The prostate is a small gland that sits under the bladder and around the urethra in men. It makes fluid that is combined with sperm for ejaculation. This fluid is designed to protect the sperm from the acidic environment within the vagina to help promote fertilization. The prostate forms before you are born, but does not grow significantly until puberty. At this point it is still quite small and near the size of a walnut. It continues to grow throughout a man's life and is sometimes associated with difficulty urinating (BPH symptoms).
Most prostate cancers develop in the small glands that make up the prostatic fluid. These occur most commonly in older men. The cells that become prostate cancer have changes in their DNA that cause them to become unregulated. The cancerous cells grow faster, live longer, and do not respond to normal signals from the body for their growth to slow. They also invade surrounding tissue areas.
There are several risk factors that have been associated with prostate cancer but they only increase the risk of prostate cancer slightly. Most people with risk factors do not develop prostate cancer. The strongest risk factor is age, meaning you are more likely to get prostate cancer the older you get. African-American men have a higher risk of being diagnosed with prostate cancer and dying of prostate cancer. Agent orange exposure, obesity and smoking have also been associated with an increased risk.
Most people do not have any symptoms when they are diagnosed with prostate cancer. If symptoms are present, they are generally mild symptoms involving difficulty urinating, urinating more frequently than usual, slow urinary stream, or difficulty emptying your bladder. Often these symptoms may be from BPH and not from cancer itself. If prostate cancer is advanced, some patients may have symptoms of decreased semen volume, inability to urinate at all or back pain.
Since the advent of the PSA blood test, most prostate cancers are now diagnosed at an early stage and long before it causes any symptoms. PSA is a substance that is created by normal prostate tissue and in high amounts by prostate cancer. This may be performed in conjunction with a digital rectal exam to feel for any tumors on the prostate.
Once there is a high suspicion for prostate cancer a urologist may suggest performing a prostate biopsy. A biopsy is a procedure that removes small samples from your body for testing. These samples are then examined by a pathologist to look for cancer cells. This is the only way to confirm a cancer diagnosis. A prostate biopsy is performed with a transrectal ultrasound (TRUS). This allows the urologist to visualize the prostate, determine its size, and to take samples accurately.
Prostate cancer cells are examined by a pathologist. Cancer cells look different than normal cells. The more different they look, the more aggressive the cancer tends to behave. A pathologist then assigns a grade. This system is confusing and changing and should be discussed with your urologist. You can read more about the new grading system here.
Staging for prostate cancer
If you are diagnosed with prostate cancer, your doctor may suggest performing certain imaging studies to see if the cancer has spread to your lymph nodes or bones. Typical indications for imaging studies include a high PSA, high Gleason score, or symptoms such as bone pain. Studies that may be done include a pelvic CT, MRI, or bone scan.
Treatments for prostate cancer vary depending on if the cancer is localized or metastatic (spread to other organs). Prior to any treatment for prostate cancer, talk to your urologist about sperm banking if you are interested in having children. For localized prostate cancer, there are multiple treatment options including Active Surveillance, Surgery, Radiation Therapy, and Cryosurgery.
Active surveillance involves closely monitoring the prostate cancer with the goal of treatment if the cancer progresses. No procedure is done to treat the cancer initially and the patient is monitored with PSA blood tests, rectal exams, and prostate biopsies on a periodic basis. The goal here is to delay the risks of treatment to a later date or indefinitely if the cancer does not progress. Patients with low risk prostate cancer may be candidates for this strategy. Studies have shown that men with low risk cancer may wait until the prostate cancer progresses before treatment without affecting life expectancy.
A radical prostatectomy is a surgery where the prostate, seminal vesicles, and a portion of the vas deferens are removed. In some situations this is done in conjunction with a lymph node dissection to see if the tumor has spread. A radical prostatectomy may be performed in an open fashion or with a robotic assisted technique. Depending on the tumor characteristics and the patient's erectile function, a nerve sparing procedure may be performed. After the surgery, a catheter is left in place for one to two weeks to drain the bladder and allow the urethra to heal. Most of the time, patients are hospitalized for one to two nights after surgery.
If the entire prostate is removed and the cancer was confined to the prostate, then the patient is cured by surgery. In patients were the cancer was outside the prostate, patients may need radiation or hormone therapy after surgery. Rarely, prostate cancer may return much later and lifelong PSA testing should be performed.
Radiation therapy for prostate cancer can be performed in two ways: external beam radiation therapy and interstitial prostate brachytherapy. All types of radiation work by damaging the DNA of cancer cells that prevent them from replicating or growing. It does not kill the cells immediately. Side effects of radiation treatment are due to the DNA damage of healthy non-cancerous cells that are also treated.
External beam radiation therapy is a non-invasive treatment where external equipment is used to pass radiation through your body. It is performed on a daily basis over a series of weeks in an outpatient clinic. The radiation created is similar to an X ray. A radiation oncologist will use CT scans and imaging studies to guide the radiation and treat the prostate. External beam radiation can also be used to treat other areas and nearby lymph nodes. For higher risk prostate cancer, external beam radiation is often given in conjunction with androgen deprivation therapy (ADT) for a period of time. ADT lowers testosterone levels and may cause other side effects (see ADT section below).
Interstitial prostate brachytherapy is a procedure where multiple small temporary or permanent radioactive particles are placed precisely within the prostate. This radiation implant then delivers radiation locally. This procedure requires a general anesthetic but is generally performed on an outpatient basis and is minimally invasive. It is a good treatment option for men with small to medium size prostate glands and in general works best with low risk disease. Unlike external beam radiation, brachytherapy can only deliver radiation to the prostate itself and cannot treat the nearby lymph nodes.
Cryosurgery or cryoablation for prostate cancer is a procedure where a urologist carefully places needles within the prostate using an ultrasound and freezes the prostate to very low temperatures to kill prostate cancer cells. It is performed under either a general or spinal anesthetic and is an outpatient minimally invasive procedure. The procedure requires careful monitoring with temperature probes to prevent freezing of surrounding structures such as the rectum and a urethral warming catheter to prevent the urethra from freezing. Following the procedure, the patient will typically have a urethral catheter for a few days. Cryoablation may be done to treat cancer initially, or it may be done after radiation fails. It has a very high rate of erectile dysfunction and is generally performed on patients that already have poor erections. The procedure is less invasive than surgery and generally has lower side effects. Compared to surgery or radiation, the long term results are not as well known. The biggest risk of the procedure is a fistula which is a connection between the urethra and the rectum. With improved technology this complication rate has decreased and is around 0.5%.
In patients with prostate cancer that has spread outside the prostate the first step in general is the initiation of androgen deprivation therapy (ADT). If the PSA continues to rise, other treatments such as chemotherapy, immunotherapy, or alternative ADT therapies may be utilized.
Prostate cancer cells are stimulated by testosterone and other male hormones. Lowering testosterone levels slows prostate cancer growth and may kill some cancer cells. It is used in combination with radiation therapy in some situations because it has shown to be more effective than radiation alone. By itself, ADT is not a cure for prostate cancer because eventually the cancer cells will find ways to grow even with low testosterone. For some cancers, this may take several years to occur. There are multiple ways to lower testosterone levels including surgery (removal of the testicles) or medications.
Side effects of ADT include reduced sexual desire, erectile dysfunction, hot flashes, breast tenderness, osteoporosis, anemia, confusion, loss of muscle mass, weight gain, fatigue, depression, and increased risk of heart attacks. Because of these side effects, your doctor should discuss the benefits of treating the prostate cancer with the risks of the medications.
Chemotherapy is a treatment where anticancer medications are given that travel throughout the body and make it difficult for prostate cancer cells to grow. Most of the time this is performed with medications in the vein by a medical oncologist. Historically, this was given only to patients who have failed hormone therapies. Newer research supports giving ADT at the same time as hormone therapy in some situations. Chemotherapy is only given to men with advanced prostate cancer and not with localized prostate cancer at this time. Chemotherapy affects both cancer cells and some normal cells which leads to the side effects. Common ones may include hair loss, mouth sores, nausea, diarrhea, loss of appetite, fatigue, increased infection risks.
The treatment of prostate cancer is complicated. It should be done in conjunction with your urologist, and sometimes in a team approach with medical oncology and radiation oncology. Have questions about prostate cancer? Give us a call at 360-733-7687 to schedule an appointment today.
Author: Daniel Reznicek, MD
Last Updated: February 22, 2017