Prostate Cancer

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prostate Cancer

About one in six men will be diagnosed with prostate cancer during his lifetime, but only one in 32 will die of this disease.

Fortunately, for many men diagnosed with this very common and usually slow-growing form of cancer, the news is encouraging. It is often responsive to treatment, especially if the cancer is caught at an early stage. In addition, the effects of treatment are usually manageable.

| What is the prostate? | What is prostate cancer? | How common is prostate cancer? | What causes prostate cancer? | What are common symptoms of prostate cancer? | How is prostate cancer detected? | What are the stages of prostate cancer? | What are the treatment options for prostate cancer? | Who treats prostate cancer? | How do I cope with prostate cancer? | What Rising PSA Means |

What is the prostate?

The prostate is a gland of the male reproductive system. It produces fluid for semen, which transports sperm during the male orgasm.

Normally, the prostate is quite small — it is nearly the same size and shape as a chestnut.

It is located in front of the rectum, just below the bladder, and wraps around the urethra, the tube that carries urine from the bladder out through the tip of the penis.

The prostate is made up of approximately 30% muscular tissue, and the rest is glandular tissue.

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What is prostate cancer?

Prostate cancer is a malignant tumor that begins growing in the prostate gland. Early prostate cancer usually does not cause any symptoms.

As the tumor grows, it may spread from one part of the prostate to surrounding areas.

Patients may experience a change in urination, including increased frequency, hesitancy or dribbling of urine.

Prostate cancer can spread from the prostate to nearby lymph nodes, bones or other organs. This spread is called metastasis.

For example, as a result of metastasis to the spine, some men experience back pain.

<.....learn more about prostate cancer>

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How common is prostate cancer?

It is the second leading cause of cancer death in men.

More than 70% of all prostate cancers are diagnosed in men over age 65. Men with family history (first-degree relatives, i.e., father, brother) have shown up to an 11-fold increase in the risk of developing prostate cancer.

The death rate for prostate cancer is more than 2 times higher in African-American men than in Caucasian men.

Because of additional risk, earlier screening for prostate cancer is recommended for men at high risk. 

Prostate cancer is the most common type of cancer, men aged 50 and older, and those over the age of 45 who are in high-risk groups, such as African-American men and men with a family history of prostate cancer, should have a prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) once every year.

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What causes prostate cancer?

No single cause of prostate cancer has been identified. There are likely a variety of causes and contributing factors that lead to prostate cancer. The major known risk factors for prostate cancer are age, race and family history.

Although there are no conclusive data, diet and other environmental factors may play a role as well.

Age

Age is the single most important factor in the development of prostate cancer. It is extremely rare for a man under the age of 40 to develop detectable prostate cancer.

However, early growth of precancerous or cancerous cells in the prostate may actually begin before that time. Detectable prostate cancer takes time to develop.  The chance of having prostate cancer increases rapidly after age 50. In fact, about 80% of all prostate cancers are diagnosed in men over the age of 65.

A man in his mid-to-late seventies is 130 times more likely to develop prostate cancer than a man in his mid-to-late forties.  It is still unclear why prostate cancer rates increase with age; however, the genetic mutations that have been linked to development of cancer occur gradually over time.

Race

A wide variation in incidence has been reported among different races and ethnic groups.  While Caucasian-Americans comprise the largest group of men that develop prostate cancer in raw numbers, more African-American men develop prostate cancer than Caucasian-American men.

In fact, African-American men are 65% more likely to develop prostate cancer than Caucasian-American men.  Moreover, African-American men appear to get more severe forms of prostate cancer and are more than twice as likely to die from it as Caucasian-American men.

The reasons for this are unknown. However, diet, genetics and, possibly, inadequate exposure to vitamin D may all play a role.

Asian men living in Asia have the lowest incidence; however, their prostate cancer risk appears to rise, the longer they live in Western culture.

Prostate cancer is most common in North America and northwestern Europe. It is less common in Asia, Central America and South America. While genetics may play a role, diet is suspected to be a major factor in these racial differences.  Because of additional risk, earlier screening for prostate cancer is recommended for African-American men.

Family History

Approximately 25% of men with prostate cancer have a history of the disease within their family.  However, it is believed that only 9% of all prostate cancers are purely hereditary.

The picture may be more complex for those patients with a family history since family members typically share other risk factors, including race, diet and other environmental factors.  The risk of prostate cancer doubles among men having a first-degree relative with the disease.

With two close relatives, a man's risk increases fivefold, and with three or more close relatives, the risk for developing prostate cancer is alarmingly high – close to 100%.

Men aged 50 and older, and those over the age of 45 who are in high-risk groups, such as African-American men and men with a family history of prostate cancer, should have a prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) once every year.

Diet, Obesity & Nutrition

Diet and weight may play a role in the development of prostate cancer.

High intake of animal fats, such as those found in red meat, and polyunsaturated fats (corn oil, safflower oil, margarine, etc.) may be associated with higher rates of prostate cancer; however, it is unclear exactly how dietary fat might relate to increased risk.

It is unclear whether animal fats themselves cause the problems or if it is the way red meat is often cooked.  Scientists have shown that charred meats (as in barbecuing) can create potent cancer-promoting chemicals.

Additionally, men with a high dietary fat intake may be less likely to eat fruits and vegetables, and it is unclear whether high fat or low fruit and vegetable intake (or a combination of both) is responsible for increasing risk.

Obesity

Recent studies have shown that men who are overweight or obese are at significantly higher risk for developing prostate cancer.  Moreover, early weight gain in life is negatively correlated with survival for men who go on to develop prostate cancer.

In other words, a man who develops prostate cancer at age 55 who became overweight at age 25 and stayed overweight is likely to have a more aggressive form of prostate cancer and shorter survival than a man who develops prostate cancer at age 55 who has not been overweight.

Nutrition

Nutrition may play an important role in the prevention of prostate cancer.

Fruits and vegetables, especially cooked tomatoes, contain key sources of cancer-fighting agents, such as lycopene, antioxidants and fiber (Prostate Cancer Nutrition).

Researchers are investigating how a low-fat diet high in soy protein and fiber may reduce the risk of prostate cancer.

Vitamin D & Sunlight

Vitamin D is known to protect the body against cancer.

While vitamin D is contained in milk and some fish, the main source is from the skin, which forms vitamin D when it is exposed to sunlight.

Studies have shown that people living in regions that get less sunlight have higher rates of prostate cancer. This may also help to explain some of the racial differences in the incidence of prostate cancer. People with dark skin absorb less sunlight and are known to have lower levels of vitamin D.

Circulating Male Hormone Level

Lifetime risk of prostate cancer may be linked to the amount of the male hormone testosterone circulating in a man's body as early as puberty or even in utero, although direct evidence of this link remains to be shown.

Prostate cancer cell growth may be fueled by the presence of testosterone. Therefore, one of the most common treatments for prostate cancer, especially if it returns after first-line treatment, is the complete suppression of testosterone production and action in the body. (Hormone Therapy).

It has also been shown that men who have their testicles surgically removed (orchiectomy; castrated) before puberty rarely develop prostate cancer.  However, these observations do not prove that prostate cancer is caused by high levels of testosterone in the body.

<.....learn more about testosterone>

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What are common symptoms of prostate cancer?

As the tumor grows, it may spread from one part of the prostate to surrounding areas.

Early stages of prostate cancer may not cause any symptoms. However, men with more advanced disease may experience a need to urinate frequently, especially at night:

  • Difficulty starting urination or holding back urine;

  • Weak or interrupted flow of urinary stream (stopping and starting);

  • Inability to urinate

  • Painful or burning urination;

  • Difficulty in having an erection;

  • Painful ejaculation;

  • Blood in urine or semen; or

  • Frequent pain or stiffness in the lower back, hips, or upper thighs.

You should speak with your doctor immediately if you have experienced any of the above symptoms or if you are a man over 50 who has not had a recent prostate cancer screening.

If you have a family history of prostate cancer, or are an African-American male, you should consider screening at age 45.

Stopping testicular production of testosterone may relieve many of these symptoms.

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How is prostate cancer detected?

Determining whether you have prostate cancer generally involves a series of steps. Your doctor will first ask you questions about your medical history and any symptoms you may be having.

Next, your doctor will most likely perform a digital rectal examination (DRE) by inserting a gloved, lubricated finger into the rectum to feel the size and texture of your prostate.

A prostate-specific antigen (PSA) test, used in addition to DRE, increases the likelihood of cancer detection.

A PSA test measures the level of prostate-specific antigen, a substance produced mainly by the prostate cells, in the bloodstream.

A high level of PSA in the bloodstream can be a warning sign that prostate cancer may be present.

Finally, the results of either or both tests (DRE and PSA) may suggest the need for a biopsy. Only a biopsy can definitively confirm the presence of prostate cancer. Read more about how prostate cancer is diagnosed.

<.....read more about diagnosing of prostate cancer>

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What are the stages of prostate cancer?

Staging is the assessment of the size and location of prostate cancer (that is, how far the cancer has already spread).

Staging is necessary for the patient and physician to decide what type of treatment is most appropriate.

  • Stage A is early cancer.  The tumor is located within the prostate gland and cannot be felt during a DRE.

  • In Stage B, the tumor is considered to be within the prostate and can be felt during a DRE.

  • In Stage C, prostate cancer is more advanced.  Stage C indicates that the tumor has spread outside the prostate to some surrounding areas. This stage of cancer can usually be detected by a DRE.

  • In Stage D, the cancer has spread to the nearby organs and usually to distant sites, such as the bones or lymph nodes.

<.....read more about how prostate cancer is staged.>

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What are the treatment options for prostate cancer?

The major treatment options for prostate cancer include hormonal therapy, such as Lupron Depot® (leuprolide acetate for depot suspension), surgery, radiation, chemotherapy, and watchful waiting (observation).

Treatment options will depend on several factors, including your age, the stage of your disease and the advice of your physician.

<.....learn more about treatment option>

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Who treats prostate cancer?

If prostate problems are discovered, your doctor may refer you to a urologist, a doctor who specializes in disorders of the urinary system and the male reproductive system.

In some cases, a patient may be referred to an oncologist, a specialist in the treatment of cancer, for additional consultation.

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How do I cope with prostate cancer?

You may want to speak to your doctor to learn if there are support groups in your area.

<.....read more about maintaining prostate health.>

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Understanding prostate cancer

Prostate cancer is a group of cancerous cells (a malignant tumor) that begins most often in the outer part of the prostate. It is the most common type of cancer (excluding skin cancer) diagnosed in American men.

Early prostate cancer usually does not cause any symptoms. However, as the tumor grows, it may spread from the prostate to surrounding areas. Change in urination, including increased frequency, hesitancy or dribbling of urine may be experienced.

Prostate cancer can spread from the prostate to nearby lymph nodes, bones or other organs. This spread is called metastasis. For example, as a result of metastasis to the spine, some men experience back pain.

The value of early detection

The overall prognosis for prostate cancer patients has dramatically improved compared with years ago. Over the past 20 years, the overall survival rates for all stages of prostate cancer combined have increased from 67% to 97%. This means more men are living longer after diagnosis.

Some of the possible reasons for this increase in survival rates include public awareness and early detection.

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Diagnosing prostate cancer

Determining whether you have prostate cancer generally involves a series of tests and exams. Before starting the testing process, your physician may ask you questions about your medical history, your family history of cancer and any symptoms you may be having, particularly problems with urination. Then, your doctor will most likely proceed to one or more of the tests described below.

  • Digital Rectal Exam (DRE)

    • The digital rectal exam should be performed along with the PSA test. The DRE is performed by a physician who will insert a gloved finger into the rectum to feel the peripheral zone of the prostate where most prostate cancers occur.

    • Because the prostate lies in front of the rectum, your physician can feel the prostate by inserting a gloved, lubricated finger into the rectum.

    • The physician will be checking for hardness of the prostate or for irregular shapes or bumps extending from the prostate – all of which may indicate a problem.

    • The DRE is particularly useful because the PSA test may miss up to 25% of cancers, and the DRE may catch some of these.

    • This simple procedure is called a digital rectal examination (DRE). It allows your physician to determine whether the prostate is enlarged or has lumps or other types of abnormal texture.

  • Prostate-Specific Antigen (PSA) test

    • It is important to note that the PSA test is an imperfect screening tool. A man can have prostate cancer and still have a PSA level in the “normal” range.

    • Approximately 25% of men who are diagnosed with prostate cancer have a PSA level below 4.0.

    • In addition, only 25% of men with a PSA level of 4–10 are found to have prostate cancer. With a PSA level exceeding 10, this rate jumps to approximately 65%

    • Used in addition to the DRE, a PSA test increases the likelihood of prostate cancer detection.

    • PSA is the abbreviation for prostate-specific antigen, a substance produced by the prostate cells.

    • A PSA test measures the level of PSA in the bloodstream and is reported as nanograms per milliliter, or ng/mL. 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.

    • Two possible causes of a high PSA level are:

      • a benign non cancerous enlargement of the prostate called benign prostatic hyperplasia (BPH)

      • prostate cancer

    • A high level of PSA in the bloodstream 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 your physician.

    • Conversely, a low PSA level does not always mean that prostate cancer is not present.

    • Any man who develops persistent urinary symptoms should contact his physician.

    • Some helpful hints for obtaining a maximally accurate PSA test include:

      • don’t ejaculate for 2 days prior to having a PSA test as this can raise PSA levels, and

      •  tell your doctor if you are taking Proscar, Avodart or Propecia. These drugs, used to treat BPH and baldness, will likely lower your PSA levels. Also,

      • be sure that the DRE is performed after drawing blood for the PSA test, as the DRE can artificially raise PSA levels.

      • herbal supplements can also affect PSA levels. Be sure to tell your doctor about any supplements that you are taking before the PSA test.

  • Transrectal Ultrasound (TRUS)

    • Transrectal Ultrasound (TRUS) is the use of sound waves to create an image of the prostate. As the waves bounce off the prostate, they create a pattern that is converted into a picture by a computer.

    •  It has been shown that TRUS alone is of limited, if any, value in the diagnosis of prostate cancer.

    • It is now used primarily to detect abnormal prostate growth and to guide a biopsy needles to the abnormal prostate area.

  • Prostate Biopsy

    • The DRE and PSA tests cannot diagnose prostate cancer; they merely indicate that further testing is needed. Abnormal findings in either the DRE or PSA may indicate the need for a biopsy.

    • During a biopsy, a TRUS is used to view and guide a needle (or multiple needles) into the prostate to take small samples of tissue.

    • Typically, a prostate cancer biopsy employs a multi-needle device that is able to take six or more tissue samples simultaneously from different parts of the prostate to be sure that cancerous tissue is not missed. This procedure is typically performed using local anesthesia.

    • Some physicians will take 12 or more tissue samples or “cores” during a biopsy. These tissues are then examined for the presence of cancer. This generates a value known as a Gleason Grade, which is used to diagnose the grade of the disease or how far it may have progressed.

    • A biopsy is the only way to confirm or diagnose the presence of prostate cancer. The biopsy procedure may cause some discomfort or pain, but the procedure is short, and it can usually be performed without an overnight hospital stay, on an outpatient basis.

    • After a biopsy, blood may be present in the urine, semen and/or bowel movements, but these symptoms generally disappear after a few weeks.

    • Some men worry that a biopsy might help spread the cancer cells either throughout the prostate or beyond. There is no evidence that cancer biopsies of any kind result in the spread of cancer.

    • While biopsies are the most accurate means of detecting the presence of cancer in the prostate, it is possible to miss a significant cancer during a biopsy – or receive a false-negative result.

    • Prostate cancer does not typically grow as one single tumor or grouping of cancer cells. Rather, prostate cancer is usually comprised of many different small tumors or cancer cell groupings in different areas of the prostate.

    • For this reason, the exact location of these various small tumors can be difficult to pinpoint with the biopsy needles. The needles are directed to the locations in the prostate that are most likely to contain prostate cancer.

    • However, the biopsy is only a sampling of tissue from various parts of the prostate. If very strong signs of cancer were present prior to the biopsy, such as a prostate lump felt during the DRE, a very high PSA and/or an elevated PSA with a very low percentage of free PSA, but no cancer was found, the patient should discuss repeating the biopsy with his doctor.

    • If the biopsy is taken and prostate cancer is found, the tumor is graded in the medical lab. The grade estimates how aggressive a prostate cancer is; that is, how fast it is growing and the likelihood of its spreading.

    • Once diagnosis is made, prostate cancer is categorized into stages based on the size and spread of the disease.

  • Percent Free PSA

    • This test measures how much PSA circulates freely in the blood and how much is bound with other proteins. The more free PSA that is present the better (or the more likely a man is to be “free” of cancer).

    • So, if a man has an elevated total PSA, but most of it is “free PSA,” then it is most likely coming from BPH rather than cancer.

    • Conversely if most of the total PSA is coming from PSA that is bound to proteins, it is more likely that the patient will have cancer.

    • In one study, researchers used a free-PSA cutoff range of 19% in men with total PSA levels between 3 and 4 and detected 90% of all cancers.

    • In another study of men with total PSA levels between 4 and 10, biopsies were performed only in men with free PSA of less than 25% of the total PSA.

    • They detected 95% of the cancers and reduced unnecessary biopsies by 20%.

  • PSA Density (PSAD)

    • PSA density is the value of the PSA divided by the size of the prostate, which can be determined by a transrectal ultrasound (TRUS).

    • The likelihood of prostate cancer is increased when the PSAD value is high.

    • In other words, if you have a relatively small prostate that is producing large amounts of PSA, there is a greater likelihood that cancer is present.

    • If the prostate is large relative to the PSA score, there is a greater chance that BPH is to blame.

  • PSA Velocity

    • Calculating the PSA velocity tracks changes in the PSA blood level over time - for example, how quickly the PSA level rises over the course of several months.

    • PSA velocity may aid the interpretation of borderline PSA results by measuring whether the PSA levels are increasing over a short period of time.

    • The test is used as a tool to keep track of how PSA levels change, but it is not used to diagnose prostate cancer.

    • If PSA increases dramatically in a short period, it may be one indicator that prostate cancer has progressed.

<.....learn more about grading and staging of prostate cancer. >

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Grading & Staging

The Gleason Grade refers to the degree of aggressiveness of a particular tumor based on the appearance of the tissue under a microscope; that is, how fast it is growing and the likelihood of its spreading.

The Gleason grading system assigns a numerical score to each of the two largest areas of cancer in the tissue samples. The lowest possible combined Gleason Grade is 2, and the highest possible Gleason Grade is 10.

The staging estimates the size and location of the cancer (including how far it has spread). Grading and staging will help determine what type of treatment, if any, is most appropriate.

Gleason Grade

How Is It Determined & Calculated?

The Gleason grading process assigns a number ranging from 1–5 based on the degree of “cell differentiation” within the tissue sample from very well differentiated (i.e., least cancerous, most normal looking [grade 1] to very poorly differentiated and most cancerous [grade 5]).

Gleason Grades 1 and 2 closely resemble normal prostate tissue – in which the cells appear round, orderly and with defined borders.

In grade 2, the cells are more loosely aggregated.

In Gleason Grade 3 cells are beginning to lose their defined borders and are starting to group together into clumps.

Gleason Grade 4 is identified by loss of normal cell structure and a more pronounced clumping together of cancerous cells.

Gleason Grade 5 means that the cells have lost most or all of their normal characteristics are very poorly differentiated and have essentially merged together into cancerous islands of cells.

The Combined Gleason Grade or Gleason Sum

The final Gleason Grade is the combination of two numbers, derived from adding the two highest grades assigned to two tissue areas extracted during the biopsy.

The pathologist will assign patterns to each section of tissue samples, a most common pattern in one sample and a second most common pattern in another specimen.

Assigning a combined grade to the two most common patterns allows for a better prediction about the prognosis.

The lowest possible Gleason Grade is 2 (1 + 1), where both the primary and secondary patterns have a Gleason Grade of 1.

A typical Gleason Grade might be 5 (2 + 3), where the primary pattern has a Gleason Grade of 2 and the secondary pattern has a grade of 3.

Another typical Gleason Grade might be 7 (4 + 3), where the primary pattern has a Gleason Grade of 4 and the secondary pattern has a grade of 3.

The highest possible Gleason Grade is 10 (5 + 5), when the primary and secondary patterns both have the most disordered Gleason Grades of 5.

Risk Relative to Gleason Grade

The Gleason Grade can help a physician to determine a man's stage of cancer.

In general, the Gleason can be an indicator of how aggressive the cancer is or will behave in the future.

However, the Gleason Grade does not determine how far the cancer has spread, whether it is confined to the prostate or to which part of the body the cancer may have spread.

Nonetheless, a high Gleason Grade (8–10) indicates a greater chance that the cancer has spread beyond the prostate and is a more aggressive form of cancer.

A very high Gleason Grade (i.e., 10) is strongly predictive for aggressive cancer that has likely grown outside of the prostate.

Conversely, a lower Gleason Grade indicates a better prognosis.

Some scientists believe that very low Gleason Grades (i.e. 2–4) may be misleading.

When prostates removed from patients with low Gleason Grades are evaluated by pathologists, the Gleason Grade is often restated because higher-grade cancers are found within the prostate that were not pinpointed with the original biopsy.

Prostate cancer is a very complex disease, and the Gleason Grade alone cannot predict the future course of disease.

Some men with low Gleason Grades have been known to do poorly, while some other men with high Gleason Grades have been known to do well.

By combining the patient's Gleason Grade with the PSA level and the clinical stage, it is possible to use prognostic tools such as the “Partin coefficient tables” to estimate the likelihood that that patient has localized or locally advanced prostate cancer of different types.  This factor – whether the cancer has spread – is an important consideration in determining the optimal treatment.

Staging & Prognosis

Staging determines the extent of prostate cancer and provides an idea of how the cancer should be treated.

The best-case scenario is that the cancer is identified at an early stage, when the tumors are very small and confined within the prostate.

Staging is based on where the cancer is in the body and where it may have spread if it has grown beyond the prostate.

Doctors use a variety of techniques to accomplish this, including feeling the prostate itself via a digital rectal exam (DRE), magnetic resonance imaging (MRI) and other techniques to visualize what is going on within the body.

Terminology you may hear:

Cancer may be described as “indolent” or “aggressive.”

  • “Indolent" means that the cancer is expected to grow slowly and not progress rapidly.

  • “Aggressive” indicates that the prostate cancer is likely to grow rapidly.

Prostate cancer is a heterogenic disease, in that some prostate cancers progress very rapidly while some grow slowly.

The aggressiveness of tumors appears to correlate directly with the proportion of higher Gleason Grade cells, but it may still be difficult to determine the prognosis and the best treatment and how responsive a particular cancer might be to treatment.

Other terminology:

  • “Localized” prostate cancer means that the cancer is confined within the prostate.

  • “Locally advanced” prostate cancer means that most of the cancer is confined within the prostate; however, some of the cancer has penetrated the capsule of the prostate or has escaped into the seminal vesicle (but not the lymph nodes).

The following describes some of the tests and procedures that may be used by a physician to determine the extent of the prostate cancer.

Imaging & Staging Methods

Lymph Node Biopsy (Lymphadenectomy)

The best way to determine whether the cancer has spread beyond the prostate is to remove tissue from areas where prostate cancer is known to spread.

When prostate cancer is suspected to have spread, a lymph node biopsy is commonly taken. Lymph nodes are often assessed during surgery when the prostate is removed.

Bone Scan

A bone scan, which is similar to an X-ray, is used to determine if prostate cancer has spread to the bones.

In this procedure, a physician will first inject a harmless radioactive substance (“radioisotope”), which is attracted specifically to bones.

Normal bones absorb the radioactive substance at a lower rate than bone that is in a process of regeneration – such as in a bone fracture or when cancer is present.

Thus, if cancer is present in the bone, the radioisotope accumulates in those locations and shows up as a “hot spot” on the X-ray-like image taken during the bone scan.

It is important to note that bone scans are not perfect tools for identifying whether prostate cancer has spread to the bone. There may be microscopic deposits of prostate cancer cells in bones that do not show up on the bone scan image – giving a “false negative” test result.

Conversely, any type of bone problems such as a current (or old) bone fractures, arthritis and infections can show up as hot spots on a bone scan – giving a “false positive” test result.

However, regular X-rays can help separate these other bone problems from suspicious sites of cancer in the bone.

Magnetic Resonance Imaging (MRI)

MRI uses a high-powered magnetic field to create an image of the prostate. The MRI can show whether the cancer has spread outside the gland into the lymph nodes or other areas around the prostate.

However, because prostate cancer tumors can be so small, MRI may miss some small or microscopic tumors that are either extending from the wall of the prostate or are in surrounding areas.

Computed Tomography (CT)

CT forms a picture out of multiple cross-sectional X-ray images put together by a computer.

It is similar to an MRI, but with less clarity. It shows the prostate and other nearby parts of the body. The drawbacks to CT are similar to MRI in that micro-metastases may easily be missed by CT images.

Chest X-ray

A chest X-ray image can show whether cancer has spread to the lungs or other parts of the chest. However, chest X-rays are not commonly used since the lungs are not a common site of early prostate cancer metastases.

Intravenous Pyelogram (IVP)

An X-ray of the kidneys, ureters and bladder taken after the patient has been injected with a dye that can be seen by X-ray.

ProstaScint Scan

This test uses antibodies with radioactive molecules attached to detect the presence of prostate cells throughout the body.

The radioactive antibodies are designed to attach to prostate cancer cells themselves so that they can be imaged through an X-ray-like process.

If the test detects the cells outside of the prostate, it indicates that the prostate cancer has spread.

The ProstaScint scan has not gained wide use because reading and interpreting the test results are challenging and very dependent on the skills of the physician reading the scan.

In other words, the test results are highly subjective or open to interpretation. This makes decision-making based upon the test results challenging.

Efforts are underway to improve the accuracy and interpretability of the ProstaScint scan technology through improvements in imaging technology.

These results are highly encouraging, especially for determining if the cancer has locally progressed.

While none of the techniques described above has emerged as the “gold standard” for determining the extent or location of prostate cancer tumors in the body, physicians commonly use one or more of them to determine the stage of the cancer – which helps to define recommended treatment approaches.

After a series of diagnostic approaches that may include biopsies, surgery and/or imaging procedures, the physician will typically assign a “stage” to the cancer that will describe the extent and location of the cancer in the body.

Currently there are two different systems used to stage prostate cancer. The traditional method classifies the disease into four clinical categories rated A through D.

The second system is called TNM, which stands for Tumor-Nodes-Metastases.

A-D Staging System

The TNM score can be combined, along with the Gleason Grade, in a process called stage grouping.

The overall stage can then be expressed in Roman numerals from I (the least advanced) to IV (the most advanced). This is done to determine the prognosis for survival or cure.

The stage groups that combine TNM score and Gleason Grade are:

  • stage I, early cancer

    • T1a, N0, M0, low Gleason Grade (2 to 4)
      The cancer is still localized to the prostate and has not spread to lymph nodes or anywhere else.

    • It was found during a transurethral resection, had a low Gleason Grade (2 to 4), and less than 5% of the tissue was cancerous.

    • The tumor is located within the prostate gland and cannot be felt during a DRE.

  • stage II, the tumor

    • T1a, N0, M0, intermediate or high Gleason Grade (5 to 10)

    • T1b, N0, M0, any Gleason Grade (2 to 10)

    • T1c, N0, M0, any Gleason Grade (2 to 10)

    • T2, N0, M0, any Gleason Grade (2 to 10)

    • The cancer is still localized to the prostate and has not spread to the lymph nodes or elsewhere, and

      • It was found during a transurethral resection.

      • It had an intermediate or high Gleason Grade (5 or higher), or more than 5% of the tissue contained cancer.

      • It was discovered because of a high PSA level, cannot be felt on DRE or seen on TRUS, and was diagnosed by needle biopsy

      • Or, it can be felt on DRE or seen on TRUS

  • stage III, prostate cancer is more advanced

    • T3, N0, M0, any Gleason Grade (2 to 10)

    • Cancer has begun to spread outside the prostate and may have spread to the seminal vesicles, but it has not spread to the lymph nodes or anywhere else.

    • In Stage III, prostate cancer is more advanced.

    • This stage of cancer can usually be detected by a DRE.

  • stage IV, the cancer has spread

    • T4, N0, M0, any Gleason Grade (2 to 10)

    • Any T, N1, M0, any Gleason Grade (2 to 10)

    • Any T, any N, M1, any Gleason Grade (2 to 10)

    • One or more of the following apply:

      • The cancer has spread to tissues next to the prostate (other than the seminal vesicles), including the bladder's external sphincter (muscles that help control urination), the rectum, and/or the pelvic wall

      • It has spread to the lymph nodes

      • It has spread to other, more distant sites

    • In Stage D, the cancer has spread to the nearby organs and usually to distant sites, such as the bones or lymph nodes.

Traditional Cancer Staging

A widely used staging system is called the TNM System. It is also known as the Staging System of the American Joint Committee on Cancer (AJCC).

  • T refers to the extent of the primary tumor (T stage) within the prostate.

  • N refers to whether the cancer has spread to the lymph nodes.

  • M refers to the absence or presence of metastasis.

TNM Staging

TNM staging takes into consideration tumor size (T) and whether the cancer has spread to lymph nodes (N) or metastasized (M) to distant sites in the body.

Tumor size is assessed on a scale of 1 to 4.

Generally, tumors graded T1 are confined to the prostate gland but are so small that they cannot be felt during a DRE or detected during ultrasound.

T2 prostate cancer is confined to the prostate, but it is large enough to be detected during a DRE.

T3 and T4 prostate cancers have expanded beyond the prostate into surrounding tissues.

Lymph node involvement is graded on a scale of 0 to 3.

N0 means that the cancer has not spread into the lymph nodes.

The number and size of lymph nodes involved dictates whether the cancer is N1, N2 or N3.

Metastasis is rated 0 or 1.

M0 means no metastasis has occurred; M1 indicates metastasis to a distant location.

Prognostic Tools

Scientists have developed tools that are used by clinicians to predict the prognosis (or outcome) of a particular man’s prostate cancer based on the various information that is accumulated during the diagnosis and staging process.

The ultimate goal is to predict the probability that the recently diagnosed primary prostate cancer is localized and treatable by surgical or radiation procedures or is advanced and will require systemic (whole body) treatment.

Partin Coefficient Tables

This prognostic tool was originally developed by a group of urologists at The Johns Hopkins University.

The Partin coefficient tables combine data on the PSA value, Gleason Grade and clinical stage of a specific patient in order to try to predict the specific risk for that patient.

They are used to estimate four different outcomes that are important in deciding how a man with prostate cancer should be treated.

  • The probability that the patient has disease completely confined to the organ.

  • The probability that the patient has established capsular penetration (prostate cancer has extended into and perhaps through the capsule of the prostate).

  • The probability that the patient has extension of prostate cancer into the seminal vesicles.

  • The probability that the patient has prostate cancer that has spread into the lymph nodes.

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Prostate cancer treatment options

Over the years, a wide array of treatments for prostate cancer have been developed including surgery, radiation, hormone deprivation therapy, chemotherapy, dietary changes and the use of various herbal supplements.

Deciding which of these treatments to select is a difficult decision. Prostate cancer is a complex heterogeneous disease that acts differently in different men. Fortunately, for most men, most prostate cancer grows very slowly.

Earlier diagnosis of prostate cancer has increased since the introduction of the PSA blood test. As a result, the overall prognosis for prostate cancer patients has dramatically improved compared with years ago. Over the past 20 years, the overall survival rates for all stages of prostate cancer combined have increased from 67% to 97%.

The major treatment options

Over the years, a wide array of treatments for prostate cancer have been developed including surgery, radiation, hormone deprivation therapy, chemotherapy, dietary changes and the use of various herbal supplements.

Deciding which of these treatments to select is a difficult decision. Prostate cancer is a complex heterogeneous disease that acts differently in different men.

Since there is no “one size fits all” treatment, each man must learn as much as he can about various treatment options and, in conjunction with his doctor, make his own decision about what is best for him.  Fortunately, for most men, most prostate cancer grows very slowly.

At this time, it is virtually impossible to know how rapidly or slowly a particular man’s prostate cancer will grow – because at the time of diagnosis it is not known how long the prostate cancer cells have been developing.

The slow rate of growth, coupled with the widely varied presentation, has made it difficult, if not impossible, to determine scientifically which treatment is best for which man.

If the cancer has been found to be contained within the prostate, it could take years for a tumor to double in size.

In fact, the cancer might stay within the confines of the prostate indefinitely and never cause problems. Alternatively, the cancer might be growing very rapidly and might spread to other parts of the body quickly.

It may be reassuring to know that 86% of all prostate cancers are diagnosed in the local and regional stages and that the 5-year relative survival rate for men whose prostate cancer is diagnosed at this early stage is nearly 100%.

Additionally, according to the most recent data, the relative 10-year survival rate is 86%, and the 15-year survival rate is 56% (ACS Cancer Facts & Figures, 2004).

A variety of factors that must be considered and evaluated before deciding on a treatment plan (or no treatment at all) include the stage of the prostate cancer, age, other health issues and the patient's willingness to undergo certain procedures or therapies – some of which may have side effects.

The major treatment options for prostate cancer include:

These options are not listed in any particular order. The options selected for your treatment will depend on several factors, including your age, the stage of your disease and the advice of your physician.

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Hormonal therapy for prostate cancer

Testosterone is a concern for those diagnosed with prostate cancer. The goal of hormonal therapy for prostate cancer is to lower the production of testosterone and/or block its effects. Testosterone, a male sex hormone produced primarily by the testicles, can stimulate the growth of hormone-dependent prostate cancer. There are three major types of hormonal therapy:

  • Drugs that reduce testosterone production by the testicles (i.e., LH-RH agonists)

  • Surgical removal of the testicles (also known as orchiectomy or castration)

  • Antiandrogen therapy to block the effects of testosterone Luteinizing Hormone-Releasing Hormone (LH-RH) agonists LH-RH agonists can decrease the amount of testosterone produced by a man's testicles, as effectively as surgical removal of the testicles. However, this effect is not immediate and occurs 2-4 weeks after initiation of therapy. Lupron Depot® (leuprolide acetate for depot suspension), one of the LH-RH agonists, is used in the palliative treatment of advanced prostate cancer.

Doctors also use LH-RH agonist therapy to slow the spread of cancerous cells and help alleviate or ease the symptoms associated with advanced prostate cancer. However, LH-RH agonists are not a cure for prostate cancer.

Orchiectomy

Orchiectomy, also known as castration, is a surgical procedure that completely removes the testicles. It is usually an outpatient procedure. Orchiectomy produces an immediate and permanent reduction in testosterone and has modest surgically-related complications. Hot flashes, impotence and loss of interest in sex are side effects associated with orchiectomy. Although this procedure is not a cure, it may delay the advance of the disease.

Antiandrogen therapy

Another treatment alternative for advanced prostate cancer involves the use of hormone-blocking drugs called antiandrogens. Antiandrogens block the body's ability to use androgens, such as testosterone. However, antiandrogens are not a cure for prostate cancer.

Examples of antiandrogens include:

  • Eulexin® (flutamide),

  • Casodex® (bicalutamide tablets), and

  • Nilandron® (nilutamide tablets).

Eulexin®, Casodex® and Nilandron® are not trademarks of TAP Pharmaceutical Products Inc.

Alternatives to hormonal therapy

For some men with prostate cancer, hormonal therapy may not be the appropriate choice of therapy. Other options include surgery, radiation, chemotherapy, or watchful waiting (observation).

Lupron Depot is indicated for the palliative treatment of advanced prostate cancer. The most common side effect associated with Lupron Depot is hot flashes. Like other treatment options, LH-RH agonists may cause impotence.

Symptoms may worsen over the first few weeks of treatment. Periodic monitoring of PSA and serum testosterone levels is recommended. The -4 Month 30 mg, -3 Month 22.5 mg and 7.5 mg dosage forms are not indicated for use in women.

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Surgical treatment for prostate cancer

The goal of surgery is to remove all the cancer. Techniques that may be used by surgeons to remove the prostate are described below.

  • Radical prostatectomy

    • Surgical removal of the entire prostate gland is called radical prostatectomy. Radical prostatectomy is usually performed to remove early-stage prostate cancer that has not yet spread to other parts of the body.

    • Often, biopsy of the pelvic lymph nodes is also performed to find out if the cancer has spread outside the prostate. Careful removal and examination of the lymph nodes — pelvic lymph node dissection — has traditionally been the final check to see if the cancer has spread. If radical prostatectomy is a treatment option for you, be sure to discuss the benefits and risks with your physician.

    • Side effects after radical prostatectomy for prostate cancer include incontinence and impotence.

      • Most men experience urinary incontinence after surgery. Many continue to have intermittent problems with dribbling caused by coughing or exertion.

      • Impotence, also known as erectile dysfunction, is the inability to achieve an erection sufficient for sexual intercourse.

      • The risk of impotence may be reduced by nerve-sparing surgery. This technique carefully avoids cutting or stretching two bundles of nerves and blood vessels that run closely along the surface of the prostate gland and are needed for an erection.

      • Success of preserving potency depends upon the age of the patient, the status of the nerves and muscular tissue, and the stage of the cancer.

      • However, nerve sparing surgery is not possible for everyone. Sometimes the cancer is too large or is located too close to the nerves.

  • Cryosurgery

    • Cryosurgery uses liquid nitrogen to freeze and kill prostate cancer cells. The procedure takes about 2 hours, and requires anesthesia (either general or spinal). It may also require a hospital stay of 1-2 days.

    • During cryosurgery, a warming catheter inserted through the penis protects the urethra, and incontinence is seldom a problem. However, the overlying nerve bundles usually freeze, so most men become impotent.

Alternatives to surgery

Other options include hormonal therapy, radiation, chemotherapy, or watchful waiting (observation).

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Radiation therapy for prostate cancer

For some men with prostate cancer, surgery may not be the appropriate choice of therapy.

Radiation therapy uses high-energy x-rays, either beamed from a machine (external beam radiation) or emitted by radioactive seeds (internal radiation) implanted in the prostate, to kill cancer cells.

During external radiation, the region around the prostate, as well as the area around the pelvis, receive varying doses of radiation, although the primary target is the prostate gland itself. Side effects may include diarrhea, frequent and painful urination, rectal irritation or bleeding, and impotence.

Internal radiation therapy makes use of tiny radioactive seeds or implants, placed directly into or next to the prostate gland to kill cancerous cells. This is also known as interstitial implantation or Brach therapy.

Compared with external beam radiation, Brach therapy may offer certain advantages:

  • The seeds can be implanted precisely in the tumor.

  • A higher dose can be used with potentially less damage to surrounding tissue.

  • Implanting the seeds takes less time than a full course of external beam radiation treatment.

Side effects include post-implant discomfort, urinary incontinence and impotence.

Alternatives to radiation therapy

Other options include hormonal therapy, surgery, chemotherapy, or watchful waiting (observation).

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Chemotherapy for prostate cancer

Chemotherapy is treatment with drugs to destroy cancer cells. These drugs work by destroying those cells that divide or turnover rapidly. However, chemotherapy can also affect normal cells that actively divide, such as those in bone marrow, gastrointestinal mucosa (lining) and hair follicles.

Different chemotherapy drugs cause different side effects. The most common side effects are feeling tired, nausea and vomiting, mouth sores, hair loss and a low white blood-cell count. To minimize the side effects, chemotherapy drugs are carefully monitored by your physician according to the amount and number of times that they are administered.

Alternatives to chemotherapy

Other options include hormonal therapy, surgery, radiation, or watchful waiting (observation).

Watchful waiting for prostate cancer

Another option is watchful waiting, also known as "observation" or "surveillance." These patients receive no active treatment unless symptoms appear. They may be asked to schedule regular medical checkups and report any new symptoms to the doctor immediately.

Alternatives to watchful waiting

Other options include hormonal therapy, surgery, radiation, or chemotherapy.

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What Rising PSA Means

If PSA levels rise again after surgery or radiation, it commonly means that the prostate cancer has returned or is growing.

If one PSA test after local therapy shows detectable or rising levels, be sure to have the test repeated again immediately to be sure the test is accurate as laboratories sometimes make mistakes.

If the detectable or rising PSA is confirmed, remember that prostate cancer is usually a very slow-growing cancer and you have some time to carefully consider the treatment path that is best for your particular situation.

A rising PSA does not mean that you will necessarily develop symptoms soon or that the cancer will spread rapidly.

There are a number of treatment options that exist to treat prostate cancer that has returned after initial treatment.

These include hormonal therapy, treatments to help prevent spread of prostate cancer to the bone and possibly chemotherapy.

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The above opinionated views and information serves to educated and informed consumer .  The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. .It should not replaced professional advise and consultation.  A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions 

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