The prostate gland is a small, walnut-sized gland in men. It is located below the bladder and surrounds the upper portion of the urethra. The prostate gland lies in front of the rectum, and its posterior (back) surface can be felt during a rectal examination. The function of the prostate is to secrete fluids that make up part of the semen. The prostate gland may be a source of many health problems in men, the most common being benign prostatic hyperplasia (BPH), prostatitis and cancer.

Prostate cancer is a significant health-care problem in the United States due to its high incidence. It is the most common non-skin cancer in men affecting nearly 200,000 American men annually with over 27,000 of these men dying each year. Prostate cancer is different from most cancers in that an appreciable percentage of men, particularly older men with a shorter life expectancy, may have a silent form of this cancer—it will not cause symptoms or progress beyond the prostate gland during their lifetime. Sometimes this cancer can be small, slow growing and present limited risk to the patient. Other times, it can progress rapidly. Clinically important prostate cancers can be defined as those that threaten the well-being or life span of a man.

What causes prostate cancer is a subject of intensive research. It is likely that prostate cancer occurs due to many reasons. Predominately a disease of elderly men, the diagnosis of prostate cancer is rare before age 40 but increases dramatically thereafter. In the United States, it is estimated that one in 55 men between the ages of 40 and 59 will be diagnosed with prostate cancer. This incidence climbs almost to one in six for men between ages 60 and 79. This association is also reflected in mortality as prostate cancer accounts for about 10 percent of cancer-related deaths in men between the ages of 60 and 79 and nearly 25 percent in those over the age of 80.

Worldwide, prostate cancer ranks third in cancer incidence and sixth in cancer mortality among men. There is, however, a notable variability in incidence and mortality among world regions. The incidence is low (but rapidly increasing in recent years) in Japan and other Asian countries and intermediate in regions of Central America and Western Africa. The incidence is higher in North America and Northern Europe. Although some of these differences may be accounted for by differences in screening for prostate cancer and the risk of other diseases among world regions, it is likely that they can be accounted for, in part, by genetic predisposition as well as diet and other environmental factors.

There are also ethnic determinants of risk. African-Americans are in the highest risk group, with an incidence of more than 200 cases per 100,000 black men. The incidence in Caucasian and Asian men is slightly more than half that of blacks. In addition, African-American men tend to present with more advanced disease and have poorer overall prognosis than Caucasian or Asian men.

Men with a family history of prostate cancer are at an increased risk of developing the disease. The risk correlates with the number of first-degree relatives (father, brother or uncle) affected by prostate cancer and the age at onset. Men with a family history of disease may have a risk of developing prostate cancer 2 to 11 times greater than men without a family history of prostate cancer.

There is also considerable evidence showing that a Western lifestyle is associated with increased prostate cancer risk and increased death from prostate cancer. However, which specific lifestyle factor...excess calorie intake, excess dietary fat, excess refined sugar intake, reduced fruit and vegetable intake, reduced exercise, or overall higher obesity rates is specifically linked with prostate cancer is not entirely clear. However, it has been clearly shown that obesity is associated with increased risk for death from prostate cancer. Thus, the simplest advice for avoiding death from prostate cancer is to prevent obesity and if you are obese, to lose weight and keep it off.

The most commonly cited dietary risk factor is a high intake of dietary fat, though some more recent studies question whether dietary fat is really linked with prostate cancer. There is a limited amount of evidence to suggest that the worldwide difference in prostate cancer incidence may, in part, be associated with dietary intake of soy proteins. In Asian countries such as Japan and the Republic of Korea where prostate cancer incidence and mortality are just a fraction of that in North America, soy consumption in the form of tofu, soymilk and miso is up to 90 times higher than that consumed in the United States. In a study of more than 40 nations, researchers found soy, on a per calorie basis, to be the most protective dietary factor. This protective role may be associated with two of soy's components, genistein and daidzein that may act as weak estrogens or through other mechanisms. Estrogens are female hormones that inhibit prostate cancer growth. Some experts have suggested that the worldwide differences in prostate cancer incidence may also be explained by the high intake of green tea by residents of Asia. However, teasing out exactly which factors from a complex dietary mix cause prostate cancer is not easy and no clear answers have emerged.

The intake of other certain dietary factors may also reduce the risk of developing prostate cancer. Such substances include lycopene and fish oil. Cooked tomatoes are rich sources of lycopene. Lycopenes are antioxidants that may protect cells from becoming cancerous. Several studies have shown that the likelihood of developing prostate cancer is reduced by high intake of lycopene. Researchers found that men ingesting two or more servings of tomato sauce per week had a 36 percent reduction in cancer risk compared to those who did not, however again, not all studies have supported this. Fish oils (omega-3 fatty acids) are thought to reduce heart disease due to reducing inflammation. Given the presumed importance of inflammation in causing prostate cancer, it stands to reason that fish oils may prevent prostate cancer. Indeed, some studies have suggested this, though others have failed to find any link with prostate cancer risk.

Finally, a word of caution is needed. Based upon very exciting data, the National Institute of Health embarked a large randomized trial of over 30,000 men to test whether vitamin E or selenium would prevent prostate cancer. Unfortunately, the trial was stopped early because there was no evidence either agent alone or in combination prevented prostate cancer. Moreover, there was a suggestion that men who took vitamin E had an increased risk of prostate cancer and men who took selenium had a slightly higher risk of diabetes! This highlights the point that there is no easy substitute for a health lifestyle involving eating a balanced diet, avoiding dietary excesses, eating plenty of fruits and vegetables, getting lots of exercise, and most importantly achieving and maintaining a normal body weight.

Prostate-specific antigen (PSA) is a substance produced by the prostate gland. With prostate disease, inflammation, or trauma, greater amounts of PSA enter a mans' blood stream. This elevated blood PSA level has become an important marker of many prostate diseases including benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer.

The Use of PSA for Early Detection of Prostate Cancer

PSA testing is one of several measures used to assess the risk of prostate cancer. If your PSA is high for your age or steadily rising, with or without an abnormal physical exam of your prostate with a DRE, a biopsy may be recommended. Your health care provider will use your PSA test and other information to help guide treatment recommendations if you are diagnosed with prostate cancer. In a prostate biopsy, tiny pieces called cores of prostate tissue are removed for examination under a microscope. The biopsy helps determine if cancer or other abnormal cells are present in the prostate.

If the biopsy shows prostate cancer is present, other measures provide valuable information you and your health care provider can use to decide which treatment if any, is best for you. These other measures include information obtained from the biopsy itself such as: the Gleason score; an estimation of the extent of the cancer known as the clinical stage; an estimate of the amount of cancer in your prostate- known as tumor volume-; the number of positive biopsy cores and the extent of cancer within those cores. These factors provide Dr. Shaw and you valuable information to help guide your treatment decisions.

The most common system to evaluate and describe prostate cancer currently in use is the Gleason grading system. After a biopsy, the pathologist assigns a primary grade from 1 to 5, with 5 being the most aggressive, to the pattern of cancer cells occupying the greatest area of the biopsy cores. A secondary grade is assigned to the pattern occupying the second largest area. These two grades added together determine the Gleason score. This score ranges from 2 to 10. It is generally agreed that tumors with a Gleason score of 2 to 4 are very uncommon but have a very low biological aggressiveness. Scores of 5 to 6 have low aggressiveness. Those men with a Gleason score equal or greater than 7 have more biologically aggressive tumors. Those with primary scores of 3 and secondary scores of 4 are thought to have intermediate aggressiveness. Primary Gleason grades of 4 or 5 are an indication of aggressive prostate cancer.

Figure 1: What a man can expect from prostate cancer screening

FACTORS TO CONSIDER ABOUT PROSTATE SCREENING

1. The goal of early prostate cancer detection.

The goal of early detection is to reduce death from prostate cancer in men. Early stage prostate cancer, has many options for treatment and cure. Even men with very advanced cancer may benefit from treatment and should discuss their options with their health care provider.

2. The proportion of clinically significant or higher risk prostate cancer detected with PSA is unknown.

There is currently no universally accepted definition of what identifies prostate cancer as either life threatening or insignificant. Ideally, the characteristics of each man?s prostate cancer will guide an informed discussion between the man and his doctor. This may avoid unnecessary or aggressive therapy in certain men. Health care providers use tools (i.e. nomograms, probability tables, etc) to help predict the likelihood of various long-term outcomes with or without treatment for men with prostate cancers.

3. Men who wish to be screened for prostate cancer should have both a PSA test and a DRE.

While blood PSA levels are currently the best single test for early prostate cancer detection, the DRE can also identify men with prostate cancer. Evidence from research studies suggests that combining both tests improves the overall rate of prostate cancer detection.

4. A variety of factors can affect PSA levels and should be considered in the interpretation of results.

The three most common prostate diseases—prostatitis, benign prostatic hyperplasia (BPH), and prostate cancer—may cause elevated PSA levels in the blood. Treatment with antibiotics will decrease PSA by approximately 30% in men whose PSA elevation is due to prostatitis alone. Other medications, treatments or trauma (which can include a prostate biopsy or cystoscopy) to the prostate can affect PSA test results. A man should talk to his health care provider about any treatments he may have received or medications and supplements he may be taking.

PSA results can vary 20-25% depending upon the type of assay each laboratory uses for their PSA test. For this reason, it is important for a man and his health care provider to know which type of assay is used the PSA test and to use the same type of assay for every PSA test he has.

5. For patients choosing to undergo PSA testing, several important factors may influence results.

• PSA velocity: Changes in PSA levels over time or PSA velocity (PSAV) is used to assess both cancer risk and aggressiveness. It is recommended at least three PSA tests should be done over a period of at least 18 months to correctly measure PSAV.
• Age: Because blood PSA levels tend to increase with age, the use of higher "normal" levels for older men results in fewer biopsies.
• Free PSA: PSA exists in the blood two ways. The PSA test measures the total amount of PSA in the blood that is bound to plasma proteins. A different test can measure the amount of PSA present in the blood in a free state, called free PSA. Non-cancerous prostate tissue contains more of the free PSA than prostate cancer tissue. Men with prostate cancer tend to have lower free-to-total ratios. Men with other prostate disease that is not cancer usually have higher free-to-total ratios. Knowing the ratio of free-to-total PSA values can help identify men who may not need to have a biopsy.
• Prostate volume: Larger prostates produce larger amounts of PSA. Adjusting the PSA value for the size of the prostate can also reduce need for a biopsy. Knowing the impact of prostate size on the PSA value may improve PSA's ability to identify cancer.

A nomogram is a prediction tool that is based on statistics that can help determine the need for a biopsy. It combines clinical and pathologic factors known to have an impact on outcome from prostate cancer. Prostate nomograms are designed to help physicians and patients decide which treatment approaches will result in the greatest benefit.

6. When should a man have a prostate biopsy?

Although an abnormal DRE or an elevated PSA test may suggest the presence of prostate cancer, a biopsy test identifies actual cancer cells in the prostate tissue. Cancer is confirmed by a pathologist's examination of prostate tissue from the biopsy. Higher values of PSA are associated with a higher risk of prostate cancer. Because of this, the AUA is not recommending a single, minimum PSA test value, to suggest the need for a prostate biopsy. The decision to proceed with a prostate biopsy should be based primarily on PSA and DRE results.

However it should also take into account the factors mentioned earlier, plus a man's family history of prostate cancer, his race, any prior biopsy history and other significant health issues he may have. These factors may also identify which men might have a "significant" or life threatening prostate cancer and should have a biopsy.

Prostate biopsy for diagnosis of prostate cancer can be obtained in several ways. The most common method is by means of a transrectal, ultrasound-guided prostate biopsy. A doctor usually performs a biopsy as an outpatient procedure with local anesthesia. Most prostate biopsies collect samples of tissue (at least 8 to 12 cores) from the different areas of the prostate. The pathologist looks at these cores to see if any cancer cells are present. The risks and benefits of a biopsy should be discussed with a health care provider.

7. PSA level in a man's blood is generally a good predictor of the risk of prostate cancer, the extent of the cancer, and the long-term outcomes after treatment of the cancer.

What is the likelihood a man has prostate cancer if he has a high PSA? The answer depends on the level of PSA in the blood and the rate at which it is rising. Men whose PSA levels rise sharply over a short period are more likely to have prostate cancer than those who do not see significant changes in their PSA velocity.

The PSA level and the rate at which it is rising relate to the extent of the cancer as well as how aggressive the prostate cancer may be. The PSA velocity can also help your health care provider predict what a man?s potential outcomes may be if he chooses treatment.

8. The decision to use PSA for the early detection of prostate cancer should be individualized. Patients should be informed of the known risks and the potential benefits of early screening.

Prostate cancer deaths have recently been declining in the United States. Research is underway to determine if the possible reduction in morbidity and death from early diagnosis of prostate cancer is sufficient to outweigh the cost and potential consequences sometimes associated with disease treatment. A diagnosis of advanced prostate cancer is associated with significant health consequences and death.

Treatment procedures for localized prostate cancer include surgery (radical prostatectomy), radiotherapy (external beam radiation, proton beam radiation, or interstitial prostate brachytherapy), or cryotherapy. These treatments all carry a risk of complications. Potential complications of active treatments include erectile dysfunction, urinary incontinence, and bowel symptoms.

Decisions regarding early detection of prostate cancer through screening should be tailored to each man. The benefits and consequences should be discussed with his health care provider before PSA testing occurs. Not all men are appropriate candidates for screening efforts for this disease. Ideally, health care providers should consider a number of factors, along with the man?s preferences. Screening in men with less than a 10-year life expectancy, either due to age or other illness or disease, is discouraged.

It is not known with certainty that that the use of PSA testing decreases the risk of dying of prostate cancer. Screening with PSA does result in identifying more cancers than would be detected without the use of PSA. However, many of these cancers may be small and very slow growing. Such cancers may not pose a threat to them men who have them. This is sometimes called over detection. If men who have such cancers are uniformly treated, many men may suffer the side effects of treatment without the benefit of a longer life (called over treatment). Prostate biopsy is associated with a small risk of side effects such as bleeding or infection. All men considering biopsy should understand the risks of the biopsy itself as well as the risks of over detection and over treatment.

9. Early detection and risk assessment of prostate cancer should be offered to men 40 years of age or older who wish to be screened.

Previously, some groups have recommended that early detection begin at age 50 years for men at average risk of prostate cancer, or sooner for those men at higher life time risk (positive family history, African American race). Although family history of prostate cancer leads to a higher risk of prostate cancer diagnosis, it is not associated with an increased risk of high grade disease. Among men in their 40s and 50s, a baseline PSA level above the middle value see for men their age is a stronger predictor of future risk of prostate cancer than family history or race. This is because prostate enlargement is less likely to influence the PSA value in younger men compared to older men.

One way to identify this high-risk group of men with a PSA level above the middle value in their 40s is to begin testing at age 40 years. This establishes a baseline PSA value. It can be used to determine future screening intervals based upon the PSA value results. Men in their 40s with a PSA value above 0.6 to 0.7 ng/mL are at higher risk for prostate cancer.

Although prostate cancer is not detected often below age 50 years, there are a number of reasons to offer early detection prior to age 50. Since death from prostate cancer occurs, on average, 15 to 20 years after diagnosis of an early cancer, men dying at age 55 to 64 likely could have been cured by diagnosis and effective treatment prior to age 50. When compared to men older than 50, younger men are more likely to have prostate cancer that can be cured. Infrequent testing of men in their 40s and after age 50 might reduce prostate cancer deaths and the cost of screening when compared to annual testing beginning at age 50 years. Knowing a man’s baseline PSA values in his 40s to compare with future PSA tests after he turns 50 could help identify those men with life threatening prostate cancer at a time when cure is still possible.

How often he should be screened should be based on the results of the PSA test since the future risk of prostate cancer is closely related to the PSA level. Research suggests that most cancers detected at two to four years after a first PSA/DRE screen are likely to be cured with treatment.

PSA screening is common among the men over age 70. These men may have limited life expectancies. Because of the long natural history of most prostate cancers and competing causes of death in men that age, the benefits of screening may decline as a man grows older. Each man?s health care provider should assess his health status to determine if he should have PSA testing at any given age.

In 2008, the U.S. Preventative Services Task Force issued guidelines, which recommend against screening men over age 75. This recommendation estimates the age at which the average American man has ten years or less life expectancy, but the recommendation for PSA screening should be individualized. This is especially true in men with excellent health, absence of other serious health concerns, and a history of long life in their family.

High-risk prostate cancer rates do in fact increase with age, accounting for 43% of cancers diagnosed in men older than 75 years vs. 25% among men less than 75 years. It is important to understand the difference between screening for prostate cancer and treatment of prostate cancer. A diagnosis of prostate cancer in this age group (over 75 years) may be informative for a man’s overall health but may never require treatment beyond active surveillance. Conversely, men with aggressive prostate cancer in this age group should not be denied the opportunity for diagnosis and treatment, which could affect their length and quality of life.

What is active surveillance: Active surveillance describes a type of close follow up performed on men with prostate cancer. Is usually consists of serial PSA, DRE, transrectal ultrasounds, and repeat prostate biopsies at regular intervals. It is different from watchful waiting in that men on active surveillance may elect treatment for cure when their disease appears to be changing and becoming more aggressive. Men on watchful waiting choose treatment, usually in the form of androgen deprivation therapy, to relieve side effects of locally progressive or metastatic disease. The goal of active surveillance is to allow men to maintain their quality of life when the disease is slow growing or inactive but still allow them to be cured of prostate cancer when the disease appears to become more aggressive or is growing.

In its early stages, prostate cancer often causes no symptoms. When symptoms do occur, they may include any of the following: dull pain in the lower pelvic area; frequent urination; problems with urination such as the inability, pain, burning, weakened urine flow; blood in the urine or semen; painful ejaculation; general pain in the lower back, hips or upper thighs; loss of appetite and/or weight; and persistent bone pain.

Currently, digital rectal examination (DRE) and prostate specific antigen (PSA) are used for prostate cancer detection. The age at which screening for prostate cancer should begin is not known with certainty. However, the American Urological Association recommends that healthy men over the age of 40 should consider obtaining a baseline prostate cancer screening with a DRE and PSA test.

DRE: The DRE is performed with the physician inserting a gloved finger into the rectum and examining the prostate gland, noting any abnormalities in size, contour or consistency. DRE is inexpensive, easy to perform and allows the physician to note other abnormalities such as blood in the stool or rectal masses, which may allow for the early detection of rectal or colon cancer. However, DRE is not the most effective way to detect an early cancer, so it should be combined with a PSA test.

PSA Test: The PSA test is usually performed in addition to DRE and increases the likelihood of prostate cancer detection. The test measures the level of PSA, a substance produced only by the prostate, in the bloodstream.

This blood test can be performed in a clinical laboratory, hospital or physician's office and requires no special preparation on the part of the patient. Ideally, the test should be taken before a DRE is performed or any catheterization or instrumentation of the urinary tract. Furthermore, because ejaculation can transiently elevate the PSA level for 24 to 48 hours, the patient should abstain from sexual activity for two days prior to having a PSA test.

Very little PSA escapes from a healthy prostate into the bloodstream, but certain prostatic conditions can cause larger amounts of PSA to leak into the blood. One possible cause of a high PSA level is benign (non-cancerous) enlargement of the prostate, otherwise known as BPH. Inflammation of the prostate, called prostatitis, is another common cause of PSA elevation, as is recent ejaculation. Prostate cancer is the most serious possible cause of an elevated PSA level. The frequency of PSA testing remains a matter of some debate. The American Urological Association (AUA) encourages men to have regular PSA testing starting at age 40. Some experts have suggested that men in their 40’s with an initial normal DRE and PSA level of less than 0.7 ng/ml can have PSA testing performed every 5 years—at least until age 50. However, a disadvantage of infrequent testing is that it limits the ability to detect a rapidly rising PSA level that can signal aggressive prostate cancer, though this is relatively uncommon for men with such low PSA values. Recently, several refinements have been made in the PSA blood test in an attempt to determine more accurately who has prostate cancer and who has false-positive PSA elevations caused by other conditions like BPH. These refinements include PSA density, PSA velocity, PSA age-specific reference ranges and use of free-to-total PSA ratios. Such refinements may increase the ability to detect cancer and these should be discussed with your physician.

Currently, it is recommended that both a DRE and PSA test be used for the early detection of prostate cancer. It is important to realize that in most cases an abnormality in either test is not due to cancer but to benign conditions, the most common being BPH or prostatitis.

Prostate Biopsy: Prostate biopsy is best performed under transrectal ultrasound guidance using a spring-loaded biopsy device coupled to the transrectal probe. The patient is prepared with an enema and an antibiotic. The lubricated ultrasound probe is inserted into the rectum.  Patients are positioned on their side for this procedure. The physician will first image the prostate using ultrasound noting the prostate gland's size and shape and whether or not any other abnormalities exist, the most common of which are shadows which might signify the presence of prostate cancer. However, not all prostate cancers are visible.

After the prostate gland has been anesthetized with an injection of a local anesthetic through a long fine needle that is passed through the probe, the physician performs the biopsy. Using the spring-loaded biopsy device attached to the ultrasound probe, the physician performs multiple biopsies of the prostate gland. Generally, 10 to 12 (or more, depending upon the size of the prostate gland and the prior PSA and biopsy history of the patient) biopsies will be performed. Each biopsy removes a cylinder of prostate tissue approximately 3/4 inch in length and 1/16 inch in width. The entire procedure takes 20 to 30 minutes. The biopsy tissue taken will then be examined by a pathologist (a physician who specializes in examining human tissue to determine whether it is normal or diseased). The pathologist will be able to confirm if cancer is present in the biopsy tissue. If cancer is present, the pathologist will also be able to grade the tumor. The grade indicates the tumor's degree of aggressiveness—how quickly it is likely to grow and spread. The Gleason grading system is the most widely used system. In this system, because often several different tumor patterns are seen, the most common tumor pattern is assigned a score from 1 to 5 and the second most common pattern is similarly assigned a score, using the same scale. The two scores are added together to give a Gleason sum ranging between 2 and 10. Scores of 2 to 6 designate mildly aggressive, 7 moderately aggressive and scores of 8 to 10 highly aggressive.

The transrectal ultrasound guided prostate biopsy is usually well tolerated. Injecting local anesthetics into the area before biopsy may minimize this discomfort. Blood in the ejaculate (hematospermia) and blood in the urine (hematuria) occur in most patients, but resolves within a few days for the urine and a few weeks for the semen. High fever is rare, occurring in only 1 to 2 percent of patients. The antibiotic is continued for at least 48 hours after the biopsy procedure.

Prostate Cancer Staging

Once prostate cancer has been diagnosed by a prostate biopsy, the physician must stage the disease to determine the extent of the cancer (i.e., the "T" stage) and whether it has spread beyond the prostate gland to the surrounding tissues, the seminal vesicles, the lymph nodes and/or the bones. The T stage is determined by the DRE and other imaging studies of the prostate gland and surrounding tissues, such as the ultrasound scan, CT scan, MRI scan, or MR spectroscopy scan. The T stage is divided into the following categories:

T1: Doctor is unable to feel the tumor
T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed and is low grade (Gleason < 6).
T1b: Cancer is found after TURP but is present in more than 5% of the tissue removed or is of a higher grade (Gleason > 6)
T1c: Cancer is found by needle biopsy that was done because of an elevated PSA
T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still appears to be confined to the prostate
T2a: Cancer is found in one half or less of only one side (left or right) of the prostate
T2b: Cancer is found in more than half of only one side (left or right) of the prostate
T2c: Cancer is found in both sides of the prostate
T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles
T3a: Cancer extends outside the prostate but not to the seminal vesicles
T3b: Cancer has spread to the seminal vesicles
T4: Cancer has spread to adjacent organs, such as the urethral sphincter, rectum, bladder, and/or wall of the pelvis

To determine if the cancer has spread to the lymph nodes or bones, the physician may order a CT or MRI scan of the pelvis. A bone scan may be obtained to rule out metastases to the bone. Sometimes follow-up imaging studies are needed to further evaluate abnormalities found on the bone scan. These tests are not recommended for men with a Gleason grade <7 and a PSA level <10 ng/ml as they rarely show disease.

Prostate cancer represents a spectrum of disease. Although some cancers may grow so slowly that treatment may not be needed, others grow fast and are a threat to life. Determining the need for treatment can be a complex decision. Initially, the need for treatment should be based on the stage and grade of the cancer as well as the age and health of the patient. Many physicians have sought to devise risk assessment schemes that predict the likelihood of disease recurrence if patients are treated and progression or significant growth of their cancer if they undergo initial surveillance or watchful waiting. By combining many types of information (i.e., serum PSA level, clinical stage, Gleason score, extent of cancer in biopsy specimens), patients can be advised of the likely aggressiveness of their cancer and the need for and types of treatment available. However, the longer the patient's life expectancy, the more uncertain the prediction becomes, as most prostate cancers progress with time. Imaging tests, such as a radionuclide bone scan, CT scan or MRI, and MR spectroscopy may help assess whether the cancer is still confined to the prostate or has spread elsewhere. When prostate cancer spreads (metastasizes) it is usually progresses, though not always in such a neat step-wise fashion, first by perforating the capsule and extending into the periprostatic tissues, then to the seminal vesicles, then to the lymph nodes and finally to the bones, lungs, and other organs. Not all men with prostate cancer need to undergo imaging tests as the risk of spread to other organs can be estimated on the basis of serum PSA levels and cancer grade. It is the standard of care to omit the bone scan in patients with newly diagnosed, untreated prostate cancer, who have no symptoms from their cancer, a Gleason score < 7 and have serum PSA concentrations less than 10 ng/ml and certainly in those with serum PSA concentrations less than 15 ng/ml (unless the Gleason score is 7 or higher) . Similarly, a pelvic CT scan or MRI may not be necessary in men with lower grade cancers, cancers still confined to the prostate and serum PSA values less than 10 ng/ml.

There is controversy about true prevention. Some physicians believe that anti-androgen drugs, such as finasteride and dutasteride, can prevent prostate cancer. However, others are skeptical, and some believe that anti-androgens can only slow the progression of well-differentiated elements but may allow higher-grade elements to emerge as the dominant elements in the tumor. In randomized trials, men taking these drugs are less likely to be diagnosed with prostate cancer, though their impact of cancer aggressiveness and whether this will translate into a lower risk of death from prostate cancer is not known. Some physicians believe that general health measures might reduce the risk of prostate cancer, such as eating achieving and maintaining a normal body weight, a healthy diet, being physically active and visiting the doctor on a regular basis. As clinical studies, which found that supplements such as vitamin E and selenium do not prevent prostate cancer, point out—there is no current short-cut that can replace a healthy lifestyle.

The number of men diagnosed with prostate cancer remains high. However, 5-year relative survival rates have increased dramatically and there has been at least a 25% reduction in the age-specific prostate cancer mortality rate since the beginning of the PSA era. It is estimated that 99 percent of men diagnosed with localized or regional prostate cancer survive at least five years, while only 33% of those with metastases at diagnosis survive 5 years.

Surgery (Laparoscopic da Vinci Robotic Prostatectomy)

Surgery is one option for men with localized prostate cancer. Compared to other treatment methods such as radiotherapy and cryotherapy, a radical robotic prostatectomy has an advantage of providing accurate local staging (determining the true extent of the disease including whether it has escaped beyond the confines of the prostate) as well as the potential for assessment of pelvic lymph nodes to determine if the cancer has spread to these nodes. For patients with prostate cancer pathologically confined to the prostate, the chance of cure with surgery alone at 10 years (undetectable PSA) is more than 90 percent. The risk of cancer progression in men with extracapsular disease (cancer beyond the capsule of the prostate gland) and/or positive surgical margins is much higher, ranging from 30 to 50 percent, and these patients may benefit from additional therapy. A recently-published randomized trial showed that for men with prostate cancer beyond the prostate at surgery, the addition of radiation given to the pelvis significantly improves the cure rate.  Although the incidence of operative complications with radical prostatectomy is quite low, the primary postoperative side effects are urinary incontinence and erectile dysfunction.

Dr. Shaw is proud to be amongst the first surgeons in the Central Texas area to offer da Vinci Robotic Prostatectomy.  For further detailed information on da Vinci Robotic Laparoscopic Prostatectomy, CLICK HERE

Prostate Cryotherapy

Cryoablation of the prostate is a treatment in which prostate cancer is eradicated by freezing the prostate gland. Cryotherapy is administered in a manner similar to that of prostate brachytherapy; special needles called "cryoprobes" are placed into the prostate transperineally under the guidance of transrectal ultrasound. Argon gas is then used to create an "iceball" which results in cell death within the predefined area. Real-time ultrasound monitoring of cryoablation combined with the use of thermocouples reduces the risk of injury to the surrounding normal tissues. Usually, the goal of cryoablation is to freeze the entire prostate but there is a growing experience with focal cryoablation in which only the region where cancer was detected is treated. Although prostate cryotherapy was initially offered for treatment of prostate cancer after failed radiotherapy, there is emerging data supporting its use as a single treatment option in men with newly diagnosed prostate cancer. Side effects can include pelvic pain, stricture and incontinence. Erectile dysfunction is also common.

Androgen Ablation Therapy

Prostate cancer is usually sensitive to medications that affect serum levels of androgens. As such, androgen ablation can result in a dramatic reduction in cancer burden in the vast majority of cases. Unfortunately, most prostate cancers eventually progress after androgen ablation and ultimately become androgen independent.  In the management of localized prostate cancer, the role of androgen ablation is usually limited to a neoadjuvant or adjuvant setting. Two most common scenarios are 1) to reduce the prostate size prior to prostate brachytherapy and 2) to sensitize malignant cells to radiation during EBRT. Randomized clinical trials suggest a survival benefit of hormonal therapy for high risk patients undergoing radiation therapy as well as for patients with nodal involvement with cancer after radical prostatectomy.

Active Surveillance

Prostate cancer is often a slowly progressive disease, and many men with prostate cancer will die from causes other than prostate cancer. Although acknowledged to be imperfect, tumor (grade, volume, PSA, stage) and patient (age and comorbidities) measures can be used to identify men at lower risk of disease progression during intermediate periods of followup. For men with lower risk cancer or for those for whom avoidance of sexual, urinary, and/or bowel complications are a primary consideration, active surveillance may also be considered.

Radiation therapy, also sometimes referred to as radiotherapy, is a general term used to describe several types of treatment, including the use of high-powered X-rays, placement of radioactive materials into the body or injection of a radioactive substance into the bloodstream. These various types of radiation treatments are used in a wide range of settings. These circumstances include primary treatment of localized prostate cancer, secondary treatment for cancer recurring within the region of the prostate and for relief of pain and other symptoms related to prostate cancer that has spread to other parts of the body.

External beam radiation therapy (EBRT): This is the most commonly used type of radiation therapy. The emergence of EBRT as a treatment for prostate cancer occurred in the 1950s with the development of high-powered X-ray machines called linear accelerators. Linear accelerators produce very powerful photons (i.e. X-rays) that penetrate deep into the body. These X-rays destroy tumor cells by damaging their DNA. Just as with a diagnostic X-ray, there is a brief exposure to the radiation, typically lasting several minutes. Once the treatment is over, there is no radiation in the patient's body. The treatment is completely non-invasive, so there is no discomfort to the patient during the delivery of the radiation. EBRT is typically given once per day, five days per week. Primary treatment for localized prostate cancer usually requires about eight weeks of treatment. The use of shorter treatment schedules is being studied.

There are different ways to deliver EBRT. Usually several radiation beams are used to shape the radiation to the prostate, called three-dimensional conformal radiation therapy. The intensity of each beam may be altered to further shape the radiation using a technique called intensity modulated radiation therapy (IMRT). Sometimes image-guidance is used to to help locate the prostate each day. Proton beam therapy is another form of EBRT that is used in a few centers in the country to treat prostate cancer. Proton beam is precise like IMRT, only it uses protons instead of photons (X-rays). Recent clinical trials have shown that increasing the dose of radiation, either with photons or protons, can be done safely and leads to improved cancer control.

Brachytherapy: Is also referred to as "seed therapy" or a "prostate implant." Brachytherapy involves the insertion of a radioactive material, commonly referred to as a source, into the body. Attempts to treat prostate cancer by placing radioactive materials into the prostate date back to the early 20th century. However, the lack of a reliable way to ensure that the radioactive materials were placed in their desired locations limited the use of brachytherapy to treat prostate cancer. In the 1980s, a technique was developed using ultrasound to guide the placement of tiny radioactive "seeds" into the prostate. This technique was first made available in the United States in the late 1980s.

The seed implant is typically an outpatient procedure (i.e. you can go home later in the day) and is performed under anesthesia. Radioactive seeds (which are smaller than a grain of rice) are loaded in individual needles that are passed into the prostate gland through the skin between the scrotum and anus. As the needles penetrate the prostate they are seen on a monitor and can be accurately guided to their predetermined position. Once the position of the needle in the prostate matches the intended position, the needle is withdrawn leaving the seeds behind in the prostate. The radioactivity of the seeds slowly decays during several weeks to months after the procedure, and there are few long-term risks associated with this treatment.

External beam radiation therapy (EBRT): The principal side effects of EBRT are related to the treated area. Common side effects of EBRT for prostate cancer include increased urinary frequency; mild burning with urination; weakened urinary stream; bowel irritability including mild diarrhea, gas, bowel urgency and tenderness; mild irritation of the skin around the rectum; slightly lower blood counts; and fatigue. Diet modification and medication may be used to manage symptoms. Within one or two months following completion of treatment, most men notice that symptoms disappear. If changes in bladder or bowel function persist, they are typically mild. About 20 percent of men, however, do experience more significant long-term bowel irritability. Relatively rare complications include significant rectal bleeding, bladder irritability and urethral stricture. A decline in sexual function is also a relatively common side effect of radiation. However, the risk of erectile dysfunction (ED) following radiation varies widely, depending on use of other treatments such as hormonal therapies and the presence of other medical conditions that may affect sexual function.

Brachytherapy: Like EBRT, urinary irritation is very common following brachytherapy. Obstructive symptoms including difficulty with urination are somewhat more common, however, as the prostate usually swells due to the insertion of needles into the prostate for the procedure. Less than 10 percent of men will experience complete urinary obstruction within several weeks of the procedure requiring use of a catheter. Usually this problem disappears within weeks as the swelling subsides. Since the radioactive seeds are placed directly into the prostate, short-term bowel side effects are also relatively uncommon. However, as the front part of the rectum lies close to the prostate, over time bowel side effects similar to those of EBRT may occur. As with other radiation treatments, erectile dysfunction may occur.

In order to guide patients in choosing an appropriate treatment, doctors depend in part on an understanding of prognostic factors that suggest how extensive or aggressive the cancer may actually be. Such factors include digital rectal examination (DRE), PSA test, Gleason score and biopsy. Given the impact on prognosis that each of these factors may have, a combination of these factors is often more useful in understanding the potential for treatment success or failure than the use of any one factor alone. Within the realm of clinically localized cancer, a combination of these factors may be used to categorize patients as "low risk," "intermediate risk" and "high risk" in terms of treatment failure. It is important to note that while prognostic factors are helpful in guiding treatment choices, there is no "cookbook" for selection of treatment, and other factors including age, overall health, urinary and bowel function and each patient's own concerns about treatment need to be taken into account. Therefore, a thorough discussion with an individual's urologist, radiation oncologist and medical oncologist is an important part of the decision-making process.

Prostate cancer that has not spread outside the immediate area around the prostate is often referred to as clinically localized cancer. An important distinction within the realm of clinically localized cancer is between prostate cancers confined to the prostate, referred to as organ-confined disease, and prostate cancer that has spread directly outside the prostate or into the seminal vesicles. The term "clinical" is applied to the setting where the determination that cancer has not spread to other sites, including lymph nodes or distant tissues and organs, is based on the findings of physical exam and diagnostic imaging tests that may include CT scan, MRI and/or bone scan. Proof of cancer stage is only obtained by invasive procedures such as surgical removal of the prostate or biopsy.

External beam radiation therapy (EBRT) may be used following prostatectomy when there is concern that cancer may remain in the region of the prostate. The use of radiation in this setting to destroy residual cancer has previously been sporadic but more recently has gained widespread acceptance. Studies from the United State and Europe have shown benefit to EBRT after prostatectomy in the setting of T3 disease (through the prostate capsule) and/or positive surgical margins, with a recent update demonstrating a survival benefit. The possibility of success with radiation following prostatectomy depends on the likelihood that any remaining cancer is confined to the region of the prostate where radiation is aimed. Therefore, the success rate varies widely depending on the presentation at the time treatment is contemplated. Diagnostic studies may be helpful but unfortunately no test can exclude the possibility of microscopic spread of the cancer. The physician must therefore assess a number of factors including the pretreatment prognostic factors, pathological findings at the time of prostatectomy and the post-surgical PSA history in determining which patients are most likely to have localized cancer versus cancer that has spread (metastasized).

Radiation is often an effective treatment for preventing or managing symptoms of prostate cancer that has spread. External beam radiation therapy is typically very helpful in decreasing or relieving pain related to prostate cancer that has spread to the bones. A short course of therapy usually no longer than two weeks is sufficient in most cases. In other cases, radiation may be used to prevent debilitating symptoms related to the uncontrolled spread of cancer near critical organs or tissues.

Talk to your urologist and/or radiation oncologist. Every tumor is different, and it is important that your doctor evaluate all aspects of your tumor (such as localization, size, position) in order to prescribe the best treatment.

Possibly. The risk of erectile dysfunction following radiation varies widely, and is dependent on the use of other treatments—such as hormonal therapy—and other medical conditions (such as diabetes and heart disease) that may affect sexual function.

Follow up testing is very important in order to be sure that the tumor has been killed. You may require regular PSA testing, digital rectal examination, and occasional imaging to be sure that the cancer has not recurred. Sometimes, you may require additional treatment if the initial radiation does not work.

Prostate Specific Antigen (PSA)

AUA Guidelines Patient Guides: Prostate Cancer Awareness for Men

Download the free Acrobat reader.

Links for additional information:

American Cancer Society

CancerLinks

Agency for Healthcare Research Quality

US Too!