Prostate Cancer

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Prostate cancer is one of the most common cancers in men, comprising about 29% of all cancers. Last year, (1999), 180,000 new diagnoses of prostate cancer were made in the United States. The lifetime risk for developing prostate cancer is 12%.

Not all prostate cancers are serious and clinically important. Most men with die with, rather than of the disease. 30% of all men over age 50 have evidence of prostate cancer found on autopsy, but only 3% will die from it. Locally advanced or metastatic disease is very serious and can cause painful suffering and premature death. Ten year survival rates after being diagnosed with prostate cancer are as follows: 75% are alive after 10 years when the disease is confined to the prostate; 55% with extension of the disease just outside the prostate; and 5% of patients with distant spread (metastases) are alive after 10 years.

Those cancers that are caught early and are truly confined to the prostate are potentially curable by a surgery called radical prostatectomy and/or radiation therapy. Watchful waiting, in which no treatment is given until the tumor gets larger, is also a treatment option at this stage. This may be the best choice for an older man (greater than 75 years old) who has a greater risk of dying of something (else) other than prostate cancer. Unfortunately, those cancers that have grown beyond the edge of the prostate cannot be cured with either radiation or surgery. These tumors must be treated with hormones that slow the cancer's growth.

Screening
The risk of getting prostate cancer is higher in some men than in others. Risk factors for getting prostate cancer are advanced age, race (African Americans have a 30% greater incidence of prostate cancer when compared to white men), a diet high in fat, and family history. If you are Black or have a father, brother, or an uncle with prostate cancer, you should get a digital rectal exam and a PSA test every year, beginning at age 40 years. White men with no family history of prostate cancer should be screened annually starting at age 50. Some studies have found that optimal screening strategy is to prescreen all men (all races) at age 40-45 years. If PSA is greater than 2.0 ng/ml, regular biennial screening is indicated. If the PSA increases to above 2.5 ng/ml in men younger than 50, biopsy is recommended. Discuss with you doctor what screening is optimal for you.

Symptoms
Symptoms of prostate cancer are similar to that which occur with benign (non-cancerous) enlargement, including slowing of the urinary stream, waking up several times during the night to urinate, blood in the urine, and a feeling of not fully emptying the bladder after urination. In most men, prostate cancer causes few symptoms until it becomes very advanced.

Detection
The usual ways in which to check for prostate cancer includes the digital rectal exam (DRE), where the prostate can be felt, and the prostatic specific antigen (PSA) blood test. These two tests are often used together to diagnose prostate cancer. During the DRE, the doctor will insert a gloved, well- lubricated finger into the rectum to feel the prostate. If any part of the gland feels hard or lumpy, prostate cancer is suspected. The PSA blood test checks the level of PSA in your blood. Men aged 40-50 usually have a PSA from 0-2.5 ng/ml. Those aged 50-60 should have a PSA lower than 4. It is important to note that things other than prostate cancer can cause a mild increase in the PSA level, including recent urinary tract infection, recent sexual activity, recent DRE, prostate gland infection, and benign prostate enlargement (also known as BPH or benign prostatic hypertrophy.)

Diagnosis
If your doctor suspects that you have prostate cancer, a biopsy of a small bit of the prostate tissue, guided by ultrasound, will be taken. A pathologist will examine the tissue to determine whether prostate cancer is present. The side effects of the biopsy are usually mild, including small amounts of blood in the urine and stool for a few days along with some rectal discomfort.

Treatment Options
If your doctor does find that you have prostate cancer, there are treatment options available. One option is radical prostatectomy, which is the surgical removal of the prostate gland and the surrounding lymph nodes. The main advantage of the surgery is that it offers the most certain chance of a cure. (if all of the cancer is removed during the surgery, you are cured.) The surgery also reveals whether or not the cancer has spread outside the prostate, because lymph nodes are taken as well. Like all things, risks and complications may be associated with the surgery. Blood loss is a possible risk during the procedure. Some people may want to save 2 units of their own blood before the surgery in case they need a blood transfusion during the surgery. The main risks include impotence (loss of normal erection) and incontinence (loss of bladder control.) The chances of impotence increase if the tumor is large, not permitting the surgeon to remove it without cutting some of the nerves.

The age of the patient and degree of sexual function before the surgery also must be taken into account. For instance, if you are less than 50 years old when undergoing this surgery, you will likely regain sexual function (although it may take up to a year to return to normal.) Men older than 70 often have more difficulty regaining this ability after surgery. However, even if nerves are cut and natural erection cannot occur, penile feeling and orgasm remain normal. There are medication and devices available that can help to make the penis erect artificially.

Less than 1% of men have severe urinary incontinence after surgery. Most men regain bladder control a few weeks to several months after the surgery. However, it may take up to a year to regain it completely. 20% of men will have some leakage of urine during coughing, heavy lifting, or laughing.

Radiation therapy is another option. There are two types available; one type is given from a machine like an x-ray, the other type involves radioactive pellets ("seeds") which are injected into the prostate gland. Both work about the same in curing prostate cancer. Radiation has a cure rate similar to that of surgery, but no surgical risks. Incontinence is rare afterward, and about 50% of all patients become impotent. Serious complications are rare, but 30% have urinary burning and bleeding, frequent urination, rectal bleeding or discomfort or diarrhea during the treatment. However, a degree of uncertainty is associated with radiation therapy. Since the prostate gland and lymph nodes are not removed and checked by a pathologist, the doctor cannot tell the exact size of the tumor, and the cancer can come back many years after the treatment. At ten years of treatment, cure rates are about the same with both surgery and radiation therapy, but surgery may give patients a better chance of cure over the long term.

Hormone therapy is an option for men whose cancer has spread out of the prostate. The purpose of hormonal therapy is to get the male sex hormone, testosterone, out of the body, because testosterone helps the prostate cancer grow. Monthly shots or surgical removal of the testicles gets testosterone out of the body. Once this happens, the prostate cancer usually shrinks. While prostate cancer usually responds to one or two years of hormone therapy, after some time the tumors start to grow again. Once this happens, the goal of treatment is simply to control symptoms. No treatment is currently available to cure prostate cancer once hormonal therapy stops working.

Watchful waiting is an another option. Many prostate cancers are small and grow very slowly. Because men with this type of tumor have the same life expectancy as men who don't even have prostate cancer, it may not be necessary to treat these types of tumors. In watchful waiting, you get no treatment, but you visit your doctor very often for rectal exams and PSA blood tests. If there is no evidence that the cancer is growing, no treatment is given. Hormone therapy can always be started if the cancer begins to grow. The problem with this option is, it can be hard to tell if a small tumor is going to grow slowly or quickly. Therefore the choice of watchful waiting is something that must be very carefully considered and discussed extensively with your doctor.

In conclusion, prostate cancer is a serious disease and can dramatically shorten life and the quality of life. However, if caught early, it can be treated and even cured, resulting with a normal and healthy life. This underscores the importance of regular screening.

Robin L. Hardie, M.D.