Click to read PCSANM’s 2024 Guide to Prostate Cancer

 

Brief Overview

 

We are not doctors or scientists. The information below has been abstracted from many sources. Please understand that the answers are generalized in order to be simple and brief. The field of prostate cancer detection and treatment is a very rapidly and evolving field. For that reason, PCSANM encourages all interested parties to take this document as a starting point and search for answers that apply to you. Do not trust any one source, including this one. This document is published as a public service. Feel free to copy it.

 

What and where is the prostate?

The prostate is a walnut-sized gland in men located directly in front of the rectum, just below the bladder and surrounds the urethra – which drains the urine from the bladder. This gland produces part of the seminal fluid and protects against infection and nourishes sperm for fertilization.

 

What is prostate cancer (PCa)?

It is prostate cells that grow out of control. If they grow and spread, they can eventually cause death. Most prostate cancer grows slowly and perhaps would not cause any problems for ten or more years.

 

What causes PCa?

No one knows, but PCa growth may be linked to a high fat diet, family history of cancer, or genetic code.

 

Who gets PCa?

About one in seven men will receive a diagnosis of PCa during their lifetime. Each year 200,000 or more American men are diagnosed with PCa. African-American men have the highest rates of PCa in the world. They are about twice as likely to develop PCa than Caucasian men and twice as likely to die from PCa.

Hispanics, Asians, and Native Americans are less likely than Caucasian men to have PCa. Men with a close family relative with PCa (father, brother or son) are more likely to have PCa than other men.

 

How deadly is this disease?

Between two and three percent of American men die of PCa, or less than 30,000 every year. Most men – including most men with PCa – die from other causes.

 

Is early detection and early treatment useful?

The membership of the Prostate Cancer Support Association consists of survivors who were diagnosed and treated for PCa. We have benefitted by the detection and treatment of our PCa. We believe for any cancer, including PCa, early detection and early treatment results in increased survival and a better quality of life.

Screening the general male population for PCa became a controversial subject in 2012 when US Preventative Services Task Force (USPSTF), an independent group of public health experts recommended that physicians not screen for PCa. In 2017 this agency changed their recommendation and now recommend that men between 55 and 69 years of age talk with their personal physician about getting screened, learn of the benefits and harms, and then make a decision as to whether or not to get screened. Recommendations by other experts, most notably the American Urological Association (AUA) and the National Comprehensive Cancer Network (NCCN) recommend that screening be done for select groups and select ages. The detailed recommendations of each entity is beyond the scope of this guide, but the earliest screening that was recommended was age 40, when there is a known family history of prostate cancer, or if the man is African American.

PCSANM recommends that you discuss screening with your personal physician and decide for yourself.

 

How is PCa detected?

Most cases are found by using the simple blood test for Prostate Specific Antigen (PSA). PSA leaks from the normal prostate cells in small amounts, but an elevated rate of leakage may indicate the presence of prostate cancer cells. If the PSA is abnormally high and the doctor feels something in the gland, a biopsy is usually performed. PSA is also used after therapy as a monitor to indicate therapy failure and if PCa is under control.

 

What is an abnormal PSA reading?

PSA readings of up to 2.5 ng/ml (nanograms per milliliter) are considered normal for a man in his forties. As men grow older, an increase in PSA is normal. Thus, a reading of 3.9 for a 70-year-old man would be considered normal. (African-Americans should lower these readings by about 0.5). A rapidly rising PSA may indicate prostate cancer. High PSA often indicates the disease is outside the prostate capsule.

 

The TNM classification system

As part of the initial exam for prostate cancer, the doctor will do a digital rectal exam. The doctor can feel the back of the prostate through the rectal wall and can feel for abnormalities. The results are reported using the TNM classification system. T refers to tumor. T1 and T2 indicate localized PCa. Stage T3 and T4 indicate increasing degrees of the tumor outside the prostate. The N refers to disease in the Lymph Nodes, and M refers to metastasis.

 

How do I know if I have PCa?

A biopsy is used to confirm suspected prostate cancer. An ultrasound probe is inserted into the rectum and hollow needles are “shot” through the rectal wall into the areas of the prostate most likely to have cancer. Twelve samples or cores are commonly taken. These biopsy cores are tiny samples of tissue that can be inspected by a pathologist under a microscope. The pathologist will determine if they are cancerous by their cell structure.

 

How can a person judge the aggressiveness of the disease?

If any of the biopsy tissue is cancerous, the pathologist will assign a pair of numbers (Gleason Sum or Score) to each tissue sample. This sum identifies the aggressiveness of the cancer. Two (1 + 1) is the very lowest, or best. Ten (5 + 5) is the most aggressive, or worst.

 

What is clinical staging and risk evaluation?

Clinical staging is the doctor’s estimate of the size and location of the cancer based on evidence from diagnostic tests. The starting point for the various staging systems is the use of the PSA value, TNM score and the Gleason score. Using these criteria, the physician will assign a risk category to the patient’s diagnosis. The three major risk categories are low risk (PSA< 10, Gleason <6, tumor confined to prostate) intermediate risk (PSA 10-20, Gleason 7, tumor confined to prostate), and high risk (PSA > 20, Gleason 8-10, and tumor extends outside the prostate). The risk group assigned is very important as this will determine the type of treatment recommended to the patient. Going into detail of staging is beyond the scope of this beginner’s guide.

 

What treatment choices are available?

Surgery (Radical Prostatectomy) Robotic surgery is replacing the open radical surgery and laparoscopic techniques. The nerve-sparing technique is preferred. The lower abdomen is entered, the gland is removed and the severed urethra is sewn back together. The patient usually spends three to six days in the hospital if the open surgery is used, fewer days with the robotic and laparoscopic techniques. A portable urinary catheter is worn for a week or longer. Surgeons usually recommend this treatment for healthy men in their sixties or younger.

External Beam Radiation is used to destroy the gland, and the cancer within it, from outside the body. This usually takes 35 or more treatments (five days a week, for seven weeks). It takes about 15 minutes per treatment. No hospital stays are needed unless there is a rare complication. This treatment is often recommended to men who are 65 years or older. Proton Beam therapy is a specialized form of external beam therapy. The major advantage of proton treatment over conventional radiation is that the energy distribution of protons is almost entirely in the tissue of the prostate, with minimal damage to the surrounding tissue.

Seed Implants (Brachytherapy) are radioactive pellets (“seeds”) inserted in the gland through hollow needles. Seed implantation is often performed on an outpatient basis. A urinary catheter may be worn for up to three days.

Another form of brachytherapy is high dose, where highly radioactive material is slid into the prostate through tubes for a short time (hours) and removed. An overnight stay in the hospital may be required.

Cryosurgery (freezing) is a relatively new technique during which hollow probes are set into the prostate from the perineum (the area between the scrotum and the anus) and the cancerous tissue is frozen.

Focal Laser Ablation Therapy is a new technique in which a laser is used, guided by multi-parametric MRI images, to destroy cancerous tissues in the prostate. This technique is still in clinical trials at this time and is only available in select facilities.

High Intensity Focused Ultrasound (HIFU) is a new technique, similar to external beam radiation, during which high intensity sound is used to destroy cancerous tissues in and near the prostate. HIFU is still considered experimental and has not been approved for use in the United States.

The treatments outlined above are “local” treatments. They only treat the prostate gland or the local area in and around the prostate. Local treatments generally have disease recurrence of four to five percent per year. After ten years, between 30 and 50 percent or more will have disease recurrence. PSA readings after therapy are used to detect disease progression (recurrence). Recurrence is not a death sentence. Average life expectancy after relapse from surgery for PCa is 13 years whereas for other cancers it is three years or less.

Hormonal Therapy (HT), a systemic therapy, is used to block testosterone. Testosterone production and prostate cancer cell utilization can be blocked with drugs called LHRH agonists and anti-androgens. This is sometimes called chemical or medical castration. This is usually reversible when one stops taking the drugs. HT can be used alone, or used before surgery or radiation to shrink the prostate, or to delay the disease and give a person time to study the available options, or in cases (such as cancer that is metastatic when initially diagnosed) where local therapies cannot be used. The important thing about HT is that it is “systemic” and works throughout the body. There are documented cases of no cancer being found in the prostate after a course of HT. Longer HT results in a higher percentage of no cancer being found. Studies have shown a six to 12-month HT treatment is better than a three-month treatment. In some circumstances, HT treatment may be continued for years.

Up Front HT – In the past HT was used when PCa had progressed to lymph nodes or bones. Now it is used by some medical oncologists “up front” – as soon as PCa is detected. Up front HT is usually prescribed for 12 to18 months. This treatment is showing great promise for treating stage T1 & T2 cases, but it is too soon to be sure that it actually results in longer life. Five year results are very encouraging. Early hormone therapy when combined with local therapies recently has shown significant reduction in prostate cancer deaths. Up front HT is also used when the cancer is too advanced, at the time of diagnosis, for the use of localized therapies.

Active Surveillance or Watchful Waiting – Both terms mean no active immediate treatment. There are some studies that indicate this option results in just as long a life as immediate treatment. This option is most often recommended to men 75 years or older, to men with less aggressive forms of PCa, or to younger men who have a condition that makes other treatments risky. With active surveillance testing is performed regularly.

 

What are the side effects or complications of these treatments?

Surgery – Between 24 and 62 percent of men may become sexually impotent, and five to 19 percent may become severely incontinent. Some studies show incontinence over 60 percent. Other complications that are usually well below 10 percent are: fecal incontinence, major bleeding, blood clots in the legs or lungs, bladder neck narrowing, and urethral narrowing.

External Beam Radiation – Following radiation, from 12 to 30 percent of men experience some degree of sexual impotence. Incontinence also occurs in one to seven percent of men. Inflammation of the bladder, rectum and intestines during treatment usually goes away. Chronic inflammation can result in strictures that require surgical intervention in up to two percent of men. Complications from cryosurgery and HIFU are similar. Fewer complications have been reported with laser ablation therapy.

Seed Implants – Impotence is reported in 10 to 25 percent of men, incontinence in two percent or less. Urinary problems – urgency, frequency, burning, irritation – occur in about 25 percent of men. Rectal problems – pain, burning, frequency, urgency and diarrhea – are a problem in about 20 percent of men, but most go away with time. The above side effects may be less than stated because of improving skill of the practitioners.

Hormonal Therapy – Impotence is common during HT, and diarrhea is a problem in 10 to 20 percent of cases. Other side effects may include: fatigue, hot flashes, breast soreness or enlargement, blood clots, nausea and weight gain. Under prolonged treatment, liver damage or osteoporosis may occur.

Active Surveillance – There are no side effects from this, as no active treatment is being used. If the disease has progressed, HT can be used and usually is effective for three to six years on advanced PCa. Don’t be too alarmed if you are diagnosed with stage T1 PCa. A total of 85 percent of these men take up to five years to progress to stage T2, and have another several years to progress further. Since early stage disease usually will not become life threatening for 15 or more years, active surveillance is a good option for anyone whose life expectancy is under 15 years. A 70- year-old man has an average life expectancy of 13 more years. An 80-year-old man would have eight more years.

What are my chances for a cure?

Doctors cannot determine whose PCa will progress to become clinically significant and whose will not. Generally, patients with low PSA, low Gleason, and low stage diagnoses have a longer disease-free time after any therapy than those with aggressive or advanced disease.

There is no cure for prostate cancer. However, the options for treatment are improving as time moves on. Most men will die with prostate cancer and not because of prostate cancer. Where are the sources for additional information?

There are many books available at libraries and book stores. Many scientific articles are published in medical journals; some of them will be available at your local hospital. The internet is a vast resource. Book lists, internet addresses, telephone help line numbers, video tapes, and mentor/buddy lists are available from PCSANM. Call, email or visit the PCSANM office.

Prostate Cancer Support Association of New Mexico

2533 Virginia St. NE, Suite C, Albuquerque, NM 87110

(505) 254-7784      (800) 278-7678

Website: www.pcsanm.org

 

DISCLAIMER: The information and opinions ex- pressed in this publication are not an endorsement or recommendation for any medical treatment, product, service or course of action. For medical, legal or other advice, please consult appropriate professionals of your choice.