Introduction – Prostate cancer is as terrifying as any cancer. Even more frightening and confusing is the cancer treatment options that you have to choose. Whether a surgery is performed or radiation therapy is administered on you, the two principal treatments of this kind of cancer, the fear is obviously overwhelming. Fear may even start from what people say about your job, your lifestyle, your family tree, your risk of developing prostate cancer, your need to be screened, if diagnosed with the disease, and what treatment is best for you.
And fear, anxious denial, hopelessness, or depression is most often equated with death. By television and newspaper accounts, prostate cancer appears to be sweeping the whole world to the point of projecting the cancer as epidemic. The answer is no, because what actually happens is that only more men have been subjected to this diagnosis and that the improved ability to detect this kind of cancer is largely due to the development and use, unlike 10 or 20 years ago, of the Prostate Specific Antigen (PSA) test. 1 Another reason is that more men have increased in number as world population grows.
So, considering population of men and PSA, you are then not at more risk of dying from prostate cancer today than your father was twenty or thirty years ago. Not only does one have to undergo fear but to suffer emotional and physical pain including the social stigma that you have been screened, diagnosed, and treated with prostate cancer. Sometimes this negative impact far outweighs the help that medical intervention can offer to hundreds of thousands of men. But the fact remains that now more men are living longer than before, although ironically more men may be diagnosed, not necessarily with cancer but for the sake of simple diagnosis.
Body – I. The prostate gland – Nestled at the bottom of the pelvic cavity, the prostate is surrounded by blood vessels, nerves and connective tissues. The primary function of the prostate gland is to produce semen. This consists of proteins and other chemicals to nourish the sperm, preserve and transport it as formed in the testicles and stored in epididymis. Without the prostate, reproduction through sexual intercourse is impossible. The prostate is made up of two tissues: epithelial (glandular) and connective (stromal). Only the epithelial tissue produces the prostate-specific antigens.
These glandular cells secrete chemicals that contribute to the seminal fluid. It is these cells that become cancerous, producing prostate cancer. The prostate continues to grow. By age 70, the prostate is between 30 and 60 grams, compared to 20 grams at age 25. This enlargement is called benign prostatic hyperplasia (BPH). 2 BPH does not necessarily result in prostate cancer and men should not worry. This benign condition is unrelated to the process of the development of prostate cancer and has no potential of spreading to “seed” itself elsewhere. Many do not even know they have BPH because they say there are no symptoms, physically.
Some symptoms of BPH include: urgency of urination, hesitancy during urination, frequency of urination, and nocturia (frequent urination at nighttime). One condition of prostate is an inflammation called prostatitis – a result of bacterial infection which causes fever, chills, and pain. It is treated with antibiotics. If nonbacterial, it is treated with anti-inflammatory medications and warm baths. II. Prostate cancer: risk and prevention – All cancers result from the complex interplay between genetics (the biological traits or blueprint we inherit from our parents) and the environment (what we eat, drink, or are exposed to).
Which is more dangerous may sometimes depend on how many relatives that have been afflicted by this disease, on how exposed you are to a lifestyle that causes the progression of cancer cells. This disease is rare in men below 40, uncommon in men younger than 50, common for men over 65. So age is an important factor associated with prostate cancer. Research indicates that when men move from low-incidence areas to high-incidence areas, their incidence level increases. Highly saturated animal fat may be more dangerous than others. Diets which are high in tomato-based products developed fewer prostate cancers.
Research suggests that if several members of your family have been diagnosed with prostate cancer, you have a greater risk of developing the disease. Regular exercise and diet low in fat make a lot of sense. Tomato products may well be preventive, so also with soy products. Vitamins A and D are said to be preventive. Drug intervention is exciting. Since the male hormone (testosterone) is said to develop prostate cancer, drugs that decrease male hormone levels may be beneficial. This chemoprevention includes finasteride (Proscar); it blocks the enzyme 5-alphe reductase which converts testosterone into dihydrotestosterone. 3 III.
What is prostate cancer? Prostate cancer is classified mostly as an adenocarcinoma, or glandular cancer, that begins when normal semen-secreting prostate gland cells mutate into cancer cells. The region of the prostate gland where the adenocarcinoma is most common is the peripheral zone. Of prostate cancer cases, 70 percent arise in the peripheral zone, 15 to 20 percent originate in the central zone, and 10 to 15 percent begin in the transitional zone. Eventually, the tumor may grow large enough to invade nearby organs as the cells are made neoplastic. Prostate cancer most commonly metastasizes to the bones, lymph nodes, rectum, and bladder.
Further mutations of a multitude of genes, can lead to progression and metastasis. This type of cancer occurs in the process of producing male hormones which results into: uncontrolled growth of cells leading to tumor, which tend to invade and metastasize. In biopsy specimen, cancerous cells appear bizarre in shape and size, the nuclei prominent, and disorganized in fashion. IV. The stages of prostate cancer – the extent of disease The stage of a prostate cancer refers to its size and the degree to which it has spread. The stage is either localized (early) or metastatic (advanced).
With localized prostate cancer, patients have no overt evidence of metastatic disease and it appears confined within the prostate. In contrast, metastatic prostate cancer patients have overt evidence of metastases, the seeds have spread to sites elsewhere in the body. 1. Stage A is diagnosed incidentally in connection with a TURP (transurethral resection of the prostate) to alleviate symptoms of BPH. 2. Stage B prostate cancers are detected by touch during a DRE (direct rectal exam). A hard nodule is felt. 3. Stage C is characterized by tumors extending beyond the prostate. 4. Stage D, men have overt evidence of metastatic disease.
The spread has reached to the lymph nodes, within the pelvis, to the bones. V. The natural history of prostate cancer – It is the succession of changes in the cell that changes accumulate, having abnormal shape, size and different degrees of uncontrolled growth. Becoming a tumor, the cancer has a grade, volume and spreads. The speed varies from every individual and this cancer behaves differently from other cancers. Hence, every individual has his own natural history of cancer, different from the rest, and this progression is slower or faster or simply unpredictable. A physician may feel no evidence of a tumor when examining your prostate.
But when a pathologist examines a biopsy a cancerous tissue under the microscope, the cells will show obvious cancerous characteristics. Pathological prostate cancer is what a pathologist sees in the microscopic examination of a biopsy while a clinical prostate cancer is what the clinician sees upon examining you. VI. Screening for prostate cancer – Traditionally used are DRE (digital rectal exam) to touch hard or soft tissues at the base parallel to the rectum, and PSA (prostate specific antigen test) to “blood test” the prostate or to measure the amount of protein in the blood.
The laboratory process is called radio-immuno assay. Some principles about the nature of this cancer that may help you are: prostate cancer screening may save your life; this cancer behaves differently; there are undetected cancers; be prepared emotionally; survival of 5 years on localized prostate cancer; age is important factor; sort out treatment calmly; and look at screening and treatment in terms of years of life saved. In all the screening activities, there should informed consent. VII. Treatment 1. Early Prostate Cancer I.
If you undergo biopsy because of an abnormal DRE or elevated PSA, ample tissue is obtained, and no cancer is found, the evidence strongly suggests that there is no significant cancer in your prostate gland. A good set of negative biopsies should assure you that it is unlikely that you have clinically significant prostate cancer. A CT (computerized tomography) scan may be employed to determine if you have metastatic prostate cancer. MRI (magnetic resonance imaging) may be recommended which involves a rectal probe or coil. The physician should educate the patient on the cure, what if not treated, and the side effects of treatment.
This early prostate cancer I may be treated with local therapy: surgery or radiation therapy or a combination of hormonal and radiation therapies. There is no hard and fast rule on the inflexibility or rigidity of one cure for all or all cure for one. But what has to be considered are: the grade, stage, volume, metastasis, inflammation, etc. The array of cure, different as they are, are not wrong in themselves. What should be put in mind is whether or not the treatment decision has been arrived at with much knowledge as possible, the options thoroughly examined and treatment of process consented to. 2.
Treatment of early prostate cancer II The cure is the operation called radical prostatectomy. This involves the surgical removal of the prostate gland and usually the nearby pelvic lymph nodes, and the urethra is reattached to the bladder. Postoperative effects include: urinary incontinence (difficulty in controlling urine) and disturbed sexual function (like no erection or impotency). At the John Hopkins Brady Urological Institute there is a revolutionary “Walsh procedure”, after its inventor Dr. Patrick Walsh, being used as the now-standard operation that removes the prostate but preserves potency and continence.
4 3. Treatment of early prostate cancer III Radiation therapy is an external-beam radiation that kills cancer cells in place; there is no surgical procedure; the prostate is not removed. Malignant tumors would shrink after exposure to radiation. Such therapy today is done by affecting the ability of cancer cells to reproduce or by stimulating a complex biochemical self-destruction process called apoptosis. Today the impressive advance of external-beam radiation therapy is the three-dimensional conformal radiation.
Your internal image is transferred to radiation therapy computer, reconstructed to form a 3-D picture of your prostate and adjacent tissues. Lead blocks are employed conforming to your prostate thus protecting from the beam noncancerous cells and tissues. Cancer cells need male hormones, androgens and testosterone, in order to grow. Hormonal therapy means the removal of the testicles since testosterone is produced there. Some doctors use medication to disrupt chemical messengers on which testosterone production depends. The major side effect however is that if the testicular production of the hormones is shut down, sex drive drops.
Cryosurgery entails freezing the prostate. Probes containing supercold liquid nitrogen are inserted directly into the tumor. The principle is that extreme cold freezes and kills cancer cells, which then will not regenerate. This is popular but impotence is common and urinary incontinence may occur. Watchful waiting may be considered for those diagnosed with localized early stage cancer and the patient has still to live long enough. But with this alone, the treatment is inadequate because prostate cancer is unpredictable, heterogeneous, and has uncertain natural history as we have said.
What is indolent and harmless now may be aggressive and life threatening one day. VIII. Life after treatment There are evaluations after treatment. These are verifications if treatment has been effective and that recovery is taking place. Physical exam may be given, like DRE, to determine if there is recurrence of tumor in this area. PSA assay should show below detectable levels; this is to determine if there is persistent residual prostate cancer. Conclusion – Much may have been said by authors and physicians about prostate cancer.
It is greatly advantageous, enlightening and assuring to be benefited from their basic and further studies and knowledge about this disease as man struggles to conquer this menace. I wish to conclude by mentioning the two major side effects of treatment from primary therapy, namely: I. Urinary incontinence – It is the stress in or loss of control of urine due to infection or blockade in the urethra. Traditional therapies include penile clamp, external urine collecting bag, implant of artificial sphincter, or reinforced underwear.
Some men strive to retrain their muscles through a regimen of Kegel exercise. 5 II. Sexual dysfunction – Radical prostatectomy or radiation therapy interferes with your erection and/or ejaculation. The nerves that control the blood vessels that engorge your penis during erection might be severed (in case of surgery) or damaged (in the case of radiation therapy or cryosurgery). Men who adore their manhood above all else and lose it after cancer treatment may rise in consternation or silently suffer in utter humility, depending on his upbringing or societal values.
Perhaps the only solace being imparted by the patient-pathologist partnership is the enlightened option of choosing the right cancer treatment for a longer life while degrading a tiny function of one’s body on the one hand, and living a shorter life span without treating the prostate cancer on the other hand. But if one is 80 years old and has to live for only 3 years because of the cancer, there is no need for treatment. But if one is of age 40, there lies the difference, but all is not lost because sexual dysfunction may be helped by use of injections to stimulate blood flow for erection and ejaculation, or an implant penile prosthesis.
This is apart from having a new lease in life, a new and longer life, which is far more important than anything else. Age does matter, after all. -o0o- Sources: Prostate Cancer :
A Family Consultation, Philip Kantoff,M. D. with Malcolm McConnell Boston New York 1996 The Prostate: A Guide and the Women who love them, Patrick C. Walsh,M. D. Urologist-in-chief,The Johns Hopkins Hospital, Janet Farrar Worthington, science writer;The Johns Hopkins University Press 1995 Henry’s Laboratory Diagnostics HARRISON’s PRINCIPLES OF INTERNAL MEDICINE http://emedicine. medscape. com/article/458011-overview.