Prostate Cancer and Prostate Gland

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The prostate is a gland found only in men that produces the liquid component of semen. Prostate cancer is the most common cancer in men mainly affects alder men. Diagnosed at an early stage, there is a good chance it can be cured.

Prostate Gland

The male reproductive system consists of the testes, scrotum, and penis that produce, store and transport sperms; and the prostate that produces a milky semen fluid that protects and nourishes the sperm.

The prostate gland surrounds the urethra, and it depends on the body's male hormone level, especially the testosterone, for its healthy cell growth and functioning.

Possible Symptoms

Symptoms Prostate cancer often has no symptoms. Sometimes, even when symptoms are present., men do not seek medical advice. However, if prostate cancer is found early, it can often be cured. The symptoms are similar to those produced by a common disease of the prostate, benign prostatic hypertrophy (BPH), and include:

a difficulty in starting to pass urine

a weak, sometimes intermittent flow of urine - dribbling of urine before and after urinating - a frequent or urgent need to pass urine

a need to get up several times in the night to urinate

Risk Factors

While the exact cause remains unknown, risk factors related to prostate cancer include:

Family history: father, brother or uncle with prostate cancer

Age: 95% of prostate cancer patients are aged 55 or more

Race: Especially Afro-Americans, Scandinavians, but less for Asians

Diet rich in animal fat

Sexual activity and previous vasectomy are NOT risk factors.

Diagnosis

Digital Rectal Examination (DRE)

A quick and safe physical examination where the doctor inserts a gloved finger into the rectum to check for hard lumps at the area where most prostate cancers first form.

Prostate Specific Antigen (PSA) Blood Test

PSA is produced by both normal and malignant prostate cells; a PSA blood test can detect elevated PSA levels, a warning sign. However, some men with BPH or prostatitis (inflamed prostate) have increased level of PSA without cancer.

Biopsy

Suspected prostate cancer through DRE and PSA can be confirmed through a biopsy - using Trans-rectal Ultrasound Scan (TRUS) to view and guide a needle into the prostate, the doctor would obtain small tissue samples for microscopic examination.

Gleason Score

A pathologist can assess a tumour's aggressiveness, or potential to worsen within a short period of time, according to the Gleason Score, where a prostate biopsy's appearance is graded and scored from 2 to 10. High score determines aggressive tumor.

Staging Tools and Protocol

If the biopsy is positive, various other scans may be taken to help determine the extent of the cancer - Computed Tomography (CT), Magnetic Resonance Imaging (IVIRI), chest X-ray and ultrasound scan and isotope bone scan. Staging is very important step after diagnosis and determines the extent of a cancer spread. These information guides the urologist or urooncologist to design a specific treatment protocol for each and every individual case.

Outcome of Staging.

Localized prostate cancer : Cancer remains confined within the prostate
Locally Advanced prostate cancer : Cancer has spread into the tissues surrounding the prostate
Advanced prostate cancer : Cancer has spread to other distant parts of the body (Metastasis)
Hormone refractory prostate cancer (HRPC): Prostate cancer is insensitive to hormone therapy. At this stage Taxotare bases chemotherapy may be indicated.

Treatment options

l. Localized prostate cancer:

Watchful Waiting

Also called "Expectant Therapy", the watch-and-wait approach to monitoring prostate cancer involves regular DRE and PSA tests, especially for patients who are either diagnosed at a very early stage, whose prostate cancer is not expected to progress quickly, or who may have other health conditions in treatment priority and have less than 10 years life expectancy. Patients must be committed to regular check-ups.

Radical Prostatectomy

Radical prostatectomy is the complete surgical removal of the prostate, with an aim to prevent further spread of localised prostate cancer in the body. About 80% of men who have this operation are still alive after 10 years.

Possible side-effects of the procedure include some urinary incontinence, sterility and erectile dysfunction (impotence), although modem surgical techniques can minimize the risks of this to some extent.

Radiation Therapy

Radiation therapy uses high-energy rays to kill prostate cancer cells, shrink tumours, and prevent cancer cells from dividing or spreading. It may optimally treat early stage cancer and help extend life in later stages. However, as its rays also damage healthy cells nearby, its side effects may include impotence, urinary incontinence, tiredness, skin reaction, frequent and painful urination.

Brachytherapy

Brachytherapy is a relatively new procedure which involves implanting radioactive pellets into the prostate, where they gradually lose their radioactivity over a period of months. The pellets are inserted under general or spinal anaesthetic under Tranrectal ultrasound guide. Brachytherapy is not recommended for men whose cancer has spread to other parts of the body.

2. Locally Advanced prostate cancer

Radiation Therapy

Eternal beam Radiation therapy is used if the cancer spreads out into the neighboring structures like seminal vesicle, periprostatic tissues etc. Surgery is not helpful at this stage.

3. Advanced prostate cancer:

Hormonal Therapy

Orchiectomy or surgical castration removes the testes, which produces 95% of the body's testosterone.

The aim is to deprive the prostate cancer cells of testosterone, thereby preventing further growth by causing the cancer to shrink. The removal of the testes is permanent, its effects irreversible.

Drug therapy is an alternative to surgery, but it works just as well, and also aims to deprive the prostate cancer cells of testosterone.

Examples : Luteinising Hormone Releasing Hormone (LHRH) analogs and antiandrogen hormonal drug therapy. Possible side effects may include hot flushes, a decrease in sexual desire, and erectile dysfunction.

Compared to LHRH analogs, antiandrogen therapy causes less impotence, decrease in libido and hot flushes.

4. Hormone refractory prostate cancer (HRPC):

Chemotherapy

Generally Chemotherapy is reserved for Hormone refractory prostate cancer patients when they do not respond to any other treatment.

Chemotherapy involves the use of Taxotare.

Early Detection Is Important :

If detected at early stage prostate cancer can be cured.

on an individual basis, it is recommended that men above 50 years old to have a DRE and PSA test every year.

Lifestyle Adjustments

Prostate cancer can trigger many different emotions. Feelings of depression, anger or despair in the patient and his family or close friends, are perfectly normal in people who are trying to cope with a difficult problem such as prostate cancer. To best cope with it, it is important for the patient to share and discuss the problem with those around him so that they may offer suitable support.

It is also important for the patient to observe routine evaluation dates for the rest of his life. This is crucial in determining if the cancer has recurred or progressed, so that it can be most effectively treated accordinaly. In addition, his doctor may evaluate any side effects that he may be experiencing from the treatment.

Area of Intimacy

The inability to achieve or maintain an erection long enough to reach an orgasm or a lack of desire for sexual activities (loss of libido) are areas of common concern after therapy for prostate cancer. Nonetheless, treatments for erectile dysfunction are available. In this aspect, it is important for the patient to express his concerns to the doctor.

Submitted By:
PROF. M. A. SALAM, MBBS, FCPS, FICS
The author is a Professor of Uro-oncology, BSMMU.

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