Dilemma of Prostate Cancer

Written by Dr harold Gunatillake FRCS
( Health writer to websites, magazines, Sunday Newspapers, and expatriate tabloids)

Prostate cancer seems to be the most common cancer among adult men, like cancer of the breast in women.

All concerned men go through blood tests to detect early cancer of the prostate, as the condition may not reveal any symptoms during the early stages when positive steps can be taken to cure, before it has spread to beyond the capsule of the gland.

There is really no simple test to detect prostate cancer and also there is no test to check whether the cancer is growing slowly or fast.

The normal tests used include:

•  Digital (finger) examination through the back passage

•  Prostate specific antigen (PSA) on blood

•  Prostate biopsy through the back passage or the area between the scrotum and anus (perineum)

Digital examination involves your doctor inserting a gloved finger into your back passage to feel you're prostate. This examination mostly reveals whether the gland is enlarged, quite a normal occurrence, and tiny growths may not be felt.

Prostate specific antigen test (PSA). Most of the PSA in your body is made in the prostate gland. There is no PSA level that is considered to be normal. The reason being that the PSA level increases with age and what is normal for one person may not be for another. However, a figure less than 4ng/ml are considered to be in the normal range.

The dilemma is that occasionally high levels of PSA are found in normal people and low level may be found in people with prostate cancer. After digital examination (PR) the blood test for PSA should be delayed for 24 hours.

Free PSA test - This may be high, although non-cancerous enlarge prostate also increase PSA levels. This test helps to tell the difference between BPH (benign hyperplasia) and prostate cancer.

AMACR – a newer test that is more sensitive than PSA test for determining prostate cancer.

Prostate biopsy

The procedure is performed through a ‘Trans-rectal ultra-sound probe' placed in the rectum to give a picture of the prostate. Then, using ultra-sound pictures as a guide, a needle is inserted through the wall of the rectum into the prostate and six or more tissue samples are taken. It is done under local anesthesia and no pain but discomfort may be experienced. A course of antibiotics are given after the procedure to prevent infection, which is common.

The following tests help to check on spread of the growth.

CT scan, Bone scan, and Chest x-ray

Staging – this helps to find out how far the cancer has grown.

There are several different ways to stage tumors, including:

•          The TNM staging system (most common)

•          The A-B-C-D staging system, also known as the Whitmore-Jewett system

The grade of a tumor describes how aggressive a cancer might be. The more tumor cells differ from normal tissue, the faster these cells are likely to grow. The grading system for prostate cancer is called the Gleason grade or score . Higher scores are usually faster growing cancers.

What is prostate cancer?

The prostate gland lies below the bladder and the bladder outlet passes through the centre of the gland as the prostatic urethra for elimination of urine. The size of the gland is about a husked areconut (used with betel chewing)

The gland gets bigger with age but in most people produce no urinary symptoms. When the gland presses against the prostatic urethra early symptoms appear, such as urine falling on your boot at micturition, etc. This innocent enlargement is called ‘ benign prostate hyperplasia' (BPH).

Benign means not-cancer, and hyperplasia means to get bigger. Benign prostate hyperplasia is far more common than cancer of the prostate. However, sometimes the growth that obstructs the urethra can be malignant (cancer).

As mentioned earlier early prostate cancer rarely has symptoms. The following are some of the symptoms people experience.

•  A weak (not forceful) hesitant narrow stream when urinating, needing to strain

•  A delay in starting when wanting to urinate, till you relax the sphincters (smooth muscles at the neck of the bladder)

•  A need to urinate more frequently, and feeling of insufficient emptying

•  A need to urinate frequently during the night (nocturnal frequency))

•  Dribbling at the end of voiding

•  Being unable to control the bladder (incontinence)

•  Complete urinary obstruction (retention)

•  Pain with bowel movements

•  Unintentional weight loss

•  Lethargy

These symptoms are also common in benign enlargement and further tests are required to differentiate.

Painful ejaculation, blood in the urine and lower back bone are more common with prostate cancer.

Slowly progressive cancer may remain within the prostate capsule for a long time. More aggressive forms spread beyond the capsule to the surrounding tissues and lymph glands. If no interventional action is taken the cancer cells may spread onto the bones of the spine and through the blood stream to the lungs and brain. This is referred to by doctors as ‘ metastatic cancer' .

Cause of cancer

The cause of prostate cancer is not known. Some studies have shown a relationship between high dietary fat intake and increased testosterone levels. In japan the incidence of prostate cancer is very low, and also among vegetarians'

There are many factors that may cause prostatic cancer

•  Age. The main risk factor for developing prostate cancer is getting older. Prostate cancer is rare in men under 50 years of age.

•  Family history. If your father or brother were diagnosed with prostate cancer at a young age, your chances of developing prostate cancer is increased. Having an elderly relative with prostate cancer is quite common and doesn't increase your chances of developing the disease.

•  Race. Prostate cancer is more common in people of African descent.

•  Diet, physical activity and alcohol. Despite considerable research examining the link between these risk factors and prostate cancer, we are not able to say with any certainty if there is anything a man can do to reduce his risk of prostate cancer. There are however plenty of other reasons to eat a diet rich in fruit and vegetables, be physically active and avoid alcohol.

Treatment

There is no stereotype treatment for prostate cancer. The decision how best to treat has to be carefully analyzed. Age and general health needs to be taken into account. Another important factor is how far the cancer has spread.

•  Early cases: active surveillance is sometimes a valid treatment option. In this situation your doctor watches to see if the cancer grows. Especially in older people where the cancer growth is slow, wait and sees is a reasonable option. In this situation repeated biopsies at interval may be required.

•  Surgery- In this situation if the growth is within the capsule, surgery is quite a reasonable decision. Surgery is usually recommended after a thorough evaluation and discussion of all treatment options. You should be aware of the benefits and risks of the procedure.

•  Radiation Therapy – the cancer cells are destroyed using x-rays. Radiation is recommended to treat localized prostate cancer without the option of surgery. Radiation therapy reduces the size of the growth, and also relieves pain, discomfort and other symptoms. It is mainly recommended to treat stage A,B, or C prostate cancers.

External beam radiation therapy is done in a radiation oncology center by specially trained radiation oncologists, usually on an outpatient basis. The exposure is painless. Side effects may include impotence, incontinence, appetite loss, fatigue, skin reactions, rectal burning or injury, diarrhea, inflamed bladder (cystitis), and blood in urine. External beam therapy is done 5 days a week for 6-8 weeks.

•  Hormone treatment – reducing the testosterone hormone in your body helps to slow the growth of the cancer. This is an option if the cancer has spread or when unsuitable for any other form of treatment. Remission can last several years

•  Removal of the testicle (Orchiectomy) is another way of reducing the testosterone levels. This operation is old fashioned and not frequently recommended today due to loss of sexual function, osteoporosis and loss of muscle mass.

•  Chemotherapy- is not routinely used in prostate cancer when first diagnosed, but may be offered if the cancer spreads and other treatments have not been effective.

•  Chemotherapy medications that may be used to treat prostate cancer include:

•  Adriamycin

•  Docetaxel

•  Estramustine

•  Mitoxantrone

•  Paclitaxel

•  Prednisone

•  Prostate brachytherapy or internal radiation involves placing radio-active seeds inside you directly into the prostate. This therapy reduces damage to the tissues around the prostate. It is recommended for early, slow growing prostate cancers.

Medications

The drugs Lupron and Zoladex are also being used to treat advanced prostate cancer.

These medicines block the production of testosterone. The procedure is often called chemical castration, because it has the same result as surgical removal of the testes. However, unlike surgery, it is reversible. The drugs must be given by injection, usually every 3 - 6 months. Possible side effects include nausea and vomiting, hot flashes, anemia, lethargy, osteoporosis, reduced sexual desire, and impotence.

Other medications used for hormonal therapy include androgen-blocking drugs, such as flutamide, which prevent testosterone from attaching to prostate cells.

Monitoring

You will be closely watched to see that the cancer does not spread after any of the therapies mentioned. Serial PSA test every three months is usually done. Bone scan or CT scan to check the cancer has spread. Complete regular blood counts. Treatment may be indicated for fatigue, weight loss, increased pain, decreased bowel and bladder function, and weakness.

The author advises the readers (men), over 50 years to go for a PSA test annually.

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