Prostate Cancer

Walter Rayford, MD, Ph.D.

The prostate gland is located underneath the bladder and in front of the rectum. Because of this location, this walnut-sized organ has to be examined by insertion of a lubricated gloved finger into the rectum. The prostate gland wraps around the urethra, which is the passageway for urine flowing from the bladder. The seminal vesicles and the ejaculatory ducts are attached to the prostate, and they empty their contents into the prostatic urethra. The prostate gland also produces hormones and enzymes. The hormones assist with the growth of the prostate gland, while prostatic enzymes help ensure the motility of sperm, which improve the chances of reproduction.

As men age, the prostate gland becomes susceptible to three common conditions: benign enlargement, infection, and cancer.

Benign enlargement of the prostate gland is usually referred to as benign prostate hyperplasia (BPH). This non-cancerous condition can cause symptoms related to this enlargement. Urinary frequency (voiding more than seven times per day), urgency (the sensation of the immediate requirement to void), urge incontinence (the inability to prevent the leakage of urine during urgency), and nocturia (awakening more than two times per night for urination in an individual less than 65 years of age) are usually the early symptoms of BPH. As this disease process progresses, men may experience a decreased force of urinary stream (slow stream), straining to void, urinary hesitancy, and the sensation of incomplete bladder emptying. Progressive symptoms can lead to the total inability to urinate, a condition called urinary retention. Treatment of BPH is usually with medications that will help relax the prostate or reduce the size of the gland. Symptoms that are unresponsive to medication can be treated with surgical intervention. The gold standard is transurethral resection of the prostate. Other minimally invasive procedures include microwave therapy, needle ablation, laser therapy, and vaporization of the prostate.

Infection of the prostate gland can lead to a condition called prostatitis. This infection can lead to inflammation of the prostate, which may become symptomatic. These symptoms can include painful urination, blood in the urine, fever, chills, and pain in the perineum, lower abdomen, and back. It can also decrease sexual performance. Treatment is usually with long-term antibiotics; typically a six-week course is required. Chronic infections may recur and require an even longer course of antibiotics. Prostatic massage, non-steroidal anti-inflammatory medications, and Sitz baths can help reduce the discomfort associated with this condition.

The third common prostate condition is cancer of the prostate gland. Prostate cancer is the uncontrolled growth of cells within the prostate gland. Prostate cancer is the most commonly diagnosed malignancy and is the second leading cause of death among American men. This year, approximately 198,100 men will be diagnosed with prostate cancer and 31,500 will die of this potentially curable disease. This means that an American male is diagnosed with prostate cancer every three minutes and death from this disease occurs every sixteen minutes.

In Louisiana, approximately 3,500 men are expected to be diagnosed with prostate cancer and 600 were predicted to die of this disease in 2001. Unlike many other states, Louisiana has not observed a significant decrease in the death rate from prostate cancer. In fact, the likelihood of developing prostate cancer has slightly risen.

The exact cause of prostate cancer is not known. However, there are primary risk factors that increase the chances of developing this disease. The first primary risk factor is age. Beginning in the fourth decade of life, advancing age positively correlates with developing prostate cancer. More than 80% of cases are diagnosed in men over 65 years of age. Race is the second primary risk factor. The highest risk in the world is among men of Sub-Saharan African descent. Asians have the lowest risk in the world. In America, African-American men have up to a 60% higher risk of prostate cancer than their Caucasian counterparts. Even more disturbing is the fact that the death rate among African-American men is twice that of their closest ethnic counterpart. The third primary risk factor is family history. Prostate cancer tends to run in families. The risk increases with the number of first-degree relatives affected. First-degree means a father, brother, or grandfather. Fathers and brothers have twice the risk of men with no affected relatives, and if there are three affected relatives the risk goes up eleven-fold.

Other risks include dietary components, lifestyle and environmental factors. Diets supplemented with vitamins A, D, E, and selenium may lower the chances of developing prostate cancer. These vitamins are contained within seafood, meats, vegetable oils, vegetables, egg yolks, and fruits. Lycopenes, which are present in tomatoes, may also lower the risk of prostate cancer. On the other hand, diets high in saturated fats may raise the risk of developing this disease. Exposure to sunlight may play a protective role against prostate cancer. Reasons to account for these dietary and environmental observations are presently being studied.

Early detection is the key to surviving this potentially curable disease. Two simple tests are recommended, a digital rectal examination and a serum prostate specific antigen (PSA) level. During the digital rectal examination, a lubricated examining finger is gently inserted into the rectum to feel for the prostate gland. This examination is associated with minimal discomfort and takes only a few seconds. Prostate specific antigen is a protein found in the blood that is usually elevated in men with prostate cancer. Many urologists believe that a normal PSA is between 0 to 2.5 nanograms per milliliter. Values higher than 2.5 nanograms per milliliter are abnormal and may need further medical workup. The important thing to remember is these two very simple tests can save your life. African-American men and men with a family history of prostate cancer should begin yearly screening at the age of 40 years, whereas all other men should begin yearly screening at 50 years of age.

The three most common reasons for an elevated PSA are BPH, prostatitis, and prostate cancer. Individuals with an elevated PSA or abnormal DRE should undergo further testing to rule out prostate cancer. This should consist of transrectal ultrasonography and biopsy of the prostate gland. This procedure is usually performed in the physician's office under a local anesthetic. It is usually associated with mild discomfort and few post-procedure complications. It takes approximately 20 minutes to perform. The ultrasound probe is inserted into the rectum to identify the prostate gland. Six or more (usually 12) biopsies are obtained from multiple sites throughout the gland. These samples are then examined under the microscope for the presence of prostate cancer.

The treatment of prostate cancer depends on multiple factors, which are age, concurrent medical conditions, stage and aggressiveness of cancer. Stage refers to whether the cancer is confined to the prostate gland (Stages A and B or T1-2) or has spread outside the capsule of the prostate to local or distant sites (Stage C and D or T3-4). Treatment options consist of:

  1. Radical prostatectomy: surgical removal of the prostate gland. Recommended for early stage disease (RESD).
  2. Interstitial brachytherapy: surgical placement into the prostate gland of small seeds that give off radiation over several months. RESD.
  3. High dose radiotherapy: the administration of high doses of radiation through needles or plastic cylinders temporarily implanted into the prostate. These needles are removed after 3-4 doses are administered (usually 24 hours after insertion). RESD.
  4. External beam radiation: radiation is administered to the prostate gland (and/or entire pelvis) daily for 6-8 weeks. RESD and locally advanced prostate cancer.
  5. Cryotherapy: probes inserted into the prostate gland are used for a double freeze and thaw cycle. RESD and prostate cancer refractory to radiation.
  6. Hormonal therapy: agents used to either decrease the production of testosterone (the male sex hormone and growth factor for prostate cancer) or prevent its action. These agents can be given as the primary form of treatment or to supplement any of the above treatments.
  7. Chemotherapy: agents that slow the growth of prostate cancer.
  8. Watchful Waiting: treatment is withheld until symptoms arise.

In conclusion, individuals with symptoms of BPH or prostatitis should see their physician (preferably a urologist) for treatment, as well as to determine whether prostate cancer is present. Prostate cancer is a curable disease if detected in the early stages. Treatment is individualized, and the risks and benefits of each option should be understood before one is selected.

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