After lung cancer, cancer of the prostate is the second most common cause of cancer deaths in men in the United States. It is estimated that up to 350,000 men are diagnosed with prostate cancer annually. Adenocarcinoma of the prostate is the clinical term for cancer that begins as a tumor on the outside of the prostate gland. As it grows, it may spread to the inner part of the prostate. If identified early enough in its development and treated before the malignancy spreads too far into the gland or out into surrounding tissues, lymph nodes or bones, it can be treated successfully with a variety of medical procedures. If not, the cancer cells will spread through the bloodstream, infecting other parts of the body, and the disease will claim the patient as one of its estimated 40,000 victims annually.
Prostate cancer is often described as a disease of men over age 50. A man's chances of being diagnosed with prostate cancer during his lifetime are about 1 in 6 slightly higher than a woman's chances of having breast cancer (1 out of 10). Significant advances in the detection of the cancer has been made because of improved tests (PSA blood test and transrectal Ultrasound guidance of biopsies), which can detect the disease early in its development, often long before symptoms appear. The likelihood of developing prostate cancer in any given year increases with age, but rises dramatically after age 50. A recent study estimated one in nearly 59,000 men age 40 to 44 are likely to be diagnosed with prostate cancer, rising to one in about 2,600 from age 50 to 59, and one in 80 beyond age 80.
The topic of prostate cancer can be very confusing for patients. Invariably, each patient knows other men who are being treated for prostate cancer. It is difficult to understand why one treatment is used in one man and a different treatment is used in another. Again, much of the treatment choice depends on the patient's age and overall health. In general, men do well with prostate cancer, provided it is diagnosed early and treated appropriately.
Prostate cancer is diagnosed with the development of an abnormal PSA, abnormal rectal exam, or both. (Click here for Dr. John Bauer's overview of prostate cancer diagnosis.)
Very rarely are symptoms of the disease the first evidence of an abnormality. The prostate biopsy under transrectal ultrasound guidanceis used to make the tissue diagnosis.
Treatment options are determined based upon the stage of the disease. Over 70% of cancers are detected solely from PSA elevations with a normal rectal exam. Since the advent of PSA, there has been a dramatic stage migration to earlier detectable disease. These days, it is rare to see a patient with metastatic disease walk into the clinic for evaluation. The extent of the cancer is referred to as the stage of disease . Stage A or T1 refers to disease which is identified incidentally at the time of surgery to remove a benign prostate. It also refers to cancers detected based on an elevated PSA without an abnormality on rectal exam. Stage B or T2 refers to cancer that can be felt on the digital rectal examination. Both Stage A and B (Tl and T2) are referred to as organ confined prostate cancer. Stage C or T3-4 disease includes those cancers that have spread outside the confines of the prostate. This determination is often made at the time of the rectal exam or the ultrasound examination. Stage D refers to those tumors, which have spread outside the prostate to the lymph nodes, bones or other sites
Treatment of prostate cancer depends on the stage of disease and the age and overall health of the patient. Treatment options available for organ confined prostate cancer (Stage A and B. T1 and T2) include observation alone or watchful waiting, radiation therapy, and radical prostatectomy. In some places in this country, cryosurgery is also used to treat organ confined prostate cancer. Although publicized heavily, this technique is still in the investigational stages. It is currently not the standard of care and it is recommended that it only be carried out as part of an investigational protocol under the auspices of a university setting.
The rationale for observation alone as a treatment choice is the recognition that some men may die of other illnesses before they die of their prostate cancer. One of the difficulties encountered in treating prostate cancer is trying to predict its biologic potential. In the older man with other health troubles, and a type of cancer that does not appear particularly aggressive, it may be appropriate to choose observation. In the younger man, this is not the favorable choice since it can be anticipated that the cancer will spread outside the prostate in 60 to 70 % of men within 10 years after diagnosis. For those men in whom the cancer spreads outside the prostate, they may subsequently die secondary to complications from the prostate cancer
Radiation therapy involves the application of x-ray treatment to the prostate in an effort to eradicate the cancerous cells or at least arrest their growth. Radiation can be delivered in two different forms: external beam radiotherapy or brachytherapy , (the insertion of radioactive seeds into the prostate). Radiation therapy has very effective treatment results at 5 and 10 years. The results are not as favorable at the 15-year mark. Radiation is a good choice for men in their 70's without other significant health troubles. It may at times be appropriate for men in their 60's who have other health troubles or who have a type of cancer with low biologic potential. If cancer remains in the prostate after radiation, a later attempt to remove the prostate through surgery is not a favorable option.
- External radiation is typically given over a course of 30 to 40 treatments. It is usually given 5 days a week for a 6 to 8 week treatment total. Complications of radiation can include damage to the urinary bladder or the rectum. This can result in urinary frequency and urgency. It can also cause diarrhea and rectal pain. Incontinence, which is the loss of urinary control, develops in less than 1% of men. Impotence, the inability to get an erection, may develop on a delayed basis in up to 1/3 of patients.
- Brachytherapy is the term used to describe the insertion of radioactive seeds into the prostate. The rationale for inserting seeds directly into the prostate is that it allows a higher dose of radiation to be delivered to the prostate with less of an affect on adjacent organs. When this technique was first developed years ago, the main problem encountered was achieving an even distribution of the seeds. With the development of transrectal ultrasound, it became possible to distribute the seeds in an even fashion. More recently, techniques using CT guidance to place the seeds have been developed which appear to provide even more precise placement of the seeds. Long-term studies regarding treatment outcome are not yet available. However, preliminary information indicates that brachytherapy is at least as effective as external radiation therapy and may be as effective as radical prostatectomy. Seed placement is now done on an outpatient basis under epidural anesthesia. Impotence may develop but incontinence rarely develops in patients treated with seeds.
Radical prostatectomy refers to the surgical removal of the prostate.
Surgery is carried out through an incision that runs from the belly button to the pubic bone (or through some “key holes”). At surgery, the first step is the removal of the lymph nodes, if indicated, to determine if there are microscopic areas of cancer spread. After lymph node removal, the prostate and the attached seminal vesicles, which are accessory glands of the prostate, are removed. The bladder is then rejoined to the urethra. Surgery typically involves a 5 to 6 day hospital stay. A catheter, which is a tube to drain urine out of the bladder, is in place for 3 weeks. Potential complications (radical retropubic prostatectomy and radical perineal prostatectomy) related to the surgery itself include bleeding and infection. There are also the general risks of an operation such as a blood clot in the legs, heart irregularity, pneumonia and so forth. Long-term potential problems include post-prostatectomy incontinence and post-prostatectomy impotence. Impotence develops in at least half of the patients even with application of the "nerve sparing" techniques. Surgery is the treatment of choice for men in their 50's and early 60's. It is also a good choice for men in their late 60's and very early 70's who do not have other health problems and whose life expectancy is at least 10 years. Surgery has the advantage over radiation of having better long-term outcomes in terms of survival and disease-free survival at the 10 and 15-year mark. On some occasions, men who are treated with radical prostatectomy can require additional therapy once they recover from surgery. If there are microscopic areas of lymph node involvement, hormonal therapy may be required. If you know your specific pre- and post-operative parameters, one could predict the risk of recurrence after surgery (pre-operative equation, post-operative equation) both before surgery and then again more accurately after the surgery has been completed.
If there is evidence of extension of the cancer up to the margins of the surgical resection, radiation may be added as follow-up treatment. For men with Stage C (T3-4) disease, treatment options include observation, radiation and hormonal therapy. Radiation therapy may provide control of local symptoms that would otherwise develop due to the size of the cancer as it encroaches on the urethra and bladder. Radical prostatectomy is typically not recommended for Stage C disease except in the very young man.
For those with Stage D disease, the primary treatment is hormonal therapy. Prostate cancer depends on testosterone, the male hormone, to grow and flourish. There are different ways to remove testosterone. These all fall under the collective term "hormonal therapy."
One of the simplest ways to remove testosterone is with orchiectomy. Orchiectomyrefers to the surgical removal of the testicles, the site where testosterone is produced.
Another popular alternative is the administration of an injection every three months, which keeps the testicles from making testosterone. This type of medicine, known as a GNRH analog, is available as either Lupron or Zoladex. The advantage of this form of therapy is that it avoids the need for surgery. The relative disadvantage is the increased cost compared to orchiectomy.
Often times, in combination with either orchiectomy or a GNRH analog, an anti-androgen is used as well. Currently, the anti-androgen used is Flutamide (Eulexin), which is taken as one to two tablets 3 times a day. This interferes with the small amount of testosterone made by the adrenal gland. Side effects of hormonal therapy include impotence in all men and hot flashes in some men. There are now many other options for anti-androgens such as Casodex (Biclutamide) and Nilandron (nilutamide) both of which are taken less frequently and have lower gastrointestinal side effects.