The management of prostate cancer is enigmatic. During the past decade, the advocates of radical prostatectomy have jousted with the opponents of external beam radiotherapy, and interstitial radiation treatment.
These debates have created confusion in the minds of people with prostate cancer. Obviously if there are this many solutions to the problem, the issues remain unresolved.
The issue of prostate cancer is multifaceted, involving speculations, illusions, differing experiences, rigid dogmas, as well as new horizons.
We hope to clear all these confusions with our well researched, and easy to understand review on prostate cancer.
Prostate cancer is the most common organ cancer in men, and is the source of much confusion. While it is the second leading cause of cancer death in men, only about 5% of men with early stage prostate cancer will die from it! There are many treatment options, including surgery, radiation therapy, hormones, castration, and even just "watching" it.
It is crucial for a man to understand his options in dealing with prostate cancer. Being knowledgable may help him preserve his potency, continence or even his life. It is important to know that one has done everything possible to fight prostate cancer successfully.
Cancer of the prostate is the most common cancer in men in the United States. The disease occurs more frequently after age 45. Early prostate cancer may be discovered by rectal examination during a physical checkup or the cancer may cause the prostate to enlarge, producing the same symptoms as a benignly enlarged prostate. About half the men found to have cancer of the prostate have an early form of the disease that has not spread outside the prostate gland. If the cancer is not discovered at an early stage, it might spread to another part of the body.
A blood test along with a rectal examination may indicate the possible presence of prostate cancer. The blood test used to detect prostate cancer is called a prostate specific antigen or PSA. If cancer of the prostate is suspected either during a routine physical exam or because of the presence of urinary symptoms, the patients primary care provider may refer him to a urologist (a specialist in urinary and genital diseases).
The urologist may recommend a biopsy of the gland in which a small sample is removed for examination. This is usually performed with ultrasound guidance. If the biopsy shows that a cancer is present, further tests such as CT scan or radioisotope bone scan may be performed to look for cancer that has spread.
Men facing prostate cancer now have several choices when it comes to their treatment. The mans age, his general health, how much importance he places on preserving sexual function and whether the disease has spread are factors in determining the choice of treatment.
When the disease has not spread further than the prostate gland, there is a high chance of cure with surgical removal of the entire prostate gland or radiation therapy. Complete removal of the prostate gland offers the highest cure rate.
Another option for prostate cancer patients is external radiation. Low-dose radiation treatments are given daily for approximately seven to eight weeks.
The newest treatment for men with prostate cancer caught in the early stages is called radioactive seed implantation therapy. This treatment involves implanting approximately 100 tiny radioactive seeds in the prostate gland where they destroy cancerous cells while leaving healthy tissue intact. This FDA-approved procedure has proven as effective as other prostate cancer treatment options, such as surgery or external radiation therapy.
Prior to the implantation procedure, the patient visits the urologist and radiation oncologist for an initial consultation and planning study. The planning information is then used by the radiation oncology physicist and dosimetrist to plan the implant and order the seeds. The actual implantation procedure is done using ultrasound to guide the placement of the seeds in the prostate gland. The seeds are distributed evenly throughout the gland to deliver radiation in a highly-targeted way.
Each seed contains low-grade radioactive material, either Iodine-125 or Palladium-103. The radioactive substance is sealed in a tiny metallic case and the seeds remain in the prostate after they become inert (expend all of their energy). These inert seeds do not cause any long-term side effects.
Compared with other methods of treating prostate cancer, the radioactive seed implant therapy has few side effects. Most men can resume normal activities within a day or so, although some may experience side effects, such as more frequent urination or impotence. These symptoms are usually temporary and disappear over time or with medication.
By age 80 a majority of men are found to have a small prostate cancer, if tested. In most of these cases, however, the cancer causes no symptoms and requires no treatment. Since prostate cancer may develop very slowly, these elderly patients may choose "watchful waiting" instead of one of the curative therapies. In patients whose life expectancy is five years or less, the best treatment may be conservative management such as observation or hormonal therapy.
Choosing a Treatment
When faced with prostate cancer, men should discuss all of the treatment options -- radioactive seed implantation, surgery, hormonal therapy, external radiation and watchful waiting -- with a specialist. It is sometimes helpful for prostate cancer patients to bring a family member along for the initial visit with the urologist and to consider obtaining a second opinion from a radiation oncologist to discuss treatment options. At that visit, the patient and/or family might wish to ask the following questions:
By discussing these and other issues, the patient, his family and his physician can make a decision that best suits his specific circumstances, concerns and needs.
How Common is Prostate Cancer?
Prostate cancer is the most common cancer in men, in the U.S.A, with 317,000 new cases in 1996 . It is the second leading cause of cancer death in men, killing about 35,000 men per year in the U.S.A. Although the deadliness of certain prostate cancers is obvious, it is also important to note that only about 5% of men with prostate cancer actually die from it, instead dying with it . Most often, some other "co-morbid" condition like heart attack or lung cancer kills the patient long before prostate cancer would. As many as 80% of men over age 80 years can be shown to have some trace of cancer in their prostates! The average patient is 65 years old at time of detection. The aggressiveness of prostate cancer is variable, and each man must understand the nature of his particular disease to make wise decisions about it. In general, Black men get prostate cancer more often than White men in the U.S.A, but Blacks in Africa have a low risk. Asian men have a low risk of prostate cancer.
What Causes, or Increases the Risk for Prostate Cancer?
As for all cancers, the exact reason why one man gets prostate cancer and another does not remains unknown . However, there are some associations, called "risk factors", that seem to increase the chances a man will develop it in the U.S.A:
1) Male Sex (since only males have a prostate), Black, older than age 60.
2) Family History of prostate cancer in father or uncles.
3) Multiple Sex Partners, a transmitted virus may be a factor.
4) High Testosterone Levels, the "sex hormone" is low in Asians, high in Blacks!
5) Benign Prostatic Hypertrophy increases risk 4 times (or chance of detection?).
6) Exposure to high dietary fat, cadmium metal.
*** Cigarettes and Alcohol do not increase the risk for getting prostate cancer.
Is Prostate Cancer Preventable?
Having only one sex partner and lowering dietary fat may help. Also, having one's testicles cut off ("bilateral orchiectomy") at a young age will reduce the risk to nearly zero (eunuchs don't get it) but this is not advised. The truth is, there isn't much you can do to prevent prostate cancer; the key is to recognize it's existence and characteristics early.
What are the Symptoms of Prostate Cancer?
As with any cancer, very early prostate cancer produces no symptoms, since the "tumor burden" is too small to cause interference with normal body functioning. It is most commonly detected symptom less ("asymptomatic") by a screening blood test called "Prostate Specific Antigen" or "PSA" for short. The prostate normally produces this enzyme and releases it into the bloodstream; it's level increases with BPH, infection, cancer or even vigorous rectal exam. However, in cancer the PSA is usually markedly increased (when adjusted for the volume of prostate tissue), compared to smaller increases with other conditions. A PSA reading of over 4.0 milligrams per milliliter of blood starts getting suspicious for prostate cancer, since 95% of men under age 50 will be below this number. A PSA reading of 30 mg/ml or over almost certainly indicates cancer (technical note-- In general, the PSA increases by 3 mg/ml for each gram of cancerous tissue). It is possible to see PSA's in the thousands when the cancer is widespread.
If and when prostate cancer actually produces symptoms, they are most likely to resemble those of BPH-- a swollen prostate causing urinary frequency, especially at night ("nocturia") along with incomplete emptying of the bladder ("post-void residual"). Symptoms of more advanced prostate cancer include pain in the pelvis (from the cancer invading nerves), impotence (ditto), swelling of the legs or genitalia (from blockage of lymphatic flow by tumor) or even complete shutdown of urine output ("uremia") which causing itching ("pruritis") and blurred thinking ("uremic encephalopathy"). The first symptoms noted may even be from cancer spread to other organs, with bone pain, weight loss, fatigue and low blood counts ("anemia"). The most common area for spread to bone is the pelvis and spine, spread to the finger or toe areas is rare. Spread to the brain may occur in advanced disease and produce neurologic symptoms of poor judgment, partial paralysis, sensory loss, and seizures. Spread to spinal cord may cause weakness and numbness requiring immediate therapy to prevent irreversible paralysis. Fortunately, most of the symptoms of prostate cancer can be alleviated (see section on "palliation" ).
How is Prostate Cancer Detected and Evaluated?
Today, the most common way of detecting Prostate Cancer is through the PSA test (Hospitals often run free screening programs, hoping to treat you if they detect cancer). Another common way the disease comes to attention is during an annual physical exam when the doctor does a"digital rectal examination" and feels a lumpy ("nodular") or diffusely enlarged prostate gland. The gloved examining finger is then applied to a specially treated card and "developer" placed on it ("guiac test") to look for occult (too little to be seen with the naked eye) blood in the rectum. If there is suspicion of prostate cancer, a PSA test will be ordered, and the patient usually sent to a "urologist." A urologist is a surgeon who specializes in operating on the urinary tract, and treating all sorts of "genito-urinary" diseases.
The Cancer Group Institute's materials explain, in plain English, the definition, types, risk factors, frequency, symptoms, evaluation, historical and latest effective treatment for prostate cancer. We desribe the specifics of radical surgery, radiation, hormones and combination therapies with their results. We tell you everything you must know to help make the right choices today for a prostate cancer problem.
Researchers at the Georgia Institute of Technology have developed a computerised system that would help radiation oncologists optimise placement of radioactive 'seeds' for non-surgical prostate brachytherapy. Beyond providing treatment more precisely tailored to each patient, the system targets escalated doses of radiation at tumour pockets and is said to account for changes that occur in the volume of the prostate during treatment.
The automated system is said to offer a dramatic reduction in the time required to design radioactive seed treatment, allowing optimised plans to be created in minutes, and revised as the procedure proceeds. To successfully treat the cancer with prostate brachytherapy physicians must carefully design the radiation dose, balancing the high radiation levels needed to eradicate the cancer against the need to protect nearby tissue.
Further complicating treatment is the edema that occurs as needles are inserted to place the seeds. Resulting changes in prostate volume can mean delivering too little radiation at the beginning of treatment and too much as the swelling subsides.
'Proper coverage of the entire prostate is very important, but it can be very difficult to carry out the plan,' said Eva K. Lee, assistant professor of industrial and systems engineering at the Georgia Institute of Technology and of radiation oncology at Emory University School of Medicine. 'The seeds cannot always be placed in the location you want, so you must be able to compensate for that. Our system allows real-time planning, and corrections can be made as you proceed.'
Ultrasound images of the patient's prostate are used by the system to help determine optimal radioactive seed placement. Mixed integer programming and computational optimisation techniques are the core technological tools utilised.
'To the physician, this will be a black box,' Lee said. 'They will not need to know what is going on with the mathematics. All they will have to do is tell the system what they want in the plan.'
Less experienced oncologists working in remote areas could use the system to aid in producing high quality treatment plans.
In most current treatments, seed placement is determined manually based on a simulation of the patient's prostate. Done days or weeks ahead of the operation, this 'pre-plan' is said to takes hours to produce. By cutting the planning time to as little as 15 minutes, the system should reduce costs and allow physicians to spend more time with their patients, Lee added. Though the expert system is ready for commercialisation, it will have to receive US FDA approval before being made available to treatment centres.
However, Lee has used real patient data to compare her system against treatment plans designed by radiation oncologists. Those results suggest the system will provide significant improvements in the outcome of treatment.
'We can deliver better precision and create the optimal plan for each patient. This system should help cut the recurrence rate for prostate cancer and reduce toxicity to healthy tissue,' concluded Lee.