prostate cancer

Prostate Cancer

 

Definition

Prostate cancer is a disease in which cells in the prostate gland become abnormal and start to grow uncontrollably, forming tumors.

Description

Prostate cancer is a malignancy of one of the major male sex glands. Along with the testicles and the seminal vesicles, the prostate secretes the fluid that makes up semen. The prostate is about the size of a walnut and lies just behind the urinary bladder. A tumor in the prostate interferes with proper control of the bladder and normal sexual functioning. Often the first symptom of prostate cancer is difficulty in urinating. However, because a very common, non-cancerous condition of the prostate, benign prostatic hyperplasia (BPH), also causes the same problem, difficulty in urination is not necessarily due to cancer.

Cancerous cells within the prostate itself are generally not deadly on their own. However, as the tumor grows, some of the cells break off and spread to other parts of the body through the lymph or the blood, a process known as metastasis. The most common sites for prostate cancer to metastasize are the seminal vesicles, the lymph nodes, the lungs, and various bones around the hips and the pelvic region. The effects of these new tumors are what can cause death.

As of the early 2000s, prostate cancer is the most commonly diagnosed malignancy among adult males in Western countries. Although prostate cancer is often very slow growing, it can be aggressive, especially in younger men. Given its slow growing nature, many men with the disease die of other causes rather than from the cancer itself.

Prostate cancer affects African-American men twice as often as white men; the mortality rate among African-Americans is also two times higher. African-Americans have the highest rate of prostate cancer of any world population group.

Causes and symptoms

The precise cause of prostate cancer is not known as of the early 2000s. However, there are several known risk factors for disease including age over 55, African-American heritage, a family history of the disease, occupational exposure to cadmium or rubber, and a high fat diet. Men with high plasma testosterone levels may also have an increased risk for developing prostate cancer.

Frequently, prostate cancer has no symptoms and the disease is diagnosed when the patient goes for a routine screening examination. However, when the tumor is big or the cancer has spread to the nearby tissues, the following symptoms may be seen:

• weak or interrupted flow of the urine
• frequent urination (especially at night)
• difficulty starting urination
• inability to urinate
• pain or burning sensation when urinating
• blood in the urine
• persistent pain in lower back, hips, or thighs (bone pain)
• painful ejaculation

Diagnosis

Prostate cancer is curable when detected early. Yet the early stages of prostate cancer are often asymptomatic, so the disease often goes undetected until the patient has a routine physical examination. Diagnosis of prostate cancer can be made using some or all of the following tests.

Digital rectal examination (dre)

In order to perform this test, the doctor puts a gloved, lubricated finger (digit) into the rectum to feel for any lumps in the prostate. The rectum lies just behind the prostate gland, and a majority of prostate tumors begin in the posterior region of the prostate. If the doctor does detect an abnormality, he or she may order more tests in order to confirm these findings.

Blood tests

Blood tests are used to measure the amounts of certain protein markers, such as prostate-specific antigen (PSA), found circulating in the blood. The cells lining the prostate generally make this protein and a small amount can be detected normally in the bloodstream. In contrast, prostate cancers produce a lot of this protein, significantly raising the circulating levels. A finding of a PSA level higher than normal for the patient's age group therefore suggests that cancer is present.

Transrectal ultrasound

A small probe is placed in the rectum and sound waves are released from the probe. These sound waves bounce off the prostate tissue and an image is created. Since normal prostate tissue and prostate tumors reflect the sound waves differently, the test is an efficient and accurate way to detect tumors. Though the insertion of the probe into the rectum may be slightly uncomfortable, the procedure is generally painless and takes only 20 minutes.

Prostate biopsy

If cancer is suspected from the results of any of the above tests, the doctor will remove a small piece of prostate tissue with a hollow needle. This sample is then checked under the microscope for the presence of cancerous cells. Prostate biopsy is the most definitive diagnostic tool for prostate cancer.

Prostate cancer can also be diagnosed based on the examination of the tissue removed during a transurethral resection of the prostate (TURP). This procedure is performed to help alleviate the symptoms of BPH, a benign enlargement of the prostate. Like a biopsy, this is a definitive diagnostic method for prostate cancer.

X rays and imaging techniques

A chest x ray may be ordered to determine whether the cancer has spread to the lungs. Imaging techniques (such as computed tomography scans (CT) and magnetic resonance imaging (MRI)), where a computer is used to generate a detailed picture of the prostate and areas nearby, may be done to get a clearer view of the internal organs. A bone scan may be used to check whether the cancer has spread to the bone.

Treatment

Once cancer is detected during the microscopic examination of the prostate tissue during a biopsy or TURP, doctors will determine two different numerical scores that will help define the patient's treatment and prognosis.

Tumor grading

Initially, the pathologist will grade the tumor based on his or her examination of the biopsy tissue. The pathologist scores the appearance of the biopsy sample using the Gleason system. This system uses a scale of one to five based on the sample's similarity or dissimilarity to normal prostate tissue. If the tissue is very similar to normal tissue, it is still well differentiated and given a low grading number, such as one or two. As the tissue becomes more and more abnormal (less and less differentiated), the grading number increases, up to five. Less differentiated tissue is considered more aggressive and more likely to be the source of metastases.

The Gleason grading system is best predictive of the prognosis of a patient if the pathologist gives two scores to a particular sample—a primary and a secondary pattern. The two numbers are then added together and that is the Gleason score reported to the patient. Thus, the lowest Gleason score available is two (a primary and secondary pattern score of one each). A typical Gleason score is five (which can be a primary score of two and a secondary score of three or visa-versa). The highest score available is 10, with a pure pattern of very undifferentiated tissue, that is, of grade five. The higher the score, the more abnormal behavior of the tissue, the greater the chance for metastases, and the more serious the prognosis after surgical treatment. A study found that the ten-year cancer survival rate without evidence of disease for grade two, three, and four cancers is 94% of patients. The rate is 91% for grade five cancers, 78% for grade six, 46% for grade seven, and 23% for grade eight, nine, and ten cancers.

Cancer staging

The second numeric score determined by the doctor will be the stage of the cancer, which takes into account the grade of the tumor determined by the pathologist. Based on the recommendations of the American Joint Committee on Cancer (AJCC), two kinds of data are used for staging prostate cancer. Clinical data are based on the external symptoms of the cancer, while histopathological data is based on surgical removal of the prostate and examination of its tissues. Clinical data are most useful to make treatment decisions, while pathological data is the best predictor of prognosis. For this reason, the staging of prostate cancer takes into account both clinical and histopathologic information. Specifically, doctors look at tumor size (T), lymph node involvement (N), the presence of visceral (internal organ) involvement (metastasis = M), and the grade of the tumor (G).

The classification of tumor as T1 means the cancer that is confined to the prostate gland and the tumor that is too small to be felt during a DRE. T1 tumors are often found after examination of tissue removed during a TURP. The T1 definition is subdivided into those cancers that show less than 5% cancerous cells in the tissue sample (T1a) or more than 5% cancerous cells in the tissue sample (T1b). T1c means that the biopsy was performed based on an elevated PSA result. The second tumor classification is T2, where the tumor is large enough to be felt during the DRE. T2a indicates that only the left or the right side of the gland is involved, while T2b means both sides of the prostate gland has tumor.

With a T3 tumor the cancer has spread to the connective tissue near the prostate (T3a) or to the seminal vesicles as well (T3b). T4 indicates that cancer has spread within the pelvis to tissue next to the prostate such as the bladder's sphincter, the rectum, or the wall of the pelvis. Prostate cancer tends to spread next into the regional lymph nodes of the pelvis, indicated as N1. Prostate cancer is said to be at the M1 stage when it has metastasized outside the pelvis in distant lymph nodes (M1a), bone (M1b) or organs such as the liver or the brain (M1c). Pain, weight loss, and fatigue often accompany the M1 stage.

The grade of the tumor (G) can assessed during a biopsy, TURP surgery, or after removal of the prostate. There are three grades recognized: G1, G2, and G3, indicating the tumor is well, moderately, or poorly differentiated, respectively. The G, LN, M descriptions are combined with the T definition to determine the stage of the prostate cancer.

Stage I prostate cancer comprises patients that are T1a, N0, M0, G1. Stage II includes a variety of condition combinations including T1a, N0, M0, G2, 3 or 4; T1b, N0, M0, Any G; T1c, N0, M0, Any G; T1, N0, M0, Any G or T2, N0, M0, Any G. The prognosis for cancers at these two stages is very good. For men treated with stage I or stage II disease, over 95% are alive after five years.

Stage III prostate cancer occurs when conditions are T3, N0, M0, any G. Stage IV is T4, N0, M0, any G; any T, N1, M0, any G; or any T, any N, M1, Any G. Although the cancers of Stage III are more advanced, the five year prognosis is still good, with 70% of men diagnosed at these stage still living. The spread of the cancer into the pelvis (T4), lymph (N1), or distant locations (M1) are very significant events, as the five year survival rate drops to 30% for Stage IV.

Treatment options

The doctor and the patient will decide on the treatment mode after considering many factors. For example, the patient's age, the stage of the disease, his general health, and the presence of any co-existing illnesses have to be considered. In addition, the patient's personal preferences and the risks and benefits of each treatment protocol are also taken into account before any decision is made.

SURGERY. For stage I and stage II prostate cancer, surgery is the most common method of treatment because it theoretically offers the chance of completely removing the cancer from the body. Radical prostatectomy involves complete removal of the prostate. The surgery can be done using a perineal approach, where the incision is made between the scrotum and the anus, or using a retropubic approach, where the incision is made in the lower abdomen. Perineal approach is also known as nerve-sparing prostatectomy, as it is thought to reduce the effect on the nerves and thus reduce the side effects of impotence and incontinence. However, the retropubic approach allows for the simultaneous removal of the pelvic lymph nodes, which can give important pathological information about the tumor spread.

The drawback to surgical treatment for early prostate cancer is the significant risk of side effects that impact the quality of life of the patient. Even using nerve-sparing techniques, studies run by the National Cancer Institute (NCI) found that 60-80% of men treated with radical prostatectomy reported themselves as impotent (unable to achieve an erection sufficient for sexual intercourse) two years after surgery. This side effect can be sometimes countered by prescribing sildenafil citrate (Viagra). Furthermore, 8% to 10% of patients were incontinent in that time span. Despite the side effects, the majority of men were reported as satisfied with their treatment choice. Additionally, there is some evidence that the skill and the experience of the surgeon are central factors in the ultimate side effects seen.

A second method of surgical treatment of prostate cancer is cryosurgery. Guided by ultrasound, surgeons insert up to eight cryoprobes through the skin and into close proximity with the tumor. Liquid nitrogen (temperature of −320.8°F, or −196°C) is circulated through the probe, freezing the tumor tissue. In prostate surgery, a warming tube is also used to keep the urethra from freezing. Patients currently spend a day or two in the hospital following the surgery, but it could be an outpatient procedure in the near future. Recovery time is about one week. Side effects have been reduced in recent years, although impotence still affects almost all who have had cryosurgery for prostate cancer. Cryosurgery is considered a good alternative for those too old or sick to have traditional surgery or radiation treatments or when these more traditional treatments are unsuccessful. There is a limited amount of information about the long-term efficacy of this treatment for prostate cancer.

Radiation therapy

Radiation therapy involves the use of high-energy x rays to kill cancer cells or to shrink tumors. It can be used instead of surgery for stage I and II cancer. The radiation can either be administered from a machine outside the body (external beam radiation), or small radioactive pellets can be implanted in the prostate gland in the area surrounding the tumor, called brachytherapy or interstitial implantation. Pellets containing radioactive iodine (I-125), palladium (Pd 103), or iridium (Ir 192) can be implanted on an outpatient basis, where they remain permanently. The radioactive effect of the seeds last only about a year.

The side effects of radiation can include inflammation of the bladder, rectum, and small intestine as well as disorders of blood clotting (coagulopathies). Impotence and incontinence are often delayed side effects of the treatment. A study indicated that bowel control problems were more likely after radiation therapy when compared to surgery, but impotent and incontinence were more likely after surgical treatment. Long-term results with radiation therapy are dependent on stage. A review of almost 1000 patients treated with megavoltage irradiation showed 10 year survival rates to be significantly different by T-stage: T1 (79%), T2 (66%), T3 (55%), and T4 (22%). There does not appear to be a large difference in survival between external beam or interstitial treatments.

HORMONE THERAPY. Hormone therapy is commonly used when the cancer is in an advanced stage and has spread to other parts of the body, such as stage III or stage IV. Prostate cells need the male hormone testosterone to grow. Decreasing the levels of this hormone or inhibiting its activity will cause the cancer to shrink. Hormone levels can be decreased in several ways. Orchiectomy is a surgical procedure that involves complete removal of the testicles, leading to a decrease in the levels of testosterone. Another method tricks the body by administering the female hormone estrogen. When estrogen is given, the body senses the presence of a sex hormone and stops making the male hormone testosterone. However, there are some unpleasant side effects to hormone therapy. Men may have "hot flashes," enlargement and tenderness of the breasts, or impotence and loss of sexual desire, as well as blood clots, heart attacks, and strokes, depending on the dose of estrogen. Another side effect is osteoporosis, or loss of bone mass leading to brittle and easily fractured bones.

WATCHFUL WAITING. Watchful waiting means no immediate treatment is recommended, but doctors keep the patient under careful observation. This is often done using periodic PSA tests. This option is generally used in older patients when the tumor is not very aggressive and the patients have other, more life-threatening, illnesses. Prostate cancer in older men tends to be slow-growing. Therefore, the risk of the patient dying from prostate cancer, rather than from other causes, is relatively small.

Treatments for prostate cancer that are under investigation in the early 2000s include evaluation of combination therapies, such as postoperative radiation delivery, use of cytotoxic agents, and hormonal treatment using luteinizing hormone-releasing hormone (LHRH) agonists and/or antiandrogens to shut down the growth of the hormone-dependent tumors. Other drugs that are being tested as of 2003 are chemoprotective agents like amifostine (Ethyol), which are given to prostate cancer patients to counteract the harmful side effects of radiation treatment.

Alternative treatment

Alternative treatments that have been found helpful in coping with the emotional stress associated with prostate cancer include meditation, guided imagery, and relaxation techniques. Acupuncture is effective in relieving pain in some patients.

A variety of herbal products have been used to treat prostate cancer, including various compounds used in traditional Chinese medicine as well as single agents like Reishi mushrooms (Ganoderma lucidum). One herbal compound that was under investigation by the National Center for Complementary and Alternative Medicine (NCCAM) as a possible treatment for prostate cancer was PC-SPES, a mixture of eight herbs adapted from traditional Chinese medicine. In the summer of 2002, however, NCCAM put its studies of PC-SPES on hold when the Food and Drug Administration (FDA) determined that samples of the product were contaminated with undeclared prescription drug ingredients. PC-SPES was with-drawn from the American market in late 2002.

Prevention

Because the cause of the cancer is not known, there is no definite way to prevent prostate cancer. Given its common occurrence and the low cost of screening, the American Cancer Society (ACS) and the National Comprehensive Cancer Network (NCCN) recommends that all men over age 40 have an annual rectal examination and that men have an annual PSA test beginning at age 50. African-American men and men with a family history of prostate cancer, who have a higher than average risk, should begin annual PSA testing even earlier, starting at age 45.

However, mandatory screening for prostate cancer is controversial. Because the cancer is so slow growing, and the side effects of the treatment can have significant impact on patient quality of life, some medical organizations question the wisdom of yearly exams. Some organizations have even noted that the effect of screening is discovering the cancer at an early stage when it may never grow to have any outward effect on the patient during their lifetime. Nevertheless, the NCI reports that the current aggressive screening methods have achieved a reduction in the death rate of prostate cancer of about 2.3% for African-Americans and about 4.6% for Caucasians since the mid-1990s, with a 20% increase in overall survival rate during that period.

A low-fat diet may slow the progression of prostate cancer. To reduce the risk or progression of prostate cancer, the American Cancer Society recommends a diet rich in fruits, vegetables and dietary fiber, and low in red meat and saturated fats.

Key terms

Antiandrogen — A substance that blocks the action of androgens, the hormones responsible for male characteristics. Used to treat prostate cancers that require male hormones for growth.

Benign prostatic hyperplasia (BPH) — A non-cancerous swelling of the prostate.

Brachytherapy — A method of treating cancers, such as prostate cancer, involving the implantation near the tumor of radioactive seeds.

Gleason grading system — A method of predicting the tendency of a tumor in the prostate to metastasize based on how similar the tumor is to normal prostate tissue.

Granulocyte/macrophage colony stimulating factor (GM-CSF) — A substance produced by cells of the immune system that stimulates the attack upon foreign cells. Used to treat prostate cancers as a genetically engineered component of a vaccine that stimulates the body to attack prostate tissue.

Histopathology — The study of diseased tissues at a minute (microscopic) level.

Luteinizing hormone releasing hormone (LHRH) agonist — A substance that blocks the action of LHRH, a hormone that stimulates the production of testosterone (a male hormone) in men. Used to treat prostate cancers that require testosterone for growth.

Orchiectomy — Surgical removal of the testes that eliminates the production of testosterone to treat prostate cancer.

Prostate-specific antigen — A protein made by the cells of the prostate that is increased by both BPH and prostate cancer.

Radical prostatectomy — Surgical removal of the entire prostate, a common method of treating prostate cancer.

Transurethral resection of the prostate (TURP) — Surgical removal of a portion of the prostate through the urethra, a method of treating the symptoms of an enlarged prostate, whether from BPH or cancer.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Prostate Cancer." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Carroll, Peter R., et al. "Cancer of the Prostate." In Cancer Principles and Practice of Oncology, edited by Vincent T. DeVita, et al. Philadelphia: Lippincott Williams & Wilkins, 2001.

Wainrib, Barbara R., and Sandra Haber. Men, Women, and Prostate Cancer. Oakland, CA: New Harbinger Productions, Inc., 2000.

Periodicals

Alimi, D., C. Rubino, E. Pichard-Leandri, et al. "Analgesic Effect of Auricular Acupuncture for Cancer Pain: A Randomized, Blinded, Controlled Trial." Journal of Clinical Oncology 21 (November 15, 2003): 4120-4126.

Chang, S. S. "Exploring the Effects of Luteinizing Hormone-Releasing Hormone Agonist Therapy on Bone Health: Implications in the Management of Prostate Cancer." Urology 62 (December 22, 2003): 29-35.

de la Fouchardiere, C., A. Flechon, and J. P. Droz. "Coagulopathy in Prostate Cancer." Netherlands Journal of Medicine 61 (November 2003): 347-354.

Dziuk, T., and N. Senzer. "Feasibility of Amifostine Administration in Conjunction with High-Dose Rate Brachytherapy." Seminars in Oncology 30 (December 2003): 49-57.

Hsieh, K., and P. C. Albertsen. "Populations at High Risk for Prostate Cancer." Urological Clinics of North America 30 (November 2003): 669-676.

Linares, L. A., and D. Echols. "Amifostine and External Beam Radiation Therapy and/or High-Dose Rate Brachytherapy in the Treatment of Localized Prostate Carcinoma: Preliminary Results of a Phase II Trial." Seminars in Oncology 30 (December 2003): 58-62.

Sliva, D. "Ganoderma lucidum (Reishi) in Cancer Treatment." Integrative Cancer Therapies 2 (December 2003): 358-364.

Spetz, A. C., E. L. Zetterlund, E. Varenhorst, and M. Hammar. "Incidence and Management of Hot Flashes in Prostate Cancer." Journal of Supportive Oncology 1 (November-December 2003): 263-273.

Wilson, S. S., and E. D. Crawford. "Prostate Cancer Update." Minerva Urologica e Nefrologica 55 (December 2003): 199-204.

Organizations

Association for the Cure of Cancer of the Prostate (CaPCure). 1250 Fourth St., Suite 360, Santa Monica, CA 90401. (800) 757-CURE. http://www.capcure.org.

National Cancer Institute. Building 31, Room 10A31 31 Center Drive, MSC 2580, Bethesda, MD 20892-2580. (800) 4-CANCER. http://cancernet.nci.nih.gov.

National Center for Complementary and Alternative Medicine (NCCAM) Clearinghouse. P. O. Box 7923, Gaithersburg, MD 20898. (888) 644-6226. http://nccam.nih.gov.

Other

FDA MedWatch Safety Alert for PC-SPES, SPES, updated September 20, 2002. http://www.fda.gov/medwatch/SAFETY/2002/safety02.htm#spes.

National Center for Complementary and Alternative Medicine (NCCAM). Recall of PC-SPES and SPES Dietary Supplements. NCCAM Publication No. D149, September 2002. http://nccam.nih.gov/health/alerts/spes/index.htm.

prostate cancer

A cancer of older men, and the second leading cause of cancer death in men; 110,000 new cases and 30,000 deaths/year, US; 35-50% of men > 70 years of age have prostate cancer; it is more common and aggressive in African Americans.
 
Diagnosis
PSA, digital rectal examination, transrectal ultrasonography1, needle biopsy.
 
Management
Observation, radiation, surgery (prostatectomy), orchidectomy, hormonal suppression, chemotherapy.
 
Prognosticators
Statistically significant factors that affect prognosis: Pre-op PSA, TNM stage when diagnosed, Gleason’s histologic score, status of surgical margins.

Prognosis
Prostate cancer often remains occult—those with occult prostate cancer tend to die of natural deaths; flow cytometry of tumour cells allows partial prediction of cancers most likely to progress 2, 3.

TNM, prostate
pT—Primary tumour.
pTx—Primary tumour cannot be assessed.
pT0—No evidence of primary tumour.
pT1—Clinically inapparent tumour not palpable or visible by imaging.
pT1a—Tumour incidental histological finding in 5% or less of tissue resected.
pT1b—Tumour incidental histological finding in more than 5% of tissue resected.
pT1c—Tumour identified by needle biopsy (e.g. because of elevated PSA).
pT2—Tumour confined within prostate1.
pT2a—Tumour involves one half of one lobe or less.
pT2b—Tumour involves more than half of one lobe, but not both lobes.
pT2c—Tumour involves both lobes.
pT3    Tumour extends through the prostate capsule2
pT3a  Extracapsular extension (unilateral or bilateral)
pT3b—Tumour invades seminal vesicle(s).
pT4—Tumour is fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles, or pelvic wall.

Notes
(1) Tumour found in one or both lobes by needle biopsy, but not palpable or visible by imaging, is classified as T1c.

(2) Invasion into the prostatic apex or into (but not beyond) the prostatic capsule is not classified as T3, but as T2.

pN—Regional lymph nodes.
pNx—Regional lymph nodes cannot be assessed.
pN0—No regional lymph node metastasis.
pN1—Regional lymph node metastasis.
pM—Distant metastasis.
pMX—Distant metastasis cannot be assessed.
pM0—No distant metastasis.
pM1—Distant metastasis.
pM1a—Non-regional lymph node(s).
pM1b—Bone(s).
pM1c—Other site(s).

Stage grouping
Stage I—T1a  N0  M0  G1
Stage II—T1a  N0  M0  G3, G3, G4
 T1b, c, T2 N0  M0  Any G
Stage III—T3 N0  M0  Any G
Stage IV—T4 N0  M0  Any G
 Any T N1  M0  Any G
 Any T N0  M1  Any G

Prostate cancer staging
(I) Confined to prostate, not palpable during digital rectal examination, not visible by imaging, asymptomatic; usually found accidentally or detected by increased PSA.

(II) Found by needle biopsy, triggered by increased serum PSA or DRE.
 
(III) Spread beyond capsule but not to lymph nodes; seminal vesicles ± involved.

(IV) Metastasised to lymph nodes or sites far from prostate—e.g., bone, liver, or lungs.

prostate cancer

Prostatic adenocarcinoma Oncology A CA of older ♂, and 2^nd leading cause of death of ♂ with 106,000 new cases and 30,000 deaths/yr, US; 35-50% of ♂ > 70 yrs of age have PC; it is more common and aggressive in African Americans Diagnosis PSA, digital rectal examination, transrectal ultrasonography, needle biopsy Staging Table Management Observation alone, RT, surgery, hormone, chemotherapy Prognosis Uncertain; PC often remains occult; those with PC often die natural deaths; flow cytometry of tumor cells allows partial prediction of PCs most likely to progress. See PSA. , Watchful waiting.

Prostate cancer stages

I Confined to prostate, not palpable during digital rectal examination, not visible by imaging, asymptomatic; usually found accidentally or detected by ↑ PSA; cancer cells may be found in only one or more areas of prostate

II Found by a needle Bx triggered by ↑ serum PSA or identified by DRE

III CA spread beyond the capsule but not to lymph nodes; seminal vesicles may be involved

IV CA has metastasized to lymph nodes or to organs and tissues far from the prostate–eg bone, liver, or lungs

prostate cancer

The most common cancer in men, with an incidence that increases with age. At autopsy, 30 per cent of men over 50 and 75 per cent of men over 80 have a prostate cancer, usually unsuspected. Most cases are adenocarcinomas arising from the ACINAR processes of the gland. Small local lymph node metastases of prostate cancer can be detected by MRI scanning especially if magnetic iron nanoparticles have been given by intravenous injection beforehand. There is growing evidence that the regular consumption of whole tomatoes is protective against the disease. Studies suggest that this effect is not only caused by the content of the carotenoid lycoprene. Most prostate cancers are androgen-dependent but metastases may later become androgen-refractory. Drug treatments for the latter with docetaxel and prednisolone have recently been developed.

Prostate Cancer

DRG Category:	713
Mean LOS:	4.4 days
Description:	SURGICAL: Transurethral Prostatectomy With CC or Major CC
DRG Category:	715
Mean LOS:	6.6 days
Description:	MEDICAL: Other Male Reproductive System Operating Room Procedure for Malignancy With CC or Major CC

Prostate cancer is the most common type of cancer in men and the second leading cause of death among men in the United States. The American Cancer Society estimated that, in 2013, there were 238,590 new cases of prostate cancer and approximately 30,000 deaths from the disease. Overall, 1 in 6 men are diagnosed with prostate cancer and 1 in 36 die from this disease. The 5-year survival rate is 99%. Prostate cancer may begin with a condition called prostatic intraepithelial neoplasia (PIN), which can develop in men in their 20s. In this condition, there are microscopic changes in the size and shape of the prostate gland cells. The more abnormal the cells look, the more likely that cancer is present. It has been noted that 50% of men have PIN by the time they are age 50.

Adenocarcinomas compose 99% of the prostate cancers. They most frequently begin in the outer portion of the posterior lobe in the glandular cells of the prostate gland. Local spread occurs to the seminal vesicles, bladder, and peritoneum. Prostate cancer metastasizes to other sites via the hematologic and lymphatic systems, following a fairly predictable pattern. The pelvic and perivesicular lymph nodes and bones of the pelvis, sacrum, and lumbar spine are usually the first areas to be affected. Metastasis to other organs usually occurs late in the course of the disease, with the lungs, liver, and kidneys being most frequently involved.

Although the recommendation is controversial, the American Cancer Society now advises screening for prostate cancer in asymptomatic men beginning at age 40. American Cancer Society guidelines include an annual digital rectal examination beginning at age 40 and annual serum prostate-specific antigen (PSA) testing beginning at age 50.

Causes

The cause of prostate cancer remains unclear, but age, viruses, family history, diet, and androgens are thought to have contributing roles. Men who have an affected first- and second-degree relative have an eightfold increased risk of developing prostate cancer. A high-fat diet may alter the production of sex hormones and growth factors, increasing the risk of prostate cancer. Environmental exposure to cadmium (an element found in cigarettes and alkaline batteries) is also considered a risk factor.

Genetic considerations

Men who have first-degree family members with prostate cancer tend to be diagnosed 6 to 7 years earlier than men without a family history. The risk of developing prostate cancer is approximately 40% higher in men with three or more affected relatives. Several genes/loci (RNASEL, MXI1, KAI1, PCAP, CAPB, HPCX1, HPCX2) have been associated with the origin, progression, or an increased susceptibility to hereditary prostate cancer. Other candidate loci have been described and are being further investigated.

Gender, ethnic/racial, and life span considerations

The peak incidence of prostate cancer is in men between ages 60 and 70; 85% of the cases are diagnosed in men over age 65. The highest incidence of prostate cancer occurs in African American men, and it is also diagnosed at a later stage than in other groups. People of Asian and Native American ancestry have the lowest rate. Prostate cancer is rare in men under age 40, but when the disease occurs in younger men, it is generally more aggressive.

Global health considerations

The global incidence of prostate cancer varies greatly by region and is approximately 22 per 100,000 males per year. The incidence is 10 to 15 times higher in developed than in developing countries, with the highest rates in North America, Western Europe, and Australia and the lowest rates in Africa and Asia.

Assessment

History

Ask about family history of prostate cancer, an occupational exposure to cadmium, and the usual urinary pattern. A patient may report symptoms such as urinary urgency, frequency, nocturia, dysuria, slow urinary stream, impotence, or hematuria if the disease has spread beyond the periphery of the prostate gland or if benign prostatic hypertrophy is also present. Presenting symptoms that include weight loss, back pain, anemia, and shortness of breath are often indicative of advanced or metastatic disease.

Physical examination

Most men with early-stage prostate cancer are asymptomatic. When symptoms occur, they include urinary complaints (retention, urgency, frequency, nocturia, dysuria, hematuria) and back pain. The physician palpates the prostate gland via a digital rectal examination (DRE). A normal prostate gland feels soft, smooth, and rubbery. Early-stage prostate cancer may present as a nonraised, firm lesion with a sharp edge. An advanced lesion is often hard and stonelike with irregular borders. A suspicious prostatic mass is further evaluated by extending the examination to the groin to look for the presence of enlarged or tender lymph nodes.

Psychosocial

Men have reported not having a rectal examination because of embarrassment. In addition, treatment for prostate cancer can be accompanied by distressful side effects, such as sexual dysfunction and urinary incontinence. Assess the patient’s knowledge and feelings related to these issues and the presence of support systems. Note the coping strategies the patient has used in the past to manage stressors. Include the patient’s spouse or significant other in conversations.

Diagnostic highlights

General Comments: Positive findings during the DRE and an elevated PSA suggest the diagnosis. Other tests may be needed to confirm and determine metastasis.

Test	Normal Result	Abnormality With Condition	Explanation
PSA	< 4 ng/mL	Increased levels, > 10 ng/mL; a small proportion of men will have cancer even with levels as low as 1 ng/mL	The higher the level, the greater the tumor burden; can be used to monitor response to treatment or recurrent cancer
Transrectal ultrasound	Prostate gland is of normal size, contour, and consistency	Enlarged, solid prostate mass is noted	Used to direct the biopsy procedure; not helpful as a screening tool
Biopsy	Benign	Malignant	Confirms the diagnosis

Other Tests: Computed tomography scan of the abdomen and pelvis, magnetic resonance imaging, lymphangiogram, intravenous pyelogram, chest x-ray, bone scan, laparoscopic pelvic lymphadenectomy, serum reverse transcriptase–polymerase chain reaction, acid phosphatase level

Primary nursing diagnosis

Diagnosis

Pain (chronic bone) related to metastatic spread of disease

Outcomes

Pain control; Pain: Disruptive effects; Well-being

Interventions

Analgesic administration; Pain management; Meditation; Transcutaneous electric nerve stimulation (TENS); Hypnosis; Heat/cold application

Planning and implementation

Collaborative

Treatment is determined in consultation with the patient. It depends on the overall life expectancy (How old is the patient? Does he have other diseases that will shorten his life span?) and the nature of the tumor. The steps include active surveillance, watchful waiting, radical prostatectomy, radiation therapy, and hormone therapy.

conservative.

The goal of active surveillance is to protect quality of life during the early management of prostate cancer by delaying invasive therapy. The healthcare team closely monitors the disease, sometimes for years, with the potential of avoiding radical treatment. Periodic observation, or “watchful waiting,” may be proposed to a patient with early-stage, less-aggressive prostate cancer. With this option, no specific treatment is given, but the progression of the disease is monitored via periodic diagnostic tests. Large-scale clinical trials show that men who opt for conservative treatment have a slightly higher risk for death and significantly higher rate of metastasis than those who have a radical prostatectomy. Note that men who ingest diets high in omega-3 fatty acids and low in glycemic index as well as weight loss may have slowed tumor growth and improved prognosis.

surgical.

Radical prostatectomy has been the recommended treatment option for men with middle-stage disease because of high cure rates. This procedure removes the entire prostate gland, including the prostatic capsule, the seminal vesicles, and a portion of the bladder neck. Two common side effects of prostatectomy are urinary incontinence and impotence. The urinary incontinence usually resolves with time and after performing Kegel exercises, although 10% to 15% of men continue to experience incontinence 6 months after surgery. Impotence occurs in 85% to 90% of patients. All men who undergo radical prostatectomy lack emission and ejaculation because of the removal of the seminal vesicles and transection of the vas deferens. A newer surgical techniques (nerve-sparing prostatectomy) preserves continence in most men and erectile function in selected cases. Cryosurgery (cryoablation of the prostate) with liquid nitrogen is less invasive and may be associated with fewer long-term consequences (impotence and incontinence). Both techniques are under study for their long-term outcomes.

Transurethral resection of the prostate (TURP) may be recommended for men with more advanced disease, especially if it is accompanied by symptoms of bladder outlet obstruction. This procedure is not a curative surgical technique for prostate cancer but does remove excess prostatic tissue that is obstructing the flow of urine through the urethra. The incidence of impotence following TURP is rare, although retrograde ejaculation (passage of seminal fluid back into the bladder) almost always occurs because of the destruction of the internal bladder sphincter during the procedure. Many men equate ejaculation with normal sexual functioning, and to some, the loss of the ejaculatory sensation may be confused with the loss of sexual interest or potency. Also, a bilateral orchiectomy may be done to eliminate the source of the androgens since 85% of prostatic cancer is related to androgens.

All patients return from surgery with a large-lumen, three-way Foley catheter. The large lumen of the catheter and the large volume in the balloon (30 mL) help splint the urethral anastomosis and maintain hemostasis. Blood-tinged urine is common for several days after surgery, but dark red urine may indicate hemorrhage. If continuous urinary drainage is used, maintain the flow rate to keep the urine light pink to yellow in color and free from clots, but avoid overdistention of the bladder.

Antispasmodics may be ordered for bladder spasms. Anticholinergic and antispasmodic drugs may also be prescribed to help relieve urinary incontinence after the Foley catheter is removed. Because of the close proximity of the rectum and the operative site, trauma to the rectum should be avoided as a means of preventing hemorrhage. Stool softeners and a low-residue diet are usually ordered to limit straining with a bowel movement. Rectal tubes, enemas, and rectal thermometers should not be used.

radiation therapy.

Both external beam radiotherapy and internal implant (brachytherapy) are used in the treatment of prostate cancer. Radiation therapy is also used in areas of bone metastasis. The goal in extensive disease is palliation: Reduce the size of the prostate gland and relieve bone pain. Brachytherapy involving the permanent (iodine-125 or gold-198) or temporary (iridium-192) placement of radioactive isotopes can be used alone or in combination with external radiation therapy.

Patients who receive permanently placed radioisotopes are hospitalized for as long as the radiation source is considered a danger to persons around them. The principles of time, distance, and shielding need to be implemented. Care needs to be exerted so that the radioisotope does not become dislodged. Dressings and bed linens need to be checked by the radiation therapy department before these items are removed from the patient’s room.

hormonal therapy.

Medication choices for hormone therapy include luteinizing hormone-releasing hormone analogue, androgen antagonists, and gonadotropic-releasing hormone agonists.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Acetaminophen/NSAIDs, opioids, combination opioids/NSAIDs	Varies by drug	Analgesic	Analgesic is determined by severity of pain; pain may be postoperative or caused by metastasis
Gonadotropic-releasing hormone (GnRH) agonists (leuprolide, triptorelin, goserelin)	Depends on stage of cancer and treatment combination; given every mo or every 3, 4, 6, or 12 mo	Antineoplastic hormonal agent	Provides medical castration ultimately by decreasing testosterone levels; Blocks the action/secretion of androgens that stimulate tumor growth (causes temporary tissue flare)
Flutamide (Eulexin), nilutamide (Nilandron), bicalutamide (Casodex)	250 mg tid, q 8 hr	Antineoplastic, hormonal agent; antiandrogen	Blocks androgens; often given with other similar agents
Ketoconazole, aminoglutethimide	Depends on drug	Adrenal androgen synthesis inhibitor	Rapidly decreases testosterone levels, sometimes in 24 hr
Abarelix (Plenaxis)	Injection, given dorsal gluteal, every 2 wk for 1 mo, then q 4 wk	LHRH antagonist	Lowers testosterone levels more quickly, and does not cause tumor flare like LHRH agonists do

Other Drugs: Finasteride (Proscar), an androgen hormone inhibitor currently being used to treat benign prostatic hyperplasia, may reduce the risk of developing prostate cancer by 25%.

Independent

Dispel misconceptions and explain all diagnostic procedures. Patients with early-stage disease need support while they make decisions about treatment options. Encourage the patient and his partner to verbalize their feelings and fears. Clarify the differences between the various treatment options and reinforce the treatment goals. Provide written materials, such as Facts on Prostate Cancer published by the American Cancer Society or What You Need to Know about Prostate Cancer published by the National Cancer Institute. Suggest that the patient write down questions that arise so they are not forgotten during visits with the physician.

Ask about pain regularly and assess pain systematically. Believe the patient and family in their reports of pain. Inform the patient and family of options for pain relief as proposed by the National Cancer Institute (pharmacologic, physical, psychosocial, and cognitive-behavioral interventions) and involve the patient and family in determining pain relief measures.

Implement postoperative strategies to decrease complications. Patients are usually able to ambulate on the first day after surgery. Help the patient to get out of bed and walk in the halls to his tolerance level, usually three or four times a day. Once nausea has passed, bowel sounds are present, and fluids are allowed, encourage a fluid intake of 2,500 to 3,000 mL/day to maintain good urine output. Adequate fluid intake, and thus output, minimizes the formation of blood clots in the urinary bladder that can obstruct the Foley catheter.

Be alert for behavior indicating denial, grief, hostility, or depression. Inform the physician of any ineffective coping behaviors and the patient’s need for more information or a referral for counseling. Postoperative incontinence and impotence may be difficult for patients to discuss. Inform patients of exercises, medications, and products that can assist with incontinence. Suggest alternative sexual behaviors, such as touching and caressing. Patients who are undergoing orchiectomy need extensive emotional support. Establish a therapeutic relationship to promote the expression of feelings. Be sensitive to the patient’s fear of his loss of masculinity. Reinforce that having the testes removed in adulthood does not affect the ability to have an erection and orgasm.

Stress to patients who are hospitalized for insertion of a radioactive implant that while the temporary implant is in place, interactions with nurses and other individuals occur only during brief time periods. Attempt to relieve feelings of abandonment and isolation by communicating with the patient via the hospital intercom system. Once the temporary implant has been removed or the permanent radioactive substance has decayed, remind the patient that he is no longer a danger to others.

Evidence-Based Practice and Health Policy

Klotz, L., Zhang, L., Lam, A., Nam, R., Mamedov, A., & Loblaw, A. (2010). Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer. Journal of Clinical Oncology, 28(1), 126–131.

• A prospective cohort study among 450 men diagnosed with prostate cancer revealed an overall survival rate of 78.6% over a median follow-up period of 6.8 years (range, 1 to 3 years). The predicted survival rate was 68% at 10 years (95% CI, 62% to 74%).
• Twenty-six percent of patients in this study were treated with a radical prostatectomy, of which the PSA failure rate was 50%.

Documentation guidelines

• Description of all dressings, wounds, drainage collection devices, and urinary output; location, color, and amount of drainage; appearance of incision; color and amount of urine; presence of clots in the urine; urinary pattern after catheter removal
• Physical findings related to the pulmonary assessment, abdominal assessment, presence of edema, condition of extremities, bowel patterns, presence of complications (hemorrhage, infection, pulmonary congestion, activity intolerance, unrelieved discomfort, blockage of Foley catheter)
• Urinary pattern following removal of Foley catheter
• Response to potential for alteration in sexual function
• Description of the skin in the radiation field or site of insertion of radiation implant

Discharge and home healthcare guidelines

teaching.

Provide the following instructions to patients who have undergone a radical prostatectomy:

• Perform Kegel exercises to enhance sphincter control after the Foley catheter is removed. Establish a voiding pattern of every 2 hours during the day and every 4 hours during the night. With each voiding, contract the pelvic muscles to start and stop urinary flow several times. Contract the pelvic floor muscles and the muscle around the anus as though to stop a bowel movement 10 to 20 times, 4 times each day.
• Maintain an oral fluid intake of 2,000 to 3,000 mL/day. Avoid alcoholic and caffeinated beverages.
• Eat high-fiber foods and take stool softeners to prevent constipation. Avoid straining with bowel movements and do not use suppositories and enemas.
• Avoid strenuous exercise, heavy lifting, and driving an automobile until the physician allows.
• Avoid sitting with the legs in a dependent position for 3 to 4 weeks and avoid sexual intercourse for 6 weeks.

care of skin in external radiation fields.

Instruct the patient to do the following:

• Wash the skin gently with mild soap, rinse with warm water, and pat dry daily.
• Leave (not wash off) the dark ink markings that outline the radiation field.
• Avoid applying any lotions, perfumes, deodorants, or powder to the treatment area.
• Wear soft, nonrestrictive cotton clothing directly over the treatment area.
• Protect the skin from sunlight and extreme cold.

care after the insertion of a permanent radioisotope.

Instruct the patient to observe for lost seeds in bed linens. Teach the patient to use tweezers to place lost seeds in aluminum foil, wrap them tightly, and take them to the radiation oncology department at the hospital. Teach the patient to call the physician if he experiences a temperature over 100°F, burning or difficulty with urination, excessive bleeding or clots in urine, or rectal bleeding.

follow-up care.

Teach the patient when to see the physician for follow-up care and to watch for any sign of recurrent disease.

Patient discussion about prostate cancer

Q. breating air that has tetrachloroethene in it how does it affect you if u have prostate cancer the air in my building has been determined to have Tetrachloroethylene in it i have just been diagnosed with prostate cancer

A. i found a research they did in Finland about tetrachloroethene, and they saw that amongst the people who were exposed to it over the years there was an increased amount of cancerous events. and even prostate cancer.

here is a link to the abstract-

http://www.ncbi.nlm.nih.gov/pubmed/7552463?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Q. What does treatment for prostate cancer consist of, and does it affect a male's ability to have sex? A very close friend of ours has been diagnosed with prostate cancer (it really *isn't* my partner or me!) and we were wondering what his treatment options might be. If the prostate gland is removed, does that eliminate the ability to have sex?

A. There is a new procedure called the da Vinci procedure that is minimally invasive and less likely to lead to the nerve damage that causes impotence. However, it is still a risk, as well as a risk of urinary incontinence. And even if you are not impotent, your orgasms will be dry - seminal fluid is produced by the prostate. There are also other procedures, such as implanting radioactive 'seeds' into the prostate. It is my understanding that the risk of impotence from that or any other radiation procedure is higher than da Vinci surgery, but less than with traditional surgery. Chemo and broader irradiation can be recommended in more advanced cases.
My brother had the daVinci procedure, and he is able to have sex.

Q. Rising PSA to 10 with two negative biospies? Expect cancer? 67 yrs old in good health otherwise.

A. High values don't always mean it's cancer. At 67 years old, you're prostate is most likely enlarging, resulting in the higher PSA results. And after two negative biopsies, it sounds like you're in the clear. Like Brandon said though, keep up with your regular check ups.
Source: http://www.northshore.org/healthresources/encyclopedia/encyclopedia.aspx?Version=Q3_08&DocumentHwid=hw5522&ViewHwid=hw5548