Disease: Prostate Cancer

    Prostate cancer facts*

    *Prostate cancer facts medical author: Charles P. Davis, MD

    • The prostate is a gland that is a part of the male reproductive system that wraps around the male urethra near the bladder
    • Common problems are BPH (Benign Prostatic Hyperplasia), acute and chronic bacterial prostatitis and chronic prostatitis (non-bacterial)
    • Prostate cancer is common in men over 50, especially in African-Americans and in men who eat fatty food and/or have a father or brother with prostate cancer
    • Symptoms of prostate problems (and prostate cancer) include urinary problems (little or no urine output, difficulty starting (straining) or stopping the urine stream, frequent urination, dribbling, pain or burning during urination), erectile dysfunction, painful ejaculation, blood in urine or semen and/or deep back, hip, pelvic or abdominal pain; other symptoms may include weight loss, bone pain and lower extremity swelling
    • Prostate cancer is definitively diagnosed by tissue biopsy; initial studies may include a rectal exam, ultrasound and PSA (prostate-specific antigen) levels
    • The diagnosis of leukemia is supported by findings of the medical history and examination, and examining blood and bone marrow samples under a microscope.
    • Treatments for prostate cancer may include surveillance, surgery, radiation therapy, and hormone therapy
    • PSA testing is considered to be yearly PSA tests; not all agree this should be done
    • Identify prostate problems early is a way to reduce future prostate problems

    What is prostate cancer?

    Prostate cancer is cancer of prostate gland. The prostate gland is a walnut-sized gland present only in men found in the pelvis, wrapped around the urethra (the tube through which urine exits the body). The prostate gland secretes part of the liquid portion of the semen, or seminal fluid, which carries sperm made by the testes. The fluid is essential to reproduction.

    Prostate cancer is the most common type of cancer that develops in men other than skin cancers, and is the second leading cause of cancer deaths in men. In 2013 the American Cancer Society estimated over 238,000 men were newly diagnosed with prostate cancer and more than 29,000 men died from the disease -- though many of them had lived with the disease for years prior to their deaths.

    Prostate cancer is comprised nearly always of adenocarcinoma cells -- cells which arise from glandular tissue. Cancer cells are named according to the organ in which they originate no matter where in the body we find such cells.

    What are the risk factors for prostate cancer?

    Certain risk factors may predispose a person to prostate cancer. These include:

    • Age: 60% of cases of prostate cancer arise in men over 65 years of age. The disease is rare in men under 40.
    • Race or ethnicity: African-American men and Jamaican men of African ancestry are diagnosed with prostate cancer more often than are men of other races and ethnicities. Asian and Hispanic men are less likely to develop prostate cancer than are non-Hispanic white males.
    • Family history: Prostate cancer can run in families. A man whose father or brother has or had prostate cancer is twice as likely to develop the disease. If several family members have had prostate cancer, and particularly if it was found at a young age in those relatives, the risk may be even higher.
    • Nationality: Prostate cancer is more common in North America, Europe (especially northwestern countries in Europe), the Caribbean, and Australia. It is less common in Asia, Africa, and South and Central America. Multiple factors, such as diet and lifestyle, may account for this.
    • Genetic factors: Mutations in a portion of the DNA called the BRCA2 gene can increase a man's risk of getting prostate cancer. This same mutation in female family members may increase their risk of developing breast or ovarian cancer. However, very few cases of prostate cancer can be directly attributed to presently identifiable genetic changes.
    • Other factors: Diets high in red meats and fatty foods and low in fruits and vegetables appear to be associated with a higher risk of developing prostate cancer. Obesity is also linked to a higher risk of the disease.

    Smoking, a history of sexually transmitted diseases, a history of prostatitis (inflammation of the prostate), and a history of vasectomy have NOT been proven to play a role in causing prostate cancer.

    How is prostate cancer diagnosed?

    The diagnosis of prostate cancer most commonly involves a combination of three tests:

    Digital rectal examination: As part of a physical examination your doctor inserts a gloved and lubricated finger into your rectum and feels toward the front of your body. The prostate gland is a walnut or larger sized gland immediately in front of the rectum, and beneath your bladder. The back portion of prostate gland can be felt in this manner.

    The exam is usually brief, and most find it uncomfortable due to the pressure used to adequately examine the prostate gland. Findings such as abnormal size, lumps, or nodules, may indicate prostate cancer.

    This examination should be part of an annual physical in all men over 50 years of age to note changes in the prostate. In men with a family history of prostate cancer, or in African American men exams should begin at 40 years of age.

    Prostate specific antigen (PSA) blood test: The PSA blood test measures the level of a protein found in the blood that is produced by the prostate gland and helps keep semen in liquid form. The PSA test can indicate an increased likelihood of prostate cancer if the PSA is at an increased or elevated level, but it does not provide a definitive diagnosis. Prostate cancer can be found in patients with a low PSA level but this occurs less than 20% of the time.

    If the PSA level is elevated (levels can depend upon your age, on the size of your prostate gland on examination, certain medications you may be taking, or recent sexual activity), further testing may be needed to rule out prostate cancer.

    PSA measurements are often tracked over time to look for evidence of a change. The amount of time it takes for the PSA level to increase is referred to as PSA velocity. A PSA doubling time can be also tracked in this fashion. PSA velocity and PSA doubling time can help your doctor determine whether prostate cancer may be present.

    The presence of an abnormal result on digital rectal examination, or a new or progressive abnormality in a PSA test may lead to a referral to a surgeon who specializes in diseases of the urinary system (a urologist) who may perform further testing, such as a biopsy of the prostate gland.

    Prostate biopsy: A biopsy refers to the taking of a sample from a tissue in the body. Prostate cancer is only definitively diagnosed by finding cancer cells on a biopsy of the prostate gland.

    The urologist may have you stop medications such as blood thinners before the biopsy. On the day of the biopsy the doctor will apply a local anesthetic by injection or topically as a gel inside the rectum over the area of prostate gland. An ultrasound probe is then placed in the rectum. This device uses sound waves to take a picture of the prostate gland and helps guide the biopsy device. The device used is a spring-loaded needle that allows the urologist to extract cores from the prostate gland. Usually 12 cores are obtained, six from each side. Two cores are taken from the upper, middle, and lower portions of the prostate gland. The cores are submitted for analysis to a pathologist (a doctor who specializes in examining tissues to make a diagnosis). Results may take several days.

    A biopsy procedure is usually uncomplicated, with just some numbness, pain, or tenderness in the area for a short time afterwards. Occasionally, a patient has some bleeding in the urine after the procedure. Rarely, the patient may develop an infection after a biopsy procedure, or be unable to urinate. Consult a doctor if this occurs.

    Prostate cancer biopsy

    The result of the pathologist's analysis of the biopsy cores under the microscope is the only way to diagnose prostate cancer. The biopsy procedure is not perfect, and cancer present in the prostate may be missed. If the urologist is still suspicious based on the results of the examination and the ultrasound images seen during the procedure, additional biopsies may be recommended.

    The pathologist's report on the biopsies showing prostate cancer will contain much detailed information. The size of the biopsy core and the percentage of involvement of each core will be reported. Most importantly the prostate cancer present will be assigned a numerical score, which is usually expressed as a sum of two numbers (for example, 3 + 4) and is referred to as the Gleason Score. This characterizes the cancer and helps predict its likely level of aggressiveness in the body. It is often also referred to as the grade of the prostate cancer.

    The Gleason score and the extent of involvement of the biopsy core expressed as a percentage, as well as the PSA level as well as your general state of health and otherwise estimated life expectancy all help the doctors make their best recommendations for you regarding how your cancer should be treated.

    The accuracy of the PSA test

    The PSA test is a tool for use by your doctor but it is not a perfect way to tell whether or not a patient has prostate cancer because is not sensitive enough to pick up all prostate cancers. It is not specific enough in that it may be elevated in people without prostate cancer, such as those whose prostate glands are infected, or just inflamed, but not cancerous. It is also elevated for days after a digital rectal exam, or after ejaculation. Nevertheless, it accurately measures the amount of PSA in the blood.

    The interpretation of the PSA result must be done with care. PSA results must be, for example, interpreted in the context of the patient's age. Younger men (under 70, and definitely under 60) may have either more aggressive prostate cancers, or more life to lose if not evaluated aggressively. Conversely, men over 70 often have more indolent or slow-moving prostate cancers, or other medical conditions which may be greater threats to their lives over the next 10 years than may prostate cancer, and thus less aggressive evaluation and treatment may be warranted. The test is best used to establish a pattern in a man with serial measurements obtained over years.

    Doctors probably only find the more aggressive prostate cancers. The disease is common as men age. It is estimated 16% of men will be diagnosed with prostate cancer in their lifetime and yet only 3% will die of it. Many men likely have small prostate cancers present by the time they are over 60 years of age, with estimates ranging from 30% to 40% having prostate cancer cells in their prostates. The presence of these small cancers also likely further increases with age. Most of these cancers are very slow-growing and not aggressive in their tendency to spread as they are never discovered or symptomatic during the men's lives. Diagnosing these prostate cancers may only increase the cost and result in treatment-related complications in these men.

    Talk to your doctor about the risks and benefits of having PSA testing if you are 40 years of age with a family history of prostate cancer (or age 50 if you do not have a family history), or are of African American ancestry. The test results should be considered in the context of the man's urinary symptoms, if any, his family history, his race and ethnicity, his diet, weight, and physical findings. Further there should be attention given to the pattern of change in his serial PSA measurements.

    Numerous different ways to refine the use of PSA testing have been attempted. Some of these include evaluations of the:

    • PSA doubling time, which refers to how long it has taken for the PSA to double.
    • PSA velocity, which looks at how rapidly the PSA values have changed over time.
    • PSA density, which looks at the PSA result and considers the prostate gland volume as determined on ultrasound evaluation.
    • PSA fractionation, which is another test that measures the amount of free PSA versus protein-bound PSA in the bloodstream. The lower the percentage of free PSA, the higher the risk of cancer.

    In patients with prostate cancer whose PSA was initially elevated, the PSA is an excellent tool to assist in care and follow up both during and after treatment.

    What are the symptoms of prostate cancer?

    A patient with early prostate cancer may have symptoms of:

    • A frequent need to urinate, especially at night
    • Difficulty in starting or stopping the urine stream
    • A weak or interrupted urine stream
    • Loss of control of urination with coughing or laughing
    • Inability to urinate when standing, requiring sitting during urination
    • Pain with urination or ejaculation
    • Blood in the urine or in the semen

    Many symptoms of early cancer of the prostate can also be attributed to benign (noncancerous) conditions of the prostate including benign prostatic hypertrophy (BPH), or infection in the prostate gland or urinary system.

    Symptoms of advanced prostate cancer that has already spread from the prostate gland to elsewhere in the body (called metastatic prostate cancer) include:

    • A new dull, then progressively severe, pain in the bones, especially the low back
    • Unexplained weight loss
    • Fatigue
    • Increasing shortness of breath while doing activities previously well tolerated

    It is always best to find and diagnose prostate cancer at an early stage and hopefully still confined to its site of origin. At that point treatments can cure it. When prostate cancer is widespread or metastatic it can be treated, but it cannot be cured.

    What are the stages of prostate cancer?

    The term “to stage” a cancer means to describe the evident extent of the cancer in the body at the time that the cancer is first diagnosed. The stage of a cancer helps doctors understand the extent of the cancer and plan cancer treatment.

    Cancer staging is first described using what is called a TNM system. The “T” refers to a description of the size or extent of the primary, or original, tumor. “N” describes the presence or absence of, and extent of spread of the cancer to lymph nodes that may be nearby or further from the original tumor. “M” describes the presence or absence of metastases -- usually distant areas elsewhere in the body other than lymph nodes to which the cancer has spread. Cancers with specific TNM characteristics are then grouped into stages, and the stages are then assigned Roman numerals with the numerals used in increasing order as the extent of the cancer being staged increases or the cancer prognosis worsens. Prognosis is finally reflected by considering the patient's PSA score at presentation as well as their Gleason score in assigning a final stage designation.

    The American Joint Commission on Cancer (AJCC) system for prostate cancer staging is:

    T designations refer to the characteristics of the prostate cancer primary tumor.

    T1 prostate cancers cannot be seen on imaging tests or felt on examination. They may be found incidentally when surgery is done on the prostate for a problem presumed to be benign, or on needle biopsy for an elevated PSA.

    • T1a means that the cancer cells comprise less than 5% of the tissue removed.
    • T1b means that cancer cells comprise more than 5% of the tissue removed.
    • T1c means that the tissue containing cancer was obtained by needle biopsy for an elevated PSA.

    T2 prostate cancers are those which can felt (palpated) on physical examination of the prostate gland (on digital rectal exam) or which can be visualized with imaging studies such as ultrasound, X-ray, or related studies. The prostate gland is comprised of two halves or lobes. The extent of involvement of those lobes is described here.

    • T2a means the cancer has grown into less than half of one lobe of the prostate.
    • T2b means the cancer has grown more than half of one lobe, but does not involve the other lobe of the prostate.
    • T2c means that the cancer has grown into or involves both lobes of the prostate.

    T3 prostate cancers have grown sufficiently to extend outside of the prostate gland. Adjacent tissues including the capsule around the prostate gland, the seminal vesicles, as well as the bladder neck may be involved in T3 tumors.

    • T3a means that the cancer has extended outside of the prostate gland but not into the seminal vesicles.
    • T3b means that the cancer has invaded into the seminal vesicles.

    T4 prostate cancers have spread outside of the prostate gland and have invaded adjacent tissues or organs. This may be determined by examination, biopsy, or imaging studies. T4 prostate cancer may involve the external sphincter or valve of the bladder, the bladder itself, the rectum, or the levator muscles or the pelvic wall. T4 tumors have become fixed to or invaded adjacent structures other than the seminal vesicles.

    N designations refer to the presence or absence of prostate cancer in nearby lymph nodes including what are referred to as the hypogastric, obturator, internal and external iliac, and sacral nodes.

    • N0 means that there is no prostate cancer evident in the nearby nodes.
    • N1 means that there is evidence of prostate cancer in the nearby nodes.
    • NX means that the lymph nodes cannot or have not been assessed.

    M refers to the presence or absence of prostate cancer cells in distant lymph nodes or other organs. Prostate cancer that has spread through the bloodstream most often first spreads into the bones, then into the lungs and liver.

    • M0 means that there is no evidence of spread of prostate cancer into distant tissues or organs.
    • M1a means that there is spread of prostate cancer into distant lymph nodes.
    • M1b means that there is evidence that prostate cancer has spread into bones.
    • M1c means that prostate cancer has spread into other distant organs in addition to or instead of into the bones.

    What is the prognosis for prostate cancer?

    Staging evaluation is essential for the planning of treatment for prostate cancer. A basic staging evaluation includes the patient examination, blood tests, and the prostate biopsy including ultrasound images of the prostate. Further testing and calculations may be performed to best estimate a patient's prognosis and help the doctor and patient decide upon treatment options. Prognosis refers to the likelihood that the cancer can be cured by treatment, and what the patient's life expectancy is likely to be as a consequence of having had a prostate cancer diagnosis.

    If a cancer is cured, your life expectancy is what it would have been had you never been diagnosed with prostate cancer. If the cancer cannot be cured, or recurs either locally (where it started) or elsewhere in the body, estimates can be made of what is likely to be your survival based again on group statistics for people who have been in the same situation.

    Nomograms are tools that use complex math from analysis of many patients' treatment results. They help to estimate the likelihood of a patient surviving free of recurrence after a treatment. They also can determine the likelihood of a cancer being found confined to the prostate, or spread beyond the prostate, or into the nearby lymph glands. Your doctor will likely input the data from your staging evaluation into a nomogram in order to best counsel you regarding your treatment options.

    The prognosis for prostate cancer varies widely, and depends on many factors, including the age and health of the patient, the stage of the tumor when it was diagnosed, the aggressiveness of the tumor, and the cancer's responsiveness to treatment, among other factors.

    What are the treatment options for prostate cancer?

    Treatment options for prostate cancer are many, and while this is an advantage in that prostate cancer is such a common disease in men, it can also be a cause of great confusion. The following overview presents some information about these options, but it is not a complete explanation of any of these. You can find more information on treatment options in the NCCN Clinical Practice Guideline for Patients on Prostate Cancer for 2014 and the Physician Data Query (PDQ) website of the National Cancer Institute.

    Conventional medical treatment options for prostate cancer include:

    • Watchful waiting
    • Surgery
    • Radiation therapy
    • Cryotherapy
    • Hormonal therapy
    • Chemotherapy
    • Immunotherapy and other targeted therapies
    • Bisphosphonates and denosumab
    • Radiopharmaceuticals (radioactive substances used as drugs)
    • Research techniques including high-intensity focused ultrasound (HIFU) and others

    Watchful waiting

    This does NOT mean doing nothing about your prostate cancer. It means that rather than having the patient undergo aggressive treatments -- usually surgery or radiation therapy -- the urologist and the patient commit to a scheduled program of follow-up examinations, blood tests including PSAs, and repeat prostate biopsies at regular intervals. If the cancer shows signs of progression in the prostate gland, or the PSA starts to rise substantially, treatments are reconsidered.

    This approach is appropriate for patients with smaller amounts of low-grade prostate cancer. It is also appropriate in patients in whom other medical conditions, or age, or both, suggest an excessively high risk of potentially serious problems developing were aggressive therapy attempted.

    Surgery

    The removal of the entire prostate gland and the attached seminal vesicles is referred to as a radical prostatectomy. This is usually done through an incision or incisions made over the front of the lower abdominal wall with the procedure, taking place behind the pubic bones at the front of the pelvis (a retropubic approach). Today the main choice is between a standard open radical prostatectomy and the use of a robotic system for performance of the procedure through smaller incisions. The former allows the surgeon to feel the tissues and make the cuts themselves. The latter uses an operating system robot, which the surgeon guides. The former takes longer to recover from, and has more risk of blood loss associated with it. The latter results in a more rapid recovery and less blood loss generally.

    Intact pelvic nerve bundles on either side of the prostate in the pelvis are essential for a man to be able to have an erection. Impotence -- or the inability to have and sustain an erection of a quality sufficient for successful intercourse -- can occur after this operation. The likelihood of impotence is primarily dependent on whether or not the necessary nerves can be preserved during surgery, AND the patient's true preoperative ability to still have an erection. Nerve-sparing surgical technique is desirable and the surgeon should plan to do this, if possible. These important pelvic nerve bundles may need to be sacrificed if they are too close to or are involved with the cancer. The objective of the surgery is to cure the patient of the prostate cancer with the least number of problems afterward as possible, but the performance of a potentially curative procedure must remain the primary objective of the surgeon.

    The radical prostatectomy involves the removal of a portion of the urethra. The urethra is the tube that runs from the bladder to the outside through the penis. It runs through the prostate gland. The procedure can disrupt the sphincter or valve, which controls urine flow from the bladder. The surgeon reconnects the urethra to the bladder after the prostate is out. The more careful and experienced the surgeon, the less the risk of long-term inability to control the flow of urine (incontinence).

    The risks of an operation lasting several hours also remain substantial and include heart problems, blood loss, as well as a risk of infection, blood clots, and rarely death. Such operations are appropriate for patients whose cancer appears to be confined to the prostate gland.

    If a preoperative nomogram in a patient with a T1 or T2 tumor suggests a 2% or greater risk of lymph node metastases, then a pelvic lymph node dissection may be performed in addition to the radical prostatectomy. Pelvic lymph node dissection is unnecessary in almost half of patients undergoing radical prostatectomy.

    Radiation therapy

    Radiation therapy involves potentially curative treatment using machines that generate and administer controlled, invisible beams of energy known as radiation. This is called external beam radiation therapy (EBRT). It also can be done using radioactive sources, or seeds, implanted permanently, or higher energy sources placed temporarily into the body. This technique is called brachytherapy.

    An X-ray machine uses a low energy radiation beam to take a picture of a portion of the body. Radiation therapy machines put out high energy beams that can be focused very precisely to deliver treatment to a site. The radiation does not “burn out” the cancer, but damages the cells' DNA, which causes the cancer cells to die. This process can take some time to occur.

    The radiation passes directly through the tissues in EBRT. Radiation treatment used today delivers very little energy to normal tissues. It just passes through. Most of the energy is delivered directly to the area of the prostate gland containing cancer. This process minimizes damage to healthy tissue.

    EBRT can be administered in a variety of different ways including 3-D CRT, IMRT, and others. EBRT is classically administered in brief daily treatments, 5 days a week over several weeks. While the radiation does not remain in the body with this approach, the effect of the daily fractions is cumulative. Newer forms of EBRT using machines called CyberKnife may be completed in shorter periods of time.

    Radiation therapy to the prostate gland by external beam technique may cause fatigue and bladder and/or rectal irritation. These effects are usually temporary but may recur or persist long after treatments are finished. Radiation damage to adjacent tissues can cause skin irritation, and local hair loss. Delayed onset of impotence can occur after radiation therapy due to its effect on normal tissues including nerves adjacent to the prostate. Radiation therapy may be given alone or in combination with hormonal therapy which can also shrink up the prostate gland thereby reducing the size of the radiation area or field that needs to be treated.

    A recently popular technique of EBRT is called proton beam radiation, which can theoretically more closely focus on the area being treated. Proton beam radiation therapy is more expensive. Its side effects presently appear similar to those discussed for standard radiation therapy.

    EBRT is appropriate for men who are candidates for radical prostatectomy but do not wish to undergo the surgery. It is also used to shrink tumors and reduce pain in areas where prostate cancer is damaging bone, or is pressing on important structures including the spinal cord.

    Brachytherapy refers to the use of radiation sources -- sometimes referred to as seeds -- placed into the prostate gland. Brachytherapy may be done with what is called low-dose rate (LDR) technique. In LDR brachytherapy types of radioactive seeds, which only briefly put out a form of radiation which does not travel very far through tissues, are permanently implanted in the prostate gland. High-dose rate (HDR) brachytherapy involves the temporary placement of different types of seeds or sources which give off higher amounts of more penetrating radiation. These seeds administer higher doses of radiation for longer periods of time and cannot be left in the body. Such sources are placed in the prostate gland through surgically implanted tubes. These HDR sources are removed along with the tubes in a couple of days. In LDR brachytherapy, the seeds are placed in the operating room using image guidance to ensure the seeds go into the right places; 40 to 100 seeds may be placed. With LDR, you can go home shortly after you wake up after the procedure. In HDR, you must stay at the hospital for a few days. If the prostate gland is large, hormonal treatment may be used to shrink the gland before the brachytherapy is done. Brachytherapy may also be combined with external beam radiation therapy to further increase the dose of radiation therapy given to the prostate gland.

    Brachytherapy can cause some blood in the urine or semen. It can cause a feeling similar to constipation due to the swelling of the prostate gland. It can also make you feel that you want to move your bowels more often. There may be some long-term problems with irritation of the rectum, difficulty urinating due to scar tissue formation, and even delayed-onset impotence.

    Brachytherapy is appropriate for men with tumors staged T1 to T3 with PSA less than 20. It is not appropriate if you have had a prior procedure -- transurethral prostatectomy (TURP) -- which removes part of the prostate in cases of benign prostatic hypertrophy (BPH).

    Note: Radiation therapy can be performed if prostate cancer recurs in the region where the prostate was, and can potentially cure a locally recurrent prostate cancer if it has not spread beyond the area.

    If radiation fails to control the cancer, surgery is difficult -- if not impossible -- to perform due to scar tissue which develops in the area.

    Cryotherapy

    Cryotherapy is most frequently used as a salvage treatment after failure of radiation therapy. As an outpatient, hollow needles are placed into the prostate through the perineum (the space between the scrotal sac and the anus) under image guidance. A gas is passed through the needles to freeze the prostate. Warm liquid is passed through the urethra at the same time to protect it. The needles are removed after the procedure. While potentially effective for local control of cancer in the prostate gland, the side effects can be significant and include pain and the inability to urinate. Potential long-term effects include tissue damage in needle-insertion areas, impotence, and incontinence. Cryotherapy is not an appropriate primary treatment for management of prostate cancer.

    Hormonal therapy

    Prostate cancer is highly sensitive to the level of the male hormone testosterone, which drives the growth of prostate cancer cells in all but the very high-grade or poorly-differentiated forms of prostate cancer. Testosterone belongs to a family of hormones called androgens, and today front-line hormonal therapy for prostate cancer is called androgen deprivation therapy (ADT).

    Doctors can block the function of the testes in a controllable and REVERSIBLE fashion with drugs which affect the hormone system of the body and stop the main driver of the testes, the pituitary gland at the base of the brain, to stop stimulating the testes to make testosterone. These agents can result in shrinkage of the prostate gland, can stop prostate cancer cells from growing for up to many years, and can relieve pain caused by prostate cancer which has spread or metastasized into the bones.

    Hormonal treatment today is primarily used in the treatment of locally advanced and metastatic prostate cancer. It can be combined with radiation therapy in attempts to cure prostate cancer. Its primary role is in the treatment of widespread or metastatic prostate cancer. While it is not a curative treatment in that setting, it can both reduce symptoms and prolong life.

    Today medicines used to block testosterone production by the testes include:

    • LH-RH agonists: Leuprolide (Lupron), goserelin (Zoladex), histrelin (Supprelin LA), and triptorelin (Trelstar) are examples of these mediations. These are either given by injection into the muscle or under the skin at varying intervals of at least one month or longer.
    • LH-RH antagonists: Degarelix (Firmagon) is a monthly injection that is given under the skin.
    • Other drugs can block the effect of testosterone. These anti-androgen drugs include flutamide (Eulexin), bicalutamide (Casodex), nilutamide (Nilandron), and an even more effective form called enzalutamide (Vfend).

    Both surgical and medical castration result in impotence. They also can cause hot flashes, fatigue, and thinning of the bones (osteoporosis) over time. They may be done individually or combined in what is called a combined androgen blockade. The combined blockade approach has not been proven to be more effective at this time than orchiectomy (removal of the testes) and is more expensive.

    Other hormonal treatment options include:

    • Estrogen: This female hormone has been utilized in the treatment of prostate cancer. It's mechanism of action remains under study, and its association with a high risk of heart attack and blood clots when used in high doses has diminished the frequency of its use, particularly in front-line therapy. Estrogen and related drugs still play a role in the treatment of metastatic prostate cancer.
    • Adrenal androgen synthesis inhibitors: This group includes a drug called ketoconazole which was primarily developed to treat fungal infections. More recently an agent called abiraterone acetate (Zytiga) has been developed. It has a similar effect on androgen synthesis, but it is more powerful than ketoconazole (Nizoral) and has fewer side effects.
    • Steroids: These agents including prednisone may have beneficial hormonal effects in prostate cancer, including slowing the production of androgen by the adrenal glands. They often make the patient feel better, but have many side effects including inducing or worsening diabetes, fluid retention, cataract formation, weight gain, and osteoporosis.
    • Agents that block the conversion of testosterone to its active metabolite: Finasteride (Proscar) and dutasteride (Avodart) have been used in treating prostate cancer by preventing the conversion of testosterone to its active metabolite called DHT (dihydrotestosterone). These drugs are frequently utilized for the symptoms of prostate enlargement in men without prostate cancer, and appear to reduce the risk of development of prostate cancer. Their side effects are limited. They are used in combination with other agents to optimize androgen blockade.

    What are the risk factors for prostate cancer?

    Certain risk factors may predispose a person to prostate cancer. These include:

    • Age: 60% of cases of prostate cancer arise in men over 65 years of age. The disease is rare in men under 40.
    • Race or ethnicity: African-American men and Jamaican men of African ancestry are diagnosed with prostate cancer more often than are men of other races and ethnicities. Asian and Hispanic men are less likely to develop prostate cancer than are non-Hispanic white males.
    • Family history: Prostate cancer can run in families. A man whose father or brother has or had prostate cancer is twice as likely to develop the disease. If several family members have had prostate cancer, and particularly if it was found at a young age in those relatives, the risk may be even higher.
    • Nationality: Prostate cancer is more common in North America, Europe (especially northwestern countries in Europe), the Caribbean, and Australia. It is less common in Asia, Africa, and South and Central America. Multiple factors, such as diet and lifestyle, may account for this.
    • Genetic factors: Mutations in a portion of the DNA called the BRCA2 gene can increase a man's risk of getting prostate cancer. This same mutation in female family members may increase their risk of developing breast or ovarian cancer. However, very few cases of prostate cancer can be directly attributed to presently identifiable genetic changes.
    • Other factors: Diets high in red meats and fatty foods and low in fruits and vegetables appear to be associated with a higher risk of developing prostate cancer. Obesity is also linked to a higher risk of the disease.

    Smoking, a history of sexually transmitted diseases, a history of prostatitis (inflammation of the prostate), and a history of vasectomy have NOT been proven to play a role in causing prostate cancer.

    How is prostate cancer diagnosed?

    The diagnosis of prostate cancer most commonly involves a combination of three tests:

    Digital rectal examination: As part of a physical examination your doctor inserts a gloved and lubricated finger into your rectum and feels toward the front of your body. The prostate gland is a walnut or larger sized gland immediately in front of the rectum, and beneath your bladder. The back portion of prostate gland can be felt in this manner.

    The exam is usually brief, and most find it uncomfortable due to the pressure used to adequately examine the prostate gland. Findings such as abnormal size, lumps, or nodules, may indicate prostate cancer.

    This examination should be part of an annual physical in all men over 50 years of age to note changes in the prostate. In men with a family history of prostate cancer, or in African American men exams should begin at 40 years of age.

    Prostate specific antigen (PSA) blood test: The PSA blood test measures the level of a protein found in the blood that is produced by the prostate gland and helps keep semen in liquid form. The PSA test can indicate an increased likelihood of prostate cancer if the PSA is at an increased or elevated level, but it does not provide a definitive diagnosis. Prostate cancer can be found in patients with a low PSA level but this occurs less than 20% of the time.

    If the PSA level is elevated (levels can depend upon your age, on the size of your prostate gland on examination, certain medications you may be taking, or recent sexual activity), further testing may be needed to rule out prostate cancer.

    PSA measurements are often tracked over time to look for evidence of a change. The amount of time it takes for the PSA level to increase is referred to as PSA velocity. A PSA doubling time can be also tracked in this fashion. PSA velocity and PSA doubling time can help your doctor determine whether prostate cancer may be present.

    The presence of an abnormal result on digital rectal examination, or a new or progressive abnormality in a PSA test may lead to a referral to a surgeon who specializes in diseases of the urinary system (a urologist) who may perform further testing, such as a biopsy of the prostate gland.

    Prostate biopsy: A biopsy refers to the taking of a sample from a tissue in the body. Prostate cancer is only definitively diagnosed by finding cancer cells on a biopsy of the prostate gland.

    The urologist may have you stop medications such as blood thinners before the biopsy. On the day of the biopsy the doctor will apply a local anesthetic by injection or topically as a gel inside the rectum over the area of prostate gland. An ultrasound probe is then placed in the rectum. This device uses sound waves to take a picture of the prostate gland and helps guide the biopsy device. The device used is a spring-loaded needle that allows the urologist to extract cores from the prostate gland. Usually 12 cores are obtained, six from each side. Two cores are taken from the upper, middle, and lower portions of the prostate gland. The cores are submitted for analysis to a pathologist (a doctor who specializes in examining tissues to make a diagnosis). Results may take several days.

    A biopsy procedure is usually uncomplicated, with just some numbness, pain, or tenderness in the area for a short time afterwards. Occasionally, a patient has some bleeding in the urine after the procedure. Rarely, the patient may develop an infection after a biopsy procedure, or be unable to urinate. Consult a doctor if this occurs.

    Prostate cancer biopsy

    The result of the pathologist's analysis of the biopsy cores under the microscope is the only way to diagnose prostate cancer. The biopsy procedure is not perfect, and cancer present in the prostate may be missed. If the urologist is still suspicious based on the results of the examination and the ultrasound images seen during the procedure, additional biopsies may be recommended.

    The pathologist's report on the biopsies showing prostate cancer will contain much detailed information. The size of the biopsy core and the percentage of involvement of each core will be reported. Most importantly the prostate cancer present will be assigned a numerical score, which is usually expressed as a sum of two numbers (for example, 3 + 4) and is referred to as the Gleason Score. This characterizes the cancer and helps predict its likely level of aggressiveness in the body. It is often also referred to as the grade of the prostate cancer.

    The Gleason score and the extent of involvement of the biopsy core expressed as a percentage, as well as the PSA level as well as your general state of health and otherwise estimated life expectancy all help the doctors make their best recommendations for you regarding how your cancer should be treated.

    The accuracy of the PSA test

    The PSA test is a tool for use by your doctor but it is not a perfect way to tell whether or not a patient has prostate cancer because is not sensitive enough to pick up all prostate cancers. It is not specific enough in that it may be elevated in people without prostate cancer, such as those whose prostate glands are infected, or just inflamed, but not cancerous. It is also elevated for days after a digital rectal exam, or after ejaculation. Nevertheless, it accurately measures the amount of PSA in the blood.

    The interpretation of the PSA result must be done with care. PSA results must be, for example, interpreted in the context of the patient's age. Younger men (under 70, and definitely under 60) may have either more aggressive prostate cancers, or more life to lose if not evaluated aggressively. Conversely, men over 70 often have more indolent or slow-moving prostate cancers, or other medical conditions which may be greater threats to their lives over the next 10 years than may prostate cancer, and thus less aggressive evaluation and treatment may be warranted. The test is best used to establish a pattern in a man with serial measurements obtained over years.

    Doctors probably only find the more aggressive prostate cancers. The disease is common as men age. It is estimated 16% of men will be diagnosed with prostate cancer in their lifetime and yet only 3% will die of it. Many men likely have small prostate cancers present by the time they are over 60 years of age, with estimates ranging from 30% to 40% having prostate cancer cells in their prostates. The presence of these small cancers also likely further increases with age. Most of these cancers are very slow-growing and not aggressive in their tendency to spread as they are never discovered or symptomatic during the men's lives. Diagnosing these prostate cancers may only increase the cost and result in treatment-related complications in these men.

    Talk to your doctor about the risks and benefits of having PSA testing if you are 40 years of age with a family history of prostate cancer (or age 50 if you do not have a family history), or are of African American ancestry. The test results should be considered in the context of the man's urinary symptoms, if any, his family history, his race and ethnicity, his diet, weight, and physical findings. Further there should be attention given to the pattern of change in his serial PSA measurements.

    Numerous different ways to refine the use of PSA testing have been attempted. Some of these include evaluations of the:

    • PSA doubling time, which refers to how long it has taken for the PSA to double.
    • PSA velocity, which looks at how rapidly the PSA values have changed over time.
    • PSA density, which looks at the PSA result and considers the prostate gland volume as determined on ultrasound evaluation.
    • PSA fractionation, which is another test that measures the amount of free PSA versus protein-bound PSA in the bloodstream. The lower the percentage of free PSA, the higher the risk of cancer.

    In patients with prostate cancer whose PSA was initially elevated, the PSA is an excellent tool to assist in care and follow up both during and after treatment.

    What are the symptoms of prostate cancer?

    A patient with early prostate cancer may have symptoms of:

    • A frequent need to urinate, especially at night
    • Difficulty in starting or stopping the urine stream
    • A weak or interrupted urine stream
    • Loss of control of urination with coughing or laughing
    • Inability to urinate when standing, requiring sitting during urination
    • Pain with urination or ejaculation
    • Blood in the urine or in the semen

    Many symptoms of early cancer of the prostate can also be attributed to benign (noncancerous) conditions of the prostate including benign prostatic hypertrophy (BPH), or infection in the prostate gland or urinary system.

    Symptoms of advanced prostate cancer that has already spread from the prostate gland to elsewhere in the body (called metastatic prostate cancer) include:

    • A new dull, then progressively severe, pain in the bones, especially the low back
    • Unexplained weight loss
    • Fatigue
    • Increasing shortness of breath while doing activities previously well tolerated

    It is always best to find and diagnose prostate cancer at an early stage and hopefully still confined to its site of origin. At that point treatments can cure it. When prostate cancer is widespread or metastatic it can be treated, but it cannot be cured.

    What are the stages of prostate cancer?

    The term “to stage” a cancer means to describe the evident extent of the cancer in the body at the time that the cancer is first diagnosed. The stage of a cancer helps doctors understand the extent of the cancer and plan cancer treatment.

    Cancer staging is first described using what is called a TNM system. The “T” refers to a description of the size or extent of the primary, or original, tumor. “N” describes the presence or absence of, and extent of spread of the cancer to lymph nodes that may be nearby or further from the original tumor. “M” describes the presence or absence of metastases -- usually distant areas elsewhere in the body other than lymph nodes to which the cancer has spread. Cancers with specific TNM characteristics are then grouped into stages, and the stages are then assigned Roman numerals with the numerals used in increasing order as the extent of the cancer being staged increases or the cancer prognosis worsens. Prognosis is finally reflected by considering the patient's PSA score at presentation as well as their Gleason score in assigning a final stage designation.

    The American Joint Commission on Cancer (AJCC) system for prostate cancer staging is:

    T designations refer to the characteristics of the prostate cancer primary tumor.

    T1 prostate cancers cannot be seen on imaging tests or felt on examination. They may be found incidentally when surgery is done on the prostate for a problem presumed to be benign, or on needle biopsy for an elevated PSA.

    • T1a means that the cancer cells comprise less than 5% of the tissue removed.
    • T1b means that cancer cells comprise more than 5% of the tissue removed.
    • T1c means that the tissue containing cancer was obtained by needle biopsy for an elevated PSA.

    T2 prostate cancers are those which can felt (palpated) on physical examination of the prostate gland (on digital rectal exam) or which can be visualized with imaging studies such as ultrasound, X-ray, or related studies. The prostate gland is comprised of two halves or lobes. The extent of involvement of those lobes is described here.

    • T2a means the cancer has grown into less than half of one lobe of the prostate.
    • T2b means the cancer has grown more than half of one lobe, but does not involve the other lobe of the prostate.
    • T2c means that the cancer has grown into or involves both lobes of the prostate.

    T3 prostate cancers have grown sufficiently to extend outside of the prostate gland. Adjacent tissues including the capsule around the prostate gland, the seminal vesicles, as well as the bladder neck may be involved in T3 tumors.

    • T3a means that the cancer has extended outside of the prostate gland but not into the seminal vesicles.
    • T3b means that the cancer has invaded into the seminal vesicles.

    T4 prostate cancers have spread outside of the prostate gland and have invaded adjacent tissues or organs. This may be determined by examination, biopsy, or imaging studies. T4 prostate cancer may involve the external sphincter or valve of the bladder, the bladder itself, the rectum, or the levator muscles or the pelvic wall. T4 tumors have become fixed to or invaded adjacent structures other than the seminal vesicles.

    N designations refer to the presence or absence of prostate cancer in nearby lymph nodes including what are referred to as the hypogastric, obturator, internal and external iliac, and sacral nodes.

    • N0 means that there is no prostate cancer evident in the nearby nodes.
    • N1 means that there is evidence of prostate cancer in the nearby nodes.
    • NX means that the lymph nodes cannot or have not been assessed.

    M refers to the presence or absence of prostate cancer cells in distant lymph nodes or other organs. Prostate cancer that has spread through the bloodstream most often first spreads into the bones, then into the lungs and liver.

    • M0 means that there is no evidence of spread of prostate cancer into distant tissues or organs.
    • M1a means that there is spread of prostate cancer into distant lymph nodes.
    • M1b means that there is evidence that prostate cancer has spread into bones.
    • M1c means that prostate cancer has spread into other distant organs in addition to or instead of into the bones.

    What is the prognosis for prostate cancer?

    Staging evaluation is essential for the planning of treatment for prostate cancer. A basic staging evaluation includes the patient examination, blood tests, and the prostate biopsy including ultrasound images of the prostate. Further testing and calculations may be performed to best estimate a patient's prognosis and help the doctor and patient decide upon treatment options. Prognosis refers to the likelihood that the cancer can be cured by treatment, and what the patient's life expectancy is likely to be as a consequence of having had a prostate cancer diagnosis.

    If a cancer is cured, your life expectancy is what it would have been had you never been diagnosed with prostate cancer. If the cancer cannot be cured, or recurs either locally (where it started) or elsewhere in the body, estimates can be made of what is likely to be your survival based again on group statistics for people who have been in the same situation.

    Nomograms are tools that use complex math from analysis of many patients' treatment results. They help to estimate the likelihood of a patient surviving free of recurrence after a treatment. They also can determine the likelihood of a cancer being found confined to the prostate, or spread beyond the prostate, or into the nearby lymph glands. Your doctor will likely input the data from your staging evaluation into a nomogram in order to best counsel you regarding your treatment options.

    The prognosis for prostate cancer varies widely, and depends on many factors, including the age and health of the patient, the stage of the tumor when it was diagnosed, the aggressiveness of the tumor, and the cancer's responsiveness to treatment, among other factors.

    What are the treatment options for prostate cancer?

    Treatment options for prostate cancer are many, and while this is an advantage in that prostate cancer is such a common disease in men, it can also be a cause of great confusion. The following overview presents some information about these options, but it is not a complete explanation of any of these. You can find more information on treatment options in the NCCN Clinical Practice Guideline for Patients on Prostate Cancer for 2014 and the Physician Data Query (PDQ) website of the National Cancer Institute.

    Conventional medical treatment options for prostate cancer include:

    • Watchful waiting
    • Surgery
    • Radiation therapy
    • Cryotherapy
    • Hormonal therapy
    • Chemotherapy
    • Immunotherapy and other targeted therapies
    • Bisphosphonates and denosumab
    • Radiopharmaceuticals (radioactive substances used as drugs)
    • Research techniques including high-intensity focused ultrasound (HIFU) and others

    Watchful waiting

    This does NOT mean doing nothing about your prostate cancer. It means that rather than having the patient undergo aggressive treatments -- usually surgery or radiation therapy -- the urologist and the patient commit to a scheduled program of follow-up examinations, blood tests including PSAs, and repeat prostate biopsies at regular intervals. If the cancer shows signs of progression in the prostate gland, or the PSA starts to rise substantially, treatments are reconsidered.

    This approach is appropriate for patients with smaller amounts of low-grade prostate cancer. It is also appropriate in patients in whom other medical conditions, or age, or both, suggest an excessively high risk of potentially serious problems developing were aggressive therapy attempted.

    Surgery

    The removal of the entire prostate gland and the attached seminal vesicles is referred to as a radical prostatectomy. This is usually done through an incision or incisions made over the front of the lower abdominal wall with the procedure, taking place behind the pubic bones at the front of the pelvis (a retropubic approach). Today the main choice is between a standard open radical prostatectomy and the use of a robotic system for performance of the procedure through smaller incisions. The former allows the surgeon to feel the tissues and make the cuts themselves. The latter uses an operating system robot, which the surgeon guides. The former takes longer to recover from, and has more risk of blood loss associated with it. The latter results in a more rapid recovery and less blood loss generally.

    Intact pelvic nerve bundles on either side of the prostate in the pelvis are essential for a man to be able to have an erection. Impotence -- or the inability to have and sustain an erection of a quality sufficient for successful intercourse -- can occur after this operation. The likelihood of impotence is primarily dependent on whether or not the necessary nerves can be preserved during surgery, AND the patient's true preoperative ability to still have an erection. Nerve-sparing surgical technique is desirable and the surgeon should plan to do this, if possible. These important pelvic nerve bundles may need to be sacrificed if they are too close to or are involved with the cancer. The objective of the surgery is to cure the patient of the prostate cancer with the least number of problems afterward as possible, but the performance of a potentially curative procedure must remain the primary objective of the surgeon.

    The radical prostatectomy involves the removal of a portion of the urethra. The urethra is the tube that runs from the bladder to the outside through the penis. It runs through the prostate gland. The procedure can disrupt the sphincter or valve, which controls urine flow from the bladder. The surgeon reconnects the urethra to the bladder after the prostate is out. The more careful and experienced the surgeon, the less the risk of long-term inability to control the flow of urine (incontinence).

    The risks of an operation lasting several hours also remain substantial and include heart problems, blood loss, as well as a risk of infection, blood clots, and rarely death. Such operations are appropriate for patients whose cancer appears to be confined to the prostate gland.

    If a preoperative nomogram in a patient with a T1 or T2 tumor suggests a 2% or greater risk of lymph node metastases, then a pelvic lymph node dissection may be performed in addition to the radical prostatectomy. Pelvic lymph node dissection is unnecessary in almost half of patients undergoing radical prostatectomy.

    Radiation therapy

    Radiation therapy involves potentially curative treatment using machines that generate and administer controlled, invisible beams of energy known as radiation. This is called external beam radiation therapy (EBRT). It also can be done using radioactive sources, or seeds, implanted permanently, or higher energy sources placed temporarily into the body. This technique is called brachytherapy.

    An X-ray machine uses a low energy radiation beam to take a picture of a portion of the body. Radiation therapy machines put out high energy beams that can be focused very precisely to deliver treatment to a site. The radiation does not “burn out” the cancer, but damages the cells' DNA, which causes the cancer cells to die. This process can take some time to occur.

    The radiation passes directly through the tissues in EBRT. Radiation treatment used today delivers very little energy to normal tissues. It just passes through. Most of the energy is delivered directly to the area of the prostate gland containing cancer. This process minimizes damage to healthy tissue.

    EBRT can be administered in a variety of different ways including 3-D CRT, IMRT, and others. EBRT is classically administered in brief daily treatments, 5 days a week over several weeks. While the radiation does not remain in the body with this approach, the effect of the daily fractions is cumulative. Newer forms of EBRT using machines called CyberKnife may be completed in shorter periods of time.

    Radiation therapy to the prostate gland by external beam technique may cause fatigue and bladder and/or rectal irritation. These effects are usually temporary but may recur or persist long after treatments are finished. Radiation damage to adjacent tissues can cause skin irritation, and local hair loss. Delayed onset of impotence can occur after radiation therapy due to its effect on normal tissues including nerves adjacent to the prostate. Radiation therapy may be given alone or in combination with hormonal therapy which can also shrink up the prostate gland thereby reducing the size of the radiation area or field that needs to be treated.

    A recently popular technique of EBRT is called proton beam radiation, which can theoretically more closely focus on the area being treated. Proton beam radiation therapy is more expensive. Its side effects presently appear similar to those discussed for standard radiation therapy.

    EBRT is appropriate for men who are candidates for radical prostatectomy but do not wish to undergo the surgery. It is also used to shrink tumors and reduce pain in areas where prostate cancer is damaging bone, or is pressing on important structures including the spinal cord.

    Brachytherapy refers to the use of radiation sources -- sometimes referred to as seeds -- placed into the prostate gland. Brachytherapy may be done with what is called low-dose rate (LDR) technique. In LDR brachytherapy types of radioactive seeds, which only briefly put out a form of radiation which does not travel very far through tissues, are permanently implanted in the prostate gland. High-dose rate (HDR) brachytherapy involves the temporary placement of different types of seeds or sources which give off higher amounts of more penetrating radiation. These seeds administer higher doses of radiation for longer periods of time and cannot be left in the body. Such sources are placed in the prostate gland through surgically implanted tubes. These HDR sources are removed along with the tubes in a couple of days. In LDR brachytherapy, the seeds are placed in the operating room using image guidance to ensure the seeds go into the right places; 40 to 100 seeds may be placed. With LDR, you can go home shortly after you wake up after the procedure. In HDR, you must stay at the hospital for a few days. If the prostate gland is large, hormonal treatment may be used to shrink the gland before the brachytherapy is done. Brachytherapy may also be combined with external beam radiation therapy to further increase the dose of radiation therapy given to the prostate gland.

    Brachytherapy can cause some blood in the urine or semen. It can cause a feeling similar to constipation due to the swelling of the prostate gland. It can also make you feel that you want to move your bowels more often. There may be some long-term problems with irritation of the rectum, difficulty urinating due to scar tissue formation, and even delayed-onset impotence.

    Brachytherapy is appropriate for men with tumors staged T1 to T3 with PSA less than 20. It is not appropriate if you have had a prior procedure -- transurethral prostatectomy (TURP) -- which removes part of the prostate in cases of benign prostatic hypertrophy (BPH).

    Note: Radiation therapy can be performed if prostate cancer recurs in the region where the prostate was, and can potentially cure a locally recurrent prostate cancer if it has not spread beyond the area.

    If radiation fails to control the cancer, surgery is difficult -- if not impossible -- to perform due to scar tissue which develops in the area.

    Cryotherapy

    Cryotherapy is most frequently used as a salvage treatment after failure of radiation therapy. As an outpatient, hollow needles are placed into the prostate through the perineum (the space between the scrotal sac and the anus) under image guidance. A gas is passed through the needles to freeze the prostate. Warm liquid is passed through the urethra at the same time to protect it. The needles are removed after the procedure. While potentially effective for local control of cancer in the prostate gland, the side effects can be significant and include pain and the inability to urinate. Potential long-term effects include tissue damage in needle-insertion areas, impotence, and incontinence. Cryotherapy is not an appropriate primary treatment for management of prostate cancer.

    Hormonal therapy

    Prostate cancer is highly sensitive to the level of the male hormone testosterone, which drives the growth of prostate cancer cells in all but the very high-grade or poorly-differentiated forms of prostate cancer. Testosterone belongs to a family of hormones called androgens, and today front-line hormonal therapy for prostate cancer is called androgen deprivation therapy (ADT).

    Doctors can block the function of the testes in a controllable and REVERSIBLE fashion with drugs which affect the hormone system of the body and stop the main driver of the testes, the pituitary gland at the base of the brain, to stop stimulating the testes to make testosterone. These agents can result in shrinkage of the prostate gland, can stop prostate cancer cells from growing for up to many years, and can relieve pain caused by prostate cancer which has spread or metastasized into the bones.

    Hormonal treatment today is primarily used in the treatment of locally advanced and metastatic prostate cancer. It can be combined with radiation therapy in attempts to cure prostate cancer. Its primary role is in the treatment of widespread or metastatic prostate cancer. While it is not a curative treatment in that setting, it can both reduce symptoms and prolong life.

    Today medicines used to block testosterone production by the testes include:

    • LH-RH agonists: Leuprolide (Lupron), goserelin (Zoladex), histrelin (Supprelin LA), and triptorelin (Trelstar) are examples of

      Source: http://www.rxlist.com

    The PSA test is a tool for use by your doctor but it is not a perfect way to tell whether or not a patient has prostate cancer because is not sensitive enough to pick up all prostate cancers. It is not specific enough in that it may be elevated in people without prostate cancer, such as those whose prostate glands are infected, or just inflamed, but not cancerous. It is also elevated for days after a digital rectal exam, or after ejaculation. Nevertheless, it accurately measures the amount of PSA in the blood.

    The interpretation of the PSA result must be done with care. PSA results must be, for example, interpreted in the context of the patient's age. Younger men (under 70, and definitely under 60) may have either more aggressive prostate cancers, or more life to lose if not evaluated aggressively. Conversely, men over 70 often have more indolent or slow-moving prostate cancers, or other medical conditions which may be greater threats to their lives over the next 10 years than may prostate cancer, and thus less aggressive evaluation and treatment may be warranted. The test is best used to establish a pattern in a man with serial measurements obtained over years.

    Doctors probably only find the more aggressive prostate cancers. The disease is common as men age. It is estimated 16% of men will be diagnosed with prostate cancer in their lifetime and yet only 3% will die of it. Many men likely have small prostate cancers present by the time they are over 60 years of age, with estimates ranging from 30% to 40% having prostate cancer cells in their prostates. The presence of these small cancers also likely further increases with age. Most of these cancers are very slow-growing and not aggressive in their tendency to spread as they are never discovered or symptomatic during the men's lives. Diagnosing these prostate cancers may only increase the cost and result in treatment-related complications in these men.

    Talk to your doctor about the risks and benefits of having PSA testing if you are 40 years of age with a family history of prostate cancer (or age 50 if you do not have a family history), or are of African American ancestry. The test results should be considered in the context of the man's urinary symptoms, if any, his family history, his race and ethnicity, his diet, weight, and physical findings. Further there should be attention given to the pattern of change in his serial PSA measurements.

    Numerous different ways to refine the use of PSA testing have been attempted. Some of these include evaluations of the:

    • PSA doubling time, which refers to how long it has taken for the PSA to double.
    • PSA velocity, which looks at how rapidly the PSA values have changed over time.
    • PSA density, which looks at the PSA result and considers the prostate gland volume as determined on ultrasound evaluation.
    • PSA fractionation, which is another test that measures the amount of free PSA versus protein-bound PSA in the bloodstream. The lower the percentage of free PSA, the higher the risk of cancer.

    In patients with prostate cancer whose PSA was initially elevated, the PSA is an excellent tool to assist in care and follow up both during and after treatment.

    Source: http://www.rxlist.com

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