Cancer Awareness: Prostate Cancer - medECUBE

Cancer Awareness: Prostate Cancer

What is Prostate Gland ?

 The prostate is a gland of the male reproductive system. It is located in front of the rectum and just below the bladder, the organ that stores urine. It is about the size of a chestnut and somewhat conical in shape, and consists of a base, an apex, an anterior, a posterior and two lateral surfaces.

What is the function of Prostate gland?

 The prostate surrounds the urethra, the tube that carries sperm and urine out of the penis. The main purpose of the prostate is to produce fluid for semen, which transports sperm during the male orgasm.

Why Does The Prostate Enlarge?

 Prostate enlargement can occur in both benign (non cancerous) and malignant (cancerous) conditions. The most common cause of prostate enlargement is benign prostatic hypertrophy (often called BPH).

BPH is a benign enlargement of the prostate that blocks the flow of urine through the urethra. The prostate cells gradually multiply, creating an enlargement that puts pressure on the urethra through which urine and semen exit the body.

Other causes of prostate enlargement include prostate cancer and prostate infection (prostatitis).

What is Prostate cancer?

Prostate cancer forms in the cells of the prostate. Though several types of cells are found in prostate, almost all prostate cancers develop from glandular cells (adenocarcinomas). Other types of prostate cancers are very rare [2].

Prostate cancer is usually a very slow growing cancer and most patients do not have significant symptoms until the cancer reaches an advanced stage.

Most men with prostate cancer die of other unrelated causes, and many never know that they have the disease. But once prostate cancer begins to grow quickly or spreads outside the prostate, it is dangerous.

How common is Postate cancer?

In western countries, prostate cancer is the most common cancer in men and is responsible for the second highest number of deaths after lung cancer.

Indian Data

Prostate is the second leading site of cancer among males in large Indian cities like Delhi, Kolkata, Pune and Thiruvananthapuram, third leading site of cancer in cities like Bangalore and Mumbai and it is among the top ten leading sites of cancers in the rest of the population based cancer registries (PBCRs) of India. The data shows that almost all regions of India are equally affected by this cancer [6].

The incidence rates of this cancer are constantly and rapidly increasing in all the PBCRs. The cancer projection data shows that the number of cases will become doubled by 2020 [7].

Is the prostate cancer Life-threatening?

The affect of harboring a prostate cancer on lifespan of an individual depends on the stage of the disease.

Introduction of PSA (prostate specific antigen) blood test, has enabled the detection of this disease at an early stage. This has increased the chances of complete cure in patients having early stage of disease. As a result, the death rate from this disease has shown a steady decline.

 

Owing to earlier diagnosis, latest research, development of newer methods of treatment and the introduction of modern technology such as robotic surgery, prostate cancer is now considered to be curable or at least controllable condition. It is now possible for most men with prostate cancer to live long lives or even their entire natural life span.

What are the treatment options for Prostate cancer?

The ideal treatment for prostate cancer depends on the stage of the disease and overall medical condition and performance status of the patient. Given the multitude of treatment options available, it is important to understand and to discuss with the UroOncologist the treatment option that suits that particular patient the best.

What Are The Tests To Find Prostate Cancer

Digital rectal exam (DRE)

DRE is a physical exam wherein physician uses a adequately lubricated gloved finger inserted through the rectum to feel for any suspicious or hard areas in your prostate gland. DRE has an integral role in diagnosis of Prostate cancer. Presence of any hard or nodular areas even in the presence of normal PSA value may signify presence of cancer and warrant a biopsy.

PSA blood test

PSA (prostate specific antigen) is a substance which is normally produced by prostate gland. It serves as a tumor marker in blood which is usually raised in malignancy. It can be measured as a simple blood test. If PSA level is high for age when other benign causes of elevated PSA (such as prostatic infection or inflammation) are ruled out, prostate biopsy is needed to see if the increase is because of cancer or not. PSA may be raised in many benign (non cancerous) conditions and on the contrary some less common varieties of Prostate cancer occur even with normal PSA.

Biopsy

The diagnosis of prostate cancer is confirmed only with biopsy. Biopsy is done with the help of Ultrasound guidance. A thin needle is used to remove many small tissue samples from your prostate.

If cancer is found, biopsy score provides an insight into whether the cancer is slow-growing or aggressive (fast-growing). Other staging investigations may then be required to evaluate whether it has spread outside the prostate.

What are the follow up tests after treatment.

The follow-up testing will depend on many factors, including treatment selected. Regular PSA blood tests, biopsies as needed and imaging tests are used after treatment to see if the cancer has returned. Because the PSA level tends to go up and down after radiation, more PSA tests may be needed to know for sure if the cancer has returned.

 

Frequently asked questions?

  1. How advanced is my disease? Whether it is localised, locally advanced or spread to other organs in the body? Is it slow- or fast-growing? It is important to know about the stage of the disease as treatment course and cure of the disease may depend on it.
  2. What are all the ways prostate cancer can be treated?
  3. What are the positives and negatives of each treatment and likely treatment duration?
  4. What is the most suitable option in my case?
  5. Will the side effects happen immediately after treatment or after some time? How long the side effects of each treatment may last? Will they get better or worse with time?
  6. How soon can I control my bladder? What is to be done during initial few months while urine leakage is present?
  7. How soon will I be able to have sex again?
  8. How to follow up after a particular treatment is done?
  9. What are the options if prostate cancer returns or spreads?

What are the treatment Options available?

ACTIVE SURVEILLANCE (AS) / (WATCHFUL WAITING)

What it literally means ?

Active Surveillance means patient lives with prostate cancer without any active intervention. However, patient remains in close follow up and is  tested regularly to see if it becomes worse.

How is patient followed up in AS

Patient undergoes a rectal exam and PSA blood test every 3-6 months, and a biopsy once a year. For each biopsy, your doctor will insert a thin needle into your prostate to remove about 12 tissue (or sometimes more) samples for testing.

Suitable Candidates/Benefits

  • Patients with shorter life expectancy ( less than 10 years)
  • Patients with slow-growing/ very low risk prostate cancer
  • Avoids possible side effects of surgery, radiation or other treatments
  • If treatment is needed in the future, tratment with curative intent possible.

 

Drawbacks

  • Compliance for close monitoring is needed.
  • As compared to surgery, patients on AS are more likely to die within 10 years from prostate cancer1
  • Regular biopsies are needed which can result in increased chance of erectile dysfunction2
  • Cancer may spread outside the prostate in the meantime.
  • May miss the chance for curative treatment in future if cancer spreads or if the patient developIf treatment is needed in the future, you may be at an age when it’s more diffcult to tolerate.
  • Many a times, (approximately 35-40%) prostate cancer can be undergraded (thought to be slow- growing when it is actually fast-growing and of higher risk)3

SURGERY (PROSTATECTOMY)

The cancerous prostate gland along with surrounding tissues (mostly including lymph nodes) is removed by a surgery. The removed gland and surrounding tissue Test results will let your doctors know how much cancer you had, and if it was all removed.

Modalities of surgery

  • Now a days, surgery is performed in Robotic-assisted manner (minimally invasive) is with a few small incisions/cuts);
  • Other Traditional mehods include laparoscopic surgery (minimally invasive with a few small incisions) or open surgery (with a large incision)

Advantages

  • The main advantage of radical prostatectomy is that when skillfully performed, it offers the possibility of cure with minimal collateral damage to surrounding tissues (Han et al, 2001b; Hull et al, 2002).
  • Further, it provides more accurate tumor staging by pathologic examination of the surgical specimen.
  • Treatment failure is more readily identified.
  • The postoperative course is much smoother than in the past.
  • The hospital stay is usually 1 to 3 days, and operative mortality is rare in the modern era.
  • Moreover, radical prostatectomy significantly reduces local progression and distant metastases and improves cancer-specific and overall survival rates compared with watchful waiting (Bill-Axelson et al.)
  • Some patients with tumor recurrence after radical prostatectomy can be salvaged with potentially curative postoperative radiotherapy

Disadvantages

  • The potential disadvantages of radical prostatectomy are the necessary hospitalization and recovery period. This has reduced with the advent of Robot assisted surgery as hospitalization is short and recovery is much faster.
  • Risk for erectile dysfunction and urinary incontinence. However, erectile dysfunction and rectal complications are less likely with nerve-sparing surgery than with radiotherapy, and good treatment options are available for both urinary incontinence and erectile dysfunction. Most patient can control their urine and recover sexual function over period of few months.

 

Benefits of da Vinci® Robotic Surgery
Surgery for prostate cancer is best done robotically now which is the standard of care. When available, da Vinci Surgery offers the following potential benefits compared to open surgery:

  • Better cancer control,
  • Faster return of erectile function
  • Better chance for return of bladder control (urinary continence)
  • Less blood loss and less need for blood transfusion
  • Less pain
  • Lower risk of complications/wound complications
  • Shorter hospital stay and fewer days with catheter
  • Faster recovery and return to normal activities

 

RADIATION THERAPY (RT)

What is radiation therapy for prostate cancer ?

A radiation oncologist will try to kill the cancer cells using high-dose radiation to the prostate, but will not remove the prostate.

Types of RT

  • EBRT (external beam radiation) : Radiation from a source outside the body.
  • Brachytherapy (radioactive seeds placed inside the prostate)
  • IMRT (intensity-modulated radiation therapy) IGRT (image-guided radiation therapy)
  • Other types of external beam radiation (EBRT)

Advantages

  • Good chance for a cure for appropriate patients
  • No hospital stay and few, if any restrictions to your activites after treatment
  • May be used as an adjuvant treatment after surgery if cancer has spread outside of the prostate

Disadvantages                     

  • More likely to die within 10 years from prostate cancer with radiation compared to surgery
  • Increased fatigue during long treatment – usually 2 months (upto 40 separate treatment sessions)
  • Urinary and bowel problems could last for years and sexual potency tends to get worse over time
  • Prostate can move during treatment and cause radiation to hit other nearby tissues/organs and you are more likely to have another cancer.
  • Very difficult to treat if cancer returns

Potential side effects of external beam radiation therapy for prostate cancer may include:

  • Frequent urination.
  • Difficult or painful urination.
  • Blood in the urine.
  • Urinary leakage.
  • Abdominal cramping.
  • Painful bowel movements.
  • Rectal bleeding.
  • Rectal leaking
  • Fatigue
  • Sexual dysfunction, including diminished erectile function or decrease in

the volume of semen

  • Skin reactions (similar to a sunburn)
  • Secondary cancers in the region of the radiation

 

 

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