Prostate cancer

Definition

Prostate cancer is cancer that starts in the prostate gland. The prostate is a small, walnut-shaped structure that makes up part of a man's reproductive system. It wraps around the urethra, the tube that carries urine out of the body.

Alternative Names

Cancer - prostate; Biopsy - prostate; Prostate biopsy; Gleason score

Causes

Prostate cancer is the most common cause of death from cancer in men over age 75. Prostate cancer is rarely found in men younger than 40.
People who are at high risk include:
- African American men, who are also more likely to develop this cancer at every age
- Men who are older than 60
- Men who have a father or brother with prostate cancer
Other people at risk include:
- Men who have been around Agent Orange
- Men who use too much alcohol
- Farmers
- Men who eat a diet high in fat, especially animal fat
- Obese men
- Tire plant workers
- Painters
- Men who have been around cadmium
Prostate cancer is less common in people who do not eat meat (vegetarians).
A common problem in almost all men as they grow older is an enlarged prostate. This is called benign prostatic hyperplasia, or BPH. It does not raise your risk of prostate cancer. But, it can increase your prostate-specific antigen (PSA) blood test result.
Prostate Cancer Myths & Facts
1. An enlarged prostate probably means you have prostate cancer.
  A. Myth
  B. Fact
  The correct answer is myth. The prostate is a small, walnut-sized gland found next to a man's bladder. It becomes enlarged in almost all men as they age. This is called benign prostatic hyperplasia, or BPH. It does not raise the risk of prostate cancer.
2. Which may be a sign of prostate cancer?
  A. Straining to urinate
  B. Slow urinary stream
  C. Blood in the urine or semen
  D. Dribbling or leakage of urine
  E. All of the above
  The correct answer is all of the above, although these symptoms can also be caused by other prostate problems. Check with your doctor if you notice any changes or difficulties when you urinate. Many prostate cancers are diagnosed before any symptoms are present.
3. A high PSA (prostate specific antigen) level is a sure sign of prostate cancer.
  A. Myth
  B. Fact
  The correct answer is myth. The PSA blood test can help detect prostate cancer, but it's not foolproof. Prostate infections or an enlarged prostate can also cause a rise in PSA. Not all experts agree about the value of using PSA test to screen for prostate cancer. Talk with your doctor about whether you should have a PSA test.
4. Which can raise your prostate cancer risk?
  A. Heavy alcohol use
  B. Diet high in animal fats
  C. Family history of prostate cancer
  D. African-American heritage
  E. All of the above
  The correct answer is all of the above. Let your doctor know if you have any of these risk factors. Men with a family history of prostate cancer (especially a brother or father) and African-American men should consider yearly screenings starting around age 40 to 45.
5. Men younger than 40 rarely develop prostate cancer.
  A. Myth
  B. Fact
  The correct answer is fact. Most prostate cancer occurs in men who are older than 60. It's the most common cause of death from cancer in men over age 75. Starting at age 50 (or earlier if you are at higher risk), talk with your doctor about the risks and benefits of prostate cancer screening.
6. A biopsy is the only way tell if you have prostate cancer.
  A. Myth
  B. Fact
  The correct answer is fact. During a biopsy, your doctor will remove some tissue from the prostate to test for cancer. Your doctor may recommend a biopsy if you have a high PSA level, or if a rectal exam shows a large prostate or a hard, uneven surface.
7. When prostate cancer is found early, treatment may involve:
  A. Surgery to remove the prostate
  B. Radiation therapy
  C. Brachytherapy (radioactive seeds)
  D. Any of the above
  The correct answer is any of the above. If the cancer has not spread beyond the prostate, treatment options include surgery, radiation therapy, or both. Brachytherapy involves placing tiny radioactive seeds inside the prostate. It's often used to treat small, slow-growing cancer.
8. Prostate cancer thrives on testosterone.
  A. Myth
  B. Fact
  The correct answer is fact. Most prostate tumors need testosterone to grow. In men whose cancer has spread beyond the prostate, hormone therapy may help reduce testosterone levels. This can relieve symptoms and keep the cancer from spreading, but it's not a cure.
9. Prostate cancer should always be treated, no matter your age.
  A. Myth
  B. Fact
  The correct answer is myth. If you are older and have a slow-growing cancer, your doctor may recommend simply monitoring the cancer with PSA tests or biopsies.
10. Prostate cancer treatments may cause impotence.
  A. Myth
  B. Fact
  The correct answer is fact. Possible problems after surgery or radiation therapy include problems controlling urine or bowel movements and erection problems. Medicines used to treat prostate cancer may also cause erection problems.
11. Prostate cancer can never be cured.
  A. Myth
  B. Fact
  The correct answer is myth. Many patients can be cured if their prostate cancer is found before it has spread beyond the prostate gland. Some patients whose cancer has not spread very much outside the prostate gland can also be cured. Even when prostate cancer cannot be cured, many man can live years with the cancer present.

Symptoms

With early prostate cancer, there are often no symptoms.
The PSA blood test may done to screen men for prostate cancer. Often, PSA level rises before there are any symptoms.
The symptoms listed below can occur with prostate cancer as it grows larger in the prostate. These symptoms can also be caused by other prostate problems:
- Delayed or slowed start of urinary stream
- Dribbling or leakage of urine, most often after urinating
- Slow urinary stream
- Straining when urinating, or not being able to empty all of the urine
- Blood in the urine or semen
When the cancer has spread, there may be bone pain or tenderness, most often in the lower back and pelvic bones.

Exams and Tests

An abnormal digital rectal exam may be the only sign of prostate cancer.
A biopsy is needed to tell if you have prostate cancer. A biopsy is a procedure to remove a sample of tissue from the prostate. The sample is sent to a lab for examination. It will be done in your doctor's office.
Your doctor may recommend a biopsy if:
- You have a high PSA level
- A digital rectal exam reveals a hard or uneven surface
The biopsy result is reported using what is called a Gleason grade and a Gleason score.
The Gleason grade tells you how fast the cancer might spread. It grades tumors on a scale of 1 through 5. You may have different grades of cancer in one biopsy sample. The two most common grades are added together. This gives you the Gleason score. The higher your Gleason score, the more likely the cancer can spread beyond the prostate:
- Scores 2 through 5: Low-grade prostate cancer.
- Scores 6 through 7: Intermediate- (or in the middle) grade cancer. Most prostate cancers fall into this group.
- Scores 8 through 10: High-grade cancer.
The following tests may be done to determine whether the cancer has spread:
The PSA blood test will also be used to monitor your cancer after treatment.

Treatment

Treatment depends on many things, including your Gleason score and your overall health. Your doctor will discuss your treatment options with you.
If the cancer has not spread outside the prostate gland, common treatments include:
- Surgery (radical prostatectomy)
- Radiation therapy, including brachytherapy and proton therapy
If you are older, your doctor may recommend simply monitoring the cancer with PSA tests and biopsies.
Hormone therapy is mainly used for cancer that has spread beyond the prostate. It helps relieve symptoms and prevents further growth and spread of the cancer. But it does not cure the cancer.
If prostate cancer spreads even after hormone therapy, surgery, or radiation has been tried, treatment may include:
- Chemotherapy
- Immunotherapy (medicine to trigger the immune system to attack and kill cancer cells)
Surgery, radiation therapy, and hormone therapy can affect your sexual performance. Problems with urine control are possible after surgery and radiation therapy. Discuss your concerns with your health care provider.
After treatment for prostate cancer, you will be closely watched to make sure the cancer does not spread. This involves routine checkups, including PSA blood tests (usually every 3 months to 1 year).

Support Groups

You can ease the stress of illness by joining a prostate cancer support group. Sharing with others who have common experiences and problems can help you not feel alone.

Outlook (Prognosis)

How well you do depends on whether the cancer has spread outside the prostate gland and how abnormal the cancer cells are (the Gleason score) when you are diagnosed.
A cure is possible if the cancer has not spread. Hormone treatment can improve survival, even if a cure is not possible.

When to Contact a Medical Professional

Discuss the advantages and disadvantages of PSA screening with your health care provider.

Prevention

Talk with your provider about possible ways to lower your risk of prostate cancer. These may include lifestyle measures, such as diet and exercise.
There are no medicines approved by the FDA for preventing prostate cancer.

References

American Urological Association Education and Research, Inc. PSA testing for the pretreatment staging and posttreatment management of prostate cancer: 2013 Revision of 2009 Best Practice Statement. Linthicum, MD: American Urological Association Education and Research, Inc. 2013. Available at: www.auanet.org/common/pdf/education/clinical-guidance/Prostate-Specific-Antigen.pdf. Accessed October 2, 2015.
Eastham JA, Scardino PT. Expectant management of prostate cancer. In: Wein AJ, Kavoussi LR, Novick AC, Patin AW, Peters CA, eds. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 101.
Loeb S, Carter HB. Early detection, diagnosis, and staging of prostate cancer. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 10th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 99.
National Cancer Institute: PDQ Prostate Cancer Treatment. Bethesda, MD: National Cancer Institute. Date last modified August 7, 2015. Available at: www.cancer.gov/cancertopics/pdq/treatment/prostate/HealthProfessional. Accessed October 2, 2015.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Prostate cancer. Version 1.2015. Available at: www.nccn.org/professionals/physician_gls/pdf/prostate.pdf. Accessed October 2, 2015.
Nelson WG, Carter HB, DeWeese TL, Eisenberger MA. Prostate cancer. In: Niederhuber JE, Armitage JO, Dorshow JH, Kastan MB, Tepper JE, eds. Abeloff's Clinical Oncology. 5th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2014:chap 84.