PROSTATE CANCER Prostate cancer is a malignant tumor that consists of cells from the prostate gland.

The prostate gland is a small, walnut-sized structure that makes up part of a man's reproductive system. It wraps around the urethra, the tube that carries urine out of the body. The function of the prostate is to secrete a slightly acidic fluid, milky or white in appearance, that usually constitutes 2030% of the volume of the semen along with spermatozoa and seminal vesicle fluid.

Incidence and risk factors Prostate cancer is the most common cause of death from cancer in men over age 75. Prostate cancer is rarely found in men younger than 40. People who are at higher risk include: African-American men, who are also likely to develop cancer at every age Men who are older than 60 Men who have a father or brother with prostate cancer

Other people at risk include: Men who have been around agent orange Men who use too much alcohol Farmers Men who eat a diet high in fat, especially animal fat Tire plant workers Painters Men who have been around cadmium

Prostate cancer is less common in people who do not eat meat (vegetarians). A common problem in almost all men as they grow older is an enlarged prostate. This is called benign prostatic hyperplasia, or BPH. It does not raise your risk of prostate cancer. However, it can increase your PSA blood test results.

Symptoms

The symptoms listed below can occur with prostate cancer, usually at a late stage. These symptoms can also be caused by other prostate problems: Delayed or slowed start of urinary stream Dribbling or leakage of urine, most often after urinating Slow urinary stream Straining when urinating, or not being able to empty out all of the urine Blood in the urine or semen Bone pain or tenderness, most often in the lower back and pelvic bones

Screening and diagnostic tests Digital rectal examination The doctor palpates the prostate gland with his gloved index finger in the rectum to detect abnormalities of the gland. Thus, a lump, irregularity, or hardness felt on the surface of the gland is a finding that is suspicious for prostate cancer. Prostate specific antigen The PSA test is a simple, reproducible, and relatively accurate blood test. It is used to detect a protein that is released from the prostate gland into the blood. The PSA level is usually higher than 4ng/mL in people with prostate cancer than in people without the cancer. Transrectal Ultrasonography This test involves inserting a probe into the rectum that sends out ultrasound waves. The waves bounce off the prostate, and a computer uses the echoes to create a picture called a sonogram. Cystoscopy (cystourethroscopy or bladder scope) involves inserting a tube into the urethra through the opening at the end of the penis. It allows the doctor to visually examine the complete length of the urethra and the bladder for polyps, strictures, abnormal growths, and other problems. Magnetic Resonance Imaging may be used to examine the prostate and nearby lymph nodes to distinguish between benign and malignant areas.

Biopsy This is the only sure way to know whether a problem is cancer. During a biopsy, the doctor removes a small amount of prostate tissue, usually with a needle. A pathologist looks at the tissue under a microscope to check for cancer cells. The results are reported using what is called a Gleason grade and a Gleason score. The Gleason grade tells you how fast the cancer might spread. It grades tumors on a scale of 1 5. You may have different grades of cancer in one biopsy sample. The two main grades are added together. This gives you the Gleason score. The higher your Gleason score, the more likely the cancer is to have spread past the prostate: Scores 2 - 5: Low-grade prostate cancer Scores 6 - 7: Intermediate-grade cancer. (Most prostate cancers fall into this group.) Scores 8 - 10: High-grade cancer

TNM staging Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. TX: Primary tumor cannot be assessed T0: No evidence of primary tumor T1: Clinically inapparent tumor not palpable or visible by imaging T1a: Tumor incidental histologic finding in 5% or less of tissue resected T1b: Tumor incidental histologic finding in more than 5% of tissue resected T1c: Tumor identified by needle biopsy (e.g. because of elevated PSA) T2: Palpable tumor confined within prostate T2a: Tumor involves half of a lobe or less T2b: Tumor involves more than half of a lobe, but not both lobes T2c: Tumor involves both lobes T3: Tumor extends through the prostatic capsule T3a: Unilateral extracapsular extension

T3b: Bilateral extracapsular extension T3c: Tumor invades seminal vesicle(s) T4: Tumor is fixed or invades adjacent structures other than seminal vesicles T4a: Tumor invades external sphincter and/or bladder neck and/or rectum T4b: Tumor invades levator muscles and/or is fixed to pelvic wall* Nodes. The N in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the prostate in the pelvic region are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes. NX: Regional lymph nodes cannot be assessed N0: No regional lymph nodes metastasis N1: Metastasis in single lymph node <2 cm in greatest dimension N2: Metastasis in single lymph node >2cm but <5 cm in greatest dimension, or multiple lymph nodes, none >5 cm N3: Metastasis in lymph node >5 cm in greatest dimension Metastasis. The "M" in the TNM system indicates whether the prostate cancer has spread to other parts of the body, such as the lungs or the bones. MX: Distant metastasis cannot be evaluated. M0: The disease has not metastasized. M1: There is distant metastasis. M1a: The cancer has spread to nonregional, or distant, lymph node(s). M1b: The cancer has spread to the bones. M1c: The cancer has spread to another part of the body, with or without spread to the bone. Cancer stage grouping Stage I: Cancer is found in the prostate only, usually during another medical procedure. It cannot be felt during the DRE or seen on imaging tests. A stage I cancer is usually made up of cells that look more like normal cells and is likely to grow slowly.

Stage IIA and IIB: This stage describes a tumor that is too small to be felt or seen on imaging tests. Or, it describes a slightly larger tumor that can be felt during a DRE. The cancer has not spread outside of the prostate gland, but the cells are usually more abnormal and may tend to grow more quickly. It has not spread to lymph nodes or distant organs. Stage III: The cancer has spread beyond the outer layer of the prostate into nearby tissues. It may also have spread to the seminal vesicles, the glands in men that help make semen. Stage IV: This stage describes any tumor that has spread to other parts of the body, such as the bladder, rectum, bone, liver, lungs, or lymph nodes. Recurrent: Recurrent prostate cancer is cancer that comes back after treatment. It may come back in the prostate area again or in other parts of the body. If there is a recurrence, the cancer may need to be staged again (re-staging) using the system above. Stage I T T1a, T1b, or T1c T2a Any T1 or T2a T1a, T1b, or T1c T1a, T1b, or T1c T2a T2b T2b T2c Any T1 or T2 Any T1 or T2 T3a or T3b T4 Any T Any T N N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N1 Any N M M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1

IIA

IIB

III IV

Treatments The treatment options for organ-confined prostate cancer or locally advanced prostate cancer usually include: a. Surgery Prostate surgery or prostatectomy is the removal of the prostate gland and will help only those patients who have confined, localized disease. This prostate cancer treatment is an invasive procedure that can be performed by a single incision to the lower abdomen (retropubic) or perineum (perineal), or by a series of small incisions (laparoscopic).

The oldest type of surgery, the radical retropubic prostatectomy, uses pelvic lymph node dissection (PLND) before surgery to ensure that the disease has not metastasized out of the gland. Radical prostatectomy is the removal of the entire prostate gland and possibly the seminal vesicles and surrounding nerves and veins. The part of the urethra travelling through the glands transition zone is also removed. The two ends of remaining urethra are reattached in a connection called the anastomosis. Excising part of the urethra may lead to a penile shrinkage or shortening. b. Brachytherapy Brachytherapy is a radiation therapy capable of delivering high and concentrated doses of radiation to the prostate gland. There are two types of brachytherapy that are used in the treatment of prostate cancer: Permanent low dose radiation (LDR) brachytherapy uses iodine-125 and palladium-103 stored in titanium cases usually referred to as brachytherapy seeds. The seeds are permanently left inside the prostate gland. Over the course of their radioactive lives, the seeds will continuously emit low levels of radiation. Temporary high dose radiation (HDR) brachytherapy uses a single radioactive seed made of iridium-194 which is sometimes referred to as an iridium wire. Soft flexible plastic catheters are inserted through the perineum and into the prostate gland. HDR brachytherapy entails an overnight stay in the hospital during which a patient undergoes two or three treatments with the wire through each catheter. c. Hormonal therapy (androgen deprivation or androgen ablation) Prostate cancer hormone therapy is the systemic ablation of the bodys testosterone. The male sex hormone, testosterone, will fuel the growth of any prostatic cell: the chemical cannot discriminate between the receptors of healthy tissue and cancerous tissue. Prostate cancer hormone therapy removes the chemical that feeds cells and for a period of time, can stop or slow the growth and spread of the tumor. There are four basic methods androgen deprivation: castration, estrogen, anti androgens, and combine androgen blockade. Today, treatment is administered as neoadjuvant, adjuvant, and salvage therapy. Neoadjuvant is used before the primary treatment to shrink the prostate gland to an acceptable volume. Adjuvant is used while patients are undergoing treatments. Salvage is used when a primary treatment has failed.

d. Cryotherapy (cryosurgery or cryoablation) Prostate cryotherapy is a minimally invasive surgery capable of using controlled freeze and thaw cycles to destroy the disease. Because cryotherapy is relatively new, that is, lacking numerous long-term survival rate studies, cryotherapy is not used as often as radiation therapy for primary treatment. Cryotherapy, however, is effective in treating cases of prostate cancer that are radioresistant and recur as a result. Some doctors believe that the use of freezing temperatures rather than stronger doses of radiation therapy is more effective for radioresistant prostate cancer. Prostate cryotherapy works because as cells freeze, ice crystals form inside and around them. The freezing and thawing processes destroy cells through dehydration, drastic changes in the pH levels, or prevention of the flow of red blood cells. Subjecting the prostate gland to freezing temperatures, specifically negative 40 degrees Celsius, also activates an anti-tumor response in the body. An anti-tumor response begins with the production of anti-bodies that work to eradicate the tumor. e. Watchful waiting Watchful waiting is the decision to delay treatment in favor of careful monitoring for the progression of prostate cancer. It may also be referred to as expectant management, conservative management, observation, or active surveillance. The theory behind watchful waiting treatment is that most prostate cancers, specifically prostate adenocarcinomas, usually grow very slowly. Patients who have low Gleason scores, other medical complications, or low grade tumors may wish to postpone treatment due to the side effects. The standard that most doctors use when recommending watchful waiting is a ten years life expectancy. If a patient can reasonably expect to benefit from a more aggressive treatment for a period of ten years or more, doctors may recommend pursuing other treatments now. Patients who are older or who wish to avoid the side effects of incontinence and impotence that usually come with other treatments may opt for watchful waiting. Patients who choose to undergo watchful waiting will be able to avoid the side effects and prolong their current activities and physical state. Patients may also be able to make lifestyle changes in their exercise and diet, which may help slow the progression of prostate cancer even more. Positive changes in diet and exercise will also benefit the patients overall physical and mental well being. Some doctors say that patients may not benefit from watchful waiting if thought of postponing treatment causes high levels of anxiety and distress that interfere with daily life.

A cure for metastatic prostate cancer is, unfortunately, unattainable at the present time. The treatments for metastatic prostate cancer include: a. Hormonal Therapy b. Chemotherapy For prostate cancer, chemo drugs are typically used one at a time. Some of the chemo drugs used to treat prostate cancer include: Docetaxel (Taxotere) Cabazitaxel (Jevtana) Mitoxantrone (Novantrone) Estramustine (Emcyt) Doxorubicin (Adriamycin) Etoposide (VP-16) Vinblastine (Velban) Paclitaxel (Taxol) Carboplatin (Paraplatin) Vinorelbine (Navelbine)

In most cases, the first chemo drug given is docetaxel, combined with the steroid drug prednisone. If this drug does not work (or stops working), a newer drug called cabazitaxel is often the next chemo drug tried (although there may be other treatment options as well). Both of these drugs have been shown to help men live several months longer, on average, than older chemotherapy drugs. They may slow the cancer's growth and also reduce symptoms, resulting in a better quality of life. Still, chemotherapy for prostate cancer is very unlikely to result in a cure.