PROSTATE CANCER

Prostate cancer, one of the most common cancers affecting men, develops in the prostate gland, a small walnut-shaped gland in the male reproductive system.

Prostate cancer, characterized by a malignant tumor in the prostate, typically affects older men, with traces of the disease often found in elderly individuals. African American men face a higher risk of developing prostate cancer and have a greater likelihood of mortality from the disease. In the United States, prostate cancers rank as one of the most common cancers among men, excluding skin cancer. However, in regions such as Asia, Africa, and Latin America, occurrences of prostate cancers are infrequent.

Progression of Prostrate cancer

Prostate cancers tend to progress slowly, often without symptoms until they reach an advanced stage. Many men with prostate cancer succumb to other causes without ever realizing they have the disease. However, when prostate cancers become aggressive or spread beyond the prostate, it poses significant risks.

Early-stage prostate cancer, confined to the prostate gland, offers favorable prospects for treatment, with approximately 85% of cases in American men being diagnosed at this stage.

Advanced prostate cancers that extend beyond the prostate, affecting areas like the bones, lymph nodes, and lungs, cannot be cured but can often be managed effectively for many years. With advancements in treatment, men with widespread prostate cancer can expect a lifespan of five years or more, and some may even live a normal life and pass away from unrelated causes, such as heart disease.

Certain medications, such as aspirin, finasteride (Proscar), and dutasteride (Avodart), have been suggested to potentially lower the risks of prostate cancers. However, further research is needed to fully understand their effectiveness in preventing the disease.

What is prostrate and where is it located

The prostate, a crucial part of the male reproductive system, produces a significant portion of the fluid that carries sperm during ejaculation. Located just below the bladder and in front of the rectum, the prostate surrounds the initial segment of the urethra. If the gland enlarges, it can obstruct the flow of urine or semen through the urethra.

Types of Prostate Cancer

Most prostate cancers (almost all) are adenocarcinomas. These start in the gland cells that produce the fluid for sperm. In rare cases, prostate cancers can develop from other types of cells.

Here are some of the less common types of prostate cancers:

Small cell carcinomas: These are fast-growing and aggressive cancers.
Transitional cell carcinomas: These cancers develop from the cells lining the urinary tract, and can rarely occur in the prostate.
Neuroendocrine tumors: These are slow-growing cancers that can sometimes produce hormones.
Sarcomas: These are cancers that form in the connective tissues of the prostate, which are less common than gland-based cancers

Causes of Prostate Cancer

Prostate cancers predominantly affect older men, with approximately 80% of cases occurring in men over 65 years old, while less than 1% are found in men under 50. African American men and those with a family history of prostate cancers are at a higher risk of developing the disease.

While the exact causes of prostate cancers remain uncertain, diet plays a significant role in its risk factors. Consuming large amounts of fat from red meat has been associated with a higher likelihood of prostate cancer. Additionally, cooking meat at high temperatures produces cancer-causing substances that can impact the prostate. Countries where diets are rich in meat and dairy products tend to have higher rates of prostate cancer compared to those where diets consist of rice, soybean products, and vegetables.

Hormones, particularly testosterone, also contribute to the development of prostate cancers. High-fat diets can increase testosterone levels in the body, thereby accelerating the growth of prostate cancer cells.

Certain occupational hazards have been identified as potential risk factors for prostate cancer. Individuals working in professions such as welding, battery manufacturing, rubber industries, and those frequently exposed to cadmium metal may have an increased likelihood of developing prostate cancers.

Lack of physical activity has also been linked to a higher risk of prostate cancer.

Prevalence

Prostate cancers are the second most common cancer in men and people AMAB, following only skin cancer. According to the U.S. Centers for Disease Control and Prevention (CDC), about 1 in 8 men will develop prostate cancer in their lifetime. The good news is that many of these cases will not require treatment and men can lead normal lives. Some may even pass away from unrelated causes.

However, prostate cancers still claim the lives of approximately 34,000 people in the United States each year. This highlights the importance of regular screenings and early detection.

Symptoms

Prostate cancer can manifest with various symptoms, including:

Difficulty initiating urination
Weak or interrupted urine stream
Frequent urination, especially during the night
Inability to fully empty the bladder
Pain or burning sensation during urination
Presence of blood in urine or semen
Persistent pain in the back, hips, or pelvis
Pain during ejaculation

Risk Factors

Several factors can influence the risk of developing prostate cancer. The most common risk factors include:

Age: The risk of prostate cancer increases with age, particularly after the age of 50. About 60% of prostate cancers are diagnosed in individuals older than 65.
Race and Ethnicity: Black individuals or those of African ancestry have a higher risk of developing prostate cancer, especially aggressive forms of the disease. They are also more likely to be diagnosed at a younger age, before turning 50.
Family History: Having a close family member, such as a father or brother, with prostate cancer increases an individual’s risk. Those with a family history of the disease are two to three times more likely to develop prostate cancer.
Genetics: Certain genetic factors can predispose individuals to prostate cancer. For example, individuals with Lynch syndrome or mutations in genes associated with increased breast cancer risk, such as BRCA1 and BRCA2, have a greater risk of developing prostate cancer.

Other potential risk factors that have been studied include:

Smoking: Some studies suggest a link between smoking and an increased risk of prostate cancer, although the evidence is not conclusive.
Prostatitis: Chronic inflammation of the prostate gland, known as prostatitis, has been associated with a higher risk of prostate cancer in some studies.
Obesity: Having a body mass index (BMI) greater than 30, indicating obesity, may also increase the risk of prostate cancer.
Sexually Transmitted Infections (STIs): Certain sexually transmitted infections have been investigated as potential risk factors for prostate cancers, although more research is needed to establish a clear link.
Exposure to Agent Orange: Exposure to Agent Orange, a herbicide used during the Vietnam War, has been suggested as a possible risk factor for prostate cancer, but further studies are required to confirm this association.

Prostate Cancer Diagnosis

Prostate cancer diagnosis typically involves screenings and additional tests to confirm the presence of cancer and determine its aggressiveness. Here’s how the diagnosis process typically unfolds:

Screening Tests:

Digital Rectal Exam (DRE): This involves a physical examination in which a healthcare provider inserts a lubricated, gloved finger into the rectum to feel the prostate gland. Abnormalities such as bumps or hard areas may indicate the presence of cancer.
Prostate-Specific Antigen (PSA) Blood Test: PSA is a protein produced by the prostate gland, and elevated levels in the blood may indicate the presence of prostate cancer. However, high PSA levels can also result from benign conditions like benign prostatic hyperplasia (BPH) or prostatitis.

Diagnostic Procedures:

Imaging: If screening tests suggest the possibility of prostate cancer, imaging tests such as MRI (Magnetic Resonance Imaging) or transrectal ultrasound may be performed. These tests provide detailed images of the prostate gland, helping healthcare providers identify suspicious areas that may require further evaluation.
Biopsy: A biopsy is the definitive diagnostic procedure for prostate cancer. During a needle biopsy, a small tissue sample is taken from the prostate gland and examined under a microscope to detect the presence of cancer cells. This procedure is typically guided by imaging techniques such as ultrasound or MRI to target specific areas of concern. Biopsy results not only confirm the diagnosis of prostate cancer but also provide information about the aggressiveness of the cancer.

Additional Testing:

Depending on the biopsy results, additional tests may be performed to further characterize the cancer and guide treatment decisions. These tests may include genetic testing of the biopsied tissue to identify specific mutations or biomarkers associated with treatment response.

There are differing recommendations regarding when and if men should undergo PSA testing:

The U.S. Preventive Services Task Force suggests that men aged 55 to 69 should make an individual decision about PSA testing after discussing the risks and benefits with their doctor.
The American Cancer Society advises a discussion between doctor and patient about the pros and cons of PSA testing, recommending that it starts around age 50 for most men at average risk and earlier for those at high risk.
The American Urological Association recommends a similar discussion between doctor and patient, typically starting at ages 55 to 69, or earlier for high-risk individuals aged 40 to 54.

While elevated PSA levels can indicate prostate cancer, they can also result from non-cancerous conditions. Therefore, further diagnostic tests may be necessary, such as a prostate biopsy, where tissue samples are taken for examination.

Additional imaging tests, such as abdominal and pelvic X-rays, MRI, and bone scans, may be conducted to determine if the cancer has spread beyond the prostate. For individuals with persistently high PSA levels but negative biopsies, a urine test called PCA-3 may be performed to aid in cancer detection and potentially avoid the need for repeat biopsies.

Staging and grading of the cancer

Prostate cancer diagnosis involves assessing both the grade and stage of the cancer to determine its severity and plan appropriate treatment. Here’s how healthcare providers use the Gleason score and cancer staging to guide management and treatment decisions:

Gleason Score:

The Gleason score evaluates the degree of abnormality in prostate cancer cells, providing insight into the aggressiveness of the cancer. This scoring system assigns a grade ranging from 1 to 5 to two different areas of the prostate cancer tissue sample obtained during biopsy. The grades are then added to calculate the Gleason score, with higher scores indicating more aggressive cancer. For example, a Gleason score of 6 or below indicates low-grade cancer, while scores of 7 or higher suggest higher-grade cancer.

Cancer Staging:

Cancer staging assesses the extent of prostate cancer spread within the body, helping healthcare providers determine the appropriate treatment approach. Staging is typically classified into four main stages:

Localized (Stage I and II): Cancer is confined to the prostate gland and has not spread beyond it.
Regional (Stage III): Cancer has spread beyond the prostate gland to nearby tissues or organs, such as the seminal vesicles or bladder.
Distant (Stage IV): Cancer has metastasized, spreading to distant organs or tissues such as the bones, lymph nodes, liver, lungs, or brain.

Can prostate cancer be cured?

Absolutely! Prostate cancers are highly curable, especially when detected early. If diagnosed in its early stages, treatment can often eradicate prostate cancers that have not spread beyond the prostate gland itself. Sometimes, the cancer progresses slowly, and immediate treatment may not be necessary. Regular screenings and prompt medical attention can significantly increase the chances of successful treatment outcomes.

Treatments for Prostate Cancer

Prostate cancer management and treatment are highly individualized, taking into account factors like overall health, cancer stage, and rate of progression. Depending on your specific circumstances, you may collaborate with various healthcare specialists, including urologists, radiation oncologists, and medical oncologists.

Here are some common treatment options:

Surveillance:

Active Surveillance: Regular screenings, scans, and biopsies are conducted to monitor cancer growth. This approach is suitable for slow-growing cancers confined to the prostate, especially if they are not causing symptoms.
Watchful Waiting: Testing is less frequent, and the focus is on managing symptoms rather than eliminating the tumor. It’s often chosen for individuals with frail health or cancer unlikely to respond well to treatment.

Surgery:

Radical Prostatectomy: Surgical removal of the diseased prostate gland. This procedure is often recommended for localized prostate cancers that haven’t spread beyond the gland.
- Open Radical Prostatectomy: Involves a single abdominal incision from the belly button to the pubic bone.
- Robotic Radical Prostatectomy: Utilizes robotic technology and multiple small incisions for precise removal of the prostate gland.

Radiation Therapy:

Radiation therapy is administered either as a standalone treatment or in conjunction with other therapies to manage prostate cancers. It can also provide relief from symptoms associated with the disease.

Brachytherapy:
- Brachytherapy involves placing radioactive seeds directly inside the prostate gland. These seeds emit radiation, targeting cancer cells while minimizing damage to surrounding healthy tissue.
External Beam Radiation Therapy (EBRT):
- EBRT delivers high-energy X-ray beams externally to the tumor site. Techniques like Intensity-Modulated Radiation Therapy (IMRT) allow precise targeting of radiation doses while sparing nearby healthy tissues.

Systemic Therapies:

Systemic therapies are recommended when cancer has spread beyond the prostate gland. These therapies circulate throughout the body to destroy cancer cells or inhibit their growth.

Hormone Therapy:
- Hormone therapy aims to block the hormone testosterone, which fuels cancer cell growth. Medications prevent testosterone from reaching cancer cells or lower testosterone levels. These include:
  - Goserelin (Zoladex)
  - Leuprolide (Eligard, Lupron)
  - Leuprolide (Camcevi)
  - Triptorelin (Trelstar)
- Alternatively, surgical removal of the testicles (orchiectomy) may be performed to reduce testosterone production.
Chemotherapy:
- Chemotherapy utilizes drugs to kill cancer cells. It may be administered alone or in combination with hormone therapy for advanced prostate cancer. Chemotherapy serves as an effective option for certain individuals facing advanced prostate cancer, particularly those who have not responded well to or have stopped benefiting from hormone therapy. In cases where traditional hormonal treatments prove ineffective, newer hormonal therapies come into play.
- Abiraterone, marketed as Zytiga, operates by blocking tissues from producing testosterone. Similarly, medications like Apalutamide (Erleada) and enzalutamide (Xtandi) work to prevent cancer cells from receiving signals to grow and divide.
- Darolutamide, known as Nubeqa, has gained approval for treating individuals whose cancer remains localized to the prostate but has not responded to standard treatments like surgery or androgen deprivation therapy. Specifically, it’s prescribed for prostate cancer patients with low testosterone levels and rising PSA levels, a condition termed nonmetastatic castration-resistant prostate cancer (nmCRPC).
Immunotherapy:
- Immunotherapy enhances the body’s immune system to better recognize and combat cancer cells. It may be recommended for advanced or recurrent prostate cancer.
Targeted Therapy:
- Targeted therapy specifically targets genetic alterations that drive cancer growth, such as mutations in the BRCA gene.

Focal Therapy:

Focal therapy is a newer approach that targets tumors within the prostate gland, particularly suitable for low-risk cancers that have not spread.

High-Intensity Focused Ultrasound (HIFU):
- HIFU uses high-energy sound waves to generate heat and destroy cancer cells within the prostate.
Cryotherapy:
- Cryotherapy involves freezing cancer cells within the prostate using cold gases, effectively eliminating the tumor.
Laser Ablation:
- Laser ablation utilizes intense heat to kill cancer cells within the prostate, destroying the tumor.
Photodynamic Therapy:
- Photodynamic therapy sensitizes cancer cells to specific wavelengths of light, which are then used to selectively destroy the cancer cells.

Side effects of the prostrate cancer treatments

Treatment for prostate cancer can lead to various side effects, which may include:

Incontinence:
- Leakage of urine, especially when coughing, laughing, or experiencing urgency to urinate.
- Typically improves within the first six to 12 months after treatment, even without intervention.
Erectile Dysfunction (ED):
- Surgery, radiation, and other treatments can damage the nerves responsible for erections.
- Difficulty in achieving or maintaining an erection may occur.
- Recovery of erectile function can take up to a year or two, sometimes sooner.
- Medications like sildenafil (Viagra®) or tadalafil (Cialis®) can help by enhancing blood flow to the penis.
Infertility:
- Treatment may impact sperm production or ejaculation, leading to infertility.
- If fertility preservation is desired, sperm can be stored in a sperm bank before starting treatment.
- After treatment, sperm extraction procedures may be considered, involving the retrieval of sperm directly from testicular tissue for implantation into the partner’s uterus.

Home Care Tips

For individuals undergoing treatments for prostate cancer, maintaining a healthy lifestyle can help manage side effects and promote overall well-being. Home care tips may include:

Eating a balanced diet rich in fruits, vegetables, and whole grains
Engaging in regular physical activity
Managing stress through relaxation techniques or support groups
Following prescribed medication regimens

Prevention

Preventing prostate cancer entirely may not be possible, but adopting these healthy habits can help reduce your risk:

Regular Prostate Screenings:
- Consult your healthcare provider about the appropriate frequency of screenings based on your individual risk factors.
Maintain a Healthy Weight:
- Work with your provider to determine what constitutes a healthy weight for you and strive to achieve and maintain it.
Exercise Regularly:
- Aim for at least 150 minutes of moderate-intensity exercise per week, which can be broken down into roughly 20 minutes of activity each day.
Follow a Nutritious Diet:
- While there’s no specific diet to prevent cancer, focusing on nutritious eating habits can bolster your overall health.
- Include plenty of fruits, vegetables, and whole grains in your diet.
- Limit consumption of red meats and processed foods, which may contribute to increased cancer risk.
Quit Smoking:
- Steer clear of tobacco products altogether.
- If you currently smoke, collaborate with your healthcare provider on a smoking cessation program tailored to your needs to successfully quit.

When to See a Doctor

If you experience any symptoms suggestive of prostate cancer, such as difficulty urinating or persistent pain, it is essential to consult a healthcare professional promptly. Additionally, men over the age of 50, or those with a family history of prostate cancer, should discuss screening options with their doctor.

Outlook/Prognosis

The outlook for prostate cancers varies depending on several factors, including the stage at diagnosis and the aggressiveness of the cancer. With early detection and advances in treatment, many men with prostate cancer can lead fulfilling lives. Survival rates for common types of prostate cancer indicate a high likelihood of living for many years after diagnosis:

5 years: Nearly 99% survival rate
10 years: 98% survival rate
15 or more years: 96% survival rate

These statistics highlight the effectiveness of early detection and advancements in treatment options. However, it’s essential to continue regular screenings and follow-up care to monitor for any changes in the condition and ensure optimal outcomes.

Sources

American Cancer Society.
Mayo Clinic.
National Cancer Institute
Prostate Cancer Research Institute.
Medscape
National Library of Medicine
National Prostate Cancer Coalition.
U.S. Preventive Services Task Force
UpToDate
CDC
FDA
American Academy of Family Physicians
American Urological Association
Harvard Health Publishing:
Prostate Cancer Foundation
World Health Organization
Clevland clinic

Prostate Cancer