Prostate Cancer: Make an Informed Decision

First of all, what is the prostate gland and what functions does it perform? The prostate gland is walnut-sized and is located between the urinary bladder and the penis, in front of the rectum, with the bulk of it wrapped around the urethra.

The urethra is the tube that carries urine from the bladder to the outside of the body. The prostate gland secretes a thick fluid that, as part of the semen, aids in the protection and motility of sperm.  The muscular tissue of the prostate aids in the expulsion of sperm during ejaculation.

Maladies which can affect the prostate are inflammation (prostatitis) which is sometimes caused by infection and can be treated with antibiotics and benign prostatic hypertrophy (BPH) which is a form of prostate growth in most men over the age of 50.

The prostate becomes enlarged and may push on the urethra, which it surrounds. There may be a difficulty in urination or to empty the bladder as the enlarged prostate gland constricts the urethra. Medications or surgery may be required to treat BPH.

There is no prevention for prostate cancer.  “Every year, about 185,000 new cases of prostate cancer will be diagnosed nationally. About one in six men will be diagnosed with prostate cancer during his lifetime, but only one in 35 will die of it. More than two million American men alive today have been diagnosed with prostate cancer at some point” (Cleveland Clinic, Treatment Guide for Prostate Cancer, 2017).

Prostate cancer will develop as small bumps on the prostate gland. More than ninety-nine percent of prostate cancer is an adenocarcinoma which develops in the gland cells (cancercenter.com, 2017).

An adenocarcinoma develops in mucous-secreting glands.  Other glands/organs which are subject to adenocarcinoma are the lungs, esophagus, colon-rectal area, the pancreas and elsewhere in the body.

Who May be Affected by Prostate Cancer?

• African American men are 30 to 50% more likely to develop prostate cancer.
• Men over the age of 50.
• Family history of prostate cancer, although more prostate cancer is found in men without a family background for this disease. Having a brother or father with prostate cancer doubles the chances to develop cancer, with having a brother with the disease more of a risk than having a father with prostate cancer. Obviously multiple relatives with prostate cancer raises the risk to greater levels.
• “Inherited mutations of the BRCA1 or BRCA2 genes raise the risk of breast and ovarian cancers in some families. Mutations in these genes (especially in BRCA2) may also increase prostate cancer risk in some men. Men with Lynch syndrome (also known as hereditary non-polyposis colorectal cancer, or HNPCC), a condition caused by inherited gene changes, have an increased risk for a number of cancers, including prostate cancer” (American Cancer Society, 2017).
• Chemical exposures found in firefighters have had some limited linkage to the development of this disease. “A few studies have suggested a possible link between exposure to Agent Orange, a chemical used widely during the Vietnam War, and prostate cancer, although not all studies have found such a link. The Institute of Medicine considers there to be “limited/suggestive evidence” of a link between Agent Orange exposure and prostate cancer” (American Cancer Society, 2017).Visit Agent Orange and  Cancer at Cancer.org site for additional information
• Those with high free PSA in the blood (see below in the screening tests section for explanation).
• For reasons unknown those who live in North America, northwestern Europe, Australia, and on Caribbean islands are more prone to have prostate cancer This disease is less common in Asia, Africa, Central America, and South America. The differences in geographic influences may be due to intense screening in developed areas of the world, but an Asian American man living in Asia has less chance for developing prostate cancer than one living in the US.

Symptoms of Prostate Cancer

• Burning during urination.
• Pain during urination.
• Loss of bladder control.
• Painful ejaculation.
• Swelling in the legs or pelvic area.
• Blood in urine.
• Blood in semen.
• Weak urine flow.
• Erectile dysfunction.
• Bone pain.

Grading and Staging for Prostate Cancer Tumors

As with all cancerous tumors, “prostate cancer is characterized by both “grade” and “stage.” The size and extent of the tumor determine its stage. Early stage prostate cancer, Stages T1 and T2, are limited to the prostate gland. Stage T3 prostate cancer has advanced to tissue immediately outside the gland. Stage T4 prostate cancer means it may have invaded adjacent structures such as the rectum, bladder and/or pelvic wall” (Cleveland Clinic, Treatment Guide: Prostate Cancer, 2017).

A Gleason score is a test to evaluate how aggressive a cancer tumor is. This score is achieved after a pathologist (doctor who specializes in identifying conditions and diseases by studying abnormal cells and tissues) examines the cells of the biopsy of the tumor/tumors. There will be a primary and secondary score using 1 to 5, with scores below 5 defining the tumor as noncancerous, scores of 6 as low-grade cancer, 7 as intermediate-grade, and 8 to 10 as the most aggressive of cancers.

The tumor-nodes-metastasis (TNM) estimates the degree of the cancer. For this score the tumor (T) part describes the primary tumor status which can range from T0 (no evidence of a primary tumor) to T4 which denote that tumors have spread from the original site in the prostate gland, to surrounding structures other than seminal vesicles.

The node (N) portion of the score describes the status of the lymph nodes with scores ranging from N0 (no metastasis or cancer spread to lymph nodes) to N3 which described metastasis greater than 5 centimeters (pencil eraser is 6 cm.) in any node.  Finally, the metastasis (M) portion describes the level of disease spread from no metastasis (M0) to M1 (distant metastasis), Cleveland Clinic, 2017).

Screening Guidelines

The first issue to consider is the risk for prostate cancer.  The American Cancer Society (ACS) advises that men 50 and older talk to their physician about whether and when to be tested for prostate cancer. Men with one or more risk factors should consult a doctor about whether to begin screenings earlier.

Those who are most at risk are men who have a brother or father diagnosed with prostate cancer before the age of 65 or are African American.  Risk factors will dictate screening before 50.

Screening tests

Author’s Note: While PSA screening is often used, please note that the PSA test may not be 100% accurate since men who do not have prostate cancer may have elevated PSA levels.  These false-positive results may lead to unnecessary biopsies. Conversely, low levels of PSA do not necessarily mean that there is no prostate cancer present in the body. Low-grade cancers found by biopsy may need no treatment at all.

“Recently, the U.S. Preventive Services Task Force (USPSTF) upgraded their recommendation about PSA screening from a D grade (don’t screen) to a C grade, indicating that they believe that the decision about whether to be screened for prostate cancer should be an individual one, based on discussion with their physicians about the potential benefits and harms of screening.

This upgrade was based on long-term results from the European Randomized Study of Screening for Prostate Cancer (ERSPC). This study showed that men ages 55 to 69 who were screened by PSA had a 25 percent reduction in the risk of dying of prostate cancer and a 35 percent reduction in the risk of needing palliative treatment for metastatic (advanced) prostate cancer compared to those who were not screened (Cleveland Clinic, 2017).

Routine screenings may involve a PSA blood test.  A prostate-specific antigen (PSA) test measures the level of PSA protein in the blood. PSA is produced by the prostate gland when there is inflammation or an abnormality, such as the development of cancer, in the gland.

PSA levels are measured in nanograms of PSA per milliliter of blood, or ng/mL. Higher levels of PSA may represent the likelihood of prostate cancer.  There are no abnormal or normal ranges for PSA in the blood. While in the past PSA levels of 4 ng/mL was considered normal and those levels above 4 would represent prostate cancer, now it is recognized that men with high levels of PSA may indeed not have prostate cancer and those with low levels may be experiencing cancer.  One in four men with a high level of PSA do have cancer, but an increase in the PSA level over time may be an indicator of prostate cancer.

Your PSA levels can also be affected by other factors such as age with levels elevating slowly with age even if there are not prostate issues.  Some medications such as finasteride (Proscar or Propecia) or dutasteride (Avodart) may give falsely lower by half, PSA levels than might normally be seen.

Another form of PSA reading is the percent-free PSA.  In more technical terms the PSA takes two main forms in the blood. One is attached, bound, to blood proteins and the other circulates through the blood stream freely. The percent-free PSA test indicates how much PSA circulates free compared to the total PSA level. This is an important fact to note since percentage of free PSA is lower in men who have prostate cancer than in men who do not.

Studies show that if your PSA results are in the borderline range (4 to 10), a low percent-free PSA (less than 10%) means that the likelihood of having prostate cancer is about 50% and that you should probably have a biopsy. Some doctors recommend biopsies for men whose percent-free PSA is 20 or less.

Yet another test is the PSA velocity which is not a separate test. This test reflects a change in PSA levels over time.

A urine PCA3 test looks for a fusion of genes that is present in 50% of PSA-tested men with prostate cancer. This is another tool to determine if a biopsy is needed.

“If you reach age 60 and your PSA is below 1 to 2 ng/mL, there is evidence to suggest that you have a very low risk of ever developing a life-threatening prostate cancer and it may be possible to stop screenings” (Cleveland Clinic, 2017).

Another routine screening test is a digital rectal exam (DRE). During a DRE the doctor will insert a gloved finger into the rectum in order to check the prostate of texture, size, and shape. A DRE is less effective than a PSA test, but may find cancer in someone who has a normal PSA.

Diagnostic tests

Ultrasound and biopsy – These two tests are used to evaluate an abnormal PSA level and or digital rectal exam.  A prostate ultrasound involves a finger-sized probe being placed a short distance into the rectum. An ultrasound produces harmless high-frequency sound waves that bounce off the surface of the prostate.

These sound waves are recorded and transformed into a photographic images or a video of the prostate gland.  The probe will be moved to different angles to provide images of all areas of the gland.  The ultrasound will be able to detect any abnormal growths as well as the size of the prostate.

A prostate biopsy uses the transrectal (through the rectum’s lining) ultrasound to guide the several small needles through the rectum wall into the prostate where any anomalies are seen.

The needles remove tiny pieces of the prostate gland which are then analyzed by a laboratory.  If cancer cells are identified, the tumors will be able to be graded and the aggressiveness and likelihood for spreading will be determined.  These important factors will be used to design the treatment for the prostate gland cancer.

Treatments

Treatment will depend on the staging and grading of the tumor (see above) and if the cancer has spread to other parts of the body. Treatment options which will be decided by your doctor as well as yourself are:

• Chemotherapy.
• Radiation therapy.
• Surgery.
• Hormone therapy.
• Clinical trials.

Plans to Follow Prostate Cancer Care

• Active surveillance with selective delayed intervention is the careful monitoring with regular check-ups and continuing testing. This usually entails a PSA every 3 to 6 months, a repeat biopsy within 12 to 24 months, digital rectal exams every 6 to 12 months, repeat biopsy within 12 to 24 moths, and/or an MRI. In this plan, the tumor will be watched for signs that it is growing more aggressively. This is often the option for older men in poor health, but can also be done for younger men who wish to avoid the potential side effects of treatment. Risks are that tumor growth can speed up and spread and will be less curable. Requires more frequent testing and perhaps worry about knowing there is cancer and it is not being actively treated. Benefits are that for the first eight years after diagnosis, the life expectancy for those who choose this option rather than treatment is the same as those who chose to begin treatment, risks of impotence and urinary incontinence caused by treatment are evaded, and there is the chance that new, less invasive treatments, will be discovered. “The current risk of being diagnosed with prostate cancer in the U.S. is 17 percent, while the lifetime risk of death is only 3 percent. This finding suggests that the majority of newly diagnosed prostate cancers do not require treatment, and active surveillance is an appropriate approach” (Cleveland Clinic, 2017).
• Surgery done under anesthesia to remove the entire prostate gland. The surgery may be either with an incision in the lower abdomen or a laparoscopic surgery through several incisions into the lower abdomen.
• External Beam Radiation which uses a radiation machine to directly focus radiation at the prostate to kill cancer cells. There treatments are short, 15 minutes sessions, five days a week, for 6 to 9 weeks. This type of radiation requires mapping and planning on the part of the nuclear radiology/radiology oncology department. The benefits of focused-beam radiation is that the treatment is limited to the cancerous area and causes no discomfort. Beam therapy can also be usedas an alternative to surgery to treat cancer that has spread to the pelvis and cannot be surgically removed, to shrink tumors of advanced disease, and to reduce pain when the cancer cannot be cured.
• Brachytherapy is a form of radiation therapy where radioactive pellets, about the size of a grain of long rice, are implanted directly into the prostate gland. These pellets can be left in permanently or removed after a dose of radiation is delivered.
• New Genetic Testing to determine the aggressiveness of the cancer.
• Cryotherapy a treatment where 4 to 8 needle-shaped probes are inserted into the prostate to freeze the area to temperatures which will kill the prostate cancer cells. This treatment is limited to prostate cancer that is only located within the prostate gland.
• Robotic Surgery is a computer-enhanced surgical system that gives a 3-D view of the surgical field (depth, high resolution, magnification) with the use of instruments that mimic the movement of the human hand with controls that allow the surgeon to control movements.
• Hormone Therapy decreases the level of male hormone (testosterone) to slow the growth of the tumor.
• Chemotherapy involves the use of drugs to kill cancer cells given either orally or injected in a vein. The drug will go throughout the entire body and will cause many side effects.
• Immunotherapy which gives the immune system the tools to attack and kill the cancer cells.
• Radionucleotides is the use of radioactive isotopes given by vein and designed to target the bones. This is used in patients who have had spread of the cancer from the prostate gland to several areas on the bones.

“Information to take away from this article is that getting screened for prostate cancer will involve you being aware of available information, your views on possible benefits, risks, or limits of prostate screening, and discussions with your doctor about what is best for you.

Many studies are currently in progress and may bring new answers for dealing with this type of cancer.  Prostate cancer is a slow growing cancer so an elderly man in poor health may die of other issues before prostate cancer would have been the cause of death.  Some treatments may cause issues with urinary and sexual functions.

Taking into account your current state of health and age will help you to make informed decisions about how you will meet this health challenge in your life”.

References

• American Cancer Society Recommendations
• Cancer Center, www.cancercenter.com
• Cleveland Clinic, Prostate Cancer Treatment Guide, 2017.
• Promedica Cancer
• Agent Orange and Cancer at Cancer.org

Carol Duff, MSN, BA, RN

Carol graduated from Riverside White Cross School of Nursing in Columbus, Ohio and received her diploma as a registered nurse. She attended Bowling Green State University where she received a Bachelor of Arts Degree in History and Literature. She attended the University of Toledo, College of Nursing, and received a Master’s of Nursing Science Degree as an Educator.

She has traveled extensively, is a photographer, and writes on medical issues. Carol has three children RJ, Katherine, and Stephen – one daughter-in-law; Katie – two granddaughters; Isabella Marianna and Zoe Olivia – and one grandson, Alexander Paul. She also shares her life with her husband Gordon Duff, many cats, and two rescues.

• Carol’s Archives 2009-2013