Prostate Cancer

What is Prostate Cancer?

Prostate Cancer, also known as Carcinoma Prostate, is a form of cancer that develops from the prostate gland, a part of the male reproductive system that produces the fluid that transports the sperm.

Is Prostate Cancer a Medical Emergency?

It is not a medical emergency, but early detection and management can help to prevent serious complications.

Types

Prostate Cancer can either develop from the cells of the prostate or may develop due to the spread of cancer cells from other organs or tissues.
The different types of prostate cancers are:

• Adenocarcinoma: This is the most commonly seen cancer and accounts for more than 95 - 99%
• Squamous cell carcinoma: It is a very aggressive cancer that develops from the cells covering the prostate gland
• Transitional cell carcinoma: It usually starts in the urethra or bladder and spreads to the prostate gland, but it can also start in the prostate and spread to the surrounding tissues
• Neuroendocrine tumors: Prostate small cell carcinoma is a neuroendocrine tumor that starts in the prostate and is a very aggressive tumor that spreads very rapidly
• Sarcomas: Not very common, and can develop from the smooth muscle of the prostate, and may be either leiomyosarcoma or rhabdomyosarcoma. They are usually seen in the younger age group (35- 60)

Causes

The exact cause of carcinoma prostate is not yet fully understood, but it develops due to mutations of the prostate gland cells that grow into abnormal cells.

Risk factors

The risk factors for carcinoma prostate include the following:

• Age: The risks increase with increasing age
• Family history: Individuals with a family history of prostate cancer are at a greater risk
• Low levels of Vitamin D
• Sexually transmitted infections or inflammations of the prostate gland increase the risk of prostate cancer

Symptoms & Signs

Early stages usually show no signs or symptoms, but in the later stages, the symptoms and signs may include:

• Frequent urination
• Increased urination at night
• Trouble starting or maintaining a steady stream of urine
• Blood in the urine
• Pain during urination
• Pain in the pelvic region or lower abdomen
• Bone pain, especially in the lower back
• Tingling sensation in the muscles of the legs, and muscle weakness
• Urinary or stool incontinence

Investigations

The following investigations may be done to detect the presence and spread of the cancer:

• Digital rectal examination (DRE): To clinically evaluate any abnormalities in the prostate
• Blood tests: To check for prostate-specific antigen (PSA) levels, which are usually higher in prostate cancer. It is not a confirmatory indicator of the cancer
• Imaging of the prostate:
  • Ultrasound imaging: Transrectal ultrasonography
  • MRI imaging: To assess the ideal region for a biopsy and for surgery-related planning
  • CT scan imaging: Only to evaluate the spread and for cancer staging in cancers that are found to be metastatic after a biopsy
  • PET scan: Only to detect recurrent cancers and evaluate the spread and for cancer staging in cancers found to be metastatic after a biopsy
  • Bone scans: Only to evaluate the spread to bones and for cancer staging in cancers found to be metastatic after a biopsy
• Prostate biopsy: An outpatient procedure in which a sample of the prostate tissue is collected using a biopsy gun. The tissue is sent for histopathological analysis to confirm the presence of cancer cells

Diagnosis

The diagnosis is established based on medical history, clinical examination, and results of investigations, mainly the biopsy.

Course & Stages

Some prostate cancers are fast-growing, while most progress very slowly. The cancer grading may be based on the Gleason score, which gives a score between 2 and 10 to the tissue sample obtained from the biopsy and based on the architectural patterns found on microscopic analysis. A higher score indicates a more aggressive grade of cancer.
Staging of cancer is done based on the tumor (T), spread to other tissues (M), and the involvement of the lymph nodes (N), the Gleason score, and the PSA level.
The stages of Prostate Cancer include:

• Stage I:
  • There is no spread to the lymph node or other tissues (N0, M0)
  • PSA level is less than 10
  • Gleason score is 6 or less
  • The tumor cannot be felt or seen but was only accidentally discovered during another procedure, or when the tumor was felt or seen only on one side, or when the prostate was removed during surgery, but the tumor was still inside the prostate and only on one side
• Stage II:
  • There is no spread to the lymph nodes or other tissues (N0, M0)
  • PSA level is between 10 -20
  • Gleason's score is 6 - 7
  • The tumor cannot be felt or seen but only accidentally discovered during another procedure, or the tumor can be felt or seen but is either only on one side of the prostate or more than half of the prostate or when the tumor is seen in a prostate removed during surgery but is still within the prostate
• Stage III:
  • There is no spread to the lymph nodes or other tissues (N0, M0)
  • PSA level is any
  • Gleason's score is 7 - 10
  • Cancer may have spread to the seminal vesicles or the urethra, or it may not have spread outside the prostate, and the tumor may or may not be felt or seen.
• Stage IVA:
  • The tumor has spread to nearby lymph nodes but not other far-off tissues (N1, M0)
  • PSA level is any
  • Gleason score is any
  • The tumor may or may not be seen or felt and may or may not have grown into the nearby tissues
• Stage IVB:
  • The tumor may or may not have spread to lymph nodes but has spread to other body parts (any N, M1).
  • PSA level is any
  • Gleason score is any
  • The tumor may or may not be felt and may or may not be growing into the nearby tissues

Treatment options

For prostate cancers that are considered low risk, management includes only active surveillance, which is the regular medical check-ups, rectal examination, and biopsies, and surgical management or radiotherapy may be advised if there is a change in the state of cancer.

Medical management

The medical management of includes the use of the following:

• Hormones therapy:
  • Luteinizing hormone-releasing hormone (LH-RH) agonists: Such as leuprolide and goserelin, act by preventing the testicles from producing testosterone
  • Anti-androgens: Such as flutamide and bicalutamide, act by preventing testosterone from reaching the cancer cells
  • High-dose estrogens: Act as anti-androgenic agents and suppress the production of testosterone
• Chemotherapy: May be required in cancers that have either spread to other parts of the body and are progressing despite other treatments or for recurrent cancers
• Immunotherapy
• Antibiotics: To protect against infections that may be acquired during investigative or treatment procedures

Interventional including surgery and indications for surgery

If surgery is required, the following procedures may be performed to remove the cancer:

• Radical prostatectomy: It is the surgical removal of the prostate along with the seminal vesicles, the vas deferens, and pelvic lymph node dissection. It may be done via open surgery or as a minimally invasive laparoscopic radical prostatectomy (LRH) with robotic assistance.
• Cryosurgery: The prostate gland is exposed to extremely cold temperatures, destroying the cancer cells.
• Orchiectomy: It is the surgical removal of both the testes and is done to reduce testosterone levels and control the growth of cancer.
• High-intensity focused ultrasound: This uses focused ultrasound waves to heat the prostate tissue and destroy the cancer cells.

Radiation

Radiotherapy, which uses ionizing radiation to kill cancer cells, is used in managing all stages of prostate cancer and may also be used after surgery to kill any leftover cancer cells. The following types of radiotherapy may be done:

• External beam radiation therapy / Intensity-modulated radiation therapy (IMRT): It uses a beam of radiation directed at the prostate, usually done over a few weeks. The beam's intensity changes according to the tumour's shape and protects the surrounding tissues of the bladder and the rectum.
• Brachytherapy: It treats low to medium-grade cancers by placing radioactive material directly into the tumour within the prostate to kill the cancer cells.

Role of diet/ Exercise/ Lifestyle changes/ Preventive measures

Maintaining a healthy lifestyle can play an important role in reducing the risk of prostate cancer. Some measures that can be taken include:

• Eating healthy food and avoiding a high-fat diet
• Exercising regularly and maintaining ideal body weight
• Protecting oneself against sexually transmitted infections
• Regular medical check-ups when there is a family history of prostate cancer

Complications

• Spread of cancer to other parts of the body, such as the bladder or the bones
• Urinary incontinence: This is the involuntary passage of urine that can happen when the bladder is involved, or it may be a side effect of surgery
• Erectile dysfunction, impotence, loss of libido

Prognosis

The prognosis depends on the type of cancer and the stage at which it is identified. Aggressive cancers already spread to other body parts have a poor prognosis, with a 30 - 45% survival rate over 5 years. Slow growing, localized, and regional cancers have a good prognosis and a 100% survival rate over 5 years.

When to contact the doctor or hospital? / How to identify the emergency or complications?

It is advisable to seek medical advice as soon as the symptoms of prostate trouble are seen to enable an early diagnosis and management plan.

Indications for hospitalization if required

Hospitalization is not required for Prostate Cancer, but the surgical management of the condition may warrant hospitalization.

Screening methods

Screening for Prostate Cancer is generally not recommended.

Suggested clinical specialists/ Departments to consult for this condition

The departments attending prostate cancer include urology, oncology, and radiation oncology.