What is Prostate Cancer?
Prostate cancer is characterized by the uncontrolled growth of abnormal cells in the prostate gland. Prostate cancerIn many cases, the disease progresses slowly and may cause no symptoms for several years. In other cases, prostatic neoplasms can evolve aggressively and give rise to metastases. Symptoms occur in more advanced stages of the disease and can be similar to conditions other than cancer, such as prostatitis and benign prostatic hyperplasia.
The onset of prostate cancer correlates to some risk factors, which can favor the neoplastic transformation of cells; first of all the age over 50 years. The extreme prevalence of prostate cancer after this age, and the excellent chances of eradication in the early stages, underline the importance of early diagnosis.
Diagnosis
Digital rectal examination (DRE)
Rectal exploration is the simplest diagnostic procedure to check the state of health of the prostate and identify any alterations by touch. With a gloved, lubricated finger, the doctor palpates the prostate and surrounding tissue through the wall of the rectum.
The exam allows you to evaluate:
- Size, firmness and texture of the prostate gland;
- Any pain caused by touching or pressing on the prostate;
- Hard areas or lumps, which may suggest the presence of one or more tumors.
However, it should be emphasized that the tumor could cause alterations that are difficult to detect by palpation. For this reason, prostate specific antigen (PSA) blood level determination is a complementary test to digital rectal examination.
PSA (prostate specific antigen) test
PSA is an enzyme produced by the prostate gland, whose function is to keep the sperm flowing after ejaculation. Normally present in low concentrations, it can be determined in the blood through a common blood test.
Cancer cells produce large amounts of prostate specific antigen; therefore, determining the levels of PSA in the blood increases the chances of detecting the presence of the tumor, even in the early stages. After treatment, the PSA test is often used to check for any signs of recurrence.
Prostate ultrasound
If a clinical suspicion of prostate cancer emerges from the urological examination and PSA values, it is likely that the doctor will request a transrectal prostate ultrasound. This examination allows to obtain more precise data on the morphology of the prostate, but once again it cannot be considered a completely reliable diagnostic test. The last word, in this sense, belongs to the prostate biopsy, the only tool currently validated for the diagnosis of cancer.
Prostate biopsy
If symptoms and test results raise the suspicion of cancer, a urologist may perform a biopsy of the prostate. This investigation is able to determine with certainty the presence of cancer cells in the prostate tissue. The procedure, performed under local anesthesia, consists in taking small samples (at least 12), coming from different areas of the prostate gland. The ultrasound guide is inserted into the rectum and transrectal or transperineal blood samples are taken with a special needle (the region between the rectum and the scrotum). The pathologist analyzes the biopsy samples under a microscope to look for any cancer cells and determine the grade of the tumor.
Staging
Doctors analyze the results of rectal examination, biopsy, and imaging to determine the stage of the tumor. This relatively complex system reflects the many varieties of prostate cancer and helps determine which type of treatment is most appropriate.
The staging of prostate cancer mainly depends on:
- Ability of the tumor to invade nearby tissues, such as the bladder or rectum;
- Ability of the tumor to metastasize to lymph nodes or other parts of the body, such as bones;
- Grade (Gleason score);
- PSA level.
Doctors identify the stage of prostate cancer using the TNM system (tumor, lymph nodes, and metastases):
- “T” describes the characteristics of the tumor;
- “N” indicates whether the cancer has spread to regional lymph nodes (they are located next to the prostate in the pelvic region).
- “M” refers to the spread of the tumor to other parts of the body (metastases).
The set of these parameters (TNM, Gleason and PSA) allows the disease to be assigned three different risk classes: low, intermediate and high risk.
Sometimes, a simpler staging number system is used.
The stages of prostate cancer are:
- Stage I – early stage tumor, very small and completely within the prostate gland; may not be found during a digital rectal exam.
- Stage II – the neoplastic mass is larger, but remains confined within the prostate.
- Stage III – the tumor extends beyond the prostate, may have invaded the seminal vesicles or other nearby tissues, but the cancer cells have not yet metastasized to the lymph nodes.
- Stage IV – advanced cancer, which has spread to lymph nodes or other parts of the body, including the bladder, rectum, bones, lungs or other organs (about 20-30% of cases are diagnosed at this stage).
If prostate cancer is diagnosed at an early stage, the chances of survival are generally good. About 90% of patients in stages I and II will live at least five more years, and 65-90% will live for at least 10 more years. Stage III correlates with a 70-80% chance of living for at least another five years. However, if prostate cancer is diagnosed when it has reached stage IV, the patient has a 30% chance of living for at least another five years.
Treatment
Treatment for prostate cancer depends on individual circumstances, in particular: tumor stage (I to IV), Gleason score, PSA level, symptoms, patient age and general health conditions. For many cases of prostate cancer, treatment may not be needed right away.
The aim of therapy is to cure or control the tumor, so as not to reduce the patient’s life expectancy.
Active surveillance
If prostate cancer is very early, growing very slowly and causing no symptoms, the patient may decide to delay treatment. Active surveillance involves an observation period, which aims to avoid unnecessary treatment of harmless cancers (and its complications), while still providing timely intervention for men who need it. Active surveillance involves regular follow-up tests to monitor prostate cancer progression: blood tests, rectal exams and biopsies. When evidence shows that the disease is progressing, treatment, such as surgery or radiation therapy, may be opted for.
Radical prostatectomy
Radical prostatectomy involves the surgical removal of the prostate gland, some surrounding tissue and some lymph nodes (for this reason, the correct name of the procedure is radical prostatectomy and bilateral pelvic lymphadenectomy). This treatment is an option for the treatment of localized prostate cancer and locally advanced cancer.
The radical prostatectomy procedure can be performed by:
- Robotic laparoscopic surgery: Instruments are attached to a mechanical device (robot) and inserted into the abdomen through small incisions. The surgeon sits at a console and uses hand controls to drive the robot, which allows for more precise movements with surgical instruments.
- Retropubic surgery: The prostate is removed through an incision in the lower abdomen. Compared to other types of surgery, it correlates with a lower risk of nerve damage, which could lead to bladder control problems and erectile dysfunction.
- Perineal surgery: To access the prostate, an incision is made between the anus and the scrotum. The perineal approach to surgery may allow for faster recovery times, but it is more difficult to avoid nerve damage.
- Laparoscopic prostatectomy: Your doctor performs surgery through small incisions in your abdomen, with the assistance of a laparoscope.
Radical prostatectomy, like any operation, carries some risks and side effects, including urinary incontinence and erectile dysfunction. In extremely rare cases, post-operative problems can lead to patient death.
Having completely removed the prostate and seminal vesicles, the patient will become sterile and will have an orgasm without ejaculations, but – in the absence of complications – he will be able to resume an almost normal sex life. The reduction or absence of an erection are common side effects of the intervention, for which there are however appropriate pharmacological solutions.
In many cases, radical prostatectomy eliminates the neoplastic cells. However, prostate cancer can come back after the operation.
Radiotherapy
Radiation therapy involves the use of radiation to kill cancer cells. The radiation source can be external or can be inserted directly into the prostate of the suitably anesthetized patient. In the latter case we speak of brachytherapy, an intervention indicated above all in patients in the low or intermediate-risk class.
Radiation therapy is an option for the treatment of localized prostate cancer and locally advanced prostate cancer. Radiation therapy can also be used to slow the progression of metastatic prostate cancer and relieve symptoms.
Radiation therapy is usually given on an outpatient basis, in short sessions five days a week, for 1-2 months. Side effects of radiation therapy can include tiredness, painful and frequent urination, urinary incontinence, erectile dysfunction, diarrhea, and pain when defecating. As with radical prostatectomy, there is a chance that the cancer could come back.
Brachytherapy
Brachytherapy is a form of “internal” radiation therapy, in which a number of small sources of radiation are surgically implanted into the prostate tissue . This method has the advantage of delivering a dose of radiation directly to the tumor, reducing damage to other tissues. However, the risk of sexual dysfunction and urinary problems is the same as with radiation therapy, although bowel complications are minor.
Hormone therapy
Hormone therapy is often used in combination with radiation therapy, to increase the chances of treatment success or to reduce the risk of recurrence. It can also be used in men with advanced prostate cancer to relieve symptoms, shrink the tumor size and slow down the proliferation of cancer cells.
Hormones control the growth of prostate cells. Specifically, the tumor needs testosterone to grow. Hormone therapy can:
- Shut down testosterone production with luteinizing hormone releasing hormone (LH-RH) agonists;
- Block the effects of testosterone, preventing the hormone from reaching the cancer cells, using antiandrogen drugs (e.g. cyproterone).
Limiting the availability of hormones can cause cancer cells to die or proliferate more slowly. The main side effects of hormone therapy are caused by their effects on testosterone and include decreased sex drive and erectile dysfunction. Other possible side effects include: hot flashes, sweating, weight gain and swelling of the breasts.
Orchidectomy
Alternatively, it is possible to opt for surgical removal of the testicles (orchiectomy).
The efficacy of orchiectomy in reducing testosterone levels is similar to that of the drug approach, but the surgery can lower testosterone levels more rapidly.
Cryotherapy and High Intensity Focused Ultrasound (HIFU)
Cryotherapy (or cryoablation) involves freezing prostate tissue to kill cancer cells: It involves inserting tiny probes into the prostate through the wall of the rectum, then cycles of freezing and thawing allow it to kill the cancer cells and some surrounding healthy tissue. Similarly, HIFU involves the use of high-intensity ultrasound focused to heat specific points in the prostate.
These procedures are used on some occasions, mainly to treat patients with localized prostate cancer. However, HIFU treatment and cryotherapy are still being evaluated and their long-term efficacy has not yet been proven.
Chemotherapy
Chemotherapy is mainly used to treat metastatic cancer and tumors that do not respond to hormone therapy. The treatment destroys cancer cells, interfering with the way they multiply. The main side effects of chemotherapy are caused by their effects on healthy cells and include: infections, fatigue, hair loss, sore throat, loss of appetite, nausea and vomiting. Sometimes, if prostate cancer has already spread, the goal is not to cure it, but to control and reduce symptoms (such as pain), as well as prolong the patient’s life expectancy.
