Prostate Cancer

Prostate gland is a small walnut sized gland situated below urinary bladder and produces part of semen. In older age groups, enlargement of prostate gland is the commonest urological problem. This enlargement can be benign (BPH – benign enlargement of prostate) or malignant (prostatic carcinoma).

Prostate cancer is second most common cancers in males. Although prostate cancer can be a 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 heightens the risk of cancer prostate. Races like African-American are at highest risk than whites. Positive family history also increases the risk.

Clinical presentation

Most patients with early prostate cancer are asymptomatic. Presence of symptoms suggests advance stage. Patient may have urinary symptoms likes poor flow, urinary frequency, blood in urine, urinary leakage, unable to hold urine, waking up multiple times in night for urination and feeling of incomplete urination after voiding. If the disease has spread to bones, it may cause bone pain. Involvement of spine may lead to weakness of lower limbs and paralysis.

Diagnosis

DRE & PSA

Digital rectal examination by urologist involves feeling of prostate gland through anal opening. Any hardness in 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 to all healthy males to go for PSA test after 40 years of age and repeat test at frequency depending on its result.

Multiparametric MRI of prostate

If DRE or PSA suspects cancer prostate, Multiparametric MRI provides non-invasive localization of cancer. This uses multiple parameters like hypoechogenecity, contrast enhancement, ADC value, spectroscopy and cystine – choline ratio to decide nature of lesion. This new modality is highly accurate in suspecting cancer and differentiating it from infection but still not confirmatory.

Prostate Biopsy

If DRE, PSA or MRI suspects cancer prostate, biopsy is required to prove it. This involves taking of prostatic tissue by needle placed through anal opening guided by ultrasound probe. The tissue taken in biopsy is examined by pathologist to confirm the prostate cancer.

Staging and risk assessment

MRI and Bone scan (if very high PSA) are done accordingly to decide the stage of the cancer. The Stage of cancer means about 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 advance 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.

Treatment

Early Disease

Options for the patients with early / localised disease are wathchful waiting, surgery and radiotherapy. Watchful waiting is an option for patients with low grade disease (gleason score6 or less and low PSA) or very old patients with other diseases or poor life expectancy. However they will need definitive treatment in case of progression of disease.

Surgery in form of Radical Prostatectomy is an option for patients with good life expectancy (more than 10 years) and age less than 75 years with localised disease. It involves removal of entire prostate gland through abdomen and it cures the cancer. Person will have the 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 localised or locally advanced disease who are elderly, unfit or unwilling for surgery. This also completely cures the cancer and gives normal life span to the patient. With the advances in machines and technology, side effects of radiotherapy due to the burning of adjoining tissues have reduced significantly. Its side effects include burning, frequency and blood in urination, diarrhoea and blood in stool.

Advanced / Metastatic Disease

Hormonal manipulations– Prostate cancer cells growth depend 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 vigour and bony weakness. Calcium supplementation and bisphophonates 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 which are given via intravenous routes to kill these cancer cells. These are toxic but in this way some months are available to the patient. Vacccination therapy can also provide some months to life of the patients of CRPC.

Supportive / palliative treatment– The patients of advance cancer with urinary retention can be relieved by endoscopic scrapping of prostate (TUR Channelling). Obstruction of 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 localised radiotherapy.

Conclusion

Prostate cancer is one of the most common cancers affecting the aging males. It is slow growing but due to late presentation it leads to debility, suffering and death. It can be diagnosed in early stage by easily available tests. If treated in early stage it gives 100% life expectancy. Even in advance stage effective treatment options 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

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