Prostate cancer

Introduction and incidence

The prostate is a gland in the male reproductive system, located below the bladder and in front of the rectum (the final part of the large intestine). Previously, it was often called the chestnut, because it is usually the size of a chestnut. The function of the prostate is to produce a fluid that is part of the seminal fluid. Prostate cancer in Croatia is the most common malignant tumor in men, and in men it accounts for 21% of all new cancer cases (data for 2017). It is also common in other developed countries of the world, so for example, it is estimated that in the USA 1 in 5 men will develop this disease during their lifetime. Fortunately, most patients who develop this disease do not die from it.

Risk factors

The most important risk factor for prostate cancer is age, and the disease occurs most often in older men. The risk is also increased in people with a positive family history (prostate cancer in the family).

Signs and symptoms

Prostate cancer may be accompanied by some of the following symptoms: weak or intermittent urine stream during urination, sudden urge to urinate (urgency), frequent urination (especially at night), difficulty starting urination, inability to urinate completely, pain and/or burning during urination, blood in the urine or semen, back and/or pelvic pain that does not go away over time, bone pain (a consequence of possible metastases). However, it should be emphasized that all of these symptoms are non-specific and are more often related to other diseases and conditions. With age, the prostate gland in most cases enlarges (prostatic hyperplasia) and can press on the urethra or bladder over time. This consequently leads to difficulty urinating and sexual difficulties. It is a benign growth of prostate tissue, but due to the symptoms, surgical treatment may be necessary in some patients. Some of the symptoms may also be the result of inflammation of the prostate or other parts of the urinary tract, so it is definitely necessary to consult a doctor to clarify the cause of the problems.

Slika 1. Prikaz digitorektalnog pregleda. Prostata je smještena odmah ispred rektuma, te liječnik prstom kroz rektum može vrlo jednostavno napipati prostatu i osjetite moguće nepravilnosti i anomalije. Digitorektalni pregled u skladu s navedenim smatra se važnim i vrlo jednostavnim dijagnostičkim testom. (source: wikipedia)

Diagnosis

The basis is a detailed examination of the patient and a thorough medical history. A digital rectal examination palpates the prostate directly through the rectum with a finger, in order to detect any nodules or abnormal parts of the prostate (Figure 1). Prostate-specific antigen (PSA), which is measured in the blood, is used as a tumor marker. It is a substance produced by the prostate and is in most cases elevated in patients with prostate cancer: however, PSA can also be elevated in some other benign conditions, such as infection or inflammation of the prostate and prostatic hyperplasia. Therefore, the finding of an elevated PSA does not immediately mean that a person suffers from prostate cancer, but it requires caution and further treatment. Routine PSA measurement in healthy people is generally not recommended. In transrectal ultrasound, a finger-sized probe is inserted through the rectum, which has an ultrasound device at the tip that is placed against the prostate. This allows the prostate tissue to be examined with relatively high precision using ultrasound and, if necessary, a sample of suspicious tissue (biopsy) can be taken for further analysis. In addition to ultrasound-guided biopsy, there is also the option of transrectal magnetic resonance, with which a biopsy can also be performed if necessary. The purpose of the biopsy is to definitively confirm the diagnosis of prostate cancer, and at the same time to determine the degree of the disease (Gleason score), which in a certain sense is a measure of the aggressiveness of the disease. The Gleason score can be ranked from 6 to a maximum of 10, with a higher number meaning a higher grade and thus a more aggressive disease.After confirmation of the diagnosis, additional diagnostic tests may be necessary to evaluate the possible extension of the disease beyond the prostate. For this purpose, bone scintigraphy, MR, CT and other tests can be done. You can read more about the diagnosis of malignant diseases in general in a separate article.

Stage of the disease

Prostate cancer is divided, like other malignant diseases, into 4 stages.

In stage I, the disease is limited to the prostate. The disease may affect up to half of one side of the prostate, and the PSA is less than 10, and the tumor grade is 1.

In stage II, the disease is also limited to the prostate, but it is somewhat more advanced. Either the PSA is greater than 10 (but not greater than 20), or the grade is greater than 1, or the disease is present on both sides of the prostate instead of just one.

In stage 3, the PSA is 20 or higher, or the disease has spread beyond the prostate to the seminal vesicles, rectum, bladder, or pelvic wall.

In stage IV, the disease has spread to regional lymph nodes or distant organs in the body in addition to surrounding organs. The most common site of prostate cancer metastasis is the bones.

Treatment

Stage I. Some of these patients should not be actively treated if it is estimated that this would cause more harm than good (elderly and frail patients burdened with comorbidities or other serious diseases), or if it is estimated that the patient will not die from prostate cancer (slowly progressive disease). Careful monitoring means regular monitoring of the patient in whom active treatment is not planned. In the event of symptoms, symptomatic treatment methods can be applied (e.g. pain management). Active surveillance also includes regular patient checks, but in the event of disease progression, active treatment is initiated with the aim of cure (treatment is postponed to avoid possible harmful consequences and is applied only if it proves necessary). In patients who are planned to be actively treated from the beginning, the main treatment options are surgery (most often radical prostatectomy is used, which removes the prostate and surrounding lymph nodes, and can be performed open or laparoscopically or robotically) and radiotherapy (primarily external radiotherapy, but there is also the possibility of using brachytherapy).

Stage II. Treatment options are generally the same as for stage I, with a higher proportion of patients being actively treated compared to stage I, given the more advanced stage of the disease.

Stage III. All treatment options for stages I and II can also be used in stage III. An additional treatment option is hormonal therapy, with combinations of different types of treatment often used in stage III. For example, radiotherapy may be required after surgery, and hormonal therapy and radiotherapy may be combined. Prostate cancer is a highly hormone-dependent disease, as these cells require male sex hormones (testosterone) to grow. There are a number of types of hormone therapy that can be used: abiraterone (for patients with advanced disease that does not respond to other forms of hormonal treatment), surgical treatment (orchiectomy, i.e. removal of both testicles in which sex hormones are produced), estrogens (female sex hormones whose aim is to prevent the production of male sex hormones in the testicles; today they are less commonly used due to significant side effects), LHRH hormone agonists (their aim is to prevent the transmission of a positive signal for the production of male sex hormones in the testicles at the level of the brain or pituitary gland, thus achieving an effect similar to that after orchiectomy; examples are leuprolide, goserelin and buserelin), antiandrogens (they do not block the creation but the effect of male sex hormones; examples are flutamide, bicalutamide, enzalutamide, apalutamide and nilutamide), drugs that prevent the creation of male sex hormones in the adrenal glands (ketoconazole, aminoglutethamide, hydrocortisone, progesterone). The exact treatment plan and protocol is determined by the oncologist in charge based on all relevant factors.

Stage IV. In stage IV, the disease is usually widespread in terms of metastases, and systemic treatment is preferred in most patients. Local options such as surgery are therefore not a good choice. Radiotherapy is also mostly used for palliation (for example, treating painful bone metastases). The main treatment options are newer generation hormone therapy (abiraterone, enzalutamide etc.), chemotherapy (primarily docetaxel and cabazitaxel) or a combination of these two treatments. In the case of bone metastases, bisphosphonates can be additionally used, drugs that treat hypercalcemia (elevated blood calcium levels as a result of bone metastases) and pain and reduce the risk of fractures by preventing bone breakdown (examples are clodronate and zoledronate). There is also radiotherapy with alpha emitters (radium 223, which imitates calcium and is incorporated into the bone and then releases radiation that acts on metastases), targeted radioligand therapy, and immunotherapy (Sipuleucel-T vaccine) and inclusion in clinical studies with new drugs are also in use. Many forms of treatment are under investigation.

Additional interesting facts

Men have a 35% higher lifetime risk of developing prostate cancer than women do of developing breast cancer.

November is Men's Health Awareness Month. The "Movember" movement is an annual event that encourages men to grow mustaches for a month to raise awareness of men's health issues, such as prostate cancer, testicular cancer, and male suicide. The goal of the project is to "change the face of men's health."

Prostate cancer is the 4th most commonly diagnosed cancer in the world. According to data from the United States, 1 in 9 men will develop prostate cancer during their lifetime. When it comes to black men, who are at increased risk of this disease, as many as 1 in 7 men will develop it.

Acinar adenocarcinoma is the most common type of prostate cancer, accounting for over 90% of cases of this disease. However, there are several other, less common forms, the most important of which is ductal adenocarcinoma of the prostate. The incidence of this subtype varies from 0.4% to 0.8% in the pure ductal form and 3% to 12.7% in the mixed ductal-acinar adenocarcinoma form. It mainly occurs in older men aged 63 to 72 years. These tumors, unlike typical acinar adenocarcinoma, are predominantly located in the periurethral (central) zone of the prostate, and therefore digital rectal examination may be completely normal in such patients. It has also been documented that in most patients the PSA level is normal, therefore the diagnosis of this subtype is difficult. According to data from large series of patients, this subtype is more aggressive than typical acinar adenocarcinoma and carries a higher risk of metastasis, therefore it requires increased caution and more regular controls.

Continue reading:

Soft tissue sarcoma

Need more information about this topic? Contact us.