The prostate gland is a small walnut-sized gland situated below the urinary bladder and produces part of semen. In older age groups, enlargement of the prostate gland is the commonest urological problem. This enlargement can be benign (BPH – benign enlargement of the prostate) or malignant (prostatic carcinoma).
Prostate cancer is the second most common cancer in males. Although prostate cancer can be slow-growing cancer, it is a leading cause of death. Most of the cases in India present in advance stages leading to high death rates. The last two decades, in particular, have witnessed an upsurge in its incidence attributed to changing lifestyles and increased proportion of elderly populations.
Old age, repeated prostatic infections, obesity and smoking habits heighten the risk of cancer prostate. Races like African-Americans are at the highest risk than whites. Positive family history also increases risk.
Most patients with early prostate cancer are asymptomatic. The presence of symptoms suggests the advance stage. The patient may have urinary symptoms like poor flow, urinary frequency, blood in urine, urinary leakage, unable to hold urine, waking up multiple times in the night for urination and feeling of incomplete urination after voiding. If the disease has spread to bones, it may cause bone pain. The involvement of the spine may lead to weakness of lower limbs and paralysis.
DRE & PSA
Digital rectal examination by urologist involves a feeling of the prostate gland through the anal opening. Any hardness in the prostate gives suspicion of cancer.
Raised value of a simple blood test of PSA (prostate-specific antigen) can also suspect prostate cancer. It is advisable for all healthy males to go for the PSA test after 40 years of age and repeat the test at a frequency depending on its result.
Multiparametric MRI of the prostate–
If DRE or PSA suspects cancer prostate, Multiparametric MRI provides non-invasive localization of cancer. This uses multiple parameters like hypoechogenicity, contrast enhancement, ADC value, spectroscopy, and cystine – choline ratio to decide the nature of the lesion. This new modality is highly accurate in suspecting cancer and differentiating it from infection but still not confirmatory.
If DRE, PSA or MRI suspects cancer prostate, the biopsy is required to prove it. This involves taking of prostatic tissue by a needle placed through the anal opening guided by the ultrasound probe. The tissue taken in a biopsy is examined by a pathologist to confirm prostate cancer.
Staging and risk assessment–
MRI and Bone scan (if very high PSA) are done accordingly to decide the stage of cancer. The Stage of cancer means the level of spread of the tumor in the body. Cancer may be confined inside the prostate gland within its capsule (Localised disease), may spread locally outside capsule (Locally advanced disease) or may spread to bones, lymph nodes, liver, lungs or brain (Metastatic/advanced disease). Further treatment depends upon the stage and grade of cancer.
Options for patients with early/localized disease are watchful waiting, surgery, and radiotherapy. Watchful waiting is an option for patients with the low-grade disease (Gleason score or less and low PSA) or very old patients with other diseases or poor life expectancy. However, they will need definitive prostate cancer treatment in Delhi in case of progression of the disease.
Surgery in the form of Radical Prostatectomy is an option for patients with good life expectancy (more than 10 years) and age less than 75 years with localized disease. It involves the removal of the entire prostate gland through the abdomen and it cures cancer. A person will have a normal life span after surgery. It can be performed by open method, Laparoscopic method or with Robotic assistance. It has the side effect of temporary urinary leakage.
Radiotherapy is indicated in patients with localized or locally advanced disease who are elderly, unfit or unwilling for surgery. This also completely cures cancer and gives normal life span to the patient. With the advances in machines and technology, the side effects of radiotherapy due to the burning of adjoining tissues have reduced significantly. Its side effects include burning, frequency and blood in urination, diarrhea, and blood in the stool.
Advanced / Metastatic Disease–
Hormonal manipulations– Prostate cancer cell’s growth depends upon the availability of Testosterone hormone which is produced in the testis. If both testes are removed surgically or blocked medically by hormonal blocking injections and tablets, cancer stops to grow and regresses. Even in case of advance prostatic cancer, this manipulation gives years of trouble free life. Its side effects include loss of vigor and bony weakness. Calcium supplementation and bisphosphonates are given to prevent and control these side effects.
However, after some years of hormonal manipulations, some smart cancer cells learn to grow on other feeds rather than Testosterone hormone or produce their own hormone and leads to CRPC (Castration-Resistant Prostate cancer)condition. Here comes the role of chemotherapy i.e. drugs that are given via intravenous routes to kill these cancer cells. These are toxic but in this way, some months are available to the patient. Vaccination therapy can also provide some months to the life of the patients of CRPC.
Supportive / palliative treatment– The patients of advance cancer with urinary retention can be relieved by endoscopic scrapping of the prostate (TUR Channelling). Obstruction of the ureter and renal failure by cancer can be treated by ureteral stenting or tube drainage of kidneys (PCN). Bony pain due to metastasis can be controlled by calcium supplementation, Bisphosphonates, and localized radiotherapy.
Prostate cancer is one of the most common cancers affecting aging males. It is slow-growing but due to late presentation, it leads to debility, suffering, and death. It can be diagnosed at an early stage by easily available tests. If treated in the early stage it gives 100% life expectancy. Even in the advanced stage, effective options for prostate cancer treatment in Noida are available to give the patients “useful years” of life.
Dr. Shailendra Kumar Goel
M.S., M.Ch., D.N.B., M.B.A., M.N.A.M.S.
Principal Consultant Urologist, Andrologist & Renal Transplant surgeon
Max Super Speciality Hospital, Vaishali & Noida