My Penis Stuff

Ever since Charles Huggins and his colleagues first demonstrated that testosterone suppression could control prostate cancer growth, hormonal therapy has played a major role in the management of this disease. But how can decreasing the activity of natural androgens — sex hormones like testosterone — curb symptoms or even shrink a tumor? The summary below should help explain how hormonal therapy can control localized prostate cancer tumors and even control those that have spread to other parts of the body.

What are androgens?

Androgens are male sex hormones responsible for characteristics such as facial hair, a deepened voice and increased muscle bulk. They come from two sources: the testicles (accounting for 90 to 95 percent of the male hormones) and the adrenal glands that produce several other androgens (accounting for 5 to 10 percent of male hormones).

Stimulating sexual development while also strengthening muscle tone and bone mass, testosterone is the most potent androgen. It is the product of a controlled process that begins when the hypothalamus, a cherry-sized control mechanism in the brain, releases a substance called luteinizing hormone-releasing hormone (LH-RH). It, in turn, stimulates the pituitary gland to manufacture and secrete luteinizing hormone (LH), the hormone that actually activates the testicles in producing testosterone.

What causes prostate cancer?

The prostate may be no bigger than a walnut, but it is a major male sex gland. Weighing just a few grams, it discharges substances into the semen as the seminal fluid passes through ejaculatory ducts connecting the seminal vesicles to the urethra.

Prostate cancer occurs when abnormal cells, fueled by male hormones such as testosterone, grow uncontrollably to form tumors. Since it frequently produces no symptoms in its earliest stages, you may only become aware of the cancer during routine screening. But the tumor eventually interferes with normal bladder and sexual function, producing both ejaculatory and urinary problems.

Diagnosis can be made using any or all of a variety of tests: digital rectal examination (DRE), prostate-specific antigen (PSA), biopsy, X-ray and other imaging techniques such as transrectal ultrasound and CT scan.

What is hormone therapy for prostate cancer?

If detected early, prostate cancer is curable. While treatment choices are still controversial, they are generally based on the stage of the disease. Surgical removal of the gland is used for early and confined tumors. Radiotherapy or small pellet radioactive implants (brachytherapy) is also used in patients with earlier stage prostate cancer or whose health makes surgery unacceptable.

When the prostate cancer is advanced, spreading to other parts of the body, treatment shifts to reducing the testosterone (male hormone) that feeds the prostate and its tumors. By depleting it, hormone therapy reduces symptoms and prevents further growth. But while hormonal manipulation causes prostate cancer to shrink in 85 to 90 percent of advanced prostate cancer patients, it does not cure the disease. In addition, the effects only last between 24 and 36 months.

Scientists believe the results are only short-lived because prostate cancer contains different genetically identical cells, some of which may respond to hormone deprivation, while others do not. It is those androgen-insensitive cells that scientists believe eventually grow, reproduce and ultimately cause death. The good news is that there is now evidence that hormonally sensitive cells may influence hormonally insensitive cells, decreasing their rate of progression.

Androgen deprivation is usually achieved by either surgery or medication, in what is commonly referred to as monotherapy because one method is used. Testosterone can be reduced by removing the testes during a bilateral orchiectomy — surgically opening the scrotum, and freeing blood vessels and nerves before cutting the testicles away from surrounding tissue. The other commonly used option, however, is chemical castration — injecting synthetic LH-RH agonists (blocks an action) or antagonists (stimulates an action) into the body every three to four months to suppress the natural production of testosterone.

A second option focuses on interfering with the effects of other adrenal hormones in addition to testicular testosterone. Referred to as complete androgen blockade (CAB), this treatment choice combines an orchiectomy or LH-RH antagonist with anti-androgens, drugs that block the effects of adrenal gland hormones by influencing a receptor in the nucleus of the prostate cancer cell. These medications include flutamide, bicalutamide and nilutamide. Some urologists add a third drug, finasteride, which blocks the conversion of testosterone to a more potent androgen, dihydrosterstosterone (DHT). In doing so, it deprives the cancer cells of an element needed for growth.

How effective is hormone therapy for prostate cancer?

While scientists and urologists agree on many aspects of hormone deprivation in the treatment of prostate cancer, there is still controversy concerning when and how to use these options. For instance, research continues in the debate over:

Monotherapy vs. complete androgen blockade (CAB): CAB has not yielded dramatic increases in survival for advanced prostate cancer patients. (At best, improvement is seven months.) But there is evidence that it may be more advantageous for patients with minimal disease, or those undergoing medical therapy. On the other hand, orchiectomy does not seem to benefit from adding the anti-androgen flutamide.

Early vs. late hormonal deprivation: Research has not provided a clear indication that early, compared to delayed, hormonal therapy improves survival. There is little argument, however, that a person with prostate cancer that has distant spread (e.g. to their bones) should be treated promptly to prevent potentially crippling effects like bone fractures and spinal cord paralysis. There is also evidence that prostate cancer patients whose disease has spread to the lymph nodes will encounter prolonged progressive-free survival and a better quality of life with early hormonal therapy. In fact, research suggests that men suffering from prostate cancer that has spread without symptoms experience fewer serious complications if they undergo hormonal therapy earlier, rather than later.

Continuous vs. intermittent androgen deprivation: The current hormonal therapy standard of care is to continue the treatment until the disease progresses or ends in death. In fact, most physicians prescribetestosterone-suppressing monotherapy even after other second-line hormonal agents or chemotherapies are introduced. But recently, research has focused on intermittent androgen deprivation (IAD), irregular hormonal therapy to possibly inhibit the molecular pathways that allow cells to become cancerous. The idea is that by stopping and starting therapy, IAD delays that transformation and may even improve quality of life. But until a current randomized National Cancer Institute trial yields its findings, scientists will not know which offers patients the best survival with the least complications — IAD or continuous hormonal therapy.

What can be expected after hormone therapy for prostate cancer?

While hormonal therapy can put your cancer in check, there are unpleasant side effects: nausea and vomiting, hot flashes, anemia, lethargy, osteoporosis, swollen and tender breasts and erectile dysfunction.

Also, if your cancer is resistant to hormonal treatments, your doctor may order chemotherapy, which consists of single drugs or a cocktail of several medications aimed at killing the cancer cells, even though this regimen causes numerous side effects.

While preliminary evidence suggests that hormonal treatment may improve cure rates when combined with radiation or surgery, that theory is still under investigation.

Can prostate cancer be cured with hormonal therapy?

At this time, there is no evidence that prostate cancer is cured with hormonal therapy. Withdrawing androgens, however, can keep the disease from progressing and relieve symptoms.

Prostate cancer is one of the most common forms of cancer in men and some of its traditional treatments can result in serious complications. However, cryoablation is an emerging alternative that shows great promise. What does this new treatment entail? What are its advantages and disadvantages? The following information should help answer those questions and more.

What is cryoablation?

Cryoablation is a form of cryotherapy for the prostate that involves the controlled freezing of the prostate gland in order to destroy cancerous cells. The damage caused by freezing occurs at several levels: molecular, cellular and whole tissue structure. Important factors influencing freezing injury are the rate of temperature reduction after the initiation of freezing, the time cells remain frozen and the subsequent heating rate during thawing.

The cells are not the only structures damaged during freezing. During cryoablation of the prostate, the surrounding connective tissue (stroma) and the smallest blood vessels (capillaries) are damaged and subsequently have an inadequate blood supply that is believed to slow the growth of cancer.

Who are the most suitable candidates for cryoablation of the prostate?

Suitable candidates for this procedure are patients who have organ-confined prostate cancer or those who have minimal spreading beyond the prostate.

How is the procedure performed?

Under anesthesia, an ultrasound probe is guided into the rectum. The prostate is imaged and its dimensions measured. An aiming grid software program is then activated and images of the prostate are projected on a screen. Under continuous monitoring with ultrasound imaging, cryoablation probes are placed at predetermined sites within the prostate. The freezing starts at the front part of the prostate by activating the front probes, followed by the middle and finally the back probes. This sequence allows continuous monitoring (by visualizing the freezing process through the transrectal ultrasound). Two freezing cycles are usually done. Between them, the prostate is allowed to thaw either passively or actively by using helium gas. If the prostate is more than 26 to 27 mm. long, an apical pullback maneuver is usually done to freeze the lower part of the prostate. Double freezing is performed again. Each of the commercially available cryosurgical systems has a different type of probe and placement strategy, but all aim to freeze the prostate, tumor(s) and surrounding tissue — except the urethral area. By keeping the urethra warm during prostate freezing, the urethral wall remains viable. This is important, as it minimizes the risk of urethral damage, obstruction and urinary incontinence. Using a flexible cystoscope, the bladder and urethra are examined meticulously for evidence of injury. If a probe is found piercing the urethra it is repositioned. A suprapubic catheter (a small catheter that is pierced into the bladder through a small opening in the lower abdomen) is inserted and secured in place by a suture. The urethral warming catheter is introduced through the urethra with its end in the bladder. During the procedure, the bladder is kept nearly full by keeping the open suprapubic catheter at a slightly higher level than the bladder. The urethral warming catheter keeps the urethra warm throughout the procedure and is kept active for about 20 minutes after complete thawing to prevent the urethra from freezing.

What can be expected after treatment?

The patient is usually kept overnight, allowed some food and encouraged to walk. The patient is usually discharged the next morning with a catheter in place for drainage.

The patient can attempt to urinate at first desire. Most patients are able to urinate in about 10 to 15 days but some may require longer recovery periods. When the patient is able to urinate well and empty the bladder satisfactorily, the suprapubic catheter is removed. Some surgeons use a urethral catheter instead of the suprapubic catheter. In that case, the urethral catheter is removed seven to ten days and trial unination is attempted. If the patient is unable to urinate, the catheter is reinserted for a few more days. Oral antibiotics are usually given for 10 to 14 days. Other symptoms and signs the patient may experience are generalized fatigue that usually persists for seven to 10 days, urethral discharge, scrotal swelling, numbness at the tip of the penis, passage of flecks of tissue, pain or burning sensation during urination and increased urinary frequency and/or urgency.

A PSA test is usually done at three months. Also, a prostatic biopsy may be done at three to six months to assess for prostate destruction and absence of viable cancer cells especially if PSA level is detectable. If the biopsy proves negative, PSA measurements are obtained monthly for one to two years, then every six months for the next one to three years and every year thereafter.

What type of results can be expected?

Five U.S. institutions reported their experience with the use of cryoablation. The results were compared to those of conformal radiotherapy and brachytherapy. Patients with a previous history of failed radiotherapy were excluded and androgen deprivation was determined and categorized separately. Patients were classified as low risk, moderate risk or high risk according to the cancer characteristics (stage of the disease, Gleason grade and PSA level). The procedure was not consistent at all institutions. Differences included the number of probes used, number of freeze cycles per patient, length of apical pullback maneuver, real-time monitoring during freezing and the system used for freezing. A total of 975 patients were studied, of whom 238 were low risk, 321 were moderate risk and 385 were high risk; risk was not determined in 38 patients. The five-year rate for non-rising postoperative PSA levels for low and medium risk patients ranged between 60 and 76 percent and for high-risk patients it was 41 percent. Only about 18 percent of the patients were found to have a positive biopsy following the procedure. These results are encouraging and may place cryoablation therapy between radical prostatectomy and radiotherapy in effectiveness.

What are the risks associated with this procedure?

New technological advances have resulted in a significant reduction of the rate of complications. Improved urethral warming devices have minimized urethral complications. Better spacing of the probes now contributes to the effectiveness and safety of the procedure. Improved monitoring of the freezing with transrectal ultrasound is also helpful. However, some risks still exist. Perhaps one of the most critical is the risk of urinary rectal fistula, which creates a channel between the prostate or the bladder and the rectum and may cause diarrhea due to urine in the rectum and possibly severe infection due to bacteria in the bladder. There is also a high incidence of erectile dysfunction. Other complications, although uncommon given technological advances, include urinary incontinence, urinary retention requiring transurethral resection of the prostate (TURP) and inflammation of the testicle. Almost all patients have a temporary need for a catheter to empty the bladder for an average of 15 days. Permanent, severe incontinence is rare (approximately 1 percent) and other rare complications include prostatic abscess and permanent penile numbness.

What are the advantages and disadvantages of cryoablation of the prostate?

Cryoablation therapy offers:

• a minimally invasive procedure
• favorable success rate and complication rates
• a short recuperation period
• procedure can be repeated if the first cryoablation has failed
• radiation therapy or radical prostatectomy is still an option if the procedure fails
• less than half the cost of the traditional treatment

The disadvantages are:

• insurance may not cover this procedure
• extensive experience and training by the surgeon are required

Is cryoablation therapy ever used after other prostate cancer treatments have been tried?

Yes. An important use of cryoablation therapy is for patients who fail or develop recurrence after radiation therapy.

Prostate cancer is the third leading cause of cancer deaths among men in the United States. Despite previous reports of chemotherapy’s ineffectiveness in fighting prostate cancer, a number of recent medical studies are providing some hope with new cancer-fighting drugs. What is chemotherapy? What are some of the chemotherapeutic agents used to fight prostate cancer? The following information should help answer these questions.

What is the prostate?

The prostate, a part of the male reproductive system, is about the same size and shape as a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum, and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What is prostate cancer?

Prostate cancer is a significant health care problem in the United States due to its high incidence. It is the most common cancer in men affecting approximately 234,000 American men each year with approximately 27,000 of diagnosed men dying each year. Prostate cancer is different from most cancers in that a large considerable percentage of men, particularly older men with a shorter life expectancy, may have a “silent form” of this cancer—it will not cause symptoms or spread beyond the prostate gland during their lifetime. Sometimes this cancer can be small, slow growing and present limited risk to the patient. Clinically important prostate cancers can be defined as those that threaten the well-being or life span of a man.

What is chemotherapy?

Although surgery and radiation therapy remove, destroy or damage cancer cells in a specific area, chemotherapy works throughout the body. Chemotherapy can destroy cancer cells that have metastasized, or spread to parts of the body far away from the primary (original) tumor. Chemotherapy is the use of specific drugs that can destroy cancer cells. The drugs circulate throughout the body in the bloodstream and can kill any rapidly growing cells, including potentially non-cancerous ones. Chemotherapy drugs are carefully controlled in both dosage and frequency so that cancer cells are destroyed while the risk to healthy cells is minimized. Often, it is not the primary therapy for prostate cancer patients, but may be used when prostate cancer has spread outside of the prostate gland or in combination with other therapies.

What are some of the side effects of chemotherapy?

Common side effects of chemotherapy depend on the type of drug used, dosage and length of treatment. The most common side effects are fatigue, nausea and vomiting, diarrhea, hair loss and increased susceptibility to infection. To minimize the side effects, chemotherapy drugs are carefully monitored according to the amount and number of times they are administered by your physician. Supportive medication is also given to further help offset the side effects caused by the drugs. For instance, new drugs to prevent nausea and vomiting can minimize these side effects. Most side effects disappear once chemotherapy is stopped.

How is chemotherapy administered?

The drugs used for chemotherapy can be administered directly into a vein while others may be taken orally. Some of the drugs must be given in the doctor’s office or clinic; others can be administered while the patient is at home. Hospitalization is rarely needed unless side effects occur.

What are some of the new chemotherapy drugs currently being tested?

Several promising new anticancer drugs are under study and are being added to surgery or radiation therapy for men with stage III (cancer has spread to surrounding tissue or seminal vesicles) prostate cancer. Chemotherapy is also being tried in conjunction with hormone therapy for men whose advanced cancers are no longer responsive to hormonal therapy alone.

Historically, chemotherapy has not proven particularly effective against slow-growing prostate cancer cells. However recent studies show significant promise in advanced prostate cancer. There are now two published clinical trials in which men with metastatic, advanced prostate cancer progressing despite hormone therapy received a chemotherapy drug called docetaxel or mitoxantrone. In each of these trials, symptom improvement, substantial PSA reduction, and increased survival were significantly more likely to occur in the group of men who received docetaxel versus another drug called mitoxantrone. Thus the current standard of care is to use docetaxel as the first chemotherapy drug in the treatment of metastatic prostate cancer.

A number of interesting new drugs are being developed to combine with docetaxel. They include bevacizumab (Avastin), atrasentan (Xinlay) and calcitriol (DN 101) and GVAX In preliminary studies, each of these drugs, when combined with docetaxel, caused substantial PSA declines in more than 50 percent of men as well as symptomatic improvement in men with advanced disease. The four combined drug regimens are now being compared to docetaxel alone in four separate phase III clinical trials. All men with metastatic prostate cancer who are considering chemotherapy are encouraged to enter one of those 4 trials.

The encouraging results of these trials have caused the initiation of other studies investigating various chemotherapy regimens in both early and late prostate cancer. For example, there are many studies underway adding docetaxel to surgery or radiation therapy for men with stage III (cancer has spread to surrounding tissue or seminal vesicles) or high-risk prostate cancer. Other studies will determine if vaccines which induce immune responses against prostate specific targets will improve outcomes for men with advanced cancers. In addition, there are new drugs in clinical trials which will target the testosterone (androgen) signaling pathway in advanced prostate cancer, as more evidence suggests that many cancers remain sensitive to better androgen deprivation, including abiraterone, and MDV3100, both of which are new approaches to androgen deprivation.

For patients whose disease has progressed despite docetaxel chemotherapy, there are currently no FDA approved agents and participation in clinical trials is highly encouraged. Current options include best supportive care, alternative chemotherapeutic regimens, bisphosphonates (bone-strengthening agents), radiation therapy, additional hormonal manipulations, and steroids. One agent being evaluated in phase III trials is an oral form of chemotherapy called satraplatin, and while it has shown early signs of benefit in terms of delaying progression, we await more long term survival results in 2007.

What are the advantages and disadvantages of chemotherapy? How do I know if it’s right for me?

Chemotherapy provides an additional means of relieving the symptoms of advanced prostate cancer possibly by reducing pain and slowing tumor growth. However, because chemotherapy is an aggressive treatment with side effects, it is important to discuss your treatment options with your doctor.

Can I take other medicines while I am getting chemotherapy?

Some medicines may interfere with the effects of your chemotherapy drugs. To ensure that your treatment is the most effective that it can be, tell your doctor about any and all prescription and non-prescription medicines you are taking. Your doctor will tell you if you should stop taking any of these medicines before you start chemotherapy. After your treatments begin, check with your doctor before taking any new medicines or stopping the ones you already take.

Can I continue with my normal activities while I am getting chemotherapy?

Whether you can continue work, school and other activities depends on your treatment and how it affects you. Hospitalization is not needed for the treatments and most people are able to continue their activities during treatment. You might be able to schedule your treatments late in the day or before the weekend to minimize their interference with your activities.

Prostate cancer is the third-leading cause of cancer deaths among men in the United States. Yet, when detected in its early stages, prostate cancer can be effectively treated and cured. What are its causes and symptoms? How is it diagnosed? The following information should help answer such questions.

What is the prostate?

The prostate gland is a small, walnut-sized gland in men. It is located below the bladder and surrounds the upper portion of the urethra. The prostate gland lies in front of the rectum, and its posterior surface can be felt during a rectal examination. The function of the prostate is to secrete a fluid that makes up part of the semen. The prostate gland may be a source of many health problems in men, the most common being benign prostatic hyperplasia (BPH), prostatitis and cancer.

What is prostate cancer?

Prostate cancer is a significant health-care problem in the United States due to its high incidence. It is the most common non-skin cancer in men affecting approximately 234,000 American men each year with approximately 27,000 of these men dying each year. Prostate cancer is different from most cancers in that an appreciable percentage of men, particularly older men with a shorter life expectancy, may have a silent form of this cancer—it will not cause symptoms or progress beyond the prostate gland during their lifetime. Sometimes this cancer can be small, slow growing and present limited risk to the patient. Clinically important prostate cancers can be defined as those that threaten the well-being or life span of a man.

What are the causes and risks associated with prostate cancer?

What causes prostate cancer is a subject of intensive research. It is likely that prostate cancer occurs due to many reasons. Predominately a disease of elderly men, the diagnosis of prostate cancer is rare before age 40 but increases dramatically thereafter. In the United States, it is estimated that one in 55 men between the ages of 40 and 59 will be diagnosed with prostate cancer. This incidence climbs almost to one in six for men between ages 60 and 79. This association is also reflected in mortality as prostate cancer accounts for about 10 percent of cancer-related deaths in men between the ages of 60 and 79 and nearly 25 percent in those over the age of 80.

Worldwide, prostate cancer ranks third in cancer incidence and sixth in cancer mortality among men. There is, however, a notable variability in incidence and mortality among world regions. The incidence is low (but rapidly increasing in recent years) in Japan and intermediate in regions of Central America and Western Africa. The incidence is higher in North America and Northern Europe. Although some of these differences may be accounted for by differences in screening for prostate cancer and the risk of other diseases among world regions, it is likely that they can be accounted for, in part, by genetic predisposition as well as diet and other environmental factors.

There are also ethnic determinants of risk. Blacks are in the highest risk group, with an incidence of more than 200 cases per 100,000 black men. The incidence in Caucasian and Asian men is slightly more than half that of blacks. In addition, blacks tend to present with more advanced disease and have poorer overall prognosis than Caucasian or Asian men.

Men with a family history of prostate cancer are at an increased risk of developing the disease. The risk correlates with the number of first-degree relatives (father, brother or uncle) affected by prostate cancer and the age at onset. Men with a family history of disease may have a risk of developing prostate cancer 2 to 11 times greater than men without a family history of prostate cancer.

There is also considerable evidence showing that prostate cancer is more common in men with a high intake of fat in their diets. The worldwide difference in prostate cancer incidence may be associated with dietary intake of soy proteins. In Asian countries such as Japan and the Republic of Korea where prostate cancer incidence and mortality are just a fraction of that in North America, soy consumption in the form of tofu, soymilk and miso is up to 90 times higher than that consumed in the United States. In a study of more than 40 nations, researchers found soy, on a per calorie basis, to be the most protective dietary factor. This protective role may be associated with two of soy’s components, genistein and daidzein that may act as weak estrogens or through other mechanisms. Estrogens are female hormones that inhibit prostate cancer growth. Some experts have suggested that the worldwide differences in prostate cancer incidence may also be explained by the high intake of green tea by residents of Asia.

The intake of other certain dietary factors may also reduce the risk of developing prostate cancer. Such substances include lycopene and selenium. Cooked tomatoes are rich sources of lycopene. Lycopenes are antioxidants that may protect cells from becoming cancerous. Several studies have shown that the likelihood of developing prostate cancer is reduced by high intake of lycopene. Researchers found that men ingesting two or more servings of tomato sauce per week had a 36 percent reduction in cancer risk compared to those who did not. Selenium intake has also been reported to lower prostate cancer risk. In a clinical trial designed to determine if selenium could lower skin cancer recurrences, men who took selenium had a 63 percent reduction in prostate cancer incidence compared to those who took a sugar pill (placebo). Attention has also focused on vitamin D’s effect on the prostate. Epidemiologic evidence shows an inverse relationship between prostate cancer risk and ultraviolet radiation, the primary source for vitamin D production. This observation has led some to suggest that higher rates of prostate cancer in the elderly may be partly due to decreased sun exposure or a decline in the body’s ability to make vitamin D with aging.

Finally, the correlation of vasectomy and prostate cancer risk remains controversial. Although some studies have suggested that men who have undergone a vasectomy are at an increased risk of developing prostate cancer, many other studies have failed to show such a correlation.

What are the symptoms of prostate cancer?

In its early stages, prostate cancer often causes no symptoms. When symptoms do occur, they may include any of the following: dull pain in the lower pelvic area; frequent urination; problems with urination such as the inability, pain, burning, weakened urine flow; blood in the urine or semen; painful ejaculation; general pain in the lower back, hips or upper thighs; loss of appetite and/or weight; and persistent bone pain.

How is prostate cancer diagnosed?

Currently, digital rectal examination (DRE) and prostate specific antigen (PSA) are used for prostate cancer detection. The age at which time screening for prostate cancer should begin is not known with certainty. However, most experts agree that healthy men over the age of 50 should consider prostate cancer screening with a DRE and PSA test. Screening should occur earlier, at age 40, in those who are at a higher risk of prostate cancer such as African-American men or those with a family history of prostate cancer.

DRE: The DRE is performed with the man either bending over, lying on his side or with his knees drawn up to his chest on the examining table. The physician inserts a gloved finger into the rectum and examines the prostate gland, noting any abnormalities in size, contour or consistency. DRE is inexpensive, easy to perform and allows the physician to note other abnormalities such as blood in the stool or rectal masses, which may allow for the early detection of rectal or colon cancer. However, DRE is not the most effective way to detect an early cancer, so it should be combined with a PSA test.

PSA Test: The PSA test is usually performed in addition to DRE and increases the likelihood of prostate cancer detection. The test measures the level of PSA, a substance produced only by the prostate, in the bloodstream.

This blood test can be performed in a clinical laboratory, hospital or physician’s office and requires no special preparation on the part of the patient. Ideally, the test should be taken before a DRE is performed or any catheterization or instrumentation of the urinary tract. Furthermore, because ejaculation can transiently elevate the PSA level for 24 to 48 hours, the patient should abstain from sexual activity for two days prior to having a PSA test. A tourniquet or rubber strap is tied around the upper arm to mildly restrict the flow of blood and keep blood in the vein. Then, a needle with a tube-like container attached is inserted into a vein, usually in the bend of the elbow or the top of the hand. After a sufficient sample of blood is obtained, the needle is withdrawn, a bandage is placed on the puncture site and firm pressure is held until the bleeding stops. The entire test takes less than five minutes and produces only mild discomfort. After, the patient may experience slight bruising at the puncture site.

Very little PSA escapes from a healthy prostate into the bloodstream, but certain prostatic conditions can cause larger amounts of PSA to leak into the blood. One possible cause of a high PSA level is benign (non-cancerous) enlargement of the prostate, otherwise known as BPH. Inflammation of the prostate, called prostatitis, is another common cause of PSA elevation, as is recent ejaculation. Prostate cancer is the most serious possible cause of an elevated PSA level. The frequency of PSA testing remains a matter of some debate. The American Urological Association (AUA) encourages men to have annual PSA testing starting at age 50. The AUA also recommends annual PSA testing for men over the age of 40 who are African-American or have a family history of the disease (for example, a father or brother who was diagnosed with prostate cancer), or for those who are interested in an early risk assessment. Some experts have suggested that men with an initial normal DRE and PSA level of less than 2.5 ng/ml can have PSA testing performed every two years. However, a disadvantage of infrequent testing is that it limits the ability to detect a rapidly rising PSA level that can signal aggressive prostate cancer. Recently, several refinements have been made in the PSA blood test in an attempt to determine more accurately who has prostate cancer and who has false-positive PSA elevations caused by other conditions like BPH. These refinements include PSA density, PSA velocity, PSA age-specific reference ranges and use of free-to-total PSA ratios. Such refinements may increase the ability to detect cancer and these should be discussed with your physician.

Currently, it is recommended that both a DRE and PSA test be used for the early detection of prostate cancer. It is important to realize that in most cases an abnormality in either test is not due to cancer but to benign conditions, the most common being BPH or prostatitis. For instance, it has been shown that only 18 to 30 percent of men with serum PSA values between 4 and 10 ng/ml have prostate cancer. This number rises to approximately 42 to 70 percent for those men whose PSA values exceeding 10 ng/ml.

Biopsy: Prostate biopsy is best performed under transrectal ultrasound guidance using a spring-loaded biopsy device coupled to the transrectal probe. The patient is prepared with an enema and an antibiotic. The lubricated ultrasound probe is inserted into the rectum. Some lubricating gels include a topical anesthetic. Patients are positioned on their side for this procedure. The physician will first image the prostate using ultrasound noting the prostate gland’s size and shape and whether or not any other abnormalities exist, the most common of which are shadows which might signify the presence of prostate cancer. However, not all prostate cancers are visible. After the prostate gland has been anesthetized with an injection of a local anesthetic through a long fine needle that is passed through the probe, the physician performs the biopsy. Using the spring-loaded biopsy device attached to the ultrasound probe, the physician performs multiple biopsies of the prostate gland. Generally, 10 to 12 (or more, depending upon the size of the prostate gland and the prior PSA and biopsy history of the patient) biopsies will be performed. Each biopsy removes a cylinder of prostate tissue approximately 3/4 inch in length and 1/16 inch in width. The entire procedure takes 20 to 30 minutes. The biopsy tissue taken will then be examined by a pathologist (a physician who specializes in examining human tissue to determine whether it is normal or diseased). The pathologist will be able to confirm if cancer is present in the biopsy tissue. If cancer is present, the pathologist will also be able to grade the tumor. The grade indicates the tumor’s degree of aggressiveness—how quickly it is likely to grow and spread. The Gleason grading system is the most widely used system. In this system, the majority tumor pattern is assigned a score from 1 to 5 and the minority pattern is similarly assigned a score, using the same scale. The majority and minority scores are added together to give a Gleason sum ranging between 2 and 10. Scores of 2 to 4 designate low aggressiveness, 5 to 6 mildly aggressive, 7 moderately aggressive and scores of 8 to 10 highly aggressive.

The transrectal ultrasound guided prostate biopsy is usually well tolerated. Injecting local anesthetics into the area before biopsy may minimize this discomfort. Blood in the ejaculate (hematospermia) and blood in the urine (hematuria) occur in most patients.. High fever is rare, occurring in only 1 to 2 percent of patients. The antibiotic is continued for at least 48 hours after the biopsy procedure.

Why is prostate cancer staged?

Once prostate cancer has been diagnosed by a prostate biopsy, the physician must stage the disease to determine the extent of the cancer (i.e., the “T” stage) and whether it has spread beyond the prostate gland to the surrounding tissues, the seminal vesicles, the lymph nodes and/or the bones. The T stage is determined by the DRE and other imaging studies of the prostate gland and surrounding tissues, such as the ultrasound scan, CT scan, MRI scan, or MR spectroscopy scan. The T stage is divided into the following categories:

T1: Doctor is unable to feel the tumor or see it with imaging (e.g., transrectal ultrasound)

T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed and is low grade (Gleason < 6).

T1b: Cancer is found after TURP but is present in more than 5% of the tissue removed or is of a higher grade (Gleason > 6)

T1c: Cancer is found by needle biopsy that was done because of an elevated PSA

T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still appears to be confined to the prostate

T2a: Cancer is found in one half or less of only one side (left or right) of the prostate

T2b: Cancer is found in more than half of only one side (left or right) of the prostate

T2c: Cancer is found in both sides of the prostate

T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles

T3a: Cancer extends outside the prostate but not to the seminal vesicles

T3b: Cancer has spread to the seminal vesicles

T4: Cancer has spread to adjacent organs, such as the urethral sphincter, rectum and/or wall of the pelvis

To determine if the cancer has spread to the lymph nodes or bones, the physician may order a CT or MRI scan of the pelvis. A bone scan may be obtained to rule out metastases to the bone. Sometimes follow-up imaging studies are needed to further evaluate abnormalities found on the bone scan. Some physicians order these scans only when the cancer is Gleason grade >7 or the patient has a PSA level > 10 ng/ml.

Prostate cancer represents a spectrum of disease. Although some cancers may grow so slowly that treatment may not be needed, others are a threat to life. Determining the need for treatment can be a complex decision. Initially, the need for treatment should be based on the stage and grade of the cancer as well as the age and health of the patient. Many physicians have sought to devise risk assessment schemes that predict the likelihood of disease recurrence if patients are treated and progression or significant growth of their cancer if they undergo initial surveillance or watchful waiting. By combining many types of information (i.e., serum PSA level, clinical stage, Gleason score, extent of cancer in biopsy specimens), patients can be advised of the likely aggressiveness of their cancer and the need for and types of treatment available. However, the longer the patient’s life expectancy, the more uncertain the prediction becomes, as most prostate cancers progress with time. Imaging tests, such as a radionuclide bone scan, CT scan or MRI, and MR spectroscopy may help assess whether the cancer is still confined to the prostate or has spread elsewhere. When prostate cancer spreads (metastasizes) it is usually progresses in a cascade-like fashion to by perforating the capsule and extending into the periprostatic tissues, then to the seminal vesicles, then to the lymph nodes and finally to the bones, lungs, and other organs. With advanced prostate cancer, meningeal metastases are relatively common. Not all men with prostate cancer need to undergo imaging tests as the risk of spread to other organs can be estimated on the basis of serum PSA levels and cancer grade. It is reasonable to omit the bone scan in patients with newly diagnosed, untreated prostate cancer, who have no symptoms from their cancer, a Gleason score < 6 and have serum PSA concentrations less than 10 ng/ml and certainly in those with serum PSA concentrations less than15 ng/ml (unless the Gleason score is > 7 . Similarly, a pelvic CT scan or MRI may not be necessary in men with lower grade cancers, cancers still confined to the prostate and serum PSA values less than 10 ng/ml.

Can prostate cancer be prevented?

There is controversy about true prevention. Some physicians believe that antiandrogen drugs, such as finasteride and dutasteride, can prevent prostate cancer. However, others are skeptical, and some believe that antiandrogens can only slow the progression of well-differentiated elements but may allow higher-grade elements to emerge as the dominant elements in the tumor. Some physicians believe that general health measures might reduce the risk of prostate cancer, such as eating a healthy diet, being physically active and visiting the doctor on a regular basis. Clinical studies are ongoing which are testing the ability of some antioxidants, such as vitamin E and selenium to prevent prostate cancer. However, the preponderance of the current evidence suggests that vitamin E does not reduce prostate cancer risk.

What is the outlook for prostate cancer?

The number of men diagnosed with prostate cancer remains high. However, 5-year relative survival rates have increased dramatically and there has been at least a 25% reduction in the age-specific prostate cancer mortality rate since the beginning of the PSA era. It is estimated that 99 percent of men diagnosed with localized or regional prostate cancer survive at least five years, while only 33% of those with metastases at diagnosis survive 5 years.