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Prostate Cancer

Anatomical facts: The prostate gland is part of the male reproductive system. Its main function is the secretion of part of the seminal fluid that transports sperm through the penis during ejaculation. This walnut-shaped organ is located in front of the rectum and under the bladder. It encircles part of the urethra, the tube that carries urine from the bladder and semen out of the body through the penis.

Prostate Cancer facts:

Prostate cancer is the most common cancer in American men (excluding skin cancer). One in six American men is diagnosed with this disease during his lifetime. The American Cancer Society estimates about 218,000 new cases of prostate cancer per year. A little over 1.8 million men in the United States are survivors of prostate cancer. Of prostate cancer cases, 90% are diagnosed while the disease is either confined to the prostate or spread only to local lymph nodes. The five-year survival rate at these stages is nearly I0O%. When prostate cancer is diagnosed after it has spread to distant organs, the five-year survival rate drops to 34%. Since 1992, the death rate has fallen about 3.6% every year, possibly because of better detection and treatment
methods.

Prostate Cancer occurrence:

Prostate cancer occurs about 60% more often in African American men than in Caucasian American men. African American men are more likely to be diagnosed at an advanced stage and are more than twice as likely to die of prostate cancer than Caucasian American men. Prostate cancer incidence among Hispanic men is similar to that of white men, and it is lowest among Asian men. The reasons for the racial differences are unclear. The likelihood of developing prostate cancer increases sharply with age. Most men diagnosed with prostate cancer are over 65 years old. It is rare in men younger than 45. Autopsy reports of men over 60 reveal that more than 60% of them had undetected prostate cancer. This finding
indicates that prostate cancer usually grows slowly; however, some prostate cancers have the ability to grow and spread quickly.

Family history and a history of high-grade prostatic intraepithelial neoplasia increase the risk. The role of diet, and especially the consumption of red meat, fruits, and vegetables, is still being evaluated in research studies.

Types:

Over 99% of prostate cancers are adenocarcinomas, and most information sources focus on this type. There are four main treatment approaches for prostate cancer: watchful waiting, surgery, radiation therapy, and hormonal therapy – which may be given as single therapies or in combination. After diagnosis, most men will have to make a decision about which treatment approach to choose.

Many men are overwhelmed by the different factors and data they have to consider and analyze in order to make an informed decision. Factors that influence the decision are age and overall health, the stage and grade of the cancer, and how likely it is to be cured with each one of the treatment modalities. Side effects are an important factor. Because of the prostate’s location and function, surgery, radiation, and hormonal therapies are all associated with serious side effects that may affect sexual and urinary functions.

Watchful waiting means monitoring the cancer very closely without active treatment such as surgery hormonal therapy or radiation therapy. It is a reasonable option for older men whose cancer is small, not causing any symptoms and is expected to grow very slowly.

Treatment of prostate cancer

The surgical procedure to remove the prostate, seminal vesicles, and part of the urethra is called prostatectomy. Sometimes it is possible to perform a nerve-sparing prostatectomy, where the surgeon avoids cutting or stretching the nerves and blood vessels that are needed for an erection. However, even with this technique, some men lose a degree of sexual function and may also suffer long-term urinary problems. The level of damage is influenced by the
man’s age, overall health, and sexual function before the surgery.

In recent years,  a new technique called laparoscopic radical prostatectomy (LRP) has emerged. In this surgery, the prostate is removed with special long instruments that are inserted into the abdomen through small incisions.

Cryosurgery: this is a less invasive procedure, which is sometimes used to treat very small prostate tumors that have not spread. With this method, long thin needles are inserted into the prostate and freeze the tumor. Cryosurgery is less invasive, so patients recover more quickly than after a radical prostatectomy, but it is still a relatively new technique, and doctors are still not sure of its long-term effectiveness.

Cryosurgery refers to the use of very low temperature to freeze and kill cells. During this process, a special needle or probe is inserted in the cancer cells. The needle is made cold with the help of a gas inside it which freezes the cells and kills them. This surgery may cause impotence and leakage of urine from the bladder or stool from the rectum.

Radiation therapy to the prostate is delivered either with external beam radiation or internally through radioactive seeds implanted in the prostate, a method called “brachytherapy.” Both methods have the potential for negative effects on sexual and urinary function. Hormonal therapy blocks the supply of male hormones that promote prostate cancer growth. The drugs that induce hormone deprivation also cause side effects such as hot flashes, impotence, loss of sexual desire, and loss of bone density.

Hormone therapy

Hormone therapy is a kind of treatment for cancer in which drugs may block the action of hormones or inhibit their production. These hormones are required by the cancer cells for their survival and growth. Male sex hormones promote the growth of prostate cancer. Therefore, it is important to block the action or synthesis of these hormones in the patient’s body.

Chemotherapy is not used to treat early-stage prostate cancer because (in most cases) it can be cured with surgery or radiation therapy. This treatment option is mainly used to treat advanced-stage cancer that has stopped responding to hormonal therapy, with the goal of slowing down tumor growth and reducing pain. Treatment approaches combining chemotherapy or targeted therapies in combination with other treatments are being evaluated.
Advanced-stage prostate cancer tends to spread to the bones. Metastatic disease can be treated with a class of drugs called bisphosphonates which slow down bone loss and strengthen bones. Bone pain can be controlled with drugs and/or radiation therapy.

Prostate cancer survivors face a number of difficulties with regard to their quality of life. Many of the sexual and urinary problems can be treated effectively by surgical procedures and/or drugs.

Surgery Overview

Surgery is one of the major treatments for prostate cancer. Surgery can be of various types:

Pelvic lymphadenectomy:  It involves the surgical removal of the nearby lymph nodes, which are then examined by a pathologist for signs of cancer.

Radical prostatectomy: It involves the surgical removal of the prostate and the surrounding tissues (including the seminal vesicles).

It can be done in two ways:

Retropubic prostatectomy: In this procedure, the prostate is removed by making an incision in the abdominal region. Lymph nodes are also removed.

Perineal prostatectomy: In this procedure, the prostate is removed by making an incision in the perineum. The perineum is the region between the anus and scrotum. Lymph nodes are also removed through a separate incision in the abdominal region..

Transurethral resection of the prostate (TURP): It is a surgical procedure to remove the prostate with the help of an instrument called resectoscope. A resectoscope is a tube-like instrument with a light at its end which is inserted through the urethra. It cuts off the tumor of the prostate which blocks the urethra. It is mainly used for relieving the symptoms before other treatments are initiated. It can also be used to remove the prostate when radical prostatectomy cannot be done.

Surgical removal of the prostate by any means may have certain problems. Leakage or urine from the bladder and stool from the urine are some of the after effects. Patient may also become impotent. A nerve-sparing surgery may be performed so that erectile function of the penis can be protected. This surgery cannot be performed if the tumor is very large. Radical prostatectomy may also cause a condition called inguinal hernia.

Radiation therapy

Radiation therapy uses high energy x-rays to destroy cancer cells. Radiation therapy is often used together with chemotherapy for more effective treatment of cervical cancer. Radiation therapy can be given in two ways:

External radiation therapy: A beam of radiation from a machine outside the body is aimed at the affected site of the patient’s body.

Internal radiation therapy or brachytherapy: Radioactive substance sealed in small pellets is placed near the affected region. Cancer cells are killed by the radiations emitted from the radioactive substances.

Doctors recommend either external or internal radiation therapy on the basis of the stage of prostate cancer.

Radiation therapy may cause problems in urination or impotence in patients. It also increases the risk of other cancers in the area where radiation is given.

Chemotherapy

Chemotherapy is the use of drugs for the treatment of cancer. It can be used alone or in combination with radiation therapy. When drugs are administered through a vein or by mouth, this is called systemic chemotherapy. Direct administration of drugs to the affected region is called regional chemotherapy. Chemotherapy can be used when the prostate cancer does not show any improvement after hormone therapy (castration-resistant prostate cancer).

Biologic therapy

Biologic therapy refers to the use of substances that stimulate the immune system of the patient to combat cancer. Advanced stage prostate cancer can be treated with biologic therapy. Sipuleucel-T may be used as a drug for biologic therapy.

High-intensity focused ultrasound

In this treatment, an endorectal probe is inserted through the rectum, which generates ultrasound of high intensity. The ultrasound can kill the cancer cells of the prostate.

Proton beam radiation therapy

This is a new kind of therapy which is under clinical trials. High energy proton beams are directed towards the prostate from the machine outside the body. The proton beams can kill the cancer cells of the prostate.

Clinical trials

Clinical trials refer to those kinds of treatment which are not yet standardized. It is a part of research that aims to develop better strategies for the treatment of cancer. The patients may willingly participate in clinical trials.

References

Crawford ED, Flaig TW. Optimizing outcomes of advanced prostate cancer: drug sequencing and novel therapeutic approaches. Oncology (Williston Park). 2012 Jan; 26(1):70-7.

Bracarda S, Logothetis C, Sternberg CN, Oudard S. Current and emerging treatment modalities for metastatic castration-resistant prostate cancer. BJU Int. 2011 Apr; 107 Suppl 2:13-20.

Djavan B, Nelson K, Kazzazi A, Bruhn A, Sadri H, Gomez-Pinillos A, Ferrari AC. Immunotherapy in the treatment of advanced prostate cancer. Can J Urol. 2011 Oct; 18(5):5865-74. Review.

This article was originally published on 7/12/2014 and last revision and update of it was 9/14/2015.

 

Additional Resources:

Bostwick, David G., et al. 2005. American Cancer Society’s Complete Guide to Prostate Cancer. Atlanta, GA: American Cancer Society. A step-by-step guide through the emotional and physical aspects of the prostate cancer experience, from testing for prostate cancer, to diagnosis and treatment.

Centeno, Arthur, and Gary Onik. 2004. Prostate Cancer: A Patient’s Guide to Treatment. Omaha, NE: Addicus Books. Two prostate cancer specialists authored this easy-to-read, concise guide to prostate cancer. It covers the basics of prostate anatomy and diagnostic tests and offers detailed explanations of various treatment methods, including data on risks, omplications, and side effects. Appendixes provide a summary of treatments for prostate cancer, resources, and a glossary.

Scardino, Peter T., and Judith Kelman. 2005. Dr. Peter Scardino’s Prostate Book: The Complete Guide to Overcoming Prostate Cancer, Prostatitis, and BPH. New York: Avery. Peter T. Scardino, M.D., a surgeon and head of the prostate cancer program at Memorial Sloan-Kettering Cancer, wrote this comprehensive book that includes information on benign and cancerous prostate conditions. Each chapter starts with a short synopsis and ends with a summary. The style is straightforward, clear, and concise.