Prostate cancer is one of the most common cancers diagnosed in American men and is second leading cause of non-skin cancer death in men after lung cancer. Close to 200,000 new cases of prostate cancer are discovered every year and close to 30,000 deaths are expected every year. Fortunately, although prostate cancer does not cause death in men with the disease, early diagnosis and treatment can be key for saving lives.
FUNCTION OF THE PROSTATE
The prostate is a gland smaller than a golf ball whose purpose is to make and store seminal fluid that nourishes sperm. After the reproductive years, the prostate has little function but does tend to cause problems due to enlargement and blockage of the urinary stream as well as being a source of cancer.
SYMPTOMS AND DIAGNOSIS OF PROSTATE CANCER
The patient is often asked if there are any symptoms of prostate cancer. Most men diagnosed with prostate cancer will have no symptoms. In fact when symptoms such as urinary blockage or pain result, often times the cancer is in an advanced stage already. The strongest risk factor for prostate cancer is family history and men with a first-degree male relative with prostate cancer are often screened earlier in life. Men of African-American descent also tend to have a higher rate of cancer diagnosed at an earlier age and thus screening is recommended at an earlier age.
Screening for prostate cancer is accomplished with two tests and is recommended to start at age 50 for most men, age 45 for African-American men and 5 years early for any man with a family history of prostate cancer. The first test is a physical exam in which a doctor will feel the prostate through the rectum. This type of examination will discover anywhere between 5% and 15% of new cases of cancer. In addition of the physical exam, a blood test called the prostate-specific antigen or PSA test has been used for over 20 years. The PSA test is a blood test that measures a protein that is made by the prostate. This level, when high, can indicate which patients are at risk for prostate cancer. In addition to prostate cancer, an enlarged prostate or prostate infection can also cause an elevated PSA level. A PSA level over 4.0 is considered high and identifies men at risk for prostate cancer. For men under the age of 60, however, PSA levels should be closer to 2 or 3 and should be sometimes evaluated with further testing even if though the level is below 4.
PSA TESTING FOR PROSTATE CANCER AND CONTROVERSY OVER ITS USE
The PSA test has come under increased scrutiny in the media and based upon recommendations from the United States Preventive Health Task Force which has caused some confusion on its use.
We believe that the PSA test can be an important tool but does not replace the important conversation between physicians and patients when it comes to prostate cancer screening and the implications of over diagnosis and overtreatment. The PSA test has been a valuable resource in identifying men with aggressive prostate cancer early in the disease and has undoubtedly saved lives. It is also true that some men have been over diagnosed and perhaps more aggressively treated in their cancer than would warrant. A good patient-physician relationship in making sure that patients are not over treated and screening is done appropriately.
PROGNOSIS OF PROSTATE CANCER
Not all patients with prostate cancer have the same outcome. In many men, the cancer can be slow growing and not require treatment at all. Other men may have a more aggressive form of the cancer and be counseled to receive treatment that can include radiation therapy, cryotherapy, proton beam therapy, or surgical removal of the prostate. The specific treatment that is right for particular man depends on many factors including age and health status of the man and aggressiveness of the cancer. The survival rate for all stages of prostate cancer can be as high as 90% and the complications of treatment can be minimized if stage and aggressiveness of the cancer is appropriately matched to the patient’s treatment.
TREATMENT FOR PROSTATE CANCER
WATCHFUL WAITING OR ACTIVE SURVEILLANCE
Watchful waiting refers to a treatment strategy in which no invasive treatment for the prostate cancer is performed but rather the patient’s symptoms, PSA level, and aggressiveness of cancer is monitored over time. This can be a very safe way of managing many patients with prostate cancer. Most patients recommended for this treatment are older or will have other medical conditions that may limit their overall life expectancy. However, younger patient with a very low volume of cancer that is felt not be overly aggressive may also qualify for this type of treatment. The biggest risk is having a cancer that may be growing more aggressively than expected; however, the natural history of prostate cancer is considered to be fairly slow growing and this treatment option is considered safe as long as the patient adheres to a strict follow-up regimen. Some patients may be counseled to receive a repeat prostate biopsy within a specified time period after initial diagnosis.
LOCALIZED THERAPY USING RADIATION, CRYOTHERAPY, HiFU
A variety of different treatments are available to treat the prostate without removing it from the body. They can include use of radiation either through radiation beams shot through the skin or using seeds implanted in the prostate, cryotherapy which uses freezing rods placed through the skin to freeze the prostate, or newer therapy using high frequency ultrasound shot through the skin to destroy the prostate. These procedures are considered highly effective in certain forms of cancer, however, are not always appropriate for every patient. All of these procedures have their own risks and types of complications and will need to be discussed carefully with your treating urologist.
SURGERY FOR PROSTATE CANCER (RADICAL PROSTATECETOMY)
Some patient’s will be counseled on the potential benefit of surgical removal of the prostate. Although this can be done through an open incision, most of these procedures are now performed laprascopically using the surgical assistance of da Vinci™ Surgical Robot System. This type of operation allows the prostate to be removed through 5 or 6 small incisions in the lower abdomen. Recovery is generally considered fairly rapid with most patients going home the next day. Complications rates are low but this procedure may not be appropriate for all patients or for all forms of cancer.
HORMONES AND CHEMOTHERAPY
Advanced prostate cancer is defined as a cancer that has escaped beyond the prostate possibly into the lymph nodes, occasionally into the bone, or other organs. In some cases the exact site of spread of the cancer is not known but the PSA might be rising even after treatment. In such cases hormone therapy is often initiated. Hormone therapy refers to the use of medications that will either reduce the amount of testosterone in the body or block the action of testosterone. Testosterone is a hormone that can be used by prostate cancer cells to grow more quickly and the removal of testosterone from the body can slow the growth of some cancers. It is believed that most patients, however, will ultimately develop cancer that is not dependent on testosterone and this type of cancer is called hormone-refractory prostate cancer.
When cancer becomes hormone-refractory oftentimes chemotherapy is initiated. Recent advances in chemotherapy have allowed several drugs to be introduced for the treatment of advanced prostate cancer. Because the treatment is constantly evolving, patients with hormone-refractory prostate cancer are often referred to an oncologist for the most advanced treatment.