Prostate Cancer
Signs and Symptoms
Prostate cancer often doesn't produce any symptoms in the early stages. Symptoms that may indicate prostate cancer, and which should be followed up with a visit to the doctor, include:
Although these symptoms may indicate prostate cancer, they also can be caused by other conditions that are not cancer, such as benign prostatic hyperplasia (BPH). As men age, the prostate often enlarges and can press on and block the urethra and bladder, producing some of the symptoms described above. BPH can be successfully treated with medication or surgery.
Diagnosis
For many men, a diagnosis of prostate cancer can be frightening not only because of the threat to their life, but because of the threat to their life style, particularly sexual function. The possible consequences of treatment, including bladder control problems and impotence, also known as erectile dysfunction, can be a greater worry for some men than the cancer itself.
If prostate cancer is detected early — when it's still confined to the prostate — you have a better chance of successful treatment with minimal or short-term side effects. On average, an American man has a 30 percent risk of having prostate cancer in his lifetime, but only a 3 percent risk of dying of the disease.
The death rate for prostate cancer is more than double for African American men compared to Caucasian men. Older men, especially those over age 65, are most commonly diagnosed with the disease, although men in their 30s and 40s also are affected.
The two most commonly used methods for screening are the digital rectal exam and the prostate-specific antigen (PSA) test.
Digital Rectal Examination (DRE) — During a digital rectal exam, a doctor inserts a gloved, lubricated finger into the rectum to feel for any irregular or abnormally firm areas in the prostate. Some, though not all, prostate cancers can be detected this way. The DRE also can be used to monitor the progress of treatment.
Prostate-Specific Antigen (PSA) Test — Prostate specific antigen (PSA) is a protein in the blood that is produced only by prostate cells. PSA reflects the volume of both benign and malignant prostate tissue. The higher the PSA level, the more likely it is that prostate cancer is present.
PSA test results are reported as nanograms per milliliter (ng/ml). Results less than 4.0 ng/ml usually are considered normal. Values over this are regarded as high. The average PSA level increases with age, so some values below 4.0 ng/ml for younger men (below age 60) should warrant a more thorough evaluation. Ask your doctor for acceptable values for your age.
For more information, please see:
Patient's Guide to Prostate Cancer
Other Tests
The following tests may be used to make a definite diagnosis of prostate cancer:
Biopsy — A biopsy is performed to obtain samples of prostate tissue, which are then examined by a pathologist, to make a formal diagnosis of prostate cancer. In most cases, a fine needle is inserted into the prostate to withdraw small samples of tissue. Local anesthesia is typically used.
Bone Scan — This test shows if cancer has spread from the prostate to the bones. Low level radioactive material is injected into the body. If diseased bone cells are present, they will take up the radioactive material. This allows the location of diseased bone to be seen on the total body bone scan image. These areas may suggest that metastatic cancer is present, although arthritis and other bone diseases can create the same pattern.
Usually, a bone scan is ordered only if there are signs of aggressive disease such as a markedly elevated PSA level, a high Gleason score — a prostate cancer grading system — or a large tumor.
Computed Tomography (CT) Scan — This test uses a rotating X-ray beam to create a series of pictures of the body from many angles that can be put together into a detailed cross-sectional image. This can help reveal abnormally enlarged pelvic lymph nodes, or spread of the cancer to other internal organs. A CT scan usually is ordered if there is a markedly elevated PSA, a high Gleason score — a prostate cancer grading system — or evidence of a large tumor.
Magnetic Resonance Imaging (MRI) — Similar to a CT scan, this test uses magnetic fields instead of X-rays to create detailed images. These scans are less effective in revealing microscopic-sized cancers, although an MRI using a rectal coil is superior to a routine pelvic MRI. A modification of the MRI that is still considered experimental, called magnetic resonance spectroscopy imaging (MRSI), may provide more precise information on where the cancer is located in the prostate gland and the surrounding area.
Transrectal Ultrasound (TRUS) Guided Biopsy — This test uses sound waves produced by a small probe placed in the rectum to create an image of the prostate on a video screen. The echoes from the waves are translated by a computer into a picture that can show the location of suspicious or abnormal areas of the prostate. An instrument called a biopsy gun quickly inserts and removes a narrow needle, obtaining small cores of tissue that are sent to the laboratory for examination. The entire prostate should be sampled since cancer may not be seen with the TRUS.
For more information, please see:
Patient Guide to Prostate Cancer
Treatment
Your team of doctors will help you decide which prostate cancer treatment is the best, most effective option for you. Each treatment has its benefits, risks and impacts on quality of life. Several treatments are very successful in providing a cure or keeping the cancer under control for many years. Most men with prostate cancer are living testimony to this.
Some prostate cancers grow quickly and spread — or metastasize — to other parts of the body. If unchecked, these cancers can be fatal. Most prostate cancers, however, are slow growing and in many cases, immediate treatment isn't necessary. Many men take several months to decide what to do. The decision can be complicated. You should consider the pros and cons of the various treatments, get second opinions and decide what is best for you, all of which may take time.
The right treatment for you may depend on a number of factors including:
Determining if your cancer is confined to the prostate is key in choosing a treatment. If the cancer is confined to the prostate, you may consider a localized treatment that attempts a cure. If the cancer has spread — to nearby lymph nodes or more distantly to bones or other organs — then the goal of treatment may be to control the cancer rather than cure it.
No matter which treatment or combination of treatments you and your doctor choose, your PSA should be monitored regularly. Here are some of the treatment options for prostate cancer:
Active Surveillance
Chemotherapy
Cryosurgery
Hormone Therapy
Radiation Therapy
Radiation — Brachytherapy
Radical Prostatectomy
New Treatments and Clinical Trials
Some prostate cancer patients don't pursue any active treatment and instead use a "watch and wait" approach, also known as "active surveillance," which involves extensive monitoring. This may be recommended if the cancer is very small and confined to one area of the prostate; is expected to grow very slowly; or if the patient is elderly, frail or has other serious health problems. Since prostate cancer tends to grow very slowly, older men with the disease may never need treatment. Younger patients, or those with a life expectancy greater than 10 years, may need a more aggressive approach. The best candidates for this regimen are those with small, low grade cancers associated with low and stable PSA levels.
Some men, however, may decide that the side effects of more aggressive treatments outweigh the benefits and they turn to alternative therapies to slow cancer development. In these cases, close monitored is critical so if the cancer develops into a more serious form, it is immediately detected.
More than 500 patients at the UCSF Prostate Cancer Center have chosen active surveillance. About one in five on active surveillance receive treatment two to three years after diagnosis, after a change is detected such as a rapidly rising PSA level or increased tumor size.
At UCSF, men on active surveillance have PSA levels checked every three to fourth months, prostate ultrasounds every six to nine months and prostate biopsies after one year of active surveillance, then again every one to two years.
Chemotherapy drugs are commonly used to treat many different cancers. They kill cancer cells directly, usually by disrupting the reproductive cycle of those cells. Chemotherapy usually is used with patients whose prostate cancer has metastasized outside the prostate and for whom hormone therapy has failed.
In the past, chemotherapy has shown only limited effectiveness in treating advanced prostate cancer. More recently, new developments in this approach — such as giving two or more drugs together, using newly developed chemotherapy agents, and combining chemotherapy with hormone therapy — have significantly improved treatment outcomes.
For more information, please see:
Patient Guide to Prostate Cancer
Cryosurgery, used to treat localized prostate cancer, kills the cancer cells in the prostate by freezing them. Probes containing liquid nitrogen are inserted into the prostate and maneuvered using ultrasound to destroy prostate tissue. This method has shown good results in treating cancer confined to the prostate, but is only offered at a limited number of medical centers around the country.
Some doctors believe that the entire prostate must be frozen, which impacts the nerve bundles on the sides of the gland. Impotence almost always results from cryosurgery when the entire gland is treated. Urinary incontinence also may occur. Some doctors are performing "nerve-sparing" cryotherapy, where only the cancerous area of the prostate is treated. This is often used for men who have failed other therapies, such as radiation therapy.
Prostate cancer cells usually require testosterone — the main male hormone or androgen — to grow. Lowering androgen levels with hormone therapy can stop or slow cancer growth. Hormone therapy may control the cancer, often for a number of years, but it is not a cure. Usually, the cancer will change over time into a form that no longer needs testosterone to grow, called androgen independent, at which point other treatments are considered.
Most prostate cancers are very responsive to hormone therapy when first diagnosed and it is usually recommended as the initial treatment for advanced cancers, including prostate cancers that have metastasized or spread. Hormone therapy does have significant side effects, such as a decrease in sexual desire and some level of erectile dysfunction. The decision to undergo this therapy should be considered carefully.
Intermittent Hormone Therapy
In this approach, also called intermittent androgen blockade, a patient is placed on hormone therapy for a period of some months to a year or more. After the patient's PSA level has dropped close to zero and remains at this level, the hormone therapy is stopped. When the PSA rises to a certain level following the return of testosterone production, the hormone therapy is resumed.
The length of time that a man can stay off treatment may range from several months to well over a year. The intermittent approach may reduce some of the side effects of hormone therapy, improve quality of life and allow some men to regain their sexual interest and potency during the off period.
This method is regarded as experimental. Studies are being conducted to compare its effectiveness with continuous hormone therapy and to determine if it delays androgen independence.
For more information, please see:
Patient Guide to Prostate Cancer
Radiation therapy uses high-energy rays and particles to kill cancer cells. The two main types are external beam radiation therapy (EBRT) and brachytherapy.
External Beam Radiation Therapy — Radiation, usually in the form of X-rays, is focused from a source outside the body onto the area affected by cancer. After imaging studies are done to locate the cancer, treatment is designed to guide where the radiation beams will be directed. Marks are placed on the patient's skin to help position the patient for treatment. Patients are treated five days per week over a period of seven to eight weeks, with each treatment lasting only a few minutes. Patients return home after each treatment and no hospital stay is required.
3-D Conformal Radiation Therapy — This is a state-of-the-art form of external beam radiation therapy that uses a sophisticated computer program to map the prostate gland more precisely and pinpoint radiation beams from up to six or seven different directions. An external mold cast keeps the patient still.
This more accurate aiming from multiple sources reduces the radiation received by nearby tissues while concentrating the dose at the cancer site. A more advanced form of this therapy — intensity modulated radiation therapy (IMRT) — can vary the intensity of the radiation beams. Another improvement on this treatment involves placing gold seeds into the prostate to help increase the accuracy of the external beams.
Intensity Modulated Radiation Therapy (IMRT) — This is the most advanced form of 3-D conformal radiation therapy, which adjusts the radiation beam to the contours of a tumor, allowing for higher, more effective doses of radiation while minimizing exposure to surrounding healthy tissue.
Proton Beam Radiation Therapy — Presently available at only a few medical centers in the country, this advanced approach uses protons rather than X-rays. Studies have shown that proton beam therapy is effective in treating localized prostate cancer. However, the data are inconclusive as to whether proton therapy yields better outcomes than X-ray therapy.
CyberKnife — One of the most advanced forms of radiosurgery, this is a painless, non-invasive therapy that delivers high doses of precisely targeted radiation to destroy tumors or lesions within the body. Radiosurgery minimizes radiation exposure to healthy tissue surrounding the tumor.
The CyberKnife uses a robotic arm to deliver highly focused beams of radiation. The flexibility of the robotic arm makes it possible to treat areas of the body, such as the spine and spinal cord, that can't be treated by other radiosurgery techniques. We are one of the few medical centers in California that offers this treatment.
There are two forms of this treatment — permanent and temporary.
Permanent Seed Implant (SI) — In this treatment, small radioactive pellets, often called "seeds," each about the size of a grain of rice, are implanted into the prostate. These seeds contain radioactive isotopes such as iodine 125 or palladium 103.
Seeds are permanently placed in the prostate and give off radiation for periods of weeks or months. This is done as an outpatient procedure. Imaging tests such as a transrectal ultrasound or an MRI are used to accurately guide the placement of the seeds into the prostate. The seeds are placed inside thin needles inserted through the skin of the perineum, the area between the scrotum and anus.
Temporary Seed Implant (SI) — In this approach, also called high-dose rate brachytherapy (HDR), the radioactive material, such as iridium, is placed in the inserted needles for relatively short periods of time and then withdrawn from the prostate. Two to three treatments administered over one to two days in a hospital is usually required.
For more information, please see:
Patient Guide to Prostate Cancer
Radiation Therapy Frequently Asked Questions (FAQ)
A radical prostatectomy removes the entire prostate gland and some surrounding tissue. Usually, it is performed when the cancer has not spread far outside the gland. The surgery is done under general anesthesia, generally takes two to four hours and requires a hospital stay of one to two days. Prostatectomies have been performed successfully for many years. In the past, these procedures were regarded as the "gold standard" although other techniques have yielded similarly good results.
There is still no guarantee, however, that the cancer will not return. Some cancers are found to be more extensive or aggressive than believed before surgery, indicating a higher risk for cancer recurrence. The value of the procedure is that the primary tumor is removed and more accurate staging of the cancer can be done.
Here are the main types of radical prostatectomy:
Laparoscopic — In this procedure, the prostate is removed through five very small (less than 1 centimeter) incisions using lighted, magnified scopes and cameras. The prostate is removed in a small bag through one of the incisions, which is expanded to 2 to 3 centimeters. Potential benefits of this procedure are less pain and earlier return to normal activities.
This procedure can be used as a nerve-sparing approach that can lower, but not completely eliminate the risk of impotence after surgery. In a nerve-sparing approach, the surgeon tries to preserve one or both of the small nerve bundles needed for unassisted erections. If cancer has spread to the nerves, nerve sparing may not be advised. Lymph nodes also can be removed for examination with laparoscopic surgery.
Perineal — In this procedure, the prostate is removed through an incision in the skin between the scrotum and anus. The lymph nodes cannot be removed through this incision. If the lymph nodes need to be examined, they are removed through a small abdominal incision or by a laparoscopic procedure. Nerve sparing also can be performed perineally.
Retropubic — In this procedure, an incision is made in the lower abdomen to remove the prostate as well as lymph nodes for examination. This procedure also can be used as a nerve-sparing approach.
Robotic Radical Prostatectomy — This advanced laparoscopic procedure uses a robotic system, called the daVinci Surgical System that provides a magnified, 3-dimensional view during the operation and maintains surgeon dexterity through its robotic arms. At UCSF, the robotic system is used to perform radical prostatectomy.
New Treatments and Clinical Trials
Research has increased our overall understanding of prostate cancer and new treatments are being tested in patients. Clinical trials primarily involve patients who have rising PSAs after treatment or who have more advanced, metastatic cancers. A number of new agents may eventually provide more treatment options for new and recurring cancers. But at this time, none of them are regarded as cures, or even as replacements for surgery, radiation or hormone therapy.
Generally, patients being treated with these new approaches have experienced fewer side effects than patients receiving more traditional treatments.
Alternative and Complementary Therapies
Alternative and complementary therapies are treatments that fall outside conventional medicine in this country. Their effectiveness for treating cancer is, as yet, unproven. The field of alternative and complementary medicine is very broad and encompasses changes in diet and lifestyle, stress reduction, acupuncture, homeopathy and other approaches.
Tell your doctor if you are using any complementary or alternative therapies. Many of these therapies may benefit patients by helping them lead more healthy and active lives, reducing emotional stress associated with prostate cancer and its treatment, and reducing pain and discomfort. The main treatments include:
Diet, Nutrition and Supplements — There is a broad consensus that diets high in fat, especially animal fat, increase the likelihood of developing prostate cancer. Some people believe that reducing the fat in your diet may slow cancer growth, but there is no agreement as to how much fat reduction is needed.
Exercise — Being physically active is not only good for the body, it also relieves depression and promotes a sense of well-being. Exercise does not have to be aerobic or intense. Taking a walk for up to an hour three times a week can provide benefit.
Stress Reduction — A wide array of activities can help reduce stress and anxiety. These include meditation, breathing exercises, visualization, relaxation exercises and massage. Classes and groups are available to teach these techniques. The Cancer Resource Center at the UCSF Helen Diller Family Comprehensive Cancer Center can provide information and resources.
Asian Medicine — There is a growing interest in the treatment and meditative practices developed over hundreds of years in Asian countries, particularly China. Acupuncture has been shown effective in reducing pain and discomfort associated with medical conditions. Stylized movements and exercises such as tai chi, qigong and yoga can help people feel more balanced and at ease.
Traditional Chinese medicine uses herbal preparations to treat many disorders, including prostate cancer. Some of these treatments are being studied in the United States.
For more information, please see:
Patient Guide to Prostate Cancer
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