TIMELY TOPICS:

Understanding the Prostate Gland

The prostate is part of a man’s reproductive system. It is located just beneath the bladder, and in front of the rectum. It encircles, like a donut, a section of the urethra. The urethra is the tube that carries urine from the bladder out through the penis. During ejaculation, semen is secreted by the prostate through small pores in the urethral walls. A healthy prostate is made up of three lobes encased in an outer covering or capsule. It is about the size of a walnut. The prostate gland is flanked on either side by the seminal vesicles, a pair of pouch-like glands that contribute secretions to the semen. Next to the seminal vesicles run the two vas deferens tubes that carry sperm from the testicles. The testicles, in addition to manufacturing sperm, produce testosterone. If the prostate grows too large, it obstructs the urethra. The symptoms are often urinary problems such as slowing or stopping the flow of urine from the penis when emptying the bladder.

What is Prostate Cancer?

Prostate Cancer, like other types of cancer, is the occurrence of cells that do not grow normally. The cells divide and create new cells that the body does not need, forming a mass of tissue called a tumor. These abnormal cells, if untreated, sometimes spread to other parts of the body and multiply (metastasize), requiring additional medical attention separate from the primary treatment.

What causes Prostate Cancer?

As with many other cancers, medical experts do not know what causes Prostate Cancer. This is being widely studied in research centers. What is known, however, is that certain factors increase the risk of cancer, including family history of the disease, aging, and smoking. There are also race and ethnic factors. Prostate Cancer is more common in African-American men than in Caucasians. It is less common in Hispanic, Asian, Pacific Islander and Native American men than in Caucasians.

How common is Prostate Cancer?

For the general population, a man in his lifetime has about a:

• 16 % chance (1 in 6) of being diagnosed with Prostate Cancer.
• 3 % chance (1 in 33) of dying from Prostate Cancer.

Risk of Being Diagnosed with Prostate Cancer by Age

Age 45 -----------------------------------------------1 in 2,500

Age 50-----------------------------------------------1 in 476

Age 55-----------------------------------------------1 in 120

Age 60-----------------------------------------------1 in 43

Age 65-----------------------------------------------1 in 21

Age 70-----------------------------------------------1 in 13

Age 75-----------------------------------------------1 in 9

Ever-------------------------------------------------1 in 6

 Is Prostate Cancer Serious?

Yes, some Prostate Cancers become a serious threat to a man's health by growing quickly, spreading beyond the prostate gland to other parts of the body, and causing death. Yet other Prostate Cancers grow slowly and never become a serious threat to health or affect how long a man lives. Doctors can’t always be sure which type of cancer is present in a given case until a biopsy and pathology interpretation is done.

Among the leading causes of cancer deaths in men, Prostate Cancer is second only to lung cancer nationally, but is the leader in Utah due to an unusually low death rate from lung cancer. (Possibly linked to less smoking.)*

Cancer diagnosed early, while confined to the capsule of the prostate gland, has the best prognosis for curing the disease.

* http://statecancerprofiles.cancer.gov

 What are the symptoms of Prostate Cancer?

Many men with Prostate Cancer have no symptoms. If symptoms occur, they can include:

• Blood in the urine
• The need to urinate frequently, especially at night
• Weak or interrupted urine flow
• Pain or burning feeling while urinating
• The inability to urinate
• Constant pain in the lower back, pelvis or upper thighs.

If you have any of these symptoms, see your doctor as soon as possible. Keep in mind that these symptoms may also be caused by other prostate problems, not just from cancer, such as an infection or an enlarged prostate.

Prostate Cancer Screening

What does “screening” mean?

Screening means looking for signs of disease in people who have no symptoms. The purpose of screening for Prostate Cancer is to determine early-stage disease when treatment may be more effective. The main screening tools for Prostate Cancer are digital rectal examination (DRE) and the prostate specific antigen (PSA) test. The DRE and PSA test cannot tell if you have cancer, they only suggest the need for further tests. Both the PSA and the DRE should be offered annually, beginning at age 50, to men who have at least a 10 year life expectancy. Men at higher risk (African-American men or those with family history of the disease) should begin testing at age 45.

The DRE or digital (finger) rectal examination is a quick examination for checking the health of the prostate.

PSA is a substance produced by cells of the prostate gland released into the blood. The PSA test measures the PSA level in the blood. A small amount of blood is drawn from the arm. The doctor uses this test to determine the level of PSA, any increase in the level from past examinations, and the speed of the change over time, are evaluated.

Some prostate glands produce more PSA than others. The PSA level can also be affected by:

• Certain medical procedures
• An enlarged prostate
• A prostate infection.

How accurate are the screening tests?

No test is right all the time and that is true of the PSA test and the DRE. The PSA may detect that small cancers are present, but the DRE may indicate cancers in men with normal PSA levels. That is why both the PSA and the DRE are usually advised.

If 100 men over age 50 take the PSA test:

• 85 will have a normal PSA (though a small number of these men will have a cancer that was missed by the elevated or rising PSA test).
• 15 will have a higher than normal PSA and require further testing.

After further testing, results may show:

• 12 do not have Prostate Cancer
• 3 have Prostate Cancer.

What do the experts say about screening for Prostate Cancer?

Medical experts agree that every man needs balanced information on the pros and cons of Prostate Cancer screening to help him make an informed decision. Balanced information is important because medical experts disagree whether men should be screened regularly for Prostate Cancer.

Pro: Medical experts who encourage regular screening believe current scientific evidence shows that finding and treating Prostate Cancer early, when treatment may be more effective, might save lives. They recommend that all men who have a life expectancy of at least 10 years should be screened after the age of 50. For those with a family history of Prostate Cancer, the process should be considered beginning at 45 years of age.

Con: Medical experts who do not recommend regular screening want more convincing evidence that finding early-stage cancer, and treating it, saves lives. They believe it is unclear if the potential benefits of screening outweigh the known side effects of treatment.

The decision is up to you and your doctor. Know your risk factors for Prostate Cancer and the pros and cons of screening.

In addition, there are numerous web sites with information that may be helpful. Some of these are:

www.cancer.gov
This is a government web site. The information is accurate and reliable. It is easy to navigate and the data is comprehensive and readable.

www.healthfinder.gov
This is another government web site. The information is presented both by text and visual explanation. This is a user friendly site. The information is consistent and based on fact.

www.pcacoalition.org
This is a not for profit foundation web site funded from individual contributions led by survivors of Prostate Cancer, including many prominent men. It is slanted toward the importance of prostate screening using logical methods, and gives the perception of the survivors.

www.medscape.com
This is a commercially funded web site. The material is factual and updated promptly. The web site is a little more difficult to navigate, using a search engine approach for specific subject material.

 What if the results of your screening tests indicate that you might need further testing?

Your doctor will most likely refer you to an urologist (a doctor who specializes in prostate-related problems). Additional testing will be preformed to determine if the problem is cancer or something else.

• Transrectal ultrasound: A procedure in which an endoscope probe (a thin, lighted tube) is inserted into the rectum to check the prostate. The endoscope is used to bounce high-energy sound waves (ultrasound) off internal organs or tissues and make echoes. The echoes form a picture of the body tissue called a sonogram. Transrectal ultrasound may be used during a biopsy procedure.
  
• Biopsy: The removal of cells or tissue so they can be viewed under a microscope to check for signs of cancer. There are two types of needle biopsy procedures used to diagnose Prostate Cancer:
  
  1. Transrectal biopsy: The removal of tissue from the prostate by inserting a thin needle through the rectal wall into the prostate. The procedure is usually done using a transrectal ultrasound to help guide the needle. Typically this is done in the urologist’s office; patient is under local anesthesia.
     
  2. Transperineal biopsy: The removal of tissue from the prostate by inserting a thin needle through the skin between the scrotum and rectum and into the prostate; patient is under local anesthesia.

• Pathology Diagnosis: A pathologist will examine the sample to check for cancer cells and determine the Gleason score. The Gleason score is based on the pathological grading of the tumor activity and how likely it is that the tumor will spread. The range of the Gleason score is 2-10. A lower score suggests more “normal like” prostate cells while a high Gleason score suggests cells that are abnormal (anaplastic) and likely to spread (metastasize).

Can these tests provide information about the prognosis if cancer is present?

The prognosis (chance of recovery) and treatment options depend on the following:

• Stage of the cancer (see next section)
• Patient’s age and health
• Whether the cancer has just been diagnosed or has recurred (come back)
• Prognosis may also depend on the Gleason score and level of PSA.

Stages of Prostate Cancer

 After Prostate Cancer has been diagnosed, tests are done to find out if the cancer cells are contained within the prostate or if they have spread to other parts of the body. The process is called staging. The following tests and procedures may be used in the staging process:

• Radionuclide bone scan: A radiological procedure to check if there are rapidly dividing cells, such as cancer cells, in the bones. A very small amount of radioactive material is injected in a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner.
  
• CT (CAT) scan: A procedure that makes a series of detailed pictures of the areas inside the body. The pictures are made by a computer linked to an x-ray machine. This procedure is also called computed tomography, computerized tomography or computerized axial tomography.
  
• MRI (magnetic resonance imaging), Pelvic lymphadenectomy and Seminal vesicle biopsy: May be considered selectively for advanced cases of Prostate Cancer. This is done at the discretion of the urologist.

What are the stages of Prostate Cancer?

 Stage I

In stage I, cancer is found in the prostate only. It cannot be felt during a DRE and is not visible by imaging. It is usually found accidentally during surgery for other reasons or an incidental finding from elevated PSA tests and screening biopsies.

Stage II

In stage II, cancer is more advanced than in stage I, but has not spread outside the prostate.

Stage III

In stage III, cancer has spread beyond the outer layer of the prostate to the nearby tissue. Cancer may be found in the seminal vesicles.

Stage IV

In stage IV, cancer has metastasized (spread) to lymph nodes near or far from the prostate to other parts of the body, such as the bladder, rectum, bones, liver or lungs. Metastatic Prostate Cancer often spreads to the bones.

Recurrent Prostate Cancer

Recurrent Prostate Cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the prostate or in other parts of the body.

The Treatment Options

What are the options for patients with Prostate Cancer?

There are different types of treatments available for patients with Prostate Cancer. Treatment considerations should be based on the patient’s age, pathological results, Gleason score, stage of the disease, localization of the cancer within the capsule of the prostate gland as is defined by the imaging studies above. In some cases, it is complicated and requires counseling and a second opinion for the decision making process.

The outcomes of treatment vary for multifactoiral reasons including: selection of treatment options, i.e, age, risk of recurrence (high, intermediate or low); life expectancy; and inability of the mode of treatment to remove or destroy the stem cells causing the cancer. Life expectancy, independent of the cancer, is also an important issue for many men with Prostate Cancer. For these reasons, careful decision making is essential. This article should not be taken as the final word in making a treatment choice, but rather, just one resource, in addition to your treating physician’s advice, you may use in reaching a final decision. Reviewing a variety of resources, as well as speaking with survivors, is encouraged in understanding and deciding on treatment options.

What are the four types of standard treatment used?

Watchful Waiting

Watchful waiting is closely monitoring a patient’s condition without giving any treatment until symptoms appear to change. This is usually indicated in men over 70 years of age with other medical problems and very early-stage disease. These patients are usually and predictably more likely to die of other diseases than a slowly growing Prostate Cancer.

 Radical Prostatectomy Surgery

Patients in good health, who are younger than 70 years of age, may be offered surgical removal for the treatment of Prostate Cancer. If surgery is considered, a number of surgical approaches are now available. For any one of these procedures, the tumor should be classified as Stage I or Stage II, have a low Gleason score, and no evidence of spreading outside of the prostate capsule. Side effects of surgery should be openly discussed prior to surgery including the nerve-saving procedure, risk of impotence, incontinence of urine or stool. Each surgical procedure will weigh these important issues. Prognosis and expectation for cure should also be discussed.

There are four types of approaches to radical prostatectomy. Each has distinct advantages and disadvantages. If successful, the earlier the detection and treatment increases the chances for curing the disease. For this reason, screening for early Prostate Cancer makes sense. If careful evaluation is done, this has a highly favorable prognosis for curing the cancer. If the cancer is clinically localized, the age of the patient is less than 70, and there are no contradictory health reasons, radical prostatectomy may be considered.

● Retropubic Prostatectomy: An open surgical procedure to remove the prostate through an incision (cut) in the abdominal wall. Removal of nearby lymph nodes is usually done at the same time, for better prognosis. Even though this procedure now uses endoscopy, this approach is losing favor among urologists due to longer post-operative recovery and hospitalization time.

● Perineal Prostatectomy: A surgical procedure to remove the prostate through an incision made in the perineum (area between the scrotum and the rectum).

Removal of nearby lymph nodes may be done at the same time. In this procedure a patient may expect less postoperative pain, have the same encouraging prognosis for success, and fewer days of post-operative recovery and hospitalization.

● Laparoscopy Prostatectomy: A surgical procedure to remove the prostate through small incisions where endoscopes are introduced to perform the prostatectomy and sampling of the nearby lymph nodes. Using this technique, the results for a positive prognosis are the same as for the Retropubic and Perineal procedures. However, this has the advantage of less post-operative pain and a shorter hospital stay.

● Robotic Surgery: The da Vinci® Surgical System is powered by state-of-the- art robotic technology. The system allows the surgeon’s hand movements to be scaled, filtered and translated into precise movements of micro-instruments within the abdominal cavity (operative site). The magnified three-dimensional view the surgeon experiences enables him or her to perform precise surgery in complex procedures through small surgical incisions. The prostatectomy and lymph node sampling can be accomplished similarly to the other approaches, including nerve-sparing technique. The disadvantages are that this is a new surgery and technology, it is very costly, it requires large operating suites to accommodate the instrumentation, and the need for an extensive learning curve in teaching the technique. It is only performed in Centers of Excellence but the data is encouraging. Early data suggests in these centers, the complication rates of impotence and incontinence is lessened. Furthermore, it may be done with short hospitalizations due to less post-operative pain. (See tables below)

Options for Surgical Treatments

*For information about the benefits offered by PEHP, for different surgical procedures, including robotic surgery, call 1-800-753-7490 . Follow the prompts for Janet Brown (press 2, then 2 again, and then 3). Or, for medical information, Linda Yeates (follow the prompts), press 2, then 1, and then 3.

 Transurethral Resection of the Prostate (TURP)

This is a surgical procedure to remove tissue from the prostate using a cystoscope (a thin lighted tube) inserted through the urethra. This procedure is sometimes done to relieve symptoms caused by a tumor before other cancer treatment is given. It is also used in Benign Prostatic Hypertrophy (a non-cancerous condition) to relieve symptoms of obstruction and in elderly men, with advanced Prostate Cancer, when other options of treatment are not advisable.

 What are the side effects of any prostate surgery?

Impotence (inability to have an erection) and leakage of urine (incontinence) from the bladder, or stool from the rectum, may occur in men treated with surgery. In some cases, doctors can use a technique known as nerve-sparing surgery. This type of procedure may save the nerves that control erection. However, men with large tumors or tumors that are very close to the nerves may not be able to have this type of surgery.

Side Effects
Vattikuti Institute Prostatectomy (VIP)
Compared to Open Prostatectomy**
Henry Ford Hospital, Detroit, Michigan

** Information Hot Line 1-888-881-1117 or http://www.davinciprostatectomy.com/about_davinci.html

Radiation Therapy

Radiation Therapy is a cancer treatment that provides high energy x-rays or other types of radiation to kill cancer cells. There are two types:

• External radiation therapy uses a machine outside the body to send radiation toward the cancer.
• Internal radiation therapy uses a radioactive substance sealed in needles, sees, wires or catheters that are placed directly into or near the cancer. The type of radiation therapy depends on the type (Gleason Score) and stage (I-IV) of the cancer being treated.

 What are the side effects of radiation therapy?

Impotence and urinary problems may occur in men treated with radiation therapy. Some immediate discomfort or burning may be experienced, but this has been reduced as the technology has improved. The outcome of treatment is changing rapidly due to technology but studies to date indicate in the high risk and intermediate risk groups, recurrence of Carcinoma may occur after five years following radiation treatment.

Once radiation has been given, there are limited surgical options. If cancer recurs, after radiation, and surgery is performed, there are increased side effects. The radiation changes in the surrounding tissue causes scarring and increased risk of fistulae, incontinence and impotency using post-radiation surgery. There are, however, some recent studies emerging to analyze post radiation surgery outcome.

Hormone Therapy

Hormone therapy is cancer treatment that acts to either remove hormones or block hormones whose action causes Prostate Cancer to grow. This is primarily testosterone hormones. Hormones are substances that are produced by glands in the body and circulated in the bloodstream. The presences of these hormones cause some cancers to grow. Tests may be done that show if the cancer cells have places (or receptors) where hormones can attach. Drugs, surgery, or radiation therapy are used to reduce production of hormones or block them from working. Hormone therapy used in the treatment of Prostate Cancer may include:

• Luteinizing hormone-releasing hormone agonists
  • Prevent the testicles from producing testosterone. Examples are leuprolid, gosereline and buserelin.
• Antiandrogens
  • Block the action of androgens (hormones that promote male sex characteristics). Examples are flutamide and bicalutamide.
• Drugs that can prevent the adrenal glands from making androgens include ketoconazole and aminoglutethimide.
• Orchiectomy is a surgical procedure to remove one or both testicles, the main gland producing testosterone.

What are the side effects of hormone therapy?

Hot flashes, impaired sexual function, and loss of desire for sex may occur in men treated with hormone therapy.

Other types of treatment being tested in clinical trials
(these may not be covered by health insurance)

 Cryosurgery

Cryosurgery is the treatment that uses an instrument for destroying Prostate Cancer cells.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to attack the cancer cells,

either by killing cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the blood stream and can reach cancer cells throughout the body (systemic chemotherapy).

When chemotherapy is injected directly into the spinal column, an organ or a body cavity such as the abdomen (for metastatic cancer), the chemotherapy mainly affects cancer cells in those areas. The way chemotherapy is given depends on the type and stage of the cancer being treated.

 Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Laboratory produced substances are used to boost, direct, or restore the body’s natural defenses against cancer. This is also call Immunotherapy.

What are Clinical Trials?

Clinical trials are methods currently under investigation for use in humans of these modalities. Information about ongoing clinical trials is available from the National Cancer Institute web site: www.NCICancer.gov.

Where can I find more information regarding treatment of Prostate Cancer?

 Radical Prostatectomy www.medscape.com
This web site uses a more complicated search engine but has excellent articles for consideration.

 Prostate Cancer Research Institute www.prostate-cancer.org
This web site is quite user friendly and the information base is extensive and reliable.

National Cancer Institute www.cancer.gov
This is the most thorough web site for cancer information and is quite easy to navigate. The sources of information are factual.

Robotic Surgery
Lanfranco, et al
Ann Surg 239(1); 14-21, 2004
Lippincott Williams & Wilkins
This is a fair appraisal of Robotic Surgery comparing it to other modalities for surgical treatment of Prostate Cancer.

da Vinci® Prostatectomy http://www.davinciprostatectomy.com/about_davinci.html
This is a very user friendly web site that reflects the experience of the Henry Ford Hospital in Detroit, Michigan, with the da Vinci® System.

How do I make an informed decision?

Take ownership of your health, seek logical and objective information from research, discussion with your urologist and utilize not for profit prostate educational agencies motivated to help control and cure Prostate Cancer.