|The Prostate The prostate is part of a man’s reproductive system and is a walnut-sized gland located between the bladder and the penis. The prostate is just in front of the rectum. The urethra runs through the center of the prostate, from the bladder to the penis, letting urine flow out of the body. The prostate is a gland. The prostate secretes fluid that nourishes and protects sperm. During ejaculation, the prostate squeezes this fluid into the urethra, and it’s expelled with sperm as semen. The vasa deferentia (singular: vas deferens) bring sperm from the testes to the seminal vesicles. The seminal vesicles contribute fluid to semen during ejaculation. Male hormones (androgens) make the prostate grow. The testicles are the main source of male hormones, including testosterone. The adrenal gland also makes testosterone, but in small amounts.
Dr. Michael Lutz discusses everything prostate;prostate cancer, screening, and treatment.
According to the American Cancer Society (ACS), prostate cancer is the most common type of cancer in men in the United States, other than skin cancer. Prostate cancer is the second leading cause of cancer death in men, exceeded only by lung cancer. Adenocarcinoma of the prostate is the clinical term for a cancerous tumor of the prostate gland. As prostate cancer grows, it may spread to the interior of the gland, to tissues near the prostate, to sac-like structures attached to the prostate (seminal vesicles), and to distant parts of the body (e.g., bones, liver, lungs). Prostate cancer confined to the gland often is treated successfully.
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. Having a risk factor doesn’t mean that a man will develop prostate cancer. Most men who have risk factors never develop the disease. Many other possible risk factors are under study. For example, researchers have studied whether vasectomy (surgery to cut or tie off the tubes that carry sperm out of the testicles) may pose a risk, but most studies have found no increased risk. Also, most studies have shown that the chance of getting prostate cancer is not increased by tobacco or alcohol use, BPH, a sexually transmitted disease, obesity, a lack of exercise, or a diet high in animal fat or meat. Researchers continue to study these and other possible risk factors.
Folate A 10-year study showed that prostate cancer risk was lower in men who had enough folate in their diets. Finasteride and Dutasteride Finasteride and dutasteride are medications typically used to treat benign enlargement of the prostate (BPH). These drugs block the enzyme that changes testosterone into dihydrotestosterone (DHT). Higher than normal levels of DHT may play a part in developing prostate cancer. Taking finasteride or dutasteride has been shown to lower the risk for prostate cancer, but it is not known if these drugs lower the risk of death from prostate cancer. The Prostate Cancer Prevention Trial (PCPT) studied whether the drug finasteride can prevent prostate cancer in men older than 55 years of age. This prevention study showed that prostate cancer was diagnosed less often in men who took finasteride compared to men who did not take the medicine. However, the number of deaths from prostate cancer was the same in both groups. Finasteride did have side effects, including erectile dysfunction, loss of desire for sex, and breast enlargement. The Reduction by Dutasteride of Prostate Cancer Events Trial (REDUCE) studied whether the drug dutasteride could prevent prostate cancer in men aged 50 to 75 years who were at a higher risk for the disease. This prevention study showed that men who took dutasteride were less likely to be diagnosed with prostate cancer compared to men who did not take it. Dutasteride also caused side effects, including erectile dysfunction and loss of desire for sex. The following have been proven NOT to affect the risk of prostate cancer, or their effects on prostate cancer risk are not known: Selenium and vitamin E The Selenium and Vitamin E Cancer Prevention Trial (SELECT) studied whether taking vitamin E and selenium (a mineral) will prevent prostate cancer. The selenium and vitamin E were taken as supplements by healthy men 55 years of age and older (50 years of age and older for African-American men). The study showed that selenium and vitamin E did not decrease the risk of prostate cancer. Diet It is not known if a low fat diet or increasing fruits and vegetables in the diet helps to decrease the risk of prostate cancer or death from prostate cancer. There are other health benefits from a healthy diet (i.e. lower cholesterol, less heart disease, etc.) Multivitamins Regular use of multivitamins has not been proven to increase the risk of localized prostate cancer. Lycopene One natural source of lycopene is tomatoes. There have been mixed results on studies regarding lycopene. Some studies have shown that a diet high in lycopene decreased the risk of developing prostate cancer, but other studies have not. It has not been proven that taking lycopene supplements decreases the risk of prostate cancer.
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:
Detection of Prostate CancerYour 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.
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. Some men may need tests that make pictures 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 doctor can work together to develop a treatment plan that meets your medical and personal needs.
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.
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. After removing the prostate, the bladder is reconnected to the urethra (tube that men urinate through). Once healed, this will allow men to urinate normally. There are several types of surgery for prostate cancer. Each type has benefits and risks. You and your doctor can talk about the types of surgery and which may be right for you:
Radiation therapy is an option for men with any stage of prostate cancer. Men with early stage prostate cancer may choose radiation therapy instead of surgery. It also may be used after surgery to destroy any cancer cells that remain in the area. It also may be used if the cancer recurs after surgery. In later stages of prostate cancer, radiation treatment may be used to help relieve pain. Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the treated area. Doctors use two types of radiation therapy to treat prostate cancer. Some men receive both types:
A man with prostate cancer may have hormone therapy before, during, or after radiation therapy. Hormone therapy is also used alone for prostate cancer that has returned after treatment. Male hormones (androgens) can cause prostate cancer to grow. Hormone therapy keeps prostate cancer cells from getting the male hormones they need to grow. The testicles are the body’s main source of the male hormone testosterone. The adrenal gland makes other male hormones and a small amount of testosterone. Hormone therapy uses drugs or surgery:
Chemotherapy may be used for prostate cancer that has spread and no longer responds to hormone therapy. Chemotherapy uses drugs to kill cancer cells. The drugs for prostate cancer are usually given through a vein (intravenous). You may receive chemotherapy in a clinic, at the doctor’s office, or at home. Some men need to stay in the hospital during treatment. The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:
Immunotherapy is a treatment that stimulates the body’s own immune system to fight a disease. Provenge (sipuleucel-T) is a treatment that uses the bodies’ own immune system to attack prostate cancer cells. This treatment is used when hormonal therapy is no longer controlling the cancer. Provenge is a vaccine that has extended the lives of patients with metastatic prostate cancer. Side effects of the medication may include chills, fatigue, fever, back pain, nausea and headache.
Education / Resources
- American Cancer Society
- National Cancer Institute (NCI)
- National Institutes of Health (NIH)
- National Comprehensive Cancer Network (NCCN)
Prostate Cancer Therapeutics
- Provenge Sipuleucel-T
- Xtandi – Enzalutamide
- Vantas – Histrelin Acetate
- LupronDepot – Leuprolide Acetate for Depot Suspension
- Eligard – Leuprolide Acetate for Injectable Suspension
- Firmagon – Degarelix for Injection
- Xgeva – Denosumab Injection
- Prolia – Denosumab
- Zytiga – Abiratirone
Bladder Cancer Therapeutics
- da Vinci Surgery – Robotic Surgery for Kidney, Prostate, and Bladder
- HealthTronics – Cryotherapy for Prostate and Kidney Cancer