Prostrate Cancer

What is prostate cancer?

The prostate (pros-tate) is a gland found only in men. As shown in the picture below, the prostate is just below the bladder and in front of the rectum. It is about the size of a walnut. The tube that carries urine (the urethra) runs through the prostate. The prostate contains cells that make some of the fluid (semen) that protects and nourishes the sperm.
The prostate begins to develop before birth and keeps on growing until a man reaches adulthood. Male hormones (called androgens) cause this growth. If male hormone levels are low, the prostate gland will not grow to full size. In older men, though, the part of the prostate around the urethra may keep on growing. This causes BPH (benign prostatic hyperplasia) which can result in problems with urinating. But BPH is not cancer.

Although there are several cell types in the prostate, nearly all prostate cancers start in the gland cells. This kind of cancer is known as adenocarcinoma (add-uh-no-car-suh-NO-muh). The rest of this information refers only to prostate adenocarcinoma.

Most of the time, prostate cancer grows slowly. Autopsy studies show that many older men (and even younger men) who died of other diseases also had prostate cancer that never caused a problem during their lives. These studies showed that 7 or 8 out of 10 men had prostate cancer by age 80. But neither they nor their doctors even knew they had it.

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Why is prostate cancer a concern for American Indian men?

Native Americans have a higher death rate (19.8 per 100,000 males) from prostate cancer than the entire U.S. (15.4 per 100,000).

Native Americans have a higher death rate (19.8 per 100,000 males) from prostate cancer than the entire U.S. (15.4 per 100,000).  However, according to I.H.S., where these statistics come from, the rates should be used with caution since the rates are from a small number of deaths.  It is therefore a major concern for Native Americans to become aware of what the prostate is and the problems associated with the powerful gland.

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What causes prostate cancer?

We do not yet know exactly what causes prostate cancer, but we do know that certain risk factors are linked to the disease. A risk factor is anything that increases a person's chance of getting a disease. Different cancers have different risk factors.

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What are some of the various types of prostate cancer?

There is only one type of prostate cancer that occurs within the prostate glands. Although, there are several cell types in the prostate, nearly all prostate cancers start in the gland cells.

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What are the risk factors of prostate cancer?

Risk Factors for Prostate Cancer include:

• Age- Age is the strongest risk factor for prostate cancer. The chance of getting prostate cancer goes up quickly after a man reaches age 50. About 2 out of every 3 prostate cancers are found in men over the age of 65.
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  Race- For unknown reasons, prostate cancer is more common among African-American men than among men of other races. African-American men are also more likely to have a more advanced disease when it is found and are more likely to die of the disease. Prostate cancer occurs less often in Asian-American and Hispanic/Latino men than in non-Hispanic whites. The reasons for these racial and ethnic differences are not clear.

• Nationality- Prostate cancer is most common in North America, northwestern Europe, and a few other places. It is less common in Asia, Africa, Central and South America. The reasons for this are not clear. More testing in some developed countries likely accounts for at least part of this difference, but other factors are likely to be important as well.

• Family History- Prostate cancer seems to run in some families. Men with close family members (father or brother) who have had prostate cancer are more likely to get it themselves, especially if their relatives were young when they got the disease.

• Diet- The exact role of diet in prostate cancer is not clear, although several different factors have been studied. Men who eat a lot of red meat or high-fat dairy products seem to have a greater chance of getting prostate cancer. These men also tend to eat fewer fruits and vegetables. Doctors are not sure which of these factors causes the risk to go up.

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What can you do to prevent getting prostate cancer?

Because we don’t know the exact cause of prostate cancer, it is not possible to prevent most cases of the disease. But some cases might be prevented.

Diet - While the results of research studies are not yet clear, you may be able to reduce your risk of prostate cancer by changing the way you eat. The ACS suggests eating less red meat and fat and eating more vegetables, fruits, and whole grains. Eat 5 or more servings of fruits and vegetables each day. These guidelines provide healthful approach to eating that may help lower your risk for some other types of cancer, as well as other diseases.

• Tomatoes, pink grapefruit, and watermelon are rich in substances (lycopenes) that help prevent damage to DNA and may help lower prostate cancer risk. Research on this is still going on.
• Some studies suggest that taking vitamin E daily may lower the risk of prostate cancer. But others have found that vitamin E has no impact on cancer risk and might raise the risk for some kinds of heart disease. Selenium, a mineral, may also lower risk. A large study is going on now to see if vitamin E or selenium lowers prostate cancer risk.
• On the other hand, vitamin A (beta-carotene) supplements may actually increase prostate cancer risk. It’s always a good idea to check with your doctor about taking vitamins or supplements before you start to do so.

A study of the drug finasteride (Proscar®) found that men taking the drug were 25% less likely to get prostate cancer than men taking a placebo (“sugar pill”). But the men taking the drug who did get prostate cancer were more likely to have cancers that looked like they might grow and spread. Also, the men taking the drug were more likely to have side effects such as lower sex drive and trouble getting an erection. On the other hand, they had fewer urinary problems. At this time it’s not clear whether taking finasteride to lower the risk of prostate cancer is a good idea or not. The results of the study will become clearer over the next few years.

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What are the signs / symptoms of prostate cancer?

There are usually no specific signs or symptoms of early prostate cancer - which is why prostate screening is so important. An annual physical examination, prostate-specific antigen (PSA) blood test, and digital rectal exam (DRE) provide the best chance of identifying prostate cancer in its earliest stages.

The following are the most common symptoms of prostate cancer. However, each individual may experience symptoms differently. Symptoms may include:

• weak or interrupted flow of urine
• urinating often (especially at night)
• difficulty urinating or holding back urine
• inability to urinate
• pain or burning when urinating
• blood in the urine or semen
• nagging pain in the back, hips, or pelvis 
• difficulty having an erection

The symptoms of prostate cancer may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

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How is prostate cancer detected?

Prostate cancer can often be found early by testing the amount of PSA (prostate-specific antigen) in your blood. Another way prostate cancer is found early is when the doctor does a digital rectal exam (DRE). Because the prostate gland lies just in front of the rectum, during the exam the doctor can feel if there are any bumps or hard places on the prostate. These might be cancer. If you have had routine yearly exams and either one of these test results becomes abnormal, any cancer you might have has probably been found at an early, more treatable stage.

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What treatments are available for prostate cancer?

There is a lot for you to think about when choosing the best way to treat or manage your cancer. There may be more than one treatment to choose from. When treating prostate cancer it is important to take into account:

• your age and how long you can expect to live 
• any other serious health problems you may have 
• the stage and grade of your cancer 
• your feelings (and your doctor's opinion) about the need to treat the cancer 
• the chance that each type of treatment will cure your cancer (or provide some other measure of benefit) 
• your feelings about the side effects common with each treatment

You may want to get a second opinion, especially if you have several treatments to choose from. Prostate cancer is a complex disease, and doctors may differ in their opinions about the best treatment options.

Treatments for Prostate Cancer include:

Watchful Waiting (Expectant Management) - Because prostate cancer often grows very slowly, some men (especially those who are older or who have other major health problems) may never need treatment for their cancer. Instead, their doctor may suggest an approach called “watchful waiting” (also called “expectant management”).

This approach involves closely watching the cancer (with PSA testing) without using treatment such as surgery or radiation therapy. It may be a good option if the cancer is not causing any symptoms, will probably grow slowly, and is small and contained in one place in the prostate.

Watchful waiting does not mean your cancer will be ignored. Rather, your doctor will observe what is going on. You will most likely have a PSA blood test and DRE every 3 to 6 months, maybe with a yearly biopsy of the prostate. If you start to have symptoms or if your cancer begins to grow more quickly, you can think about active treatment. A possible downside of this approach is that there's a chance it could allow the cancer to become more advanced, which might limit your treatment options.

Surgery- The most common operations for prostate cancer are radical prostatectomy and transurethral resection of the prostate (TURP). Each is explained in more detail below.

Radical Prostatectomy- This surgery is done to try to cure the cancer. It is done most often if it looks like the cancer has not spread outside the prostate. The entire prostate gland and some tissue around it are removed.

There are 2 main types of radical prostatectomy.

• Radical Retropubic (ret-tro-pew-bic) Prostatectomy- An incision is made in the lower abdomen.  The doctor may first remove lymph nodes near the prostate and have them looked at under a microscope. If any of the nodes contain cancer, it means the cancer has spread. Since the cancer probably can’t be cured, the doctor may stop the operation.
  
  • Radical Perineal (pair-uh-nee-ul) Approach- In the perineal approach, the surgeon makes the incision in the skin between the anus and the scrotum. The surgeon can remove some lymph nodes using a separate technique, if needed. Because this operation is often shorter, it might be used for men who don’t need the nerve-sparing procedure or who have other medical problems that make the first approach harder.
    
    
• Laparoscopic Radical Prostatectomy (LRP) - Is a surgery where a surgeon makes an incision to remove the prostate. A newer method involves making several smaller cuts and using special long instruments to remove the prostate. It is called laparoscopic surgery (laparoscopic radical prostatectomy or LRP) and is being used more and more in this country.
  • LRP has advantages over the open approach: less blood loss and pain, shorter hospital stays, and faster recovery time. Nerve-sparing is possible with LRP, and the side effects seem to be about the same as for open prostatectomy.

Robotic-assisted Laparoscopic Radical Prostatectomy- The surgeon sits at a panel near the operating table and controls robotic arms to perform the operation through several small incisions in the patient's abdomen. For the patient, there is little difference between direct and remote (robotic) LRP, either during surgery or recovery.

Transurethral resection of the prostate (TURP) - This procedure is done to relieve symptoms, such as trouble urinating, in men who can’t have other types of surgery. It is not done to cure the disease or to remove all the cancer. The same operation is used even more often to relieve symptoms of non-cancerous prostate swelling called BPH.

Radiation Therapy- Radiation therapy is treatment with high-energy rays (such as x-rays) to kill or shrink cancer cells. The radiation may come from outside the body (external radiation) or from radioactive materials placed directly in the tumor (brachytherapy or internal radiation).
Radiation is sometimes used as the first treatment for low-grade cancer that has not spread outside the prostate gland, or has spread only to nearby tissue. It is also sometimes used if the cancer is not completely removed or comes back (recurs) in the area of the prostate after surgery. Cure rates for men treated with radiation seem to be about the same as for men having surgery. If the cancer is more advanced, radiation may be used to shrink the tumor and provide pain relief.

External Beam Radiation Therapy (EBRT)- This treatment is much like getting a regular x-ray, but for a longer time. Each treatment lasts only a few minutes. Men usually have 5 treatments per week in an outpatient center over a period of 7 to 9 weeks. The treatment itself is quick and painless. 

Brachytherapy (brake-ee-ther-uh-pee) (Internal Radiation)- In one approach (permanent or low dose brachytherapy), small radioactive pellets (each about the size of a grain of rice) are placed directly into the prostate. Sometimes these pellets are referred to as “seeds.” Because they are so small, they cause little discomfort and are often simply left in place after their radioactive material is used up.

In another form of brachytherapy (temporary or high dose brachytherapy), needles are used to place soft tubes (catheters) in the prostate. A strong radioactive substance is placed in these catheters for 5 to 15 minutes and then removed.

Cryosurgery- This approach is sometimes used to treat prostate cancer by freezing the cells with cold metal probes. It is used only for prostate cancer that has not spread but may not be a good option for men with large prostate glands. The probes are placed through incisions between the anus and the scrotum. Cold gases are then passed through the probes, which creates ice balls that destroy the prostate gland. Some type of anesthesia is used during this procedure.
A catheter is also put in place (usually through the abdomen) so that when the prostate swells (it usually does after this treatment) urine does not stay trapped in the bladder.

Hormone Therapy- The goal of hormone therapy (also called androgen deprivation) is to lower the levels of the male hormones or androgens (an-dro-jens), such as testosterone (tes-toss-ter-own). Androgens, which are made mostly in the testicles, cause prostate cancer cells to grow. Lowering androgen levels often makes prostate cancer shrink or grow more slowly. Hormone therapy can control, but will not cure the cancer. It is not a substitute for treatments aimed at a cure.

Hormone therapy is often used in the following situations:

• In men who do not have surgery or radiation as good treatment options.
• For men whose cancer has spread to other parts of the body or has come back after earlier treatment.
• It may be used along with radiation in men who are at high risk of having the cancer return after treatment.
• Sometimes it is used before surgery or radiation to shrink the cancer.

While hormone therapy does not cure the cancer, it can provide relief from symptoms.

Chemotherapy (Chemo)- Chemo is the use of drugs for treating cancer. The drugs are often injected into a vein. Some can be swallowed in pill form. Once the drugs enter the bloodstream, they spread throughout the body to reach and destroy the cancer cells.

At one time, chemo was not thought to work very well in treating prostate cancer, but this has changed in recent years. In the past few years, new drugs have been shown to relieve symptoms from prostate cancer in men with advanced disease.

Like hormone therapy, chemo is unlikely to result in a cure. This treatment is not expected to destroy all the cancer cells, but it may slow the cancer's growth and reduce symptoms, resulting in a better quality of life.

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