Prostate Cancer

One in eight men in the U.S. will be diagnosed with prostate cancer during his lifetime. The earlier it is detected, the more options for treatment and the higher the chance of survival.

Frequently, prostate cancer has no symptoms. However, some advanced cancers may cause:

• Difficulty starting or stopping urine flow
• Increased urinary frequency, particularly at night
• Weak urine flow
• Blood in the urine or semen
• Pain in the lower back, hips or upper thighs
• Weight loss

Like most cancers, the cause of prostate cancer is not known. However, the following factors increase the risk of developing prostate cancer:

• Age: Men who are 65 or older and/or with an immediate family history of prostate cancer are at greater risk.
• Race: African American men have the highest risk for prostate cancer—the disease tends to start at younger ages and grows faster than in men of other races. These men should begin testing around age 40.
• Family History: Men whose fathers or brothers have had prostate cancer have a higher risk than men who do not have a family history of the disease. Prostate cancer risk also appears to be slightly higher for men from families with a history of breast cancer.
• Diet: Risk may be higher for men who eat high-fat diets.
• Smoking
• Obesity

What to know before your visit to Advanced Urology Institute:

• During your visit, your doctor will ask you questions regarding your medical, surgical, and family history, and perform an exam.

Other tests that may be performed during or after your visit:

• Lab tests will often be performed including PSA, and urine studies.
• Digital rectal exam: To get an idea of the size and condition of the prostate, your doctor inserts a lubricated, gloved finger into your rectum and feels the prostate through the rectal wall.
• Prostate needle biopsy (a hollow needle is used to remove tissue samples):
  • Transperineal prostate biopsy: This involves placement of an ultrasound probe in the rectum. However, instead of taking biopsies through the rectum, biopsies are taken through the skin located between the scrotum and the rectum (typically 12 biopsies are taken, but occasionally more). The procedure lasts approximately 10-15 minutes. This has been associated with lower infection rates and higher cancer detection rates.
  • Transrectal prostate biopsy: An ultrasound probe is placed into the rectum to measure the size of the prostate, provide local anesthetic, and perform biopsies of the prostate (typically 12 biopsies). The procedure lasts about five minutes.
  • MRI fusion biopsy: MRI/ultrasound fusion technology uses MRI images and targets abnormal areas that have been identified on those images. While performing the biopsy, the urologist will then have the annotated images of the MRI with the suspicious areas marked on these images available on his/her monitor. These images will then be fused with the real-time transrectal ultrasound image of the prostate. This subsequently allows an MRI-targeted sampling of suspicious areas, under ultrasound guidance. This is usually performed under sedation.

Grading tumors

If cancer cells are found, a pathologist studies the tissue samples under a microscope to determine the grade of the tumor. This tells how much the tumor tissue differs from normal prostate tissue. It suggests how fast the tumor is likely to grow. Imaging is often needed after the diagnosis of prostate cancer: CT, MRI, and/or bone scan.

Tumors with higher grades tend to grow faster than those with lower grades. They are also more likely to spread. Doctors will use your tumor grade along with your age and other factors to suggest treatment options.

Gleason score

The most commonly used system for grading the aggressiveness of prostate cancer is the Gleason score. Gleason scores range from 2 to 10. A high Gleason score indicates a high-grade prostate tumor, which is more likely to grow quickly and spread.

The Gleason score along with the tumor stage are used to guide therapy.

Tumor stage

The tumor stage describes how the cancer was detected and the extent of the cancer in your body. Your doctor will tell you if the cancer is:

• Stage I or II: Limited to the prostate (early localized)
• Stage III (locally advanced): Detected in organs next to the prostate, extending into the seminal vesicles (a gland behind it that helps produce semen), sphincter (muscles that control urine flow), bladder, rectum, or wall of the pelvis
• Stage IV (advanced metastatic): Spread beyond the prostate into the lymph nodes or other organs including bones

Every patient is unique. Your treatment approach will depend on your personal situation.

Treatments for early local growth (stages I and II) include:

• Surgical removal of the prostate through:
  • Open surgery: Prostate removal through a cut in the abdomen or an incision between the prostate and the anus. This is not as common in the U.S.
  • Laparoscopic prostatectomy, usually involves using robotic assistance: The surgeon removes the entire prostate through small cuts, rather than a single long cut in the abdomen. A thin, lighted tube (a laparoscope) helps the surgeon see. Other instruments are passed through the small cuts. These instruments are used to remove the prostate. This procedure can be performed either without robotic assistance (less common in U.S.) or with robotic assistance (most common way to remove the prostate currently in the U.S.).
  • Cryosurgery: For some men, cryosurgery is an option. The surgeon inserts a small probe through the skin into the prostate. The device freezes and kills prostate tissue. Cryosurgery may also be used if the cancer returns following radiation therapy.
  • High Intensity Focused Ultrasound (HIFU): Uses high frequency sound waves to destroy prostate cancer by creating heat. Depending on the tumor characteristics, the procedure can treat the whole gland or part of the gland.
• Radiation:​
  • External Beam Radiation Therapy (EBRT):
    • Intensity modulated radiation therapy (IMRT): Computer-guided radiation is targeted at the cancer cells in daily sessions over several weeks (can be up to 9 weeks). Uses two- and three-dimensional imaging to direct radiation and is often referred to as IMRT or IGRT. This is the most commonly used type of radiation for prostate cancer.
    • Stereotactic body radiation therapy (SBRT): Delivers high doses of radiation in a small number of treatment sessions – five outpatient sessions on consecutive days or over a two-week period. This may be limited to certain patient characteristics.

• • Brachytherapy: Seeds containing radioactive material are inserted directly into the prostate. May be used in combination with external beam radiation therapy.
• Active surveillance: No cancer treatment is provided. Instead, urological exams, including regular PSA tests, digital rectal exams, and repeat biopsies occur periodically to monitor the progression of the cancer. Further treatment may eventually be needed if the cancer grows or spreads. This is usually recommended for less aggressive tumor grades, patients with less likelihood of the cancer progressing, or those with limited life expectancy.

Treatment options for stages III and IV:

• Hormone therapy: Medications block the production of testosterone, which feeds cancer cells. Without its energy source, the cancer slows and potentially shrinks.
• Immunotherapy: Stimulates your body’s immune system to find and destroy cancer cells. This may be used in combination or in series with chemotherapy, radiation, surgical removal of the tumor, and more recently developed immunotherapies that use your body’s own immune system to attack cancer cells.
• Chemotherapy: For patients whose cancer is not responding to other treatments.
• Radioligand targeted therapy: This medication delivers radiation directly to cancer cells via a molecule that binds to specific cancer cell markers.
• TURP: A man with advanced prostate cancer may choose TURP (transurethral resection of the prostate) to relieve symptoms. The surgeon inserts a long, thin scope through the urethra. A cautery loop at the end of the scope removes tissue from the inside of the prostate. TURP is not a cure for the cancer, but it can remove tissue that blocks the flow of urine.