Prostate cancerDefinition Prostate cancer involves a malignant tumor growth within the prostate gland. Causes, incidence, and risk factors The cause of prostate cancer is unknown, although some studies have shown a relationship between high dietary fat intake and increased testosterone levels. When testosterone levels are lowered either by surgical removal of the testicles (castration, orchiectomy) or by medication, prostate cancer can regress. There is no known association with benign prostatic hyperplasia (BPH). Prostate cancer is the third most common cause of death from cancer in men of all ages and is the most common cause of death from cancer in men over 75 years old. Prostate cancer is rarely found in men younger than 40. Men at higher risk include black men older than 60, farmers, tire plant workers, painters, and men exposed to cadmium. The lowest incidence occurs in Japanese men and vegetarians. Prostate cancers are classified or staged based on their aggressiveness and how different they are from the surrounding prostate tissue. There are several different ways to stage tumors, a common one being the A-B-C-D staging system, also known as the Whitmore-Jewett system:
This system also contains several substages. Symptoms With the advent of PSA testing, most prostate cancers are now found before they cause symptoms. Additionally, while most of the symptoms listed below can be associated with prostate cancer, they are more likely to be associated with non-cancerous conditions.
Additional symptoms that may be associated with this disease:
Signs and tests A rectal exam often reveals the hard, irregular surface of an enlarged prostate. Testing considerations:
A newer test called AMACR is more sensitive for determining the presence of prostate cancer than the PSA test and may soon be more widely used to diagnose disease. Treatment The appropriate treatment of prostate cancer is often controversial. Treatment options vary based on the stage of the tumor. In the early stages, surgical removal of the prostate (prostatectomy) and radiation therapy may be used to eradicate the tumor. Metastatic cancer of the prostate may be treated by hormonal manipulation (reducing the levels of testosterone by drugs or removal of the testes) or chemotherapy. SURGERY Surgical treatment is usually only recommended after thorough evaluation and discussion of treatment options. A man considering surgery should be aware of the expected benefit of the procedure, as well as its potential risks.
RADIATION THERAPY Radiation therapy is used primarily to treat prostate cancers classified as stages A, B, or C. Whether radiation is as good as prostate removal is a debatable topic, and the decision about which to choose can be difficult. In patients whose health makes the risk of surgery unacceptably high, radiation therapy is often the preferred alternative. Radiation therapy to the prostate gland may be performed in a number of ways:
MEDICATIONS Hormonal manipulation aims at lowering testosterone levels. Since prostate tumors require testosterone, reducing the testosterone level is often very effective in preventing further growth and spread of the cancer. This can be done either through surgical removal of the testes or by using medications. Hormone manipulation is mainly used to relieve symptoms in men whose cancer has spread. Preliminary evidence suggests that it may improve cure rates when combined with radiation or surgery. However, this is still under investigation. Synthetic drugs like Lupron or Zoladex that mimic the function of LHRH (luteinizing hormone releasing hormone) are being used increasingly to treat advanced prostate cancer. These medications suppress testostorone production. The procedure is often called chemical castration, because it has the same result as surgical removal of the testes, although it is reversible, unlike surgery. The drugs must be given by injection, usually every 3 months. Possible side effects include nausea and vomiting, hot flashes, anemia, lethargy, osteoporosis, reduced sexual desire, and erectile dysfunction (impotence). Other medications used for hormonal therapy include androgen-blocking agents (such as flutamide) which prevent testosterone from attaching to prostate cells. Possible side effects include erectile dysfunction, loss of sexual desire, liver problems, diarrhea, and enlarged breasts. Chemotherapy is often used to treat prostate cancers that are resistant to hormonal treatments. An oncology specialist will usually recommend a single drug or a combination of drugs aimed at destroying the cancer cells. Medications that may be used to treat prostate cancer include:
Most men receive their chemotherapy (after the initial dose) on an outpatient basis at a clinic or physician's office. Possible side effects are numerous and specific to a given chemotherapy drug. LIFESTYLE CHANGES Surgery, radiation therapy, and hormonal manipulation all have the potential to disrupt sexual desire or performance on either a temporary or permanent basis. Discuss your concerns with your health care provider. Additionally, several options are available for managing sexual problems related to prostate cancer treatment. MONITORING You will be closely monitored for progression of the disease regardless of the type of treatment you receive. Monitoring will include:
Support Groups The stress of illness may be eased by joining a support group whose members share common experiences and problems. See support group - prostate cancer. Expectations (prognosis) The outcome varies greatly, primarily because the disease is found in older men who may have a variety of other complicating diseases or conditions, such as cardiac or respiratory disease, or disabilities that immobilize or greatly decrease activities. Complications Impotence is a potential complication after prostatectomy or radiation therapy. Recent improvements in surgical procedures have made this complication occur less often. Urinary incontinence is another possible complication. Medications can have side effects, including hot flashes and loss of sexual desire. Calling your health care provider Call for an appointment if you are a man older than 50 who has:
You should discuss the advantages and disadvantages to PSA screening with your physician. Prevention No preventive measures are known. Adopting a vegetarian, low-fat diet or one that mimics the traditional Japanese diet may lower risk. Early identification (as opposed to prevention) is now possible by yearly screening of men over 40 or 50 years old through digital rectal examination (DRE) and PSA blood test. There is a debate, however, as to whether PSA testing should be done in all men. There are several potential downsides to PSA testing. The first is that elevated PSAs do not always mean a patient has prostate cancer. The second is that physicians are detecting and treating some very early-stage prostate cancers that may never have caused the patient any harm. The decision about whether to pursue a PSA should be based on a discussion between patient and physician. September is Prostate Cancer Awareness Month in the US. Several urology centers across the country hold screening clinics that provide free rectal exams and PSA blood testing. Contact a hospital or medical center in your area for information on its program for prostate cancer awareness. Additional information may be obtained by contacting your local chapter of the American Cancer Society. Illustrations
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