Prostate Cancer

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What is Prostate Cancer?

Cancer begins when normal cells in the prostate change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body).

About the prostate gland

The prostate is a walnut-sized gland located behind the base of a man’s penis, in front of the rectum, and below the bladder. It surrounds the urethra, the tube-like channel that carries urine and semen through the penis. The prostate's main function is to make seminal fluid, the liquid in semen that protects, supports, and helps transport sperm.

Types of prostate cancer

Prostate cancer is a malignant tumor that begins in the prostate gland. Some prostate cancers grow very slowly and may not cause symptoms or problems for years. Many times, when a man develops prostate cancer much later in life, it is unlikely to cause symptoms or shorten the man’s life, and aggressive treatment may not be needed. For this reason, early detection for prostate cancer with prostate specific antigen (PSA) testing in men who don’t have symptoms of the disease is controversial. PSA is found in higher-than-normal levels in men with various prostate conditions, including benign prostatic hyperplasia (BPH, an enlarged prostate), inflammation or infection of the prostate, and prostate cancer.

Prostate cancer is somewhat unusual, compared with other types of cancer, because many tumors do not spread from the prostate. And often, even metastatic prostate cancer can be successfully treated, allowing men with prostate cancer to live with good health for several years. However, if the cancer does metastasize (spread) to other parts of the body and is not well controlled with treatment, it can cause pain, fatigue, and other symptoms.

More than 95% of prostate cancers are a type called adenocarcinomas. A rare type of prostate cancer known as neuroendocrine cancer or small cell anaplastic cancer tends to spread earlier but usually does not make PSA.

Risk Factors and Prevention : A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

Because the exact cause of prostate cancer is still unknown, it is also unknown how to prevent prostate cancer. The following factors can raise a man’s risk of developing prostate cancer:

Age. The risk of prostate cancer increases with age, especially after age 50. More than 80% of prostate cancers are diagnosed in men who are 65 or older.

Race/ethnicity. Black men have a higher risk of prostate cancer than white men. They are more likely to develop prostate cancer at an earlier age and to have aggressive tumors that grow quickly. The exact reasons for these differences are not known and may involve socioeconomic and other factors. Hispanic men have a lower risk of developing prostate cancer and dying from the disease than white men. Prostate cancer occurs most often in North America and northern Europe. It also appears that prostate cancer is increasing among Asian people living in urbanized environments, such as Hong Kong, Singapore, and North American and European cities, particularly among those who have a more western lifestyle.

Family history. A man who has a father or brother with prostate cancer has a higher risk of developing the disease than a man who does not. Researchers have discovered specific genes that may possibly be associated with prostate cancer, although these have not yet been shown to cause prostate cancer or to be specific to this disease. 

Diet. No study has proven that diet and nutrition can directly cause or prevent the development of prostate cancer, but many studies that look at links between certain behaviors and cancer suggest there may be a connection. There is not enough information yet to make clear recommendations about the role diet plays in prostate cancer, and dietary changes may need to be made many years earlier in a man’s life to reduce the risk of developing prostate cancer. The following dietary information may be helpful:

A diet high in fat, especially animal fat, may increase prostate cancer risk. In fact, many doctors believe that a low-fat diet may help to reduce the risk of prostate cancer in addition to having other health benefits.

A diet high in vegetables, fruits, and legumes (beans and peas) may decrease risk of prostate cancer. It is unclear which nutrients are directly responsible. Lycopene, found in tomatoes and other vegetables, may slow or prevent cancer growth. In any case, such a diet does not cause harm and can lower a person’s blood pressure and risk of heart disease.

Selenium, an element that people get in very small amounts from food and water, and vitamin E have been tested to find out if either or both of these nutrients can lower the risk of prostate cancer. However, in a clinical trial (a research study involving people) of more than 35,000 men called the Selenium and Vitamin E Cancer Prevention , researchers found that selenium and vitamin E supplements (pills), taken alone or together for an average of five years, did not prevent prostate cancer and may even cause harm in some men. Because of this risk, the National Cancer Institute has stopped the SELECT study. Men should talk with their doctor before taking selenium and vitamin E supplements to prevent prostate cancer.

It’s important to remember that specific changes to diet may not stop or slow the development of prostate cancer, and it’s possible such changes would need to begin early in life to have an effect.

Hormones and chemoprevention. High levels of testosterone (a male sex hormone) may speed up or cause the development of prostate cancer. For instance, it is very uncommon for a man whose body no longer makes testosterone to develop prostate cancer. And, stopping the body’s production of testosterone, called androgen deprivation therapy, often shrinks advanced prostate cancer.

A class of drugs called 5-alpha-reductase inhibitors (5-ARIs) that includes finasteride (Proscar) and dutasteride (Avodart) may lower a man’s risk of prostate cancer. In clinical trials, both drugs lowered the risk of prostate cancer. Research has suggested that some men who received these drugs have a higher risk of developing a more aggressive type of prostate cancer than the men who did not receive the drugs, possibly because they caused the prostate gland to shrink, allowing the doctors to find these more aggressive cancers. However, the data is still being reviewed, the subject is very controversial, and these drugs have not been approved yet for prostate cancer prevention by the U.S. Food and Drug Administration (FDA).

Prostate cancer early detection : Screening for prostate cancer is done to find evidence of cancer in otherwise healthy men. Two tests are commonly used to screen for prostate cancer: the PSA blood test and digital rectal examination (DRE, a test in which the doctor inserts a gloved lubricated finger into a man’s rectum and feels the surface of the prostate for any irregularities).

There is controversy about using the PSA test to look for prostate cancer in men with no symptoms of the disease. On one hand, the PSA test is useful for detecting early prostate cancer, which helps men get the treatment they need before the cancer spreads. On the other hand, PSA screening find conditions that are not cancer and slow-growing prostate cancers that would never threaten a man’s life. Because of this, screening for prostate cancer may mean that some men have surgery and other treatments that may not ever be needed. For this reason, many men and their doctors may consider active surveillance of the cancer rather than immediate treatment.

Because biopsies and treatment have significant side effects, such as impotence (inability to get and maintain an erection) and incontinence (inability to control urine flow) treating it unnecessarily may seriously affect a man’s quality of life. However, it is not easy to predict which tumors will grow and spread quickly and which will grow slowly.

According to a provisional clinical opinion on PSA screening for men with no symptoms of prostate cancer, ASCO recommends that men expected to live 10 years or less should not have PSA screening and men expected to live longer than 10 years should talk with their doctors to find out if the test is appropriate for them. Every man should discuss his situation and risk of prostate cancer and work with his doctor to make a decision. To help with this discussion,

Symptoms and Signs

Often, prostate cancer is found through a PSA test or DRE  in men who have not had any symptoms or signs. If prostate cancer is suspected based on a PSA test or DRE, more monitoring and testing is needed to diagnose prostate cancer.  When prostate cancer does cause symptoms or signs, they may include the following:  

Frequent urination

Weak or interrupted urine flow or need to strain to empty the bladder

Blood in the urine

The urge to urinate frequently at night

Blood in the seminal fluid

Pain or burning during urination (much less common)

Discomfort when sitting, caused by an enlarged prostate

None of these symptoms is specific to prostate cancer. Men who have a noncancerous condition called BPH or an enlarged prostate also have these symptoms. Urinary symptoms also can be caused by an infection or other conditions. In addition, sometimes men with prostate cancer do not have any of these symptoms.

If cancer has spread outside of the prostate gland, a man may experience:

Pain in the back, hips, thighs, shoulders, or other bones

Unexplained weight loss

Fatigue

If you are concerned about a symptom or sign on this list, please talk with your doctor. Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Diagnosis : Doctors use many tests to diagnose cancer and find out if it has metastasized. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis, but this situation is rare for prostate cancer. For example, a biopsy may not be done when a patient has another medical problem that makes it difficult to do a biopsy, or when a person has a very high PSA level and a bone scan that indicates cancer. Imaging tests may be used to find out whether the cancer has spread. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Severity of symptoms

Previous test results

In addition to a physical examination, the following tests may be used to diagnose prostate cancer:

PSA test. As described in Risk Factors and Prevention, PSA is a type of protein released by prostate tissue that is found in higher levels in a man's blood when there is abnormal activity in the prostate, including prostate cancer, BPH, or inflammation of the prostate. Doctors can look at features of the PSA value—such as absolute level, change over time, and level in relation to prostate size—to decide if a biopsy is needed. In addition, a version of the PSA test allows the doctor to measure a specific component, called the “free” PSA, which can sometimes help find out if a tumor is noncancerous or cancerous.

DRE. A doctor uses this test to find abnormal parts of the prostate by feeling the area using a finger. It is not very precise; therefore, most men with early prostate cancer have normal DRE test results.

If the PSA or DRE test results are abnormal, the following tests can confirm a diagnosis of cancer:

Transrectal ultrasound (TRUS). A doctor inserts a probe into the rectum that takes a picture of the prostate using sound waves that bounce off the prostate. This procedure is usually done at the same time as a biopsy (see below).

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. To get a tissue sample, a surgeon most often uses TRUS and a biopsy tool to take very small slivers of prostate tissue. The sample removed with the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). A patient usually can have this procedure at the hospital or doctor’s office without needing to stay overnight. The patient is given local anesthesia beforehand to numb the area. A patient may also receive antibiotics before the procedure to prevent an infection afterwards.

To find out if cancer has spread outside of the prostate, doctors may perform the imaging tests listed below. Because prostate cancer is unlikely to have spread, many of these tests are not used when a man’s PSA level is only slightly increased. 

Bone scan. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Generally, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture. MRI scans are sometimes used to help doctors find out if a biopsy is needed.

Staging with Illustrations

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Staging for prostate cancer also involves looking at test results to find out if the cancer has spread from the prostate to other parts of the body. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.

There are two types of staging for prostate cancer:

The clinical stage is based on the results of tests done before surgery, which includes DRE, biopsy, x-rays, CT scans, and bone scans. X-rays, bone scans, and CT scans may not always be needed. They are recommended based on the level of serum PSA, the grade and volume (size) of the cancer, and the clinical stage of the cancer.

The pathologic stage is based on information found during surgery, plus the laboratory results (pathology) of the prostate tissue removed during surgery (which often includes the removal of the entire prostate and some lymph nodes).

One tool that doctors use to describe the stage is the TNM system, developed by the American Joint Committee on Cancer (AJCC) and the Union International Contre le Cancer (UICC). This system is most commonly used in the United States and judges three factors: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are four stages: stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How large is the primary tumor, and where is it located? (Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer spread to other parts of the body? (Metastasis, M)

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: The primary tumor cannot be evaluated.

T0: There is no evidence of a tumor in the prostate.

T1: The tumor cannot be felt during the DRE and is not seen during imaging (any test that produces pictures of the inside of the body, such as a CT scan). It may be found when surgery is done for another reason, usually for BPH, or abnormal growth of noncancerous prostate cells.

T1a: The tumor is in 5% or less of the prostate tissue removed through surgery.

T1b: The tumor is in more than 5% of the prostate tissue removed through surgery.

T1c: The tumor is found during a needle biopsy, usually because the patient has an elevated PSA level.

T2: The tumor is found only in the prostate, not other parts of the body. It is large enough to be felt during the DRE.

T2a: The tumor has spread to one-half of one lobe (part or side) of the prostate.

T2b: The tumor has spread to more than one-half of one lobe of the prostate, but not to both lobes.

T2c: The tumor has grown into both lobes of the prostate.

T3: The tumor has grown through the prostate capsule (into the tissue just outside the prostate) on one side.

T3a: The tumor has grown through the prostate capsule either on one side or on both sides of the prostate, or it has spread to the neck of the bladder.

T3b: The tumor has grown into the seminal vesicle(s), the tube(s) that carry semen.

T4: The tumor is fixed, or it is growing into nearby structures other than the seminal vesicles, such as the external sphincter (part of the muscle layer that helps to control urination), the rectum, levator muscles, and/or the 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: The regional lymph nodes cannot be evaluated.

N0: The cancer has not spread to the regional lymph nodes.

N1: The cancer has spread to the regional lymph node(s).

Distant 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

Doctors assign the stage of the cancer by combining the T, N, and M classification See the table further below for all of the TNM combinations for each stage. 

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 (called re-staging) using the system above.

Stage Grouping Chart

Prognostic factors

In addition to stage, doctors use other prognostic factors to help plan the best treatment and predict how successful treatment will be. Below are prognostic factors for patients with prostate cancer.

PSA test. As described in Risk Factors and Prevention, PSA is a measurement of prostate-specific antigen levels in a man’s blood. These results are usually reported as nanograms per milliliter (ng/mL), such as 7 ng/mL for a PSA level of 7. For men already diagnosed with prostate cancer, the PSA level (and the Gleason score, described below) helps the doctor understand and predict a patient’s prognosis. This measurement gives doctors more information about the cancer to help make treatment decisions. Some prostate cancers do not cause an increased PSA level, so a normal PSA does not always mean that there is no prostate cancer.

Gleason score for grading prostate cancer. Prostate cancer is also given a grade called a Gleason score, which is based on how much the cancer looks like healthy tissue when viewed under a microscope. Less dangerous tumors generally look more like healthy tissue, and more dangerous tumors that are likely to grow and spread to other parts of the body look less like healthy tissue.

The Gleason System is the most common prostate cancer grading system used. The pathologist looks at how the cancer cells are arranged in the prostate and assigns a score on a scale of 1 to 5. Cancer cells that look similar to healthy cells are given a low score, and cancer cells that look less like healthy cells are given a higher score. To assign the numbers, the doctor determines the main pattern of cell growth (area where the cancer is most obvious), looks for any other less common pattern of growth, and gives each one a score. The scores are added to come up with an overall score between 2 and 10. The interpretation of the Gleason score by doctors has changed recently. Originally, doctors used a wide range of scores. Today, doctors no longer use Gleason scores of 5 or lower for cancer found with a biopsy. The lowest score used is 6, which is a low-grade cancer. A Gleason score of 7 is a medium-grade cancer, and 8, 9, or 10 is a high-grade cancer. A lower-grade cancer grows more slowly and is less likely to spread than a high-grade cancer. Doctors look at the Gleason score in addition to stage to help plan treatment. For example, active surveillance may be an option for a patient with a small tumor, low PSA level, and a Gleason score of 6. On the other hand, patients with high Gleason score (8-10) may need more intensive treatment even if it doesn’t appear that the cancer has spread.

Gleason X: The Gleason score cannot be determined.

Gleason 6 or lower: The cells are well-differentiated.

Gleason 7: The cells are moderately differentiated.

Gleason 8, 9, or 10: The cells are poorly differentiated or undifferentiated.

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