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Prostate Cancer

Prostate cancer occurs when cells in the prostate (a gland in the male reproductive system found below the bladder in front of the rectum) grow and multiply uncontrollably, damaging surrounding tissue and interfering with the normal function of the prostate. The cells can then spread to other parts of the body. Mostly occurring in older men, prostate cancer is the most common form of male cancer, with approximately 186,320 new cases diagnosed in 2008. Your best chance for surviving prostate cancer is detecting it early. When found early, there is nearly a 100 percent chance for cure.

Symptoms

Men with prostate cancer may have one or more of these symptoms:

  • Painful or burning urination
  • Inability to urinate or difficulty in starting to urinate
  • Frequent or urgent need to urinate
  • Trouble emptying the bladder completely
  • Blood in the urine or semen
  • Continual pain in the lower back, pelvis or thighs

None of these symptoms are specific for cancer, and most men with prostate cancer have none of them. However, they may point to other health problems. Their presence should prompt men to seek medical evaluation, including a digital rectal exam (DRE) of the prostate and serum PSA, from a urologist or other physician.

Diagnosis

Prostate Biopsy

A biopsy, or sampling of prostate tissue, is currently the only definitive method of diagnosing prostate cancer. A biopsy is performed on all men with a strong suspicion of cancer based on PSA test results and other factors. A biopsy takes about 35 minutes to perform and is done as an outpatient procedure. Biopsies are generally well-tolerated with minimal pain and bleeding. Before the biopsy, the patient undergoes an enema and is given an antibiotic. Lidocaine is used to deaden the nerves that lie alongside the prostate gland to make the procedure more comfortable.

A transrectal ultrasound (TRUS) probe is inserted into the rectum so the oncologist can view the prostate, which takes about 10 minutes. Then, a fine-gauge, spring-loaded biopsy needle is used to remove six to 10 tiny “core” samples of tissue from specific, predetermined areas on the prostate gland. The biopsy specimens take about three to seven days to process.

Gleason Grading System

Prostate cancers contain several types of cells that appear differently under a microscope. The Gleason grading system uses the numbers 1– 5 to “grade” the most common (primary) and next most common (secondary) cell types found in a tissue sample. Together, the sum of these two numbers is the Gleason score, ranging from 2–10, and tells the physician how aggressive the tumor appears under the microscope. The higher the Gleason score, the more aggressive the cancer. The Gleason score is considered along with other factors to help select the most appropriate treatment for the patient.

Treatment

Prostate Surgery

Prostatectomy (surgical prostate removal) is the most common treatment for prostate cancer. Innovative surgical techniques have provided more options for men who desire complete cancer control with minimal impact on quality of life.

There are two types of "open" prostatectomy:

Retropubic: An incision is made between the navel and pubic bone. The surgeon removes the prostate and any affected lymph nodes and then sews the urethra and bladder back together. Retropubic prostatectomy provides the best chance of sparing the urethra to preserve urinary continence, as well as the neurovascular bundles responsible for erection. The procedure takes 2.5 to 3 hours if nerves are not spared; 3.5 to 4 hours if nerves are spared. It is the most common type of prostatectomy.

Perineal: The incision is made between the scrotum and rectum, and the prostate is approached from the bottom. Perineal surgery is less invasive than retropubic, with a faster recovery time and fewer days on a catheter, but it is seldom used today and few surgeons are trained on this approach. Perineal prostatectomies are best for low-grade and/or early stage tumors with no lymph node involvement, or for very obese patients.

da Vinci Robotic Prostatectomy

da Vinci Prostatectomy is performed with the assistance of the da Vinci Robotic Surgical System—the latest evolution in robotics technology. For more information on robotic surgery at St. Jude Medical Center, click here.

Nerve-Sparing Surgery

Nerve-sparing surgery is performed during a prostatectomy in order to preserve the two neurovascular bundles next to the prostate that are responsible for erections. Before 1980, these nerves were routinely taken to make sure all cancer cells were removed, but the unfortunate result was sexual impotence.

The decision for nerve-sparing surgery is largely up to the patient, but controlling the cancer is the surgeon's primary goal. The best candidates for nerve-sparing surgery are men with:

  • Localized tumors
  • A PSA level of 10 or less
  • A Gleason score of 6 to 7 or less
  • No prior use of erectile dysfunction (ED) drugs

Nerve-sparing surgery is not recommended for men with large tumors or high-grade disease, or for those who have pre-existing erectile dysfunction unrelated to cancer treatment.

Laparoscopic Radical Prostatectomy (LRP)

Minimally invasive surgery is quickly becoming an alternative to standard "open" surgery for treating prostate cancer. A laparoscopic radical prostatectomy (LRP) involves the use of a laparoscope, which is a thin tube with a tiny camera. An incision less than an inch long is made at the navel and the laparoscope is inserted so that surgeons can view the treatment area on a monitor. Four other tiny incisions are made for miniature surgical instruments that can remove the entire prostate.

Although LRP is more complicated than traditional surgery and may take longer, there are many benefits for the patient:

  • Less blood loss during surgery
  • Shorter hospital stay
  • Decreased recovery time
  • Decreased reliance on narcotic pain medications
  • Less fluid buildup
  • Fewer days with a urinary catheter

Other benefits may include a decreased risk of post-surgery bladder and bowel continence. Outcomes appear to be similar to standard surgery.

The best candidates for LRP are men with low to intermediate grade prostate cancer who have no prior pelvic radiation or surgery. Age is not a factor, but generally, surgery is not offered to men over age 70.

Radiation Therapy

Radiation therapy is a primary treatment option for both localized and locally advanced prostate cancer. For early-stage disease, patients often have a choice between surgery and radiation, with similar outcomes. For larger or more aggressive tumors, radiation therapy may be used in combination with hormone therapy.

There are four types of radiation therapy used for prostate cancer

External Beam Radiation is the most commonly used radiation therapy for prostate cancer. Pre-treatment planning with a CT scan determines the treatment field and where radiation beams will be aimed. The patient lies on a special bed designed to keep him immobile during treatment, and the radiation machine, or gantry, moves around the bed to deliver beams from eight different angles

Intensity Modulated Radiation Therapy (IMRT), an advanced form of external beam radiation, is used to further focus radiation beams, with the goal of increasing the dose to the prostate while sparing normal tissue. IMRT has 80-100 tiny lead "leaves" on each side of the beam that are moved in or out to define the treatment field with pinpoint accuracy.

Radiation treatment involves 8 to 9 weeks of daily radiation treatments. Daily x-ray based or CT-based images of the treatment area and taken to localize the target for image guidance.

Brachytherapy involves the use of tiny radioactive seeds implanted directly in the prostate, delivering a constant dose of radiation.

Chemotherapy

Chemotherapy generally is not a standard treatment for prostate cancer. Since most tumors are slow-growing and occur in older men, the side effects from chemotherapy usually outweigh any benefit that treatment may provide.

However, chemotherapy may be an option for men with advanced or recurrent prostate cancer, or who have not responded to other treatments.

Hormone Therapy

The majority of prostate cancers are hormone-sensitive, which means they depend on the male hormone (testosterone) as fuel for tumor growth. Of the 230,000 men diagnosed with prostate cancer in the United States, about one-third will require hormone therapy, which removes all traces of testosterone from the body in an effort to reduce the tumor size.

There are three types of hormone therapies for prostate cancer:

LHRH agonists work by overstimulating the pituitary gland to release luteinizing hormone-releasing hormone (LHRH), which signals the testicles to suppress testosterone production. Zoladex and Leuprolide are LHRH agonist drugs, administered by regular injections ranging from once a month to once a year. A disadvantage of this therapy is that it causes a short spike in testosterone levels before suppression takes effect. However, its effects are not permanent, so patients who cannot cope with treatment side effects can be taken off the drug and can resume testosterone production.

Orchiectomy (surgical removal of the testicles) used to be the standard hormone therapy for prostate cancer. Because orchiectomy is an efficient, cost-effective and convenient method of reducing testosterone, it is still an option for certain patients, particularly elderly men.

Clinical Trials

New treatments are always being tested in clinical trials and some patients with cancer may want to consider participating in one of these research studies. These studies are meant to help improve current cancer treatments or obtain information on new treatments. Talk to your doctor about the clinical trials that may be right for you.