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  1. THE PROSTATE CANCER ADVISOR
  2. FIVE TIPS ON PROSTATE CANCER
  3. BENIGN PROSTATIC HYPERPLASIA (BPH)
  4. PROSTATITIS
  5. PROSTATE CANCER
  6. ERECTILE DYSFUNCTION
  7. INCONTINENCE
  8. GLOSSARY

THE PROSTATE CANCER ADVISOR

PROSTATE CANCER AWARENESS WEEK

For more than 17 years the third week in September has been dedicated to Prostate Cancer Awareness and Screening. The Prostate Cancer Education Council (PCEC) is the coordinating organization for hundreds of prostate cancer screening sites across the country that offer FREE or LOW COST screenings to men over the age of 45 or high risk males over the age of 35. Prostate cancer is the second leading cause of cancer death in men. There is no way to detect prostate cancer in its early stages except through a prostate specific antigen (PSA) blood test and a digital rectal exam (DRE) done by a trained professional.

THE PROSTATE CANCER EDUCATION COUNCIL (PCEC)

The Prostate Cancer Education Council (PCEC) is a 501-c3 Non-Profit Organization that has been coordinating Prostate Cancer Awareness Week (PCAW) since its inception. The council is made up of respected medical doctors, researchers and professionals dedicated to the research and educational efforts designed to reduce and maybe one day eliminate the threat of prostate cancer. Since 1989, when PCAW was initiated, the percent of new prostate cancer cases diagnosed which were localized and potentially curable has increased from 60% to 90%,(Jemal, A, Murray T, Ward E, et al, Cancer Statistics, Ca, , 55:10-30, 2005), , indicating a dramatic increase in awareness among the general public about the importance of early detection. Aside from screening millions of men, PCAW and the PCEC as an organization often participate in new research and technology development to help advance the treatment and detection of prostate cancer.

WHAT IS THE PROSTATE?

The prostate is a gland of the male reproductive system. It is located above the rectum and just below the bladder. The main purpose of the prostate is to produce fluid that helps nourish and transport sperm during the male orgasm.  The prostate is a gland that is necessary for procreation.

WHEN DO PROSTATES DEVELOP PROBLEMS?

For men under 40 years of age, it is likely that the prostate has not caused any problems. But for men who are 40 and over, the prostate may become a source of problems. For instance, 1 in 6 men will develop prostate cancer. Early stages of prostate cancer usually do not cause any symptoms; thus, yearly medical checkups are very important. Other problems, such as benign prostatic hyperplasia (BPH) and prostatitis (inflammation of the prostate) can cause bothersome urinary symptoms.

FIVE TIPS ON PROSTATE CANCER 

Prostate Cancer, two words no man wants to hear.  However, there’s good news all men should listen to.  Surviving prostate cancer is greatly increased when diagnosed early and; there are several steps that can be taken now to help beat the odds of developing advanced prostate cancer.  The Prostate Cancer Education Council suggests the following five tips to accomplish this.

1. Get Screened
The best prevention against advanced prostate cancer is early detection!  Because symptoms of prostate cancer may not occur until the disease is advanced, screening is the first step.  Screening includes a physical exam and a blood test.  Men at high risk should be screened at thirty-five (high risk factors include a family history of prostate cancer and/or men of African American descent.) All other men should begin screening at age 40.  All men should undergo screening once per year.

2. Women speak up!
Women have a role in beating prostate cancer as well.  As many as 60% of men screened say that their wives, girlfriends or another female encouraged them to checked.

3. Diet makes a difference
A Harvard study showed that a diet high in dairy and fatty foods, particularly those of animal origin, increased the risk of developing prostate cancer by 80%.  Studies of Asian men reveal a low incidence of prostate cancer which may be attributed to a diet higher in fermented soy food products as well as a low fat diet.  Supplements and food sources rich in anti-oxidents (vitamin E and selenium) have been shown to control cell damage and may prevent prostate cancer.

4. Get active!
A healthy exercise program will increase circulation, lower stress and may decrease levels of prostate-stimulating androgens. Several studies suggest a relationship between obesity and more aggressive prostate cancer.

5. Do your homework
The more you know and the earlier you know it, the more control you have over your outcome.  Read, ask others and go on-line to educate yourself about prostate cancer.

Prostate Cancer Risk List

Age:  Prostate Cancer is most common in men over 40 and the risk increase with age. The lifetime risk of developing prostate cancer is 1 in 6.  96% of prostate cancer deaths occur in men over 60, and 50% are in men over 80. 21% of all cancer deaths in men over 80 are from prostate cancer. As the US male population continues to age, the risk that the “golden years” will be shortchanged by prostate cancer is significant!

Race:  African American men are more likely to be diagnosed with advanced prostate cancer disease and to die from it. The death rate for African American men is almost 2.5 times greater than white men.
Family History:  The chance of getting prostate cancer doubles if just one close relative (father or brother) has the disease.

BENIGN PROSTATIC HYPERPLASIA (BPH)

BENIGN PROSTATIC HYPERPLASIA (BPH) is a non-cancerous enlargement of the prostate that may cause difficulty or frequency with urination.

An enlarged prostate occurs commonly in men over the age of 40. Experts do not yet know what causes BPH, but the condition may be related to the hormones testosterone and estrogen. There may also be a hereditary component.  The fact that the prostate begins to grow larger is not necessarily a problem. In fact, some men have extremely enlarged prostates but suffer no ill effects. On the other hand, some men have prostates that are only slightly enlarged and they suffer from bothersome urinary symptoms. These symptoms include straining to void, a slow stream, incomplete voiding, the need to urinate quite frequently, and awaking during the night to urinate. BPH is not cancer, and does not lead to cancer. However, one of the confounding problems in men with BPH is that the PSA may be elevated, necessitating an evaluation for prostate cancer. As a crude measure, it has been shown that the PSA may go up one point (1 ng/ml) for every 10 cc (10 grams) of prostate size. To date, no relationship has been identified between BPH and prostate cancer (except that they may coexist in the same patient).

CURRENT BPH TREATMENT OPTIONS

Because BPH is rarely life threatening, treatment is usually required only if the symptoms are bothersome or if the urinary function is severely affected. The decision to choose drug therapy, surgical treatment, or watchful waiting depends on various factors. These factors include the severity and urgency of the symptoms, the physician’s diagnosis, the patient’s overall physical condition and personal desires.

1. WATCHFUL WAITING

Watchful waiting is an option in which a physician monitors the symptoms of BPH but chooses not to treat immediately. As part of the evaluation the physician may order certain tests to assess bladder emptying of function.

Clinical studies have shown that the symptoms of BPH can sometimes wax and wane and even improve on their own. For that reason, if a man’s BPH symptoms are not severe enough to be bothersome, he and his physician may choose a program of watchful waiting. It involves periodic examinations by a physician to carefully monitor the progression of symptoms and possible complications. These complications may include urinary retention, bladder stones, infection, blood in the urine, or damaging backup of urine into the kidney.

2. MEDICAL THERAPY USING PRESCRIPTION MEDICATIONS

Alpha-blockers and 5-alpha reductase inhibitors are two common types of treatments used for BPH. While they work differently on the prostate, both therapies improve symptoms and increase the flow of urine.

Alpha-Blockers - Alpha-blockers work by relaxing the smooth muscle of the prostate and bladder neck to reduce outlet resistance, improve urine flow and reduce bladder outlet obstruction almost immediately. Although alpha-blockers may relieve the symptoms of BPH to varying degrees, they usually do not reduce the size of the prostate. Ask your physician which Alpha Blocker would be best for you.

5-Alpha Reductase Inhibitors – Finasteride and dutasteride shrink the enlarged prostate by decreasing dihydrotestosterone, the male hormone responsible for prostate growth. By shrinking the prostate, these medications gradually improve urine flow rate and decrease the symptoms of BPH. Patients treated with these medications should be aware that they may reduce PSA levels by as much as 50% from baseline. This information needs to be taken into consideration when screening a patient for prostate cancer. For further information, including adverse events, please consult your physician.

3. MIMIMALLY INVASIVE AND SURGICAL TREATMENT

In spite of drug therapy, for some men the symptoms of BPH progress to the point where drug therapy is no longer effective.  In those cases, surgery or minimally invasive procedures may be necessary. For these men, there are a number of options to help relieve the pressure the prostate puts on the urethra. All of the surgical procedures to remove or reduce tissue that is obstructing the flow of urine described below leave the part of the prostate that is at risk for developing cancer in tact.  Men who undergo these procedures still need to be screened for prostate cancer annually. Any of these procedures can also affect the PSA level (usually lower).

TURP - A transurethral resection of the prostate (TURP) involves removing the obstructive prostate tissue by inserting an instrument called a resectoscope into the penis through the urethra. This procedure relieves the symptoms of BPH and makes urinating easier by scraping out some of the enlarged tissue surrounding the urethra. The result is a larger channel for the urine to pass through. The removed tissue is sent to the pathologist were it is examined for the presence of cancer.

TUIP - A more limited surgical procedure, transurethral incision of the prostate (TUIP), may be an option in some cases. TUIP, is usually performed in men who have a relatively small prostate. In this procedure, an instrument is passed through the urethra and an incision is made into the bladder neck and prostate tissue. This incision allows the prostate to “spring” open , thus improving the urine flow rate and reducing the symptoms of BPH. Unlike the TURP, no tissue is removed and sent to pathology.

LASER PROSTATECTOMY - A laser fiber is inserted through the resectoscope and laser (light) energy is used to destroy prostatic tissue and create a larger channel. Like the TUIP, no tissue is removed.
TUNA - Transurethral needle ablation of the prostate is a procedure which removes obstructing tissue through heating probes placed into the prostate via the urethra.  This procedure can be done in your urologist’s office, but does not create as large an opening as the other procedures.
Open Prostatectomy - At times, if the prostate is very large, an open prostatectomy may be necessary. In this procedure, an incision is made in the skin of the lower abdomen so that the physician can remove the inner core of the prostate. This surgery is different from a radical prostatectomy where the whole prostate is removed. Like the TURP, tissue is sent to the pathologist for examination. Of all the procedures used to treat symptomatic BPH, open prostatectomy, creates the greatest relief from the obstructing tissue. However, because it is the most aggressive approach, it also has the longest recuperation time and potential for complications.

Microwave Therapy - In transurethral microwave therapy (TUMT), an instrument that sends out microwave energy is inserted through the urethra to a location inside the prostate. Microwaves are then used to heat the inside of the prostate. Cooling fluid is circulated around the microwave antenna to prevent heat from damaging the wall of the urethra. The temperature becomes high enough inside the prostate to damage the surrounding tissue. Initially the prostate swells, making the urinary symptoms worse, but over time the prostate shrinks reducing the blockage of urine flow. This procedure can also be performed in the physicians office.

4. ALTERNATIVE THERAPIES

Vitamins, herbs, natural remedies and  other nontraditional therapies are also available for men with BPH. and other medical conditions.. It is certainly possible that some herbal medicines may be helpful, but no one should take any herbal medication or attempt to treat BPH without first consulting a physician. Saw Palmetto is derived from the berry of the plant Serenoa repens. Some studies suggest it may have have similar efficacy to finasteride. Beta-sitosterol preparations (Harzol) are derived from South African star grass, Hypoxis rooperi, and other plant species. They have been shown to improve urinary symptoms and flow. Pygeum Africanum (Tadenan) is an extract from the bark of an African plum tree. In an analysis of 18 trials, the agent provided a moderate improvement in urinary symptoms compared to placebo. Side effects were mild.

DISTINGUISHING BETWEEN BPH AND PROSTATE CANCER

Because the symptoms of BPH may also indicate prostate cancer, it is important for men suffering these symptoms to be tested. A digital rectal exam and a blood test for total prostate-specific antigen (PSA) are the recommended first steps in this process. An elevated level often triggers a recommendation for further evaluation. This might include a repeat PSA test, a more specific PSA analysis such as the “percent-free” or “bound” PSA test, or even a biopsy of the prostate. A request for the free or bound PSA is an attempt to distinguish whether the elevated PSA is more likely coming from prostate cancer cells of BPH cells. The PSA molecule (a protein) is made in the glandular epithelial cells of the prostate that are responsible for the BPH process and prostate cancer. Thus, in both conditions, the PSA can be elevated. When it travels in the blood it can  exist in a free state or be bound to a carrier molecule (bound state). Patients with BPH are more likely to have an elevation of “free” or unbound PSA, whereas, men with prostate cancer more often have an  elevation of the bound component. A low free/total PSA ratio or an elevated bound PSA level may suggest the need for a biopsy.

ERECTILE DYSFUNCTION

ERECTILE DYSFUNCTION is the inability to achieve and/or maintain an erection sufficient for satisfactory sexual activity.
Erectile Dysfunction (ED) is a significant and common medical condition sometimes referred to as “impotence”.  It is estimated that as many as 100 million men worldwide suffer from ED. However, more than 85% of men with ED don’t seek treatment. Among the reasons is the incorrect assumption that ED is a normal consequence of aging and that there is no treatment available. The truth is the likelihood of ED increases with age because the prevalence of the underlying conditions associated with ED also increase with age. The failure of sufferers to seek treatment is especially unfortunate because ED is a treatable condition and may be a symptom of another underlying medical problem that needs to be treated as well.

MYTH OR FACT:
 

CAUSES OF ED

Many people incorrectly believe that ED is a purely psychological problem. Erectile Dysfunction is primarily physical in origin, but psychological factors, alone or in combination with physical factors, can cause ED.

Among the conditions associated with ED are:

 CURRENT TREATMENTS FOR ED

Various treatment alternatives are available and you should discuss them with your doctor. A primary care doctor can give a preliminary diagnosis of ED based on a patient history and a physical examination, but may refer a patient to a specialist, such as a urologist. Current treatments for ED include:
These methods have varying degrees of effectiveness and tolerability and are used to treat ED caused by physical or psychological conditions.

INCONTINENCE

INCONTINENCE is the inability to control urination.

Incontinence can result from uncontrolled leakage (stress incontinence) or the inability to postpone the urge to urinate (urge incontinence). Incontinence is not a normal result of aging, but rather occurs from a variety of etiologies or causes. Patients with  this problem, are often too embarrassed or upset to ask for help. Don’t be. It is estimated that over 12 million Americans have urinary incontinence. Incontinence affects all ages, both sexes, and people of every social and economic level. It is also estimated that 15 to 30 percent of people over the age of 60 who live at home have incontinence. Although, the exact number of people with incontinence is not known, the total number of people affected may be far greater than current estimates.

TYPES OF INCONTINENCE

Incontinence is classified by the symptoms of or circumstances occurring at the time of urine leakage.

Stress incontinence

Stress incontinence may be due to poor bladder support by the pelvic muscles or to a weak or damaged sphincter. This condition allows urine to leak when you do anything that strains or stresses the abdomen, such as coughing, sneezing, laughing, or even walking. This is the type of incontinence men may experience after prostate surgery.

Urge incontinence (over active bladder)

Urge Incontinence results when an overactive bladder contracts without being full and without the individuals ability to suppress the urge. At times, urine may leak may occur without any warning at all. A bladder can become overactive because of infection that irritates the bladder lining. The nerves that normally control the bladder can also be responsible for an overactive bladder. In other cases, the cause may be unclear.

Mixed incontinence

Mixed Incontinence is a combination of both conditions above—stress and urge incontinence.

Overflow incontinence

Overflow Incontinence occurs when the bladder is allowed to become so full that it simply overflows. This happens when bladder weakness or a blocked urethra prevents normal emptying. An enlarged prostate can result in such blockage. For this reason, overflow incontinence is much more common in men than in women. Bladder weakness can develop in both men and women, but it happens most often in people with diabetes, heavy alcohol users, and others with decreased nerve function.

Environmental incontinence

Environmental Incontinence (sometimes called functional incontinence) occurs when people cannot get to the toilet or get a bedpan when they need it. The urinary system may work well, but physical or mental disabilities or other circumstances prevent normal toilet usage.

Nocturnal enuresis

Nocturnal Enuresis is incontinence that occurs during sleep. This is most common in children younger than 15 years of age and is generally outgrown with time.

TREATMENT FOR INCONTINENCE

The first step is to locate a health care provider, such as a urologist, who is well informed about treating incontinence. Be sure to come prepared for the visit with: (1) a list of all the medications , including those you purchase without a prescription, (2) the dates and outcomes of any bladder-related tests or surgical procedures and (3) a bladder diary (including a record of how much fluid consumed).
Treatments for incontinence depend on the type and reason for the condition.  Treatment options include:
  1. Medication
  2. Surgery
  3. Exercise
  4. Biofeedback and behavior modification
  5. Implantation of neurostimulator

PROSTATITIS

PROSTATITIS is the inflammation of the prostate gland.

There are three main classifications of prostatitis:
  1. Acute bacterial prostatitis-acute infection of the prostate gland.
  2. Chronic bacterial prostatitis-recurrent infection of the prostate gland. This condition is associated with chronic urinary infection and commonly, calcifications in the prostate (prostatic stones). In the cases of bacterial prostatitis, the culprit usually is a bacterium known as Escherichia coli. The cause of bacterial prostatitis is not well defined, but one theory suggests a reflux of urine from the bladder into prostatic ducts. This reflux of urine may lead to prostatitis.
  3. Nonbacterial prostatitis-inflammation of the prostate without any evidence of infection. The cause of chronic nonbacterial prostatitis is unknown, but this condition makes up 95% of the cases of prostatitis.  Since the cause of nonbacterial prostatitis is not known, cure is difficult. In addition, there is another condition termed prostatodynia. The symptoms are similar to prostatitis, but there is no evidence of prostate inflammation.

SYMPTOMS OF PROSTATITIS

Each form of prostatitis has a slight variation in signs and symptoms.

Acute bacterial prostatitisPain in lower back or rectum

Chronic bacterial prostatitis

Nonbacterial prostatitis


DIAGNOSING and TREATING PROSTATITIS

Doctors may diagnose prostatitis by examining prostatic secretions for bacteria. In acute bacterial prostatitis, the urine readily shows infection. Patients with chronic bacterial prostatitis are more difficult to diagnose. For these patients the prostate is usually massaged through the rectum and the fluid that is  expressed (EPS) by this massage is sent for culture. If positive for bacteria, treatment is with appropriate antibiotics for a longer time. In patients with nonbacterial prostatitis  the EPS will have evidence of inflammation, but bacteria will not be present. Patients with nonbacterial prostatitis have been treated with anti-inflammatory medications, behavior modification and dietary changes.  Prostatitis has also been known to elevate the PSA reading, which should be repeated, if elevated, once the condition resolves.
 

PROSTATE CANCER

Prostate Cancer Statistics

New Cases: An estimated 220,000 new cases of prostate cancer will occur in the United States this year. Prostate cancer incidence rates remain significantly higher in African-Americans and in men with a family history of the disease.

Deaths: An estimated 27,000 deaths will occur this year due to prostate cancer, the second leading cause of cancer death in men. Although mortality rates are declining among white and African-American men, rates in African-American men remain more than twice as high as rates in white men.

Early Detection: Men age 40 and older who have at least a 10-year life expectancy should talk with their health care professional about having a digital rectal exam of the prostate gland and a prostate-specific antigen (PSA) blood test every year. Men who are at high risk for prostate cancer (African-American men and/or men who have a history of prostate cancer in close family members) should consider beginning these tests at age 35.

Survival: Ninety-one percent of all prostate cancers are discovered in the local (confined to the prostate) and regional stages; the 5-year relative survival rate for patients whose tumors are diagnosed at these stages approaches 100%. Over the past 20 years, the five year survival rate for all stages combined has increased from 67% to 98%. According to the most recent data, 84% of men diagnosed with prostate cancer survive 10 years and 56% survive 15 years.

American Cancer Society Cancer Facts and Figures 2007

WHAT IS CANCER?

Cancer is a disease characterized by the uncontrolled growth and potential spread of abnormal cells. The human body is made up of billions of cells that normally divide to reproduce themselves. Occasionally, cells abnormally divide too quickly. Rapidly dividing cells can create a mass called a tumor. Some tumors are benign (noncancerous, no potential to spread). Others are malignant (cancerous). The growth of a benign tumor may interfere with body functions, such as urinating, but these tumors are seldom life threatening. On the other hand, malignant tumors, invade and destroy normal tissue. By a process called metastasis, cells break away from a cancerous tumor and spread through the blood and lymphatic system to other parts of the body, where they form new tumors. Sometimes cancer grows and spreads rapidly. In other cases, it develops and spreads slowly.

WHAT IS PROSTATE CANCER?

The prostate is a walnut-shaped gland that wraps around the urethra like a small donut (the tube that carries urine from the bladder out through the tip of the penis). As with many other organs of the body, cancer cells can grow inside the prostate. In certain more advanced cases, the cancer can spread beyond the prostate. Prostate cancer is the most commonly diagnosed type of cancer among all Americans (excluding basal and squamous skin cancers). The incidence of prostate cancer increases with age. Some studies have shown an overall 2- to 3-fold increase in the risk of prostate cancer in men who have a history of this disease in their family. Family history is defined as prostate cancer in a brother, father, or an uncle. It is more significant if a family member was diagnosed with prostate cancer at a younger age (less than 60 years old). The incidence rate of prostate cancer is nearly two times higher in African-American men than Caucasian men.

WHAT CAUSES PROSTATE CANCER?

The exact cause of prostate cancer is unknown. Prostate cancer is a group of cancerous cells (a tumor) that begins most often in the back portion of the prostate. A fatty diet, family history, older age and African American ethnicity are the only factors currently know to increase one’s risk for prostate cancer. Sexual activity (or lack there of), vasectomy, smoking, and benign prostatic hyperplasia do not appear to be risk factors for prostate cancer. If left untreated, prostate cancer may spread from the prostate to nearby lymph nodes, bones, or other organs. This spread is called metastasis. As a result of metastases, many men experience aches and pains in the bones, pelvis, hips, ribs, and back.

SYMPTOMS OF PROSTATE CANCER

Unfortunately, there are often no early warning signs of prostate cancer and without regular screening; prostate cancer can go undetected for years. In some cases, as the tumor grows it may exert pressure on the urethra, blocking the flow of urine from the bladder causing urinary symptoms. Occasionally the first warning sign may be blood in the urine. Note: symptoms may not occur until the cancer has developed to an advanced stage.

Typical symptoms of prostate cancer:

DIAGNOSIS OF PROSTATE CANCER

Determining the presence of prostate cancer generally involves a series of tests and exams. Before starting the testing process, the physician will ask questions about the medical history, family history of cancer and existing symptoms, and particularly problems with urination. From there, the doctor may proceed to any one of the tests described below.

Digital Rectal Exam (DRE)

Because the prostate lies in front of the rectum, the physician can feel the prostate by inserting a gloved, lubricated finger into the rectum. This simple procedure is called a digital rectal examination (DRE). It allows the physician to determine whether the prostate is enlarged or has lumps or other types of abnormal texture. While this examination may produce momentary discomfort, it should not cause significant pain.

Prostate Specific Antigen (PSA) Test

Used in addition to the digital rectal examination (DRE), a PSA test significantly increases the likelihood of early prostate cancer detection. PSA is the abbreviation for prostate specific antigen, a protein produced by the prostate cells and released into the blood stream. A PSA test measures the concentration of PSA in the bloodstream. Very little PSA escapes from a healthy prostate into the bloodstream, but certain prostate conditions can cause larger amounts of PSA to leak into the blood. Three possible causes of a high PSA level are: 1) a benign enlargement of the prostate called Benign Prostatic Hyperplasia (BPH), 2) Prostatitis (infection) or irritation in the area and 3) Prostate Cancer. An elevated level of PSA is a warning sign that prostate cancer may be present, but since other kinds of prostate disease can also cause high PSA levels, PSA testing by itself cannot confirm the presence of prostate cancer. A high PSA level only indicates the possibility of prostate cancer and the need for additional evaluation by the physician. Conversely, a low PSA level does not always mean that prostate cancer is not present. Although values differ by age, the standard cut-off point for a normal PSA is less than 4.0 ng/ml. Men younger than 50 should have a PSA less than 2.5 ng/ml. In addition, a rise in PSA of more than 1.0 ng/ml per year, regardless of the prior PSA may be significant. New studies suggest how fast the PSA doubles has also been found to be helpful. The significance of all of this is that the physician may not be using just one test or value, but rather a number of different methods to fully evaluate the situation. It may even be necessary to reach back several years to compare old PSA levels to current ones. Men over the age of 40, and those men over the age of 35 who are in high-risk groups, such as African-American men and/or men with a family history of prostate cancer, should have a PSA blood test and digital rectal examination once every year. Any man who develops persistent urinary symptoms should contact his physician.

Biopsy

If the results of the digital rectal exam (DRE), the prostate specific antigen (PSA) tests are suspicious, a biopsy may be necessary. During the biopsy procedure, several small amounts of tissue are removed from the prostate with a needle. This tissue is then examined under a microscope for cancer cells. Only a biopsy can definitely confirm the presence or absence of prostate cancer. A biopsy of the prostate can be performed in the physician’s office. Local anesthesia may be administered and the procedure takes about fifteen minutes. On average, 10-16 samples are taken. Keep in mind that it is still possible to have cancer, even if the biopsy is negative, because the needle, being tiny, may have missed a small focus of cancerous cells.

Grading of Tumors

If the biopsy is taken and prostate cancer is found, the pathologist will assign a grade to the lesion. A 5 point scale is typically used to classify the tumor, with 5 as the most aggressive (dangerous). The grade is determined by the characteristics under the microscope. The pathology report includes the two most common tumor grades encountered. After scanning several regions of biopsy material, the pathologist will report the two most common grades. This is reported as the sum of these two as: Gleason score: 4+3=7 (for example). The first number represents the most common pattern, while the second the next most common. In general, a Gleason’s score of 2-6 is thought to represent a low-risk cancer, a Gleason Score of 7 represents a cancer of intermediate risk, and a cancer graded with a Gleason Score of 8-10 represents high-risk disease. The Gleason score is the most important predictor of the cancer’s aggressiveness. Your physicians will also use this score to help them decide what is the best treatment.

STAGING OF PROSTATE CANCER

Once prostate cancer is discovered, the physician must estimate the size and extent of the cancer (how far it has already spread). This assessment is called staging of the tumor. Currently there are two different systems for staging prostate cancer. The traditional methods classify the disease into four clinical categories rated A through D. The second system is called TNM, which stands for Tumor-Nodes-Metastases, and is considered the most accepted staging system to date.

Staging is generally performed by digital rectal exam and is necessary for you and your physician to decide what type of treatment, if any, is most appropriate. Local stages include A or T1, B or T2 and C or T3. In addition to local staging within the prostate, an effort is also made to stage the extent of prostate cancer outside of the prostate as well. The most frequent areas of prostate cancer spread (metastasis) are to the surrounding lymph nodes (N+) and the bony skeleton (D or M+). For patients with high-grade, clinically high-stage disease or with a PSA > 10-20 ng/ml, a clinician may recommend a CT (computerized tomography) or bone scan to evaluate for external spread. These are generally not considered necessary in patients with low-risk disease.

PSA and percentage of biopsy cores found to harbor cancer are also important prognostic variables predicting prostate cancer outcome. In general, PSA values less than 10ng/ml indicates lower-risk disease, PSA values between 10-20 ng/ml are indicators of intermediate-risk disease, and PSA values higher than 20 are indicators of high-risk disease. In addition, if less than a third of all biopsy tissue submitted for microscopic review harbors cancer, the cancer is predicted to be of lower risk, if between 33 and 50% of the submitted tissue harbors cancer the disease is felt to be of intermediate risk, and if greater than 50% of the tissue submitted contains cancer, the cancer is considered higher risk. This biopsy risk stratification is additive to the risk status that would be assigned based on the stage, Gleason score and PSA.

Many tables and configurations have been developed that attempt to account for these four independently predictive variables and predict prognosis (tumor stage, grade, PSA and percentage of biopsy cores positive). In general, patients with low-risk features by all four measures are candidates for all treatment options (including watchful waiting in older patients, surgery, radiation, either external beam or radioactive seed placement (brachytherapy), as well as cryoablation (freezing). Patients considered intermediate risk are generally counseled against watchful waiting (if a 10-15 year life expectancy is predicted) Finally, men with high-risk disease should understand that they have significant risk of cancer recurrence after treatment and that multiple types of treatments may be necessary.

A - D Staging System

 

TNM Staging

The Tumor-Node-Metastases (TNM) system breaks down the staging of prostate cancer into more categories than the A-D staging system does. As a result, the TNM system is much more complex and technical. The chart below lists all of the TNM stages. Your physician can tell you what TNM stage your have.

TNM Staging
Primary Tumor, Clinical (T)
 
T0 No evidence of primary tumor
T1 Clinically not palpable or visible by imaging
T1a Found incidental to other surgery; present in 5% or less of tissue
T1b Found incidental to other surgery; present in 5% or more of tissue
T1c Identified by needle biopsy
T2 Tumor confined within prostate
T2a Involving half a lobe or less of prostate
T2b Involving half a lobe
T2c Involving both lobes
T3 Tumor extends through prostate capsule
T3a Extends through one lobe or both lobes
T3b Extends into seminal vesicles
T3c Extends into seminal vesicles
T4 Tumor is fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, and/or pelvic wall
    
 
Distant Metastases - (M)
 

PROSTATE CANCER TREATMENT OPTIONS

Over the past 20 years, overall survival rates for all stages of prostate cancer combined have increased significantly. Some of the possible reasons for the increase in survival rates include public education, new techniques of early detection, and better medical therapies. The major treatment options for prostate cancer include: surgery, radiation, medical therapy, a combination of medical therapy and surgery or radiation, chemotherapy, cryoablation and watchful waiting. A patient’s treatment options will depend upon his age, grade of disease, PSA level, the stage of the disease, and the advice of a physician.

Surgery for Prostate Cancer

The goal of surgery is to remove the entire prostate gland, seminal vesicles and all of the cancer. What follows is a description of a number of techniques used by surgeons when operating on the prostate.

The Complete (Radical) Prostatectomy

The surgical removal of the entire prostate gland is called radical prostatectomy. Radical prostatectomy is usually performed to remove early-stage prostate cancer before it can spread to other parts of the body. Often, the pelvic lymph nodes are also sampled for a biopsy as a precautionary measure. Patients who undergo radical prostatectomy should expect at least a 1- to 3- day stay in the hospital, while full recovery takes 4-6 weeks. As with all major surgeries, some prostatectomy patients may require a blood transfusion. Rarely, hormonal therapy is used before surgery to shrink the prostate cancer so it can be removed more effectively. The nerve-sparing approach to prostatectomy has reduced the rate of incontinence and erectile dysfunction dramatically following surgery.

Robotic and Laparascopic Prostatectomy

Surgery can be performed with the laparoscope (with small instruments) as well as through a small incision above the pubic bone. With laparoscopic surgery an incision large enough to remove the prostate (2-3inches) is still required to remove the prostate after it has been dissected from the body. Laparoscopic surgery may be performed with or without the assistance of an operating robot (DaVinci System). The usual hospital stay following robotic or laparoscopic radical prostatectomy is 1-2 nights. One of the most important factors to consider when evaluating surgery as an option for prostate cancer is the surgeon. Studies have clearly shown that those surgeons more experienced with a particular operation are more likely to have positive outcomes. The cancer cure and side effects associated with the prostatectomy procedures are all similar regardless of the type of procedure performed (open, laparoscopic, or robotic).

External Beam Radiation Therapy/Brachytherapy Seeds

Radiation therapy involves exposing cancer cells to high doses of radiation to kill the tumor. The most widely used types are external beam radiation therapy and internal radiation therapy (brachytherapy). External beam radiation therapy treats the prostate and other selected tissues with a carefully targeted beam of radiation administered from machines outside the body. Brachytherapy or interstitial therapy, tiny radioactive seeds are implanted in the prostate through a surgical procedure. The newest technology for external beam radiation therapy is IGRT or image guided radiation therapy. Both IGRT and brachytherapy allow the physicians to increase the dose of radiation to the tumor and with a lower risk of damage to the tissues near the prostate (rectum, bladder and nerve supply). Higher doses of radiation are necessary when patients have intermediate and high risk disease. Sometimes your physician may recommend a combination of IGRT and brachytherapy. These recommendations are often made to patients with the highest risk prostate cancer.

External beam radiation is sometimes recommended after prostatectomy. Recent studies have found a benefit to adding radiation therapy after prostatectomy when the pathologist has determined the cancer has spread outside of the gland. In such cases the radiation is usually started 2-3 months after the prostatectomy (adjuvant radiation). Following the prostatectomy, the PSA is usually <0.2 ng/ml. A slowly rising PSA after a prostatectomy may indicate a local recurrence. Patients with a local recurrence following prostatectomy may also be good candidates for radiation therapy (salvage radiation).

Cryoablation

Cryoablation has undergone significant evolution since its initial use. Some advances include the use of transrectal ultrasound monitoring, temperature-sensing thermocouples, and a urethral warming device. Longer term data has recently become available suggesting this treatment may be as effective as the others in certain clinical situations. Cryoablation can also be used in cases where cancer has recurred following radiation (either external beam or brachytherapy). Following radiation therapy the PSA usually decreases to a low value (<0.5 ng/ml). A transient increase (PSA bounce) can happen in almost 50% of patients following radiation treatment. This bounce can happen 1-3 years following the treatment. An increase of 2 ng/ml is considered a failure. If you have received radiation therapy and your PSA has risen more than this amount you may want to speak to your physician about performing a prostate biopsy. If the biopsy is positive (showing persistent cancer) you may be a candidate for salvage cryoablation. Prostate cryoablation is performed in the operating room with one night hospital stay or as an outpatient procedure.

Side Effects of Local Treatment

All treatments for localized prostate cancer carry some risk of complications. The most common side effects include impotence and incontinence (involuntary loss of urine). In general, these side effects are more common with surgery than with radiation. However, impotence and incontinence tend to appear later when radiation is used, whereas, they are more pronounced immediately after surgery. Some studies suggest that with long follow-up, long term complications may only be minimally different between all of the different treatment choices. The individual expertise of the surgeon, radiotherapist or brachytherapist is one of the most important factor contributing to a positive outcome.

Watchful Waiting

Watchful waiting is another option involving careful observation without immediate treatment for prostate cancer. This may be an appropriate therapeutic course for men who:
Patients electing watchful waiting will need regular careful observation of their cancers. This may require frequent PSA testing and repeat prostate biopsies.

Hormones (Androgen Deprivation), Bisphosphonates, and Prostate Cancer

Hormonal therapy results in a decrease in the male hormone (testosterone) to castrate levels. In the past, female hormones were used to achieve this goal. Today medications can lower testosterone levels without the side effects of female hormones (estrogen). Hormonal therapy is sometimes used before radiation therapy to shrink the prostate and the tumor. The smaller prostate may allow the radiation to be more tightly focused, concentrating the dose so that the tumor receives more rays. Studies demonstrate that the combination of hormone therapy with radiation increase cure and survival rate in patients with more aggressive prostate cancer. Hormone therapy (also called androgen deprivation) is also used for palliative care in patients with very advanced or recurrent prostate cancer. When hormone therapy is used testosterone levels decrease (like castration), the tumor shrinks and PSA levels generally drop, often to undetectable (< 0.1 ng/ml). In patients with metastases, the disease can be stabilized and most patients will go into remission, usually for many years.

Oral and injectable agents are used in achieving androgen deprivation. Injectable agents, in general, are classified as leutinizing-hormone releasing hormone (LHRH) agonist. These agonists alter the signal that causes testosterone production and are available in intramuscular and subcutaneous pellet forms and are given at monthly, quarterly, longer intervals. The main side effects of LHRH agonists include hot flashes and erectile dysfunction (loss of erection). Additional complaints include fatigue, mental status changes, decreased muscle mass, increased body fat, and osteoporosis with extended use. Despite these drawbacks, many patients tolerate LHRH agonist therapies for many years without difficulty.

Oral medications called anti-androgens block the action of testosterone circulating in the bloodstream. Anti-androgens can be taken with injectable LHRH agonists, at the initiation of LHRH agonist treatment, or as a solitary treatment for prostate cancer. The advantage of using both LHRH agonists and anti-androgen medications together is a more complete control of the cancer. Anti-androgens should always, however, be used at the initiation of LHRH injections. LHRH agonists when used alone can cause a flare in the serum testosterone which can have significant negative side effects. You should discuss with your physician which medications would best for your individual situation.

Androgen Independent Prostate Cancer and Clinical Trials

Once a patient has been on androgen deprivation treatment for an extended period of time, prostate cancer may progress in spite of androgen deprivation. In this scenario, low serum testosterone levels are verified and anti-androgen tablets are added if they have not been used in the past. If a patient has been taking anti-androgen tablets, these are either discontinued or switched, as rarely anti-androgen tablets can serve to increase the activity of the androgen receptor. Once these conservative measures have been tried and failed, a patient is considered to have “androgen independent prostate cancer.” This condition is also referred to as hormone refractory prostate cancer. Certain chemotherapeutic combinations have been shown to improve survival in androgen independent prostate cancer, such as docetaxol. Mitoxantrone and prednisone has also been used in this setting and has been shown to improve the quality of life in patients with this condition. Newer chemotherapeutic agents, gene therapy and immunotherapy are constantly being tested. You may be a good candidate for a clinical trial if this situation arises. You should speak to your physician about all options should you develop hormone refractory disease.

THE VALUE OF EARLY DETECTION

Detection of the disease when it is at an early stage offers the best opportunity for successful treatment of prostate cancer. In other words, if the disease is diagnosed when it is confined to the prostate and is treated promptly, complete recovery can be achieved. This means having your physician check you for prostate cancer yearly, if you are 40 years of age or older or if you are 35 years of age and are considered to be at high risk.

You are at high risk for prostate cancer if one or more of the following factors pertain to you:

PROSTATE CANCER PREVENTION/RESEARCH

There is a great deal of active research on the prevention of prostate cancer. Although clinical trials are still not conclusive, many individuals believe that a low fat diet rich with lycopene foods and supplements such as selenium and vitamin E may help prevent prostate cancer.

Lycopene /Vitamin E/Selenium/Supplements

Lycopene is the antioxidant that gives tomatoes and other fruits their red color. Cooking the tomatoes breaks down the cell walls, allowing your body to access the lycopene much easier than from fresh tomatoes. Some studies have suggested prostate cancer may be reduced in men who consume large amounts of lycopene. Be sure to consult your physician about any changes you make to your diet. Recent studies have shown that vitamin E and selenium supplements may have some health benefits with respect to the prevention of prostate cancer. Multivitamins and supplements contain compounds that can interfere with the successful outcomes of your prostate cancer treatment. For example, vitamin E can increase bleeding, which could complicate prostate cancer surgery. Antioxidants can interfere with the efficacy of radiation. The current recommendations are to stop all vitamins and supplements 2 weeks before surgery and during the entire course of radiation therapy. You should discuss your vitamins and supplement intake with your physician before any treatments.

WHAT TO ASK YOUR DOCTOR

Talking to your doctor is one of the best ways to help you understand your medical condition. When sitting in your doctor’s office, it can be hard to remember all the questions that you may have. Sometimes it is helpful to write down a list of concerns to discuss with your physician.

WHAT TO ASK ABOUT PROSTATE CANCER

If you have been diagnosed with prostate cancer, you and your family probably have a lot of questions about the disease and its treatment. Printing out this list and taking it with you to your doctor’s office may help you get the answers you need. Be sure to write out the answers, so that you can review the information as often as you like.

 

WHAT TO ASK ABOUT BPH

If you have been diagnosed with BPH, you and your family probably have a lot of questions about the disease and its treatment.

Printing out this list and taking it with you to your doctor’s office may help you get the answers you need. Be sure to write out the answers, so that you can review the information as often as you like.

GLOSSARY

Adrenal Glands
Located above the kidneys, the adrenal glands produce a small amount of the male hormone testosterone, cortisone and proteins that help maintain fluid and salt balance.

Antiandrogen Drug
A drug that blocks the activity of an androgen hormone, the main one being testosterone.

Benign Prostatic Hyperplasia (BPH)
Noncancerous enlargement of the prostate that may cause difficulty in urination.

Benign Tumor
A tumor that is not cancerous and does not metastasize (spread).

Biopsy
The removal of body tissue samples for diagnostic examination.

Brachytherapy
Treatment with radiation from tiny radioactive seeds inserted into the prostate.

Chemotherapy
The use of chemical agents in the treatment or control of cancer.

Digital Rectal Examination (DRE)
A common screening procedure for prostate cancer, whereby a doctor inserts a gloved, lubricated finger into the rectum in order to feel the size and shape of the prostate through the rectal wall.

Ejaculation
The sudden release of seminal fluid during sexual climax (orgasm) in males.

Erectile Dysfunction (ED)
The inability to achieve and/or maintain an erection sufficient for satisfactory sexual activity. (see Impotence)

Estrogen
A female sex hormone.

External Beam Radiation Therapy
Radiation therapy that uses photon (light) rays from a machine directed toward parts of the body.

Grade
Aggressiveness of a cancer as seen under the microscope.

Hormone Therapy
In prostate cancer, treatment that interferes with the production or activity of male hormones, primarily testosterone, that promote prostate tumor growth.

Impotence
The inability to achieve and/or maintain an erection sufficient for satisfactory sexual activity. (see Erectile Dysfunction)

Incontinence
The involuntary loss of urinary control resulting in leakage of urine.

Interstitial Radiation Therapy
Treatment with rays from radioactive compounds placed inside the tumor or tumors.

LH-RH Analogs
A class of drugs known as luteinizing hormone-releasing hormone analogs that are used to shut down the testosterone produced by the testicles, and in turn, slow hormone dependent prostate cancer cell growth.

Malignant Tumor
A tumor that is cancerous and has the ability to grow and metastasize (spread).

Metastasis
The spread of cancer cells from one part of the body to another.

Oncologist
A physician who specializes in the treatment of cancer.

Orchiectomy
Surgical removal of the testicles.

Pelvic Lymph Node Dissection
Removal of possible cancer-carrying lymph nodes near the prostate for their microscopic evaluation.

Prostate Specific Antigen (PSA)
A substance manufactured by the prostate and found in the blood that often increases in cases of prostate cancer and other prostate conditions.

Prostate Specific Antigen (PSA) Test
Measurement in the blood of a substance produced by the prostate that indicates the possibility of prostate cancer.

Radiation Therapy
Treatment with X-rays radiation.

Radical Prostatectomy
Surgical removal of the entire prostate.

Rectum
The last five or six inches of the intestine leading to the outside of the body.

Retrograde Ejaculation
Ejaculation of semen backward through the urethra into the bladder, instead of outside the body.

Scrotum
The external sac or pouch containing the testicles.

Semen
Whitish fluid containing sperm and secretions from the glands of the male reproductive tract.

Seminal Vesicles
Pouch-like paired glands connected to the prostate that produce and store seminal fluid.

Stage
A term used to describe the size and extent of cancer.

Staging
Tests conducted to determine the stage of a cancer.

Testosterone
A male hormone produced mainly by the testicles. Testosterone stimulates a man’s sexual desire and the growth of other sex organs, including the prostate.

Tissue
A group of cells organized to perform a special function.

Transurethral Incision of the Prostate (TUIP)
A procedure for BPH in which an instrument is passed through the urethra to make cuts into the bladder neck and the prostate.

Transurethral Resection of the Prostate (TURP)
The use of a special instrument inserted into the penis through the urethra to remove prostate tissue, used mainly to treat BPH.

Tumor
An abnormal, excessive growth of cells resulting from rapid cell growth. Tumors may be benign or malignant.

Urethra
The channel that carries urine from the bladder and semen from the sex glands to the outside of the body.

Urologist
A doctor and a surgeon who is specially trained in the diagnosis and treatment of diseases of the male genital tract and urinary tract in patients of any age or gender.
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