Prostate Cancer

Overview

What is the prostate gland?

The prostate gland is part of the male reproductive system (see the picture below). The prostate makes a fluid that mixes with sperm and other fluids during ejaculation. A normal prostate is about the size of a walnut.

What is prostate cancer?

Prostate cancer is when abnormal cells grow in the prostate gland. Prostate cancer is one of the most common types of cancer in men. Most types of prostate cancer grow slowly, but some types can be aggressive. This means the cancer grows quickly and can spread to other parts of the body. When cancer spreads, doctors say the cancer has “metastasized.”

Symptoms

What are the symptoms of prostate cancer?

Prostate cancer, especially in its early stages, often does not have any symptoms. Symptoms are more likely to appear as the cancer grows.

Tell your doctor if you have any of the following symptoms:

  • Difficulty starting urination
  • Less force to the stream of urine
  • Dribbling after you finish urinating
  • A need to urinate often, especially at night
  • Pain while urinating
  • Blood in the urine or semen
  • Difficulty starting or maintaining an erection
  • Pain with ejaculation
  • Pain or stiffness in the lower back, hips, pelvis and upper thighs
  • Unintended weight loss and/or loss of appetite

Causes & Risk Factors

What causes prostate cancer?

Doctors don’t know exactly what causes prostate cancer, but they do know that certain things may increase your risk for developing prostate cancer.

What are the risk factors for prostate cancer?

The risk factors for prostate cancer include:

  • Older age: Although men of any age can get prostate cancer, it is most common in men older than 65 years of age. In fact, more than 65% of prostate cancers are diagnosed in men older than 65 years of age.
  • Race: For unknown reasons, African-American men are 60% more likely to develop prostate cancer than Caucasian men.
  • Family history: Men who have a father or brother with prostate cancer have an increased risk for developing prostate cancer themselves.
  • Obesity: Obese men who are diagnosed with prostate cancer are more likely to have an advanced or aggressive cancer.

Diagnosis & Tests

What is prostate cancer screening?

A prostate cancer screening is a test that your doctor uses to look for prostate cancer before you have any symptoms.

Should I be screened for prostate cancer?

The U.S. Preventive Services Task Force (USPSTF) and the American Academy of Family Physicians (AAFP) recommend against routine prostate cancer screening for all men, regardless of age. Learn why.

What prostate screening tests are available?

Prostate screening tests include:

If you choose to be screened for prostate cancer, most doctors will recommend that you have both screening tests. It’s important to remember that these tests only help your doctor determine whether your prostate is healthy. An abnormal screening test result does not mean that you have cancer.

  • Digital rectal exam (DRE): During a DRE, your doctor will put a gloved, lubricated finger a few inches into your rectum to feel your prostate gland. A normal prostate feels firm. If there are hard spots on the prostate, your doctor may suggest additional testing to check for prostate cancer.
  • Prostate-specific antigen (PSA) test: The PSA test is a blood test that measures the level of PSA in your blood. PSA is a substance produced by the prostate. Men who have prostate cancer may have a higher level of PSA in their blood. However, a PSA level can also be high because of less serious causes, such as infection or prostate enlargement. The USPSTF and AAFP recommend against routine PSA-based screening for prostate cancer. Learn why.

What happens if my screening test results are abnormal?

If your screening test results are abnormal, your doctor may recommend other tests to determine whether you actually have cancer. Those tests may include:

Ultrasound: A transrectal ultrasound provides your doctor with an image of your prostate. During the test, your doctor will insert a small probe into your rectum. This probe sends out sound waves (called ultrasound) that bounce off your prostate gland. A computer uses the sound waves to create an image of your prostate.

Biopsy: A transrectal biopsy is when your doctor removes a very small piece of your prostate to check it for cancer cells. A biopsy is the only 100% sure way to diagnose prostate cancer. During the biopsy, your doctor will insert a needle through your rectum and into your prostate. The needle collects tissue from your prostate. Your doctor may take tissue samples from several different areas of your prostate.

What if my biopsy is normal?

If your biopsy is normal, you do not have prostate cancer. Talk to your doctor about whether another condition may have caused your symptoms or your high PSA level. Ask your doctor about how often you should have checkups.

What if my biopsy is positive for cancer?

If your biopsy results are positive for cancer, the next step is for your doctor to grade and stage the cancer.

  • Grading tells you how aggressive (fast-growing) the cancer is. Cancers with higher grades are more likely to grow and spread than cancers with lower grades. A common system of grading is called the Gleason score. Gleason scores range from 2 (not aggressive) to 10 (very aggressive).
  • Staging tells you how advanced the cancer is, or how far it has spread. To determine the stage, your doctor may order imaging tests such as ultrasound, bone scan, computerized tomography (CT) scan, or magnetic resonance imaging (MRI). Stages I or II mean the cancer was caught early and has not spread outside of the prostate. Stages III and IV mean the cancer has spread to nearby tissues or organs, or to other body parts.

Pros & Cons of PSA Testing

What is prostate cancer screening?

A prostate cancer screening is a test that your doctor uses to look for prostate cancer before you have any symptoms. The 2 types of prostate cancer screening tests are the digital rectal exam (DRE) and the prostate-specific antigen (PSA) test.

Should I be screened for prostate cancer?

The U.S. Preventive Services Task Force and the American Academy of Family Physicians recommend against routine prostate cancer screening for all men, regardless of age.

Based on evidence from research studies, prostate cancer screening — and especially the PSA test — may cause more harm than good for most men. Learn more about the PSA test and the pros and cons of this test below.

What is the PSA test?

The PSA test is a blood test that measures the level of prostate-specific antigen (PSA) in your bloodstream. PSA is a substance produced by the prostate gland. A small amount of PSA usually is found in the blood. But because cancer cells produce more PSA than normal cells, men who have prostate cancer may have a higher level of PSA in their blood. A PSA level can also be high because of less serious causes, such as infection or prostate enlargement.

What are the pros of PSA testing?

The main goal of the PSA test is to find prostate cancer early. For people who have fast-growing (aggressive) tumors, early detection could be very helpful (if the cancer has not spread outside of the prostate at the time it is detected). Cancer is usually easier to treat and is more likely to be cured if it is caught early. However, most men who have prostate cancer do not have the fast-growing, aggressive form of prostate cancer that might benefit from being found early.

What are the cons of prostate cancer screening?

Most men who have prostate cancer have a slow-growing form of cancer. This means that they probably do not have symptoms and may not ever need treatment. However, 90% of men who learn that they have cancer through screening go on to receive treatment anyway. Many experience long-term side effects of treatment, such as urinary incontinence and erectile dysfunction, or have serious complications. Out of every 1,000 men who receive surgery, up to 5 will die from complications of surgery.

In addition, PSA test results aren’t always accurate. Studies suggest that up to 80% of PSA test results are false-positives. This means that the PSA test result suggests that you might have cancer when in fact you do not. A false-positive test result can lead to unnecessary tests (such as a biopsy) and side effects from testing, and may cause worry for you and your family.

For these reasons, some medical organizations, including the U.S. Preventive Services Task Force and the American Academy of Family Physicians, recommend against routine PSA testing for men of all ages.

How do I make a decision?

Ultimately, the choice is yours. If you’re thinking about being screened for prostate cancer, talk to your doctor. Consider the pros and cons of screening, your health and individual risk factors, your preferences regarding diagnosis and treatment, and your doctor’s opinion and advice.

Where can I learn more about prostate cancer screening?

Doctors and researchers are performing research studies (called clinical trials) to learn more about the risks and benefits of prostate cancer screening. Ask your doctor about the most recent study results.

To stay up to date on new developments in prostate cancer screening, treatment, and research, visit the Prostate Cancer Foundation or the American Cancer Society.

To read the prostate cancer screening guidelines issued by various medical organizations, visit the following websites:

Treatment

What are some of the treatment options for prostate cancer?

The treatment options for prostate cancer depend on your age, your overall health, and the grade and stage of your cancer. If you have prostate cancer, it is very important for your doctor to monitor the growth of your cancer carefully. Fast-growing tumors can quickly spread to other organs in the body, and this makes treatment much more difficult. But men who have slow-growing tumors may not need treatment for a long time, and some do not ever need treatment.

Common treatment options include the following:

  • Watchful waiting
  • Radiation therapy
  • Radical prostatectomy
  • Hormone therapy
  • Chemotherapy

What is watchful waiting?

During watchful waiting, you have no treatment, but you see your doctor often. During this time, your doctor will monitor the growth of your cancer through follow-up blood tests, rectal exams, and biopsies. If there’s no sign the cancer is growing, you continue to have no treatment.

What is radiation therapy?

There are 2 types of radiation therapy. In one type, called external (beam) radiation therapy, radiation is given from a machine like an x-ray machine. In another type, called internal radiation therapy, radioactive pellets (called “seeds”) are injected into the prostate gland. This is sometimes called seed therapy or brachytherapy (say: “brake-ee-ther-uh-pee”). Both types have about the same results in curing prostate cancer. Sometimes, both types are used together.

The external beam radiation therapy usually only takes about 10 minutes, but it is given 5 days a week over 6 to 8 weeks. Some people might find this time consuming. However, you don’t need any anesthesia for this kind of treatment. The side effects are milder than the side effects that can occur with seed therapy.

Seed therapy can be done with just one hospital visit. For seed therapy, you’ll need to have anesthesia for a few minutes, but you should be able to go home right after the treatment. In seed therapy, higher doses of radiation can be put right into the cancer. You may feel more discomfort after this treatment.

What is radical prostatectomy?

Radical prostatectomy is a surgery to remove the whole prostate gland and the nearby lymph nodes. After the prostate gland is taken out through an incision, a catheter (a narrow rubber tube) is put through the penis into the bladder to carry urine out of the body until the area heals.

Other types of prostate surgery

There are several different types of prostate surgery. Some are less invasive, and each type has different risks and recovery rates. Your doctor will help decide which type of surgery is the best option for you.

Your doctor will talk to you about the kind of anesthesia used during surgery. You may be given general anesthesia, which puts you into a sleep-like state. Or an epidural or spinal anesthesia may be given instead. This kind of anesthesia blocks nerve routes from the spine and numbs the area.

What is the purpose of hormone therapy? Are there side effects?

The purpose of hormone therapy is to lower the level of male hormones, called androgens, which are produced mostly in the testicles. Androgens, such as testosterone, help the prostate tumor grow. Shots or pills can be given over a period of several months, or the testicles can be surgically removed. Once the testosterone is out of your body, the prostate cancer usually shrinks and new growth slows down. Hormone treatments are often used in combination with other kinds of prostate cancer treatments.

What happens after prostate cancer treatment?

Talk with your doctor about how often you will need follow-up PSA blood tests or other exams.

Risks and Benefits of Common Prostate Cancer Treatments

What are the risks and benefits of radical prostatectomy?

If you’re young and in good health, the short-term risks of this surgery are low. The hospital stay is usually 2 to 3 days, with the catheter left in place for 2 to 3 weeks. You’re usually able to go back to work in about 1 month. You shouldn’t have severe pain with this surgery. Most men regain bladder control a few weeks to several months after the surgery.

The main advantage of surgery is that it offers the most certain treatment. That is, if all of the cancer is removed during surgery, you are probably cured. Also, the surgery provides your doctor with accurate information about how advanced your cancer is, since the nearby lymph nodes are taken out along with the tumor.

Surgery does have risks. The main risks of radical prostatectomy are incontinence (loss of bladder control) and impotence (loss of the ability to get or keep an erection long enough to have sex). Most bladder and impotence problems improve with time.

Fortunately, only a very low percentage of men have severe incontinence after radical prostatectomy. Up to 35% of men have some accidental leakage of urine during heavy lifting, coughing, or laughing. The chance of impotence (erectile dysfunction) is lower if the surgeon is able to avoid cutting the nerves. This may not be possible if the tumor is large. Your age and degree of sexual function before the surgery are also important factors. If you’re younger than 50 years of age when you have this surgery, you’re likely to regain sexual function. If you’re older than 70 years of age, you’re more likely to lose sexual function. Remember, even if the nerves are cut, feeling in your penis and orgasms remain normal. Only the ability to get an erection for sexual intercourse is lost. However, there are medicines and devices that can help get an erection. You could lose a lot of blood during this surgery. Before the surgery, you might want to save about 2 units of your own blood in case you need a transfusion.

What are the risks and benefits of radiation therapy?

Older studies show that about one-half of patients become impotent within 5 years of having radiation therapy, but newer forms of radiation may have different outcomes. Many men feel very tired at the end of the treatment period. About 15% to 30% of men who have radiation therapy have side effects like urinary burning, urinary bleeding, frequent urination, rectal bleeding, rectal discomfort, or diarrhea during or shortly after the treatment. Erectile dysfunction (impotence) is a common side effect and often gets worse over time. More serious complications are rare. However, a degree of uncertainty goes along with radiation treatment. Since the prostate gland and the lymph nodes are not taken out, your doctor can’t tell the exact size of the tumor. The cancer could come back many years after radiation treatment.

At 10 years after treatment, cure rates are about the same for radiation therapy and radical prostatectomy. Men who have radiation therapy avoid the risks of surgery. There is also no risk of bleeding. You don’t have to stay in the hospital and you’ll recover faster. Daily activities can usually go on during the treatment. Incontinence is extremely rare after radiation therapy. Surgery, however, may give you a better chance of cure over the long term.

What are the risks and benefits of hormone therapy?

Hormone therapy often is used in combination with other treatments. It does have side effects. Some of the more serious side effects include loss of sex drive, weakened bones, erectile dysfunction, fatigue, and osteoporosis.

Hormone treatments may be used in patients who have cancer that has spread beyond the prostate gland. While prostate cancer that has spread usually responds to 1 or 2 years of hormone therapy, it does not cure the disease and most tumors eventually begin to grow again. Once this happens, the treatment goal is to control symptoms. No current treatment can cure prostate cancer once hormone therapy stops working. Recently however, chemotherapy has been shown to help some people who have advanced prostate cancer live longer.

Questions to Ask Your Doctor

  • When should I start getting screened for prostate cancer?
  • If I start having problems urinating, should I be tested for prostate cancer?
  • My father had prostate cancer. Does that mean I’m more likely to get it?
  • Is watchful waiting the right thing for my prostate cancer?
  • If we choose watchful waiting, how often will I need to come in for exams?
  • What is the best treatment for my prostate cancer?
  • Will I have a normal sex life after my prostate surgery?
  • Will I have any problems with urinating after prostate surgery?
  • How long will my treatment last?
  • Are there any support groups in my area?

Citations

  • MayoClinic.com. Prostate Cancer. Accessed 08/21/12
  • National Cancer Institute. What You Need to Know About Prostate Cancer. Accessed 08/21/12
  • Prostate Cancer Foundation. Understanding Prostate Cancer. Accessed 08/21/12
  • Treatment Options for Prostate Cancer: Evaluating the Evidence by V Bhatnagar, RM Kaplan(American Family Physician 05/15/05, http://www.aafp.org/afp/20050515/1915.html)
  • National Guideline Clearinghouse, Agency for Healthcare Research and Quality. Screening for Prostate Cancer. Accessed 08/21/12
  • U.S. Preventive Services Task Force. Screening for Prostate Cancer. Accessed 08/21/12