PROSTATE CANCER

In front of the bladder is a small organ that looks like a tiny chestnut - the prostate. The urethra runs from the bottom of the bladder right through the middle of the prostate.

Urine continually collects in the bladder  Every so often the muscles at the bottom of your bladder relax, while the muscles surrounding the bladder contract, squirting the urine into the urethra which runs through the prostate and continues through the penis and out of the body.

Situated under the bladder, and wrapped around the urethra, the prostate gland's primary job is to add special fluid to the sperm before it is ejaculated out from the penis. Sperm is produced in the testicles. From the testicles it moves up into the epididymis, where it matures, then into the two small, muscular tubes called the vas deferens, which coil up and around the bladder to the seminal vesicles.

Prostate cancer ordinarily grows slowly but once the cells that make up prostate cancer have grown inside the prostate for a long enough time to reach a critical mass in size and number of cells, the cancer can spread outside of the prostate gland to other parts of the body. Once free of the prostate, the cancer cells can find new homes in the bones, liver, brain, lungs, spinal cord or elsewhere.

 

Prostate cancer is found mainly in older men. As men age, the prostate may get bigger and block the urethra or bladder. This may cause difficulty in urination or can interfere with sexual function. The condition is called benign prostatic hyperplasia (BPH), and although it is not cancer, surgery may be needed to correct it. The symptoms of benign prostatic hyperplasia or of other problems in the prostate may be similar to symptoms for prostate cancer.

Possible signs of prostate cancer include a weak flow of urine or frequent urination.
These and other symptoms may be caused by prostate cancer or by other conditions. A doctor should be consulted if any of the following problems occur:

  • Weak or interrupted flow of urine

  • Frequent urination (especially at night)

  • Difficulty urinating

  • Pain or burning during urination

  • Blood in the urine or semen

  • Nagging pain in the back, hips, or pelvis

  • Painful ejaculation

Tests that examine the prostate and blood are used to detect  and diagnose prostate cancer.
The following tests and procedures may be used:

Digital rectal exam
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.

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 an increased amount 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 non-cancerous, prostate).

Trans-rectal ultrasound:
A procedure in which an endoscope (a thin, lighted tube) is inserted into the rectum to check the prostate. The endoscope 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. Trans-rectal ultrasound may be used during a biopsy procedure.

Biopsy
The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. There are 2 types of biopsy procedures used to diagnose prostate cancer:

  • Trans-rectal biopsy: The removal of tissue from the prostate by inserting a thin needle through the rectum and into the prostate. This procedure is usually done using trans-rectal ultrasound to help guide the needle. A pathologist views the tissue under a microscope to look for cancer cells.

  • Trans-perineal biopsy: The removal of tissue from the prostate by inserting a thin needle through the skin between the scrotum and rectum and into the prostate. A pathologist views the tissue under a microscope to look for cancer cells.

A pathologist will examine the sample to check for cancer cells and determine the Gleason score. The Gleason score ranges from 2-10 and describes how likely it is that a tumour will spread. The lower the number, the less likely the tumour is to spread.

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.

Stages of Prostate Cancer
The process used to find out if cancer has spread within the prostate or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan the best treatment. The following stages are used for prostate cancer:
Stage I
Stage II
Stage III
Stage IV The following tests and procedures may be used in the staging process:

  • Radionuclide bone scan: A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.

  • 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).

  • 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.

  • 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.

  • Seminal vesicle biopsy: The removal of fluid from the seminal vesicles (glands that produce semen) using a needle. A pathologist views the fluid under a microscope to find out if cancer is present.

The results of these tests are viewed together with the results of the original tumour biopsy to determine the prostate cancer stage.

The following stages are used for prostate cancer:
Stage I
In stage I, cancer is found in the prostate only. It is usually found accidentally during surgery for other reasons, such as benign prostatic hyperplasia. Stage I prostate cancer may also be called stage A1 prostate cancer.

Stage II
In stage II, cancer is more advanced, but has not spread outside the prostate. Stage II prostate cancer may also be called stage A2, stage B1, or stage B2 prostate cancer.

Stage III
In stage III, cancer has spread beyond the outer layer of the prostate to nearby tissues. Cancer may be found in the seminal vesicles (glands that help produce semen). Stage III prostate cancer may also be called stage C prostate cancer.

Stage IV
In stage IV, cancer has metastasized (spread) to other parts of the body, such as the bladder, rectum, bone, liver, lungs, or to lymph nodes near or far from the prostate. Metastatic prostate cancer often spreads to the bones. Stage IV prostate cancer may also be called stage D1 or stage D2 prostate cancer.

Recurrent Prostate Cancer
Recurrent prostate cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the prostate or in other parts of the body.

Different types of treatment are available for patients with prostate cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the “standard” treatment, the new treatment may become the standard treatment.

Four types of standard treatment are used:

Watchful waiting
Watchful waiting is closely monitoring a patient’s condition without giving any treatment until symptoms appear or change. This is usually used in older men with other medical problems and early-stage disease.

Surgery
Patients in good health who are younger than 70 years old are usually offered surgery as treatment for prostate cancer. The following types of surgery are used:

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. If the lymph nodes contain cancer, the doctor will not remove the prostate and may recommend other treatment.

Radical prostatectomy
A surgical procedure to remove the prostate, surrounding tissue, and nearby lymph nodes. The 2 types of radical prostatectomy are:
Retropubic prostatectomy: A surgical procedure to remove the prostate through an incision (cut) in the abdominal wall. Removal of nearby lymph nodes may be done at the same time.
Perineal prostatectomy: A surgical procedure to remove the prostate through an incision (cut) made in the perineum (area between the scrotum and anus). Removal of nearby lymph nodes may be done at the same time.

Transurethral resection of the prostate (TURP)
A surgical procedure to remove tissue from the prostate using a cystoscope (a thin, lighted tube) inserted through the urethra. This procedure is sometimes done to relieve symptoms caused by a tumour before other cancer treatment is given. Transurethral resection of the prostate may also be done in men who cannot have a radical prostatectomy because of age or illness.
Impotence and leakage of urine from the bladder or stool from the rectum may occur in men treated with surgery. In some cases, doctors can use a technique known as nerve-sparing surgery. This type of surgery may save the nerves that control erection. However, men with large tumours or tumours that are very close to the nerves may not be able to have this surgery.

Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Impotence and urinary problems may occur in men treated with radiation therapy.

Hormone therapy
Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances produced by glands in the body and circulated in the bloodstream. The presence of some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy are used to reduce the production of hormones or block them from working.

Hormone therapy used in the treatment of prostate cancer may include the following:

  • Luteinizing hormone-releasing hormone agonists can prevent the testicles from producing testosterone. Examples are leuprolide, goserelin, and buserelin.

  • Antiandrogens can block the action of androgens (hormones that promote male sex characteristics). Two examples are flutamide and bicalutamide.

  • Drugs that can prevent the adrenal glands from making androgens include ketoconazole and aminoglutethimide.

  • Orchiectomy is surgery to remove one or both testicles, the main source of male hormones, to decrease hormone production.

  • Oestrogens (hormones that promote female sex characteristics) can prevent the testicles from producing testosterone. However, oestrogens are seldom used today in the treatment of prostate cancer because of the risk of serious side effects.

  • Hot flushes, impaired sexual function, and loss of desire for sex may occur in men treated with hormone therapy.

Other types of treatment are being tested in clinical trials.

Cryosurgery
Cryosurgery is a treatment that uses an instrument to freeze and destroy prostate cancer cells. This type of treatment is also called cryotherapy.

Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly in the spinal column, a body cavity such as the abdomen, or an organ, the drugs mainly affect cancer cells in those areas. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Biologic therapy
Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defences against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Treatment Options By Stage
Stage I Prostate Cancer
Treatment of stage I prostate cancer may include the following:

  • Watchful waiting

  • External-beam radiation therapy

  • Radical prostatectomy, usually with pelvic lymphadenectomy, with or without radiation therapy after surgery. It may be possible to remove the prostate without damaging nerves that are necessary for an erection

  • Implant radiation therapy

  • A clinical trial of radiation therapy

  • A clinical trial evaluating new treatment options

Stage II Prostate Cancer
Treatment of stage II prostate cancer may include the following:

  • Watchful waiting

  • External-beam radiation therapy

  • Radical prostatectomy, usually with pelvic lymphadenectomy, with or without radiation therapy after surgery. It may be possible to remove the prostate without damaging nerves that are necessary for an erection

  • Implant radiation therapy

  • A clinical trial of radiation therapy

  • A clinical trial of ultrasound-guided cryosurgery

  • A clinical trial of hormone therapy followed by radical prostatectomy

  • A clinical trial evaluating new treatment options

Stage III Prostate Cancer
Treatment of stage III prostate cancer may include the following:

  • External-beam radiation therapy with or without hormone therapy

  • Hormone therapy

  • Radical prostatectomy, usually with pelvic lymphadenectomy, with or without radiation therapy after surgery

  • Watchful waiting

  • Transurethral resection of the prostate as palliative therapy to relieve symptoms caused by the cancer

  • A clinical trial of radiation therapy

  • A clinical trial of ultrasound-guided cryosurgery

  • A clinical trial evaluating new treatment options

Stage IV Prostate Cancer
Treatment of stage IV prostate cancer may include the following:

  • Hormone therapy

  • External-beam radiation therapy with or without hormone therapy

  • Radiation therapy or transurethral resection of the prostate as palliative therapy to relieve symptoms caused by the cancer

  • Watchful waiting

  • A clinical trial of radical prostatectomy with orchiectomy

  • A clinical trial of chemotherapy

Treatment Options for Recurrent Prostate Cancer
Treatment of recurrent prostate cancer may include the following:

  • Radiation therapy

  • Prostatectomy for patients initially treated with radiation therapy

  • Hormone therapy

  • Pain medication, external radiation therapy, internal radiation therapy with radioisotopes such as strontium-89, or other treatments as palliative therapy to lessen bone pain

  • A clinical trial of ultrasound-guided cryosurgery

  • A clinical trial of chemotherapy or biological therapy

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