Prostate Conditions & Treatments

Cancer occurs when cells in the body begin changing and multiplying out of control. These cells can form lumps of tissue called tumors. Cancer that starts in the prostate is called prostate cancer. Cancer can grow and spread beyond the prostate, threatening health and life.

Understanding the Prostate

The prostate is a gland about the size and shape of a walnut. It surrounds the upper part of the urethra in men, the tube that carries urine from the bladder.The prostate produces most of the semen in which sperm travel. During orgasm, semen exits the body through the urethra.

When Prostate Cancer Forms

As a man ages, his prostate may change. Inside a changing prostate, groups of cells may form tumors or other growths. Some may be benign (not cancerous), but they may still cause symptoms. Others may be cancerous.

• Noncancerous growths. As a man ages, the prostate may grow larger. This condition is called benign prostatic hyperplasia (BPH). Extra prostate tissue often squeezes the urethra, causing symptoms such as difficulty urinating. But BPH does NOT lead to cancer.
• Atypical cells (prostatic intraepithelial neoplasia, or PIN). Some cells don’t appear normal, but they are not cancer. These cells may indicate that cancer is present or is likely to form.
• Cancer. Abnormal cells form a tumor (a lump of cells that grow uncontrolled). Cancer may or may not produce symptoms. Some tumors can be felt during a physical exam, others can’t.
• Cancer spread. Prostate cancer may spread to nearby organs. In some cases, the cancer spreads further, to bones or organs in distant parts of the body. This is called metastasis.

Diagnosing Prostate Cancer

Prostate cancer may not cause symptoms at first. Urinary problems often are not a sign of cancer, but of another condition. To find out if you have prostate cancer, your doctor must examine you and order tests. Tests help confirm a diagnosis of cancer. They also help give more information about a cancerous tumor. Tests include:

• Prostate specific antigen (PSA) testing: PSA is a chemical made by prostate tissue. The PSA level (amount of PSA in the blood) is tested to evaluate a man’s risk for prostate cancer. In general, a high or rising PSA level may mean an increased cancer risk. PSA testing is also used to evaluate the success of cancer treatments.
• Core needle biopsy: This test involves taking tissue samples from the prostate to provide more information about cancer cells. During the test, a small probe is inserted into the rectum as you lie on your side. This lets an image of your prostate be seen on a video monitor. With this image as a guide, the doctor uses a thin needle to remove tiny tissue samples from the prostate. You are given medications so you don’t feel pain during the test.

Cancer that has spread beyond the prostate can often be treated. Hormone therapy can slow the growth and spread of the cancer. Chemotherapy may help relieve symptoms and control the cancer. Cancer pain can be managed with medications.

Testosterone can cause the cancer to grow. Treatments can include:

• Luteinizing hormone-releasing hormone (LHRH) agonists. These medications reduce the amount of testosterone made by the testicles. LHRH agonists are injected monthly or every 3 to 4 months.
• Antiandrogens. These medications block the body’s ability to use testosterone. They are given by pill.
• Orchiectomy. This surgery removes the testicles, the main source of testosterone.

Chemotherapy

Chemotherapy (chemo) uses medications to destroy cancer cells anywhere in the body. Chemo may be given by pill or injection. It may be used with or instead of other treatments. It may slow the growth of cancer, and may relieve pain and other symptoms. A medical oncologist manages chemo treatments.

Pain Control

Prostate cancer that has spread may cause pain. This pain can be treated. Pain medications can improve your quality of life. Using them can relieve stress, helping you to better withstand the cancer. Discuss the side effects of these medications, and any other concerns you have, with your doctor.

Risks and Complications of Hormone Therapy

• Hot flashes.
• Breast enlargement or tenderness.
• Sexual dysfunction.
• Osteoporosis (bone loss).
• Diarrhea.
• Loss of energy.

Problems with the prostate (a gland in the male reproductive system) become more common as a man ages. These problems include prostate cancer, a common cancer in men. This cancer can often be cured or controlled, especially if it is found and treated early. Screening tests help detect prostate cancer before it causes any symptoms.

Prostate Cancer

Cancer is an uncontrolled growth of abnormal cells. These cells form in one area and can spread through the body. Prostate cancer causes no symptoms in its early stages. In fact, urinary problems are more likely to be symptoms of another condition.

Risk Factors for Prostate Cancer

The things that can increase a man’s chance of developing prostate cancer are called risk factors. These include:

• Age. The risk of developing prostate cancer increases as you grow older.
• Family history. If your father or brother has had prostate cancer, your risk of developing it is higher.
• Race. African American men are more likely than other men to develop prostate cancer. They are also more likely to die of prostate cancer than other men with this disease.

Screening for Cancer

Screening for prostate cancer is done with a physical exam and blood tests. These tests can help determine whether it is likely that you have cancer. The American Urological Association recommends that men with risk factors begin yearly screening at age 40. Men with no risk factors are offered yearly screening at age 50.

Tests You May Have

Prostate cancer screening tests include the digital rectal exam (DRE) and a lab test called the PSA test. If the DRE or PSA suggests that cancer may be present, other tests are then done. These tests help show whether a man has prostate cancer.

Medical History and DRE

During your medical exam:

• Your healthcare provider will ask about your personal and family medical history. He or she will also ask about any symptoms you have.
• Your provider will ask about any medications you take, including herbs and supplements.
• If you’re having problems with urination, your provider may order a urinalysis to check for a urinary tract infection.
• Your provider will perform a DRE. This involves inserting a lubricated gloved finger into the rectum. Because the prostate is next to the rectum, many prostate abnormalities can be detected with this exam.

The PSA Test

PSA (prostate specific antigen) is a protein produced by prostate tissue. The PSA level is measured with a blood test. The result helps assess the likelihood of prostate cancer. To screen for prostate cancer, the PSA test is done once a year.

Evaluating the PSA

A high or rising PSA level suggests that prostate cancer may have formed. A lower PSA level indicates that cancer is less likely. In addition to the PSA level, your doctor may look at:

• The ratio of free PSA (PSA that is not bound to a certain protein in the blood) to total PSA.
• The PSA velocity (how fast the PSA level is rising).
• The PSA density (the relation of the PSA level to the size of the prostate).

Factors That Affect PSA

Many factors can affect PSA levels. Some, such as age, BPH, and prostate cancer, are ongoing. Others, such as prostatitis or recent sexual activity, have only a temporary effect on PSA. Your healthcare provider can explain how these factors may affect the timing of the PSA test and your results.

Further Testing

Abnormalities found with DRE may not be tumors. And a high PSA level doesn’t always mean cancer. More tests need to be done. After looking at the results of your screening tests, your doctor may recommend other tests.

Biopsy

This test involves taking tissue samples from the prostate. With transrectal ultrasound (TRUS) as a guide, a thin needle is used to remove samples. The tissue samples are then analyzed in a lab to check whether there are cancer cells and, if so, how likely they are to grow quickly.

Imaging Studies

If cancer is found, imaging studies may be done to check for its spread. Bone scans(x-rays) check whether cancer has spread to bones. CT and MRI can detect tumors in bones and soft tissues.

Should you be screened yearly for prostate cancer, even if you have no symptoms? Experts disagree. Below are some factors to think about as you make a decision.

Pros

• Many experts believe that screening saves lives. Prostate cancer is the second leading cause of cancer death in men. Screening is the best way to find prostate cancer in its early stages. When found early, prostate cancer can nearly always be successfully treated. When it is found at a more advanced stage, the outlook often is not as good.
• The younger you are, the more likely it is that early detection of cancer will add years to your life.
• The side effects of prostate cancer therapies are often temporary and can be treated.

Cons

• Screening tests show how likely cancer is. But they are not perfect. So some of the biopsies done based on these tests will be unnecessary. Doing a biopsy has risks, such as bleeding and infection.
• Prostate cancers are often slow-growing. Many never become life-threatening and never need treatment. If you find out you have cancer, you may feel you need to treat it, even if tests show that it’s not a dangerous cancer. Prostate cancer treatments have side effects that can affect quality of life, such as incontinence and erectile dysfunction. So in some cases, treating the cancer causes more problems than not treating it.

Weighing Your Options

Before making a decision about screening, talk to your doctor. Ask any questions you have about testing. Talking to your partner, friends, or family members may also be helpful. Things to consider include:

• Whether you have risk factors.
• Your age, overall health, and life expectancy.
• Your feelings about treatment. If you found out that you had prostate cancer, would you want to have it treated?

Being told that you have cancer is frightening. But most men diagnosed with prostate cancer don’t die from it. Even though a cure can’t be guaranteed, treatment can often keep the cancer under control. The treatment your healthcare team will suggest depends on many factors. These include your age, your overall health, how fast the cancer is growing, and whether it has spread. Discuss your options with your healthcare team.

Your Healthcare Team

The professionals who assist in your care include:

• A urologist, a doctor who treats and performs surgery on the urinary system and the male reproductive system.
• A radiation oncologist, a doctor who uses radiation to treat cancer.
• A medical oncologist, a doctor who treats cancer with medications.
• A nurse practitioner, who may perform exams and manage follow-up care.
• Your primary care physician, who refers you to the appropriate specialists. He or she also monitors your overall health.

Choosing the Best Treatment

Knowing the cancer’s grade and stage helps with forming a treatment plan. Discuss your treatment options with your healthcare team to find what is best for you.

• Watchful waiting. Depending on the cancer’s grade and stage, your age, and your overall health, you may not need treatment. Your healthcare team will monitor your health and PSA, decide when you’ll need follow-up exams, and schedule treatment at a later date if needed.
• Treating to cure. If cancer is detected at an early stage, chances for recovery are good. Low- or mid-stage cancer can often be cured by removing it surgically or destroying it inside your body using radiation.
• Treating to control. High-grade or high-stage cancer often can’t be cured, but may be controlled using surgery, radiation, hormone therapy, or chemotherapy.

New Treatment Options

New treatment options for prostate cancer may become available in the future. These may include new surgical or radiation techniques or new medications. Your healthcare team can tell you if any of these options might be right for you. Ask the members of your healthcare team whether you could be treated as part of a clinical trial (a research project to study a new treatment).

Radical (total) prostatectomy is surgery to remove the entire prostate. It may be done if diagnostic tests show that the cancer is confined to the prostate. Your surgeon will give you detailed instructions on preparing for surgery. After surgery, you’ll be told how to care for yourself at home as you recover. Be sure to ask any questions you have about the procedure and recovery.

Before Surgery

• Don’t eat or drink after midnight the night before surgery.
• You may be given a laxative or have an enema one day before surgery.

How Surgery Is Performed

• Surgery may be performed through an incision in the abdomen (retropubic approach) or behind the scrotum (perineal approach). Or surgery may be done laparoscopically, with surgical tools inserted through tiny incisions in the abdomen. Robotic-assisted procedures allow more complex surgeries to be done through very small incisions.
• The urologist may remove and check the lymph nodes near the prostate to see if cancer has spread. (If the cancer has spread, the urologist may decide not to remove the prostate.)
• The prostate, the seminal vesicles, and a portion of urethra will then be removed.
• Nerve-sparing techniques may be used to help preserve erectile function (the ability to achieve and maintain an erection).

After Surgery

• Urine will drain through the catheter into a sterile bag. The urine may be bloody or cloudy at first.
• You may return home in 1-3 days.
• Medications to control pain will be prescribed.
• The catheter will be left in place when you go home. You’ll be given instructions on how to manage it.
• The catheter and stitches will be removed at a follow-up visit. This is often 1-2 weeks after surgery.
• Bladder control often takes a few weeks to several months to return. Improvement can continue for up to a year.

Call Your Doctor If

• You have fever or chills.
• The incision is draining or increasingly painful or red.
• Your leg or ankle begins to swell.
• Urine isn’t draining from the catheter.
• You can’t urinate after the catheter has been removed.

Risks and Complications of Prostatectomy

• Erectile dysfunction (difficulty achieving or maintaining an erection).
• Incontinence (loss of bladder control).
• Infection.
• Excessive bleeding.
• Difficulty urinating.
• Pneumonia.
• Blood clots.
• Bowel perforation.

Radiation therapy is one way to destroy cancer cells. Cancer cells continue to die for months after the therapy ends. Radiation can be delivered from material placed inside the prostate gland. This is called interstitial brachytherapy. “Seeds” (tiny pieces of radioactive material) are implanted in the prostate. These seeds can be either permanent or temporary.

Permanent Seeds

Permanent seeds release decreasing amounts of radiation over a period of months. You can most likely go home soon after the seeds are implanted.

Temporary Seeds

Temporary seeds release a single high dose of radiation. They are implanted and removed. You may stay in the hospital for a day or more after the first dose. One or more doses may be given during the next day.

Before, During, and After Treatment

• Before treatment. You may be given hormone therapy to shrink the prostate. Ultrasound or a CT scan is then used to map the size and shape of the prostate.
• During treatment. You are given anesthesia to keep you free from pain during the procedure. Needles are then inserted behind the scrotum. These needles are used to implant the seeds. The procedure takes about 1-2 hours.
• After treatment. Soon after treatment, you can resume normal activities. Your healthcare team will help you to manage any side effects. With permanent seeds, you may need to restrict contact with young children and pregnant women for a period of time. Discuss these precautions with your healthcare team.

Risks and Complications of Interstitial Brachytherapy

• Erectile dysfunction
• Incontinence.
• Frequent urination, possibly with a burning feeling.
• Pain in the perineal region.
• Bleeding or inflammation of the bladder or rectum.
• Urinary obstruction.
• Bowel problems.
• Movement of seeds out of prostate.

No matter what type of treatment you choose, life with prostate cancer can be a challenge. Your goal during treatment should be to live as normal a life as possible. Your healthcare team can help you to cope with any physical and emotional issues that result from treatment. The support of your family and friends can help, too. Don’t be afraid to ask your loved ones for help with the challenges you are facing.

Sexuality

Treatment for prostate cancer may affect your sexuality. It can result in erectile dysfunction or a lowered sex drive. Often, these problems can be treated. Ask your urologist for help. And talk to your partner about ways to nurture your relationship so that it will be satisfying for both of you.

Urinary Problems

Incontinence or other urinary problems can occur due to treatment for prostate cancer. Effective treatments exist for most urinary problems. Talk to your urologist or radiation oncologist about what may help you.

The Future

During and after treatment, your urologist will monitor your prostate health. Your healthcare team will also help you control any ongoing symptoms resulting from treatment. Keep in mind that each man responds differently to prostate cancer treatment. Continue working with your team throughout treatment. Mention any concerns you have, and be sure to get your questions answered. Above all, think about how best to live your life. Prostate cancer may or may not shorten your life. But living life to the fullest is a good goal for anyone.

To form your treatment plan, your healthcare team must learn more about your cancer. What do the cancer cells look like? Has the cancer spread beyond the prostate? Cells removed during biopsy will be viewed under the microscope. Treatment will depend on how the cells look (grade) and where they are located (stage).

Grading the Cancer

A cancer is graded using tissue removed during a biopsy. A pathologist (a doctor who identifies diseases by studying cells and tissues) looks at this tissue under a microscope. He or she then determines the cancer’s grade, from 1 to 5. Low-grade cancers are similar to normal tissue. High-grade cancers differ from normal tissue in the way cells are organized, and in cell size and shape. The higher the grade, the faster the cancer is likely to be growing. The pathologist will give a report to your urologist.

Grade 1 or 2

Seen under a microscope, grade 1 or 2 cells are abnormal, but still appear to be organized in rings. This may indicate a slow-growing cancer.

Grade 3 or 4

Grade 3 or 4 cells vary more in size and shape. Fewer rings are visible. These cancer cells may grow more rapidly.

Grade 5

Grade 5 cells don’t form rings. They vary even more in size and shape than lower-grade cells. This indicates a fast-growing cancer.

The Gleason Score

Often there is more than one cancer grade within a tumor. The two most common grades found in the tumor are added together to get the Gleason score (or sum), a number between 2 and 10.

To form your treatment plan, your healthcare team must learn more about your cancer. What do the cancer cells look like? Has the cancer spread beyond the prostate? Cells removed during biopsy will be viewed under the microscope. Treatment will depend on how the cells look (grade) and where they are located (stage).

Staging the Cancer

Your urologist will assign your cancer a stage based on PSA, DRE, and imaging tests. Lower-stage cancers are confined to the prostate. Higher-stage cancers have spread from the prostate to nearby organs, bone, or other body tissues.

Stage T1

A tumor that is completely inside the prostate. It can’t be felt during DRE.

Stage T2

A tumor that can be felt during DRE, but is still completely inside the prostate.

Stage T3 or T4

Cancer that has spread to the outside of the prostate or to the seminal vesicles.

Stage N+, M+

Cancer that has spread to the lymph nodes (N+), or to the bones or other organs (M+).