Prostate Cancer


When you’re told you have prostate cancer, it’s natural to wonder what may have caused the disease. But no one knows the exact causes of prostate cancer. Doctors seldom know why one man develops prostate cancer and another doesn’t. However, research has shown that men with certain risk factors are more likely than others to develop prostate cancer. A risk factor is something that may increase the chance of getting a disease. Studies have found the following risk factors for prostate cancer: Age over 65: Age is the main risk factor for prostate cancer. The chance of getting prostate cancer increases as you get older. In the United States, most men with prostate cancer are over 65. This disease is rare in men under 45. Family history: Your risk is higher if your father, brother, or son had prostate cancer. Race: Prostate cancer is more common among black men than white or Hispanic/Latino men. It’s less common among Asian/Pacific Islander and American Indian/Alaska Native men. Certain genome changes: Researchers have found specific regions on certain chromosomes that are linked to the risk of prostate cancer. According to recent studies, if a man has a genetic change in one or more of these regions, the risk of prostate cancer may be increased. The risk increases with the number of genetic changes that are found. Also, other studies have shown an elevated risk of prostate cancer among men with changes in certain genes, such as BRCA1 and BRCA2.

 

Symptoms of Prostate Cancer

A man with prostate cancer may not have any symptoms. Symptoms of prostate cancer are often similar to those of Benign Prostatic Hyperplasia/Enlarged Prostate (BPH). Men observing the following signs and/or symptoms should see their physician for a thorough examination: 

  • Urinary problems
  • Not being able to urinate
  • Having a hard time starting or stopping the urine flow 
  • Needing to urinate often, especially at night 
  • Weak flow of urine 
  • Urine flow that starts and stops 
  • Pain or burning during urination 
  • Difficulty having an erection 
  • Blood in the urine or semen
  • Frequent pain in the lower back, hips, or upper thighs

 

If you have any of these symptoms, you should tell your doctor so that problems can be diagnosed and treated.

 

 

Detection of Prostate Cancer

Your doctor can check for prostate cancer before you have any symptoms. During an office visit, your doctor will ask about your personal and family medical history. You’ll have a physical exam. You may also have one or both of the following tests:

Digital rectal exam: Your doctor inserts a lubricated, gloved finger into the rectum and feels your prostate through the rectal wall. Your prostate is checked for hard or lumpy areas. 
Blood test for prostate-specific antigen (PSA): A lab checks the level of PSA in your blood sample. 

The prostate makes PSA. A high PSA level is commonly caused by BPH or prostatitis (inflammation of the prostate). Prostate cancer may also cause a high PSA level. The digital rectal exam and PSA test can detect a problem in the prostate. However, they can’t show whether the problem is cancer or a less serious condition. If you have abnormal test results, your doctor may suggest other tests to make a diagnosis. All, or none, of these tests may be ordered by your doctor: Free PSA: In the bloodstream, some of the PSA is bound to proteins and some is not. The percent of PSA that is not bound to proteins (free PSA) may help to determine if an abnormal PSA is more likely to be elevated due to benign enlargement of the prostate (BPH) or due to cancer. PCA3 Plus: PCA3 is a gene that is overexpressed in prostate cancer cells. After an attentive prostate exam, a urine sample is obtained. Cells in the urine are checked for levels of PCA3. This is test is used more frequently when people have had a negative biopsy previously.


Transrectal ultrasound: The ultrasound technician inserts a probe into the rectum to check your prostate for abnormal areas. It also measures the size of the prostate, which can help to determine if 

the PSA level is elevated for the size of the prostate. The probe sends out sound waves that people cannot hear (ultrasound). The waves bounce off the prostate. A computer uses the echoes to create a picture called a sonogram. 


Transrectal biopsy: A biopsy is the removal of tissue to look for cancer cells. It’s the only sure way to diagnose prostate cancer. The doctor inserts a needle through the rectum into the prostate. The doctor removes small tissue samples (called cores) from many areas of the prostate. Transrectal ultrasound is usually used to guide the insertion of the needles. A pathologist checks the tissue samples for cancer cells.

 

Diagnosis of Prostate Cancer

If cancer cells are found, the pathologist studies tissue samples from the prostate under a microscope to report the grade of the 

tumor. The grade tells how much the tumor tissue differs from normal prostate tissue. It suggests how fast the tumor is likely to grow. Tumors with higher grades tend to grow faster than those with lower grades. They are also more likely to spread. Doctors use tumor grade along with your age and other factors to suggest treatment options. The most commonly used system for grading is the Gleason score. Gleason scores range from 2 to 10. To come up with the Gleason score, the pathologist uses a microscope to look at the patterns of cells in the prostate tissue. The most common pattern is given a grade of 1 (most like normal cells) to 5 (most abnormal). If there is a second most common pattern, the pathologist gives it a grade of 1 to 5, and adds the two most common grades together to make the Gleason score. If only one pattern is seen, the pathologist counts it twice. For example, 4 + 3 = 7. This means that the most commonly seen grade of tumor cells seen is a 4 and the second most commonly seen tumor cells is a 3. Together a Gleason score of 7 is obtained. A high Gleason score (such as 10) means a high-grade prostate tumor. High-grade tumors are more likely than low-grade tumors to grow quickly and spread.

 

Staging of Prostate Cancer

If the biopsy shows that you have cancer, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment. Staging is a careful attempt to find out whether the tumor has invaded nearby tissues, whether the cancer has spread and, if so, to what parts of the body.
Stage I: The cancer can’t be felt during a digital rectal exam, and it can’t be seen on an imaging study, such as ultrasound. It’s found by chance when surgery is done for another reason, usually for BPH. The cancer is only in the prostate and is very low grade (low Gleason score)Stage II: The tumor is more advanced or a higher grade than Stage I, but the tumor doesn’t extend beyond the prostate. It may be felt during a digital rectal exam, or it may be seen on a sonogram. It is detected either after a needle biopsy or surgery done for other reasons, i.e. resection of the prostate for benign enlargement. 
Stage III: The tumor extends beyond the capsule (outer covering) of the prostate. The tumor may have invaded the seminal vesicles, but cancer cells haven’t spread to the lymph nodes, bones or other organs.Stage IV: The tumor may have invaded the bladder, rectum, or nearby structures (beyond the seminal vesicles). It may have spread to the lymph nodes, bones, or to other parts of the body.

 

 

Treatment of Prostate Cancer

Men with prostate cancer have many treatment options. The treatment that’s best for one man may not be best for another. Your doctor will make recommendations that are best for each individual. The options include active surveillance (also called watchful waiting), surgery, radiation therapy, cryotherapy, hormone therapy, and chemotherapy. You may have a combination of treatments. The treatment that’s right for you depends mainly on your age, the grade of the tumor (the Gleason score), the number of biopsy tissue samples that contain cancer cells, the stage of the cancer, your symptoms, and your
general health. Your doctor can describe your treatment choices, the expected results of each, and the possible side effects. You and your doctorcan work together to develop a treatment plan that meets
your medical and personal needs.

 

Active Surveillance

You may choose active surveillance if the risks and possible side effects of treatment outweigh the possible benefits. Your doctor may suggest active surveillance if you’re diagnosed with early stage prostate cancer that seems to be slowly growing. Your doctor may also offer this option if you are older or have other serious health problems. Choosing active surveillance doesn’t mean you’re giving up. It means you’re putting off the side effects of surgery or radiation therapy. Having surgery or radiation therapy is no guarantee that a man will live longer than a man who chooses to put off treatment. If you and your doctor agree that active surveillance is a good idea, your doctor will check you regularly (such as every 3 to 6 months, at first). After about one year, your doctor may order another biopsy to check the Gleason score. You may begin treatment if your Gleason score rises, your PSA level starts to rise, or you develop symptoms. You’ll receive surgery, radiation therapy, or another approach at that time. Active surveillance avoids or delays the side effects of surgery and radiation therapy, but this choice has risks. For some men, it may reduce the chance to control cancer before it spreads. Also, it may be harder to cope with surgery or radiation therapy when you’re older. If you choose active surveillance but grow concerned later, you should discuss your feelings with your doctor. Another approach is an option for most men.

 

The most common treatments for prostate cancer are:

Surgery:

Surgery is an option for men with early (Stage I or II) prostate cancer. It’s sometimes an option for men with Stage III or IV prostate cancer. Before the surgeon removes the prostate, the lymph nodes in the pelvis may be removed. If prostate cancer cells are found in the lymph nodes, the disease may have spread to other parts of the body. If cancer has spread to the lymph nodes, the surgeon does not always remove the prostate and may suggest other types of treatment. 

Hormone Therapy:

Also called androgen deprivation therapy (ADT) lowers androgen levels.  Androgens, including testosterone, stimulate prostate cancer cell growth. Lowering androgen to levels that simulate castration can shrink or slow cancer cell growth.

Advanced Prostate Cancer

Most men with prostate cancer eventually stop responding to hormone therapy.  When this happens and the cancer continues to grow, despite hormone therapy, it is referred to as castration-resistant prostate cancer. Your MIU Advanced Prostate Clinic doctor may prescribe advanced hormonal oral medications such as ZYTIGA® (abiraterone acetate), Erleada, (apalutamide), or XTANDI® (enzalutamide) to treat castration-resistant prostate cancer.

Learn More About Zytiga Here!

Learn More About Xtandi Here!

Learn More About Erleada Here!

Immunotherapy:

PROVENGE® (sipuleucel-T) is an immunotherapy that works by boosting your own immune system to fight your advanced prostate cancer.  PROVENGE® is a personalized treatment that is made from your own immune cells.  After your immune cells are collected, they are ‘activated’ to recognize and attack your prostate cancer cells, once they are returned to your body through a brief infusion process. 

National cancer guidelines recommend PROVENGE® as a first line treatment option for advanced prostate cancer for men with few or no cancer-related symptoms.

Learn More About Provenge Here!

If you would like more information regarding Provenge therapy please contact Pamela Jones: jonesp@michiganurology.com.

Radiotherapy:

XOFIGO® (Radium -223), is approved by the FDA for use in men who have advanced prostate cancer that has spread to the bones, and are having pain and/or decreased quality of life.  It works by binding to minerals within bones to deliver radiation directly to bone tumors.  It improves survival and can relieve pain.  Palliative Radiation therapy delivered externally by machine technology, is another option of radiotherapy.

Learn More About Xofigo Here!