THE PROSTATE
The prostate is an organ found only in men. Located just below the bladder, it produces prostatic fluid, which is part of the semen. Testosterone stimulates the growth of the prostate during puberty. Later it stimulates the production of prostatic fluid. Unfortunately, it also stimulates any cancer cells that may develop.
Description of the prostateSYMPTOMS
Symptoms of prostate cancer may include:
- frequent urination, especially at night
- inability to urinate, trouble starting to urinate, or weak flow
- dribbling after urination, or incontinence
- pain or burning during urination
- blood in the semen or the urine
- pain during ejaculation
- pain during bowel movement
- pain or stiffness in the lower back or pelvis
The presence of any of these symptoms does not necessarily indicate cancer but does mean that you should see a doctor. The absence of these symptoms does not necessarily indicate that you do not have cancer. Most men who have developed prostate cancer do not feel any special pain.
Two other problems can produce some of these symptoms:
Benign prostatic hyperplasia (BPH)
Prostatitis, an infection or irritationDETECTION
Regular physical exams are the only real means of detecting prostate cancer at an early stage. African-American men and any man who has a blood relative who had prostate cancer or breast cancer should have a physical every year after the age of forty. Others should begin by the age of fifty. The physical must include a digital rectal examination, usually called a DRE, and a blood test for an antigen known as PSA.
More about DREsPSA stands for prostate-specific antigen. Prostate cancer tissue produces approximately ten times as much of this protein than benign tissue does. For that reason, an elevated PSA (for example, from 3.5 to 8.0) does not necessarily reflect cancer. It is, however, a reason to consult a urologist. Similarly, a normal level of PSA does not guarantee that there is no cancer. You should be aware that there are several other things that affect PSA levels.
More about PSA
Things that may affect your PSA levelBIOPSIES
If prostate cancer is suspected, the next step is a biopsy. This means that a hollow needle will be shot into the prostate. The cores that the needles remove will be inspected by a pathologist to see if they contain cancerous cells. Unfortunately, biopsies do not provide confirmation that cancer is not there. According to Dr. Alan Partin, "about 20% of cancers are missed on the first biopsy." Johns Hopkins InteliHealth site, May 19, 1998
Number of Samples. Traditionally, urologists have taken six samples: three from each side, near the top, center, and base. However, researchers at Wake Forest University discovered that by taking seven additional samples, they discovered one-third more cases than were found with just the usual six (the sextant approach). Journal of Urology 157, 1997. So far, however, the systematic five-region biopsy does not seem to have been widely adopted.
For the most accurate results, the needle should be guided with an ultrasound probe, not with a finger and a prayer. And make sure the urologist provides a local anesthetic. Ten cc of 2-percent intrarectal lidocaine gel administered 10 minutes before the biopsy has been found to provide "safe and satisfactory anesthesia." Journal of Urology 2000;164:397-399
Biopsies, brief explanationTHE UNDERGRADING OF BIOPSIES
Detection, technical version
Pathologic examination of biopsies
About ultrasoundIf you know you have cancer, why have your biopsy slides reviewed? Because too many mistakes are made. And those mistakes, which almost always result in undergrading, can affect your treament in very important ways. One reason is that the majority of pathologists examine all kinds of slides. Their experience is not principally with prostate cancer. Others are simply not competent, as the recent case of the failure of pathologists at a hospital in Massachussetts who to recognize cancer cells in many instances. (Which suggests that perhaps even negative slides should be sent out for a second opinion.) The only way to be reasonably certain is to get the review done by a recognized expert in the field.
From a study based on Medicare claims:
Preoperative staging was documented in only 39% of the medical records but when present the reported staging underestimated the extent of disease in more than 50% of the cases. Pathologic examination revealed Stage C disease in 49% of the patients and positive surgical margins were commonly noted by pathology. Based on this review, it appears that many of the patients who underwent radical prostatectomy during this time frame may have been candidates for a less invasive form of therapy for their prostate cancer.
Preoperative (and clinical) mean staging done before any procedure is performed, while pathological refers to staging based on observation of the organ following surgery. Positive surgical margins means that the tumor reached or penetrated the edge of the prostate.The Department of Pathology of the Mayo Clinic found:
Current staging is limited by a significant level of clinical understaging (up to 59% in our experience) and overstaging (up to 5%) based on comparison with pathologic examination of resected specimens. Semin Surg Oncol 1994 Jan-Feb;10(1):60-72