Prostate Cancer

Introduction

The prostate is a small gland, normally in the size of walnut placed behind the base of the penis, in front of the rectum, and beneath the bladder. The prostate continues to expand as of age. This expansion of the prostate sometimes reduces the size of the urethra in the process called benign prostatic hypertrophy (BPH). BPH is a common state, which is associated with growing older, and the risk of getting prostate cancer are not more.

About the Prostate Cancer:

Prostate cancer is slightly different when compared with other types of cancer. This is because many prostate tumours do not spread speedily to other parts of the body. Sometimes signs and symptoms may not occur for years as the prostate cancer grow very slow.
Even when the prostate cancer has spread to other parts of the body, it can often be manageable for a long time. Therefore, people with prostate cancer, and even the people with advanced prostate cancer, have the possibility to lead a healthy life for many years.
Prostate cancer can be handled by observing the growth of the prostate tumours, whether they are growing slowly or quickly.

Prostate-specific antigen (PSA)

Prostate-specific antigen (PSA) is a protein made of prostate cells. It is secreted normally into the ducts in the prostate, where it helps make semen. When PSA leaks into the blood, it can be measured with a blood test called the PSA test. In prostate cancer, more PSA gets into the bloodstream. However, high PSA level is not proof of cancer, and many other things can cause a false-positive test result. For example, blood PSA levels are often increased with prostatitis or BPH.

Risk Factors:

The following are the features that increase a person’s risk of getting prostate cancer:

Age

The people older than 50 years have high risk of prostate cancer. Older prostate cancer patients can face distinctive tasks, specially related to prostate cancer treatment.

Race

Black men within the United States, and different men of African ancestry, are diagnosed more when compared to the men of other races.

North American or northern European location

Prostate cancer happens more frequently in North America and northern Europe.

Family history

The prostate cancer that runs in a family is called familial prostate cancer. It develops by sharing genes, environmental and lifestyle factors.
Hereditary prostate cancer, which is inheriting the risk from a relative, is uncommon and accounts for about 5% of all cases. Hereditary prostate cancer occurs when changes in genes passes from 1 generation to the next within the family.
The probability of getting hereditary prostate cancer includes if a family history has any of the following features:
✔ More than 2 first-degree relations with prostate cancer.
✔ 3 generations on the same side of the family having prostate cancer.
✔ 2 or more nearby relatives, like parent, sibling, grandparent, uncle etc., who are diagnosed before the age 55 with prostate cancer

Eating habits

According to many studies, there is a connection between eating habits and cancer. Healthy diet and exercise is recommended. For example, overweight is connected to many cancers, which includes prostate cancer.

Screening:

Screening is watching for cancer before having any symptoms or signs. If cancer is found while screening and have no symptoms then it is called earlier stage. Treatment is done accordingly and the danger is less and the cancer might be cured. The whole objectives of cancer screening are to:
✔ Lessen the number of prostate cancer deaths.
✔ Decrease the growth of cancer in many people.
Commonly used tests for screening prostate cancer

Digital Rectal Examination (DRE)

A routine examination in which a physician inserts a lubricated, gloved finger into the rectum and feels abnormal areas to detect cancer of the prostate.

PSA Blood Test

Prostate specific antigen (PSA) test detects low-risk and slow-growing prostate cancer, which is not danger. It is useful to find the cancer in the early stage even with no symptoms.
Prostate cancer treatment remains controversial because potential benefits might be outweighed from over detection and overtreatment. Due to which other health problems may arise if unnecessary treatments are done.

Symptoms and Signs:

Most of the prostate cancers does not show any signs or symptoms. Some prostate cancer symptoms are as follows:
✔ Increased frequency of urination, often during the night.
✔ Decreased force in the stream of urine, which leads to weak or interrupted flow of urine.
✔ Blood in the urine or semen.
✔ May experience painful ejaculation and erectile dysfunction.
✔ Pain or burning during urination.
✔ Uneasiness or pain when sitting, caused by an expanded prostate.
Other BPH or an expanded prostate show some same symptoms which is not a cancer. Sometimes similar symptoms may cause other health problems which are not connected with cancer.
If cancer spreads outside the prostate gland, then the symptoms are:
✔ Backache
✔ Body pains
✔ Excessive fluid in the legs
✔ Swellings of legs
✔ Unexplained weight loss
✔ Fatigue
✔ Change in bowel habit

Types of Treatment

How Prostate Cancer is Treated

In most of the prostate cancer patients, the tumour will be found increasing slowly. In the beginning, days there will be no bigger risk. Nevertheless, it is very much important to consult a doctor. Depending upon the growth of the prostate cancer treatment will be done. Treatment will depend upon:
✔ Increase in the PSA levels and having symptoms.
✔ Checking whether the cancer is spreading to the bones
✔ Health history
✔ Quality of life
✔ Current urinary and sexual function
✔ Other medical problems
Here are some common steps for treating prostate cancer according to the stage:

Active surveillance and watchful waiting

In the early stage of the prostate cancer, the growth is very slow. Treatment at this stage may cause many other problems than the disease. Active surveillance or watchful waiting is recommended by doctor.

Active surveillance:

Prostate cancer treatments can disturb the patients health very badly by creating many side effects such as erectile dysfunction etc.
Moreover in most of the cases prostate cancers growth is very slow without any signs or symptoms. Due to this reason the treatment of prostate cancer is delayed and not started immediately, which is called active surveillance.
At this time the prostate cancer is supervised thoroughly. If any symptoms are noticed or if the condition becomes worse then immediate treatment will be started. Active surveillance is chosen regularly for low risk cancer patients who can be treated easily.
Tests are done during active surveillance. Based on the results of the tests treatment should be done.
ASCO recommends the following testing schedule for active surveillance:
✔ PSA test for every 3 to 6 months
✔ DRE for at least once a year
Prostate biopsy from 6 to 12 months

Watchful waiting:

Watchful waiting is for patients who are quite ill, elderly having lot of other illnesses and are unlikely to be living 5 or 10 more years.
Waiting is done in watchful waiting for the symptoms. If symptoms are found then the treatment is done to get rid of them.

Local Treatments

Through local treatments cancer cells are removed from definite area of the body. Such treatments include surgery and radiation therapy. Patients having early stage cancer can be cured through local treatment.

Surgery

Surgery is an operation which removes the tumour and surrounding lymph nodes. Depending on the stage of the cancer many types of surgeries are there.

Radical (open) prostatectomy

A radical prostatectomy is the surgery which removes the prostate completely. Lymph nodes in the pelvic area will also be removed.

Robotic or laparoscopic

Robotic surgery is less invasive than a radical prostatectomy and may take less time for recovery. Some instruments and a camera are injected through small hole openings into the patient’s abdomen. The prostate tumour is removed by directing the instruments.

Bilateral orchiectomy

Bilateral orchiectomy is the surgery which removes both the testicles.

Transurethral resection of the prostate (TURP)

TURP is a surgical procedure to remove the part of the prostate gland. TURP is often used for BPH to get rid of urinary blockage.

Radiation Therapy

High energy rays are used to treat tumour in radiation therapy.

External-beam radiation therapy

A machine called a linear accelerator is used to send radiation toward the cancer for treatment from outside the body in external-beam radiation therapy.
There are different methods of external-beam radiation therapy used to treat prostate cancer.
✔ Hypo fractionated radiation therapy
In this therapy heavy dose of radiations are given for lesser period.
✔ Moderate hypo fractionated radiation therapy
In this therapy, 20 to 28 radiation therapies are included.
✔ Extreme hypo fractionated radiation therapy
In this therapy, the entire treatment is completed in 5 or less than 5 radiation therapies.

Brachytherapy

Brachytherapy is a form of radiation therapy that uses radioactive seeds or pellets placed directly into the prostate under ultrasound guidance. The seeds are left there permanently and radiation is given off gradually over a period of months.

Intensity-modulated radiation therapy (IMRT)

IMRT uses high doses of radiation that can be delivered at the prostate and stops growing. IMRT reduces the spread of cancer to the other organs.

Proton therapy

Proton therapy treats the patient in the non-invasive ways. Proton therapy is a precise form of radiation for prostate cancer which eliminates cancer cells.
It uses subatomic particles called protons accelerated to very high speeds in order to attack and kill cancer cells.

Side effects of Radiation Therapy

Radiation therapy can cause side effects during treatment. Most of the side effects generally not seen after treatment. The side effects include:
Frequent urination, diarrhoea, sexual problems, problems with bowel function, rectal discomfort, or rectal bleeding and fatigue.

Focal therapies

In focal therapy, a part of the prostate tumour is treated rather than treating the complete prostate gland. If whole prostate gland is treated then many other different problems may arise. It is better to consider focal therapy because it has less side effects when compared to the other treatments.
Focal therapy uses different methods to kill a part of the tumour. It could use radiation, high-intensity focused ultrasound, laser treatments, freezing the gland, radiofrequency ablation, seed implant radiation or beam radiation, which is also called Cyber knife or SBRT.

Hormonal Therapy

Hormone therapy is not a curative treatment for prostate cancer but it is a process of slowing down the growth of the prostate gland. It can be used for both low-risk and high-risk prostate cancer patients.
Hormone therapy is a treatment that targets to decrease the production of or block the action of their male hormone testosterone. Hormone therapy aims to reduce prostate cancer symptoms and slow cancer growth. Hormone therapy can be accomplished through either surgery or medications.

Types of hormonal therapy

Bilateral orchiectomy

Bilateral orchiectomy is also called surgical castration. It is the process of removing the testicles which produces 95% of the body’s testosterone.
It is a minor operation that can usually be performed as an outpatient procedure. The surgeon makes a small incision into the scrotum and removes both testicles. It is easy process with less side effects.

LHRH agonists

LHRH stands for luteinizing hormone-releasing hormone. LHRH agonists are drugs that block signals from the brain that tell the testicles to produce testosterone. Research shows that these drugs may lower the level of testosterone just as effectively as surgical removal. These injections are given once a year.

Androgen receptor (AR) inhibitors

Androgen receptor(AR) inhibitors do not prevent testosterone production but block the action of testosterone on the prostate by blocking hormone receptors. They prevent testosterone from nourishing prostate cancer cells.

Androgen synthesis inhibitors

LHRH agonists and orchiectomy prevent testosterone release from the testicles, but a small amount of testosterone is still released by adrenal glands. Androgen synthesis inhibitors block the action of this testosterone at the prostate.

Combined androgen blockade

Androgen receptor inhibitors are used in combination with LHRH agonists or bilateral orchiectomy for complete blockade of testosterone.

Intermittent hormonal therapy

Intermittent therapy also called as on-again off-again hormone therapy. This treatment involves giving hormone therapy for a period until certain response achieved for example a decreased PSA value or resolved symptoms.
Hormone therapy is temporarily discontinued until there is evidence of disease progression. If there are any symptoms then therapy is resumed. Advantage of intermittent therapy is that when treatment is withheld, sexual function and quality of life may improve.

Targeted Therapy

Targeted therapy uses drugs to stop the growth of prostate cancer cells, during which a small damage occurs to healthy cells. Not same targeted therapy treatment works in all patients. Different types of targeted therapy treatments are there.

PARP inhibitors

PARP inhibitors have multiple functions including inhibiting DNA repair causing regulation of transcription. The two drugs called Olaparib (Lynparza) and Rucaparib (Rubraca) are known as PARP inhibitors.
To receive these drugs the following tests should be done to decide which drug is suitable for the patient
✔ Genetic testing for an hereditary change
✔ Genomic sequencing of tumour tissue and DNA in the blood
Genomic sequencing will be executed on tissue that was formerly collected.
✔ Germline mutation testing

Chemotherapy

In Chemotherapy drugs are used that actually causes the death of cancer cells. Chemotherapy can slow down the growth of the disease. It is mostly used in the later stages of the prostate cancer than in the earlier stage.
Several drugs are used in chemotherapy depending on the condition of the patient. Usually used drug is decetaxel(Taxotere), generally given with prednisone. Chemotherapy can prolong life but may have several side effects like hair loss, diarrhoea, fatigue, etc.

Immunotherapy

Immunotherapy, also called biologic therapy. It is the process of increasing human immune system to fight with the prostate cancer. Immunotherapy is becoming a key player in the treatment of many prostate cancer patients.

Radiation Therapy by Infusion

A radioactive substance called Radium-223 is used for the treatment of prostate cancer which is effected to the bone. Radium-223 is an alpha-emitter radio nucleotide that mimics calcium and targets areas in the bone where the cancer is causing changes. This treatment delivers radiation particles directly to tumours found in the bone, limiting damage to healthy tissue, including the bone marrow, where normal blood cells are made. Through intravenous injection (IV) Radium-223 is given twice a year.

Bone-Modifying Drugs

People with prostate cancer should be very careful about the bone health. Hormone therapy can cause bone thinning in some men. Patients therefore require monitoring of bone health during treatment. Additional treatment is required to strengthen the bones. Osteopenia and osteoporosis are bone conditions that can be caused by hormonal therapy.
The treatments which are used for prostate cancer affects bones negatively. If prostate cancer spreads to the bones then many bone problems will arise which are called as skeletal-related events.
Osteoporosis and metastatic prostate Cancer are the health issues occurred when prostate cancer affects bone. Bone-modifying drugs will be suggested to decrease these issues.

Physical, Emotional, and Social Effects of Cancer

A person affected by cancer may face many physical, emotional and social effects like side effects, financial problems etc.,
Controlling of all the above difficulties is called palliative care or supportive care. It plays very important role to slow or stop cancer growth along with the treatment.
After the diagnosis supportive care crucial role in many aspects. Any type of patient can receive supportive care. This often includes meditation, relaxation practices, spiritual and emotional support and some other therapies.

Remission and the Chance of Recurrence

Remission is a period during which the patient seems to recover for some time with no symptoms. This period can also be called “no evidence of disease” or NED.
Many of the recovered patients have the doubt of getting cancer again as remission is not always permanent. By different types of treatment PSA level in the blood decreases, and hence symptoms are not shown.
At times the dropped PSA level increases which shows that cancer cells are not completely dead. Again tests will be done to find out the reason and place of recurrence.
Sometimes cancer tumour is not found even if the PSA level is increased. The treatment is planned according to the form of reappearance.