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Prostate cancer is a tumor (single or multiple) that grows inside a man’s prostate, a gland that is part of the urinary system, and also produces some fluid that helps to transport sperm. Prostate cancer is a very common form of cancer, but usually grows slowly; as long as it remains confined to the prostate itself, it does not typically cause harm. When it escapes the prostate and metastasizes to other organs, however, there is treatment but no cure. Therefore, prostate cancer has a much better chance of being cured if detected early while still inside the gland.
Most men over the age of 50 will have some problems with their prostates, either with an enlarged gland, known as Benign Prostatic Hyperplasia (BPH, which is not cancerous), or prostate cancer. Prostate cancer is the most common non-skin cancer in men.
We don't know for sure, but we do know that there is a significant genetic component. In addition, environmental factors may play a role, including diet, particularly when high in fat. Inflammation may also play a role.
Age. The risk of prostate cancer increases with age. Most cases are found in men over 65. One in six men will be diagnosed with prostate cancer in their lifetimes. Autopsy studies show 30 percent of men over age 50 have some cancer cells in their prostates, however.
Being African-American. Blacks have a higher rate of prostate cancer than whites and prostate cancer in blacks is likely to be more aggressive. It is not known why.
Family history. If a man has a father or brother with the disease, he has double the risk of developing the disease than does a man with no family history.
This is controversial. Some medical groups recommend against screening healthy men for prostate cancer, questioning its benefits and noting its potential harms. Others strongly recommend all men over age 50 get regular screenings and say men with risk factors should be screened at an even earlier age.
The American Cancer Society recommends talking with your doctor about the issue and deciding together what is best for you as an individual. At BIDMC, we believe that men between 40 and 55 years of age with risk factors for prostate cancer (listed above), and all men between 55 and 69 years should speak to their primary doctor about the risks and benefits of prostate cancer screening.
There are two main tests. The first is the digital rectal exam (DRE) in which your doctor feels your prostate, looking for abnormalities in size, shape or texture. This should be done in all men over 50 on a yearly basis by the primary care doctor.
The other is the prostate-specific antigen or PSA test, a blood test that measures the level of an enzyme that is naturally produced by the prostate. If the number is elevated, it may signal the presence of cancer, but not always. Some medical groups advise against regular PSA testing because it can lead to unnecessary biopsies and, in some cases, unneeded treatments. They say studies have shown such testing has not been proven to save lives. But others are just as adamant in favor of regular PSA testing, saying it can catch the cancer at an early stage when it is more easily treated.
Typically, a PSA level of 4 ng/dl of blood is a red flag. Usually, the doctor will want the test repeated at a later date to determine whether the high reading was typical. PSA can fluctuate wildly and certain things can cause an elevated reading, such as prostatitis (inflammation), sex in the days before the test or even a bicycle ride.
If the level is again high, your doctor may want to you have regular PSA tests to see if the number is increasing over time, or may want to you undergo a tissue biopsy looking for cancer cells. An abnormal DRE may cause your doctor to want to you undergo a biopsy without delay or an ultrasound.
A biopsy is an outpatient procedure in which the doctor uses ultrasound guidance to stick your prostate with a needle, usually between 12 and 20 times, taking a sample of tissue from each area that is stabbed. The samples are sent to a lab where the tissue is analyzed by a pathologist who determines — based on how the cells look — whether they are cancerous, and how aggressive the cancer cells look. The test is not a perfect test, as only a representative sampling from each section of your prostate is taken. If cancer is present, one or more of the sticks may find it — or none. Negative test results do not necessarily mean there is no cancer present, but are certainly encouraging.
The key information obtained from a biopsy is whether cancer is present, how much is present and what grade it might be. If cancer is found in just one stick, that is better than if it is found in two or three or more sticks. The percentage of cancer cells found in each needle is also measured. For example, you might be found to have cancer cells in two of 12 samples and in each of those two the percentage of cancer was 20 percent. That would be better than if cancer was found in more than two of the sticks and if each stick was found to contain a higher percentage of cancer cells.
Also, each sample found is graded on what is known as the Gleason scale to measure the cancer’s aggressiveness. Samples can be graded from 6 to 10. A level 6 is considered a low-grade cancer, 7 is intermediate and 8-10 is aggressive. Most cancers found today in the post-PSA era are early stage, but this may change with recent changes in PSA screening recommendations.
If your doctor considers your cancer to be high risk, you may be given a bone scan, CT scan or MRI scan to check if the cancer has spread beyond the prostate. If the cancer has spread to other organs, it is incurable, and therapy directed only towards the prostate is usually not offered. Hormonal therapy can buy time but cannot cure.
If your doctor believes that your cancer is very low risk, you may be able to defer treatment and go on what is known as active surveillance. Prostate cancer is considered very low risk if the cancer is found in just one or two samples or “cores,” cancer makes up less than half of each needle core, the Gleason score is 6 and the PSA level is less than 10.
Active surveillance, sometimes called watchful waiting, is a strategy used by many men found to have very low risk prostate cancer. It involves deferring treatment and having regular tests, which include PSA tests, repeat prostate biopsies and possibly MRIs, to monitor the cancer and see if it is becoming more severe. If it is not, active surveillance continues. The point of this is to delay definitive treatment of prostate cancer in a safe and dependable way because all treatments are associated with side effects, which can be very bothersome.
In addition to the regular testing, many men adopt healthier lifestyles, including eating better and exercising. If something changes on the tests over time, doctors may recommend definitive treatment, which is usually either with surgery or with radiation.
If the cancer has not spread beyond the gland, your options include an operation called a radical prostatectomy, in which the prostate is surgically removed, or radiation. There are two ways the surgery can be done: traditional “open” surgery, and minimally invasive surgery, usually done with the assistance of a doctor-controlled robot. BIDMC has one of the most experienced minimally invasive urologic surgery team in the nation.
Most surgeons today are using the so-called “nerve sparing” procedure developed by Dr. Patrick Walsh at Johns Hopkins in Baltimore. It is designed to allow patients to be able to function sexually after the operation. There is no guarantee that it will succeed in that goal, however, and its use may be limited in men with aggressive cancer.
Radiation also comes in a variety of fashions, including brachytherapy, where radioactive seeds are placed inside the prostate; external beam radiation, which uses X-rays or protons to deliver the radiation; image guided radiation therapy; or stereotactic radiosurgery, including CyberKnife, an advanced technology available at BIDMC.
At BIDMC, this is our specialty. We work with you as a multidisciplinary team (urologists, medical oncologists, and radiation oncologists) to help you make the best decision for treatment. This is different for every patient, and we individualize our recommendations based on your preferences, quality-of-life, and cancer details. We offer specialized tools in decision-making that let us better understand what’s important to you, and then gear our advice based on your preferences.
As long as the cancer has not spread, there is a good chance surgery or radiation will cure the cancer, but neither is foolproof. Some men have a recurrence even after treatment that was thought to be curative. That is probably because the cancer had already spread. But a 2010 Mayo Clinic study of 10,000 men who had surgery found a median survival time of 19 years. Cure rates for those receiving radiation are about the same as those who have surgery, according to the American Cancer Society.
At BIDMC, review of our own experience over the last three years shows that 75 percent of men are no longer using pads for urinary incontinence at 6 months after surgery. This number increases to around 90 percent at 2 years after surgery. In other words, the vast majority of men regain urinary control.
In terms of sexual function, results depend heavily on the age of the patient, the patient’s pre-operative sexual function and whether nerve sparing is performed. Most men report immediate loss of sexual function following surgery, but gradually have return of function up to two years after surgery. At BIDMC, we use our excellence in quality-of-life research to predict the chances of men having return of erections after treatment so that expectations can be made clear to patients prior to treatment. Your doctor would speak to you about your individual risks of incontinence and impotence after treatment.
In terms of urination, urinary incontinence occurs infrequently, but most forms of radiation, especially brachytherapy, can result in symptoms of bladder irritation or obstruction such as urinary frequency, urgency and weak urinary stream. These symptoms tend to occur around the time of radiation, and then do gradually improve afterwards, but men may require urinary medications afterwards. Most men do not experience dramatic changes in their urinary function, with the exception of men who already have problems with urination, which tend to get worse after radiation.
In terms of sexual function, some patients report an immediate impact after treatment, but most find that problems come on gradually, almost as if aging of the sexual system is accelerated. Some report no problems at all.
After CyberKnife radiotherapy, a type of radiation treatment, very few patients (close to zero) experience incontinence. In terms of sexual function, if a patient under age 65 had good erections prior to treatment, there is an 80 percent chance he will continue to do so after treatment. Of the 20 percent who experience erectile dysfunction, some 80 percent respond to Viagra. The rate goes down for men over 65, those who smoke, those with certain conditions such as diabetes or vascular disease, and those on beta blockers, anti-depressants and some other medications.
Fewer than five percent of men who had surgery reported moderate to big bowel problems afterwards. The figure for men who had external beam radiation was about 10 percent and for those who had seeds the figure was between 10 and 20 percent.
At the BIDMC Cancer Center, we believe that prostate cancer treatment is not just about cancer. It’s also about taking care of the quality-of-life issues that may occur after cancer. We are committed not only to excellent cancer care, but also to survivorship care. We stick with you before treatment to help you make the best decision for YOU, we have an expert cancer treatment team, and perhaps most importantly, we stick with you after treatment, too, and continue to help until every patient is satisfied with his quality of life.
For example, even if urinary or sexual function does not return to pre-treatment levels, the BIDMC Prostate Cancer Program is committed to helping men achieve their quality of life goals, and continue to work with men on reaching those goals for as long as it takes after every prostate cancer treatment.