Frequently Asked Questions About Prostate Cancer
Prostate cancer is the process in which cells begin to grow abnormally and crowd out healthy cells. As the abnormal cells multiply, they form a malignant (cancerous) growth or tumor. Prostate cancer is the most common cancer in men after skin cancer. More than 230,000 men in the U.S. will be diagnosed with prostate cancer every year. However, 30,000 men die of the disease every year.
Thanks to better screening methods and greater awareness, prostate cancer is being detected much earlier. That is giving men more options for treatment and leading to better survival rates and an improved quality of life. The American Cancer Society estimates that some 2 million men who have been diagnosed with prostate cancer are leading active lives today.
Not all growths in the prostate are cancerous; some can be benign or non-cancerous. A non-cancerous growth is called benign prostatic hyperplasia (BPH) disease. BPH is a very common condition in men over age 50. It requires treatment, but it is not malignant.
The prostate is a small walnut-size gland in men that is part of the reproductive system. It helps produce seminal fluid, the fluid that carries semen out of the body during ejaculation. The nerves that control erections found alongside and immediately adjacent to the prostate. These are the nerves that are preserved during surgery to enable a man to continue to have erections.
The prostate is located in front of the rectum which is why it can be felt during a physical exam at the doctor’s office. It is also positioned under the bladder, where it surrounds the upper part of the urethra. The urethra is the long tube through which urine and semen flow out of the penis. If the prostate becomes enlarged or inflamed, it can put pressure on the urethra and interfere with normal urine flow.
Risk factors are circumstances or actions that increase a man’s potential for developing cancer. Some risk factors are modifiable, such as smoking, diet and exercise. Others, including age, race and family history are beyond individual control. It is important to remember that even if a man has one or more risk factors, it does not mean he will develop prostate cancer. However, each man should talk with his physician about whether he would benefit from earlier and more frequent screening.
The risk factors for prostate cancer include:
- Age: The incidence of prostate cancer increases for men age 65 and over. Prostate cancer is rare in men younger than age 40, but can affect one in six men between ages 60 and 79.
- Race: Men of African-American heritage are at higher risk for prostate cancer than Caucasian, Hispanic or Asian men. African-American men are also more frequently diagnosed with advanced stage disease and they have lower survival rates.
- Family History: The risk of prostate cancer increases sharply when a first-degree relative (a father, brother or uncle) has been diagnosed with the disease, especially at a young age. The risk increases further with more relatives diagnosed with prostate cancer.
- Lifestyle Factors: Some research has shown a link between a high-fat diet and prostate cancer.
The goal of prostate screening is to detect prostate cancer as early as possible, ideally at a manageable and even curable stage. Prostate cancer screening is composed of both a digital rectal examination and a serum PSA. Both of these are important in the screening process, and an abnormality in either of these warrants further evaluation. Roughly 20% of prostate cancers are found by rectal examination; most are detected by an abnormal PSA.
Prostate cancer screening should be performed on a yearly basis, except for men with an initially low PSA level who may want to consider screening on an every-other-year basis. As you continue with screening on a yearly basis, changes in the PSA (beyond what is believed to be a change caused by a benign growth of the prostate) or rectal examination will prompt further evaluation. It is hoped that through the use of prostate cancer screening, the morbidity and mortality associated with prostate cancer will be diminished. More recent studies are showing increased survival as a result of prostate cancer screening.
At this point, Medicare covers annual digital rectal examination and PSA for qualified Medicare patients aged 50 and older. Most health insurance providers are also providing similar coverage. The costs of the various treatments for prostate cancer vary from institution to institution. Most HMOs cover treatment of prostate cancer if the treatment is performed by an HMO-affiliated physician.
If you received care outside of the HMO system, then you may be responsible for the cost of your treatment. If you have questions regarding insurance coverage, it is always best to check with your insurance company before you start screening and treatment to make sure that you are fully aware of your coverage and its possible limitations.
After your prostate biopsies have been obtained, they are sent to the pathologist, a doctor who specializes in the diagnosis of disease by studying cells and tissues under the microscope. The pathologist looks at the cells in the prostate biopsy specimens to see if they appear normal or not.
The pathologist may identify normal-appearing prostate cells, prostatitis, benign prostatic enlargement, or cancerous cells. If cancerous cells are present, then the pathologist will look closely at the cells and assign a Gleason grade and score. The Gleason grading system helps describe the appearance of the cancerous cells and may affect your prognosis. In addition to the Gleason grade and score, the pathologist will also comment on how much of each biopsy specimen had prostate cancer cells in it; this, too, may affect your prognosis.
By staging your cancer, your doctor is trying to assess, based on your prostate biopsy results, your physical examination, your PSA, and other tests and x-rays, whether your prostate cancer is confined to the prostate, and if it is not, to what extent it has spread.
Studies of large numbers of men who have undergone radical prostatectomy and pelvic lymph node dissections have established some guidelines regarding the likelihood of prostate capsular involvement and lymph node metastases. Patients may be asked to obtain a prostate MRI to evaluate the surrounding tissue depending on the grade and stage of the cancer.
Knowing the stage (the size and the extent of spread) of the prostate cancer helps the doctor counsel you on treatment options. USMD Prostate Cancer Center follows the American Urological Association “T” staging system for prostate cancer:
- T1 – tumor is visible or can be seen with imaging.
- T1a – cancer was found during treatment for benign prostate enlargement but is present in less than five percent of the tissue and has a low-grade Gleason score.
- T1b – cancer was found during treatment for benign prostate enlargement but is present in more than five percent of the tissue and has a higher grade Gleason score.
- T1c – cancer was diagnosed from a biopsy due to an elevated PSA lab test.
- T2 – tumor can be felt during a digital rectal exam but appears to be confined to the prostate.
- T2a – cancer is found in one half or less of the left or right side only of the prostate.
- T2b – cancer is found on both sides of the prostate.
- T3 – cancer has begun to spread outside the prostate and may include the seminal vesicles.
- T3a – cancer has spread outside the prostate but not to the seminal vesicles.
- T3b – cancer has spread to the seminal vesicles.
- T4 – cancer has spread to nearby organs.
The decision to undergo treatment of any kind rests in the hands of the patient, and it is our job as physicians to provide you with the information that will allow you to make that decision. When forced to make a difficult decision, we often rely on loved ones, close friends and knowledgeable individuals to help us, but these people do not have to live with the effects of that decision. As you weigh the pros and cons of each of the various treatment options, it is very important that you think of how they will affect you. Now is the time to be very honest with yourself about what side effects you can and cannot tolerate.
It is your physician’s responsibility to accurately inform you of the likelihood of side effects of each of the treatment options and the remedies that are available to treat those side effects. When faced with a diagnosis of prostate cancer, the first impulse may be to get rid of cancer at any cost. Unfortunately, once the prostate cancer has been treated and the worry quiets down, the side effects of the treatment can become more bothersome– so you should think seriously about them beforehand. Many patients can be managed conservatively with lower grade prostate cancer, but there are some inherent risks with surveillance as well as treatment. Make sure that your physician covers all of these treatment modalities with you. Guidelines do exist to help patients reach a decision and one such example is the NCCN Guidelines.
If your primary care provider is performing your prostate cancer screening and detects an abnormality in your PSA and/or rectal examination, he or she may refer you to a urologist or to a urology practice for further evaluation. When choosing a urologist for your prostate biopsies, you should consider a urologist who deals with prostate cancer on a regular basis. Several issues should be considered with you select a physician:
- You want a capable doctor who is knowledgeable and can apply that knowledge.
- Technical skills. If you are planning to have prostate cancer surgery, you want to select an individual who performs a lot of radical prostatectomies. The urologist should know his or her own complication rate (a complication is an undesirable result of treatment) and success rate and should feel comfortable discussing these with you. The old dictum “practice makes perfect” holds true to some extent.
- Cancer is a scary word and disease no matter how you look at it. You want a physician who understands this and is willing to take the time to help you make your management decision so that you will feel comfortable with your decision.
- As you go through the decision-making process, you want to be able to ask questions of your physician and have these questions answered in a timely manner. Delays in diagnosis and treatment only add to your anxiety.
These same concepts apply in your choice of an oncologist or radiation oncologist. Friends who have prostate cancer may also be able to assist you with the identification of a urologist, oncologist or radiation oncologist who specializes in the treatment of prostate cancer.
Watchful waiting is following prostate cancer conservatively with no plan for intervention in the future. This is ideally suited for men with a less than 10-year life expectancy with lower-risk of prostate cancer. This is in contrast to active surveillance which surveils the patient with prostate cancer closely with serial PSA readings, digital rectal exams and sequential prostate biopsies to ensure the patient continues to remain at low risk for progression. Rather than treating the cancer immediately, the physician monitors the PSA value at various intervals to assess whether it is increasing and at what rate (the PSA velocity). Ideally, the patient and the physician identify a point at which therapy would be instituted and the patient is monitored without therapy until he changes his mind or that point is reached.
Active surveillance is ideally suited for patients with low risk and lower grade (Gleason score < 6) prostate cancer. In these individuals, it is less likely that prostate cancer will be the cause of their death. With more patients considering active surveillance as an approach for prostate cancer, it has become increasingly important to ensure these patients are not harboring a higher grade or higher volume of prostate cancer during this surveillance process.
Radical prostatectomy is the surgical procedure whereby the entire prostate is removed, as well as the seminal vesicles, the section of the urethra that passes through the prostate, the ends of the vas deferens, and a portion of the bladder neck. Currently, over 85% of all radical prostatectomy surgeries in the United States are performed as robotic prostatectomies. After the prostate and surrounding structures are removed, the bladder is then reattached to the remaining urethra. A catheter, which is a hollow tube, is placed through the penis into the bladder before the stitches that attach the bladder to the urethra are tied down. The catheter allows urine to drain while the bladder and urethra heal together.
Laparoscopic radical prostatectomy is a relatively new procedure that has the advantages of a retropubic approach, but because there are several small abdominal incisions as opposed to the longer midline incision, the discomfort is less and the recovery is quicker with this approach.
External-beam radiation therapy (EBRT) is the use of radiation therapy to kill or inactivate cancer cells. The total radiation dose is given in separate individual treatments, known as “fractionation.” Cancer cells are most sensitive to radiation at different phases in their growth. By giving the radiation on a daily basis, the radiation oncologist hopes to catch the cancer cells in the sensitive phases of growth and also to prevent the cells from having time to recover from the radiation damage. Conformal EBRT uses CT images to help better visualize the radiation targets and the normal tissues; with three-dimensional images, the radiation oncologist can identify critical structures, such as the bladder, the rectum and the hip bones. This allows the radiation oncologist to deliver more radiation to the prostate tissue but reduce the amount of normal tissue that is irradiated.
The advantage of conformal EBRT over EBRT is that conformal EBRT causes less rectal and urinary irritation. The construction of an immobilization device and the placement of the small, permanent tattoos ensure that you are properly positioned for the radiation treatment each day. Through the assistance of computers, the radiation to the prostate and surrounding tissues and the computer determine the appropriate beam configuration to create this desired distribution.
The side effects of EBRT or conformal EBRT can be either acute (occurring within 90 days after EBRT) or late (occurring over 90 days after EBRT). The severity of the side effects varies with the total and the daily radiation dose, the type of treatment, the site of treatment, and the individual’s tolerance. The most commonly noted side effects include changes in bowel habits, bowel bleeding, skin irritation, edema, fatigue, and urinary symptoms, including dysuria, frequency, hesitancy, and nocturia. Less commonly, swelling of the legs, scrotum or penis may occur. Late side effects include persistence of bowel dysfunction, the persistence of urinary symptoms, urinary bleeding, urethral stricture and erectile dysfunction.
Cryosurgery is a technique used for prostate cancer treatment that involves controlled freezing of the prostate gland. This procedure is performed under anesthesia. Transrectal ultrasound evaluation (similar to that used with your prostate biopsy) is used throughout the procedure to visualize the prostate and to monitor the position of the freezing probes, which are placed through the perineal skin (the area below the scrotum and in front of the anus) into the prostate. During the freezing, the transrectal ultrasound demonstrates an “ice ball” in the prostate. The freezing process kills both hormone-sensitive and hormone-insensitive cancer cells. Proper positioning of the probe may allow one to kill cancer cells even at the edge of the prostate, the prostate capsule.
During the freezing, a catheter is placed into the urethra, and a warming solution is run through the catheter to protect the urethra from freezing. Despite this, irritation of the urethra and/or bladder can occur and may lead to frequency, urgency, burning, pain with urination, and blood in the urine. Similarly, irritation of the rectal wall may occur, leading to blood in the stools, rectal pain, and pain with bowel movements. Up to 80% of men undergoing cryosurgery can have troubles with erectile dysfunction, and an increased incidence occurs in men in whom attempts were made to include the prostate capsule in the freezing. Less commonly seen side effects include urethral scar formation, trouble urinating that requires a TURP and urinary incontinence.
A serious complication of cryosurgery is a urethrorectal fistula, a miscommunication between the urethra and the rectum, which can lead to leakage of urine from the rectum and urinary tract infections. With 3rd generation cryoablation technology, the risk of fistula formation has become exceedingly rare. Currently, cryosurgery is being used as primary therapy and for salvage therapy (a procedure intended to “rescue” a patient after a failed prior therapy) for men who fail to respond to EBRT or interstitial seeds. Ideal candidates are men with a Gleason score < 8 and a PSA <10 with cancer localized to the prostate.
Prostate cancer, like all cancers, does not “play by the rules.” It does not reach out to areas outside of the prostate in a straight line such that if no cancer is present at the edge of the prostate then no cancer exists at all outside of the prostate. Cancer cells may remain in the pelvis, get into the bloodstream, or be present in the bones and not grow quickly enough for them to be noticed for several years. In the strictest sense, a cancer is considered to be “cured” when there is no evidence of any cancer ten years after treatment. This seems like an awfully long time, and certainly, you do not need to hold your breath and put your life on hold during this time: the PSA testing along the way will help assure you that all is going well. PSA testing is the most sensitive way of detecting a recurrence of prostate cancer and detects it sooner than bone scans or other types of x-ray studies.
With radical prostatectomy, the PSA decreases to an undetectable level in most people because the producer of PSA, the prostate, has been removed. Rarely, small glands in the urethra may produce small amounts of PSA, with may account for a PSA level that is slightly above undetectable but does not increase over time. With radiation therapy (both interstitial seeds and IMRT) and cryotherapy, the prostate is not removed, and thus the PSA does not decrease to an undetectable range. The PSA will drop, however, reflecting the death of the cancer cells and the loss of PSA production. Biopsy of the prostate is not routinely used to confirm that treatment has been effective unless the PSA increases in 3 consecutive readings at least 6 months apart. This is also known as the ASTRO criteria for PSA failure.
When prostate cancer metastasizes, it tends to travel to the pelvic lymph nodes first and then to the bones. Bone metastases may be silent, meaning that they do not cause any pain, or they may be symptomatic, causing pain or leading to a fracture. Bone metastases are typically identified on bone scans and can also be seen on a plain x-ray.
There are many ways to treat bone pain. Your doctor will likely try the simplest treatments and those associated with the least side effects first, and then progress as needed. Nonsteroidal anti-inflammatories such as ibuprofen are typically used as a first-line treatment. If the pain is not controlled with these, then narcotics such as Tylenol with codeine are needed. For patients with a localized bone metastasis that is causing persistent discomfort, localized IMRT may be used. IMRT provides pain relief in 80% to 90% of patients, and the relief may last for up to one year in slightly more than half of these men. Usually, the total radiation dose is given over 5 to 15 quick treatment sessions.
The side effects of localized IMRT vary with the area that is being irradiated. Treatment of metastases to the skull may cause hair loss and flaking and redness of the scalp. Treatment of cervical spine (neck bone) metastases may cause discomfort with swallowing and hoarseness. If the mid-spine is treated, nausea and vomiting may result. Treatment of pelvic bone metastases may cause diarrhea. Treatment side effects often resolve with time.
Impotence is the consistent inability to achieve adequate penile rigidity for penetration or adequate duration of rigidity for completion of sexual performance. Approximately 50% of men 40 to 70 years of age experience erectile dysfunction. To achieve an adequate erection, you must have properly functioning nerves, arteries and veins. When you are stimulated or aroused, your brain releases chemicals that tell the nerves in the pelvis to release chemicals that in turn tell the arteries in the penis to open and increase blood flow into the penis. At the same time that blood is moving into the penis, the veins in the penis collapse so that the blood remains in the penis, making it rigid and allowing the rigidity to last. Anything that can affect the brain, nerves, arteries, or veins can cause trouble with erections. More common causes of erectile dysfunction include strokes, spinal cord injury, Parkinson’s disease, high cholesterol levels, heart disease, poor circulation in the legs, high blood pressure and medications used to treat high blood pressure, depression and medications used to treat depression, diabetes, surgery (such as radical prostatectomy and colorectal cancer surgeries), pelvic radiation and hormone therapy for prostate cancer.
When seeking treatment for prostate cancer, many men are very concerned about the effects the treatment have on erectile function. Basically, all of the treatment options carry a risk of erectile dysfunction; however, they differ in how soon after treatment the erectile dysfunction occurs and how likely it is to occur. If you are already having trouble with erections, none of the treatments for prostate cancer will improve your erections. The incidence of erectile dysfunction associated with radical prostatectomy varies with patient age, erectile function before surgery, nerve-sparing status, and the surgeon’s technical ability to perform a nerve-sparing radical prostatectomy. The erectile function continues to improve for up to 3.5 years after surgery although most men regain their potency within the first 12-18 months. During this time, men can improve their function further by utilizing phosphodiesterase inhibitors such as Cialis, Viagra and Levitra, utilizing a Vacuum Erection device to improve blood flow to the penis and injection therapy directly to the penis to obtain erections.
Urinary incontinence, the uncontrolled loss of urine, is one of the most bothersome risks of prostate cancer treatment. Although it is more commonly associated with radical prostatectomy, it may also occur after any treatments for prostate cancer. Urinary incontinence may lead to anxiety, hopelessness and loss of self-control and self-esteem. Fear of leakage may limit social activities and participation in sex. If you are experiencing these feelings, you should discuss this with your doctor and spouse or significant other.
If you experience persistent urinary incontinence after surgery or radiation therapy, your doctor will want to identify the degree and the type of incontinence. You will be asked questions regarding the number of pads you use per day, what activities precipitate incontinence, how frequently you urinate if you have frequency or urgency, how strong your force of urine stream is if you feel that you are emptying your bladder well, what types and how much fluid you are drinking. The doctor may check to make sure that you are emptying your bladder well. This is usually done by having you urinate and then scanning your bladder with a small ultrasound probe to determine how much urine is left behind. Normally, less than one tablespoon remains after urination. There are several different types of urinary incontinence and these different types may co-exist. The treatment of urinary incontinence varies with the type. The types that may be encountered in men being treated for prostate cancer include stress, overflow, and urge incontinence. Men who have undergone radical prostatectomy typically experience a type of stress incontinence called “intrinsic sphincter deficiency.” Stress incontinence may also occur after interstitial seed therapy and is much more common if a TURP of the prostate was performed in the past. In men, urinary control is primarily at the bladder outlet by the internal sphincter muscle. This muscle remains closed and opens only during urination.
An additional muscle, the external sphincter, is located further away from the bladder and is the “back-up” muscle. The external sphincter is the muscle that you contract when you feel the urge to urinate and there is no bathroom in sight. During a radical prostatectomy, the internal sphincter is often damaged with the removal of the prostate because it lies just at the top of the prostate. Continence then depends on the ability of the remaining urethra to close and on the external sphincter.
In the fall, Prostate Cancer Awareness Week typically includes free prostate cancer screening. This screening includes a digital rectal examination and a PSA level determination. The examining physician tells you whether he or she thinks your prostate feels suspicious and whether further evaluation by a urologist is recommended. You receive your PSA results by mail at a later time. If your PSA is elevated, you will be told that further evaluation is indicated, and you will be expected to make an appointment with a urologist for this. Often, this service is provided at your local hospital and may be advertised in the newspaper. If you have not seen advertisements in the past, you may want to call your local hospital to see if it is offered. If you are unable to obtain any information from your local hospital, you may want to try the offices of local urologists.
If you plan to return to the free prostate cancer screening on a yearly basis, keep in mind that the same person may not examine your prostate each year and the PSA results from year to year may not be compared. For this reason, it is important that you keep track of the results and compare them yourself. Ideally, the PSA should not change by more than .7 to .75 ng/mL per year, even if each of the values is within the normal range. If the change is greater than .7ng/mL per year, even if both numbers fall within the “normal range,” then you should seek further evaluation. Transrectal ultrasound-guided prostate biopsies are not part of the free prostate cancer screening.
The diagnosis of prostate cancer comes as a shock to most men. Often, they are feeling fine and experience no signs or symptoms to make them suspicious. When they are faced with such a shock, common reactions are fear, anger, confusion and depression. It is not unusual to initially “retreat” from life as you absorb the reality of the situation and begin to gather information and start the decision-making process.
If you find that you have feelings of failure, are continuing to withdraw socially, feel that you are being punished, are thinking about committing suicide, feel helpless and can’t make decisions, have lost interest in activities that brought you pleasure, or are crying a lot, then you may suffer from more severe depression and you should discuss this with your doctor. Sometimes, when faced with such potentially overwhelming situations, you may need some assistance to help you gain control of your life again and make the decisions you will need to make regarding your treatment.