Prostate Cancer

Prostate cancer continues to be the most common solid tumor diagnosed in men today, with 1 man in every 6 diagnosed with it at some point in their lifetime. Fortunately, prostate cancer is typically a slow-growing cancer, and there are currently many excellent treatments. With modern screening with prostate specific antigen (PSA) and digital rectal examination (DRE), most prostate cancers are now being discovered early while the cancer is still confined to the prostate. This has resulted in earlier treatment and improved cancer-free and overall survival.

Frequently asked questions:

What is the Prostate and what does it do?

The prostate is a small gland located below the bladder and above the urinary sphincter and urethra in men. It can range from the size of a walnut to the size of an apple (see BPH). It is surrounded by important structures like the rectum behind it (which is how your doctor can feel the prostate during a Digital Rectal Examination). On the right and left sides of the prostate are important delicate nerves and blood vessels (NVB, or NeuroVascular Bundle) that help with erections and urinary control. The prostate secretes a fluid that makes up part of the semen (ejaculate). Also behind and connected to the prostate are the seminal vesicles and the vasa deferentia. These structures help deliver sperm and fluids to the prostate and urethra. The seminal vesicles are attached closely to the prostate (squeezed between the prostate, bladder, and rectum) and are an important site for prostate cancer spread (See Staging).↑ top

 

What are the symptoms of Prostate Cancer ?

Prostate cancer is usually asymptomatic, which means patients usually can not tell that they have the disease. In advanced cancer, patients may experience urinary blockage or slower urination, blood in the urine, decreased urine output from obstruction of the kidneys (hydronephrosis), or even impotence. Today, prostate cancer is usually detected by a combination of digital rectal examination and a blood test called, Prostate Specific Antigen (PSA).

↑ top

 

How is Prostate Cancer diagnosed?

Prostate Cancer Screening: The combination of physical exam with DRE and the PSA blood test has resulted in more prostate cancers being detected early when the disease is most likely to be confined to the prostate. Current cancer screening guidelines recommend all men 50 years or older should undergo annual DRE and PSA check. Men at higher risk, such as black men or men with a family history (father, uncles, or brothers) of prostate cancer should start undergoing DRE and PSA checks as early as 45 or 40 years old. While uncommon, prostate cancer can be found in men in their early 40's.↑ top

 

What is Prostate Specific Antigen (PSA)?

Prostate Specific Antigen: or "PSA", is a protein made by normal and cancerous prostate cells. It is measured in the blood and is often elevated in patients with prostate cancer. PSA can also be elevated due to non-cancerous conditions such as infection, enlarged prostate (BPH), intercourse, etc. Most men with prostate cancer will have a PSA greater than 4.0. However, it is also important to keep track of the rate of rise in PSA. PSA will rise in almost all men as they age. In men with prostate cancer, the PSA may rise at a faster rate. In other words, it is possible to have prostate cancer with a "normal" PSA less than 4. Some experts recommend prostate biopsy for even lower PSA levels, if the patient is young, or to catch more prostate cancer even earlier. This is controversial and may lead to some unnecessary or premature prostate biopsies. Certainly if the PSA is over 4 or has jumped up recently, patients should be referred to a urologist for further evaluation and probably a prostate ultrasound and biopsy. 

↑ top

 

What is Digital Rectal Examination (DRE)?

This is a simple exam done by the primary care physician or urologist. The physician inserts a gloved, lubricated finger in the rectum to feel the posterior aspect of the prostate. The prostate should feel smooth and rubbery without any irregular bumps or areas of hardness. The physician can also get a good idea of how big the prostate is during DRE. Any abnormality on DRE should be referred to a urology specialist for further evaluation with a prostate ultrasound and biopsy.↑ top

 

What is a Trans-Rectal Ultrasound Prostate Biopsy?

This procedure is done in the urologist's office. It is usually done to further evaluate either a PSA or DRE abnormality (or both). It can be an uncomfortable (but very necessary) procedure. To minimize this discomfort, your urologist may provide a mild oral sedative or pain medication. Also, many urologists will use a numbing anesthetic (lidocaine) at key areas around the prostate (Patients should ask their urologist if they do this before biopsy!) Most patients will usually tolerate this procedure with minimal to no lasting discomfort.

Brief Description of Procedure:

The anus and rectum are prepared with an antimicrobial cleanser and a numbing anesthetic lubricant. A lubricated ultrasound probe (width of a thumb) is gently inserted into the rectum. The prostate is then anesthetized with numbing anesthetic. High-resolution ultrasound pictures of the prostate are analyzed for any suspicious areas. Under ultrasound guidance, a thin biopsy needle is directed and biopsies of the prostate are taken. Many urologists take only 6 biopsies. Prostate cancer can be in several small areas throughout the prostate, so Dr. Yew prefers to take a broader sampling of the prostate and will usually take an expanded pattern of biopsies (12-18 or more). By numbing and anesthetizing the rectum and prostate, patients usually tolerate these extra biopsies without any added discomfort. If tiny amounts of cancer or an early prostate cancer is present, these extra biopsies may increase the chances of catching it, and may decrease the chances of having to undergo the procedure again later. Read more about prostate biopsy.

↑ top

 

How can you tell how "bad" Prostate Cancer is?

Prostate biopsies are analyzed microscopically. Prostate cancer cells are "graded" based on how they look using the Gleason Grade from 1 to 5 and a cumulative Gleason Score from 2 to 10. Cells that look the most abnormal, and typically are the most aggressive cancers, have a grade of 5. Grade 1 prostate cells look almost normal. Two areas are examined, graded, and then added together to come up with a Gleason Score. So, if all the biopsies are analyzed and they all look like Grade 3, then the patient's Gleason Score will be Gleason 3+3=6. This is the most common pattern seen today and usually has an excellent prognosis.

While "grade" assesses how the individual prostate cancer cells look like under a microscope, "staging" tries to determine where the prostate cancer is in the patient's entire body. Staging tests may include: CT scan abdomen & pelvis, nuclear medicine bone scan or ProstaScint scan, or even an MRI. These tests try to determine if prostate cancer has spread beyond the prostate into the surrounding tissues, lymph nodes, bones, or distant areas. How the prostate feels on DRE is also important in staging prostate cancer. If the prostate feels hard, has irregular lumps, or feels fixed to adjacent areas, these are usually signs that the cancer is more aggressive and likely to have spread beyond the prostate. ↑ top

 

How do you treat Prostate Cancer?

Typically, prostate cancer is slow-growing, and there are excellent treatment modalities. If diagnosed with prostate cancer, you should closely consider all of your treatment options, which may include:

Watchful-Waiting

Like the name implies, it means monitoring the cancer, but not treating it. This may be an option for select cases of very low-risk cancers, or for patients who are very frail or unable to tolerate other treatments. In most cases, more aggressive and curative treatments should be considered.

Radiation Therapy

This typically comes in 2 forms: (1) Brachytherapy or Radiation Seeds, or (2) External Beam Radiation. These treatments leave the cancerous prostate intact within your body. Radiation Therapy kills the prostate cancer cells with radiation energy delivered either by implanting radioactive seeds directly within the prostate or by accurately aiming and shooting beams of radiation (from outside) through the body and into the prostate gland. For many cases of prostate cancer, radiation is an excellent treatment. It may be ideal for low-risk prostate cancer or patients who cannot tolerate the traditional open radical prostatectomy surgery. For high-risk prostate cancer, recent research indicates combining radiation with hormonal blockade (see below) therapy may be a reasonable option. There are considerable side-effects of radiation that you should discuss with your radiation oncologist and urologist. Furthermore, typically after radiation, your PSA will not drop entirely down to undetectable levels. Your PSA will have to be followed closely after any type of treatment for prostate cancer. If PSA starts to rise after radiation and suggest recurrence of prostate cancer, you will need further imaging studies and cancer treatments.

Surgical Radical Prostatectomy

Surgical removal of the prostate and the attached seminal vesicles is still considered one of the most effective treatments for prostate cancer. There have been numerous advances in the history of radical prostatectomy:

Open Radical Retropubic Prostatectomy (RRP)

The traditional open radical retropubic prostatectomy involves making a large open incision in the lower abdomen to enter the pelvis, expose the bladder and prostate. This continues to be an excellent operation with high cure rates. Historically, patients undergoing this operation suffered from impotence and urinary incontinence. This was revolutionized by Dr. Patrick Walsh at Johns Hopkins, who developed the nerve-sparing approach to RRP. Since this development, incontinence and impotence have declined with meticulous nerve-sparing technique. Open RRP requires a thorough understanding of the delicate anatomy surrounding the prostate.
In preserving the delicate nerves and vessels (NeuroVascular Bundle, NVB), the surgeon minimizes the use of thermal energy used to control bleeding. As a result, an open nerve-sparing RRP can possibly involve a greater amount of operative bleeding. For this reason, patients will often donate blood in advance of open surgery in case they require blood transfusion during or after surgery. Besides bleeding, the main side-effects of open RRP include incontinence and impotency. The traditional open radical retropubic prostatectomy continues to be the gold standard and is the most common surgical treatment for removal of the cancerous prostate today.

Laparoscopic Radical Prostatectomy (LRP)

Laparoscopy entered the treatment of prostate cancer initially with the laparoscopic pelvic lymph node removal. This technique used a camera and long surgical instruments inserted through 5-6 tiny puncture incisions. The abdomen was inflated with an inert gas to expand the abdomen and create a big operating space. Removing the prostate was not feasible due to limitations in the optical technology of the laparoscopic cameras and instruments. Now, with modern optical laparoscopic cameras and instruments, and techniques pioneered in France by Drs. Bertrand Guillonneau and Guy Vallancien, it is now possible to surgically remove the prostate laparoscopically. Laparoscopic Radical Prostatectomy (LRP) has the same benefits as the open RRP. Surgeons still adhere to Dr. Walsh's nerve-sparing principles. Although the laparoscopic cameras today are only 2-dimensional and not magnified, visualization is superior to open since the camera puts the surgeon's "eyes" right down by the prostate anatomy. Pressure from the inert gas inflating the abdomen creates a sizeable working space for the surgeon. It also compressing tissues, decreasing bleeding dramatically. LRP is a challenging operation and takes a considerable amount of time to learn and perform adequately. The limitations of LRP are the lack of flexibility and dexterity of the surgical instruments and the lack of depth perception due to the 2-dimensional camera. These limitations may impair the surgeon's ability to do the best possible job of sparing the NVBs alongside the prostate and reconnecting the bladder down to the urethra. Also, due to the location of the prostate within the pelvis and the location of the standing surgeon during LRP, the surgeon will be operating in a less ergonomic or comfortable position. LRP is challenging, and the learning curve is very high. Nevertheless, the LRP was a huge advance in the treatment of prostate cancer with much less blood loss. In skilled hands, LRP continues to be an excellent treatment choice today.

da Vinci Robotic Laparoscopic Radical Prostatectomy. (DVP)

The da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA) utilizes a high-resolution 3-dimensional computer-enhanced vision system and dextrous small robotic instrumentation. In the hands of well-trained, experienced, surgeons, this innovative system allows for superior surgical vision and meticulous fine dissection. Robotic surgery is still considered laparoscopic surgery. It incorporates all the advantages of laparoscopy and LRP: an expanded abdominal and pelvic operating space; compressed tissues; and decreased blood loss. What robotic technology adds to traditional laparoscopy are: improved depth perception; computer-enhanced 3-dimensional visualization of the most delicate structures: and fine surgical instruments with versatility, flexibility, and range of motion that exceeds even the human hand.

The disadvantages of DVP are that currently the equipment is state-of-the-art, and thus, very expensive. Only a few top centers throughout the United States are currently offering this operation due to the cost of the equipment and the lack of adequately trained surgeons. DVP is a demanding operation requiring a thorough knowledge of the prostate and surrounding anatomy. The learning curve for DVP is very high. Excellent results require a skilled and experienced surgeon, preferably one with specialized training in robotic surgery, who has successfully performed many cases of DVP.

Pelvic Lymph Node Dissection

In all surgery to remove the cancerous prostate, it is possible to also remove the lymph nodes in the pelvis located near the major blood vessels supplying the lower body. These pelvic lymph nodes are an important site for prostate cancer spread. See Staging. There are some rare, but potentially significant, added risks to removing these lymph nodes that you should discuss with your surgeon. To get a rough statistical estimate of the chances of prostate cancer spreading to the lymph nodes and beyond, please visit: www.prostatecalculator.org

Cryotherapy (Freezing the Prostate)

This minimally-invasive surgery involves freezing the prostate to kill the cancerous and normal prostate cells. It involves accurate placement of probes into the prostate under ultrasound guidance. This is done with the patient under general anesthesia. Once the probes are in place, they are activated and create an ice ball that must be closely monitored under ultrasound to avoid damage to the rectum, urethra, and adjacent neurovascular bundles. Typically, two separate cycles of freezing and thawing are performed to kill the prostate tissue. Patients usually go home the same day or morning after surgery.

Hormonal Blockade Treatments for Prostate Cancer

For advanced cases of prostate cancer, hormone blockade has been the mainstay of treatment. Normal and cancerous prostate cells require testosterone for survival. By blocking testosterone, prostate cell growth can be slowed or even stopped. This is most frequently accomplished by an injection of an LH-RH agonist (Lupron & Zoladex) medication that shuts off the body's production of androgens. This is also sometimes combined with an oral medication called an anti-androgen (Casodex). This treatment slows prostate cancer dramatically, but it is not considered a cure. While on hormone treatment, prostate cancer cells eventually will become resistant to the hormone medications at which point prostate cancer will grow and spread aggressively. There are many side-effects of hormone blockade therapy including: decreased sex drive (libido), impotence, hot flashes, decreased energy, osteoporosis, breast enlargement/tenderness, and decreased blood count (anemia). Read more on hormonal blockade for prostate cancer.↑ top

 

Prostate Cancer Staging

 

Primary Tumor (T)
TX Primary tumor cannot be assessed.
T0 No evidence of primary tumor.
T1a Tumor found incidentally in 5% or less of tissue removed.
T1b Tumor is found incidentally in more than 5% of tissue removed.
T1c Tumor found by needle biopsy for elevated PSA.
T2a Tumor involves one-half of one lobe or less.
T2b Tumor involves more than one-half of one lobe, but not both lobes.
T2c Tumor involves both lobes.
T3a Tumor extends through the prostate capsule.
T3b Tumor invades seminal vesicle(s).
T4 Tumor invades adjacent structures, e.g. bladder neck, rectum, and/or pelvic wall.
Regional Lymph Nodes (N)
NX Regional lymph nodes were not assessed.
N0 No regional lymph node metastasis.
N1 Metastasis in regional lymph node(s).
Distant Mestasis (M)
MX Distant metastasis was not assessed.
M0 No distant metastasis.
M1a Non-regional lymph node(s).
M1b Bone(s).
Mic Other site(s) with or without bone disease.




↑ top