Prostate Cancer

Prostate cancer is diagnosed and treated by the Urology Division of Premier Medical Group. The function of the prostate is to store and secrete a slightly alkaline fluid, milky or white in appearance, that constitutes about 25-30% of the volume of the semen. The alkalinity of semen helps neutralize the acidity of the vaginal tract, prolonging the lifespan of sperm.

The prostate also contains some smooth muscles that help expel semen during ejaculation.

Another important prostate function is controlling the flow of urine during ejaculation. A complex system of valves in the prostate sends the semen into the urethra during ejaculatory process and a prostate muscle called the sphincter seals the bladder, thereby preventing urine entry into the urethra.

What is prostate cancer?

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Prostate cancer is the most common cancer in men (besides skin cancer). About 1 man in 6 will be diagnosed with prostate cancer in his lifetime. Because prostate cancer is usually slow growing, only about 1 in 35 men will die of the disease. Prostate cancer accounts for about 10% of cancer-related deaths in men. More than 2 million men in the United States who have been diagnosed with prostate cancer at some point are still alive today. Prostate cancer is the second leading cause of cancer death in American men, behind lung cancer.

Adenocarcinoma of the prostate is the clinical term for most cancerous tumors in the prostate gland. As prostate cancer grows, it may spread to the interior of the gland, to tissues near the prostate, to sac-like structures attached to the prostate (seminal vesicles), and to distant parts of the body (e.g., bones, lymph nodes, liver, and lungs). Prostate cancer confined to the gland is often treated successfully, with very high cure rates.

What causes prostate cancer?

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As with benign prostatic hyperplasia (BPH) the risk for prostate cancer increases with age. About two out of every three men with prostate cancer are over 65. The exact etiology of prostate cancer is not clear, but risk factors associated with it include:

  • Age: The risk of developing prostate cancer increases as you grow older.
  • Family history: Having a father or brother with prostate cancer increases your risks; having more than one primary relative doubles your risk.
  • Race: African-American men are at slightly higher risk to develop prostate cancer, higher risk of advanced disease and have higher mortality rates than Caucasians.

What are the symptoms of prostate cancer?

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Most cases of prostate cancer have no associated symptoms. There are no specific warning signs or symptoms of early prostate cancer, but occasionally patients can have the following symptoms, which are similar to those of BPH.

  • Blood in the urine or semen
  • Frequent urination, especially at night
  • Inability to urinate
  • Painful ejaculation
  • Pain or burning during urination (dysuria)
  • Weak or interrupted urinary flow

Symptoms of advanced prostate cancer include:

  • Dull, incessant deep pain or stiffness in the pelvis, lower back, ribs or upper thighs; arthritic pain in the bones of those areas
  • Loss of weight and appetite, fatigue, nausea, or vomiting
  • Swelling of the lower extremities
  • Anemia
  • Difficulty moving your legs, leg pain, and sensation in lower extremities

What is a PSA Screening?

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Prostate-specific antigen (PSA) is produced by the cells of the prostate gland. Patients with benign prostatic hyperplasia (BPH) or prostatitis produce greater amounts of PSA. The PSA level also is determined in part by the size and weight of the prostate.

The test measures the amount of PSA in the blood in nanograms per milliliter (ng/mL). Most men have PSA levels under 4 ng/mL or lower is considered normal. Men with prostate cancer often have PSA levels higher than four, although cancer is a possibility at any PSA level. Most men with slightly elevated PSA levels do not have prostate cancer, and many men with prostate cancer have normal PSA levels. A highly elevated level may indicate the presence of cancer.

PSA in the blood may be bound molecularly to one of several proteins or may exist in a free, or unbound, state. Total PSA is the sum of the levels of both forms; free PSA measures the level of unbound PSA only. In an effort to make PSA testing more sensitive, percent free PSA is used to help quantify risk of underlying cancer.

According to published reports, men who have a prostate gland that feels normal on examination and a PSA less than four have a 15% chance of having prostate cancer. Those with a PSA between four and 10 have a 25% chance of having prostate cancer and if the PSA is higher than 10, the risk increases to 67%.

Younger patients, less than 50 years of age, tend to have smaller prostates and lower PSA values, so any elevation of the PSA in younger men above 2.5 ng/mL is a cause for concern. Older patients can have higher PSAs because of BPH, and there are age-specific valves. However, there is no safe PSA level.

Just as important as the PSA number is the trend of that number, (whether it is going up, how quickly, and over what period of time). It is important to understand that the PSA test is not perfect, and there are lots of controversies regarding PSA screening, but the American Urological Association still feels this is an important tool that can save lives. You should discuss the benefits and potential harms of PSA screening with your urologist.

PSA blood tests and DRE should be offered in all men beginning at age 40, especially African American men and those with a family history.

If your doctor is concerned that you might have prostate cancer based on either your PSA level or a rectal exam, a biopsy (a lab testing of a small amount of tissue from the prostate) will be this next step. This is the only way to positively identify the presence of cancer.

The diagnosis of cancer is confirmed only by a biopsy. Once prostate cancer is diagnosed, additional testing such as CT scan, or bone scan may be useful to adequately stage the disease.

PSA screening is done the Poughkeepsie, Fishkill, Newburgh, Kingston and Rhinebeck offices.

Call your doctor if

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  • You have difficulty urinating or find that urination is painful or otherwise abnormal. Your doctor will examine your prostate gland to determine whether it is enlarged, inflamed with an infection, or may have cancer.
  • You have chronic pain in your lower back, pelvis, upper thighbones, or other bones. Ongoing pain without explanation always merits medical attention. Pain in these areas can have various causes but may be from the spread of advanced prostate cancer.
  • You experience unexplained weight loss.
  • You have swelling in your legs.

How is prostate cancer tested and diagnosed?

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Several tests are used to diagnose prostate cancer:

Digital rectal examination (DRE)

In a DRE, the physician inserts a lubricated, gloved finger into the rectum to feel the surface of the prostate gland. Healthy prostate tissue is soft, like the fleshy tissue of the hand where the thumb joins the palm. Malignant tissue is firm, hard, and often asymmetrical or stony, like the bridge of the nose. However, as many as one-third of patients diagnosed with prostate cancer have a normal DRE.

The physician “stages” the tumor based on its size, the character of its cells, and the extent of metastasis. TBM staging is considered standard. Prostate cancer staging is the process by which physicians categorize the risk of cancer having spread beyond the prostate, or equivalently, the probability of being cured with local therapies such as surgery or radiation. Once patients are placed in prognostic categories, this information can contribute to the selection of an optimal approach to treatment. The information considered in such a prognostic classification can be based on physical examination, imaging studies and blood tests (so-called “clinical stage”), or based on the extent of disease as revealed in a surgical specimen (so-called “pathologic stage”).

There are two schemes commonly used to stage prostate cancer. The most common is promulgated by the American Joint Committee on Cancer, and is known as the TNM system, which evaluates the size of the tumor, the extent of involved lymph nodes, and any metastasis (distant spread) and also takes into account cancer grade. As with many other cancers, these are often grouped into four stages (I‐IV). Another scheme, now used less commonly for research, but often still used by clinicians, is the Whitmore-Jewett stage.

Briefly, Stage I disease is cancer that is found incidentally in a small part of the sample when prostate tissue was removed for other reasons, such as benign prostatic hypertrophy, and the cells closely resemble normal cells and the gland feels normal to the examining finger. In Stage II more of the prostate is involved and a lump can be felt within the gland. In Stage III, the tumor has spread through the prostatic capsule and the lump can be felt on the surface of the gland. In Stage IV disease, the tumor has invaded nearby structures, or has spread to lymph nodes or other organs. Grading is based on cellular content and tissue architecture from biopsies (Gleason) which provides an estimate of the destructive potential and ultimate prognosis of the disease.

TNM Staging

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Evaluation of the (primary) tumor (‘T’)

  • TX: cannot evaluate the primary tumor
  • T0: no evidence of tumor
  • T1: tumor present, but not detectable clinically or with imaging
  • T1a: tumor was incidentally found in less than 5% of prostate tissue resected (for other reasons)
  • T1b: tumor was incidentally found in greater than 5% of prostate tissue resected
  • T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA
  • T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate
  • T2a: the tumor is in half or less than half of one of the prostate glands two lobes
  • T2b: the tumor is in more than half of one lobe, but not both
  • T2c: the tumor is in both lobes
  • T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2)
  • T3a: the tumor has spread through the capsule on one or both sides
  • T3b: the tumor has invaded one or both seminal vesicles
  • T4: the tumor has invaded other nearby structures

It should be stressed that the designation “T2c” implies a tumor which is palpable in both lobes of the prostate.

Tumors which are found to be bilateral on biopsy only but which are not palpable bilaterally should not be staged as T2c.

Evaluation of the regional lymph nodes (‘N’)

  • NX: cannot evaluate the regional lymph nodes
  • N0: there has been no spread to the regional lymph nodes
  • N1: there has been spread to the regional lymph nodes

Evaluation of distant metastasis (‘M’)

  • MX: cannot evaluate distant metastasis
  • M0: there is no distant metastasis
  • M1: there is distant metastasis
  • M1a: the cancer has spread to lymph nodes beyond the regional ones
  • M1b: the cancer has spread to bone
  • M1c: the cancer has spread to other sites (regardless of bone involvement)

Evaluation of the histologic grade (‘G’)

Usually, the grade of the cancer (how different the tissue is from normal tissue) is evaluated separately from the stage; however, for prostate cancer, grade information is used in conjunction with TNM status to group cases into four overall stages.

  • GX: cannot assess grade
  • G1: the tumor closely resembles normal tissue (Gleason 2–4)
  • G2: the tumor somewhat resembles normal tissue (Gleason 5–6)
  • G3–4: the tumor resembles normal tissue barely or not at all (Gleason 7–10)

Of note, this system of describing tumors as “well-“, “moderately-“, and “poorly-” differentiated based on Gleason score of 2-4, 5-6, and 7-10, respectively, persists in SEER and other databases but is generally outdated. In recent years pathologists rarely assign a tumor a grade less than 3, particularly in biopsy tissue. A more contemporary consideration of Gleason grade is:

  • Gleason 3+3: tumor is low grade (favorable prognosis)
  • Gleason 3+4: tumor is mostly low grade with some high grade
  • Gleason 4+3: tumor is mostly high grade with some low grade
  • Gleason 4+4 / 4+5 / 5+4 / 5+5: tumor is all high grade

Overall Staging

The tumor, lymph node, metastasis, and grade status can be combined into four stages of worsening severity.

Whitmore-Jewett staging

The Whitmore-Jewett system is similar to the TNM system, with approximately equivalent stages. Roman numerals are sometimes used instead of Latin letters for the overall stages (for example, Stage I for Stage A, Stage II for Stage B, and so on).Whitmore-Jewett staging

Prostate Anatomy

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The prostate gland is located in the pelvis, below the bladder, above the urethral sphincter and the penis, and in front of the rectum in men. It is made up of glandular tissue and muscle fibers that surround a portion of the urethra. The gland itself serves to liquefy semen, as it is initially in semi-solid form.

How is prostate cancer treated?

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The three options for early-stage/low-risk prostate cancer are surgery, radiation therapy, and active surveillance, also known as expectant management, or watchful waiting.

Medical

  • Active Surveillance (also called watchful waiting) is a logical course of action for patients who are elderly, who are in poor health, or who have low-risk, early stage cancer. Untreated prostate cancer may take years to become problematic. Your urologist should carefully monitor this condition for any marked or sudden progression, which may signal the need for more aggressive treatment.
  • Hormone therapy for prostate cancer involves removing, blocking, or adding hormones to fight prostate cancer. Drugs are given to block the production of testosterone, which prostate cancer cells use to grow. Although effective such treatment can have debilitating side effects such as hot flashes, depleted bone density, and weight gain.
  • Treatment for bone metastasis when prostate cancer causes bone metastases, bone tissue breaks down, which releases calcium into the bloodstream. In addition to treatment to block androgen, an IV bisphosphonate zoledronic acid is used to stabilize bone mineral density in this setting.

Brachytherapy (radioactive seed implantation)

This procedure, which has been used for over a century, involves placing radioactive seeds directly in the prostate. The radiation given off is tightly localized.

The radioactive seeds are about the size of a grain of rice, and give off radiation that travels only a few millimeters to kill nearby cancer cells. With permanent implants the radioactivity of the seeds decays with time while the actual seeds permanently stay within the treatment area.

Tests before the brachytherapy procedure may include blood tests, an electrocardiogram (EKG), and chest x-rays. The results are used by anesthesiologists to determine what kind of anesthesia to use during the brachytherapy procedure.

An ultrasound probe is inserted into the rectum, which will show the prostate gland on a television monitor, to aid the doctor in placement of the seeds. The seeds are then implanted into the prostate through very thin needles. Depending on different variables, between 50 and 100 seeds are used. The needles are inserted into the skin between the scrotum and rectum and are guided to the right place to most effectively treat the cancer. At the end of the procedure, a catheter will be placed in your bladder to help you pass urine during recovery.

External radiation treatment (XRT)

This is the treatment of prostate cancer with high energy beams, from x-rays or other sources, directed at a target inside the body. The linear accelerator moves around you to deliver radiation from several angles. The linear accelerator can be adjusted so that it delivers the precise dose of radiation.

Radiation damages both cancer cells and normal cells, interfering with their ability to divide and grow. However, scheduled breaks between radiation sessions allow normal cells a chance to repair while not giving cancer cells enough time to recover. You typically receive external beam radiation on an outpatient basis five days a week over a period of at least two to 10 weeks. Expect each treatment session to last approximately 10 minutes to 30 minutes. In some cases, a single treatment may be used to help relieve pain or other symptoms associated with more advanced cancers.

Surgical Treatment

Radical prostatectomy is an operation to remove the entire prostate and any nearby tissue that may contain cancer. It can be done as open surgery through an incision (cut) in the belly, or as laparoscopic surgery, or robotic surgery.

Laparoscopic radical prostatectomy surgery

This is done through several very small incisions in the abdomen utilizing a tiny camera and special instruments to remove the prostate.

Robotic surgery is a new category of minimally invasive surgery performed with the da Vinci® Surgical System. Robotic surgery is a form of laparoscopic surgery that utilizes robotic arms and instruments to facilitate dissection in a more precise manner than traditional laparoscopic surgery.

The da Vinci System® is a sophisticated robotic platform designed to expand the surgeon’s capabilities.

Patients benefit from the potential for significantly less pain, a shorter hospital stay, and faster return to normal daily activities – as well as the potential for better clinical outcomes. It is important to know that surgery with da Vinci does not place a robot at the controls; your surgeon is controlling every aspect of the surgery. At the same time, state-of-the-art robotic and computer technologies scale, filter, and flawlessly interpret your surgeons hand movements into the precise micro-movements of the da Vinci instruments.

At Premier Medical Group Urology Division we continue to bring the latest technology to our patients such as the da Vinci robotic surgical system. Dr. Naeem Rahman and Dr. Walter Parker both specialize in the robotic surgery of the prostate.  They see patients in the Kingston, Fishkill and Poughkeepsie locations. Dr. Praneeth Vemulapalli and Dr. Jaspreet Singh, also specialize in robotic surgery of the prostate and see patients in the Newburgh location.

Cryosurgery (cryoablation)

This minimally invasive outpatient procedure, offered at Premier Medical Group Urology Division, destroys cancer cells by rapidly freezing and thawing cancerous tissue. It is recommended for patients who cannot tolerate surgery or radiation, have prostate-confined tumors (stage T3 or lower), do not respond to radiation (both external-beam and brachytherapy), and are elderly. It is increasingly being used for patients who fail radiation therapy, as it offers an effective treatment for those cancers.

High intensity focused ultrasound (HIFU)

This is currently undergoing clinical trials in the United States. This is a noninvasive treatment that uses precision-focused ultrasound waves to heat and destroy (ablate) targeted prostatic tissue without affecting healthy surrounding tissue. It has been shown to effectively treat localized prostate cancer as well as benign prostatic hyperplasia (BPH). To date, the FDA has not approved this treatment in the United States.

Chemotherapy

Chemotherapy is the use of any one or combination of drugs that can destroy cancer cells and tumors, and may be an option for cancers that don’t respond to hormone therapy.  There are two types of chemotherapy, systemic and regional.  Systemic chemotherapy is taken orally or injected into a vein or muscle and it is intended to reach cancer through the body. Regional chemotherapy is delivered straight into the prostate. Chemotherapy is usually reserved for patients whose prostate cancer has metastasized to the bone or elsewhere in the body, and can be used in combination with other treatments, such as radiation. It is not used to treat early stage disease. Chemotherapy is given in series of treatments followed by a recovery period. The total treatment commonly lasts three to six months, depending on the type of chemotherapy medications given.