Prostate Cancer

What is the prostate gland?

The prostate is a gland in the male reproductive system. It lies just below the bladder (the organ that collects and empties urine) and in front of the rectum (the lower part of the intestine). It is about the size of a walnut and surrounds part of the urethra (the tube that empties urine from the bladder). The prostate gland makes fluid that is part of the semen

Prostate cancer is a disease in which malignant (cancer) cells form in the tissues of the prostate

Prostate cancer is most common in older men. In the U.S., about 1 out of 8 men will be diagnosed with prostate cancer.

Signs of prostate cancer:

Weak or interrupted (“stop-and-go”) flow of urine.
Sudden urge to urinate.
Frequent urination (especially at night).
Trouble starting the flow of urine.
Trouble emptying the bladder completely.
Pain or burning while urinating.
Blood in the urine or semen.
A pain in the back, hips, or pelvis that doesn’t go away.
Shortness of breath, feeling very tired, fast heartbeat, dizziness, or pale skin caused by anemia.

Other conditions may cause the same symptoms. As men age, the prostate may get bigger and block the urethra or bladder. This may cause trouble urinating or sexual problems. The condition is called benign prostatic hyperplasia (BPH), and although it is not cancer, surgery may be needed. The symptoms of benign prostatic hyperplasia or of other problems in the prostate may be like symptoms of prostate cancer.

Tests that examine the prostate and blood are used to diagnose prostate cancer.

The following tests and procedures may be used:

Physical exam and health history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Digital rectal exam (DRE): An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the rectum and feels the prostate through the rectal wall for lumps or abnormal areas.ENLARGE
Prostate-specific antigen (PSA) test: A test that measures the level of PSA in the blood. PSA is a substance made by the prostate that may be found in higher than normal amounts in the blood of men who have prostate cancer. PSA levels may also be high in men who have an infection or inflammation of the prostate or BPH (an enlarged, but noncancerous, prostate).
Transrectal ultrasound: A procedure in which a probe that is about the size of a finger is inserted into the rectum to check the prostate. The probe is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. Transrectal ultrasound may be used during a biopsy procedure. This is called transrectal ultrasound guided biopsy.ENLARGETransrectal ultrasound. An ultrasound probe is inserted into the rectum to check the prostate. The probe bounces sound waves off body tissues to make echoes that form a sonogram (computer picture) of the prostate.
Magnetic Resonance Imaging (MRI): A procedure that uses a strong magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. A probe that gives off radio waves is inserted into the rectum near the prostate. This helps the MRI machine make clearer pictures of the prostate and nearby tissue. A transrectal MRI is done to find out if the cancer has spread outside the prostate into nearby tissues. This procedure is also called nuclear magnetic resonance imaging (NMRI). Transrectal MRI may be used during a biopsy procedure. This is called transrectal MRI guided biopsy.

A biopsy is done to diagnose prostate cancer and find out the grade of the cancer (Gleason score).

A transrectal biopsy is used to diagnose prostate cancer. A transrectal biopsy is the removal of tissue from the prostate by inserting a thin needle through the rectum and into the prostate. This procedure may be done using transrectal ultrasound or transrectal MRI to help guide where samples of tissue are taken from. A pathologist views the tissue under a microscope to look for cancer cells.

Transrectal biopsy. An ultrasound probe is inserted into the rectum to show where the tumor is. Then a needle is inserted through the rectum into the prostate to remove tissue from the prostate.

Sometimes a biopsy is done using a sample of tissue that was removed during a transurethral resection of the prostate (TURP) to treat benign prostatic hyperplasia.
If cancer is found, the pathologist will give the cancer a grade. The grade of the cancer describes how abnormal the cancer cells look under a microscope and how quickly the cancer is likely to grow and spread. The grade of the cancer is called the Gleason score.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis and treatment options depend on the following:

The stage of the cancer (level of PSA, Gleason score, Grade Group, how much of the prostate is affected by the cancer, and whether the cancer has spread to other places in the body).
The patient’s age.
Whether the cancer has just been diagnosed or has recurred (come back).

Treatment options also may depend on the following:

Whether the patient has other health problems.
The expected side effects of treatment.
Past treatment for prostate cancer.
The wishes of the patient.

Most men diagnosed with prostate cancer do not die of it.

Stages of Prostate Cancer

After prostate cancer has been diagnosed, tests are done to find out if cancer cells have spread within the prostate or to other parts of the body.
There are three ways that cancer spreads in the body.
Cancer may spread from where it began to other parts of the body.
The Grade Group and PSA level are used to stage prostate cancer.
The following stages are used for prostate cancer:
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
Prostate cancer may recur (come back) after it has been treated.

After prostate cancer has been diagnosed, tests are done to find out if cancer cells have spread within the prostate or to other parts of the body.

The following tests and procedures also may be used in the staging process:

Bone scan: Bone scan. A small amount of radioactive material is injected into the patient’s bloodstream and collects in abnormal cells in the bones. As the patient lies on a table that slides under the scanner, the radioactive material is detected and images are made on a computer screen or film.
MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
Pelvic lymphadenectomy: A surgical procedure to remove the lymph nodes in the pelvis. A pathologist views the tissue under a microscope to look for cancer cells.
Seminal vesicle biopsy: The removal of fluid from the seminal vesicles (glands that make semen) using a needle. A pathologist views the fluid under a microscope to look for cancer cells.
PSMA scan: A procedure to check for cancer that has spread from the prostate to other parts of the body, such as the lymph nodes. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material attaches to prostate cancer cells and is detected by a scanner. The radioactive material shows up as a bright spot on the picture in areas where there are a lot of prostate cancer cells.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

Tissue. The cancer spreads from where it began by growing into nearby areas.
Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body

Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if prostate cancer spreads to the bone, the cancer cells in the bone are actually prostate cancer cells. The disease is metastatic prostate cancer, not bone cancer.

Prostate cancer may recur (come back) after it has been treated.

The cancer may come back in the prostate or in other parts of the body.

Treatment Options

There are different types of treatment for patients with prostate cancer.
Eight types of standard treatment are used:
1. Watchful waiting or active surveillance
2. Surgery
3. Radiation therapy and radiopharmaceutical therapy
4. Hormone therapy
5. Chemotherapy
6. Targeted therapy
7. Immunotherapy
8. Bisphosphonate therapy
There are treatments for bone pain caused by bone metastases or hormone therapy.
New types of treatment are being tested in clinical trials.
1. Watchful waiting or active surveillance
2. Surgery
3. Radiation therapy and radiopharmaceutical therapy
4. Hormone therapy
5. Chemotherapy
6. Targeted therapy
7. Immunotherapy
8. Bisphosphonate therapy
Treatment for prostate cancer may cause side effects.
Patients may want to think about taking part in a clinical trial.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Follow-up tests may be needed.

Surgery

Patients in good health whose tumor is in the prostate gland only may be treated

Radical prostatectomy: A surgical procedure to remove the prostate, surrounding tissue, and seminal vesicles. Removal of nearby lymph nodes may be done at the same time. The main types of radical prostatectomy include:
1. Open radical prostatectomy
2. Radical laparoscopic prostatectomy
3. Robot-assisted laparoscopic radical prostatectomy
4. Hormone therapy
5. Chemotherapy
6. Targeted therapy
7. Immunotherapy
8. Bisphosphonate therapy
Pelvic lymphadenectomy: A surgical procedure to remove the lymph nodes in the pelvis.
Transurethral resection of the prostate (TURP): A surgical procedure to remove tissue from the prostate using a resectoscope (a thin, lighted tube with a cutting tool) inserted through the urethra. This procedure is done to treat benign prostatic hypertrophy and it is sometimes done to relieve symptoms caused by a tumor

In some cases, the nerves that control penile erection can be saved with nerve-sparing surgery. However, this may not be possible in men with large tumors or tumors that are very close to the nerves.

Possible problems after prostate cancer surgery include the following:

Impotence.
Leakage of urine from the bladder or stool from the rectum.
Shortening of the penis (1 to 2 centimeters). The exact reason for this is not known.
Inguinal hernia (bulging of fat or part of the small intestine through weak muscles into the groin). Inguinal hernia may occur more often in men treated with radical prostatectomy than in men who have some other types of prostate surgery, radiation therapy, or prostate biopsy alone. It is most likely to occur within the first 2 years after radical prostatectomy.

Radiation therapy and radiopharmaceutical therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are different types of radiation therapy:

External radiation therapy uses a machine outside the body to send radiation toward the area of the body with cancer. Conformal radiation is a type of external radiation therapy that uses a computer to make a 3-dimensional (3-D) picture of the tumor and shapes the radiation beams to fit the tumor. This allows a high dose of radiation to reach the tumor and causes less damage to nearby healthy tissue. Hypofractionated radiation therapy may be given because it has a more convenient treatment schedule. Hypofractionated radiation therapy is radiation treatment in which a larger than usual total dose of radiation is given once a day over a shorter period of time (fewer days) compared to standard radiation therapy. Hypofractionated radiation therapy may have worse side effects than standard radiation therapy, depending on the schedules used.
Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. In early-stage prostate cancer, the radioactive seeds are placed in the prostate using needles that are inserted through the skin between the scrotum and rectum. The placement of the radioactive seeds in the prostate is guided by images from transrectal ultrasound or computed tomography (CT). The needles are removed after the radioactive seeds are placed in the prostate.
Shortening of the penis (1 to 2 centimeters). The exact reason for this is not known.
Radiopharmaceutical therapy uses a radioactive substance to treat cancer. Radiopharmaceutical therapy includes the following:
1. Lutetium – 177 PSMA therapy
2. Actinium – 225 PSMA therapy
3. Radium – 223 therapy

The way the radiation therapy is given depends on the type and stage of the cancer being treated. External radiation therapy, internal radiation therapy, and radiopharmaceutical therapy are used to treat prostate cancer.

Men treated with radiation therapy for prostate cancer have an increased risk of having bladder and/or gastrointestinal cancer.
Radiation therapy can cause impotence and urinary problems that may get worse with age.

Hormone therapy

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances made by glands in the body and circulated in the bloodstream. In prostate cancer, male sex hormones can cause prostate cancer to grow. Drugs, surgery, or other hormones are used to reduce the amount of male hormones or block them from working. This is called androgen deprivation therapy (ADT).

Hormone therapy for prostate cancer may include the following:

Abiraterone acetate can prevent prostate cancer cells from making androgens. It is used in men with advanced prostate cancer that has not gotten better with other hormone therapy. It is also used in men with high-risk prostate cancer that has improved with treatments that lower hormone levels.
Orchiectomy is a surgical procedure to remove one or both testicles, the main source of male hormones, such as testosterone, to decrease the amount of hormone being made.
Estrogens (hormones that promote female sex characteristics) can prevent the testicles from making testosterone. However, estrogens are seldom used today in the treatment of prostate cancer because of the risk of serious side effects.
Luteinizing hormone-releasing hormone agonists can stop the testicles from making testosterone. Examples are leuprolide, goserelin, and buserelin.
Antiandrogens can block the action of androgens (hormones that promote male sex characteristics), such as testosterone. Examples
Drugs that can prevent the adrenal glands from making androgens include ketoconazole, aminoglutethimide, hydrocortisone, and progesterone.