Prostate cancer is the most common cancer, excluding skin cancer, in American men. The American Cancer Society estimates that more than 200,000 men are affected by this disease annually, and more 25,000 will die from prostate cancer.
Among men diagnosed with prostate cancer, nearly 100% survive at least 5 years, 93% survive at least 10 years and 77% survive at least 15 years.
Modern methods of detection and treatment mean that prostate cancers are detected earlier and treated more effectively, which has led to a yearly drop in death rate of about 3.5% in recent years.
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Prostate cancer usually doesn’t produce any noticeable symptoms in its early stages, so many cases of prostate cancer aren’t detected until the cancer has spread beyond the prostate. For most men, prostate cancer is first detected during a routine screening such as a prostate-specific anitigen (PSA) test or a digital rectal exam (DRE).
When signs and symptoms do occur, they depend on how advanced the cancer is and how far the cancer has spread.
Early signs and symptoms of prostate cancer can include urinary problems, caused when the prostate tumor presses on the bladder or the tube that carries urine from the bladder (urethra). However, urinary symptoms are much more commonly caused by benign prostate problems, such as an enlarged prostate (benign prostatic hyperplasia) or prostate infections. Less than 5 percent of cases of prostate cancer have urinary problems as the initial symptom. When urinary signs and symptoms do occur, they can include:
- Trouble urinating
- Starting and stopping while urinating
- Decreased force in the stream of urine
Cancer in your prostate or the area around the prostate can cause:
- Blood in your urine
- Blood in your semen
Prostate cancer that has spread to the lymph nodes in your pelvis may cause:
- Swelling in your legs
- Discomfort in the pelvic area
Advanced prostate cancer that has spread to your bones can cause:
- Bone pain that doesn’t go away
- Bone fractures
- Compression of the spine
Cancer is a group of abnormal cells that grow more rapidly than normal cells and that refuse to die. Cancer cells also have the ability to invade and destroy normal tissues, either by growing directly into surrounding structures or after traveling to another part of your body through your bloodstream or lymph system (metastasize). Microscopic cancer cells develop into small clusters that continue to grow, becoming more densely packed and hard.
What causes prostate cancer and why some types behave differently are unknown. Research suggests that a combination of factors may play a role, including heredity, ethnicity, hormones, diet and the environment.
Beginning at age 50, the American Cancer Society recommends having yearly screening tests for prostate cancer. If you’re black or have a family history of the disease, you may want to begin at a younger age. Yearly screenings can help detect prostate cancer early, when it’s easier to treat.
Prostate cancer may not cause any symptoms at first. The first indication of a problem may come during a routine screening test, such as:
- Digital rectal exam (DRE) – During a DRE, your doctor inserts a gloved, lubricated finger into your rectum to examine your prostate, which is adjacent to the rectum. If your doctor finds any abnormalities in the texture, shape or size of your gland, you may need more tests.
- Prostate-specific antigen (PSA) test – A blood sample is drawn from a vein and analyzed for PSA, a substance that’s naturally produced by your prostate gland to help liquefy semen. It’s normal for a small amount of PSA to enter your bloodstream. However, if a higher than normal level is found, it may be an indication of prostate infection, inflammation, enlargement or cancer. Studies have not been able to show that routine screening decreases the chance that anyone will die of prostate cancer, but screening with PSA and DRE can help identify cancer at an earlier stage.
- Transrectal ultrasound – If other tests raise concerns, your doctor may use transrectal ultrasound to further evaluate your prostate. A small probe, about the size and shape of a cigar, is inserted into your rectum. The probe uses sound waves to get a picture of your prostate gland.
- Prostate biopsy – If initial test results suggest prostate cancer, your doctor may recommend biopsy. To do a prostate biopsy, your doctor inserts a small ultrasound probe into your rectum. Guided by images from the probe, your doctor uses a fine, spring-propelled needle to retrieve several very thin sections of tissue from your prostate gland. A pathologist who specializes in diagnosing cancer and other tissue abnormalities evaluates the samples. From those, the pathologist can tell if the tissue removed is cancerous and estimate how aggressive your cancer is.
Determining how far the cancer has spread
Once a cancer diagnosis has been made, you may need further tests to help determine if or how far the cancer has spread. Many men don’t require additional studies and can directly proceed with treatment based on the characteristics of their tumors and the results of their pre-biopsy PSA tests.
- Bone scan – A bone scan takes a picture of your skeleton in order to determine whether cancer has spread to the bone. Prostate cancer can spread to any bones in your body, not just those closest to your prostate, such as your pelvis or lower spine.
- Ultrasound – Ultrasound not only can help indicate if cancer is present, but also may reveal whether the disease has spread to nearby tissues.
- Computerized tomography (CT) scan – A CT scan produces cross-sectional images of your body. CT scans can identify enlarged lymph nodes or abnormalities in other organs, but they can’t determine whether these problems are due to cancer. Therefore, CT scans are most useful when combined with other tests.
- Magnetic resonance imaging (MRI) – This type of imaging produces detailed, cross-sectional images of your body using magnets and radio waves. An MRI can help detect evidence of the possible spread of cancer to lymph nodes and bones.
- Lymph node biopsy – If enlarged lymph nodes are found by a CT scan or an MRI, a lymph node biopsy can determine whether cancer has spread to nearby lymph nodes. During the procedure, some of the nodes near your prostate are removed and examined under a microscope to determine if cancerous cells are present.
When a biopsy confirms the presence of cancer, the next step, called grading, is to determine how aggressive the cancer is. The tissue samples are studied, and the cancer cells are compared with healthy prostate cells. The more the cancer cells differ from the healthy cells, the more aggressive the cancer and the more likely it is to spread quickly.
Cancer cells may vary in shape and size. Some cells may be aggressive, while others are not. The pathologist identifies the two most aggressive types of cancer cells when assigning a grade. The most common scale used to evaluate prostate cancer cells is called a Gleason score. Based on microscopic appearance of cells, individual ratings from 1 to 5 are assigned to the two most common cancer patterns identified. These two numbers are then added together to determine your overall score. Scoring can range from 2 (nonaggressive cancer) to 10 (very aggressive cancer).
Afterr the level of aggressiveness of your prostate cancer is known, the next step, callled staging, determines if or how far the cancer has spread. Your cancer is assigned one of four stages, based on how far it has spread:
- Stage I – Signifies very early cancer that’s confined to a microscopic area that your doctor can’t feel.
- Stage II – Your cancer can be felt, but it remains confined to your prostate gland.
- Stage III – Your cancer has spread beyond the prostate to the seminal vesicles or other nearby tissues.
- Stage IV – Your cancer has spread to lymph nodes, bones, lungs or other organs.
Complications from prostate cancer are related to both the disease and its treatment. One of the biggest fears of many men who have prostate cancer is that treatment may leave them incontinent or unable to maintain an erection firm enough for sex (erectile dysfunction). Fortunately, therapies exist to help cope with or treat these conditions.
The typical complications of prostate cancer and its treatments include:
- Spread of cancer – Prostate cancer can spread to nearby organs or travel through your bloodstream or lymphatic system, affecting your bones or other organs. Treatments for prostate cancer that has spread can include hormone therapy, radiation therapy and chemotherapy.
- Pain – Although early-stage prostate cancer typically isn’t painful, once it’s spread to bones it can be. Not all people with cancer that has spread to bones have pain, but in some cases, pain is intense and doesn’t go away. Treatments directed at shrinking the cancer often can produce significant pain relief. Medications ranging from over-the-counter pain relievers to prescription narcotics can alleviate pain. If your pain is severe, you may need to see a pain specialist. While it’s not always possible to make all of your pain go away, your doctor will work with you to try to control pain to a point where you’re comfortable. If you’re in serious pain, tell your doctor. Pain can be controlled, and there’s no reason you have to suffer.
- Difficulty urinating (urinary incontinence) – Both prostate cancer and its treatment can cause incontinence. Treatment depends on the type of incontinence you have, how severe it is and the likelihood it will improve over time. Treatments include behavior modifications (such as going to the bathroom at set times rather than just according to urges), exercises to strengthen pelvic muscles (commonly called Kegel exercises), medications and catheters. If incontinence continues for a prolonged period without getting better, your doctor may suggest more aggressive procedures. These may include implanting an artificial urinary sphincter, placement of a sling of synthetic material to compress the urethra, or the injection of bulking agents into the lining of the urethra at the base of the bladder to reduce leakage.
- Erectile dysfunction (ED) or impotence – Like incontinence, ED can be a result of prostate cancer or its treatment, including surgery, radiation or hormone treatments. Medications and vacuum devices that assist in achieving erection are available to treat ED. Medications include sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra). If other treatments fail, penile implants can be inserted surgically to help create an erection.
- Depression – Many men may feel depressed after a diagnosis of prostate cancer or after trying to cope with the side effects of treatment. These feelings may last for only a short time, they may come and go, or they may linger for weeks or even months. Talk to your doctor if you have depression that interferes with your ability to get things done or enjoy your life. Treatment such as counseling or antidepressant medication can make a big difference.
There’s more than one way to treat prostate cancer. For some men a combination of treatments — such as surgery followed by radiation or radiation paired with hormone therapy — works best. The treatment that’s best for each man depends on several factors. These include how fast your cancer is growing, how much it has spread, your age and life expectancy, as well as the benefits and the potential side effects of the treatment. The most common treatments for prostate cancer include the following:
External beam radiation therapy – External beam radiation treatment uses high-powered x-rays to kill cancer cells. This type of radiation is effective at destroying cancerous cells, but it can also scar adjacent healthy tissue.
The first step in radiation therapy is to map the precise area of your body that needs to receive radiation. Computer-imaging software helps your doctor find the best angles to aim the beams of radiation. Precisely focused radiation kills cancer in your prostate while minimizing harm to surrounding tissue.
Treatments are generally given five days a week for about eight weeks. You do not need anesthesia because the treatment isn’t painful. You will be asked to arrive with a full bladder. This will push most of your bladder out of the path of the radiation beam. A body supporter holds you in the same position for each treatment. Ink marks on your skin help guide the radiation beam, and small gold markers may be placed in your prostate to ensure the radiation hits the same target each time. Custom designed shields help protect nearby normal tissue, such as your bladder, erectile tissues, anus and rectal wall.
Side effects of External Beam Radiation can include:
- Urinary problems – The most common signs and symptoms are urgency to urinate and frequent urination. These problems usually are temporary and gardually diminish in a few weeks after completing treatment. Long-term problems are uncommon.
- Loose stools, rectal bleeding, discomfort during bowel movements or a sense of needing to have a bowel movement (rectal urgency). In some cases these problems persist for months after treatment, but they improve on their own in most men. If you do have long-term rectal symptoms, medications can help. Rarely, men develop persistent bleeding or a rectal ulcer after radiation. Surgery may be necessary to alleviate these problems.
- Sexual side effects. Radiation therapy doesn’t usually cause immediate sexual side effects such as erectile dysfunction, but some men who’ve had the treatmment have sexual problems later in life.
Radioactive seed implants – Radioactive seeds implanted into the prostate have gained popularity in recent years as treatment for prostate cancer. The implants, also known as brachytherapy, deliver a higher dose of radiation than do external beams, but over a substantially longer period of time. The therapy is generally used in men with smaller or moderate-sized prostates with small and lower grade cancers.
During the procedure, between 40 and 100 rice-sized radioactive seeds are placed in your prostate through ultrasound-guided needles. The implant procedure typically lasts one to two hours and is done under general anesthesia — which means you won’t be awake. Most men can go home the day of the procedure. Sometimes, hormone therapy is used for a few months to shrink the size of the prostate before seeds are implanted. The seeds may contain one of several radioactive isotopes — including iodine and palladium. These seeds don’t have to be removed after they stop emitting radiation. Iodine and palladium seeds generally emit radiation that extends only a few millimeters beyond their location. This type of radiation isn’t likely to escape your body in significant doses. However, doctors recommend that for the first few months, you stay at least six feet away from children and pregnant women, who are especially sensitive to radiation. All radiation inside the pellets is generally exhausted within a year.
Side effects of radioactive seed implants can include:
- Urinary problems. The procedure causes urinary signs and symptoms such as frequent, slow and painful urination in nearly all men. You may require medication to treat these signs and symptoms. Some men need medications or the use of intermittent self-catherization to help them urinate. Urinary symptoms tend to be more severe and longer lasting with seed implants than with external beam radiation.
- Sexual problems. Some men experience erectile dysfunction due to radioactive seed implants.
- Rectal symptoms. Sometimes this treatment causes loose stools, discomfort during bowel movements or other rectal symptoms. However, rectal symptoms from radioactive seed implants are generally less severe than with external beam radiation.
Hormone therapy – Hormone therapy involves trying to stop your body from producing the male sex hormone teststerone, which can stimulate the growth of cancer cells. This type of therapy can also block hormones from getting into cancer cells. Sometimes doctors use a combination of drugs to achieve both. In most men with advanced prostate cancer, this form of treatment is effective in helping both shrink the cancer and slow the growth of tumors. Sometimes doctors use hormone hormone therapy in early-stage cancers to shrink large tumors so that surgery or radiation can remove or destroy them more easily. In some cases, hormone therapy is used in combination with radiation therapy or surgey. After these treatments, the drugs can slow the growth of any stray cancer cells left behind.
Some drugs used in hormone therapy decrease your body’s production of testosterone. The hormones, known as luteinizing hormone-releasing hormone (LHRH) agonists, can set up a chemical blockade. This blockade prevents the testicles from receiving messages to make testosterone. Drugs typically used in this type of hormone therapy include leuprolide (Lupron, Eligard) and goserelin (Zoladex). They’re injected into a muscle once every three or six months. You can receive them for a few months, a few years or the rest of your life, depending on your situation.
Other drugs used in hormone therapy block your body’s ability to use testosterone. A small amount of testosterone comes from the adrenal glands and is not suppressed by LHRH agonists. Certain medications, known as anti-androgens, can prevent testosterone from reaching your cancer cells.
Simply depriving prostate cancer of testosterone usually doesn’t kill all of the cancer cells. Within a few years, the cancer often learns to thrive without trestosterone. Once this happens, hormone therapy is less likely to be effective. However, several treatment options still exist. To avoid such resistence, intermittent hormone therapy programs have been developed. During this type of therapy, the hormonal drugs are stopped after your PSA drops to a low level and remains steady. You will need to resume taking the drugs if your PSA level rises again.
Side effects of hormone therapy can include:
- Breast enlargement (gynecomastia)
- Reduced sex drive
- Erectile dysfunction
- Hot flashes
- Weight gain
- Reduction in muscle and bone mass
Certain hormmone therapy medications can also cause:
- Liver damage
Recent reports have shown that men who undergo hormone therapy for prostate cancer may have a higher risk of having a heart attack in the first year or two after starting hormone therapy. So your doctor should carefully monitor your heart condition and aggressively treat any other conditions that may predispose you to a heart attack, such as high blood pressure, high cholesterol or smoking.
Surgery to remove the testicles, which produce most of your testosterone, is as effective as other forms of hormonal therapy. Many men are not comfortable with the idea of losing their testicles, so they opt for the above-noted methods of lowering testosterone in the body. However, removing the testicles has the advantage of not having to have an injection every three or six months and can be less expensive. The surgery can be done on an outpatient basis using a local anesthetic.
Radical prostatectomy – Surgical removal of your prostate gland, called radical prostatectomy, is used to treat cancer that’s confined to the prostate gland. During this procedure, your surgeon uses special techniques to completely remove your prostate and nearby lymph nodes. This surgery can affect muscles and nerves that control urination and sexual function. Two surgical approaches are available for a prostatectomy — retropubic surgery and perineal surgery.
- Retropubic surgery. The gland is taken out through an incision in your lower abdomen that typically runs from just below the navel to an inch above the base of the penis. It’s the most commonly used form of prostate removal for two reasons. First, your surgeon can use the same incision to remove pelvic lymph nodes, which are tested to determine if the cancer has spread. Second, the procedure gives your surgeon good access to your prostate, making it easy to save the nerves that help control bladder function and erections.
- Perineal surgery. An incision is made between your anus and scrotum. There’s generally less bleeding with perineal surgery, and recovery time may be shorter, especially if you’re overweight. With this procedure, your surgeon isn’t able to remove nearby lymph nodes.
During either type of operation, a catheter is inserted into your bladder through your penis to drain urine from the bladder during your recovery. The catheter will likely remain in place for one to two weeks after the operation while the urinary tract heals.