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 have dealt with prostate cancer.
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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, but some are much larger.
There are no clear symptoms of early-stage prostate cancer. It is detected with two tests and confirmed with another.
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 volume (size) 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 things as sexual stimulation, ejaculation, or taking long bike rides, so avoid them at least two days before a PSA test.
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).
There are several things you must know before you can decide how to treat the cancer.
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 is the Gleason score (for example, 2 + 4 = 6).
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, a 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. 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 be near or outside 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 is equal to A1, II to A2‑B2, III to C1‑C2, and IV to D1‑D2.
The stage is based on the DRE, PSA, Gleason score, number of biopsy cores that contain cancer cells, the approximate sizes and locations of the tumors, and other tests.
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 in 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.
Your clinical stage, Gleason score, age, test results, and other factors affect which of the procedures is likely to be the safest for you. 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 can affect the outcome.
The NCCN Prostate Cancer Guidelines estimates the relative risk of prostate cancer returning after treatment:
|AMOUNT OF RISK||LOW||MEDIUM||HIGH||VERY HIGH|
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.
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.
Find out as much as you can about prostate cancer and the procedures. You should know what is happening (or should be happening) at every step. Medical errors are not unusual, especially errors involving medications.
Study your options carefully, and don’t let anyone pressure you into making a decision before you’ve learned enough.
The more you learn, the better your chances.
Sources of information There are lots of sources, 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 Reliable Medical Information at the end of this document.
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 who have very little experience, 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 will.
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 there ahead of time.
Keep records Request copies of your biopsy report, prostate volume, every test that was done, and all other important health information. Make a list of the causes of death of family members, the medicines, herbs, and supplements you take, and any major health problems you have had. Records are too often lost, misplaced, or unavailable, so make an extra set to bring to every appointment.
First try to find out:
Then ask yourself:
When interviewing specialists, ask:
Premise 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 side effects are not. Any procedure could cause damage to nearby nerves and organs, allow cancer cells to escape, or lead to permanent side effects or life-threatening complications.
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 usually 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.
Disadvantages Skin over the target area may become red and sensitive. Some diarrhea and urinary frequency is likely. Patients may feel tired.
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 at predetermined locations. The radiation diminishes over three to six months, depending on the type of material.
Advantages Fast and relatively painless. Seeds can be placed outside the prostate to kill cancer cells that might have already escaped. Everyday life can soon be resumed.
Disadvantages Temporary urinary and rectal problems occur as the body reacts to constant radiation. Misplaced or stray seeds can cause serious damage.
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.
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 A vertical incision about 4 inches (10 cm) long is made in the center of the lower abdomen.
Perineal A semi-circular incision is made behind the testicles.
Laparoscopic Several small incisions are made in the abdomen, through which miniature instruments and a tiny 2D video camera are inserted. They are 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 The prostate is immediately examined to see if there are positive margins (indications that cancer cells reached the edge of the prostate). If they did, measures can be taken to kill them. Patients feel relieved because the prostate is no longer there.
Disadvantages Blood clots may occur in legs or lungs. Hernias may develop later on. Infections are common. 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.
Premise Freezing kills cells.
Practice An extremely cold liquid or gas is sent through very thin hollow needles to create tiny balls of ice in the tumors.
Advantages Advantages It is fast, relatively painless, and comparatively inexpensive. Everyday life can soon be resumed.
Disadvantages Normal cells do not recover. Dead tissue may block the urethra. A catheter must be worn for about a week.
This technique has not yet been approved for use in the United States but is available in some 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.
You should have a course of external-beam radiation around the prostate or hormonal therapy (to block testosterone) following the procedure to kill any cancer cells that may have escaped (adjuvant therapy).
Hormonal therapy is sometimes begun several months before 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 produce dangerous side effects and increase the risk of osteoporosis.
How successful your treatment is depends on your age, stage, general health, the type of procedure, your specialist’s skill, and a certain amount of luck.
Incontinence Urinary problems may occur after any procedure and continue for a few weeks or longer. This may be a permanent condition if organs, nerves, or muscles have been damaged. But there are ways to reduce or manage the problems.
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 that 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 after a procedure, so any rise may be temporary. If the cancer does return, there are procedures (salvage therapies) that may be able to stop it.
Worrying about recurrence (PSA anxiety) only makes it harder to enjoy the good things in your life.
Before you are treated, ask your doctor how long you should plan to remain in that city 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.
Once cancer has spread through the body (metastasized), 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 Slows tumor growth by blocking the production of testosterone.
Practice Drugs or, in some cases, castration.
Advantages When the cancer no longer needs testosterone, stopping the drugs will slow growth once again.
Disadvantages Side effects may include hot flashes, anemia, abdominal pain, and liver failure. Eventually the tumors will be able to grow with or without testosterone.
Premise Relieves pain by reducing the size of tumors that press against nerves and bones.
Practice Patients receive external radiation aimed at the tumors or injections of radioisotopes that migrate to them.
Advantages Patients feel better and may live longer. Bones are less likely to fracture.
Disadvantages Side effects may include lowered immunity, fatigue, and skin reactions.
Premise Drugs target and kill 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 intravenously (directly into the bloodstream) during a hospital visit or with patient-operated devices, pills, liquids, or capsules.
Advantages Patients may live a little longer. (Some extremely expensive drugs may extend life by a 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 can have different side effects.
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.
Finding Reliable Medical Information www.hypertext.org/ENGLISH/INFO.html
Biopsies, staging, etc. http://en.wikipedia.org/wiki/Prostate_biopsy
Treatment options overview
US Too support groups www.ustoo.org/
US Too international support groups http://www.ustoo.org/Chapter_NearYou.asp">
Man to Man support groups http://goo.gl/ylnugA
Prostate Problems E-Patient Group http://www2.acor.org/listservs/join/115
British support groups http://www.patient.co.uk/selfhelp.asp
Canadian support groups http://www.prostatecancer.ca
Australian support groups http://goo.gl/0jfcov
Women Against Prostate Cancer www.womenagainstprostatecancer.org
Cancer support in more countries http://goo.gl/Jhv7f5
National Cancer Institute’s Cancer Information Service
American Cancer Society http://www.cancer.org/cancer/prostatecancer/index
Hormone (androgen deprivation) therapy for prostate cancer http://goo.gl/iuzw1
About erectile dysfunction (ED) http://goo.gl/X0wMS
About urinary incontinence kidney.niddk.nih.gov/KUDiseases/pubs/uimen/index.aspx
PubMed medical search engine www.ncbi.nlm.nih.gov/sites/entrez
Prostate Cancer Research Institute newsletters http://goo.gl/OhLUr
National Center for Complementary and Alternative Medicine http://www.nccam.nih.gov
Getting your medical records http://goo.gl/4FzBY
A Primer on Prostate Cancer by Stephen B. Strum M. D. and Donna Pogliano
The Dattoli Challenge by Michael Dattoli M. D. and Jennifer Cash ARNP
Man to Man: Surviving Prostate Cancer by Michael Korda (patient)
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.
Copyright © by William Dyckes 1997-2013 firstname.lastname@example.org
Permission to reproduce: You may print one copy of this text but you may not change it, publish it, put it on another website, or sell it without the written permission of the author.
Permission for support groups: www.hypertext.org/ENGLISH/perm.html