Revised and expanded August 2013 - www.hypertext.org/ENGLISH/OVER.html
It’s hard to focus when you’re reading about cancer, which is why you should begin with this overview. In less than half an hour it will give you a general idea of what the disease is and what you can do about it. After that, it will be much easier to understand what you find in books and other sources.
The author was treated for prostate cancer in 1997. This overview is based on careful research, his own experiences, and those of other men who had prostate cancer.
FINDING THE CANCER
The prostate, which is part of the male reproductive system, is located directly beneath the bladder. The average prostate is about the size of a walnut. Some are much larger.
A prostate B bladder C pelvic bone
D rectum E urethra F pelvic-floor
muscles G seminal vesicle
A prostate B bladder
C pubic bone
F pelvic-floor muscles
G seminal vesicle
There are no clear symptoms of early-stage prostate cancer. It is detected with two tests and confirmed with another.
DIGITAL RECTAL EXAM (DRE)
A doctor presses a finger against the wall of the rectum next to the prostate (at point D on the drawing). A slight hardness may indicate a tumor.
Prostate-specific antigen levels are measured with a blood test. A high level of PSA is not a cause of cancer, but it may be a symptom. PSA is produced to form part of the ejaculate. Some of it normally leaks into the bloodstream, but more escapes if tumors develop.
Having a PSA of less than 1.0 does not guarantee there is no cancer present, and a PSA of 10 does not necessarily mean that there is. Many things affect PSA levels and how dangerous they might be, including age, race, the size (volume) of the prostate, urinary infections, and a non-cancerous prostate tumor called BPH (benign prostatic hyperplasia). Moreover, PSA levels can vary from day to day, so a high PSA should be tested again in a few weeks. Temporary rises can be caused by such as sexual stimulation, ejaculation, or taking long bike rides, so avoid them at least two days before a PSA test.
But many things can affect PSA levels, including age, race, the size (volume) of the prostate, urinary infections, and BPH (benign prostatic hyperplasia), a non-cancerous tumor of the prostate. And PSA levels vary over time. A high PSA should be tested again a few weeks later. For at least two days before the test, avoid things that might cause a temporary rise, such as having any kind of sex or taking long bike rides.
The two types of biopsy are the transrectal (from inside the rectum) and the transperineal (from the area between the anus and the testicles). Before the procedure the patient is given antibiotics to prevent infections and a local anesthetic to reduce pain. A biopsy gun, guided by ultrasound, is used to inject a dozen or more very thin hollow needles into the prostate to collect samples of cells (cores).
ASSESSING THE CANCER
There are several things you must know before you can decide how to treat the cancer.
GLEASON GRADES AND SCORE
A pathologist examines the cells in the biopsy cores and rates them from one (normal) to five (very deformed). These are the Gleason grades. The sum of the two most common grades, for example, 2 + 4 = 6, is the Gleason score. The more-common (primary) grade is listed first. If it is higher than the second, or the score is more than six, the cancer is likely to be more aggressive. A score of less than six suggests that the tumors are growing slowly.
Because most pathologists must deal with many kinds of cells, your Gleason score may not be accurate. You should get a second opinion of your biopsy slides from a pathologist who specializes in prostate cancer.
The clinical stage of the cancer is an estimate of the size of the tumors and how far the disease may have spread. It is based on the DRE, PSA, Gleason score, number of biopsy cores that contain cancer cells, the approximate sizes and locations of the tumors that were found, and other tests.
The most common classification systems for prostate cancer stages are ABCD and TNM (Tumor, Node, Metastasis).
T1-T2c or A1-B2 are local or organ-confined. The tumor is still inside the prostate.
T3-T4b or C1-C2 are regional or extracapsular. The tumor appears to extend beyond the edge of the prostate.
N1-M1c or D1-D2 are metastatic or systemic. Cancer cells have reached the lymph nodes (N1-N3 or D1) or other parts of the body (M1-M1c or D2).
In the older I-IV system, I was equal to A1, II to A2-B2, III to C1-C2, and IV to D1-D2.
These may be needed to estimate your stage more precisely and to establish a baseline (your current status), so that the progress of your treatment can be measured. Magnetic resonance imaging (MRI) and other techniques can help staging the cancer. They may also be used to create 3D computer images of your prostate and the surrounding area to help plan the procedure. The very precise mapping needed for focal therapies (cryotherapy and HIFU) is done with a 3D or saturation biopsy.
The clinical stage, Gleason score, age, test results, and other factors affect which of the procedures is likely to be the safest. Statistical tables called nomograms, based on the long-term results of the treatments of thousands of men, can be used to predict the likelihood of a successful procedure. There are, of course, other factors, such as the specialist’s experience, that will affect the outcome.
DECIDING WHAT TO DO
Don’t waste time and don’t rush into anything. Unless the cancer has begun to spread, it is more important to make an informed decision than a quick one.
HOW TO IMPROVE YOUR CHANCES
Remain calm Stress makes your life harder and may harm your immune system. Antidepressants, meditation, or other remedies may help. And do things that make you laugh.
Join a support group It helps to know that you are not the only one with this problem, and to meet men who have dealt with it successfully. Group members and specialists who speak to the group may provide useful information about treatments and doctors. (But be wary of anyone who strongly recommends doing what he did. He may really be trying to convince himself that he did the right thing.)
Change your habits Exercise and healthful eating habits can slow cancer growth. Tumors need calories, so avoid sugars, fats, and alcohol. Excess weight may make it harder to treat the prostate, make tumors more aggressive, make PSA levels seem lower, and increase the chances the cancer will return.
Eat less of all kinds of meat, especially red. Avoid charred or fried meat or fish. Cut back on eggs and dairy products. Eat fruit, especially citrus, and plant foods, especially tomatoes, garlic, onions, broccoli, and green, leafy vegetables. Beans, nuts, lentils, berries, whole grains, and olive oil are also good for you. Drink green, red, or white tea.
Don’t overdo supplements—many vitamin pills provide much more than the daily recommended amount.
Talk to your family and friends Your cancer worries them too. Talking about it will help them deal with it and may help you work out your own feelings.
Counseling Cancer takes an emotional toll. You and some of your family members might benefit from counseling.
DO YOUR HOMEWORK
Study your options carefully, and don’t let anyone pressure you into making a decision before you’ve learned enough.
It is essential that you find out as much as you can about the disease and the procedure. You should know what is happening (or should be happening) at every step. Medical errors are not unusual, especially errors involving medications.
The more you learn, the better your chances.
Sources of information There are quite a few types, and you should look into as many as you can. E‑patient communities, patient diaries, and books are especially useful. For more about the best (and worst) sources, see the link to Finding Medical Information at the end of this document.
Paying for your treatment Getting health insurance in the U.S. is no longer as much of a problem it used to be, thanks to the Affordable Care Act. For information about that and what uninsured people can do right now, see the link to Health Insurance in the United States at the end of this document.
DECIDING ON A PROCEDURE
There are more than half a dozen ways to treat prostate cancer. Don’t pick one before you’ve talked to several kinds of specialists.
Your choice of a specialist is probably more important than your choice of a procedure. Avoid those with little experience, who don’t seem to have kept up-to-date, or just don’t seem to care. If a doctor does not listen to you or answer your questions, find one who does.
Appointments Prepare questions for every office visit. Use a recorder so you won’t have to write everything down. Bring someone who can help you focus. And be on time.
Request copies of your biopsy report, prostate volume, every test that was done, and all other important health information. If you haven’t already, list the causes of death of family members, the medicines, herbs, and supplements you take, and any health problems you have had. Records are too often lost, misplaced, or unavailable, so make extra copies you can bring to every appointment.
QUESTIONS YOU SHOULD ASK
First try to find out:
Which procedures are likely to be appropriate for you.
What all of the possible side effects for each procedure are.
Who the best specialists for each procedure are.
Where those specialists are located.
If your insurer/HMO will approve the procedure—and the specialist—you want.
Then ask yourself:
Which side effects worry me the most?
Which procedure seems to make the most sense?
When you interview specialists, ask:
Will my age or health make this procedure too risky?
What other tests should I have?
Are you board-certified for this procedure?
How many of these procedures have you done?
What are your personal success rates for your patients’ long-term survival, incontinence, and erectile dysfunction?
How soon will my life be back to normal?
TREATING EARLY-STAGE PROSTATE CANCER
WAITING (watchful waiting, active surveillance, expectant management)
PSA testing has made it possible to detect cancers so small that they are unlikely to ever become a problem. If the cancer is growing very slowly, your Gleason score is low, and your life expectancy is 10 to 20 years, you may never need to be treated. Your life will probably not be any shorter, and you won’t risk any of the painful and permanent side effects that a procedure might cause.
Practice PSA tests, DREs, and biopsies to monitor the cancer.
Advantages Exercise and better eating habits can slow the growth of tumors. And there will probably be plenty of time to have a procedure if it becomes necessary.
Disadvantages There may be tumors that were not found, or the cancer may begin to grow more rapidly. And it’s not easy to keep from worrying.
Survival rates are about the same for all procedures, but rates of incontinence, erectile dysfunction, and other problems are not. Any of these procedures may cause damage to nerves and nearby organs, permanent side effects, or life-threatening complications. Some of the cancer may escape in the process.
The following descriptions are not complete. You must do a lot of research before you choose one of them.
Premise Radiation damages cell DNA. Normal cells usually recover, cancer cells do not.
Practice Patients go to a center once a day five times a week for six to eight weeks or twice a day for a shorter period.
Three-dimensional conformal radiotherapy (3D-CRT) X-rays are aimed from several angles to distribute radiation evenly and limit damage to other tissues and organs. The more-advanced types of x-ray equipment are:
Intensity-modulated radiotherapy (IMRT) A computer adjusts hundreds of microbeams of variable intensities to match the shape of the prostate from every angle.
Image-guided IMRT (4D IGRT, IG-IMRT) Similar to IMRT, but it can also track small movements such as those caused by breathing. The beams instantly adjust to changes in the shape or position of the prostate.
Hadron radiation The energy of proton, neutron, or ion beams can be focused to reach its strongest point inside tumors. But very few centers offer any of these forms of radiation, and the treatment is much more expensive than x-ray therapy.
Advantages External radiation is usually painless. It can kill cancer cells at the edge of the prostate. Everyday life is only interrupted by the daily sessions.
DisadvantagesSkin over the target area may become red and sensitive. Some diarrhea and urinary frequency is likely. Patients may feel tired.
Permanent implants (seeds)
Premise If the source of the radiation is inside the prostate, it can be more powerful, better-focused, and constant.
Practice Tiny metal cylinders containing radioactive materials are inserted in the prostate. The radiation diminishes over three to six months, depending on the type of material.
Advantages Seeds can be placed outside the prostate to kill any cancer cells that might have already escaped. Fast and relatively painless. Everyday life can soon be resumed.
Disadvantages Temporary urinary and rectal problems occur as the body reacts to constant radiation. Misplaced seeds may cause serious damage.
Temporary implants (high-dose radiation, HDR)
Premise Tumors that receive very high doses of radiation at the start of the treatment have less chance of recovering.
Practice Highly radioactive materials are inserted in the prostate through temporary tubes for brief periods over several days. This is followed by a complete course of external-beam radiation.
Advantages Tumors receive much higher doses of radiation than otherwise possible. Everyday life is only interrupted by the initial hospital stay and daily external-beam radiation sessions.
Disadvantages Patients must remain in a hospital bed during the first stage. Some diarrhea is likely. Patients may feel tired.
SURGERY (radical prostatectomy, RP)
Premise If the prostate comes out, so does the cancer.
Practice The prostate is removed and the urethra is sewn back to the bladder. The types of prostatectomies are:
Retropubic An incision of about 4 inches (10 cm) is made down the center of the lower abdomen.
Perineal An incision is made behind the testicles.
Laparoscopic Miniature instruments and a video camera are inserted through small incisions in the abdomen and controlled by a surgeon watching a television screen.
Robotic laparoscopy Similar to laparoscopic surgery, but the surgeon controls the instruments and a 3D camera from a computer console.
Advantages Patients feel relieved because the prostate is no longer there. It is immediately examined to see if cancer cells reached the edge of the prostate (if there are positive margins) and escaped. If so, measures can be taken to kill them.
Disadvantages Patient’s blood must be drawn and stored before surgery. Blood clots may occur in legs or lungs. Hernias may develop later. A catheter must be worn for a week or more.
Note Some procedures for treating BPH (non-cancerous tumors of the prostate) are also called prostatectomies.
This technique has not yet been approved for use in the United States but is available in other countries.
Premise Extreme heat kills cells.
Practice High-energy ultrasonic waves are focused on tumors.
Advantages The heat only affects the tumors. Fast and relatively painless. Everyday life can soon be resumed.
Disadvantages Heat causes the prostate to swell, which may shift the tumors. Dead tissue may block the urethra. A catheter must be worn for about a week.
IMPROVING THE ODDS
You should have a course of hormonal therapy (drugs that block testosterone) or external-beam radiation after your procedure to kill any cancer cells that may have escaped (adjuvant therapy).
Hormonal therapy may also be recommended before a procedure (neoadjuvant therapy) if a prostate is very large or the cancer is near the edge of the prostate. This will shrink the prostate and tumors. But hormonal therapy can have dangerous side effects and increase the risk of osteoporosis.
SIDE EFFECTS OF THE PROCEDURES
How successful your treatment is depends on your staging, age, general health, the type of procedure, your specialist’s skill, and a certain amount of luck.
Incontinence Some type of urinary problem may occur after any procedure and continue for a few days or longer. Incontinence may be a permanent condition if organs, nerves, or muscles have been damaged. But there are ways to reduce or manage the problem.
Erectile dysfunction(ED, impotence) Most men cannot have a natural erection for a while after a procedure. If the nerves that affect erections have been damaged or removed, impotence may be a permanent condition. But drugs and other things may still make it possible for some men to have sex.
Recurrence The longer you are cancer-free (in remission), the more likely it is the cancer is gone. If it does return, it will probably be detected by a rapid rise in PSA (biochemical failure). But PSA levels vary from test to test, especially in the months following a procedure, so a rise may not be important. If the cancer does return, there are procedures (salvage therapies) that may be able to stop it. The NCCN Guidelines for Patients® has estimated the likelihood of recurrence.
AMOUNT OF RISK
AMOUNT OF RISK
AFTER THE PROCEDURE
Before you are treated, ask your doctor how long you should plan to remain in the area in case there are complications. You will have to see your specialist a few times in the next few months for checkups.
If the cancer did not escape and there are no lasting side effects, you have a good chance of leading a normal life. Continue to exercise, eat well, and have regular exams.
TREATING ADVANCED CANCER
Once cancer spreads throughout the body (metastasizes), no treatment can stop it. There are only ways to reduce pain and extend life. But if there are no more than five bone lesions (the cancer is oligometastatic), aggressive treatment may produce significantly longer survival times.
Premise Blocking testosterone will slow tumor growth.
Practice Drugs or castration.
Advantages When the cancer no longer needs testosterone, stopping the drugs will slow growth once again.
Disadvantages Hot flashes, liver failure, and more-dangerous side effects may occur. Tumors will eventually be able to grow with or without testosterone.
Premise This relieves pain by reducing tumors that press against nerves and bones.
Practice Patients receive external radiation or injections of radioisotopes that migrate to the tumors.
AdvantagesPatients feel better and may live longer. Bones are less likely to fracture.
Disadvantages Side effects may include lowered immunity, fatigue, and skin reactions.
Premise Chemotherapy targets and kills rapidly dividing cells. When hormonal therapy is no longer effective, these drugs can slow the spread of the cancer and relieve symptoms.
Practice The drugs are delivered directly into the bloodstream (intravenously) during hospital visits or administered with pills, liquids, capsules, or other means.
Advantages Patients may live a little longer. (Some extremely expensive drugs may extend life by few more months.)
Disadvantages It is not effective for long. Strong side effects, including possible nerve and kidney damage, anemia, reduced immunity, memory loss, and vomiting. Different kinds of chemotherapy drugs may have different side effects.
COMPLEMENTARY AND ALTERNATIVE THERAPIES
Complementary therapies supplement medical treatments. Some, like meditation or massage won’t compromise your treatment. But others, such as herbs or dietary supplements, might. Always check with your specialist before you try one.
Alternative therapies are not supported by scientific evidence. Many, like Laetrile, raise unrealistic hopes, cost a lot of money, may interfere with your treatment, and don’t work.
If you have advanced cancer, consider taking part in a clinical trial of a potential cure. It is not likely to save your life, but what is learned might save many lives in the future.
The Hypertext Guide to Prostate Cancer is one of several “high quality and informative sites” that address specific types of cancer: Cancer information resources: digital and online sources (PMID: 11955682). The full text is at http://goo.gl/L0OUu (section 7.5, page 32).
Other recommendations: http://goo.gl/DyQ4L
Disclaimer: This overview is only intended for educational purposes. It is not a substitute for informed medical advice from a physician.
The cross-section is a side view of a man's lower abdomen and genitals, facing left.
At the top of the picture is the bladder, roughly triangular. The prostate is at the base of the bladder. The tube that carries the urine out of the bladder (the urethra) passes through the prostate. Other tubes from the seminal vessicles enter the prostate from behind the bladder and join the urethra.
The prostate, and other abdominal organs, are supported by the pelvic-floor muscles. In front of the prostate and in front of and beneath the bladder is the pubic bone. One end of the pelvic-floor muscles is attached to the pubic bone.
The large intestine (the colon) descends directly behind the bladder. The wall of the rectum is very close to the prostate. This is where doctors are able to feel the prostate.