Prostate Cancer

The prostate is a small gland that sits below the bladder. As a result, when urine exits the bladder, it first flows through the prostate and then out the penile urethra. A “normal” sized prostate gland is about the size of a walnut. The prostate gland is responsible for producing fluid in the semen when a man ejaculates.

Like many organs in the body, the cells in the prostate may grow with time. Most commonly this occurs in a non-cancerous way and is a benign enlargement and can be likened to getting gray hair, a normal process of aging but may produce urinary symptoms. However, sometimes the prostate cells grow abnormally and form a cancer within the prostate. In most cases, prostate cancer is a slow growing disease.

Prostate cancer is the most common internal tumor in U.S. males and 1 out of every 6 men will be diagnosed with prostate cancer in their lifetime. In addition, it is the second leading cause of cancer death in men in the U.S. but only a small percentage of men (3%) will actually die from their disease. That means that most prostate cancers do not cause death.

Symptoms

Most patients do not develop symptoms at all until later stages of the disease. This is precisely why it is important to speak with your physician about your risk factors and appropriate screening.

Some of the symptoms may include:

  • Weak urine stream
  • Frequent urination during daytime or night
  • Painful urination or ejaculation
  • Blood in the urine or semen
  • Pain in the back, hips, or legs.

Causes

We don’t yet fully understand why prostate cancer occurs and we are still trying to pinpoint all of the risk factors.

Risk factors for prostate cancer:

  • Higher age (especially age >65)
  • African descent
  • Family history- The risk of prostate cancer increases over two-fold when a first degree relative (brother, father) has prostate cancer.
  • Diet- Some evidence suggests a high fat diet may increase risk of prostate cancer

Prevention of prostate cancer:

  • Selenium, Vitamin E, Vitamin C, Soy, lycopene has all been studied and do not show definitive ability to prevent prostate cancer.
  • Smoking- It is unclear if smoking causes prostate cancer however there is evidence that suggests that smoking cessation may reduce the risk of developing a more aggressive form of cancer if prostate cancer does develop.

Diagnosis

Your doctor may perform a blood test called a PSA to screen for prostate cancer. There is currently not a specific level of PSA that indicates cancer but in general a PSA level more than 4ng/mL is considered elevated. In addition, you physician will perform a “prostate check”, a rectal exam to assess abnormal anatomy of the prostate.

If deemed necessary, you will have a needle biopsy of the prostate. This is a short 15-20-minute procedure performed in the office that is tolerated very well with local anesthesia for comfort. Once your biopsy results return (about a week or two) you can discuss the next step with your urologist.

Treatment

If you are diagnosed with prostate cancer you physician will provide a comprehensive overview of various options. Because prostate cancer can present with different stages and grades not all therapies/options may be right for you.

Active Surveillance: Men may be diagnosed with a very early stage and very low grade of prostate cancer. In specific circumstances, it may be prudent to observe the tumor with a repeat biopsy to see if the cancer has become more aggressive. This may be a good option for some patients as treatment for prostate cancer can significantly impact quality of life. You may be a candidate for surveillance if:

  • There is very low risk disease and life expectancy < 20 years
  • There is low risk or intermediate risk disease and life expectancy <10 years
  • PSA level <10 ng/mL

Risks of active surveillance include progression of disease and men may have up to a 25% chance of death over a 10-year period depending on their initial biopsy grade.

Benefits include avoidance of significant side effects of more aggressive therapy. Active surveillance requires diligence and willingness to submit to sometimes quarterly blood tests and examinations as well as future biopsies.

Prostatectomy (Da Vinci Robotic Surgery): This is a minimally invasive surgical procedure to remove the prostate. The surgeon maintains complete control throughout the entire case and the robot allows for pin point movements and precise visualization. There is typically less blood loss and shorter recovery time/hospital stay.

Our urologic oncologists will perform the surgery to provide you with the best cancer care while minimizing common side effects of the surgery. Specifically, they can carefully spare the nerves that are responsible for erections allowing you the best chance possible to restore your sexual health.

Risks of prostatectomy:

  • Decrease in penile length (average about 1/4 inch)
  • Erectile Dysfunction: This depends largely on your pre-surgical sexual function; age (less than 60 provides better outcomes); and sparing the nerves during the surgery. Erectile function tends to improve with time from surgery.
  • Urinary leakage: This may occur but usually improves within the first year after surgery. Only 5% of men will have bothersome urine leakage one year after surgery.
  • Infertility
  • Bleeding, Infection, Damage to surrounding organs

Radiation Therapy: This technique uses high energy x-rays delivered to the prostate to destroy the cancer cells. It requires several short sessions of therapy at a radiation center but does not require overnight hospital stays. The x rays can be delivered externally (external beam radiation therapy) or internally with radioactive seeds placed into the prostate (brachytherapy).

Risks of Radiation:

  • Erectile Dysfunction: Erections are initially preserved with radiation therapy but worsen over several years after therapy.
  • Bladder or Rectal Irritation
  • Scarring of the urethra
  • Difficulty passing urine
  • Urinary leakage
  • Infertility

Advanced Stage Disease Therapy: Prostate cancer may progress despite surgery or radiation. This can be indicated by an increase in the PSA value and may indicate that the disease has returned. If that is the case, your physician may suggest starting additional systemic therapy: hormonal therapy, chemotherapy or an array of therapies for cancer that is resistant to hormonal therapy. These therapies can improve symptoms and help maintain quality of life in advanced disease.

  • Hormonal Therapy: Prostate cancer grows in response to the male hormone testosterone and therefore can be managed by reducing levels of testosterone in the body. Most testosterone is produced by the testicles however the adrenal glands (above the kidneys) also produce testosterone. Hormone therapy is not curative but can slow the growth of the disease and may be used in some combination with another therapy or on its own depending your cancer stage.
  • Chemotherapy
  • Sipuleucel-T
  • Abiraterone
  • Enzalutamide