Prostate cancer

Definition

Prostate cancer is a disease where cells of the prostate become abnormal and start to grow uncontrollably, forming tumors.

Description

Prostate cancer is a malignancy of one of the major male sex glands. Along with the testicles and the seminal vesicles, the prostate secretes the fluid that makes up semen. The prostate is about the size of a walnut and lies just behind the urinary bladder. A tumor in the prostate interferes with proper control of the bladder and normal sexual functioning. Often the first symptom of prostate cancer is difficulty in urinating. However, because a very common, non-cancerous condition of the prostate, benign prostatic hyperplasia (BPH), also causes the same problem, difficulty in urination is not necessarily due to cancer.

Cancerous cells within the prostate itself are generally not deadly on their own. However, as the tumor grows, some of the cells break off and spread to other parts of the body through the lymph or the blood, a process known as metastasis . The most common sites for prostate cancer to metastasize are the seminal vesicles, the lymph nodes, the lungs, and various bones around the hips and the pelvic region. The effects of these new tumors are what can cause death.

Demographics

Second only to skin cancer, the American Cancer Society estimates that in 2000 at least 180, 400 new cases of prostate cancer were diagnosed. Of this number, the disease will cause at least 31, 900 deaths. Although prostate cancer is often very slow growing, it can be aggressive, especially in younger men. Given its slow growing nature, many men with the disease die of other causes rather than from the cancer itself.

Prostate cancer affects African-American men twice as often as white men and the mortality rate among African-Americans is also two times higher. African-Americans have the highest rate of prostate cancer of any world population group.

Causes and symptoms

The precise cause of prostate cancer is not known. However, there are several known risk factors for disease including age over 55, African-American heritage, a family history of the disease, occupational exposure to cadmium or rubber, and a high-fat diet. Men with high plasma testosterone levels may also have an increased risk for developing prostate cancer.

Frequently, prostate cancer has no symptoms and the disease is diagnosed when the patient goes for a routine screening examination. However, when the tumor is big or the cancer has spread to the nearby tissues, the following symptoms may be seen:

• weak or interrupted flow of the urine
• frequent urination (especially at night)
• difficulty starting urination
• inability to urinate
• pain or burning sensation when urinating
• blood in the urine
• persistent pain in lower back, hips, or thighs (bone pain)
• painful ejaculation

Diagnosis

Prostate cancer is curable when detected early. Yet the early stages of prostate cancer are often asymptomatic, so the disease often goes undetected until the patient has a routine physical examination. Diagnosis of prostate cancer can be made using some or all of the following tests.

Digital rectal examination (DRE)

In order to perform this test, the doctor puts a gloved, lubricated finger (digit) into the rectum to feel for any lumps in the prostate. The rectum lies just behind the prostate gland, and a majority of prostate tumors begin in the posterior region of the prostate. If the doctor does detect an abnormality, he or she may order more tests in order to confirm these findings.

Blood tests

Blood tests are used to measure the amounts of certain protein markers, such as prostate-specific antigen (PSA), found circulating in the blood. The cells lining the prostate generally make this protein and a small amount can be detected normally in the bloodstream. In contrast, prostate cancers produce a lot of this protein, significantly raising the circulating levels. A finding of a PSA level higher than normal for the patient's age group therefore suggests that cancer is present.

Transrectal ultrasound

A small probe is placed in the rectum and sound waves are released from the probe. These sound waves bounce off the prostate tissue and an image is created. Since normal prostate tissue and prostate tumors reflect the sound waves differently, the test is an efficient and accurate way to detect tumors. Though the insertion of the probe into the rectum may be slightly uncomfortable, the procedure is generally painless and only takes 20 minutes.

Prostate biopsy

If cancer is suspected from the results of any of the above tests, the doctor will remove a small piece of prostate tissue with a hollow needle. This sample is then checked under the microscope for the presence of cancerous cells. Prostate biopsy is the most definitive diagnostic tool for prostate cancer, and this procedure is done quickly and with little pain or discomfort.

Prostate cancer can also be diagnosed based on the examination of the tissue removed during a transurethral resection of the prostate (TURP). This procedure is performed to help alleviate the symptoms of BPH, a benign enlargement of the prostate. Like a biopsy, this is a definitive diagnostic method for prostate cancer.

X rays and imaging techniques

A chest x ray may be ordered to determine whether the cancer has spread to the lungs. Imaging techniques (such as computed tomography (CT) scans and magnetic resonance imaging (MRI)), where a computer is used to generate a detailed picture of the prostate and areas nearby, may be done to get a clearer view of the internal organs. A bone scan may be used to check whether the cancer has spread to the bone.

Treatment team

Prostate cancer is often treated by a team of specialists including a urologist (who may or may not perform surgery), a surgeon (if surgical treatment is used and it is not performed by the urologist), a medical oncologist, and, if radiation therapy is used, a radiation oncologist.

Clinical staging, treatments, and prognosis

Once cancer is detected during the microscopic examination of the prostate tissue during a biopsy or TURP, doctors will determine two different numerical scores that will help define the patient's treatment and prognosis.

Tumor grading

Initially, the pathologist will grade the tumor based on his or her examination of the biopsy tissue. The pathologist scores the appearance of the biopsy sample using the Gleason system. This system uses a scale of one to five based on the sample's similarity or dissimilarity to normal prostate tissue. If the tissue is very similar to normal tissue, it is still well-differentiated and given a low grading number, such as one or two. As the tissue becomes more and more abnormal (less and less differentiated), the grading number increases, up to five. Less differentiated tissue is considered more aggressive and more likely to be the source of metastases.

The Gleason grading system is best predictive of the prognosis of a patient if the pathologist gives two scores to a particular sample—a primary and a secondary pattern. The two numbers are then added together and that is the Gleason score reported to the patient. Thus, the lowest Gleason score available is two (a primary and secondary pattern score of one each). A typical Gleason score is five (which can be a primary score of two and a secondary score of three or visa-versa). The highest score available is 10, with a pure pattern of very undifferentiated tissue, that is, of grade five. The higher the score, the more abnormal behavior of the tissue, the greater the chance for metastases, and the more serious the prognosis after surgical treatment. A study found that the ten-year cancer survival rate without evidence of disease for grade two, three, and four cancers is 94% of patients. The rate is 91% for grade five cancers, 78% for grade six, 46% for grade seven, and 23% for grade eight, nine, and ten cancers.

Cancer staging

The second numeric score determined by the doctor will be the stage of the cancer, which takes into account the grade of the tumor determined by the pathologist. Based on the recommendations of the American Joint Committee on Cancer (AJCC), two kinds of data are used for staging prostate cancer. Clinical data is based on the external symptoms of the cancer, while histopathological data is based on surgical removal of the prostate and examination of its tissues. Clinical data is most useful to make treatment decisions, while pathological data is the best predictor of prognosis. For this reason, the staging of prostate cancer takes into account both clinical and histopathologic information. Specifically, doctors look at tumor size (T), lymph node involvement (N), the presence of visceral (internal organ) involvement (metastasis = M), and the grade of the tumor (G).

The classification of tumor as T1 means the cancer that is confined to the prostate gland and the tumor that is too small to be felt during a DRE. T1 tumors are often found after examination of tissue removed during a TURP. The T1 definition is subdivided into those cancers that show less than 5% cancerous cells in the tissue sample (T1a) or more than 5% cancerous cells in the tissue sample (T1b). T1c means that the biopsy was performed based on an elevated PSA result. The second tumor classification is T2, where the tumor is large enough to be felt during the DRE. T2a indicates that only the left or the right side of the gland is involved, while T2b means both sides of the prostate gland has tumor.

With a T3 tumor, the cancer has spread to the connective tissue near the prostate (T3a) or to the seminal vesicles as well (T3b). T4 indicates that cancer has spread within the pelvis to tissue next to the prostate such as the bladder's sphincter, the rectum, or the wall of the pelvis. Prostate cancer tends to spread next into the regional lymph nodes of the pelvis, indicated as N1. Prostate cancer is said to be at the M1 stage when it has metastasized outside the pelvis in distant lymph nodes (M1a), bone (M1b) or organs such as the liver or the brain (M1c). Pain, weight loss , and fatigue often accompany the M1 stage.

The grade of the tumor (G) can be assessed during a biopsy, TURP surgery, or after removal of the prostate. There are three grades recognized: G1, G2, and G3, indicating the tumor is well, moderately, or poorly differentiated, respectively. The G, LN, M descriptions are combined with the T definition to determine the stage of the prostate cancer.

• Stage I prostate cancer comprises patients that are T1a, N0, M0, G1.
• Stage II includes a variety of condition combinations including T1a, N0, M0, G2, 3 or 4; T1b, N0, M0, Any G; T1c, N0, M0, Any G; T1, N0, M0, Any G or T2, N0, M0, Any G.
• Stage III prostate cancer occurs when conditions are T3, N0, M0, any G.
• Stage IV is T4, N0, M0, any G; any T, N1, M0, any G; or any T, any N, M1, Any G.

Prognosis

The prognosis for cancers at Stages I and II is very good. For men treated with stage I or stage II disease, over 95% are alive after five years. Although the cancers of Stage III are more advanced, the five-year prognosis is still good, with 70% of men diagnosed at this stage still living. The spread of the cancer into the pelvis (T4), lymph (N1), or distant locations (M1) are very significant events, as the five-year survival rate drops to 30% for Stage IV.

Treatment options

The doctor and the patient will decide on the treatment mode after considering many factors. For example, the patient's age, the stage of the disease, his general health, and the presence of any co-existing illnesses have to be considered. In addition, the patient's personal preferences and the risks and benefits of each treatment protocol are also taken into account before any decision is made.

SURGERY. For stage I and stage II prostate cancer, surgery is the most common method of treatment because it theoretically offers the chance of completely removing the cancer from the body. Radical prostatectomy involves complete removal of the prostate. The surgery can be done using a perineal approach, where the incision is made between the scrotum and the anus, or using a retropubic approach, where the incision is made in the lower abdomen. Perineal approach is also known as nerve-sparing prostatectomy, as it is thought to reduce the effect on the nerves and thus reduce the side effects of impotence and incontinence . However, the retropubic approach allows for the simultaneous removal of the pelvic lymph nodes, which can give important pathological information about the tumor spread.

The drawback to surgical treatment for early prostate cancer is the significant risk of side effects that impact the quality of life of the patient. Even using nerve-sparing techniques, studies by the National Cancer Institute (NCI) found that 60% to 80% of men treated with radical prostatectomy reported themselves as impotent (unable to achieve an erection sufficient for sexual intercourse) two years after surgery. This side effect can be sometimes countered by prescribing sildenafil citrate (Viagra). Furthermore, 8% to 10% of patients were incontinent in that time span. Despite the side effects, the majority of men were reported as satisfied with their treatment choice. Additionally, there is some evidence that the skill and the experience of the surgeon are central factors in the ultimate side effects seen.

A second method of surgical treatment of prostate cancer is cryosurgery or cryotherapy . Guided by ultrasound, surgeons insert up to eight cryoprobes through the skin and into close proximity with the tumor. Liquid nitrogen (temperature of -320.8 degrees F, or -196 C) is circulated through the probe, freezing the tumor tissue. In prostate surgery, a warming tube is also used to keep the urethra from freezing. Patients currently spend a day or two in the hospital following the surgery, but it could be an outpatient procedure in the near future. Recovery time is about one week. Side effects have been reduced in recent years, although impotence still affects almost all who have had cryosurgery for prostate cancer. Cryosurgery is considered a good alternative for those too old or sick to have traditional surgery or radiation treatments or when these more traditional treatments are unsuccessful. There is limited amount of information about the long-term efficacy of this treatment for prostate cancer.

RADIATION THERAPY. Radiation therapy involves the use of high-energy x rays to kill cancer cells or to shrink tumors. It can be used instead of surgery for stage I and II cancer. The radiation can either be administered from a machine outside the body (external beam radiation), or small radioactive pellets can be implanted in the prostate gland in the area surrounding the tumor, called brachytherapy or interstitial implantation. Pellets containing radioactive iodine (I-125), palladium (Pd 103), or iridium (Ir 192) can be implanted on an outpatient basis, where they remain permanently. The radioactive effect of the seeds last only about a year.

The side effects of radiation can include inflammation of the bladder, rectum, and small intestine. Impotence and incontinence are often delayed side effects of the treatment. A study indicated that bowel control problems were more likely after radiation therapy when compared to surgery, but impotence and incontinence were more likely after surgical treatment. Long-term results with radiation therapy are dependent on stage. A review of almost 1, 000 patients treated with megavoltage irradiation showed 10-year survival rates to be significantly different by T-stage: T1 (79%), T2 (66%), T3 (55%), and T4 (22%). There does not appear to be a large difference in survival between external beam or interstitial treatments.

HORMONE THERAPY.

Hormone therapy is commonly used when the cancer is in an advanced stage and has spread to other parts of the body, such as stage III or stage IV. Prostate cells need the male hormone testosterone to grow. Decreasing the levels of this hormone, or inhibiting its activity, will cause the cancer to shrink. Hormone levels can be decreased in several ways. Orchiectomy is a surgical procedure that involves complete removal of the testicles, leading to a decrease in the levels of testosterone. Another method tricks the body by administering the female hormone estrogen. When this is given, the body senses the presence of a sex hormone and stops making the male hormone testosterone. However, there are some unpleasant side effects to hormone therapy. Men may have "hot flashes, " enlargement and tenderness of the breasts, or impotence and loss of sexual desire, as well as blood clots, heart attacks, and strokes, depending on the dose of estrogen.

WATCHFUL WAITING.

Watchful waiting means no immediate treatment is recommended, but doctors keep the patient under careful observation. This is often done using periodic PSA tests. This option is generally used in older patients when the tumor is not very aggressive and the patients have other, more life-threatening, illnesses. Prostate cancer in older men tends to be slow-growing. Therefore, the risk of the patient dying from prostate cancer, rather than from other causes, is relatively small.

Alternative and complementary therapies

A mixture of eight Chinese herbs have been tested in the treatment of prostate cancer that does not respond to hormone therapy. The mixture is called PC-SPES and is believed to stimulate the production of hormones in the body. In a small study, the herbal mixture causes a drop of 52% in PSA levels for 87% of the study participants. The herb mixture does have side effects, including blood clots and nipple tenderness and the potency of the herbs suffers from batch variation.

Coping with cancer treatment

The treatment process for prostate cancer can be a physically and emotionally exhausting time. Here are six general suggestions that can help make the process easier. Patients should:

• put their faith and trust in their doctor once a treatment course has been chosen
• remember that a patient is never without power and rights during the course of treatment
• put practical affairs in order
• closely monitor each step of the treatment
• keep close family and friends informed and delegate responsibilities as necessary
• work to make visits pleasant and comfortable
• be careful to eat, sleep, exercise, and conduct daily activities in a healthy manner

Clinical trials

Patients with extraprostatic disease are suitable candidates for clinical trials . One trial is the testing of a vaccine (GVAX) that causes the body to mount an immune response against all prostate cells. As the prostate is a nonessential organ, the destruction of the normal cells with the tumor cells is not a problem. The vaccine was made using cancer cells from a tumor that had been genetically engineered to express granulocyte/macrophage colony-stimulating factor (GM-CSF), a potent activator of the entire immune system. The additional protein jumpstarted the immune response against the prostate cells upon vaccination and resulted in antitumor immune response.

Other trials for prostate cancer include evaluation of combination therapies, such as postoperative radiation delivery, use of cytotoxic agents, and hormonal treatment using luteinizing hormone-releasing hormone (LHRH) agonists and/or antiandrogens to shut down the growth of the hormone-dependent tumors.

Prevention

Because the cause of the cancer is not known, there is no definite way to prevent prostate cancer. Given its common occurrence and the low cost of screening, the American Cancer Society (ACS) and the National Comprehensive Cancer Network (NCCN) recommends that all men over age 40 have an annual rectal exam and that men have an annual PSA test beginning at age 50. African-American men and men with a family history of prostate cancer, who have a higher than average risk, should begin annual PSA testing even earlier, starting at age 45.

However, mandatory screening for prostate cancer is controversial. Because the cancer is so slow growing, and the side effects of the treatment can have significant impact on patient quality of life, some medical organizations question the wisdom of yearly exams. Some organizations have even noted that the effect of screening is discovering the cancer at an early stage when it may never grow to have any outward effect on the patient during their lifetime. Nevertheless, the NCI reports that the current aggressive screening methods have achieved a reduction in the death rate of prostate cancer of about 2.3% for African-Americans and about 4.6% for Caucasians since the mid-1990s, with a 20% increase in overall survival rate during that period.

A low-fat diet may slow the progression of prostate cancer. To reduce the risk or progression of prostate cancer, the American Cancer Society recommends a diet rich in fruits, vegetables and dietary fiber, and low in red meat and saturated fats.

Special concerns

The availability of an early detection system for prostate cancer with the development of the PSA serum test has complicated the treatment of this disease. Early detection of an often slow-growing cancer, where treatment can significantly impact the quality of life of the patient, can be complicated. Long-term studies are currently in progress that should provide the first real quantitative information about the relative efficacy of the different treatment options, the actual occurrence of side effects, and the comparative benefits of watchful waiting treatment compared with more aggressive action.

Resources

BOOKS

Carroll, Peter R., et al. "Cancer of the Prostate." In Cancer Principles and Practice of Oncology, Devita, Vincent T., et al., eds. Philadelphia: Lippincott Williams & Wilkins, 2001.

Wainrib, Barbara R., and Sandra Haber. Men, Women, and Prostate Cancer. Oakland, CA: New Harbinger Produc tions, Inc., 2000.

PERIODICALS

Nelson, W.G., et al. "Cancer Cells Engineered to Secrete Gran ulocyte-Macrophage Colony-Stimulating Factor Using Ex Vivo Gene Transfer as Vaccines for the Treatment of Gen itourinary Malignanacies." Cancer Chemotherapy and Pharmacology 46 (2000): s67-72.

ORGANIZATIONS

National Cancer Institute. Building 31, Room 10A31 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 4-CANCER. <http://cancernet.nci.nih.gov>.

The Association for the Cure of Cancer of the Prostate (CaPCure). 1250 Fourth St., Suite 360, Santa Monica, CA 90401. (800) 757-CURE. <http://www.capcure.org>.

OTHER

"Using Herbs to Fight Prostate Cancer." HealthScout@CancerOnline 30 May 2000. 18 July 2001 <http://www.healthscout.com>.

Lata Cherath, Ph.D.

Michelle Johnson, M.S., J.D.

KEY TERMS

Antiandrogen

—A substance that blocks the action of androgens, the hormones responsible for male characteristics. Used to treat prostate cancers that require male hormones for growth.

Benign Prostate Hyperplasia (BPH)

—A non-cancerous swelling of the prostate.

Brachytherapy

—A method of treating cancers, such as prostate cancer, involving the implantation near the tumor of radioactive seeds.

Gleason Grading System

—A method of predicting the tendency of a tumor in the prostate to metastasize based on how similar the tumor is to normal prostate tissue.

Granulocyte/macrophage colony stimulating factor (GM-CSF)

—A substance produced by cells of the immune system that stimulates the attack upon foreign cells. Used to treat prostate cancers as a genetically engineered component of a vaccine (sargramostim) that stimulates the body to attack prostate tissue.

Histopathology

—The study of diseased tissues at a minute (microscopic) level.

Luteinizing hormone releasing hormone (LHRH) agonist

—a substance that blocks the action of LHRH, a hormone that stimulates the production of testosterone (a male hormone) in men. Used to treat prostate cancers that require testosterone for growth.

Orchiectomy

—Surgical removal of the testes that eliminates the production of testosterone to treat prostate cancer.

Radical Prostatectomy

—Surgical removal of the entire prostate, a common method of treating prostate cancer.

Prostate-Specific Antigen

—A protein made by the cells of the prostate that is increased by both BPH and prostate cancer.

Transurethral resection of the prostate (TURP)

— Surgical removal of a portion of the prostate through the urethra, a method of treating the symptoms of an enlarged prostate, whether from BPH or cancer.

QUESTIONS TO ASK THE DOCTOR

• How do my age, general health, and other medical conditions affect my treatment choices?
• What are the T, N, and M stages of my cancer and how do they influence my treatment options?
• How do the Gleason score of my cancer and my blood prostate-specific antigen (PSA) level predict my outlook for survival and affect treatment options?
• What are the likely side effects of each proposed therapy and how will they affect my quality of life?
• What can be done to help manage the side effects of treatment?

Prostate Cancer

Definition

Prostate cancer is a disease in which cells in the prostate gland become abnormal and start to grow uncontrollably, forming tumors.

Description

Prostate cancer is a malignancy of one of the major male sex glands. Along with the testicles and the seminal vesicles, the prostate secretes the fluid that makes up semen. The prostate is about the size of a walnut and lies just behind the urinary bladder. A tumor in the prostate interferes with proper control of the bladder and normal sexual functioning. Often the first symptom of prostate cancer is difficulty in urinating. However, because a very common, non-cancerous condition of the prostate, benign prostatic hyperplasia (BPH), also causes the same problem, difficulty in urination is not necessarily due to cancer.

Cancerous cells within the prostate itself are generally not deadly on their own. However, as the tumor grows, some of the cells break off and spread to other parts of the body through the lymph or the blood, a process known as metastasis. The most common sites for prostate cancer to metastasize are the seminal vesicles, the lymph nodes, the lungs, and various bones around the hips and the pelvic region. The effects of these new tumors are what can cause death.

As of the early 2000s, prostate cancer is the most commonly diagnosed malignancy among adult males in Western countries. Although prostate cancer is often very slow growing, it can be aggressive, especially in younger men. Given its slow growing nature, many men with the disease die of other causes rather than from the cancer itself.

Prostate cancer affects African-American men twice as often as white men; the mortality rate among African-Americans is also two times higher. African-Americans have the highest rate of prostate cancer of any world population group.

Causes and symptoms

The precise cause of prostate cancer is not known as of the early 2000s. However, there are several known risk factors for disease including age over 55, African-American heritage, a family history of the disease, occupational exposure to cadmium or rubber, and a high fat diet. Men with high plasma testosterone levels may also have an increased risk for developing prostate cancer.

Frequently, prostate cancer has no symptoms and the disease is diagnosed when the patient goes for a routine screening examination. However, when the tumor is big or the cancer has spread to the nearby tissues, the following symptoms may be seen:

• weak or interrupted flow of the urine
• frequent urination (especially at night)
• difficulty starting urination
• inability to urinate
• pain or burning sensation when urinating
• blood in the urine
• persistent pain in lower back, hips, or thighs (bone pain)
• painful ejaculation

Diagnosis

Prostate cancer is curable when detected early. Yet the early stages of prostate cancer are often asymptomatic, so the disease often goes undetected until the patient has a routine physical examination. Diagnosis of prostate cancer can be made using some or all of the following tests.

Digital rectal examination (DRE)

In order to perform this test, the doctor puts a gloved, lubricated finger (digit) into the rectum to feel for any lumps in the prostate. The rectum lies just behind the prostate gland, and a majority of prostate tumors begin in the posterior region of the prostate. If the doctor does detect an abnormality, he or she may order more tests in order to confirm these findings.

Blood tests

Blood tests are used to measure the amounts of certain protein markers, such as prostate-specific antigen (PSA), found circulating in the blood. The cells lining the prostate generally make this protein and a small amount can be detected normally in the bloodstream. In contrast, prostate cancers produce a lot of this protein, significantly raising the circulating levels. A finding of a PSA level higher than normal for the patient's age group therefore suggests that cancer is present.

Transrectal ultrasound

A small probe is placed in the rectum and sound waves are released from the probe. These sound waves bounce off the prostate tissue and an image is created. Since normal prostate tissue and prostate tumors reflect the sound waves differently, the test is an efficient and accurate way to detect tumors. Though the insertion of the probe into the rectum may be slightly uncomfortable, the procedure is generally painless and takes only 20 minutes.

Prostate biopsy

If cancer is suspected from the results of any of the above tests, the doctor will remove a small piece of prostate tissue with a hollow needle. This sample is then checked under the microscope for the presence of cancerous cells. Prostate biopsy is the most definitive diagnostic tool for prostate cancer.

Prostate cancer can also be diagnosed based on the examination of the tissue removed during a transurethral resection of the prostate (TURP). This procedure is performed to help alleviate the symptoms of BPH, a benign enlargement of the prostate. Like a biopsy, this is a definitive diagnostic method for prostate cancer.

X rays and imaging techniques

A chest x ray may be ordered to determine whether the cancer has spread to the lungs. Imaging techniques (such as computed tomography scans (CT) and magnetic resonance imaging (MRI)), where a computer is used to generate a detailed picture of the prostate and areas nearby, may be done to get a clearer view of the internal organs. A bone scan may be used to check whether the cancer has spread to the bone.

Treatment

Once cancer is detected during the microscopic examination of the prostate tissue during a biopsy or TURP, doctors will determine two different numerical scores that will help define the patient's treatment and prognosis.

Tumor grading

Initially, the pathologist will grade the tumor based on his or her examination of the biopsy tissue. The pathologist scores the appearance of the biopsy sample using the Gleason system. This system uses a scale of one to five based on the sample's similarity or dissimilarity to normal prostate tissue. If the tissue is very similar to normal tissue, it is still well differentiated and given a low grading number, such as one or two. As the tissue becomes more and more abnormal (less and less differentiated), the grading number increases, up to five. Less differentiated tissue is considered more aggressive and more likely to be the source of metastases.

The Gleason grading system is best predictive of the prognosis of a patient if the pathologist gives two scores to a particular sample—a primary and a secondary pattern. The two numbers are then added together and that is the Gleason score reported to the patient. Thus, the lowest Gleason score available is two (a primary and secondary pattern score of one each). A typical Gleason score is five (which can be a primary score of two and a secondary score of three or visa-versa). The highest score available is 10, with a pure pattern of very undifferentiated tissue, that is, of grade five. The higher the score, the more abnormal behavior of the tissue, the greater the chance for metastases, and the more serious the prognosis after surgical treatment. A study found that the ten-year cancer survival rate without evidence of disease for grade two, three, and four cancers is 94% of patients. The rate is 91% for grade five cancers, 78% for grade six, 46% for grade seven, and 23% for grade eight, nine, and ten cancers.

Cancer staging

The second numeric score determined by the doctor will be the stage of the cancer, which takes into account the grade of the tumor determined by the pathologist. Based on the recommendations of the American Joint Committee on Cancer (AJCC), two kinds of data are used for staging prostate cancer. Clinical data are based on the external symptoms of the cancer, while histopathological data is based on surgical removal of the prostate and examination of its tissues. Clinical data are most useful to make treatment decisions, while pathological data is the best predictor of prognosis. For this reason, the staging of prostate cancer takes into account both clinical and histopathologic information. Specifically, doctors look at tumor size (T), lymph node involvement (N), the presence of visceral (internal organ) involvement (metastasis = M), and the grade of the tumor (G).

The classification of tumor as T1 means the cancer that is confined to the prostate gland and the tumor that is too small to be felt during a DRE. T1 tumors are often found after examination of tissue removed during a TURP. The T1 definition is subdivided into those cancers that show less than 5% cancerous cells in the tissue sample (T1a) or more than 5% cancerous cells in the tissue sample (T1b). T1c means that the biopsy was performed based on an elevated PSA result. The second tumor classification is T2, where the tumor is large enough to be felt during the DRE. T2a indicates that only the left or the right side of the gland is involved, while T2b means both sides of the prostate gland has tumor.

With a T3 tumor the cancer has spread to the connective tissue near the prostate (T3a) or to the seminal vesicles as well (T3b). T4 indicates that cancer has spread within the pelvis to tissue next to the prostate such as the bladder's sphincter, the rectum, or the wall of the pelvis. Prostate cancer tends to spread next into the regional lymph nodes of the pelvis, indicated as N1. Prostate cancer is said to be at the M1 stage when it has metastasized outside the pelvis in distant lymph nodes (M1a), bone (M1b) or organs such as the liver or the brain (M1c). Pain, weight loss, and fatigue often accompany the M1 stage.

The grade of the tumor (G) can assessed during a biopsy, TURP surgery, or after removal of the prostate. There are three grades recognized: G1, G2, and G3, indicating the tumor is well, moderately, or poorly differentiated, respectively. The G, LN, M descriptions are combined with the T definition to determine the stage of the prostate cancer.

Stage I prostate cancer comprises patients that are T1a, N0, M0, G1. Stage II includes a variety of condition combinations including T1a, N0, M0, G2, 3 or 4; T1b, N0, M0, Any G; T1c, N0, M0, Any G; T1, N0, M0, Any G or T2, N0, M0, Any G. The prognosis for cancers at these two stages is very good. For men treated with stage I or stage II disease, over 95% are alive after five years.

Stage III prostate cancer occurs when conditions are T3, N0, M0, any G. Stage IV is T4, N0, M0, any G; any T, N1, M0, any G; or any T, any N, M1, Any G. Although the cancers of Stage III are more advanced, the five year prognosis is still good, with 70% of men diagnosed at these stage still living. The spread of the cancer into the pelvis (T4), lymph (N1), or distant locations (M1) are very significant events, as the five year survival rate drops to 30% for Stage IV.

Treatment options

The doctor and the patient will decide on the treatment mode after considering many factors. For example, the patient's age, the stage of the disease, his general health, and the presence of any co-existing illnesses have to be considered. In addition, the patient's personal preferences and the risks and benefits of each treatment protocol are also taken into account before any decision is made.

SURGERY. For stage I and stage II prostate cancer, surgery is the most common method of treatment because it theoretically offers the chance of completely removing the cancer from the body. Radical prostatectomy involves complete removal of the prostate. The surgery can be done using a perineal approach, where the incision is made between the scrotum and the anus, or using a retropubic approach, where the incision is made in the lower abdomen. Perineal approach is also known as nerve-sparing prostatectomy, as it is thought to reduce the effect on the nerves and thus reduce the side effects of impotence and incontinence. However, the retropubic approach allows for the simultaneous removal of the pelvic lymph nodes, which can give important pathological information about the tumor spread.

The drawback to surgical treatment for early prostate cancer is the significant risk of side effects that impact the quality of life of the patient. Even using nerve-sparing techniques, studies run by the National Cancer Institute (NCI) found that 60-80% of men treated with radical prostatectomy reported themselves as impotent (unable to achieve an erection sufficient for sexual intercourse) two years after surgery. This side effect can be sometimes countered by prescribing sildenafil citrate (Viagra). Furthermore, 8% to 10% of patients were incontinent in that time span. Despite the side effects, the majority of men were reported as satisfied with their treatment choice. Additionally, there is some evidence that the skill and the experience of the surgeon are central factors in the ultimate side effects seen.

A second method of surgical treatment of prostate cancer is cryosurgery. Guided by ultrasound, surgeons insert up to eight cryoprobes through the skin and into close proximity with the tumor. Liquid nitrogen (temperature of −320.8°F, or −196°C) is circulated through the probe, freezing the tumor tissue. In prostate surgery, a warming tube is also used to keep the urethra from freezing. Patients currently spend a day or two in the hospital following the surgery, but it could be an outpatient procedure in the near future. Recovery time is about one week. Side effects have been reduced in recent years, although impotence still affects almost all who have had cryosurgery for prostate cancer. Cryosurgery is considered a good alternative for those too old or sick to have traditional surgery or radiation treatments or when these more traditional treatments are unsuccessful. There is a limited amount of information about the long-term efficacy of this treatment for prostate cancer.

Radiation therapy

Radiation therapy involves the use of high-energy x rays to kill cancer cells or to shrink tumors. It can be used instead of surgery for stage I and II cancer. The radiation can either be administered from a machine outside the body (external beam radiation), or small radioactive pellets can be implanted in the prostate gland in the area surrounding the tumor, called brachytherapy or interstitial implantation. Pellets containing radioactive iodine (I-125), palladium (Pd 103), or iridium (Ir 192) can be implanted on an outpatient basis, where they remain permanently. The radioactive effect of the seeds last only about a year.

The side effects of radiation can include inflammation of the bladder, rectum, and small intestine as well as disorders of blood clotting (coagulopathies). Impotence and incontinence are often delayed side effects of the treatment. A study indicated that bowel control problems were more likely after radiation therapy when compared to surgery, but impotent and incontinence were more likely after surgical treatment. Long-term results with radiation therapy are dependent on stage. A review of almost 1000 patients treated with megavoltage irradiation showed 10 year survival rates to be significantly different by T-stage: T1 (79%), T2 (66%), T3 (55%), and T4 (22%). There does not appear to be a large difference in survival between external beam or interstitial treatments.

HORMONE THERAPY. Hormone therapy is commonly used when the cancer is in an advanced stage and has spread to other parts of the body, such as stage III or stage IV. Prostate cells need the male hormone testosterone to grow. Decreasing the levels of this hormone or inhibiting its activity will cause the cancer to shrink. Hormone levels can be decreased in several ways. Orchiectomy is a surgical procedure that involves complete removal of the testicles, leading to a decrease in the levels of testosterone. Another method tricks the body by administering the female hormone estrogen. When estrogen is given, the body senses the presence of a sex hormone and stops making the male hormone testosterone. However, there are some unpleasant side effects to hormone therapy. Men may have "hot flashes," enlargement and tenderness of the breasts, or impotence and loss of sexual desire, as well as blood clots, heart attacks, and strokes, depending on the dose of estrogen. Another side effect is osteoporosis, or loss of bone mass leading to brittle and easily fractured bones.

WATCHFUL WAITING. Watchful waiting means no immediate treatment is recommended, but doctors keep the patient under careful observation. This is often done using periodic PSA tests. This option is generally used in older patients when the tumor is not very aggressive and the patients have other, more life-threatening, illnesses. Prostate cancer in older men tends to be slow-growing. Therefore, the risk of the patient dying from prostate cancer, rather than from other causes, is relatively small.

Treatments for prostate cancer that are under investigation in the early 2000s include evaluation of combination therapies, such as postoperative radiation delivery, use of cytotoxic agents, and hormonal treatment using luteinizing hormone-releasing hormone (LHRH) agonists and/or antiandrogens to shut down the growth of the hormone-dependent tumors. Other drugs that are being tested as of 2003 are chemoprotective agents like amifostine (Ethyol), which are given to prostate cancer patients to counteract the harmful side effects of radiation treatment.

Alternative treatment

Alternative treatments that have been found helpful in coping with the emotional stress associated with prostate cancer include meditation, guided imagery, and relaxation techniques. Acupuncture is effective in relieving pain in some patients.

A variety of herbal products have been used to treat prostate cancer, including various compounds used in traditional Chinese medicine as well as single agents like Reishi mushrooms (Ganoderma lucidum ). One herbal compound that was under investigation by the National Center for Complementary and Alternative Medicine (NCCAM) as a possible treatment for prostate cancer was PC-SPES, a mixture of eight herbs adapted from traditional Chinese medicine. In the summer of 2002, however, NCCAM put its studies of PC-SPES on hold when the Food and Drug Administration (FDA) determined that samples of the product were contaminated with undeclared prescription drug ingredients. PC-SPES was with-drawn from the American market in late 2002.

Prevention

Because the cause of the cancer is not known, there is no definite way to prevent prostate cancer. Given its common occurrence and the low cost of screening, the American Cancer Society (ACS) and the National Comprehensive Cancer Network (NCCN) recommends that all men over age 40 have an annual rectal examination and that men have an annual PSA test beginning at age 50. African-American men and men with a family history of prostate cancer, who have a higher than average risk, should begin annual PSA testing even earlier, starting at age 45.

However, mandatory screening for prostate cancer is controversial. Because the cancer is so slow growing, and the side effects of the treatment can have significant impact on patient quality of life, some medical organizations question the wisdom of yearly exams. Some organizations have even noted that the effect of screening is discovering the cancer at an early stage when it may never grow to have any outward effect on the patient during their lifetime. Nevertheless, the NCI reports that the current aggressive screening methods have achieved a reduction in the death rate of prostate cancer of about 2.3% for African-Americans and about 4.6% for Caucasians since the mid-1990s, with a 20% increase in overall survival rate during that period.

A low-fat diet may slow the progression of prostate cancer. To reduce the risk or progression of prostate cancer, the American Cancer Society recommends a diet rich in fruits, vegetables and dietary fiber, and low in red meat and saturated fats.

KEY TERMS

Antiandrogen— A substance that blocks the action of androgens, the hormones responsible for male characteristics. Used to treat prostate cancers that require male hormones for growth.

Benign prostatic hyperplasia (BPH)— A non-cancerous swelling of the prostate.

Brachytherapy— A method of treating cancers, such as prostate cancer, involving the implantation near the tumor of radioactive seeds.

Gleason grading system— A method of predicting the tendency of a tumor in the prostate to metastasize based on how similar the tumor is to normal prostate tissue.

Granulocyte/macrophage colony stimulating factor (GM-CSF)— A substance produced by cells of the immune system that stimulates the attack upon foreign cells. Used to treat prostate cancers as a genetically engineered component of a vaccine that stimulates the body to attack prostate tissue.

Histopathology— The study of diseased tissues at a minute (microscopic) level.

Luteinizing hormone releasing hormone (LHRH) agonist— A substance that blocks the action of LHRH, a hormone that stimulates the production of testosterone (a male hormone) in men. Used to treat prostate cancers that require testosterone for growth.

Orchiectomy— Surgical removal of the testes that eliminates the production of testosterone to treat prostate cancer.

Radical prostatectomy— Surgical removal of the entire prostate, a common method of treating prostate cancer.

Prostate-specific antigen— A protein made by the cells of the prostate that is increased by both BPH and prostate cancer.

Transurethral resection of the prostate (TURP)— Surgical removal of a portion of the prostate through the urethra, a method of treating the symptoms of an enlarged prostate, whether from BPH or cancer.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Prostate Cancer." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Carroll, Peter R., et al. "Cancer of the Prostate." In Cancer Principles and Practice of Oncology, edited by Vincent T. DeVita, et al. Philadelphia: Lippincott Williams & Wilkins, 2001.

Wainrib, Barbara R., and Sandra Haber. Men, Women, and Prostate Cancer. Oakland, CA: New Harbinger Productions, Inc., 2000.

PERIODICALS

Alimi, D., C. Rubino, E. Pichard-Leandri, et al. "Analgesic Effect of Auricular Acupuncture for Cancer Pain: A Randomized, Blinded, Controlled Trial." Journal of Clinical Oncology 21 (November 15, 2003): 4120-4126.

Chang, S. S. "Exploring the Effects of Luteinizing Hormone-Releasing Hormone Agonist Therapy on Bone Health: Implications in the Management of Prostate Cancer." Urology 62 (December 22, 2003): 29-35.

de la Fouchardiere, C., A. Flechon, and J. P. Droz. "Coagulopathy in Prostate Cancer." Netherlands Journal of Medicine 61 (November 2003): 347-354.

Dziuk, T., and N. Senzer. "Feasibility of Amifostine Administration in Conjunction with High-Dose Rate Brachytherapy." Seminars in Oncology 30 (December 2003): 49-57.

Hsieh, K., and P. C. Albertsen. "Populations at High Risk for Prostate Cancer." Urological Clinics of North America 30 (November 2003): 669-676.

Linares, L. A., and D. Echols. "Amifostine and External Beam Radiation Therapy and/or High-Dose Rate Brachytherapy in the Treatment of Localized Prostate Carcinoma: Preliminary Results of a Phase II Trial." Seminars in Oncology 30 (December 2003): 58-62.

Sliva, D. "Ganoderma lucidum (Reishi) in Cancer Treatment." Integrative Cancer Therapies 2 (December 2003): 358-364.

Spetz, A. C., E. L. Zetterlund, E. Varenhorst, and M. Hammar. "Incidence and Management of Hot Flashes in Prostate Cancer." Journal of Supportive Oncology 1 (November-December 2003): 263-273.

Wilson, S. S., and E. D. Crawford. "Prostate Cancer Update." Minerva Urologica e Nefrologica 55 (December 2003): 199-204.

ORGANIZATIONS

Association for the Cure of Cancer of the Prostate (CaPCure). 1250 Fourth St., Suite 360, Santa Monica, CA 90401. (800) 757-CURE. 〈http://www.capcure.org〉.

National Cancer Institute. Building 31, Room 10A31 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 4-CANCER. 〈http://cancernet.nci.nih.gov〉.

National Center for Complementary and Alternative Medicine (NCCAM) Clearinghouse. P. O. Box 7923, Gaithersburg, MD 20898. (888) 644-6226. 〈http://nccam.nih.gov〉.

OTHER

FDA MedWatch Safety Alert for PC-SPES, SPES, updated September 20, 2002. 〈http://www.fda.gov/medwatch/SAFETY/2002/safety02.htm#spes〉.

National Center for Complementary and Alternative Medicine (NCCAM). Recall of PC-SPES and SPES Dietary Supplements. NCCAM Publication No. D149, September 2002. 〈http://nccam.nih.gov/health/alerts/spes/index.htm〉.

Prostate Biopsy

Definition

Prostate biopsy is a surgical procedure that involves removing a small piece of prostate tissue for microscopic examination.

Purpose

This test is usually done to determine whether the patient has prostate cancer. Occasionally, it may also be used to diagnose a condition called benign prostatic hyperplasia that causes enlargement of the prostate. In the United States, prostate cancer is the most common cancer among men over 50, and is the second leading cause of cancer deaths. According to statistics released in 2003, African American men in the United States are at much greater risk of developing prostate cancer after age 50 than Caucasian or Asian American men.

Prostate biopsy is recommended when a digital rectal examination (a routine screening test for prostate diseases) reveals a lump or some other abnormality in the prostate. In addition, if blood tests reveal that the levels of certain markers, such as PSA, are above normal, the doctor may order a biopsy.

Description

The prostate gland is one of the three male sex glands and lies just below the urinary bladder, in the area behind the penis and in front of the rectum. It secretes semen, the liquid portion of the ejaculate. The urethra carries the urine from the urinary bladder and the semen from the sex glands to the outside of the body.

Prostate biopsies can be performed in three different ways. They can be performed by inserting a needle through the perineum (the area between the base of the penis and the rectum), by inserting a needle through the wall of the rectum, or by cytoscopy. Before the procedure is performed, the patient may be given a sedative to help him relax. Patients undergoing cytoscopy may be given either general anesthesia or local anesthesia. The doctor will ask the patient to have an enema before carrying out the biopsy. The patient is also given antibiotics to prevent any possible infection.

Needle biopsy via the perineum

The patient lies either on one side or on his back with his knees up. The skin of the perineum is thoroughly cleansed with an iodine solution. A local anesthetic is injected at the site where the biopsy is performed. Once the area is numb, the doctor makes a small (1 in) incision in the perineum. The doctor places one finger in the rectum to guide the placement of the needle. The needle is then inserted into the prostate, a small amount of tissue is collected, and the needle is withdrawn. The needle is then re-inserted into another part of the prostate. Tissue may be taken from several areas. Pressure is then applied at the biopsy site to stop the bleeding. The procedure generally takes 15-30 minutes and is usually done in a physician's office or in a hospital operating room. Although it sounds painful, it typically causes only slight discomfort.

Needle biopsy via the rectum

This procedure is also done in the physician's office or in the hospital operating room, and is usually done without any anesthetic, although some doctors prefer to inject a local anesthetic, usually lidocaine. The patient is asked to lie on his side or on his back with his legs in stirrups. The doctor attaches a curved needle guide to his finger and then inserts the finger into the rectum. After firmly placing the needle guide in the rectum, the biopsy needle is pushed along the guide, through the wall of the rectum and into the prostate. The needle is rotated gently, prostate tissue samples are collected and the needle withdrawn. When an ultrasound probe is used to guide the needle, the procedure is called a transrectal ultrasound-guided biopsy, or TRUS.

Cytoscopy

For this procedure, the patient is given either a general or a local anesthetic. An instrument called a cytoscope (a thin-lighted tube with telescopic lenses) is passed through the urethra. By looking through the cytoscope, the doctor can see if there is any blockage in the urethra and remove it. Tissue samples from the urinary bladder or the prostate can be collected for microscopic examination.

This test is generally performed in an operating room or in a physician's office. An hour before the procedure, the patient is given a sedative to help him relax. An intravenous (IV) line will be placed in a vein in the arm to give medications and fluids if necessary. The patient is asked to lie on a special table with his knees apart and stirrups are used to support his feet and thighs. The genital area is cleansed with an antiseptic solution. If general anesthesia is being used, the patient is given the medication through the IV tube or inhaled gases or both. If a local anesthetic is being used, the anesthetic solution is gently instilled into the urethra.

After the area is numb, a cytoscope is inserted into the urethra and slowly pushed into the prostate. Tiny forceps or scissors are inserted through the cytoscope to collect small pieces of tissue that are used for biopsy. The cytoscope is then withdrawn. The entire procedure may take 30-45 minutes. Sometimes a catheter (tube) is left in the urinary bladder to help the urine drain out, until the swelling in the urethra has subsided.

Alternate procedures

Many different tests can be performed to diagnose prostate diseases and cancer. A routine screening test called digital rectal examination (DRE) can identify any lumps or abnormality with the prostate. Blood tests that measure the levels of certain protein markers, such as PSA, can indicate the presence of prostate cancer cells. X rays and other imaging techniques (such as computed tomography scans, magnetic resonance imaging, and ultrasonograms), where detailed pictures of areas inside the body are put together by a computer, can also be used to determine the extent and spread of the disease. However, a prostate biopsy and examination of the cells under a microscope remains the most definitive test for diagnosing and grading prostate cancer.

Preparation

Before scheduling the biopsy, the doctor should be made aware of all the medications that the patient is taking, if the patient is allergic to any medication, and if he has any bleeding problems. The patient may be given an antibiotic shortly before the test to reduce the risk of any infection afterwards. If the biopsy is done through the perineum, there are no special preparations. If it is being done through the rectum, the patient is asked to take an enema and is instructed on how to do it.

If a cytoscopy is being performed, the patient is asked to sign a consent form. The patient is also asked to take antibiotics before and for several days after the test to prevent infection due to insertion of the instruments. If a general anesthetic is going to be used, food and liquids will be restricted for at least eight hours before the test.

Aftercare

Following a needle biopsy, the patient may experience some pain and discomfort. He should avoid strenuous activities for the rest of the day. He may also notice some blood in his urine for two to three days after the test and some amount of rectal bleeding. If there is persistent bleeding, pain, or fever, and if the patient is unable to urinate for 24 hours, the doctor should be notified immediately.

When a cytoscopy is performed under a local anesthetic, the patient is asked to lie down for 30 minutes after the test and is then allowed to go. If general anesthesia is used, the patient is taken to the recovery room and kept there until he wakes up and is able to walk. He is allowed food and liquids after he wakes up. After general anesthesia, the patient may experience some tiredness and aching of the muscles throughout the body. If local anesthesia was administered, there is a brief burning sensation and a strong urge to urinate when the cytoscope is removed.

After the procedure, it is common to experience frequent urination with a burning sensation for a few days. Drinking a lot of fluids will help reduce the burning sensation and the chances of an infection. There may also be some blood in the urine. However, if blood clots are seen, or if the patient is unable to pass urine eight hours after the cytoscopy, the doctor should be notified. In addition, if the patient develops a high fever, and complains of chills or abdominal pain after the procedure, he should see the doctor right away. Although serious infections are rare, a few patients develop such severe illnesses as meningitis following a prostate biopsy.

Risks

Prostate biopsy performed with a needle is a low-risk procedure. The possible complications include some bleeding into the urethra, bleeding from the rectum, an infection, a temporarily lowered sperm count, or an inability to urinate. These complications are treatable and the doctor should be notified of them.

Cytoscopy is generally a very safe procedure. The most common complication is an inability to urinate due to a swelling of the urethra. A catheter (tube) may have to be inserted to help drain out the urine. If there is an infection after the procedure, antibiotics are given to treat it. In very rare instances, the urethra or the urinary bladder may be perforated because of the insertion of the instrument. If this complication occurs, surgery may be needed to repair the damage.

Normal results

If the prostate tissue samples show no sign of inflammation, and if no cancerous cells are detected, the results are normal.

Abnormal results

Analysis of the prostate tissue under the microscope reveals any abnormalities. In addition, the presence of cancerous cells can be detected. If a tumor is present, the pathologist "grades" the tumor, in order to estimate how aggressive the tumor is. The most commonly used grading system is called the "Gleason system."

Normal prostate tissue has certain characteristic features that the cancerous tissue lacks. In the Gleason system, prostate cancers are graded by how closely they resemble normal prostate tissue. The system assigns a grade ranging from 1 to 5. The grades assigned to two areas of cancer are added up for a combined score that is between 2 and 10. A score between 2 and 4 is called low and implies that the cancer is a slow-growing one. A Gleason score of 8 to 10 is high and indicates that the cancer is aggressive. The higher the Gleason score, the more likely it is that the cancer is fast-growing and may have already grown out of the prostate and spread to other areas (metastasized).

KEY TERMS

Benign prostatic hyperplasia (BPH)— A noncancerous condition of the prostate that causes overgrowth of the prostate tissue, thus enlarging the prostate and obstructing urination.

Biopsy— The surgical removal and microscopic examination of living tissue for diagnostic purposes.

Computed tomography (CT) scan— A medical procedure in which a series of x rays are taken and put together by a computer in order to form detailed pictures of areas inside the body.

Digital rectal examination— A routine screening test that is used to detect any lumps in the prostate gland or any hardening or other abnormality of the prostate tissue. The doctor inserts a gloved and lubricated finger (digit) into the patient's rectum, which lies just behind the prostate. Typically, since a majority of tumors develop in the posterior region of the prostate, they can be detected through the rectum.

Magnetic resonance imaging (MRI)— A medical procedure used for diagnostic purposes where pictures of areas inside the body are created using a magnet linked to a computer.

Pathologist— A doctor who specializes in the diagnosis of disease by studying cells and tissues under a microscope.

Ultrasonogram— A procedure in which high-frequency sound waves that cannot be heard by human ears are bounced off internal organs and tissues. These sound waves produce a pattern of echoes that are then used by the computer to create sonograms or pictures of areas inside the body.

Urethra— The tube that carries the urine from the urinary bladder and (in males) the semen from the sex glands to the outside of the body.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Prostate Cancer." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Adamakis, I., D. Mitropoulos, K. Haritopoulos, et al. "Pain During Transrectal Ultrasonography Guided Prostate Biopsy: A Randomized Prospective Trial Comparing Periprostatic Infiltration with Lidocaine with the Intrarectal Instillation of Lidocaine-Prilocain Cream." World Journal of Urology 20 (December 2003): E-pub.

Hsieh, K., and P. C. Albertsen. "Populations at High Risk for Prostate Cancer." Urological Clinics of North America 30 (November 2003): 669-676.

Jones, J. S., and C. D. Zippe. "Rectal Sensation Test Helps Avoid Pain of Apical Prostate Biopsy." Journal of Urology 170 (December 2003): 2316-2318.

Meisel, F., C. Jacobi, R. Kollmar, et al. "Acute Meningitis after Transrectal Prostate Biopsy." [in German] Der Urologe: Ausg. A 42 (December 2003): 1611-1615.

Seitz, C., S. Palermo, and B. Djavan. "Prostate Biopsy." Minerva Urologica Nefrologica 55 (December 2003): 205-218.

Shetty, Sugandh, MD. "Transrectal Ultrasound of the Prostate (TRUS)." eMedicine March 1, 2004. 〈http://www.emedicine.com/med/topic3477.htm〉.

ORGANIZATIONS

American Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA 30329-4251. (800) 227-2345. 〈http://www.cancer.org〉.

American Urologic Association. 1120 N. Charles St., Baltimore, MD 21201. (410) 223-4310.

National Prostate Cancer Coalition. 1300 19th Street NW, Suite 400, Washington, DC 20036. (202) 842-3600 ext. 214.

Prostate Cancer InfoLink. 〈http://www.comed.com/Prostate/index.html〉.

PROSTATE CANCER

Prostate cancer is the most common cancer in men and the second leading cause of cancer-related death in men. An estimated 191,000 cases of prostate cancer will be diagnosed in 2001 in the United States along with 30,500 prostate cancer-related deaths. The disease is detected by a combination of abnormal serum prostate-specific antigen (PSA) and digital rectal exam (DRE), and less often as an incidental finding after prostate resection for obstructive benign disease. It is uncommon at this time to diagnose prostate cancer in association with gross urinary obstruction, bleeding, or unexplained skeletal pain.

The disease is both hereditary and sporadic with one gene (HPC2), and several gene loci recently identified. The risk for developing prostate cancer increases twofold if a first-degree relative is affected and it further increases as more family members are afflicted (first- and second-degree relatives). Although no specific cause for prostate cancer has been identified, several factors contribute to the development of the disease. This includes the level of saturated animal fat in the diet, vitamin D production, and ethnic origin. African Americans have the highest rate of prostate cancer in the world, while it is the lowest in native Asians. The disease is more commonly seen after the age of fifty.

The natural history of prostate cancer is strongly driven by the tumor grade. The risk of prostate cancer death is low (less than 10%) in patients of almost all ages with low-grade disease; however, it is substantial for patients with moderate- or high-grade disease. Metastatic disease has a very predictable natural history, with a median survival of thirty to thirty-three months after diagnosis.

Prostate cancer is generally detected by an abnormal serum PSA determination and/or an abnormal DRE. The diagnosis is generally made by an ultrasound-guided needle biopsy of the prostate. These techniques have led to a stage shift in the disease, with the majority of lesions now detected in the clinically localized state. Contemporary treatments for clinically localized disease include watchful waiting, radical prostatectomy, radiation therapy (external beam or brachytherapy), or cryosurgery. Androgen ablation (removal of testosterone-like substances from the system) can be used alone or in combination with other modalities, and is the principle form of therapy for advanced disease.

The decision whether to treat the disease or observe the patient should be based on the probability of the patient reasonably living another five to ten years, and thus takes into account the patient's age and comorbid conditions. Surgery can be very effective and is generally employed in younger men where nerve-sparing surgery can be used to preserve erectile function. The major side effect is urinary incontinence, which can be significant in a small percentage of patients. External beam radiation therapy is also a standard form of therapy which is generally performed in older patients (over age seventy). It is usually well tolerated, but a small percentage of men can develop gastrointestinal side effects related to rectal irritation.

Brachytherapy refers to the implantation of radioactive pellets in the prostate gland, usually under ultrasound guidance. This technique has been employed for approximately a decade and is an effective form of therapy in men with appropriate lesions. The major side effect from this therapy is an increase in irritative voiding symptoms. An increasing body of knowledge suggests that the addition of androgen ablation may improve the outcomes of patients receiving radiation.

Approximately 20 percent of patients treated for localized disease will experience a rise in their PSA within five years. This group of biochemical- failure patients are an enlarging cohort of patients for which exact treatment recommendations are not available. Gross loco-regional disease has become less common in the PSA era. Prostate cancer generally metastasizes to the lymph nodes and the bones, with less common involvement of the visceral organs.

Prostate tumors are classically dependent on endogenous androgens as growth factors. The removal of androgens by castration (surgical or chemical) results in a regression of symptoms and measurable disease in 80 percent of patients. Unfortunately, there are androgen-resistant clones in most tumors, which makes this form of therapy palliative. Androgen ablation can be performed by the removal of the testicles or the administration of a luteinizing hormone releasing hormone (LHRH) antagonist.

Prostate cancer relapsing after androgen ablation is designated androgen independent prostate cancer. The median survival for such patients is approximately eleven months. Although newer chemotherapy agents are displaying activity in advanced prostate cancer, treatment is generally palliative. This is an area of intense clinical investigation and protocol therapy.

S. Bruce Malkowicz

(see also: Cancer; Prostate-Specific Antigen [PSA] )

Bibliography

Albertson, P. C.; Hanley, J. A.; Gleason, D. R. et al. (1998). "Competing Risk Analysis of Men Aged 55 to 74 Years at Diagnosis Managed Conservatively for Clinically Localized Prostate Cancer." Journal of the American Medical Association 280:975–980.

Catalona, W. J., and Smith, D. S. (1998). "Cancer Recurrence and Survival Rates after Anatomic Radical Retropubic Porstatectomy for Prostate Cancer: Intermediate-Term Results." Journal of Urology 160:2428–2434.

D'Amico, A. V.; Whittington, R.; Malkowicz, S. B. et al. (1998). "Biochemical Outcome after Radical Prostatectomy, External Beam Radiation Therapy or Interstitial Radiation Therapy for Clinically Localized Prostate Cancer." Journal of the American Medical Association 280:969–974.

Eisenberg, M. A.; Blumenstein, B. A.; Crawford, E. D. et al. (1998). "Bilateral Orchiectomy with or without Flutamide for Metastatic Prostate Cancer." New England Journal of Medicine 339:1036–1042.

Powel, I. J. (1998). "Prostate Cancer in the African-American: Is This a Different Disease?" Seminars in Urologic Oncology 16:221–226.

Ragde, H.; Blasko, J. C.; Grimm, P. D. et al. (1997). "Interstital Iodine-125 Radiation without Adjuvant Therapy in the Treatment of Clinically Localized Prostate Carcinoma." Cancer 80:442–453.

prostate cancercancer originating in the prostate gland . Prostate cancer is one of the most malignancies in men in the United States, second only to skin cancer, and as a cause of cancer death in men is second only to lung cancer. It occurs predominantly in older men; the median age at diagnosis is 72 years. Black men have a higher incidence than white men. The cause of prostate cancer is unknown, but the incidence varies markedly by geographic region, an indication that there are environmental factors that may trigger the disease. For example, men in China and Japan have a low rate of prostate cancer, but the incidence rises in Chinese and Japanese men who move to the United States. The hormone testosterone is believed to have a role in the development of prostate cancer, and studies have shown a relationship between high dietary fat intake and increased testosterone levels. Prostate tumors are often slow growing. Around 95% are classified as adenocarcinomas (arising from epithelial glandular tissue). The most common site of metastasis is the bone, and bone metastasis is the leading cause of death from prostate cancer.

Screening and Diagnosis

Traditionally, prostate cancer screening consisted of digital-rectal examination. Since 1986, however, a blood test for a tumor marker called prostate-specific antigen (PSA) has greatly increased the number of early-stage prostate cancers diagnosed. An elevated level of PSA can indicate the presence of prostatic malignancy. Elevated PSA is further investigated by an ultrasound test and needle biopsy , in which a fine needle is inserted into the gland and cells are extracted for laboratory analysis. In some cases a bone scan is also performed to rule out metastatic disease. Because PSA tests detect not only aggressive cancers but slow-growing cancers that are not life-threatening, many people disagree with routine PSA testing of asymptomatic men. A review of the test by a U.S. task force indicated that the test has led to treatments that compromise quality of life without assuring a longer life; the task force recommended (2011) that the test not be given to normal healthy men. An additional problem with the test is that some men with normal PSA levels will in fact have prostate cancer.

Treatment

For most patients with localized tumors, even slow-growing ones, surgical removal of the prostate gland (prostatectomy) is the initial treatment, despite possible side effects of urinary incontinence and impotence. Localized prostate cancer can often be cured. After surgery, a repeated blood test for protein-specific antigen can indicate whether any cancer remains. In metastatic disease, other treatments are employed depending on the stage of the disease and the age and health of the patient. Treatment options include external-beam radiation, implantation of radioactive isotopes, and palliative surgery. Hormonal manipulation by giving estrogens or other drugs, or by orchiectomy (removal of the testes), is sometimes used to decrease levels of testosterone. Very small cancers or slow-growing cancers in older men are sometimes watched, but not treated, without compromising life expectancy.

Bibliography

See M. Korda, Man to Man (1996), and P. Walsh and J. F. Worthington, Dr. Patrick Walsh's Guide to Surviving Prostate Cancer (2001). See also publications of the National Cancer Institute and the American Cancer Society.

PROSTATE CANCER

DEFINITION

Prostate cancer is a disease in which the cells of the prostate become abnormal. They start to grow uncontrollably, forming tumors. A tumor is a mass or lump of tissue made of abnormal cells. Tumors may be malignant or benign. A malignant tumor can spread to other parts of the body. Malignant tumors are cancerous. Benign tumors cannot spread to other parts of the body.

DESCRIPTION

The prostate is one of the major male sex glands. It is about the size of a walnut and lies just behind the urinary bladder. Together with the testicles and seminal vesicles, the prostate produces the fluid that makes up semen.

Prostate cancer is the most common form of cancer among men in the United States. It is the second-leading cause of cancer deaths. According to the American Cancer Society there were approximately 179,300 new cases of prostate cancer diagnosed in the United States in 1999. About thirty-seven thousand American men died of the disease in 1999.

Prostate cancer affects black men twice as often as it does white men. The mortality rate among blacks is also twice as great. African American men have the highest rate of prostate cancer in the world.

As prostate cancer develops, it may metastasize. Metastasis is the process by which cancer cells travel from one part of the body to another. The most common sites to which it spreads are the lymph nodes, the lungs, and various bones in the hip region.

Prostate Cancer: Words to Know

Benign:

A term for a tumor that does not spread and is not life-threatening.

Biopsy:

A procedure in which a small sample of tissue is removed so that it can be studied under a microscope.

Chemotherapy:

A method of treating cancer using certain chemicals that can kill cancer cells.

Estrogen:

A female sex hormone.

Hormone therapy:

A method of treating prostate cancer by adjusting the level of testosterone in the patient's body.

Malignant:

A tumor that can spread to other parts of the body and that poses a serious threat to a person's life.

Metastasis:

The process by which cancer cells travel from one area of the body to another.

Radiation therapy:

The use of high-energy radiation to treat cancer.

Seminal vesicles:

The organs that produce semen.

Testicles:

Two egg-shaped glands that produce sperm and sex hormones.

Testosterone:

A male sex hormone.

Tumor:

A mass or lump of tissue made of abnormal cells.

CAUSES

The cause of prostate cancer is not known. It is found primarily in men over the age of fifty-five. The average age of diagnosis is seventy-two. As men grow older, their likelihood of getting prostate cancer increases. For men under the age of forty, the chance of getting prostate cancer is about 1 in 100,000. For men seventy to seventy-four years old, the chance rises to 1,326 in 100,000.

Certain factors increase a man's risk for prostate cancer. These factors include:

• A family history of prostate cancer
• A high-fat diet
• Work in the electroplating, welding, and rubber industries
• High blood testosterone (a male sex hormone) levels

SYMPTOMS

In many cases prostate cancer has no symptoms in its early stages. The disease is usually discovered during a routine physical examination. As the

disease develops, certain symptoms are more likely to appear. These symptoms include:

• Weak or interrupted flow of urine
• Frequent urination, especially at night
• Difficulty in starting to urinate
• Inability to urinate
• Pain or burning sensation during urination
• Blood in the urine
• Continuous pain in the lower back, hips, or thighs
• Painful ejaculation

DIAGNOSIS

The first step in diagnosing prostate cancer is usually a digital rectal examination. In a digital rectal examination, a doctor places a gloved, lubricated finger into the patient's rectum. The doctor feels for lumps in the prostate.

If the doctor detects a lump, additional tests may be necessary. The first test may be a blood test. The purpose of a blood test is to search for a particular chemical associated with prostate cancer. This chemical is called prostate-specific antigen (PSA). PSA occurs naturally in the blood, but it occurs in much higher amounts if prostate cancer is present.

A second test that may be used is a transrectal (across the rectum) ultrasound. In this test, sound waves are bounced off the prostate gland. The reflected waves form a picture of the prostate. The picture shows the presence of any tumors.

A prostate biopsy may also be necessary. A biopsy is a procedure in which a small sample of tissue is removed. The sample is then studied under the microscope. Cancer cells can be detected under the microscope because of their distinctive appearance.

Other tests may be conducted to see if the cancer has begun to spread. For example, a chest X ray will show if cancer has spread to the lungs. A bone scan may be used to check whether the cancer has spread to the bone.

TREATMENT

A number of treatments are available for prostate cancer. The treatment chosen depends on the patient's age and general health, the stage of the tumor, the presence of other illnesses, and other factors.

The two most common forms of treatment for early prostate cancer are surgery and radiation. Surgery involves the removal of the prostate gland. In addition, a sample of the lymph nodes near the prostate is removed. This sample is then tested to see whether the cancer has spread.

Removal of the prostate also involves removal of the seminal vesicles that lie next to it. The seminal vesicles are the organs that make semen. Since they are usually removed along with the prostate, the patient usually becomes sterile as a result of the operation.

Radiation involves the use of high-energy rays to kill cancer cells. In most cases, the radiation comes from radioactive materials. Radioactive materials are substances that give off high-energy radiation, similar to X rays. The radiation can be given either externally or internally. If it is given externally, the radioactive source is placed above the patient's body in the area of the cancer. Radiation from the source penetrates the body and destroys cancer cells. Radiation can also be given internally by implanting the source in the patient's body.

For more advanced cases of prostate cancer, hormone therapy may be necessary. Prostate cells need the male hormone testosterone to grow. One way to stop the growth of prostate cells, then, is to reduce the amount of testosterone in the body. One way to do that is to surgically remove the patient's testicles. The testicles are the organ that produces testosterone. Another way to achieve the same goal is to give the patient a medication that reacts with testosterone. The medication "cancels out" the testosterone produced by the body.

Finally, the patient may be given a female hormone, such as estrogen. The estrogen makes the body stop producing testosterone. This treatment has some undesirable side effects, however. For example, a man may have "hot flashes," have enlarged and tender breasts, and lose sexual desire.

Chemotherapy may be used if the cancer has metastasized (pronounced muh-TASS-tuh-sized). Chemotherapy involves the use of chemicals that kill cancer cells. These chemicals can be given either orally (by mouth) or intravenously (into the bloodstream). The chemicals spread throughout the patient's body and attack cancer cells wherever they occur. Chemotherapy is sometimes used to treat prostate cancer that has recurred after other treatments.

A final form of treatment is no treatment at all. Prostate cancers sometimes develop very slowly. It may take years for them to become a serious threat to the patient's life. That fact is considered in treating older men. In many cases, the man is likely to die of other causes before prostate cancer becomes a serious concern. The approach in such cases is called "watchful waiting." The patient receives regular checkups. If no major change is found, no treatment is offered. If the tumor becomes significantly larger, one of the above forms of treatment is used.

PROGNOSIS

According to the American Cancer Society, the survival rate for all stages of prostate cancer combined increased from 67 percent in the late 1970s to 93 percent in the late 1990s. The main reason for this change is early detection. When tumors are still small, they can be removed successfully in almost all cases.

About 99 percent of all patients diagnosed with prostate cancer now live at least five years. More than 60 percent survive for ten years, and about 50 percent survive for fifteen years after diagnosis.

PREVENTION

There is no way to prevent prostate cancer. However, early detection can dramatically reduce the threat posed by the disease. The American Cancer Society (ACS) recommends that all men over the age of forty have an annual rectal examination. The ACS also recommends an annual PSA test once a year for men over the age of fifty.

A low-fat diet may slow the progress of prostate cancer. The ACS recommends a diet rich in fruits, vegetables, and fiber and low in red meat and saturated fats.

FOR MORE INFORMATION

Books

Bostwick, David G., Gregory T. MacLennan, and Thayne R. Larson. Prostate Cancer: What Every Man—and His Family—Needs to Know. New York: Villard Books, 1999.

Dollinger, Malin, Ernest H. Rosenbaum, and Greg Cable. Everyone's Guide to Cancer Therapy. Kansas City, MO: Somerville House Books, 1994.

Loo, Marcus, H., and Marian Betancourt. The Prostate Cancer Sourcebook : How to Make Informed Treatment Choices. New York: John Wiley & Sons, 1998.

Morra, Marion, and Eve Potts. Choices. New York: Avon Books, 1994.

Oesterling, Joseph A. The ABC's of Prostate Cancer : The Book That Could Save Your Life. Lanham: Madison Books, 1997.

Wallner, Kent. Prostate Cancer: A Non-Surgical Perspective. Seattle: SmartMedicine Press, 1996.

Organizations

American Cancer Society. 1599 Clifton Rd., N.E., Atlanta, GA 30329. (800) 227–2345.

American Urologic Association. 1120 N. Charles St., Baltimore, MD 21201. (410) 223–4310.

Cancer Research Institute. 681 Fifth Ave., New York, NY 10022. (800) 992–2623.

National Cancer Institute. 31 Center Drive, Bethesda, MD 20892–2580. (800) 4–CANCER. http://www.nci.nih.gov.

National Prostate Cancer Coalition. 1300 19th St., NW, Suite 400, Washington, DC 20036. (202) 842–3600.

Web sites

"Ask NOAH About: Prostate Cancer." NOAH: New York Online Access to Health. [Online] http://www.noah.cuny.edu/cancer/nci/cancernet/201229.html (accessed on October 28, 1999).

"Prostate Action Network." http://rattler.cameron.edu/pacnet (accessed on October 28, 1999).

"Prostate Cancer." The Prostate Cancer Resource Center. [Online] http://www3.cancer.org/cancerinfo/main_cont.asp?st=wi&ct=36 (accessed on October 28, 1999).

The Prostate Cancer Info Link. [Online] http://www.comed.com/Prostate/ (accessed on October 28, 1999).

Prostate Cancer

Christina’s Story

What Is Prostate Cancer?

What Are the Symptoms of Prostate Cancer?

How Is Prostate Cancer Diagnosed?

How Is Prostate Cancer Treated?

Life after Prostate Cancer

Can Prostate Cancer Be Prevented?

Resources

Prostate cancer occurs when cells in the prostate, a male reproductive gland located between the bladder and the rectum*, take on an abnormal appearance and start dividing without control or order. These cancer cells often spread to nearby tissues and organs and sometimes to other parts of the body.

* The rectum

is the final portion of the large intestine, connecting the colon to the outside opening of the anus.

KEYWORDS

for searching the Internet and other reference sources:

Cancer

Impotence

Proctology

PSA tests

Christina’s Story

Christina loved that her grandfather lived with her family. He certainly didn’t act like most seventy-year-olds! He taught her everything she knew about basketball and shot baskets with her every night during the season. Lately, though, Grandpa admitted that he wasn’t quite feeling up to playing with Christina. He often woke up feeling tired because he had to go to the bathroom several times each night.

Christina heard her grandfather tell her mother that he felt like his bladder was always full and that sometimes his urine even looked pinkish or reddish, like it might have blood in it. When Grandpa’s doctor heard what his symptoms were, he told him to come in right away. The doctor ran some tests and confirmed his initial suspicion: Grandpa had prostate cancer.

When Christina heard the word “cancer,” she was scared. She knew that people could die from this disease. Grandpa reassured her that there were treatments available that could help him. Plus, the doctor had said that his cancer was growing slowly and had not spread to other parts of the body. This was a very good sign.

What Is Prostate Cancer?

Prostate cancer is the most common kind of cancer and second most common cause of cancer deaths in men in the United States. It is found almost exclusively in men age 50 and older. With each decade of life after 50, a man’s chance of developing prostate cancer increases. Each year, about 200,000 men in the United States find out that they have this disease.

Prostate cancer occurs when cells in the prostate gland divide without control or order, forming tumors*. The prostate is the walnut-sized male gland located below the bladder and in front of the rectum. The prostate surrounds the upper part of the urethra (yoo-REE-thra), the tube that empties urine from the bladder and out of the penis. This gland releases a thick fluid that helps transport sperm*.

* tumor

(TOO-mor) refers to an abnormal growth of body tissue. Tumors may or may not be cancerous.

* sperm

are the tiny tadpole-like cells males produce in their testicles. Sperm can unite with a female’s egg to result eventually in the birth of a child.

Prostate cancer varies widely among men with the condition. Some men develop small, slow-growing tumors that remain within the prostate gland. Others develop fast-growing, aggressive tumors that spread quickly into the surrounding bone. They also can spread to nearby organs such as the bladder, rectum, and lymph nodes*. There are still other men who fit somewhere in between these two extremes. How doctors treat the disease usually depends on how rapidly the tumor is growing.

* lymph node

(LIMF node) is a small, round mass of tissue that contains immune cells that filter out harmful microorganisms.

What Are the Symptoms of Prostate Cancer?

When it first starts to develop, prostate cancer usually does not cause any symptoms. That is why doctors recommend that men age 40 and older have digital rectal examinations as part of their yearly checkups. During this exam, the doctor inserts a gloved finger into the rectum and feels the prostate, which is located just on the other side of the wall of the rectum. If the gland feels hard, lumpy, or enlarged, this may be an early sign of prostate cancer.

As it continues to develop, prostate cancer may cause some of the following symptoms:

• a need to urinate frequently, especially at night
• difficulty urinating or holding back urine
• pain or burning while urinating or having sex
• blood in the urine or semen
• frequent pain or stiffness in the lower back, hips, or upper thighs.

Although these symptoms may indicate prostate cancer, they can also be caused by some other condition.

How Is Prostate Cancer Diagnosed?

Doctors usually start with a digital rectal examination. They also may take a blood sample and test it for a substance called prostate-specific antigen (AN-ti-jen), or PSA. Usually, this substance is present at abnormally high levels when a man has prostate cancer or some other problem with the prostate. Physicians may order additional laboratory tests or a urine sample to check for blood or other signs of infection.

The only sure way to know whether cancer is present is to do a biopsy (BY-op-see). The doctor uses a needle to remove a small amount of tissue from the prostate and has it examined under a microscope. The appearance of the cells will show whether cancer is present, and if so, how quickly it is likely to grow and spread. Cells that are slightly abnormal but still look a lot like healthy prostate cells suggest that the cancer is slow growing. Extremely abnormal-looking cells mean that the cancer is likely to grow and spread more quickly.

More Men Are Talking about Prostate Cancer

Just 15 to 20 years ago, few men talked about prostate cancer, perhaps because they felt embarrassed or ashamed of the condition. After all, it affects two of men’s most private activities: going to the bathroom and having sex. But in the 1990s, many famous men have stepped forward to speak about their own experiences with this disease.

Bob Dole, former U.S. senator and the 1996 Republican presidential candidate, was diagnosed with prostate cancer in 1991. He made this information public and used his fame to encourage other men to have yearly tests that might catch the disease early. He also introduced an amendment that called for increased funding for prostate cancer research.

U.S. Army General Norman Schwarzkopf is used to tough battles, having led the U.S. troops in the Gulf War. Now, as a prostate cancer survivor, he is leading efforts to promote awareness of this disease.

Professional golfers Arnold Palmer and Jim Colbert both have made their experiences with prostate cancer public. Now, they are cochairmen of the Senior PGA Tour for the Cure, which raises money to support the Association for the Cure of Cancer of the Prostate. Fans can pledge money for each birdie that their favorite players make.

If cancer is diagnosed, the doctor may order additional tests to determine whether it has spread to other parts of the body.

How Is Prostate Cancer Treated?

Treatment depends on several different things: the man’s age and general health, how aggressive the cancer is, and whether it has spread outside the prostate.

Sometimes, the best treatment is no treatment at all. This might sound strange at first, but for some older men and men with serious health problems, the possible risks and side effects of treatment may outweigh the benefits. Also, men whose cancer is slow growing or found at an early stage may not require treatment right away. In these cases, doctors prefer to monitor the situation carefully and wait to see how the cancer develops.

When treatment is necessary, the usual methods are surgery, radiation therapy, or hormonal (hor-MOAN-al) therapy. Some patients may receive a combination of these treatments. The surgery is called radical prostatectomy (RAD-i-kal pros-ta-TEK-to-mee), and it involves removing the entire prostate gland. Sometimes, nearby lymph nodes are removed as well.

Radiation therapy uses high-energy rays to damage cancer cells and stop them from growing and dividing. These rays might come from a machine, or they may come from radioactive material that is placed into or near the tumor. Hormonal therapy works by blocking the male hormones that the prostate cancer cells need to grow.

There are different approaches to hormonal therapy. Sometimes, surgeons might remove the testicles (TES-ti-kulz), the smooth, oval-shaped glands located behind the penis. These are the body’s main source of male hormones. Doctors also might give drugs or other hormones that prevent the testicles from making testosterone (tes-TOS-ter-one).

Life after Prostate Cancer

In many men, prostate cancer can be controlled or even cured. However, the treatments often cause lasting side effects. Some men can no longer have an erection, which means that the penis no longer becomes hard during sex. Also, some men can no longer control the release of urine from the bladder. Fortunately, new treatments and surgical methods are available that may avoid these side effects. However, if these side effects occur, men may feel depressed or upset. Some men find it helpful to join a support group so they can talk to others in the same situation.

Can Prostate Cancer Be Prevented?

There is nothing a man can do to prevent prostate cancer. A diet high in fruits and vegetables and low in fat may help, but researchers have not confirmed this. Studies are under way to test certain drugs that could help to prevent prostate cancer, but no definite results are available. The best way for men to protect themselves is to see their doctors every year for checkups and report any unusual symptoms right away. Like other types of cancer, prostate cancer is easier to treat when found early.

See also

Cancer

Incontinence

Resources

Organizations

The American Cancer Society, 1599 Clifton Road, N.E., Atlanta, GA 30329. Information is available on prostate and other types of cancer. Telephone 800-ACS-2345 http://www.cancer.org/

National Cancer Institute, National Institutes of Health, Rockville, MD. This organization provides an open help line during working hours. Telephone 800-4-CANCER http://cancernet.nci.nih.gov/

National Kidney and Urologie Diseases Information Clearinghouse, 3 Information Way, Bethesda, MD 20892-3580. This organization provides patient information. Telephone 800-891-5388 http://www.niddk.nih.gov/

prostate cancer (pros-tayt) n. a malignant tumour (carcinoma) of the prostate gland, a common form of cancer in elderly men. In most men it progresses slowly over many years and gives symptoms similar to those of benign enlargement of the prostate (see prostate gland).