The following questions and answers provide a general overview of prostate cancer. The information provided is not intended to substitute for consultation with a medical professional. Please consult with your physician if you have any questions.

What is the prostate?

What is prostate cancer?

Am I at risk for prostate cancer?

What symptoms are associated with prostate cancer?

How is prostate cancer diagnosed?

Should I have my PSA checked?

What is a prostate biopsy, and when is it recommended?

What are the risks of prostate biopsy?

What information does the biopsy provide?

How can you tell if the cancer has spread outside the prostate?

How is prostate cancer treated?

My neighbor/friend/relative had prostate cancer and he…?

What is the prostate?

The prostate is a walnut-sized gland deep in a man’s pelvis that completely surrounds the urethra tube where urine first exits the bladder. The back surface of the prostate gland touches the rectum, and therefore the surface of the prostate can be felt during a rectal exam.

The prostate secretes fluid that makes up part of the ejaculate. It is responsible for three main health problems in men:

• Benign enlargement, or BPH, which can progressively cause urinary symptoms as men get older (e.g., weak urinary stream, waking at night to urinate, frequent urination, difficulty postponing urination, etc.)
• Prostatitis, which is an infectious or inflammatory condition.
• Prostate Cancer

What is prostate cancer?

In the United States, prostate cancer is the second most common type of cancer in men. Approximately 240,000 men will be diagnosed each year, and nearly 30,000 men will die from prostate cancer each year. One in every six men will be diagnosed with prostate cancer in his lifetime.

Prostate cancer behaves differently from one man to the next. In many men, particularly older men, it can be a very slow growing cancer that may never cause a problem. In other cases, prostate cancer poses a greater threat to the patient and becomes an important problem requiring treatment.

Am I at risk for prostate cancer?

Prostate cancer likely results from a genetic component, combined with environmental factors that remain quite poorly defined. The impact of diet on the development of prostate cancer is the subject of intense research and is beyond the scope of this summary. However, some evidence suggests that high fat diets may predispose men to prostate cancer. Having a first degree relative who had prostate cancer does increase the risk of prostate cancer. In addition, certain ethnic groups such as African Americans are at higher risk for prostate cancer.

What symptoms are associated with prostate cancer?

In the majority of cases, prostate cancer is diagnosed at an early stage, and typically causes no symptoms whatsoever. In its later stages, however, prostate cancer may cause pain in the pelvis, hips, or lower back, urinary symptoms, and/or blood in the ejaculate or urine. The majority of men diagnosed with prostate cancer will have no symptoms.

How is prostate cancer diagnosed?

Suspicion for prostate cancer is typically generated in two ways:

• PSA test: PSA stands for "prostate specific antigen." PSA is a substance found in the bloodstream that only comes from the prostate. Prostate cancer can cause the PSA to be elevated. A number of non-cancerous conditions can cause the PSA to be elevated as well, including benign enlargement, prostatitis, ejaculation (temporary PSA rise), and bladder catheterization. PSA also changes with age, as the prostate tends to grow. There is much debate about what number constitutes a “normal” value for PSA. Clarification on your specific situation is best accomplished by discussing the results with your physician.
• Digital rectal exam (DRE): Because the back surface of the prostate is in contact with the rectum, your doctor can feel the contour of the prostate through the thin wall of the rectum. This is convenient, since the majority of cancers, if present, tend to grow in this area of the prostate. The doctor determines the size of the prostate, as well as any suspicious areas. Combining PSA and digital rectal exam is a good screening method for prostate cancer. However, the only way to diagnose prostate cancer with certainty is by performing a biopsy.

Should I have my PSA checked?

Only you and your physician can decide together whether you should have your PSA checked. Various professional societies have established guidelines for PSA screening, which differ slightly in their recommendations. The American Urological Association (AUA) recommends yearly PSA screening starting at age 50. For men at higher risk for prostate cancer (e.g. men with family members who have a history of prostate cancer or certain high risk ethnic groups such as African Americans), PSA testing should start at age 40.

What is a prostate biopsy, and when is it recommended?

If your PSA blood test and/or digital rectal exam are abnormal, your doctor may recommend a prostate biopsy. The biopsy is performed under ultrasound guidance. During the procedure, an ultrasound probe is inserted into the rectum, and images of the prostate are obtained. Using a fine needle, 12 biopsy samples are taken and later examined by a pathologist under the microscope. The entire procedure typically takes less than 10 minutes. It does not require anesthesia, and you are able to go home right after the procedure.

What are the risks of prostate biopsy?

Prostate biopsy is a routine procedure, and major risks are rare. Typical risks include bleeding (blood in the urine is common for 48 hours after the procedure) and infection. Temporary swelling of the prostate may aggravate urinary symptoms for several days.

What information does the biopsy provide?

If the biopsy does detect cancer, (approximately 30 percent of men with a PSA between 4 and 10 ng/ml), the pathologist will give the cancer what is called a “Gleason score.” This score describes how aggressive the cancer cells appear under the microscope. The score can range from 1 (not aggressive) to 5 (very aggressive). Each cancer gets two scores, one describes the majority of the cancer, and the second describes the secondary pattern. They are combined into a sum, which ranges from 2 to 10. For example, if the primary pattern is a Gleason 3, and some smaller areas show a pattern of Gleason 4, the report would call this a Gleason “3+4” or “7”. Today, it is unusual to see prostate cancer with Gleason scores less than 6.

The biopsy will also give information about how much of the prostate might be involved with cancer, depending on how many of the biopsy samples contained cancer cells. The biopsy typically does not reveal whether the prostate cancer has spread outside the prostate.

Considered together, your PSA, rectal exam findings and biopsy results allow your physician to determine whether your cancer falls into a low, intermediate, or high risk profile. This allows us to formulate an individualized treatment plan.

How can you tell if the cancer has spread outside the prostate?

Radiographic tests to determine whether the prostate cancer has spread include CT scan, bone scan, and MRI. The majority of patients diagnosed with low risk prostate cancer have statistically insignificant chances of metastasis (spreading of cancer). These tests are only indicated in specific circumstances, such as when the PSA test is markedly elevated. Ask your physician if such testing is appropriate.

How is prostate cancer treated?

The decision process for prostate cancer treatment is a personal one. This brief summary is not intended to substitute for an in-depth physician consultation, but rather broadly describes the spectrum of currently available treatment options.

1. Active Surveillance - Active surveillance, formerly referred to as “watchful waiting” involves repeating the PSA at defined intervals, as well as repeating the prostate biopsy after a period of time. The hope is that physicians might offer treatment only to men who show some cancer progression, while simply following those whose cancer remains in a low risk category, as those men are able to avoid treatment side effects. Active surveillance may be appropriate, for example, in men with a short remaining life expectancy for whom prostate cancer may not be life threatening.
2. Surgery – Surgery for prostate cancer involves removing the entire prostate gland with the seminal vesicles. The prostate is disconnected from the bladder on one side, and the urethra tube on the other. The bladder is reconnected to the urethra, and this new connection heals over a catheter that remains temporarily in the bladder. Depending on the cancer profile, the surgeon may attempt to spare the delicate nerves for erection that lie right next to the prostate gland. The main side effects of surgery are urinary leakage (incontinence) and difficulty with erections. While most men temporarily leak urine for a short period of time after the surgery, permanent incontinence is rare (3 to 8 percent). Erection function also slowly recovers after surgery and depends on patient age, preexisting erection function and the amount of nerve tissue that is “spared” during the procedure.
   Regardless of the approach (open, laparoscopic, robotic), the same surgery is performed on the inside. The approaches differ, however, in their recoveries and side effect profiles. Please see the section on robotic prostatectomy for more information in this regard.
3. Radiation therapy – For radiation therapy approaches, instead of removing the prostate, it is treated in the body with radiation. It appears that radiation and surgery offer similar rates of cancer cure within the first decade after treatment. There are two broad categories of radiation delivery to the prostate.
   • Brachytherapy – often referred to as “seeds” or “seed implants”, radioactive pellets are permanently implanted in the prostate and evenly distributed so that the radiation dose covers the whole prostate. The seeds are typically placed under ultrasound guidance, but may be placed by MRI in some centers. Radiation can be given at a low or high dose depending on the cancer profile. This procedure is performed by a radiation oncologist, sometimes with the assistance of a urologist.
   • External beam radiation therapy (EBRT) – Small beams of radiation are directed to the prostate gland from outside the body. These are delivered from different angles, so that your normal body tissue gets minimal doses of radiation. The beams are designed to intersect at the prostate, which receives the maximal radiation dose. Intensity modulated radiation therapy (IMRT) and 3D conformal radiation therapy are types of EBRT. This procedure is also performed by a radiation oncologist.
     Side effects from both of these radiation procedures include bladder and bowel (rectal) symptoms and erectile dysfunction.
4. Other Treatments
   • Hormonal therapy – Testosterone is one of the nutrients for prostate cancer. “Hormonal therapy,” also called “androgen ablation,” decreases the body’s testosterone to starve the cancer cells. Hormonal therapy does not cure prostate cancer as a primary treatment. It is typically used for locally advanced or metastatic prostate cancer, or as an adjunct to radiation therapy in some cases. Side effects of hormonal therapy are similar to menopause in women (e.g., hot flashes, fatigue, breast tenderness, etc,) and also include the weakening of bones over time.
   • Cryotherapy – Small probes are introduced under ultrasound guidance into the prostate, and the prostate is frozen at a low temperature to kill the cancer cells. Cryotherapy is still considered by many to be experimental and has a limited role as a primary treatment for prostate cancer.

My neighbor/friend/relative had prostate cancer and he…?

As you can tell from the issues covered, the prostate cancer profile is quite unique from person to person, and therefore very difficult to compare. Each person’s cancer is associated with a different PSA level, Gleason score, age at diagnosis, amount of cancer, prostate gland size, and patient history. Each of these factors influences which treatment is chosen, and an individual’s personal preferences play a crucial role. Therefore, generalizations about prostate cancer can be problematic, and anecdotes are not certain to apply from one person to the next. At the Lahey Institute of Urology at Parkland Medical Center, we take pride in making sure that the ultimate treatment plan is individually tailored.