Prostate Cancer

Prostate Cancer

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Prostate cancer is the most diagnosed cancer in men. Estimates indicate that it is found in as many as half of all men over the age of 70 and in almost all men over the age of 90 in America. Since the discovery of the blood test for Prostate Specific Antigen (PSA) in the 1980's, prostate cancer can now be detected at a much earlier stage. While most men may eventually develop prostate cancer, most don't need treatment.

 

In fact, survival rates for prostate cancer have been improving for the last 20 years. For this reason, more than 2 million men in the US count themselves as prostate cancer survivors. So, whether you’re worried about developing prostate cancer, making decisions about your treatment, or trying to stay well after treatment, we can provide answers, explain treatment options, and offer you peace of mind.

 

General Information

The prostate is the walnut shaped gland in men located between the bladder and the urethra that is involved in production of part of the ejaculate. The gland is made up of secretory cells with a surrounding muscular and connective tissue stroma. Prostate cancer is the transformation of these secretory cells into malignant cells that have the potential to grow more rapidly and spread outside of the prostate.

 

Prostate cancer starts localized in the prostate, but some aggressive forms can then spread into adjacent tissue structures, lymph nodes and bones if not detected early. The most common site of metastatic disease is the bone, but it can also spread to the lung, liver and other organs.

 

Risk Factors

It is largely unknown as to what causes prostate cancer. It is thought, as with other cancers, to be a combination of environmental risk factors in conjunction with a genetic predisposition. Risk factors are not "causes," but are factors that make you statistically more likely than others in the general population to have a certain condition. The following is list are some of the more well-known and accepted risk factors for the development of prostate cancer.

 

• Age

• Family History

• Race

• Dietary Fat

 

Advanced age, family history and race are the three most important factors. It is for this reason that men begin screening for prostate cancer at the age of 50, unless they are African American or have a family history, then screening can begin earlier. Prostate cancer screening should be a shared decision between you and your caregiver.

 

Approximately 9% of all prostate cancers are termed "familial." This is a form of cancer that is genetically passed on in an autosomal dominant fashion. This tends to cause prostate cancer in younger individuals (less than age 55). Newer genetic tests can be performed to see if you carry any of these genetic risk factors. It is recommended to check if you have higher grades of prostate cancer or have certain relatives with prostate cancer.

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Symptoms

Localized prostate cancer does not cause any symptoms. Until the development of the PSA blood test, detection of localized prostate cancer could only occur if the cancer grew to the point where it was able to be felt via a digital rectal examination (DRE) or if it was found incidentally during transurethral resection of the prostate for obstructive symptoms.

 

Prostate cancer that has metastasized may cause pain, especially from spread to the bones. Weakness from anemia may occur if prostate cancer has affected multiple areas of the bone marrow, limiting the body's ability to produce red blood cells. In advanced cases, malignant enlargement of the prostate can obstruct urine flow, resulting in backup of urine into the kidneys (hydronephrosis) with possible kidney failure if this process affects both kidneys.

 

Locally advanced prostate cancers may obstruct urinary flow and/or cause severe irritation in the bladder region when the cancer extends from the prostate into the base of the bladder. Treatment of this locally advanced cancer can be very difficult. Obstruction to urinary flow may be opened by transurethral resection of the prostate, but there is a delicate balance between opening the urethra adequately to void and opening the urine passage too much, resulting in incontinence.

 

Early Detection

We consider the use of a number of tests to look for warning signs of prostate cancer. The most common of these is the PSA blood test (link to PSA). Other detection tests/techniques include:

 

• Percent-free PSA

• PSA velocity

• PSA density

• Age-specific PSA ranges

• Digital rectal exam (DRE)

• Transrectal ultrasound (TRUS)

• Prostate MRI

• Genetic Testing

• Blood tests (4K etc.)

• Urine tests (ExoDx etc.)

 

These early detection tests help us understand your risk for having clinically significant prostate cancer. If the results of one or more of these tests are abnormal, you may need a prostate biopsy to determine if you have cancer.

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Prostate Cancer Grading and Staging

 

First things first. What is the difference between grade and stage? The grade of the cancer is how aggressive it is. It’s the personality or predisposition of cancer cells to want to be aggressive. The lower the grade the more favorable the prognosis. The stage of a cancer is where is it at the moment. While stage usually follows grade you can have a high grade (aggressive) tumor that is low stage (localized) and you can have low grade tumors that if left long enough can spread and be higher or later stage.

 

Grading

Initially prostate cancer was graded using the Gleason Sum. Each area of cancer was graded between 1 and 5 (5 being the most aggressive) and the most common area was added to the next most common area. For example, a patient could have mostly Gleason score 3 but some 4 and they would be a Gl 3+4=7. After some time, it was decided that Gl 1 & 2 were not actually cancer. This gives us 2 problems. We have a grading system that ranges from 6-10 (confusing) and we have Gl 7 that can be less aggressive (3+4) or more aggressive (4+3). These limitations were addressed recently when we switched and now use grading groups (1-5).

 

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Stage indicates where the cancer is at and how far it has progressed. This is different than the grade, which is how aggressive a cancer is going to behave. Since the widespread use of PSA testing, most patients diagnosed with prostate cancer have non-metastatic or low stage disease at presentation. Most patients are only familiar with the Tumor (T-stage) staging but true staging includes N or Nodal stage and M or metastasis (spread) stage.

 

Stage I - (T1) - Tumor remains confined to the prostate and is too small to be detected on DRE. This is an incidentally found cancer either by an elevated PSA or found after a transurethral resection of the prostate.

 

Stage II - (T2) - Tumor is still confined to the prostate; 2a < ½ of 1 lobe, 2b >1/2 of 1 lobe, 2c tumor in both lobes.

 

Stage III - (T3) - The prostate cancer has spread through the prostatic capsule and may involve locally surrounding tissues; 3a extracapsular extension, 3b tumor invades seminal vesicles.

 

Stage IV - (T4) - Locally advanced (T4) or metastatic (Stage IV) prostate cancer in which the cancer involves local structures like the bladder or rectum. Stage IV also includes patients with nodal involvement (N1), bone involvement (M1b), or metastasis to other sites like lung or liver (M1c). 

 

 

Prostate Cancer Risk Groups

To help patients understand their risk many doctors use a combination of grade, T stage, initial PSA and biopsy results to separate patients into the following risk groups. These help direct patients 

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The risk groups can help determine what other tests should be done as well as direct treatment.

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Treatment Options

 

The following is a list of possible treatment options. The PeeDocs will work with you to recommend a course of treatment that offers the greatest chance of success for you. These are only brief descriptions of each.  

 

Active Surveillance: 

Patients with very low risk prostate cancer and some with low risk prostate cancer are good candidates for active surveillance.  These patients are followed closely to make sure there is no progression. Those patients who are followed expectantly should have regular physical examinations, serial PSA levels, MRIs and occasional biopsies. Progression of the disease would be an indication to change plans and treatment modality.

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Cryosurgery:

This involves placing several percutaneous probes into the prostate and the prostate is then frozen, thawed and then frozen again. The freezing and thawing kill prostate cancer cells. This is done under anesthesia.

 

Robotic Surgery - daVinci Prostatectomy

Robotic assisted surgery, allows doctors to perform many types of complex procedures with more precision, flexibility and control than is possible with conventional techniques. Robotic surgery is usually associated with minimally invasive surgery — procedures performed through tiny incisions and are considered part of laparoscopic surgery.

Robotic surgery with the da Vinci Surgical System was approved by the Food and Drug Administration in 2000.  The technique has been adopted by many hospitals in the United States and Europe for use in the treatment of a wide range of conditions, including the surgical treatment of many urological diseases and cancers. Here at the Arizona Center for Urology we are proud to offer robotic surgery as a choice for many of our patients. It is the most common surgical treatment for Prostate Cancer.

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The most widely used clinical robotic surgical system includes a camera arm and mechanical arms with surgical instruments attached to them. The surgeon controls the arms while seated at a computer console near the operating table. The console gives the surgeon a high-definition, magnified, 3-D view of the surgical site. The surgeon leads other team members who assist during the operation.

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Surgeons who use the robotic system find that for many procedures it enhances precision, flexibility and control during the operation and allows them to better see the site, compared with traditional techniques. Using robotic surgery, surgeons can perform delicate and complex procedures that may have been more difficult with other methods. Robotic surgery allows the surgeon to create a pattern for doing an operation that allows for consistent results that will minimize side effects and improve the quality of each operation.

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Often, robotic surgery makes minimally invasive surgery possible and creates distinct advantages over more traditional open surgery. The benefits of minimally invasive surgery include:

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• Fewer complications, such as surgical site infection

• Less pain and blood loss

• Quicker recovery

• Smaller, less noticeable scars

 

Robotic surgery involves risk, some of which may be similar to those of conventional open surgery, such as a small risk of infection and other complications. Your surgeon will discuss those specific risks further with you at the time of the planning for an operation and what is done to minimize the risks that come with any surgery.

 

 

Radiation Therapy:

Radiotherapy, the use of ionizing radiation to destroy cancer cells, has been proven to be effective in the treatment of many cancers including prostate cancer. It has one of the lowest side effect profiles of all prostate cancer treatments and is performed by a radiation oncologist who works with your urologist.

 

Hormonal Ablation Therapy:

Prostate cancer grows in response to testosterone. Testosterone is produced in the testicles and the adrenal gland. Testosterone production can be stopped medically and surgically which will stop and reverse prostate cancer growth. This is often used in patients with advanced disease but can be combined with radiation to improve cure rates in local prostate cancer.

 

Metastatic Prostate Cancer

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Some patients present with cancer that is already outside of the prostate, or metastatic prostate cancer. These patients are usually started on hormonal ablation therapy and for those who respond well may end up treating the prostate with radiation.

 

Hormone Resistant Prostate Cancer

At some point some cancer cells quit responding to hormones. We call this hormone resistant or Castrate Resistant prostate cancer. For patients who have hormone-resistant prostate cancer growth, there are still many options. While chemotherapy used to be the next option we have seen a number of new treatments that may allow these patients to avoid chemotherapy. Some of these include:

 

            Advanced Anti-Androgens - newer medications such as Xtandi and Zytiga can block the hormones and recepters at a cellular level and can be effective when normal treatments fail.

 

            PARP Inhibitors – Certain genetic factors in prostate cancer may make them susceptible to a new line of medications called PARP inhibitors.

 

            Provenge – This treatment involves removing some of your blood and training your immune system to fight your metastatic prostate cancer. This takes 2 days, every other week, for 3 treatment cycles and has been show to significantly increase life expectancy in advanced, metastatic prostate cancer.