One out of nine American men will be diagnosed with prostate cancer in their lifetime
Prostate cancer is the most common cancer among men in the United States.
Probability of developing cancer, 2013-2015
About the prostate
The prostate is a small-sized gland that is part of the male reproductive system. The prostate is about the same size and shape as that of walnut. It is located just behind the base of a penis, below the bladder, and anterior to the rectum. The urethra, a fibromuscular tube that carries semen and urine, runs through the center of the prostate, from the bladder to the penis, letting urine flow out of the body. The crucial function of the prostate is to secrete a fluid that nourishes and protects sperm. In humans, prostate secretion usually constitutes roughly 30% of the volume of semen, while the other 70% being sperm and seminal vesicle fluid.
There are 3 main ways in which the prostate can cause medical problems:
- Prostatitis: Which is inflammation of the prostate and is usually secondary bacterial infection.
- Benign prostate hyperplasia (BPH): BPH refers to an enlargement of the prostate size which may result in blockage of the urethra and urine flow. It is a very common condition as men get older and can cause difficulty with urination. BPH symptoms may include trouble starting to urinate, weak urine stream, dribbling of urine, needing to stop and start urinating several times, and feeling that the bladder is full, even right after urinating.
- Prostate cancer: Which is a form of cancer that develops in the prostate gland.
About prostate cancer
The term cancer generally means uncontrolled cell growth. Similarly, in the case of prostate cancer, the healthy prostate cells undergo some change, and subsequently, these cells divide uncontrollably. Prostate cancer cells can spread by breaking away from a prostate tumor. They can travel through blood vessels or lymphatic system to reach other parts of the body (most commonly lymph nodes and bone). After spreading, cancer cells may attach to other tissues and grow to form new tumors, causing damage where they land.
Most of cancer has a deleterious effect on the organs, and they spread quickly throughout the body. But the prostate cancer is different from other cancers because the cancerous tumor of the prostate doesn’t spread as quickly as other cancers throughout the body. Some of them grow very slowly, and they won’t even show any problems or symptoms for a long period of time. Sometimes the prostate can be easily managed even if cancer has been escalated to other organs as well. This allows men who are at an advanced stage of the prostate to live a healthy life for many years. But there are often times when prostate cancer cannot be managed by advanced techniques and treatments. In this case, cancer can cause fatigue and pain and in some cases, it can lead to death. Therefore, prostate cancer should be managed and monitored properly. The best practice is to have the prostate checked by the doctor and on the basis of the growth pattern, the doctor can suggest the treatment. The important thing is to monitor the prostate’s growth periodically to determine the rate of growth.
About PSA (Prostate-Specific Antigen)
PSA or Prostate-specific Antigen is a protein that is produced exclusively by the cells present in the prostate gland, and these antigens are then released in the bloodstream. The PSA levels can be easily measured with a simple blood test. The PSA level in a man can help in determining the early stages of Prostate cancer. There is no specified normal PSA level, but an unusual higher PSA level is found in prostate cancer patients. PSA levels can also be higher due to some other reasons, as well, like ejaculation can lead to a temporary increase in PSA levels, therefore before checking the PSA levels, ejaculation should be avoided. Several non-cancerous conditions in prostate like prostatitis or BPH can also increase the PSA level. Therefore, PSA measurement is considered a screening tool rather than a diagnostic test, and in case of elevated PSA further workup is warranted.
Risk factors, as the name suggests, are the factors that increase the possibility of developing any kind of cancer in an individual. The cancer is not directly caused by risk factors; they just influence the possibility of developing cancer. Knowing and talking about your risk factor with the doctor is beneficial, and it will help your physician with his medical decision-making process. In some cases, there is no cancer development despite having various known risk factors, but in some cases, there is cancer development without having any known risk factors.
Several risk factors linked with the development of prostate cancer are:
- Age: Prostate cancer is rare in men younger than 40, but the possibility of having prostate cancer rises rapidly after age 50. More than 60% of new prostate cancer diagnosis is in men older than 65.
- Family history: Prostate cancer seems to run in some families, which suggests that in some cases there may be an inherited or genetic factor. Epidemiological studies have shown that having a first-degree relative (brother or father) with prostate cancer is associated with an approximately two- to three-fold increased risk of prostate cancer in an individual. Risk is further increased by early age at onset in relatives and multiple relatives with the disease. However, still, most prostate cancers occur in men without a family history of it.
- Race/Ethnicity: Black men are more prone to prostate cancer than white men. They have more chances of developing prostate cancer in earlier ages, and their tumors are likely to be more aggressive, which grows quickly. The real reason for this phenomenon is yet to be discovered. Similarly, Non-Hispanic white men have a high risk of developing prostate cancer than Hispanic white men. Non-Hispanic men also have a higher chance of dying due to the disease than Hispanic men.
On the basis of geographic location, prostate cancer is more common in North America, northwestern Europe, Australia, and on Caribbean islands. It is less common in Asia, Africa, Central America, and South America. In general, the risk of developing prostate cancer is higher in men having an unhealthy lifestyle and in men who perform less physical activity.
- Exposure to Agent Orange: The United States Department of Veterans Affairs has verified that Agent Orange’s exposure is associated with the development of Prostate cancer. Agent Orange is a chemical that was widely used during the war with Vietnam. Therefore veterans who fought in Vietnam far have a higher chance of developing prostate cancer, and they are advised to monitor the prostate with the help of the doctor.
- Eating Habits: There is no strong evidence that directly relates the nutrition intake and diet with the development of prostate cancer. But there are some studies that dealt with certain links between cancer and eating behavior like many cancers like breast cancer, prostate cancer, etc. are associated with obesity. Therefore, a healthy and nutritious diet is recommended to avoid obesity.
- Hereditary Breast and Ovarian Cancer (HBOC) syndrome: The mutation in the BRCAI or BRCA2 genes which changes the DNA-repair mechanism s associated with HBOC. Generally, HBOC is associated with a higher risk of ovarian and breast cancer in women, but men associated with HBOC are prone to developing aggressive prostate cancer and breast cancer. Screening of prostate cancer is recommended to men having mutations in BRCA1 and BRCA2 genes. Familial Prostate cancer can also be rarely developed due to the mutations in BRCA2 and BRCA1 genes. In the above cases, talking to a doctor or a genetic counselor necessary.
Many factors are associated with the development of any type of cancer. Extensive research is being done in the field of cancer, and still, there is no solution to prevent this disease completely, but there are ways to lower the risk.
There is not enough strong evidence that gives a clear relation between eating behavior and prostate cancer. However, keeping a healthy diet is always beneficial for one’s health, and in the case of prostate cancer, studies suggest that certain eating habits may help.
If you want to reduce your risk of prostate cancer, consider trying to:
- Choose a low-fat diet. Diet containing food rich in fat, mainly animal fat (trans fats and saturated fats) can increase the chance of developing prostate cancer. While the intake of healthy fats such as omega-3 fatty acids from nuts, seeds, and fish may be beneficial.
- Increase the amount of fruit and vegetables you eat each day. Eating food rich in legumes, fruits, and vegetables like peas and beans can lower the chances of the development of prostate cancer. The data obtained so far from the studies have no conclusive relationship, but it is believed that lycopene, a nutrient present in tomatoes, is responsible for lowering the chance of developing prostate cancer.
- Making dietary changes in the earlier stages of life can affect the risk of developing prostate cancer.
Maintain a healthy weight
- Men with obesity (a body mass index (BMI) of 30 or higher) may have an increased risk of prostate cancer. In general, losing weight and maintaining a healthy weight as you age can help reduce your risk of cancer and many other health problems.
Physical activity and regular exercise
- In addition to helping you achieve a healthy weight, exercise can reduce inflammation, improve immune function. Several studies showed that men who regularly exercise may have a reduced risk of prostate cancer.
Screening is a method that is used to look for cancer before any signs or symptoms. If the cancer is found early, it should be at an early stage, and cancer can be successfully treated at early stages. Many methods have been developed over the years to screen a person according to the type of cancer.
Screening for prostate cancer
Two techniques have been developed to screen prostate cancer in a healthy man:
- Prostate-Specific Antigen (PSA) blood test: PSA is a protein made by normal, as well as malignant cells of the prostate gland. The PSA test measures the level of PSA in a man’s blood. The PSA level is often elevated in men with prostate cancer. In 1994, the FDA approved the use of the PSA test in conjunction with a digital rectal exam (DRE) to screen men for prostate cancer. Many doctors use a PSA cutoff point of 4 ng/mL or higher when deciding if a man might need further testing.In addition to prostate cancer, a number of benign (not cancerous) conditions can cause elevated PSA in men. The most frequent benign prostate conditions that cause an elevation in PSA levels are prostatitis (inflammation of the prostate) and benign prostatic hyperplasia (BPH). Other factors like age, urinary tract infection, ejaculation, riding a bicycle, and any recent urologic procedure may also increase the PSA level.Accordingly, the PSA test is considered a screening test but not a diagnostic test. However, elevated PSA in an appropriate setting can be an indication to perform diagnostic work up to look for prostate cancer.
- Digital Rectal Examination (DRE): This is a physical examination to check the growth of the prostate. The doctor checks the prostate’s surface for any unevenness by inserting a lubricated, gloved finger into the rectum.PSA screening is not recommended by ASCO for men who have a life expectancy of fewer than 10 years. If it is more than 10 years, ASCO suggests consulting a doctor to check whether the test is appropriate or not. Other organizations recommend the following things:
- The United States Preventive Services Task Force (USPSTF) states that PSA is more prone to risk, and men above 70 shouldn’t have PSA screening to check Prostate cancer. While for the men between the ages of 55 and 69, they can consult the doctor for the procedure.
- National Comprehensive Cancer Network takes various factors into consideration like PSA value, patient’s age, DRE results, and several other factors.
- American Cancer Society and the American Urological Association recommend that men need to know about the benefits and risks of PSA and then proceed with any kind of procedure.
The best practice is to discuss with your doctor before undergoing any kind of procedure and have a mutual decision about what procedure would be the best for you.
Symptoms can be seen in the later stages of prostate cancer. In the early stages, there are no signs or symptoms. This is precisely why screening for prostate cancer is so important. Some of the symptoms are:
- Frequent Urination
- Weak Urine Flow
- Frequent urination during the night
- Blood in seminal fluid
- Pain during urination, this is a rare symptom
- Pelvic or perineal pain or discomfort
- Blood present in the urine
These symptoms mentioned above are not specific to prostate cancer. They can also be caused by non-cancerous conditions alike. The urinary symptoms can be due to bladder infections, prostatitis, as well as other medical conditions. If prostate cancer spreads (metastatic disease), the following signs and symptoms can manifest:
- Swelling in the feet or legs
- Pain in shoulders, thighs, hips or back
- Change in bowel movements
- Unexplained weight loss
If you or your loved one experiences any of the above changes or symptoms, it is imperative to let your doctor know immediately. Prompt diagnosis, symptom management, and supportive care are crucial to appropriate treatment. We are here to answer any and all questions as well as guide you through each step of workup, diagnosis, and treatment.
Many tests and techniques are used by physicians to diagnose or detect cancer. Doctors also check whether cancer has spread to other parts of the body; this spreading phenomenon is called metastasis.
The primary diagnostic tool to detect the presence of prostate cancer is the transrectal ultrasound-guided biopsy of the prostate. This minimally invasive procedure allows your Urologist to sample several “cores,” or pieces of prostate tissue, and send them for pathological analysis. The biopsy is routinely performed in the office with minimal patient discomfort. We do have a multitude of adjunct tests that can help aid in the diagnosis and prognosis of prostate cancer (i.e. Urine and blood tests).
Preliminary testing along with the physical examination are the key components to diagnose prostate cancer. Some of the preliminary exams are:
- PSA test: As described above, PSA is a protein produced exclusively by prostate and PSA level can help in diagnosing any unusual activity in the prostate. Looking at certain features of the PSA like PSA velocity (rate of PSA rise), PSA density (value according to the prostate size), and percentage free PSA, your Urologist can recommend further tests for diagnosis.
- Free PSA test: The majority of PSA is bound to protein in the bloodstream while a relatively small amount remains “free” or unbound. The ratio of free PSA to total PSA can be measured using the Free PSA test. This ratio can sometimes be helpful in determining the possibility of prostate cancer.
- Biomarker test: A biomarker is produced by the body as a response to the presence of cancer or by the tumor itself. It is also known as a tumor marker. It can be found in urine, blood, and tissues affected by cancer. Various tools are now available to ascertain specific markers unique to prostate cancer (i.e. 4kscore, Urine DNA- methylation tests, gene analysis, etc.). These tests help the Urologist to stratify patients by risk and give advice on prognosis.
- DRE: Also known as the digital rectal exam, is a physical examination in which a doctor uses a gloved figure covered with lubricant to manually feel the prostate to identify any abnormality- namely nodules, asymmetry, or induration (a hard area). These abnormalities often correspond to the presence of prostate cancer.
- Transrectal Ultrasound (TRUS): Here, a picture of the prostate is taken using sound waves that are reflected from the prostate. A probe is inserted into the rectum for this procedure. The size of the prostate, as well as abnormalities within the tissue, can be identified using this imaging method.
Confirming the Diagnosis
Following preliminary testing, additional diagnostics are required to confirm the presence of cancer:
- Prostate Biopsy (trans-rectal US guided): This is the test that definitively confirms the presence of cancer. In a biopsy, representative sampling is taken from the tissue and examined under the microscope. The sample is removed from the prostate using a biopsy needle under ultrasound guidance (TRUS). Usually, 12 pieces of tissue or “cores” are taken from several parts of the prostate to ensure appropriate sampling. The procedure takes only 10-15 minutes. Prior to the procedure, patients are given antibiotics to prevent infection. Local anesthesia is administered to aid in patient comfort. After the procedure, a pathologist will analyze the tissue cores and provide the final diagnosis. The procedure is well tolerated in an office setting.
- MRI Fusion Biopsy: This is a combination of MRI scans and TRUS. The MRI scan identifies suspicious areas in the prostate, and then ultrasound is performed. Computer software maps a 3D image which helps in targeting the area for biopsy.
Finding Out If Cancer Has Spread
Imaging tests help the Urologist determine whether cancer has spread beyond the prostate. This is known as metastasis.
- Whole-Body Bone Scan: Here, Technetium-99, a radiotracer, is used to examine the entire skeleton. The radioactive tracer is inserted in the vein, and it accumulates at the site of recent metabolic activity in the bone(s)- this corresponds to cancer implants in bone and confirms the metastatic disease.
- Computed Tomography (CT scan): X-ray is used to create 3D images of the body to reveal the location of the tumor spread to various organs or lymphatic tissue (lymph nodes). A contrast medium is used to increase accuracy and provide greater detail. Local prostate tumor invasion can sometimes also be seen on a CT scan.
- MRI (Magnetic Resonance Imaging): Here powerful magnets are employed to produce a strong magnetic field for detailed imaging. Contrast medium can also be used for more detailed images, and tumor size can be determined using MRI.
A Urologist will help interpret the results of the above studies to guide and tailor an individualized treatment course for each patient.
Staging is used to determine the extent of cancer both locally in the prostate as well as beyond the prostate (i.e. metastasis). Diagnostic tests as described previously help the Urologist accurately stage cancer. This process dictates what treatment would be best for the patient, and it also helps in the prediction of the patient’s overall prognosis. For prostate cancer staging is of 2 types:
- Clinical Staging: This is determined on the basis of PSA, DRE, and prostate biopsy. Need for further testing and, ultimately, treatment is based on clinical staging
- Pathologic Staging: This staging is based on the information gained during surgery from the final pathology. During prostate surgery, lymph nodes can be removed and examined under the microscope. This can provide more diagnostic and prognostic information.
TNM Staging System
This system is used to describe the stage of Prostate cancer.
- Tumor (T): The size of the primary tumor and its location.
- Node(N): The development of the tumor in the lymph node.
- Metastasis(M): Where and how much cancer has spread to other parts of the body.
The results from previously mentioned tests are combined to find the stage of cancer. Accurate staging can help the doctor decide the type of treatment required.
The letter ‘T” along with a number describes the location and size of the tumor. There are some subdivisions as well for more details. Some of the stages are:
TX: The tumor’s location and size cannot be evaluated.
T0: No proof of the presence of a tumor.
T1: In this stage, the tumor is not identified using imaging tests or DRE, but it is incidentally discovered during benign prostate surgery (i.e. transurethral resection of the prostate- TURP) or based on elevated PSA.
- T1a: Less than 5% tumor present in TURP specimen.
- T1b: More than 5% tumor present in TURP specimen.
- T1c: Needle biopsy (TRUS guided prostate biopsy) is used to determine cancer presence. An elevated PSA prompts the biopsy.
T2: In this stage, the tumor is palpated using DRE.
- T2a: One-half of one side of the prostate is involved in the tumor.
- T2b: More than one-half of one side of the prostate is involved in the tumor.
- T2c: Tumor is present on both sides of the prostate.
T3: The tumor has spread locally just outside the prostate.
- T3a: EPE (Extraprostatic Extension) is present indicating that cancer has spread outside of the capsule of the prostate.
- T3b: Tumor is present in seminal vesicles.
T4: In this stage, the tumor is either fixed or it invades adjacent structures other than seminal vesicles (i.e., bladder, levator muscles, and/or pelvic wall).
Pathological T (No T0, T1 or TX classification)
T2: The tumor is present in the prostate only.
T3: Extraprostatic Extension is present.
- T3a: Either EPE or the bladder’s neck has been invaded by a tumor.
- T3b: Growth of tumor into seminal vesicles.
T4: The tumor is either fixed, or it gets spread into nearby organs except for seminal vesicles.
The ‘N’ delineates lymph nodes. These are the small bean-shaped organ that helps in fighting infection. There are two categories of lymph node spread: Regional and Distant. Regional lymph nodes are found near the prostate in the pelvis, while the latter is present in other parts of the body.
NX: Evaluation of regional lymph nodes cannot be done.
N0: Cancer is not present in the regional lymph nodes.
N1: Regional lymph node(s) has been invaded by cancer.
This is used to indicate the growth or spread of cancer into other parts of the body.
MX: Evaluation of distant metastasis cannot be done.
M0: The disease has not spread.
M1: Distant Metastasis is present.
Gleason Score for Grading Prostate Cancer
Gleason score is based on the analysis of the cancerous tissue under a microscope. Less aggressive cancer has a low Gleason score as the cells look more like normal healthy tissue. More aggressive cancer has a high Gleason score and doesn’t look like healthy tissue. Two locations are scored on a scale from 3 to 5, and then both values are added to get an overall score, which lies between 6 and 10.
- Gleason 6 or lower: The cancer is low grade and will likely grow slowly.
- Gleason 7: The cancer is intermediate grade.
- Gleason 8, 9 and 10: The cancer is high grade.
Cancer Stage Grouping
The stage is determined using the TNM system, as well as grade group and PSA level. This system is helpful with risk stratification.
Stage 1: Cancer grows slowly, low PSA level, and the tumor is present only on one-half of one side of the prostate or even less. Well-differentiated cancer cells are present.
Stage 2: Low or medium PSA level, tumor present only in the prostate. High risk of spreading and growing.
- Stage 2A: Medium PSA levels, well-differentiated cancer cells, and the tumor are only on half of one part of the prostate. Large tumors are also included if cells are well differentiated.
- Stage 2B: Tumor is present only in the prostate, and it can be determined using DRE. Moderately differentiated cancer cells and medium PSA levels.
- Stage 2C: Tumor is present only in the prostate, and can be found during DRE. Poorly or moderately differentiated cancer cells and medium PSA levels.
Stage 3: High PSA level, high-grade cancer, and the tumor continues to grow. The cancer is more likely to spread.
- Stage 3A: High PSA level and nearby tissue are invaded due to the growth of cancer. Cancer can also spread in seminal vesicles.
- Stage 3B: Rectum or Bladder might be invaded by cancer.
- Stage 3C: Poorly differentiated cancer cells.
Stage 4: Cancer has advanced and spread to other organs.
- Stage 4A: Spreading of cancer into regional lymph nodes.
- Stage 4B: Spreading of cancer into distant lymph nodes and/or other organs in the body.
Recurrent: If cancer returns after treatment, it is called recurrent prostate cancer. It might return within the prostate in cases of radiation therapy or the area where the prostate used to be in cases where surgery was the primary treatment. Sometimes cancer can return to other organs of the body. The same set of tests and scans are performed to diagnose, and the treatment is decided according to these imaging and blood test results.
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