indiacancer.org - Prostatic Cancer

Prostatic Cancer

		What is the Prostate?
		What is Prostatic Cancer?
		How does Prostatic Cancer present?
		How is Prostate Cancer detected?
		What is staging and grading?
		How is Prostate Cancer treated?
		What are the side effects of Prostate Cancer treatment?
		How do Prostate Cancer patients return to normal life?
		What is the importance of followup?
		What are the possible causes of Prostate Cancer?

What is the Prostate?

The prostate is a walnut-size gland present in males located below the bladder and in front of the rectum. The prostate encompasses the upper part of the urethra, which is the short duct emptying urine from the bladder to the outside. The prostate expresses prostatic fluid, which is a thick fluid, which forms part of the semen. The prostate cannot function without the male hormone testosterone and other male hormones. Testosterone is primarily made by the testicles and the other male hormones are made in small quantities by the suprarenal glands.

An abnormal growth of benign prostate cells is called benign prostatic hyperplasia (BPH) or more correctly, benign enlargement of the prostate (BEP).

In BEP, the prostate enlarges, presses the urethra and bladder, and causes a mechanical obstruction in urinary outflow. It is almost synonymous with old age, and many men above the age of 60 have got BEP in our country. This condition is not life threatening, but its symptoms can be quite troublesome and require relief.

Side view of a cut section through the penis and the Testicles with the Prostate and Urinary Bladder on the top

What is Prostatic Cancer?

Cancer arising from the glands located in the prostate is called adenocarcinoma of the prostate or prostatic cancer. If the cancer penetrates the capsule of the prostate and spreads to adjacent organs such as the bladder or the rectum then it is called locally advanced prostatic cancer. In case, the prostatic cancer spreads to distant organs such as bones then it is known as metastatic prostate cancer. However, the cancer cells lodged in the bones are still prostatic in origin and it is not a bone cancer per se.

How does Prostatic Cancer present?

	The usual way prostatic cancer presents (otherwise known as symptoms of prostate cancer) are as follows:
		Symptoms of mechanical obstruction to urinary outflow, which means difficulty starting the process of urination.
		Difficulty in maintaining a steady good stream of urine
		Urination in stops and starts.
		Complete inability to urinate.
		Difficulty in holding back urine.
		Painful or burning urination.
		Painful ejaculation.
		Blood in urine or semen.
		An extreme urgency or frequent need to pass urine, especially at night.
	Symptoms associated with metastatic prostatic cancer include:
		Frequent pain or stiffness in the lower back, hips, and upper thighs.
		There could also be fractures especially in the bones of the spine without any provocation.
		Such patients could also present primarily with paraplegia or paralysis of the lower limbs.
	Any of these symptoms maybe caused by conditions other than cancer. These conditions could also be serious but of a lesser degree than cancer for, e.g., benign enlargement of the prostate, or a prostatic infection, or a bladder problem. What you have to do in such cases is to visit the doctor as early as possible, because you do not want to wait until you start feeling pain due to prostate cancer. Early prostate cancer causes no pain. It is only when it invades other tissues or nerves in the neighboring areas, or it goes to the bones that it starts causing pain.

How is Prostate Cancer detected?

	There are several steps to establishing the presence of a prostate cancer:
		Digital rectal examination (DRE), in which the doctor inserts a lubricated gloved finger into the rectum and feels the prostate, its contours, whether there are any hard or lumpy areas which are felt through the rectal wall on the prostate.
		Blood tests, which specifically include levels of prostate-specific antigen (PSA) and its various components or/and prostatic acid phosphatase (PAP) in the blood. It is important for the patient to realize that just a rise in PSA is not an indicator of prostate cancer, but it is degree of rise in PSA, which is important. This is something the doctor will explain to you. Do not get anxious if the level of PSA shown in the investigation form is out of range, because even if you have benign enlargement of prostate, the PSA level can rise. However, the rise is not as significant or marked as in prostatic cancer.
		The urine may be checked after a prostatic massage for cytology or blood.
		There maybe other special tests ordered by the doctor including TRUS which stands for transrectal ultrasonography in which an ultrasound is performed by putting a special probe into the patient's rectum. This is used to map out the contours of the prostate and to look for any abnormal pictures.
		The other investigation which could be ordered by the doctor is an IVU, which consists of a series of contrast enhanced x-rays of urinary tract organs.
		Cystoscopy is another procedure in which the doctor uses a thin, self illuminating,metallic or fiber optic tube to look into the patient's bladder and urethra, and to visualize the prostate at the base of the bladder.
		The doctor may perform a transrectal biopsy using either TRUS guidance or even without a TRUS guidance in order to establish tissue diagnosis of or confirmation of prostatic cancer.

What is staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully the degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs.

The grading of a cancer is a microscopic issue, in which the pathologist tells you how aggressive this particular type of cancer is; in which well differentiated means less aggressive, moderately differentiated intermediately aggressive, and poorly differentiated is more aggressive.

One way of grading prostate cancer is called the Gleason system, which has a scoring method ranging from 2-10. All you have to remember as a patient is that prostate cancers which have a higher Gleason score or a higher grade have greater chance of spreading, or invading other organs.

Staging may require additional imaging tests such as CT scan, bone scan, or chest x-ray.

Following are the stages of Prostate Cancer:

Stage I The cancer is not detectable by a digital rectal examination and is asymptomatic. The cancer is incidentally found during some other surgical procedure to relieve urinary problems. Stage I tumors may occupy more than one area of the prostate, but there is no evidence of spread outside the prostate.

Stage II The tumor is rectally palpable or detectable during blood chemistry, but there is no evidence of cancer spread outside the prostate.

Stage III There is spread outside the prostate to nearby tissues.

Stage IV Cancer cells are detectable in lymph nodes or in other distant parts of the body.

How is Prostate Cancer treated?

A lot depends on the patient's constitution, the grade of his disease, and its staging. Patients are usually treated by a team of specialists, which utilizes a multipronged approach. This includes an urologist, an onco surgeon and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy or biological therapy may become add ons.

Treatment strategies

There is an important consideration while starting treatment for prostate cancer in early lesions, which are entirely asymptomatic and discovered incidentally. Many of these patients may be very old and the treatment if too radical could have possibly more side effects and risks, which could outweigh the possible benefits the patient would derive from it. In these cases, possibly the best policy would be to wait and watch and intervene only if the patient becomes too symptomatic.

In all other cases, the bastion of treatment for prostate cancer is surgery and the surgery to remove the prostate in entirety is called radical prostatectomy. It can be done by two methods.

In perineal prostatectomy, the prostate is removed from below in an incision passing midway between the scrotum and the anal opening. In a retropubic prostatectomy, the prostate and the neighboring lymph nodes are removed through an incision in the abdomen anteriorly. During perineal prostatectomy, lymph nodes may be removed through a separate incision in the abdomen.

In case there is evidence that the disease has spread to the lymph nodes, then the patient may require additional therapy, because it is highly likely that the disease is present in microscopic amounts in other parts of the body.

The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It also affects cancer cells only in the zones treated. Radiation therapy is also employed for palliation, i.e., control of symptoms alone in an advanced prostate cancer.

Radiation therapy can also be used in adjunct to surgery or hormonal or chemotherapy, either before or after.

Teletherapy or external radiation is given via a machine remote from the body while, brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation.

Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used.

The prostate and the cancers originating from the prostate are dependent upon the male hormones. Hormonal therapy is a form of systemic therapy, which aims at cutting of the supply of hormones to the cancerous cells and to the prostate in order to prevent their further propagation and replication. While there are many methods of providing hormone therapy, it could be safely divided into surgical and nonsurgical.

The surgical method is to remove the testicle, the source of male hormones. This operation is called an orchidectomy.

The nonsurgical methods comprise of giving the patient a certain hormonal agonist or antagonist. An agonist is a prodrug and antagonist is an antidrug. The common drug used is a luteinizing hormone releasing hormone or (LHRH) agonist. This prevents the testicles from producing testosterone.
The patient could also take the feminizing hormone estrogen, which stops the testicles from producing testosterone in much the same way.

Although, after taking LHRH agonist or estrogen or after having an orchidectomy performed, the body no longer gets testosterone supplied from the testicles, it is important to remember that a minor source of testosterone are the suprarenal glands which are located above the two kidneys. Therefore, sometimes the patients also are supplied with antiandrogens which block the effect of any remaining male hormones while the primary therapy with orchidectomy or LHRH agonist or estrogen is in progress. This treatment is called a total androgen blockade. Metastatic prostate cancer, or cancer of the prostate which has spread to various parts of the body can often be controlled quite effectively with hormonal therapy for a certain period of time.

A newer modality of treatment, which is being thoroughly investigated and tried out at various places in the world, is called cryosurgery, which uses extreme cold to destroy cancer cells. This is being thought of as an alternative to radiation therapy and surgery. The hallmark of cryosurgery is that it is believed to spare the near by healthy tissues.

Chemotherapy and biological therapies are also used in prostate cancer patients for whom hormonal therapy has no effect, however; the results are still very discouraging.

What are the side effects of Prostate Cancer treatment?

	Unfortunately treatments for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. Besides the general discomfort felt during the first year after surgery, the patient may develop permanent impotence, and sometimes, urinary incontinence, which is loss of control over the urinary stream and the voluntary ability to hold back urine. These are, however, much less common than it used to be in the past with the refinement of surgical technique. Many surgeons, these days, use nerve-sparing surgery, which prevents permanent injury to nerves that control erection and bladder urine control. If these surgeries are successful, then the problems of impotence and urinary incontinence are only temporary and therefore soon alleviated. One important thing to be informed to the patient is that these patients after removal of the prostate will never produce semen, so they will always have dry orgasms. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. It is also not uncommon to see impotence develop in those patients who are subjected to external radiation. Although impotence is also seen with patients subjected to internal radiation or brachytherapy, it is much less common than external radiation. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. Amongst the treatments used for hormonal therapy, estrogen is very infrequently used these days because estrogen has a notoriety of causing cardiac problems and estrogen is definitely contraindicated in those males with prostate cancer who already have concomitant cardiac disease. LHRH agonists have a peculiar phenomena associated with them, which is known as the' tumor flare'. In this phenomenon, initially under the influence of the LHRH agonist, there is a flare up in the size and the symptoms associated with the tumor and the patient feels much worse. However, after a short period of time as the hormonal levels of the patient start to drop, the patient feels much, much better. Orchiectomy, LHRH agonist and estrogen all are associated with loss of libido, impotence and 'hot flashes'. Antiandrogen and estrogen therapy are also associated with nausea and vomiting and tender gynecomastia, which is swelling of the male breast. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient. Biological therapy may cause the following problems:
		Low-grade fever.
		Nausea and vomiting (usually mild).
		Rashes and bruises.
	All these problems disappear on cessation of therapy.

How do Prostate Cancer patients return to normal life?

Especially in those patients who have undergone a radical prostatectomy or external radiation therapy, and suffer from the potential social embarrassment of having impotence or urinary incontinence and garment wetting, it is very important that the doctor, nurses, and especially the close relatives get together and make the patient feel as much at home as is possible. It must be stressed to him that there is no need for guilt and it is not really his fault.

During rehabilitation, it is important for both clinician and relatives to realize that physical recovery always outpaces emotional recovery, and just a removal of the final stitch does not signify the end of the recovery phase. A significant part of the rehabilitation process is for the relatives to be as positive as possible, and to get the patient off his emotional crutches as fast as possible.

What is the importance of followup?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit.

Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal examination), a chest x-ray, an ultrasonography, a PSA study, or a CT scan, and various other blood studies as indicated.

What are the possible causes of Prostate Cancer?

The following factors have strong links with prostate cancer:
	People above the age of 55 years have greater chance of developing prostate cancer. So it is important that one becomes more vigilant after this period.
	The following occupations (due to exposure to cancer causing agents at the work place) have a higher risk for prostate cancer.
		Workers who are exposed to the metal cadmium, especially electroplaters, who make batteries, welders, and also workers in the rubber industry appear to have a greater affinity for prostate cancer. It must be emphasized here that research is still going on in these risk related occupations and clear-cut proof for their cause and effect relationship with prostate cancer is still to come forth.
	Various other etiological or causative factors have been put forth for prostate cancer including a diet rich in fat, and also benign enlargement of prostate, and viral sexually transmitted diseases, but all these are largely unproven.