Prostate Cancer

Signs and Symptoms

Prostate cancer in its early stage often doesn't cause any symptoms. But prostate cancer can cause these problems:

• A need to urinate frequently, especially at night
• Difficulty starting urination or holding back urine
• Inability to urinate
• Weak or interrupted flow of urine
• Painful or burning urination
• Difficulty in having an erection
• Painful ejaculation
• Blood in urine or semen
• Frequent pain or stiffness in the lower back, hips, or upper thighs

The prostate gland is located just below the bladder and surrounds the bottom portion of the urethra, the tube that drains urine from the bladder. The prostate's primary function is to produce most of the fluid in semen, including fluid that nourishes and transports sperm.

Most men experience a second period of prostate growth when they reach their mid-40s. At that time, cells in the central portion of the gland -- where the prostate surrounds the urethra -- reproduce more rapidly than normal. As tissues in the area enlarge, they often press on the urethra and partially block urine flow. Benign prostatic hyperplasia is the medical term for this condition, more commonly called BPH, which affects about half of men in their 60s and close to 80 percent of men in their 80s. For some men, the symptoms may be severe enough to require treatment. BPH is not a form of prostate cancer and will not predispose you to developing prostate cancer.

If prostate cancer develops, it may remain in the prostate or spread beyond that gland. If it spreads, it usually spreads to the bones or nearby lymph nodes. It also may grow locally and invade the bladder. When cancer spreads from its original location to another part of the body, the new tumor has the same abnormal cells as the primary tumor.

Diagnosis

Among American men, prostate cancer is the most common cancer and the second leading cause of cancer deaths. But 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 sexuality. In fact, the possible consequences of treatment -- which include bladder control problems and impotence -- can be a greater worry for some men than the cancer itself.

The good news is that if prostate cancer is detected early -- when it's still confined to the prostate gland -- 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.

Modern treatment methods are designed to cure prostate cancer and minimize adverse effects on urinary, bowel and sexual function. Curing cancer that has spread beyond the prostate gland is more difficult. But treatments exist that can help control the cancer.

If your have symptoms or test results that suggest prostate cancer, your doctor will ask about your personal and family medical history, perform a physical exam and may order laboratory tests. The exams and tests may include a digital rectal exam, a urine test to check for blood or infection and a blood test to measure prostate-specific antigen (PSA). In some cases, your doctor also may check the level of prostatic acid phosphatase (PAP) in the blood, especially if the results of the PSA indicate there might be a problem.

Your doctor may recommend exams to learn more about the cause of the symptoms. These may include:

• Prostate-Specific Antigen (PSA) Test -- A small amount of blood is drawn from your arm and analyzed for PSA. The substance is naturally produced in your prostate gland to help liquefy semen. But a small amount of it circulates through your bloodstream. If higher than normal levels of PSA are detected in your blood or if levels rise over time, it could indicate prostate inflammation, prostate enlargement or prostate cancer.

• Transrectal Ultrasonography -- Sound waves that cannot be heard by humans (ultrasound) are sent out by a probe inserted into the rectum. The waves bounce off the prostate, and a computer uses the echoes to create a picture called a sonogram. This sonogram can be used to visualize abnormal areas in the prostate and to direct a biopsy or sampling of tissue from the prostate. This tissue sample is used to determine if cancer is present.

If cancer is found in your prostate, your doctor needs to know the stage, or extent, of the disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. Your doctor may use various blood and imaging tests to learn the stage of the disease. Treatment decisions depend on these findings. Prostate cancer staging is a complex process. Your doctor may describe staging using the Tumor-Nodes-Metastasis (TNM) system:

• T1a/b -- The cancer cannot be felt during a rectal exam, but is discovered incidentally when prostate surgery is performed for another reason.

• T1c -- The cancer cannot be felt during a rectal exam, but is discovered due to an elevated serum PSA level.

• T2a -- The cancer is felt on one side of the prostate during a rectal exam.

• T2b -- The cancer is felt on both sides of the prostate during a rectal exam.

• T3a -- The cancer has spread outside the prostate to nearby tissues.

• T3b -- The cancer has spread to the seminal vesicles, glands at the base of the bladder that are connected to the prostate.

• T4 -- The cancer has spread to adjacent organs such as the bladder or rectum.

• N0 -- Prostate cancer has not spread to lymph nodes.

• N+ -- Lymph nodes are involved with prostate cancer.

• M0 -- There is no evidence of distant spread or metastases from prostate cancer.

• M+ -- The prostate cancer has spread or metastasized to other locations in the body such as the bones, liver or lung.

Treatment

Decisions about prostate cancer treatment involve many factors. Prostate cancer may have a prolonged course in some patients and may progress rapidly, requiring aggressive treatment, in others. Some patients, especially the elderly or those with other medical conditions, may die with prostate cancer rather than of prostate cancer.

Treatment may involve watchful waiting, surgery, radiation therapy or hormonal therapy. Some patients receive a combination of therapies. In addition, our doctors are studying other methods of treatment to find out whether they are effective against this condition.

Watchful Waiting

Watchful waiting may be suggested for some men who have prostate cancer that is found at an early stage and appears to be slow growing. Watchful waiting may be advised for older men or men with other serious medical problems. For these men, the risks and possible side effects of surgery, radiation therapy or hormonal therapy may outweigh the possible benefits.

Surgery

Surgery is a common treatment for early stage prostate cancer. The doctor may remove all of the prostate, performing a type of surgery called radical prostatectomy, or only part of it.

• Radical Prostatectomy -- In many cases of prostate cancer, radical prostatectomy is the preferred treatment. Evolution in the surgical technique over the past 20 years has improved the ability to cure the cancer while reducing potential complications such as blood loss, incontinence and erectile dysfunction. Surgeons at UCSF Medical Center have extensive experience with radical prostatectomy and have achieved excellent results in all aspects of the associated surgical outcomes.

• Robotic Radical Prostatectomy -- Minimally invasive, laparoscopic prostatectomy uses a the state-of-the-art robotic system that provides a magnified, three-dimensional view during the operation while surgeons to use its robotic arms. With robotic surgical technology, our experienced surgeons achieve successful outcomes similar to open prostatectomy with the additional benefits that include less blood loss during surgery, decreased pain after the operation and faster recovery.

In some cases, the doctor can use a new technique known as nerve-sparing surgery. This type of surgery may save the nerves that control erection. However, men with large tumors or tumors that are very close to the nerves may not be able to have this surgery.

Radiation Therapy

Radiation therapy, also called radiotherapy, uses high-energy X-rays to kill cancer cells. Like surgery, radiation therapy is local therapy. It can affect cancer cells only in the treated area. In early stage prostate cancer, radiation can be used instead of surgery, or it may be used after surgery to destroy any cancer cells that may remain in the area. In advanced stages, it may be given to relieve pain or other problems.

Radiation may be directed at the body by a machine, called external radiation, or it may come from tiny radioactive seeds placed inside or near the tumor, called internal or implant radiation and brachytherapy. Men who receive radioactive seeds alone usually have small tumors. Some men receive both kinds of radiation therapy. For external radiation therapy, patients go to the hospital or clinic, usually five days a week for several weeks. Patients may stay in the hospital for a short time for implant radiation.

Hormonal Therapy

Hormonal therapy prevents cancer cells from getting the male hormones they need to grow. It is called systemic therapy because it can affect cancer cells throughout the body. Systemic therapy is used to treat cancer that has spread. Sometimes this type of therapy is used to try to prevent the cancer from coming back after surgery or radiation treatment.

There are several forms of hormonal therapy:

• Orchiectomy is surgery to remove the testicles, the main source of male hormones.

• Drugs known as luteinizing hormone-releasing hormone (LH-RH) agonists can prevent the testicles from producing testosterone. Examples of these drugs are leuprolide, goserelin and buserelin.

• Drugs known as antiandrogens can block the action of androgens, a male sex hormone. Two examples are flutamide and bicalutamide.

• Drugs that can prevent the adrenal glands from making androgens include ketoconazole and aminoglutethimide.