1. The Prostate
   
2. Understanding Cancer Process
   
3. Prostate Cancer: Who's at Risk
   
4. Detecting Prostate Cancer
   
5. Recognizing Symptoms
   
6. Diagnosing
7. Staging
8. Orthodox Treatment
9. Side Effects of Treatment
   

The Prostate

The prostate is a gland in a man's reproductive system. It makes and stores seminal fluid, a milky fluid that nourishes sperm. This fluid is released to form part of semen. The prostate is about the size of a walnut. It is located below the bladder and in front of the rectum. It surrounds the upper part of the urethra, the tube that empties urine from the bladder. If the prostate grows too large, the flow of urine can be slowed or stopped.

To work properly, the prostate needs male hormones (androgens). Male hormones are responsible for male sex characteristics. The main male hormone is testosterone, which is made mainly by the testicles. Some male hormones are produced in small amounts by the adrenal glands.

Understanding Cancer Process

Cancer is a group of many related diseases. These diseases begin in cells, the body's basic unit of life. Cells have many important functions throughout the body.

Normally, cells grow and divide to form new cells in an orderly way. They perform their functions for a while, and then they die. This process helps keep the body healthy.

Sometimes, however, cells do not die. Instead, they keep dividing and creating new cells that the body does not need. They form a mass of tissue, called a growth or tumor.

Tumors can be benign or malignant:

Benign tumors are not cancer. They can usually be removed, and in most cases, they do not come back. Cells from benign tumors do not spread to other parts of the body. Most important, benign tumors of the prostate are not a threat to life.

Benign prostatic hyperplasia (BPH) is the abnormal growth of benign prostate cells. In BPH, the prostate grows larger and presses against the urethra and bladder, interfering with the normal flow of urine. More than half of the men in the United States between the ages of 60 and 70 and as many as 90 percent between the ages of 70 and 90 have symptoms of BPH. For some men, the symptoms may be severe enough to require treatment.

Malignant tumors are cancer. Cells in these tumors are abnormal. They divide without control or order, and they do not die. They can invade and damage nearby tissues and organs. Also, cancer cells can break away from a malignant tumor and enter the bloodstream and lymphatic system. This is how cancer spreads from the original (primary) cancer site to form new (secondary) tumors in other organs. The spread of cancer is called metastasis.

When prostate cancer spreads (metastasizes) outside the prostate, cancer cells are often found in nearby lymph nodes. If the cancer has reached these nodes, it means that cancer cells may have spread to other parts of the body--other lymph nodes and other organs, such as the bones, bladder, or rectum. When cancer spreads from its original location to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if prostate cancer spreads to the bones, the cancer cells in the new tumor are prostate cancer cells. The disease is metastatic prostate cancer; it is not bone cancer.

Prostate Cancer: Who's at Risk

The causes of prostate cancer are not well understood. Doctors cannot explain why one man gets prostate cancer and another does not.

Researchers are studying factors that may increase the risk of this disease. Studies have found that the following risk factors are associated with prostate cancer:

• Age. In the United States, prostate cancer is found mainly in men over age 55. The average age of patients at the time of diagnosis is 70.
• Family history of prostate cancer. A man's risk for developing prostate cancer is higher if his father or brother has had the disease.
• Race. This disease is much more common in African American men than in white men. It is less common in Asian and American Indian men.
• Diet and dietary factors. Some evidence suggests that a diet high in animal fat may increase the risk of prostate cancer and a diet high in fruits and vegetables may decrease the risk. Studies are in progress to learn whether men can reduce their risk of prostate cancer by taking certain dietary supplements.

Detecting Prostate Cancer

A man who has any of the risk factors described in the "Prostate Cancer: Who's at Risk" section may want to ask a doctor whether to begin screening for prostate cancer (even though he does not have any symptoms), what tests to have, and how often to have them. The doctor may suggest either of the tests described below. These tests are used to detect prostate abnormalities, but they cannot show whether abnormalities are cancer or another, less serious condition. The doctor will take the results into account in deciding whether to check the patient further for signs of cancer. The doctor can explain more about each test.

Digital rectal examination --the doctor inserts a lubricated, gloved finger into the rectum and feels the prostate through the rectal wall to check for hard or lumpy areas.

Blood test for prostate-specific antigen (PSA)--a lab measures the levels of PSA in a blood sample. The level of PSA may rise in men who have prostate cancer, BPH, or infection in the prostate.

Recognizing Symptoms

Early prostate cancer often does not cause symptoms. But prostate cancer can cause any of these problems:

• A need to urinate frequently, especially at night;
• Difficulty starting urination or holding back urine;
• Inability to urinate;
• Weak or interrupted flow of urine;
• Painful or burning urination;
• Difficulty in having an erection;
• Painful ejaculation;
• Blood in urine or semen; or
• Frequent pain or stiffness in the lower back, hips, or upper thighs.

Any of these symptoms may be caused by cancer or by other, less serious health problems, such as BPH or an infection. A man who has symptoms like these should see his doctor or a urologist (a doctor who specializes in treating diseases of the genitourinary system).

If a man has symptoms or test results that suggest prostate cancer, his doctor asks about his personal and family medical history, performs a physical exam, and may order laboratory tests. The exams and tests may include a digital rectal exam, a urine test to check for blood or infection, and a blood test to measure PSA. In some cases, the doctor also may check the level of prostatic acid phosphatase (PAP) in the blood, especially if the results of the PSA indicate there might be a problem.

The doctor may order exams to learn more about the cause of the symptoms. These may include:

• Transrectal ultrasonography --sound waves that cannot be heard by humans (ultrasound) are sent out by a probe inserted into the rectum. The waves bounce off the prostate, and a computer uses the echoes to create a picture called a sonogram.
• Intravenous pyelogram --a series of x-rays of the organs of the urinary tract.
• Cystoscopy --a procedure in which a doctor looks into the urethra and bladder through a thin, lighted tube.
• Biopsy --removing tissue samples from the prostate to be checked under a microscope for cancer cells. If cancer is present, the pathologist usually reports the grade of the tumor.
  

If cancer is found in the prostate, the doctor needs to know the stage, or extent, of the disease. Staging is a careful attempt to find out whether the cancer has spread and, if so, what parts of the body are affected. The doctor may use various blood and imaging tests to learn the stage of the disease. Treatment decisions depend on these findings.

Prostate cancer staging is a complex process. The doctor may describe the stage using a Roman number (I-IV) or a capital letter (A-D). These are the main features of each stage:

Stage I (A)--The cancer cannot be felt during a rectal exam. It may be found by accident when surgery is done for another reason, usually for BPH. There is no evidence that the cancer has spread outside the prostate.

Stage II (B)--The tumor involves more tissue within the prostate, it can be felt during a rectal exam, or it is found with a biopsy that is done because of a high PSA level. There is no evidence that the cancer has spread outside the prostate.

Stage III (C)--The cancer has spread outside the prostate to nearby tissues.

Stage IV (D)--The cancer has spread to lymph nodes or to other parts of the body.

Treatment for prostate cancer may involve watchful waiting, surgery, radiation therapy, or hormonal therapy. Some patients receive a combination of therapies.

Watchful waiting may be suggested for some men who have prostate cancer that is found at an early stage and appears to be slow growing. Also, watchful waiting may be advised for older men or men with other serious medical problems. For these men, the risks and possible side effects of surgery, radiation therapy, or hormonal therapy may outweigh the possible benefits. Men with early stage prostate cancer are taking part in a study to determine when or whether treatment may be necessary and effective.

Surgery is a common treatment for early stage prostate cancer. The doctor may remove all of the prostate (a type of surgery called radical prostatectomy) or only part of it. In some cases, the doctor can use a new technique known as nerve-sparing surgery. This type of surgery may save the nerves that control erection. However, men with large tumors or tumors that are very close to the nerves may not be able to have this surgery.

The doctor can describe the types of surgery and can discuss and compare their benefits and risks.

In radical retropubic prostatectomy, the doctor removes the entire prostate and nearby lymph nodes through an incision in the abdomen.

In radical perineal prostatectomy, the doctor removes the entire prostate through an incision between the scrotum and the anus. Nearby lymph nodes are sometimes removed through a separate incision in the abdomen.

In transurethral resection of the prostate (TURP), the doctor removes part of the prostate with an instrument that is inserted through the urethra. The cancer is cut from the prostate by electricity passing through a small wire loop on the end of the instrument. This method is used mainly to remove tissue that blocks urine flow.

If the pathologist finds cancer cells in the lymph nodes, it is likely that the disease has spread to other parts of the body. Sometimes, the doctor removes the lymph nodes before doing a prostatectomy. If the prostate cancer has not spread to the lymph nodes, the doctor then removes the prostate. But if cancer has spread to the nodes, the doctor usually does not remove the prostate, but may suggest other treatment.

Radiation therapy (also called radiotherapy) uses high-energy x-rays to kill cancer cells. Like surgery, radiation therapy is local therapy; it can affect cancer cells only in the treated area. In early stage prostate cancer, radiation can be used instead of surgery, or it may be used after surgery to destroy any cancer cells that may remain in the area. In advanced stages, it may be given to relieve pain or other problems.

Radiation may be directed at the body by a machine (external radiation), or it may come from tiny radioactive seeds placed inside or near the tumor (internal or implant radiation, or brachytherapy). Men who receive radioactive seeds alone usually have small tumors. Some men with prostate cancer receive both kinds of radiation therapy.

For external radiation therapy, patients go to the hospital or clinic, usually 5 days a week for several weeks. Patients may stay in the hospital for a short time for implant radiation.

Hormonal therapy keeps cancer cells from getting the male hormones they need to grow. It is called systemic therapy because it can affect cancer cells throughout the body. Systemic therapy is used to treat cancer that has spread. Sometimes this type of therapy is used to try to prevent the cancer from coming back after surgery or radiation treatment.

There are several forms of hormonal therapy:

Orchiectomy is surgery to remove the testicles, which are the main source of male hormones.

Drugs known as a luteinizing hormone-releasing hormone (LH-RH) agonist can prevent the testicles from producing testosterone. Examples are leuprolide, goserelin, and buserelin.

Drugs known as antiandrogens can block the action of androgens. Two examples are flutamide and bicalutamide.

Drugs that can prevent the adrenal glands from making androgens include ketoconazole and aminoglutethimide.

After orchiectomy or treatment with an LH-RH agonist, the body no longer gets testosterone from the testicles. However, the adrenal glands still produce small amounts of male hormones. Sometimes, the patient is also given an antiandrogen, which blocks the effect of any remaining male hormones. This combination of treatments is known as total androgen blockade. Doctors do not know for sure whether total androgen blockade is more effective than orchiectomy or LH-RH agonist alone.

Prostate cancer that has spread to other parts of the body usually can be controlled with hormonal therapy for a period of time, often several years. Eventually, however, most prostate cancers are able to grow with very little or no male hormones. When this happens, hormonal therapy is no longer effective, and the doctor may suggest other forms of treatment that are under study.

Side Effects of Treatment

The side effects of cancer treatment depend mainly on the type and extent of the treatment. Also, each patient reacts differently.

Surgery
Patients are often uncomfortable for the first few days after surgery. Their pain usually can be controlled with medicine, and patients should discuss pain relief with the doctor or nurse. The patient will wear a catheter (a tube inserted into the urethra) to drain urine for 10 days to 3 weeks. The nurse or doctor will show the man how to care for the catheter.

It is also common for patients to feel extremely tired or weak for a while. The length of time it takes to recover from an operation varies. Surgery to remove the prostate may cause long-term problems, including rectal injury or urinary incontinence. Some men may have permanent impotence. Nerve-sparing surgery is an attempt to avoid the problem of impotence. When the doctor can use nerve-sparing surgery and the operation is fully successful, impotence may be only temporary. Still, some men who have this procedure may be permanently impotent.

Men who have a prostatectomy no longer produce semen, so they have dry orgasms. Men who wish to father children may consider sperm banking or a sperm retrieval procedure.

Radiation Therapy
Radiation therapy may cause patients to become extremely tired, especially in the later weeks of treatment. Resting is important, but doctors usually encourage men to try to stay as active as they can. Some men may have diarrhea or frequent and uncomfortable urination.

When men with prostate cancer receive external radiation therapy, it is common for the skin in the treated area to become red, dry, and tender. External radiation therapy can also cause hair loss in the treated area. The loss may be temporary or permanent, depending on the dose of radiation.

Both types of radiation therapy may cause impotence in some men, but internal radiation therapy is not as likely as external radiation therapy to damage the nerves that control erection. However, internal radiation therapy may cause temporary incontinence. Long-term side effects from internal radiation therapy are uncommon.

Hormonal Therapy
The side effects of hormonal therapy depend largely on the type of treatment. Orchiectomy and LH-RH agonists often cause side effects such as impotence, hot flashes, and loss of sexual desire. When first taken, an LH-RH agonist may make a patient's symptoms worse for a short time. This temporary problem is called "flare." Gradually, however, the treatment causes a man's testosterone level to fall. Without testosterone, tumor growth slows down and the patient's condition improves. (To prevent flare, the doctor may give the man an antiandrogen for a while along with the LH-RH agonist.)

Antiandrogens can cause nausea, vomiting, diarrhea, or breast growth or tenderness. If used a long time, ketoconazole may cause liver problems, and aminoglutethimide can cause skin rashes. Men who receive total androgen blockade may experience more side effects than men who receive a single method of hormonal therapy. Any method of hormonal therapy that lowers androgen levels can contribute to weakening of the bones in older men.