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This site, by Memorial Sloan-Kettering Cancer Center, offers computerized tools to help patients and their physicians decide among the major treatment choices for several cancers including breast cancer, gastric carcinoma, lung cancer, melanoma, pancreatic cancer, prostate cancer, renal cell carcinoma and sarcoma.
Provides information on all forms of cancer and offers numerous brochures and publications for patients and healthcare professionals. Their prostate cancer section helps users to answer critical questions about prostate cancer treatment options.
Created by The American Foundation for Urologic Disease (A.F.U.D.), this guide offers chapters from choosing your cancer care provider to insurance coverage issues to tips from survivors.
This site is dedicated to helping its members stay current on the latest research and best practices in the field of urology. The prostate section includes a comprehensive look at prostate cancer as well as sections on benign prostatic hyperplasia and prostatitis.
As the name suggests, this site is designed to make searching the World Wide Web for information about cancer faster and easier. It features a page specifically devoted to links to information about prostate cancer.
MHN is a non-profit educational organization comprised of physicians, researchers, public health workers, individuals and other health professionals. Their site is devoted to general men's health topics and includes a Prostate Health Guide.
This U.S. government site provides information on prostate cancer treatment, screening, prevention, genetics, clinical trials and supportive care.
NCCN works to develop treatment guidelines for most cancers and supports research that improves the quality, effectiveness and efficiency of cancer care. They offer a number of programs to help cancer patients make informed decisions such as NCCN Treatment Guidelines for Patients. These are easy-to-read booklets developed from the NCCN Clinical Practice Guidelines in Oncology™. Many treatment guidelines are available in Spanish.
This site is devoted to improving awareness of prostate cancer through education, outreach programs and government advocacy. It includes sections on prevention, detection, treatment and research.
This site provides comprehensive information about a broad range of urologic conditions, including prostate cancer. It includes information about medical, radiation and surgical treatments.
Episode number: 
202

The prostate is the gland in men that helps manufacture the fluid in semen (seminal fluid). It lies between a man's bladder and his rectum and surrounds the urethra (the tube that carries urine from the bladder). Normally, it's about as big as a walnut. If it grows too large, it can squeeze the urethra and slow or even stop the flow of urine.

Prostate and nearby organs and the inside of the prostate, urethra, rectum, and bladder

Prostate cancer is one of the conditions that can cause the prostate to grow, and urinary problems are one of its symptoms.

In America, prostate cancer is the most common form of cancer in men (25% of men diagnosed with cancer have prostate cancer), and the second most common cause of cancer deaths in men.But unlike many types of cancer, prostate cancer tends to grow slowly. That's why, when detected early, it's quite curable.

A variety of conditions can cause symptoms similar to prostate cancer.  The most common of these conditions is BPH (Benign Prostatic Hyperplasia).  

 

BPH is an enlarged but non-cancerous prostate. The enlargement can lead to urinary problems or changes in urinary habits (such as needing to urinate more often).  Though statistics seem to vary (some studies say 25% of men over 40 and 33% of men over 65 have some BPH symptoms; others say more than 50% of men over 65 have some BPH symptoms), it is clear that BPH is very common in men over 50 and often starts earlier. But for many men with BPH (perhaps 50%) the symptoms are not bothersome enough to need treatment.  

 

Because this and other conditions have symptoms that mimic prostate cancer, if you do have any symptoms, it's very important to get tested and diagnosed.  Furthermore, in its earliest stages, prostate cancer may not cause any symptoms at all.  That's why an annual prostate cancer screening (being tested for the disease) is recommended for men over 50, whether or not they have any symptoms.  For details about prostate cancer screening go to Prostate Cancer Key Point # 1).).


Quick Facts

  • Prostate Cancer is the most common form of cancer in men, and the second most common cause of cancer deaths in men. But if it's found early enough, it can be cured and today there is medical help for potential side effects.

  • Although the causes of prostate cancer are currently unknown, we do know that risk factors include age, family history, race and possibly diet.- There are several conditions, including BPH (a benign [non-cancerous] enlargement of the prostate) and prostatitis (an inflammation of the prostate) that cause some of the same symptoms as prostate cancer (such as urinating more frequently, difficulty urinating, and a weak urine stream). On the other hand, in its earliest stages, prostate cancer may not cause any symptoms at all.

  • The simplest and most common prostate cancer screening tests are not conclusive proof of cancer's presence or absence. If a DRE (digital rectal exam) or a PSA blood test indicate the possibility of prostate problems, further tests may be needed to rule out or diagnose cancer.

  • There's no single "best way" to treat prostate cancer. Treatment options include surgery, radiation, hormone therapy, watchful waiting, or a combination of these. For all of them, the side effects of most concern are the possibility of impotence and/or incontinence. Treatment decisions should be made after considering the patient's general health, the grade and stage of his cancer, and whether the benefits of treatment outweigh the possible risks and side effects.

  • Cancers are "graded" and "staged." The grade denotes how aggressive the cancer is, that is, how fast it is likely to grow and spread in the future. The stage indicates how large the cancer is and how much it has already spread. There are several ways to measure both grade and stage, but usually the higher the number, the more aggressive and the larger the cancer.

  • BPH (Benign Prostatic Hyperplasia) is very common in men over 50 and often starts earlier. Statistics vary, but some say 25% of men over 40 and more than 50% of men over 65 have some BPH symptoms. But of these, as many as half find the symptoms mild enough to not need treatment.

 *Quick Facts have been reviewed by Medical Advisors and are current as of October 2005.

Ask Your Doctor

This list of questions is a good starting point for discussion with your doctor. However, it is not a comprehensive list.

 

  • How do I get a second opinion?
  • What are the treatment options, and what are their benefits, risks, and side effects?
  • How will the treatment options affect my sex life?
  • How will the treatment options affect my urinary control?
  • What are the short-term effects of the treatment options?
  • What are the long-term effects of the treatment options?
  • Concerning the recommended treatment, how do I get a second opinion?
  • What follow-up care will I need?
  • If I have pain, how will it be managed?
  • Am I a good candidate for a clinical trial?
  • If you were going to have this sort of treatment, who would you want to do it?
  • Is there an alternative (less risky, less costly, fewer side affects) to this procedure?
  • How many of these treatments have you done and what is your record for morbidity, side effects and successful outcome?
  • What will the recovery period be like?
  • What medications can I take to slow down the progression of my condition?

Key Point 1

 

All men are at risk of developing prostate disease.  The decision as to when and by what method to begin screening (testing for it) is based upon factors unique to each individual.

 

For example, although the causes of prostate cancer are currently unknown, we do know some risk factors (things that seem to increase the chance of a man getting the disease).  These include:

 

  • Age: The chance of getting the disease goes up with age.  Most men with prostate cancer are older than 65; it rarely strikes men younger than 45. 
  • Family history: The chance of getting the disease goes up (is higher than average) if a close relative had it.
  • Race: The chance of getting the disease is higher for African-American men than white men, including Hispanic white men. It is lowest for Asian and American Indian men. The reasons for this are not known.
  • Diet: The chance of getting the disease may go up if you eat a diet high in animal fat or meat and may go down if you eat a diet high in fruits and vegetables.
  • Certain prostate changes: The chance of getting the disease may go up if you have abnormal prostate cells (called high-grade prostatic intraepithelial neoplasia or PIN). 

 

Having one or more of these risk factors does not mean you will definitely get prostate cancer.  But not having any of them does not mean you will not get the disease.  So you should be aware of its symptoms, which include:

 

  • Urinary problems
    • Inability to urinate
    • Difficulty starting or stopping the urine flow
    • Urinary frequency (the need to urinate frequently) especially at night
    • Urinary urgency (strong need to urinate and/or difficulty controlling it)
    • Weak or interrupted urine flow
    • Painful or burning urination
  • Blood in the urine or semen
  • Frequent pain or stiffness in the lower pelvic area, and in lower back, hips, upper thighs, or bones
  • Unexplained weight loss or appetite loss

 

However, it's important to remember these two facts:

  • On one hand, there are several conditions that cause the same symptoms as prostate cancer.
  • On the other hand, in its earliest stages, prostate cancer may not cause any symptoms at all.

 

Given these facts about risk factors and symptoms, it makes sense to see your doctor or a urologist if you have any of the symptoms, especially if you have one or more of the risk factors. 

 

You should also think seriously about having an annual prostate cancer screening, even if you have no symptoms at all, if you're over 50, and/or have any of the risk factors mentioned above.

 

There are several ways to screen for prostate cancer.  The two simplest and most common are:

 

  • Digital rectal exam (DRE): Wearing a lubricated rubber glove, the doctor inserts a finger into the rectum and feels the prostate through the rectal wall (the separation between the rectum and the prostate) to check for abnormalities, lumps and hard areas.
  • Blood test for prostate-specific antigen (PSA): In a blood test, a small amount of blood is taken from the patient and sent to the lab for analysis.  In this test, the lab measures the amount of  PSA in the blood stream.
    • PSA is a protein produced by the prostate and usually found in semen.  However, a small amount does circulate through the blood stream.  A larger than normal amount in the blood may indicate some problem in the prostate, such as BPH, prostatitis, or cancer.
    • PSA test results are usually reported as nanograms of PSA per milliliter of blood (ng/ml). According to the National Cancer Institute, in the past most doctors considered PSA values below 4.0 ng/ml as "normal." However, recent research found prostate cancer in men with PSA levels below 4.0 ng/ml.  Many doctors are now using the following ranges, with some variation:
      • 0 to 2.5 ng/ml is low
      • 2.6 to 10 ng/ml is slightly to moderately elevated
      • 10 to 19.9 ng/ml is moderately elevated
      • 20 ng/ml or more is significantly elevated
    • There is no specific "normal" PSA level, but the higher the level, the more likely that cancer is present. But many things can cause PSA levels to change. So one elevated PSA test does not necessarily mean you need other diagnostic tests. If PSA levels continue to rise over time, then you may need them.
    • A portion of the PSA enzyme is bound in the bloodstream to other chemicals.  In patients who have prostate cancer almost all the enzyme is in the form that's bound, so there's very little that's unbound or "free."  For people who have benign enlargement of the prostate (the most common scenario) a higher proportion of the enzyme is in the free form.  So, if it's a high PSA number with a low "free" number there's a better chance it's cancer.
    • In general, early detection of cancer is beneficial.  But the National Cancer Institute does point out that we don't yet know if the PSA test actually saves lives or if its benefits outweigh the risks of follow-up diagnostic tests and cancer treatments.  For more information about the pros and cons of PSA testing, go to  The National Cancer Institute

 

A third way to screen for prostate problems is a urine test.  The patient provides a small sample of urine which is sent to the lab for analysis.  The lab can detect blood in the urine and other signs of infection or abnormalities.

 

Note that none of these tests is conclusive for prostate cancer.  That is, they can reveal the presence of a prostate problem, but they can't show whether its cause is cancer or another condition.  If these tests do indicate a prostate problem, the doctor may ask for further tests to find the cause.  (For information about these tests, go to Prostate Cancer Key Point # 2)

 

Key Point 2

 

You need to know what your pathology numbers are and get your doctor to explain your numbers to you, the patient. You need to understand your pathology because the pathology will affect the treatment that you get.

 

The DRE and PSA tests can reveal the presence of a prostate problem, but can't say whether its cause is cancer or another condition. (For information about these tests, go to Prostate Cancer Key Point # 1. If these tests do indicate a prostate problem, the doctor may ask for further diagnostic tests to find the cause.  These tests could include: 

 

  • Transrectal ultrasound (TRUS; also called endorectal ultrasound): A small probe inserted into the rectum sends out ultrasound waves (sound beyond the range of human hearing) that bounce off the prostate. A computer uses these echoes to create a picture (or "sonogram") of the prostate.
  • Cystoscopy: Using a cystoscope (a thin, telescope-like instrument with a fiber-optic lighting system and a special lens), the doctor looks directly into the urethra and bladder.
  • Intravenous pyelogram (IVP): This is a form of x-ray that uses a special dye, injected into a vein, to make it easier to see abnormalities in the urinary system. 
  • Biopsy: This is the removal of tissue that is then examined in the lab to look for cancer cells. It is the only conclusive way to diagnose cancer.

 

If the tests show cancer in the prostate, the cancer will be "graded" and "staged."

 

The grade denotes how aggressive the cancer is, that is, how fast it is likely to grow and spread in the future.  There are several ways to measure aggressiveness, but the most common is the "Gleason Score."  The pathologist (the doctor who examines tissue removed during a biopsy for the presence of cancer cells) gives each area of cancer a grade from 1 to 5, with 1 being the least aggressive.  The Gleason Score is the two most common grades added together.  Therefore, Gleason Scores range from 2 to 10.  The higher the score, the more aggressive the cancer.

 

The stage denotes how large the cancer is and how much it has already spread.  One or more tests may be needed to determine the stage.  Most are "imaging" tests, that is, tests that create pictures of areas inside the body to show if cancer is there. These include x-rays, bone scans, CT (or "CAT") scans, MRI, and ultrasound.  A lymph node biopsy (examining tissue removed from the lymph nodes) will show if cancer has spread to the lymph nodes.

 

The grade and stage usually determine the type of treatment recommended.   

 

Getting a diagnosis of prostate cancer is, to say the least, a disturbing experience.  You will want to learn all you can about your condition so you can make smart decisions about your medical care. But shock and stress can make it hard to react, hard to think of everything you want to ask the doctor – and hard to process the answers. Here are some helpful tips:

 

  • Make a list of questions before a medical appointment.
  • During an appointment, take notes or use a tape recorder to help you remember the details.
  • Bring a family member or friend with you to the doctor – to take notes, to ask additional questions and take part in the discussion, or just to listen.
  • Get a second opinion about your diagnosis and treatment options. Some insurance companies require one; others may cover it if you or your doctor asks for it.

Key Point 3

Treatment decisions will be made by balancing treatment effectiveness with side effects.

 

There's no single "best way" to treat prostate cancer. Along with effectiveness and side effects, you and your doctor will consider your general health and the grade and stage of the cancer. (For information about how cancer is graded and staged, go to Prostate Cancer Key Point # 2 ) 

 

In general, treatment options include surgery, radiation, hormone therapy, watchful waiting, or a combination of these.  For all of them, the side effects of most concern are the possibility of impotence (inability to have an erection sufficient to have sex) and/or incontinence (difficulty or inability to control urination). 

 

Surgery involves removing all or part of the prostate.  If possible, the surgeon will use a technique called nerve-sparing surgery. It may save the nerves that control erection, reducing the possibility of impotence as a side effect.  But the size and location of the cancer may make this technique impossible.  Several types of surgery are possible, including:

 

  • Radical retropubic prostatectomy: The entire prostate and nearby lymph nodes are removed through an incision in the abdomen
  • Radical perineal prostatectomy: The entire prostate but no lymph nodes are removed through an incision between the scrotum and the anus; nearby lymph nodes are sometimes removed through a separate incision in the abdomen. This is the less common form of surgery.
  • Transurethral resection of the prostate (TURP): Part of the prostate is removed using an instrument inserted through the urethra. This procedure may not remove all the cancer, but it does remove tissue that blocks urine flow.
  • Pelvic lymphadenectomy: Lymph nodes in the pelvis are removed to see if cancer has spread to them. This may be done before the prostate is removed.

 

New, less invasive types of surgery are now being practiced successfully at various medical centers.  These include:

 

  • Cryosurgery: This procedure uses an instrument that freezes and destroys abnormal tissues.
  • Laparoscopic prostatectomy: The surgeon makes very small incisions and uses a laparoscope (a thin, lighted tube used to look at inside the body) and tiny surgical instruments and a tiny camera (to see the surgery on a video monitor) to remove the prostate. 
  • Robotic laparoscopic prostatectomy:  In this advanced, computer controlled form of laparoscopic prostatectomy, robotic arms manipulate the tiny surgical tools. The surgeon controls their movements through a computer system that allows the surgery to be extremely precise. 
    • Evidence indicates that this technique leads to faster recovery, less post-operative pain and smaller scars than traditional surgery.
    • It may not be able to readily remove all lymph nodes as open surgery can.

 Radiation therapy (also called radiotherapy) kills cancer cells using high-energy rays. There are two main types, and some men receive both:

 

  • External radiation: A machine aims a beam of radiation at the cancerous area.  Newer forms of this treatment use advanced techniques to aim the radiation more precisely and spare normal tissue.
  • Brachytherapy (also called radioactive seed implants, implant  radiation, or internal radiation or): Radioactive material is put into seeds, needles, or thin plastic tubes that are put directly into the cancerous area. Again, new, computer controlled systems allow for more precise placement of the radioactive material.   

Hormone therapy uses drugs and other techniques to stop the body from producing the male hormones (androgens) that help cancer cells grow or to stop those hormones from getting to cancer cells.  Some of the forms of hormone therapy are:

 

  • Luteinizing hormone-releasing hormone (LH-RH) agonists: The main male hormone, testosterone, is manufactured mostly in the testicles. These drugs stop that process.
  • Other anticancer drugs: The adrenal glands make small amounts of testosterone. These drugs stop that process.
  • Antiandrogens: These drugs can block the effect of androgens or stop them from reaching the cancer cells.
  • Orchiectomy (also called castration): This is an operation to remove the testicles, which manufacture testosterone.

 

Although hormone therapy can be effective for several years, eventually most prostate cancers are able to grow with very little or no male hormones. Research is now underway to develop new treatments (such as new antiandrogens) that will remain effective.

 

Watchful waiting, as its name implies, means doing very little actual treatment, but monitoring the prostate cancer closely and carefully.  This is possible because prostate cancer grows very slowly.  It is, therefore, especially useful for older men with less life expectancy, men who have other serious medical problems that lower their life expectancy, and men with the earliest stages of prostate cancer that appears to be growing slowly.  One might also choose this approach if the risks and possible side effects of other treatments seem to outweigh their benefits.

Medline Plus

Medline Description: 

Conduct an off-site search for Prostate Cancer information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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