Prostate Cancer: Diagnosis and Prevention By : Christopher Scott 7/25/2005

What is the prostate? The prostate gland is found only in men; therefore, only men get prostate cancer. It is just below the bladder and in front of the rectum. The urethra, the tube that carries urine, runs through the prostate. The prostate normally starts out about the size of a walnut. By the time a man is age 40, the prostate may already have grown to the size of an apricot; by age 60, it may be as big as a lemon. Most cancers are named after the part of the body where the cancer first starts. Prostate cancer starts in the prostate gland.

The Prostate

Main duties of the prostate gland One of the prostate's main duties is to create the seminal fluid which mixes with and carries sperm out of the penis upon ejaculation. The prostate also helps to pump the semen and sperm with sufficient power out of a man's body on its way to fertilizing a woman's egg. The prostate functions as a gland and contains muscle fibers which contract and relax

What is prostate cancer? Except for skin cancer, cancer of the prostate is the most common malignancy in American men. It was estimated that nearly 221,000 men in the United States will be diagnosed with prostate cancer in 2003. In most men with prostate cancer grows very slowly. The majority of men with low-grade, early prostate cancer (confined to the gland) live a long time after their diagnosis. Even without treatment, many of these men will not die of the prostate cancer, but rather will live with it until they eventually die of some other, unrelated cause. Nevertheless, nearly 29,000 men have died of prostate cancer in 2003.

Prostate cancer Prostate cancer is the number-two cancer killer in men. Unfortunately, once the cells that make up prostate cancer have grown inside the prostate for a long enough time to reach a critical mass in size and number of cells, the cancer can spread outside of the prostate gland to other parts of the body. Like boiling water in a pot bubbling over, prostate cancer "pours" out of the prostate gland into the surrounding tissue. Once free of the prostate, the cancer cells can find new homes in the bones, liver, brain, lungs, spinal cord, or elsewhere. When that happens, the cancer that was simply annoying becomes deadly. More than 20% of all prostate cancers in the U.S. have moved beyond the prostate gland before they are detected.

What causes prostate cancer? While researchers still do not know the exact answer to this question, they have identified some risk factors. These include environment, genetics and family history. Incidence increases with age More than 70% of all prostate cancers are diagnosed in men over age 65. Information regarding first-degree relatives (i.e., father, brother) has shown an over 2- to 11-fold increase in the risk of prostate cancer in men who have a history of this disease in their family. The death rate for prostate cancer is more than 2 times higher in African-American men than in Caucasian men. Because of additional risk, earlier screening for prostate cancer is recommended for African-American men. According to the American Cancer Society, men aged 50 and older, and those over the age of 45 who are in high-risk groups, such as African-American men and men with a family history of prostate cancer.

What are some of the symptoms of prostate cancer? 9 of the most common symptoms are: Need to urinate frequently, especially at night. Difficulty starting to urinate or hold back urine. Inability to urinate. Weak or interrupted flow of urine. Painful or burning urination. Difficulty having an erection. Painful ejaculation. Blood in urine or semen (this can also be a symptom of prostatitis, an inflammation of the prostate) Frequent pain or stiffness in the lower back, hips or upper thighs. Note: Early prostate cancer often does not cause symptoms.

Who is at risk for prostate cancer? All men are at risk. The most common risk factor is age. More than 70 percent of men diagnosed with prostate cancer each year are over the age of 65. Dramatic differences in the incidence of prostate cancer are also seen in different countries, and there is some evidence that a diet higher in fat, especially animal fat, may account for some of these differences. Genetic factors also appear to play a role, particularly for families in whom the diagnosis is made in men under 60 years of age. The risk of prostate cancer rises with the number of close relatives who have the disease.

How is prostate cancer diagnosed? The diagnosis of prostate cancer can be confirmed only by a biopsy. During a biopsy, a urologist (a doctor who specializes in diseases of urinary and sex organs in men, and urinary organs in women) removes tissue samples, usually with a needle. This is generally done in the doctor’s office with local anesthesia. Then a pathologist (a doctor who identifies diseases by studying tissues under a microscope) checks for cancer cells.

Signs and Symptoms of Prostate Cancer When symptoms finally appear, they often are similar to those caused by prostate enlargement: When cancer grows through the prostate capsule, it invades nearby tissues. It also may spread to the lymph nodes of the pelvis, or it may spread throughout the body (metastasize) via the bloodstream or the lymphatic system. Prostate cancer tends to metastasize to the bone. As a result, bone pain, particularly in the back, can be another symptom of prostate cancer.

What can go wrong with the prostate gland? Three main types of problems Infection - called prostatitis Enlargement Cancer Can afflict the prostate. Prostatitis is fairly common in men from the teen years on.

What is an Enlarging Prostate? In many men, the prostate begins to grow when they are in their 50s, and it may continue to grow for the rest of their lives. An enlarged prostate is usually an “enlarging prostate” for most men over age 50, which means that if your prostate has started to grow, it may continue to grow. As the prostate grows, it puts pressure on the urethra—the tube that carries urine and semen out of the body. This increasing pressure on the urethra can lead to bothersome urinary symptoms and future problems such as surgery on your prostate. This condition is known as Enlarging Prostate, or benign prostatic hyperplasia (BPH). Although prostate cancer can also cause the prostate to grow, Enlarging Prostate is not a cancerous condition —it is not the same as prostate cancer, and it does not lead to cancer. Enlarging Prostate is not life threatening, but you and your doctor need to keep an eye on it so that it does not get worse.

Know the symptoms of Enlarging Prostate If you have an enlarging prostate, you may find that you likely have one or more of the following symptoms: It is difficult to start urinating. It is difficult to empty your bladder completely, and because of this, urine may dribble after you are done. The stream of your urine is weak and may start and stop. You urinate more often, especially at night. You feel the need to urinate more often. You get sudden strong urges to urinate. You feel bothered about the difficulty your urinary problems are causing you.

What are the symptoms of prostatitis? What is prostatitis?  To put it simply, prostatitis is inflammation of the prostate gland. Here are some of the main classifications of prostatitis: What are the symptoms of prostatitis?  Each type of prostatitis has a slight variation in signs and symptoms: Acute bacterial prostatitis Fever and chills Pain in lower back or rectum Urinary symptoms Chronic bacterial prostatitis Relapsing urinary tract infections Painful urination or other voiding problems Genital pain Nonbacterial prostatitis Urinary symptoms such as difficult or painful urination

How is prostatitis diagnosed?  Since the prostate lies in front of the rectum, your doctor will most likely perform a digital rectal examination (DRE) by inserting a gloved, lubricated finger into the rectum. By doing this, he or she will be able to feel the prostate and determine if it is enlarged or if it has lumps or other abnormalities. The physician may also check for possible infection or other prostate or urinary tract disorders.

How is prostatitis treated?  Acute and chronic bacterial prostatitis is routinely treated with antibiotics. If you have nonbacterial prostatitis, your doctor might prescribe medications to reduce the difficulty in urination or anti-inflammatory drugs for pain. Lifestyle changes (diet, stress management) may be suggested by your doctor

The PSA test and others: screening for prostate cancer There are four major tests for prostate cancer, including the well-known PSA test. These tests fall into two categories: those that screen for the disease, and those that help the doctor determine the stage of the disease when it is found. Screening tests for prostate cancer include: Prostate-specific antigen test (PSA test.) The PSA test analyzes a blood sample drawn. It checks the sample for PSA, a substance the prostate gland naturally produces to help liquefy semen. A small amount of PSA naturally enters the bloodstream. If higher-than-normal levels of PSA occur (above a level of 4 ng/ml), it may indicate prostate infection, inflammation (prostatitis), enlargement of the prostate gland—or cancer. Digital rectal exam (DRE). The prostate is located next to the rectum. A doctor performs a digital rectal exam by inserting a gloved, lubricated finger into the rectum to examine the prostate. If the doctor finds any abnormalities in the texture, shape or size of the gland, more tests may be needed.

Urine test. A urine test checks the urine for abnormalities that may indicate a problem. The test does not detect prostate cancer, but it can help detect or rule out other conditions with similar symptoms. Transrectal ultrasound. If the doctor has concerns, he or she may use transrectal ultrasound to further evaluate the prostate. This involves inserting a small probe into the rectum. The probe emits sound waves to produce a picture of the prostate gland Grading & Staging Once prostate cancer is discovered, the tumor is graded and staged. The grade estimates how aggressive a prostate cancer is; how fast it is growing and the likelihood of its spreading. The staging estimates the size and location of the cancer (including how far it has spread). Grading and staging will help determine what type of treatment, if any, is most appropriate.

Grading The grade indicates how different the cancer cells appear from normal cells, when seen through a microscope. Sometimes you will hear the grade referred to as the Gleason grade. A Gleason grade ranges from 1 through 5. Prostate cancers often have areas with different grades. Therefore, a grade is assigned to each of the two areas that make up most of the cancer. These two grades are added together to yield a Gleason score of between 2 and 10. Low Gleason grades and scores indicate slow-growing cancer. High grades and scores indicate a cancer likely to grow aggressively.

Staging Staging is the assessment of the size and location of prostate cancer (that is, how far the cancer has already spread). Staging is necessary for the patient and physician to decide what type of treatment is most appropriate. There is more than one system for staging prostate cancer. The TNM system is used most often and gives three key pieces of information: T refers to the Tumor. There are actually two types of T classifications for prostate cancer. The clinical stage is based on digital rectal exam, needle biopsy and transrectal ultrasound findings. The pathologic stage is based on what the doctor finds when the entire prostate gland, both seminal vesicles and, in some cases, nearby lymph nodes are removed and examined. N describes how far the cancer has spread to nearby lymph Nodes. M shows whether the cancer has spread (Metastasized) to other organs of the body

T Stages (Tumor) T1 The tumor cannot be felt or seen with imaging such as transrectal ultrasound. T1a The cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement and is present in less than 5 percent of the tissue removed. T1b The cancer is found through TURP and is present in more than 5 percent of the tissue removed. T1c The cancer is found by needle biopsy done because of an elevated PSA level. T2 The cancer can be felt through a digital rectal exam (DRE). T2a The cancer is in one side of the prostate. T2b The cancer is in both sides of the prostate. T3 The cancer has begun to spread outside the prostate and may involve the seminal vesicles. T3a The cancer extends outside the prostate but not to the seminal vesicles. T3b The cancer has spread to the seminal vesicles. T4 The cancer has spread to tissues next to the prostate (other than the seminal vesicles), such as the bladder's external sphincter (muscles that help control urination), the rectum and/or the wall of the pelvis.

N Stages (Lymph nodes) N0 The cancer has not spread to any lymph nodes. N1 The cancer has spread to one or more regional (nearby) lymph nodes in the pelvis. M stages (Metastasis) M0 The cancer has not spread beyond the regional nodes. M1 The cancer has spread to distant (outside of the pelvis) lymph nodes, bones or other organs such as the lungs, liver or brain.

A-D Staging System Stage A is early cancer. The tumor is located within the prostate gland and cannot be felt during a DRE. In Stage C, prostate cancer is more advanced. Stage C indicates that the tumor has spread outside the prostate to some surrounding areas, but not to other organs. This stage of cancer can usually be detected by a DRE. In Stage B, the tumor is considered to be within the prostate and can be felt during a DRE. In Stage D, the cancer has spread to the nearby organs and usually to distant sites, such as the bones or lymph nodes.

How is localized prostate cancer treated? Three treatment options are generally accepted for men with localized prostate cancer: radical prostatectomy, radiation therapy, and surveillance (also called watchful waiting). Radical prostatectomy is a surgical procedure to remove the entire prostate gland and nearby tissues. Sometimes lymph nodes in the pelvic area (the lower part of the abdomen, located between the hip bones) are also removed. Radical prostatectomy may be performed using a technique called nerve-sparing surgery that may prevent damage to the nerves needed for an erection. Radiation therapy involves the delivery of radiation energy to the prostate. The energy is usually delivered in an outpatient setting using an external beam of radiation. The energy can also be delivered by implanting radioactive seeds in the prostate using a needle. Surveillance, taking a wait-and-see approach, may be recommended for patients with early-stage prostate cancer, particularly those who are older or have other serious medical conditions.

How does a patient decide what is the best treatment option for localized prostate cancer? Choosing a treatment option involves the patient, his family, and one or more doctors. They will need to consider the grade and stage of the cancer, the man’s age and health, and his values and feelings about the potential benefits and harms of each treatment option. Often it is useful to seek a second opinion, and patients may hear different opinions and recommendations. Because there are several reasonable options for most patients, the decision can be difficult. Patients should try to get as much information as possible and allow themselves enough time to make a decision. There is rarely a need to make a decision without taking time to discuss and understand the pros and cons of the various approaches

Prevention Doctors cannot always explain why one person gets cancer and another does not. However, scientists have studied general patterns of cancer in the population to learn what things around us and what things we do in our lives may increase our chance of developing cancer. Anything that increases a person’s chance of developing a disease is called a risk factor; Anything that decreases a person’s chance of developing a disease is called a protective factor. For example, although you can choose to quit smoking, you cannot choose which genes you have inherited from your parents. Both smoking and inheriting specific genes could be considered risk factors for certain kinds of cancer, but only smoking can be avoided. Prevention means avoiding the risk factors and increasing the protective factors that can be controlled so that the chance of developing cancer decreases. Although many risk factors can be avoided, it is important to keep in mind that avoiding risk factors does not guarantee that you will not get cancer. Also, most people with a particular risk factor for cancer do not actually get the disease. Some people are more sensitive than others are to factors that can cause cancer. Talk to your doctor about methods of preventing cancer that might be effective for you.

Resources for prostate diseases Dealing with prostate disease involves you, your family and your physician. The following Web sites include more information about prostate disease and treatment options. Some of the organizations mentioned can put you in contact with prostate disease support groups. Some even offer meetings where you can discuss the latest treatments for prostate disease with other people diagnosed with prostate disease. Sometimes guest physicians are invited to the meetings to discuss treatment options. TAP Pharmaceuticals Products Inc. cannot assure the accuracy or timeliness of the information available at the following Web sites and information resources. American Association for Cancer Research www.aacr.org The American Association for Cancer Research provides research grants and publishes several medical journals. American Cancer Society (800) 227-2345 www.cancer.org The American Cancer Society (ACS) can be a starting point for dealing with family members and other issues that may arise after a prostate cancer diagnosis. The site also includes information about the ACS and statistics about prostate cancer incidence rates. American Foundation for Urologic Disease (800) 242-2383 www.afud.org This organization is dedicated to the prevention and cure of urologic diseases such as prostate cancer through research, education and public awareness. The site includes research facts, educational material and advocacy information.

Cancer. gov (800) 422-6237 www. cancer Cancer.gov (800) 422-6237 www.cancer.gov This is a useful gateway into the National Cancer Institute for information. From here you can access a portion of the contents of PDQ — the Physician Data Query database — which provides detailed information about specific cancers written for both medical professionals and patients. Center for Prostate Disease Research (CPDR) www.cpdr.org The CPDR is a prostate cancer research program funded by the U.S. Army that conducts research nationwide at U.S. Army, Navy and Air Force hospitals. The Web site explains the program and provides education and research updates. Doctor's Guide www.docguide.com This site contains the latest medical news for healthcare professionals, patients, family and friends of those diagnosed with enlarged prostate (BPH - benign prostatic hyperplasia) or prostate cancer. National Coalition for Cancer Survivorship (888) 937-6227 www.canceradvocacy.org The National Coalition for Cancer Survivorship is a grassroots network of individuals and organizations working on behalf of people with all types of cancer. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) www.niddk.nih.gov The NIDDK, under the auspices of the National Institutes of Health, provides a site with answers to questions about BPH, talks about the lifestyle of a patient with BPH, and provides additional reading

Prostate Cancer Foundation (800) 757-2873 www.prostatecancerfoundation.org The Prostate Cancer Foundation, an organization dedicated to finding a cure for prostate cancer, is the largest private source for research funding for prostate cancer. They offer information on prostate cancer, treatment options and clinical trials. The Prostate Pointers www.prostatepointers.org/prostate Here you will find helpful patient education material on prostate cancer, compiled from a wide variety of medical sources. US TOO (800) 808-7866 www.ustoo.com US TOO helps survivors of prostate cancer and prostate disease and their families lead healthy and productive lives. This organization offers fellowship, shared counseling and discussion sessions in both formal and informal settings. Book Resource: Ellsworth P, Heaney J, Gill C. 100 Questions & Answers About Prostate Cancer. Boston, Mass: Jones and Bartlett Publishers; 2003.