PROSTATE CANCER

Our doctors at Cleveland Urology Associates are experienced in every stage and manifestation of the disease and have a very high success rate in treating prostate cancer. A multispeciality team of specialists from Urology, Radiation and Medical Oncology at our Cancer Center works with the patients to determine the best treatment options available. In addition to Radical Prostatectmy, we perform Brachytherapy (radiation seed implants), Intensity modulated radiation therapy (IMRT), hormonal therapy and chemotherapy.

An overview of Prostate Cancer

• Prostate cancer is the most common cancer among American men
• Prostate cancer is the third leading cause of cancer specific death among men in the United States.
• This year, 218,890 new cases and 27,050 prostate cancer related deaths are estimated to occur.
• By age 50, upto 1 in 4 men may have some cancerous cells in the prostate gland.
• As you age, your risk of prostate cancer increases.
• It is estimated that one out of every 10 American men will develop prostate cancer before the age of 85.
• The advent of  Prostate Specific Antigen (PSA) screening in the early 1990s resulted in an overall downstaging of newly diagnosed prostatae cancer, and presently, approximately 77% of prostate cancers are found while they are still localized to the prostate.
• Prostate cancer grows very slowly in most men. Infact, 80% of patients have a 5 year survival rate, and 60% live at least 10 years after the diagnsis is made and proper treatment is implemended.
• Some prostate cancers are very aggressive and deadly. Unfortunately, we are unable to predict their behaviour at this time.
• Eventually, the cancer may spread outside the prostate gland to other parts of the body.
• When prostate cancer spreads, they often go to bones and pelvic lymph nodes.

What is Prostate?

The prostate is a small, walnut-sized gland located in front of the rectum, behind the base of the penis, and under the bladder. It surrounds the first inch of the urethra, the tube that carries urine from the bladder. Its location allows us to feel through the rectum (during digital rectal examination) the part of the gland where most tumors occur. The prostate is made up largely of muscular and glandular tissues. Its only function is to produce fluid for sperm, which transports the sperm. During the male orgasm (climex) muscular contractions expell the prostate fluid into the urethra. Sperms, which are produced in the testicles, are also propelled into the urethra during orgasm. The sperm containing seminal fluid leaves the penis during ejaculation.

What is Prostate Cancer?

Prostate cancer is a malignant tumor that most often begins in the outer part of the prostate. As the tumor grows, it may spread to the inner part of the prostate and may block the flow of urine. Like any other cancers, prostate cancer can spread beyond the prostate to other parts of the body.

Early prostate cancer usually does not cause any symptoms, as the cancer progresses, however, it may constrict the urethra, and urinary problems may begin. Prostate cancer should not be confused with other common prostate conditions, most commonly known as Benign Prostatic Hyperplasia (BPH). This non-cancerous growth may press on the urethra and cause urinary symptoms. BPH is not cancer, nor does it lead to cancer, but a man can have both BPH and prostate cancer.

What causes Prostate Cancer?

• The exact cause is not known
• There is evidence that testosterone (male sex hormone) plays an important role. Men with high testosterone levels are at higher risk of developing prostate cancer.
• Diet high in animal fat (red meat and dairy products)
• Obesity
• African Ancestry - African American me are 60% more likely to have prostate cancer
• Blood relatives with prostate cancer (Father or Brother). If your father or brother has prostate cancer, you are twice as likely to have prostate cancer.

What are the symptoms of Prostate Cancer?

• In the very early stages of prostate cancer, there are no symptoms.
• When symptoms do develop, they vary according to the size and location of the tumor and are often the same as those for Benign Prostatic Hyperplasia (BPH). Infact, these symptoms would indicate BPH rather than cancer. Therefore, symptoms are not a reliable way to tell whether or not a man might have prostate cancer. Symptoms of prostate problems include:
  
  

1. Frequent urination, especially at night
2. Weak urinary stream
3. Slow urinary stream
4. Difficulty emptying the bladder
5. Blood in the semen
6. Blood in the urine
7. Difficulty in starting or stopping urination
8. Pain and burning on urination
9. Pain in the pelvis
10. Back pain or bone pain
11. Weight loss
12. Loss of appetite

"If you have any of these symptoms, please call your primary care physcian or call us to determine for sure whether your prostate condition is benign or cancerous".

How is Prostate Cancer diagnosed?

• The goal is to indentify cancers as early as possible.
• Every man over the age of 40 should have a digital rectal examination as part of his regular annual physcial checkup. The physcian inserts a gloved, lubricated finger into the rectum to palpate the prostate. Normal prostate is firm and smooth. Almost all prostate cancers begin in that part of the prostate gland that can be easily palpated by rectal examination and if there is a cancer in the prostate. The gland will be nodular, harder and irregular.
• We also recommend that men 50 and over have an annual blood test called Prostate Specific Antigen (PSA)
• If there is family history of cancer of the prostate in father or brother, screening PSA should begin at age 40.
• If either digital rectal examination or PSA test is abnormal, we recommend further evaluation; Transrectal Ultrasonography of Prostate and Needle Biopsies.

What is PSA?

• PSA - Prostate Specific Antigen is a protein produced by the prostatic epithelium and periurethral glands. PSA is secreted into seminal fluid in high concentration and it is also found in low concentration in blood.
• PSA levels under 4 ng/ml are generally considered normal, while levels over 4 ng/ml are considered abnormal.
• PSA levels between 4 and 10 ng/ml indicate a risk of prostate cancer higher than normal. When the PSA level is above 10 ng/ml, risk of prostate cancer is much higher.
• An elevated PSA does not always indicate cancer, nor does normal PSA means that you do not have cancer (a false negative result).
• PSA is not a perfect test.
• The blood test does not tell you whether or not you have prostate cancer.
• Some men with prostate cancer do not have an elevated PSA, and many men with an elevated PSA do not have prostate cancer.
• PSA levels may be high if you have prostate cancer, prostate gland is enlarged (BPH) or there is inflammation in the prostate (prostatitis).
• PSA levels may be lower in patients who take Proscar or Avodart.
• Several other ways to look at PSA have been developed to avoid the short comings of PSA (false positive and false negative). The include:
  
  

1. Age - specific reference ranges: PSA increases with age primarily because of increase in prostate size, and age-adjustment of PSA is a means of accounting for this size increase with age. Age-adjustment of PSA - compared to the use of a single PSA cutoff for all ages - may lead to increased cancer detection in younger men thus avoiding false negative PSA.
   Age 40 to 50 years 0 to 2.5 ng/ml
   Age 50 to 60 years 0 to 3.5 ng/ml
   Age 60 to 70 years 0 to 4.5 ng/ml
   Age 70 to 80 years 0 to 6.5 ng/ml
2. PSA Velocity:
   The rate of rise of the PSA over time is called PSA velocity
   A change in PSA of more than 0.5 ng/ml per year indicates presence of prostate cancer.
3. PSA Density:
   The vast majority of men (80%) with elevated PSA have serum levels in the range of 4.0 to 10.0 ng/ml
   In these men, the most likely reason for elevated PSA is  BPH not prostate cancer.
   The ratio of PSA to prostate gland volume measured by is ultrasound called the PSA density.
4. Total and Percent Free PSA:
   Approximately 90% of the PSA in the blood is bound to protein and lesser amount is free (not bound to protein)
   Studies have suggested that patients with prostate cancer have lower percentage of Free PSA than patients with benign disease. If your serum PSA is between 4-10 ng/ml your free PSA should be at least 25% of Total PSA value.
   "PSA is the single test with the highest positive predictive value for cancer"
   If the results of digital rectal examination of prostate or blood test (PSA) suggest that you may have prostate cancer, we would suggest that you should consider Transrectal Ultrasonography and Ultrasound guided Biopsy of the Prostate.

What is Transrectal Ultrasound?

Transrectal ultrasound is the examination of prostate using a machine called ultrasound. We insert a finger like probe into the rectum to examine the prostate. Ultrasound creates  a picture of prostate using high-frequency sound waves. These sound waves come out of the probe and are transmitted through body tissues. The sound waves then bounce off the tissue and return to the probe. These returning sound waves are called echoes and are translated and recorded into photographic images.
Transrectal Ultrasonography provides excellent visualization of the prostate and abnormalities that may be present in the prostate. We can also easily guide the biopsy needle under ultrasound guidance into the prostate where cancer is suspected.
The ultrasound machines in our offices are capable of doing color doppler studies and three dimensional (3D) reconstruction of the gland. Usually there is increased blood flow within the cancerous lesion or adjacent to the lesion and color doppler helps us precisely guide the biopsy needle into the lesion for accurate biopsy.
Transrectal ultrasonography is also used to estimate the prostate volume accurately to calculate PSA density.
Transrectal ultrasonography also provides images sensitive enough to defect capsular involvement and extention of cancer into the seminal vesicles (staging of cancer).

What is biopsy and how is it done?

Once we find an abnormal area in the prostate on ultrasound, we need to remove small pieces of prostate for pathological examination called prostate biopsy.
While the ultrasound probe is in the rectum, a biopsy needle is inserted through the probe and under the ultrasound guidance, biopsies are performed. Six to twelve tiny pieces of tissue are taken from the prostate. These pieces of prostate tissue are then sent to a laboratory where a pathologist who is an expert in prostate cancer examines these pieces under the microscope to determine

• Whether cancer is present
• Evaluate microscopic features of cancer (Gleason Score)
• Whether suspicious lesions are present (PIN)
• Or the biopsy is negative for cancer
• Whether inflammation is present

What happens if my biopsies comes back negative?

Just because your biopsies are negative, does not mean that you do not have cancer in your prostate. You need to be seen on a regular basis for digital rectal examination and PSA testing. If there is significant change in your PSA, we may suggest repeat biopsies. The average risk of finding cancer in a repeat biopsy following a benign diagnosis is about 18%. 

What is prostate intraepithelial neoplasia (PIN) or atypical or suspicious cells on biopsy?

In about 10% of prostate needle biopsy reports, the pathologist will tell us that the final diagnosis is neither benign nor malignant. They describe this condition as

1. High Grade Intraepithelial Neoplasia (High Grade PIN)
   A premalignant condition
   Biopsy should be repeated soon
   25% risk of cancer on repeat biopsy
2. Low Grade Intraepithelial Neoplasia
   Repeat biopsy is not indicated unless there is a rise in PSA
3. Atypia
   Repeat biopsy should be done as risk of having cancer is about 40%

In these difficult cases, pathologist will use specific stains to determine the exact diagnosis.

What happens if my biopsy shows cancer?

If a prostate cancer is found we need to determine the stage of the cancer, whether it is contained within the prostate, or beyond the prostate gland into the surrounding tissues or had spread into the lymph nodes and bones (called metastases). In order to rule out metastases we may perform bone scan, CT scan, MRI, Prostatint scan and other follow-up imaging studies.

Based on these studies we describe cancer of the prostate in four stages.

Stage I: Low grade cancer discovered incidently during an operation for benign prostatic hyperplasia (BPH). Cancer is present in less than 5% of the tissue removed.

Stage II: Cancer is confined within the prostate

Stage III: The cancer extends outside the prostate into the seminal vesicles

Stage IV: Cancer has invaded other pelvic organs, or has spread to the lymph nodes or bones.

What determines how my cancer is going to behave?

There are many factors that influence whether cancer will remain dormant in the prostate or will grow outside the prostate into the surrounding tissues and spread into the lymph nodes and bones:

• How high is PSA
• Whether PSA was rising over time
• Tumor volume in the prostate
• Patients age
• Gleason score

Gleason grading system or commonly called Gleason score is the most commonly accepted and relates to clinical outcome. In assigning a grade to a cancer pathologist assign a primary grade and a secondary grade (from 1-5) Gleason score is combination of these two grades (from 2-10). Gleason score of 2-4 represent will differentiated cancer with very good prognosis. Gleason score of 5-6 represent moderately differentiated tumor with good prognosis Gleason score of 8-10 are poorly differentiated tumor with poor prognosis. Gleason score 7 could be 3+4=7 (good prognosis) or 4+3=7 (poor prognosis).