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Prostate Cancer: What patients should know about
May 15, 2024, 10:08

Prostate Cancer: What patients should know about

Prostate Cancer

Prostate cancer (PC) is a type of cancer that develops in the prostate gland, which is a part of the male reproductive system. It typically grows slowly and may not cause noticeable symptoms in its early stages. However, if left untreated, it can spread beyond the prostate and become more aggressive, potentially leading to serious health complications. Screening tests such as prostate-specific antigen (PSA) tests and digital rectal exams are commonly used for early detection. Treatment options vary depending on the stage and aggressiveness of the cancer and may include surgery, radiation therapy, hormone therapy, chemotherapy, or a combination of these approaches.

Cleveland Clinic has created a brief video addressing prostate cancer.

Prevalence

PC is a highly prevalent cancer among men worldwide. Here are some key statistics on the prevalence of PC:

  • PC is the second most common cancer in men worldwide, with an estimated 1,414,259 new cases diagnosed in 2020
  • The incidence of PC increases with age, from 1 in 350 men under 50 to 1 in 52 men aged 50-59, and nearly 60% of cases occur in men over 65
  • The lifetime risk of a PC diagnosis is approximately 16%, making it the most common malignancy among men. However, the lifetime risk of death from PC is only about 3.4%.

Risk Factors

The main risk factors for PC include:

  • AgeThe risk of PC increases considerably with age. About 60% of PCs are diagnosed in men over 65. The disease is rarely seen in men under 40.
  • Family History and Genetics – Men with a first-degree relative (father or brother) diagnosed with PC have a 2-3 times higher risk. Certain genetic mutations, such as BRCA1, BRCA2, and HOXB13, have been linked to an increased risk of PC.
  • Race – African American men and Caribbean men of African ancestry have a higher risk of PC compared to other racial and ethnic groups. PC incidence is lower in Asian men living in Asia compared to those living in Western countries.
  • Diet and Lifestyle –  A diet high in red meat, dairy products, and saturated fat may increase the risk of PC. Obesity and a sedentary lifestyle have also been associated with a higher risk of aggressive PC.

Other potential risk factors include geographical location (higher risk in North America and northern Europe), exposure to certain chemicals like Agent Orange, and certain medications. However, more research is needed to establish causality for these factors.

Types

There are several types of PC, but the vast majority (over 95%) are adenocarcinomas that start in the gland cells of the prostate. The main subtypes of adenocarcinoma are:

  • Acinar adenocarcinoma (conventional adenocarcinoma): This is the most common type, accounting for virtually all prostatic adenocarcinomas. It starts in the acini cells that line the prostate’s fluid-secreting glands.
  • Prostatic ductal adenocarcinoma (PDA): A rarer but more aggressive form that develops in the cells lining the tubes and ducts of the prostate gland. It frequently occurs along with acinar adenocarcinoma.

Other rare types of PC include:

  • Neuroendocrine PCs (small-cell and large-cell PC)
  • Glandular PCs (ductal, mucinous, and signet ring cell PC)
  • Basal cell prostate cancer
  • Transitional cell PC
  • Prostate sarcomas (rare cancers that develop from smooth muscle cells)

Some men may have a mix of common and rare PC types. The rare types are often more aggressive and may spread more quickly.

Diagnosis

PC is typically diagnosed through a combination of screening tests and diagnostic procedures. The main steps in diagnosing PC include:

Screening Tests

  • PSA blood test: Measures the level of PSA in the blood. Higher than normal levels may indicate prostate cancer, but can also be caused by other conditions.
  • Digital rectal exam (DRE): The doctor inserts a gloved, lubricated finger into the rectum to feel the prostate for any abnormal areas

Diagnostic Tests

  • Transrectal ultrasound (TRUS): A small probe inserted into the rectum uses sound waves to create an image of the prostate. It is often used to guide a prostate biopsy.
  • Prostate biopsy: A thin needle is inserted into the prostate to collect tissue samples. This is usually done using TRUS guidance. The samples are examined under a microscope to check for cancer cells.
  • Multiparametric MRI (mpMRI): An advanced MRI technique that can help detect, assess and stage prostate tumors. It may be used before a biopsy to identify suspicious areas

Determining Aggressiveness

  • Gleason score: Pathologists examine the biopsy samples under a microscope and assign a grade from 1 to 5 based on how abnormal the cancer cells look. The two most common grades are added together to get the Gleason score, which ranges from 6 to 10. A higher score indicates a more aggressive cancer.

Staging Tests

If cancer is diagnosed, further tests may be done to determine the stage and extent of the cancer, such as:

  • Bone scan
  • CT scan
  • MRI
  • PET scan

These imaging tests help identify if cancer has spread beyond the prostate to other parts of the body. In summary, PC is typically diagnosed through a combination of PSA testing, DRE, prostate biopsy, and imaging tests. The Gleason score helps determine the aggressiveness of the cancer, while staging tests assess how far the cancer has spread. This information guides treatment decisions.

Prostate cancer staging; six panel drawing showing a side view of normal male anatomy and closeup views of Stage I, Stage IIA, Stage IIB, Stage III, and Stage IV showing cancer growing from within the prostate to nearby tissue and then to lymph nodes or other parts of the body.

Prostate cancer staging. This image is taken from ncbi.nlm.nih.gov.

Treatment

There are several treatment approaches for PC, depending on the stage and aggressiveness of the cancer, as well as the patient’s age and overall health. The main treatment options include:

  • Active Surveillance – For men with low-risk, early-stage prostate cancer, active surveillance may be recommended as an alternative to immediate treatment. This approach involves regular monitoring with PSA tests, digital rectal exams (DREs), and sometimes repeat biopsies to ensure that the cancer is not progressing.
  • Surgery – Radical prostatectomy is a surgical procedure that removes the entire prostate gland and some surrounding tissue. It may be performed using open, laparoscopic, or robotic-assisted techniques. Potential side effects include urinary incontinence and erectile dysfunction
  • Radiation Therapy – External beam radiation therapy (EBRT) and brachytherapy (internal radiation therapy) are common radiation therapy options for prostate cancer. EBRT uses high-energy X-rays to destroy cancer cells, while brachytherapy involves implanting radioactive seeds directly into the prostate. Potential side effects include urinary and rectal irritation and erectile dysfunction.
  • Hormone Therapy – Androgen deprivation therapy (ADT) is a type of hormone therapy that reduces the levels of male hormones (androgens) in the body. It may be used alone or in combination with other treatments for advanced or high-risk prostate cancer. Potential side effects include hot flashes, decreased libido, erectile dysfunction, and osteoporosis.
  • Chemotherapy and Immunotherapy – Chemotherapy and immunotherapy are typically reserved for men with advanced, castration-resistant prostate cancer that has spread to other parts of the body. Chemotherapy drugs like docetaxel and cabazitaxel may be used, while immunotherapy agents like sipuleucel-T and pembrolizumab are also options.

Other Treatments

Other treatment options for PC include:

  • Cryotherapy (freezing prostate tissue)
  • High-intensity focused ultrasound (HIFU) therapy (heating prostate tissue)
  • Proton beam radiation therapy
  • Targeted therapy with PARP inhibitors

Treatment choice depends on several factors, including the stage and grade of the cancer, the patient’s age, overall health, and personal preferences. Treatment may be used alone or in combination, and the goal is to cure or control the disease while minimizing side effects and maintaining quality of life.

In this video, Ron shares his experience with prostate cancer.

Prognosis

The prognosis for prostate cancer is generally quite good, especially when detected early. Here are the key points about prostate cancer prognosis:

Overall Survival Rates
The 5-year relative survival rate for all stages of prostate cancer combined is nearly 100%. This means men with prostate cancer have about the same chance of surviving 5 years as men without prostate cancer. The 10-year relative survival rate is 98% and the 15-year rate is 95%. These excellent long-term survival rates are due to prostate cancer often being slow-growing and most cases being detected at an early, localized stage. However, prostate cancer is still the second leading cause of cancer death in American men, with an estimated 34,700 deaths in 2022. This highlights the need for continued research to improve outcomes for high-risk and advanced diseases.

Prognosis by Stage
For localized prostate cancers (stage I-II), the 5-year relative survival rate is 100%. Many men with these early-stage cancers will be disease-free after treatment. For regional stage cancers (stage III), the 5-year relative survival rate is also 100%. Regional stage means the cancer has spread to nearby lymph nodes or tissues. For distant-stage prostate cancers that have metastasized to distant lymph nodes, bones or other organs (stage IV), the 5-year relative survival rate is 34%. However, treatments can often keep advanced prostate cancer under control for several years.

Factors Affecting Prognosis
The prognosis is better for men with lower-grade, less aggressive cancers (Gleason score ≤7). Higher-grade cancers (Gleason score 8-10) have a poorer prognosis. Younger age at diagnosis is associated with a slightly worse prognosis, likely because younger men tend to have more aggressive cancers. African American men have higher prostate cancer incidence and mortality rates compared to other races, even after adjusting for differences in stage and treatment. The reasons for this disparity are not fully understood. Men with certain genetic mutations like BRCA1/2 may have a higher risk of aggressive prostate cancer and worse outcomes.

Recurrence Risk
About 20-30% of men will experience a recurrence (rising PSA levels) after initial treatment, usually within 5 years.
The risk of recurrence depends on cancer stage, grade, PSA levels, and other factors. Men with high-risk features like Gleason score 8-10 or PSA >20 ng/mL have the highest recurrence rates. Recurrence can often be treated, but the prognosis is worse than for men who remain disease-free after initial treatment.

Patient’s Survivorship

Prostate cancer survivorship encompasses the physical, emotional, and social aspects of life after diagnosis and treatment. While surviving cancer is a victory, survivors often face challenges such as managing long-term side effects, coping with anxiety or depression, and navigating changes in relationships and daily life. Survivorship programs and support groups play a crucial role in helping patients address these challenges, providing resources, education, and a sense of community to promote overall well-being and quality of life beyond cancer treatment.

Survivorship challenges

Fatigue – Fatigue is a common side effect of prostate cancer treatments, especially androgen deprivation therapy (ADT) and combination therapies. Fatigue can lead to decreased energy and vitality, making it difficult for patients to maintain their daily activities and exercise routines.

Sexual Dysfunction – Prostate cancer treatments, particularly surgery and radiation therapy, can cause sexual dysfunction, including erectile dysfunction and decreased libido. This can have a significant impact on a patient’s quality of life and relationships.

Communicate openly with your partner about changes in sexual function and intimacy. Use oral medications like sildenafil (Viagra) or tadalafil (Cialis) to treat erectile dysfunction. Try vacuum devices or penile injections if oral medications are not effective. Seek counseling to cope with changes in sexual function and intimacy

Urinary Incontinence – Urinary incontinence is a common side effect of prostate cancer treatments, particularly surgery. It can cause embarrassment, social isolation, and decreased quality of life.

Strengthen pelvic floor muscles with Kegel exercises. Try bladder training, gradually increasing time between bathroom trips. Use pads for light leaks. Consult your doctor about medications or minimally invasive procedures like Botox or nerve stimulation if needed.

Bowel Dysfunction – Radiation therapy for prostate cancer can cause bowel dysfunction, including diarrhea, rectal bleeding, and fecal incontinence. This can lead to discomfort, embarrassment, and decreased quality of life.

Avoid bowel irritants. Use over-the-counter or prescription medications like antidiarrheals or fiber supplements. Try bowel training for scheduled movements. Strengthen anal sphincter muscles with pelvic floor exercises. Surgery may be an option for structural issues like rectal prolapse if other treatments fail.

Adherence to Treatment – Long-term adherence to prostate cancer treatments, particularly oral medications, can be challenging for some patients. Poor adherence can lead to suboptimal outcomes and increased healthcare costs.

Anxiety and Depression – The stress of a cancer diagnosis and treatment side effects can lead to anxiety and depression. Counseling, support groups, and sometimes medications can help patients cope with emotional challenges.

Isolation and Abandonment – Some men feel isolated after treatment ends and miss the regular support from their cancer care team. Maintaining follow-up appointments and seeking support from family, friends, and support groups can help.

Recurrence Risk- There is always a risk of the cancer returning, especially in the first few years after treatment. Regular PSA testing and follow-up appointments are important to monitor for recurrence.

Recommendations for Patients

  • Screening and Early Detection – Discuss the potential benefits and limitations of prostate cancer screening with your doctor to make an informed decision about testing. If you choose to be screened, start at age 45 if you are at high risk (African American or have a first-degree relative diagnosed before age 65) or age 50 if at average risk.
  • Diagnosis – If a screening test suggests prostate cancer, your doctor may recommend further tests like a digital rectal exam (DRE), prostate biopsy, or multiparametric MRI to confirm the diagnosis. Ask your doctor to explain the results of any diagnostic tests in plain language so you fully understand your cancer stage and grade.
  • Treatment Decision-Making – Work closely with your urologist and oncologist to choose the best treatment approach for your situation. Consider factors like your age, overall health, cancer characteristics, and personal preferences when deciding on treatment. Ask your doctor to explain the potential benefits, risks, and side effects of each treatment option.
  • Active Surveillance – If you have low-risk, early-stage prostate cancer, active surveillance may be an appropriate option to avoid or delay treatment. During active surveillance, you will have regular PSA tests, DREs, and possibly repeat biopsies to monitor for cancer progression. If the cancer shows signs of growing, you and your doctor can decide if it’s time to start treatment.
  • Treatment – If you require treatment, options may include surgery (radical prostatectomy), radiation therapy (external beam or brachytherapy), hormone therapy, chemotherapy, or targeted therapies. Ask your doctor about newer treatment approaches like robotic surgery, intensity-modulated radiation therapy (IMRT), and proton beam therapy that may have fewer side effects. Be aware that all treatments can cause side effects like urinary incontinence, erectile dysfunction, and bowel problems. Discuss ways to manage these with your doctor.
  • Follow-Up Care – After treatment, you will need regular follow-up appointments to monitor for cancer recurrence or progression. Attend all scheduled appointments and get recommended PSA tests and other screening tests. Communicate openly with your doctor about any side effects or concerns you have during follow-up.

The most important things are to be informed about your disease, work closely with your healthcare team, and make treatment decisions that align with your values and goals. With proper screening, diagnosis, treatment, and follow-up, many men with prostate cancer can be cured or have their disease well-controlled.

Conclusion

While a PC diagnosis can be scary, there are many reasons to be hopeful. It is one of the most treatable cancers, especially when found early through regular screening. Modern treatments like robotic surgery and targeted radiation can often cure the cancer while minimizing side effects. With a proactive approach and access to today’s advanced therapies, many men with PC can look forward to long, healthy lives after diagnosis and treatment. Ongoing research continues to uncover better ways to detect, treat, and manage this disease, giving patients and their families more reasons for optimism.

Resources

  1. World Cancer Research Fund International – wcrf.org
  2. Centers for Disease Control and Prevention – cdc.gov
  3. American Cancer Society – cancer.org
  4. John Hopkins Medicine – hopkinsmedicine.org
  5. Prostate Cancer UK – prostatecanceruk.org
  6. City of Hope – cancercenter.com
  7. American Society of Clinical Oncology (ASCO) – Cancer.net 
  8. National Cancer Institute – cancer.gov
  9. Prostate Cancer – PubMed
  10. Prostate Cancer Review: Genetics, Diagnosis, Treatment Options, and Alternative Approaches – PubMed