Urology Health Specialists, LLC - Urologists, Philadelphia, Pennsylvania

Prostate Cancer

Overview

Prostate cancer is the most commonly diagnosed malignancy in men. The National Cancer Institute estimates that in 2008 over 181,000 new cases will be diagnosed and close to 29,000 men will die of the disease this year. About 1 in 6 men will be diagnosed with prostate cancer at some time in their life. Since the chance of developing prostate cancer increased as men age, most urologists recommend routine screening for prostate cancer starting at age 50 (age 40 in African-American men or those men with a strong family history of prostate cancer).

Symptoms

In its early stages, prostate cancer has no symptoms. It is usually diagnosed by routine screening, which consists of checking the PSA blood test (prostatic specific antigen) and/or rectal examination. (See below)

It is common for men to develop some difficulties urinating as they age. However, these symptoms are signs of an enlarged prostate, usually not prostate cancer. In advanced stages, prostate cancer can cause urinary difficulties as the prostate enlarges and squeezes the channel (urethra) through which the urine passes. With prostate cancer, these symptoms may develop more rapidly. Symptoms are reported to appear in weeks to months, whereas in benign conditions of the prostate that produce similar symptoms, these symptoms are more likely to develop over a period of years.

Advanced prostate cancer may also occasionally cause blood in the urine and irritative voiding symptoms such as frequency, urgency and dysuria (painful urination). When cancer spreads outside of the prostate, it will commonly spread to the bones and can cause pain, weakness and possible fractures. If prostate cancer presents for the first time in the advanced stages, it may become evident as a consequence of symptoms associated with pathological long bone fractures.

Diagnosis

Screening for prostate cancer is usually performed starting at age 50 (age 40 in African-American men or those with a family history of prostate cancer). Screening requires a yearly digital rectal examination and PSA (prostatic specific antigen). The rectal examination allows the physician to feel the prostate and determine if any abnormal feeling areas are present. PSA is a blood test that potentially aids the physician in diagnosing prostate cancer even when no abnormalities are felt on rectal examination. For proper screening, both tests are necessary since prostate cancer may exist when either the rectal examination or the PSA are normal.

Once any abnormality in the PSA or rectal exam is discovered, a prostate biopsy must be performed in order to diagnose prostate cancer. Since some benign conditions of the prostate can cause abnormalities of PSA or rectal exam, only a prostate biopsy can diagnose prostate cancer.

A recent enhancement in the utility of the PSA value is the ability to measure the level of free PSA (sometimes called PSA II). This test is most commonly useful when the PSA is between 4 and 10. Since a normal PSA is less than 4, (and in some cases, such as young healthy men, less than 2.5), free PSA is sometimes helpful to determine whether or not an abnormal PSA is due to benign or malignant conditions. The free PSA test does not take the place of a prostate biopsy but may help some patients avoid additional biopsies, if the initial biopsy reveals no evidence of prostate cancer. Unfortunately, a negative prostate biopsy does not guarantee that there is actually no prostate cancer present in the prostate gland, nor that prostate cancer will not subsequently develop, and therefore continued follow-up is recommended.

A prostate biopsy may be performed by either a urologist’s office or hospital. The procedure is commonly done with the guidance of transrectal ultrasound (TRUS). Transrectal ultrasound allows the urologist to take systematic biopsies throughout the prostate. The TRUS may also radiologically detect abnormalities in the prostate that may actually represent prostate cancer and therefore improve the sensitivity of the biopsy procedure. Since TRUS will not detect all cancers and since many abnormalities detected by ultrasound will not be cancer, the TRUS by itself has not proven to be as useful for detecting prostate cancer as had once been hoped.

Once prostate cancer is detected by biopsy, a Gleason score will be determined by the pathologist. “Gleason score” is a measure of the degree of aggressiveness of an individual prostate tumor. A “Gleason score” is the sum of two individual numbers called the “Gleason grade”. The Gleason grade is a number between 1 and 5, with a 1 representing the least aggressive and 5 representing the most aggressive tumor. Since the “Gleason score” is the sum of two “Gleason grade”, the Gleason score can range between 2 and 10. A Gleason score of 2 indicates a tumor with a low level of aggressiveness and a Gleason score of 10 indicates a very aggressive tumor. However, Gleason scores of 2 through 5 are now rarely reported, and therefore Gleason 6 is typically considered low-grade (less aggressive), Gleason 7 is middle-grade (medium in aggressiveness), and Gleason 8 through 10 are considered high-grade (more aggressive).

Staging

Once prostate cancer is diagnosed by biopsy, proper staging must be performed to determine whether or not the cancer is localized to the prostate. Once the cancer spreads outside of the prostate gland, the treatment choices may change. The necessity for staging will depend upon the size and extent of the tumor based on physical examination, the PSA level, and the Gleason score. Using statistical tables, the urologist an predict the likelihood that the cancer has spread.

Commonly used staging modalities may include:

CT scan of the abdomen and pelvis
Bone scan
MRI of prostate with or without endorectal coil
Prostascint study

Prostate cancer may be localized to the prostate at the time of diagnosis. At this stage, an individual patient may be a candidate for all treatments. If the tumor is found locally outside of the prostate, or found in the regional lymph nodes or in other organs, at the time of diagnosis, the options for treatments may be dramatically different.

In general, prostate cancer is staged as follows:

Localized prostate cancer

Clinical Stage	Clinical Description
T1c	Normal prostate exam; biopsy performed for elevated PSA
T2a	Less than ½ of cancer on 1 side of the prostate
T2b	More than ½ of cancer on 1 side of the prostate
T2c	Cancer on both sides of the prostate

Advanced prostate cancer

Clinical Stage	Clinical Description
T3a	Extension of cancer outside of prostate capsule (1 side only)
T3b	Extension of cancer outside of prostate capsule (both sides)
T3c	Extension to seminal vesicles
T4	Cancer extends to adjacent organs

Treatment

More than any other urologic tumor, the treatment of prostate cancer should be specifically individualized. Treatment for prostate cancer not only depends upon the characteristics of the tumor, but it also depends upon the patient’s age, medical condition and anticipated lifespan.

The recommended treatment for prostate cancer can only be determined after consultation with your urologist. Although treatment options will be reviewed here, patient must discuss these options with their urologist prior to determining what is the best treatment option.

Surgery – Robotic, Laparoscopic, or Open Prostatectomy

For younger patients without significant medical problems, surgical removal of the prostate (radical prostatectomy) may offer the best option for long-term survival. Surgery is a treatment option for those patients with localized disease who have a life expectancy of at least 15 years.

There are several surgical approaches – open, laparoscopic, and robotic. The goal of each surgical approach is the same – to remove the entire prostate and all cancer cells while sparing the urinary sphincter (responsible for maintaining urinary continence) and, in appropriate situations, saving the nerves responsible for erections, called a nerve-sparing procedure. With any surgical approach, just like with any other treatment for prostate cancer, there is always a risk for cancer recurrence, and all steps possible are taken to minimize this risk.

Surgery, like all forms of treatment, has several risks. The main risks of radical prostatectomy include difficulty with urinary incontinence and erectile dysfunction. Due to improved surgical techniques and technology over the last few years, risks have improved with respect to continence and erectile function. For patients who are candidates for robotic surgery, studies have shown less blood loss and lower blood transfusion rate, faster recovery and less trauma to the body. Studies have shown results from robotic surgery with respect to cancer control, continence and erections are at least as good as, and some studies have implied results are better than, open surgery.

If complications do, in fact, occur, treatments are available for managing these complications. These treatments are designed to minimize the impact of surgical complications on quality-of-life issues.

Radiation therapy

There are currently several forms of radiation therapy available for treatment of prostate cancer:

External beam radiation (Intensity Modulated Radiation Therapy – IMRT, and Image Guided Radiation Therapy - IGRT)
Permanent radiation seed implantation (brachytherapy or interstitial radiation therapy)
Combination protocols utilizing both interstitial brachytherapy and external beam radiation

External beam radiation

External beam radiation therapy is considered an effective means of curing prostate cancer and is commonly used as an alternative to radical prostatectomy. External beam radiation therapy has also improved substantially over the last 10-15 years but also has its own risks. Since organs surrounding the prostate are also affected by radiation, patients may develop any of the following symptoms:

Diarrhea and cramps
Bloody bowel movements
Rectal bleeding
Frequent urination
Urinary urgency
Urinary incontinence
Blood in the urine
Erectile dysfunction

Although many of these symptoms may be temporary, some of these symptoms may be permanent. Again, as with the management of surgical complications, there are treatments available to minimize symptomatic discomfort.

Radioactive seed implantation (brachytherapy)

Radioactive seed implantation (brachytherapy) requires that small radioactive pellets be permanently implanted directly into the prostate. The procedure is either performed on an outpatient basis or the patient may be admitted to the hospital overnight. Side effects are similar to external beam radiation therapy.

Care must be taken in determining which patients are best suited for radiation seeds. In general, those patients with small tumor volume, low PSA (less than 10.0), and low Gleason score (6 or less) make the best candidates. A history of prior transurethral resection of the prostate (usually for symptoms of benign prostatic blockage), is generally a contraindication for permanent brachytherapy, even when performed many years earlier.

Hormonal therapy

Although not intended to “cure” prostate cancer, hormonal therapy may be used to control advanced prostate cancer. At times, hormones are used prior to treatment with radiation.

Prostate cancer typically needs the male hormone testosterone to grow. If the body is deprived of testosterone, the prostate tumor will usually shrink in size. However, hormonal deprivation is a therapy utilized to control the cancer since it does not kill all of the cancer cells. In fact, most prostate tumors will eventually become resistant to the hormonal therapy, and grow locally and spread in spite of hormonal treatment.

Common medications used for hormonal therapy include:

Eligard/Lupron (leuprolide)
Vantas (histrelin)
Zoladex (goserelin)
Eulexin (flutamide)
Casodex (bicalutamide)
Nilandron (nilutamide)

Hormonal deprivation may also be accomplished by surgical castration i.e. removal of the testicles.

Watchful waiting/Active surveillance

In certain patients, the best treatment option may be to defer treatment at the time of cancer diagnosis. This option is usually reserved for older patients, patients with multiple other medical problems, tumors with low Gleason scores, or any patient in whom the risks of treatment outweigh the benefits. Sometimes it may be pertinent to complete an extent of disease evaluation, before a final decision is made regarding the appropriateness of this approach.

Other therapies

Newer therapies include cryotherapy (freezing of the prostate tissue) and high-intensity focused ultrasound (HIFU). These treatments also have side effects and have not yet been proven to have equivalent long-term cancer control rates, yet they are still available options.