diet. Vitamin E and Soy products contain isoflavones have been postulated to reduce the risk and progression of the disease. However, there are no firm data showing benefits from these dietary products.

Drug protection

There is some preliminary evidence that indicates that the non-steroidal anti-inflammatory drugs (Advil, Motrin, naproxen may prevent prostate cancer. These drugs inhibit an enzyme called COX-2, which is found in prostate cancer cells. However, more studies are needed to confirm whether NSAID use actually results in lower rates of prostate cancer or reduced death from the disease.

Once a diagnosis of prostate cancer is made, the news is always devastating and depressing. Many individuals may not be able to cope with such news. To cope with a prostate cancer, the best way is to educate oneself. One should maintain a normal routine of lifestyle and work. One should not suffer the burden of a cancer diagnosis on their own and seek counseling from family members friends and help is even available by calling the National Cancer Organization(s). The best way to deal with the cancer is by being well informed with the cancer.

Alternative medicine

Like everything in medicine, alternative medicine is fast catching on as a treatment for all cancers. This is mainly because of the dissatisfaction of individuals with conventional medicine. The problem is that many individuals cannot accept that life is not eternal and conventional medicine is not a cure for all diseases. Before seeking alternative medicine, one should know that the majority of the products have never been proven scientifically and the field is full of charlatans who prey on desperately ill people.

There are numerous nutrition supplements and herbs which are found in every store all over the country- all of them claiming great success in treating prostate disease and cure all other cancers. Most of the success of these products is claimed by the industry and the manufacturers.

The question remains, are these therapies effective? Anecdotal data always suggests that these products are effective but no large controlled trials are available on the majority of these products. Even though these products are widely used, there is absolutely no regulation or control of these products. The ingredients, their content or their purity is not assessed and their long term safety remains unknown. In addition, fake supplements are on the increase and buyer better beware

Herbal Supplements

There are a number of nutritional herbs claiming to be effective in the treatment of prostate cancer but there is not an iota of medical evidence that any of these substances work. The herbs postulated to have activity against prostate cancer include chaparral, PC SPES and shark cartilage. The majority of these products have not been shown to have any benefit in humans and yet they are sold in all herbal stores.

Because it's not always easy to tell which products may be unsafe, the best advice is to seek advice from your physician. These products are by no means cheap and by having blind faith in these products, one not only tends to lose their money but also their life.