Prostate Cancer

Prostate cancer is a disease in which malignant (cancer) cells form in the tissues of the prostate. Prostate cancer is among the most common cancers diagnosed in men. In the United States, one in six men will be diagnosed in his lifetime.

While no one will say facing prostate cancer is easy, the good news is that with increased awareness and screening, more men are diagnosed early. That means most cancers are found while still localized in the prostate before the cancer has spread.

The prostate is a gland in the male reproductive system located just below the bladder and in front of the rectum. It is about the size of a walnut and surrounds the urethra (the tube that empties urine from the bladder). The prostate gland produces fluid that is one of the components of semen.

Statistics

Prostate cancer is the most common non-skin malignancy in men and is responsible for more deaths than any other cancer, except for lung cancer. However, microscopic evidence of prostate cancer is found during autopsies in many men. The American Cancer Society (ACS) estimated that about 186,320 new cases of prostate cancer were diagnosed in the United States during 2008. And while one man in six will be diagnosed with prostate cancer during his lifetime, only one man in 34 will die of it. More than 1.8 million men in the U.S. are survivors of prostate cancer.

Prognosis and treatment

Treatment options and prognosis depend on the patient's age and general health, the stage of the cancer, and the patient's Gleason score.

Developed by pathologist Donald Gleason, MD, in 1966, the Gleason score helps to evaluate the stage of cancer and predict probable responses to treatment, long-term results to treatment, and odds of survival.

According to the ACS, a pathologist assigns a Gleason grade ranging from 1 through 5 based on how much the cancer cells under the microscope look like normal prostate cells. Those that look a lot like normal cells are graded as 1, while those that look the least like normal cells are graded as 5. The combination of the two Gleason grades used in classifying each prostate cancer based on how the cells look under the microscope. Because prostate cancers often have areas with different grades, a grade is assigned to the two areas that make up most of the cancer. These two grades are added to give a Gleason score between 2 and 10. The higher the Gleason score, the faster the cancer is likely to grow and the more likely it is to spread beyond the prostate.

With greater public awareness, early detection of prostate cancer is on the rise and mortality rates are declining. And thanks to new advances in medical technology, cancer patients are returning to active and productive lives after their treatment.

Common treatment options

When prostate cancer is believed to be localized, there are five common treatment options available:

  • Removal of the cancerous prostate (radical prostatectomy).
  • Radiation of the cancerous prostate, through either external radiation or radioactive seed implants (radiation therapy or brachytherapy, respectively).
  • Freezing of the cancerous prostate (cryotherapy).
  • Hormonal therapy is non-curative when used alone, so often is done in conjunction with radiation therapy or cryotherapy.
  • Active surveillance (sometimes referred to as observation or watchful waiting).

What treatment option is best?

For localized prostate cancer, radical prostatectomy (removal of the prostate gland and some tissue around it) is considered the definitive way to treat the cancer. An estimated 91 percent of prostate cancer cases diagnosed in the U.S. are localized, which means many men are potential candidates for cancer removal. Patients should discuss the advantages and disadvantages of each treatment approach with their doctor.

Surgery

Surgically removing the cancerous prostate lets your doctor see how aggressive the tumor is and whether it has spread. This step can be critical, since up to 35 percent of tumors are more aggressive than presurgery assessment and biopsy results indicate.

Choosing surgery over radiation can make it easier for your doctor to detect a cancer recurrence through careful PSA (prostate-specific antigen) monitoring. Surgery also can help preserve your options if your cancer returns. After radiation therapy, there may be damage to the tissue surrounding the prostate. If that happens, nerve-sparing surgery may no longer be an option if your cancer returns. But, radiation usually remains an option for patients who have had surgical treatment of their prostate cancer.

With any cancer treatment, the first priority is survival. Several medical studies suggest there is a greater chance of long-term survival for patients undergoing surgery over other potential treatments.

According to one study, patients undergoing radical prostatectomy had a 40 percent lower risk of death from prostate cancer than radiation patients 15 years after treatment. (This study was of 3,159 men adjusted for age at diagnosis, race, socioeconomic status, Gleason score, biopsy grade of tumor, and year of diagnosis.)

Da Vinci prostatectomy

Da Vinci prostatectomy is the No. 1 choice for minimally invasive surgery of localized prostate cancer in the U.S.

In prostate cancer treatment, millimeters matter. Nerve fibers and blood vessels are attached to the prostate gland. To spare these nerves, they must be delicately and precisely separated from the prostate before its removal.

Using the robotic-assisted da Vinci Surgical System, surgeons view a high-resolution, 3D picture of a patient's anatomy. This enhanced vision is especially critical and helps the surgeon preserve important nerves and blood vessels during removal of the cancerous prostate. For most patients, da Vinci prostatectomy offers numerous benefits:

  • Less blood loss
  • Less scarring
  • Significantly less pain
  • Fewer complications
  • A shorter hospital stay
  • A faster return to normal daily activities

Several published medical studies of the da Vinci prostatectomy also have shown equal or lower rates of positive surgical margins (meaning margins with cancer cells left behind) than medical studies of other forms of surgery.

Urinary continence and sexual function after treatment are of concern for prostate cancer patients. Those who undergo a da Vinci prostatectomy may experience a faster return of urinary continence following surgery and lower rates of urinary pain than radiation (brachytherapy) patients. Patients who are potent prior to surgery usually recover their sexual function (defined as an erection for intercourse) within a year following da Vinci prostatectomy. Talk to your surgeon about reasonable expectations for recovery of sexual function and a rehabilitation program that may include exercises and drug therapy.

All surgical procedures are both patient- and procedure-specific. While prostatectomy using the da Vinci Surgical System is considered safe and effective, this procedure may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as the risks and benefits.

Radiation

Radiation therapy uses high-energy X-rays, either beamed from a linear accelerator or emitted by radioactive seeds implanted in the prostate (brachytherapy), to kill cancer cells. When prostate cancer is localized, radiation therapy serves as an alternative to surgery.
 

External beam radiation therapy is commonly used to treat men with regional disease whose cancers have spread too widely in the pelvis to be removed surgically, but who have no evidence of cancer spreading to the lymph nodes. In men with advanced disease, radiation therapy can help to shrink tumors and relieve pain.

Radiation can cause long-term damage to the nerves and important structures involved in sexual function. Many patients undergoing brachytherapy or external beam radiation treatment develop erectile dysfunction (as many as 50 percent in several studies.) Some radiation patients with higher risk cancers also are placed on hormone therapy for a year or more, which has an immediate negative impact on sexual function.

Freezing

Cryosurgery uses low temperatures to freeze and kill prostate cancer cells. The doctor places cryo needles into preselected locations in the prostate gland. Argon gas in the cryo probes forms an ice ball that freezes the prostate cancer cells. As the cells thaw, they rupture. The procedure takes about two hours, requires anesthesia (either general or spinal), and requires a one- to two-day hospital stay.

Hormonal Therapy

Hormonal therapy combats prostate cancer by cutting off the supply of male hormones (androgens) such as testosterone that encourage prostate cancer growth. Hormonal control can be achieved by surgical removal of the testicles (the main source of testosterone) or by medications.

Hormonal therapy targets cancer that has spread beyond the prostate gland and is thus beyond the reach of local treatments such as surgery or radiation therapy. Hormonal therapy is helpful in alleviating the painful and distressing symptoms of advanced disease. Although hormonal therapy cannot cure prostate cancer, it usually will shrink or halt the advance of disease, often for years.

Hormonal therapy is being investigated in current medical trials as a way to arrest cancer before it has a chance to metastasize.

Active surveillance

Observation or watchful waiting means that a physician closely monitors a patient's condition without giving any treatment until prostate cancer symptoms appear or change. This is usually used in older men over age 70 with other medical problems and early-stage disease. Watchful waiting is based on the premise that localized prostate cancers may advance so slowly that they are unlikely to cause men—especially older men—any problems during their lifetimes.

Some men who opt for active surveillance have no active treatment unless symptoms appear. They are often asked to schedule regular medical checkups and to report any new symptoms to their doctor immediately.