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Prostate Cancer

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Posted by on Thursday, September 30, 2010, 3:42
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Prostate Cancer Symptoms:

There are no warning signs or symptoms of early prostate cancer. Once a malignant tumor causes the prostate gland to swell significantly, or once cancer spreads beyond the prostate, the following symptoms may be present:

* A frequent need to urinate, especially at night.
* Difficulty starting or stopping the urinary stream.
* A weak or interrupted urinary stream.
* A painful or burning sensation during urination or ejaculation.
* Blood in urine or semen.

Prostate Cancer
Prostate Cancer

These are not symptoms of the cancer itself. Instead, they are the symptoms of the blockage from the cancer growth within the prostate and surrounding tissues.

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.

Call Your Doctor If:

* 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.

Stages of Prostate Cancer

Like other forms of cancer, the prognosis for prostate cancer depends on how far the cancer has spread at the time it’s diagnosed. Doctors use a system of classification called staging to describe prostate cancer’s spread.

Prostate cancer stages can be complex and difficult to understand. WebMD takes a look at prostate cancer stages and what they mean to you.

Assess Your Risk for Prostate Cancer and 4 Other Common Cancers
Prostate Cancer Stages: Growth and Spread

Prostate cancer grows locally within the prostate, often for many years. Eventually, prostate cancer extends outside the prostate. Prostate cancer can spread beyond the prostate in three ways:

* By growing into neighboring tissues (invasion)
* By spreading through the lymph system of lymph nodes and lymph vessels
* By traveling to distant tissues through the blood (metastasis)

Prostate cancer stages describe the precise extent of prostate cancer’s spread.
Tests to Identify Prostate Cancer Stage

After a prostate cancer diagnosis, tests are done to detect how the cancer has spread, if it has, outside the prostate. Not all men need every test. It depends on the characteristics of a man’s prostate cancer, seen on biopsy. Tests to help determine the stage of prostate cancer include:

* Digital rectal exam (the infamous gloved finger)
* Prostate-specific antigen (blood test)
* Transrectal ultrasound
* MRI of the prostate using a rectal probe
* CT scan of the abdomen and pelvis, looking for prostate cancer metastasis to other organs
* MRI of the skeleton, or a nuclear medicine bone scan, to look for metastasis to bones
* Surgery to examine the lymph nodes in the pelvis for any prostate cancer spread

The TNM System for Prostate Cancer Stages

As they do for most cancers, doctors use the TNM system of prostate cancer stages. The prostate cancer stages are described using three different aspects of tumor growth and spread. It’s called the TNM system for tumor, nodes, and metastasis:

* T — for tumor — describes the size of the main area of prostate cancer.
* N — for nodes — describes whether prostate cancer has spread to any lymph nodes and to what extent.
* M — for metastasis — means distant spread of prostate cancer, for example, to the bones or liver.

There are other ways of classifying prostate cancer, such as the Gleason system. Sometimes, the TNM system and Gleason score are combined together to describe prostate cancer stage.
Prostate Cancer Stage I

In stage I, prostate cancer is found in the prostate only. Stage I prostate cancer is microscopic; it can’t be felt on a digital rectal exam (DRE), and it isn’t seen on imaging of the prostate.
Prostate Cancer Stage II

In stage II, the tumor has grown inside the prostate but hasn’t extended beyond it.
Prostate Cancer Stage III

Stage III prostate cancer has spread outside the prostate, but only barely. Prostate cancer in stage III may involve nearby tissues, like the seminal vesicles.
Prostate Cancer Stage IV

In stage IV, the cancer has spread (metastasized) outside the prostate to other tissues. Stage IV prostate cancer commonly spreads to lymph nodes, the bones, liver, or lungs.

Accurately identifying the prostate cancer stage is extremely important. Prostate cancer stage helps determine the optimal treatment, as well as prognosis. For this reason, it’s worth going through extensive testing to get the correct prostate cancer stage.

Prostate Cancer: Latest Treatments and Emerging Therapies

If you’ve been diagnosed recently with prostate cancer, you might find the latest treatment options somewhat confusing. Each has its benefits and risks. And no single treatment is right for every man with prostate cancer. In this article, WebMD examines the various treatment options and their side effects. We’ll consider the options in terms of:

* The grade and stage (severity) of cancer
* Your age
* Lifestyle considerations
* Other important factors

Ultimately, though, you’ll need to decide for yourself, with the help and guidance of your doctor, which is best for you.

What are the options for early stage prostate cancer?

Early-stage prostate cancer refers to cancer that is contained entirely within the prostate gland. It has not spread — metastasized — either to local tissues or to distant body parts, such as bone. This type of cancer, which doctors often call low-risk disease, is the most curable.

One out of every two men diagnosed with prostate cancer is aged 72 or older. Since prostate cancer often grows very slowly, many of these men may die from other causes before the prostate cancer causes any significant problems. In other words, many men will die with prostate cancer but not from prostate cancer. Another thing to keep in mind is that therapies for prostate cancer can have significant side effects and complications. So trying for a cure – what doctors call “definitive therapy” — may not always be the right choice.

There are three basic options for early stage prostate cancer. The two active treatment options — surgery and radiation — can often lead to a cure when used alone. Men with intermediate-risk or high-risk disease usually need a combination of therapies to achieve a high likelihood of cure or disease control.

The three options for early-stage/low-risk prostate cancer are:

* Surgery
* Radiation therapy – either external beam radiation or radioactive tumor seeding (brachytherapy)
* Active surveillance, also known as expectant management or watchful waiting

The third option is not actually a form of treatment. Instead, it’s a form of close patient management.

There is a fourth basic treatment option: hormone therapy. It is usually reserved for older men and for treatment of men with more advanced disease.

Chemotherapy plays only a limited role in prostate cancer treatment. It’s reserved primarily for the treatment of men with advanced or recurrent prostate cancer that does not respond to hormone therapy.

Your choice of surgery, radiation, or expectant management may depend on several factors:

* Your age and life expectancy
* Other serious health problems you may have, such as heart disease
* Your personal preference, informed by your doctor’s opinion, about whether to begin treatment or to wait
* Your concerns about the side effects common with prostate cancer therapies

Side effects may include things that affect your lifestyle. For example, erectile dysfunction and incontinence, or urine leakage, are both possible side effects.

What’s involved with surgery for early-stage prostate cancer?

If the tumor is entirely contained within the prostate, a skilled surgeon can remove the entire gland. The procedure is known as a radical prostatectomy. Prostatectomy may be a good option for younger men — men in their 40s, 50s, and 60s — who are otherwise in general good health. That’s because these men may be more likely to die from prostate cancer than men in their 70s, 80s, or 90s.

Before a radical prostatectomy is done, doctors need to ensure the disease is contained within the prostate gland. It’s possible it may have spread to nearby lymph nodes. If so, that signals the likelihood of more extensive disease that is less likely to be cured by surgery.

To make sure cancer hasn’t spread, surgeons perform a pelvic lymphadenectomy. In this procedure, they remove lymph nodes within the pelvis. The nodes are then examined by a pathologist who looks for evidence of cancer cells. If the pathologist sees cancer cells under the microscope, surgeons generally will not perform a radical prostatectomy. They may instead refer the patient for other forms of treatment.

In a radical prostatectomy, the prostate gland and the seminal vesicles are completely removed. The seminal vesicles are small glands that contribute fluid to semen. Surgeons have several options for getting to the prostate:

* The first is a retropubic prostatectomy. The surgeon makes an incision in the wall of the abdomen to reach the prostate. While operating, the surgeon can also remove nearby lymph nodes. This is a precautionary measure that may help prevent the spread of disease.
* The second option is called perineal prostatectomy. The surgeon makes an incision in the perineum. That’s the area between the scrotum and the anus. With this surgery an extra incision in the abdomen is needed to remove lymph nodes.
* In some hospitals, surgeons may do a laparoscopic or “keyhole” prostatectomy. The surgeon uses instruments that are passed through a few small incisions. This option is generally associated with fewer complications and faster recovery. But it is technically challenging and may not be appropriate for taking out all tumor types.
* Some men may undergo transurethral resection of the prostate, or TURP. This is a type of surgery that is also used to treat benign enlargement of the prostate. The surgeon inserts a small surgical instrument into the urethra. That’s the tube that carries urine from the bladder to the penis. Then the surgeon removes prostate tissue that causes problems such as difficult or painful urination. The surgery does not, though, remove the entire prostate gland. The process is sometimes used to relieve prostate cancer symptoms in older men. That’s because these men may not be suitable candidates for a radical prostatectomy.

Some treatment centers also perform cryosurgery. This is an investigational technique in which prostate tissue is destroyed by alternate freezing and thawing. The experience with this type of surgery for prostate cancer is limited. So it’s not yet clear whether it offers any advantages over conventional surgery or radiation therapy.

What are the complications and side effects of surgery for early-stage prostate cancer?

There is a bundle of delicate, easily damaged nerves that runs through or near the prostate. Even the most skilled and careful surgeon may not be able to avoid complications. One possible complication is erectile dysfunction. Some surgeons use a nerve-sparing technique. There is, though, no guarantee that erectile dysfunction will not occur. And nerve-sparing surgery may not be an option for men with tumors that lie close to the nerves. It also may not be an option for men with large tumors.

Erectile dysfunction after prostate cancer surgery tends to improve over time. About half of all men whose nerves were left intact during surgery recover normal erectile function after one year. And three-fourths recover normal function after two years. Studies have shown that drugs such as Viagra, Cialis, and Levitra can help men who have erectile dysfunction after nerve-sparing surgery. But these drugs are less effective if there is significant damage to the penile nerves.

Other common complications of radical prostatectomy include urinary incontinence — the involuntary leakage of urine from the bladder – and fecal incontinence, the involuntary leakage of stool from the rectum. These complications may get better over time. They may even completely disappear. But some men continue to have problems indefinitely. About 25% of men have urine leakage after surgery and need to use absorbent pads or disposable absorbent underwear for up to six months after surgery. But after two years, less than 10% need absorbent pads. In severe cases, some men may need surgery to support the sphincter muscles that control the release of urine.
What’s involved with radiation for early-stage prostate cancer?

There are two basic types of radiation therapy: external beam radiation, and brachytherapy or “tumor seeding.”

In external beam radiation, the prostate is exposed to high energy X-rays from a machine outside the body. The process is repeated over multiple treatment sessions. In brachytherapy, small radioactive pellets or “seeds” are placed in or near the tumor. Radiation can also be delivered to the prostate with the use of needles, wires, or thin tubes called catheters.

Proton beam therapy is a type of external radiation therapy. It involves the use of a tightly focused beam of protons. These are atomic particles with a positive electric charge. The advantage of this type of therapy is that the beam delivers most of its energy to the target tissue. That spares surrounding, healthy tissues from large doses of radiation. This type of therapy is very expensive. It’s offered in only a few treatment centers in the United States and may not be covered by insurance. Right now, there is no clear evidence that suggests that proton beam therapy is better than standard radiation techniques.

What’s involved with radiation for early-stage prostate cancer? continued…

Modern radiation therapy is often done with a conformal technique. That’s a technique in which three-dimensional imaging systems map out the shape of the prostate tumor. That allows for more precise delivery of high-dose radiation directly to the tumor. At the same time, it minimizes exposure to nearby healthy structures such as the bowel or urinary tract. A refinement of conformal radiation therapy is called intensity-modulated radiation therapy (IMRT). IMRT allows more precise delivery of high-energy radiation to the tumor with lower exposure of healthy tissues. Doing so often results in a lower incidence of side effects in the urinary tract or bowel.

“For low-risk prostate cancers,” says W. Warren Suh, MD, MPH, “radiation, either in the form of brachytherapy or external beam radiation treatment such as IMRT or proton therapy are very good treatment options.” Suh is assistant professor of radiation oncology at Harvard Medical School. He is also a radiation oncologist at the Brigham & Women’s Hospital and Dana-Farber Cancer Institute, all in Boston. Suh adds that cure rates for radiation compare favorably to those of prostatectomy.

There have been no major head-to-head studies that compare the effectiveness of surgery and radiation therapy for low-risk prostate cancer. But there is general agreement that patients should not select a therapy based on comparative cure rates. Rather, Suh tells WebMD, men should consider the possibility of side effects and the impact they may have on their quality of life.
What are the complications and side effects of radiation?

Common complications of radiation therapy include erectile dysfunction and urinary incontinence. Erectile dysfunction after radiation tends to improve more gradually than after surgery. But newer radiation techniques have lowered the risk of long-term erectile dysfunction.

Other complications may include short-term bladder infections and irritation or discomfort during voiding. Men who have radiation therapy are often given a short-term course of alpha-blockers. Those are drugs commonly prescribed to treat voiding problems caused by benign enlargement of the prostate. Drugs in this category include Flomax and Hytrin.

Radiation therapy may also cause infections of the lining of the anus and intestinal infections. The incidence of these complications, though, is significantly lower with the use of conformal or IMRT techniques than with conventional external beam radiation. Some men also experience fatigue after multiple radiation sessions. The fatigue usually resolves over time.
How does active surveillance or expectant management of early-stage prostate cancer work?

It seems counterintuitive. But active surveillance or “watchful waiting” may be a good option for many older men who have early-stage, nonaggressive disease without bothersome symptoms. Active surveillance may also be a suitable option for some men with other illnesses. That’s because the illness may be complicated by surgery or radiation.

With active surveillance, men with small volume, low-grade, early-stage cancers can have regular follow-up visits every six months. The visits include a digital rectal examination of the prostate and blood tests. In addition, the men receive annual prostate biopsies. This routine is an alternative to immediate radical prostatectomy.

How does active surveillance or expectant management of early-stage prostate cancer work? continued…

“We super-select people who have low-risk disease for our active surveillance program” explains H. Ballentine Carter, MD. Carter is professor of urology at Johns Hopkins Medical School in Baltimore. He is also director of adult oncology at the James Buchanan Brady Urological Institute at Johns Hopkins.

Currently about half of all men diagnosed with prostate cancer will have low-risk disease at the time of diagnosis, Carter tells WebMD. This is based on several different criteria, including:

* A prostate-specific antigen (PSA) level of less than 10
* A Gleason (tumor aggressiveness scale) score of 6 or less on a scale of 2-10
* Stage T1c disease, meaning that the tumor cannot be felt on digital rectal exam and is detected only on needle biopsy, or
* Stage T2a disease, meaning minimal detectable disease in one half lobe of the prostate or less

“We select people from that group of individuals,” Carter says. “And we recognize that some of them are going to have a disease that could be potentially lethal. We select men who we believe have very, very minimal disease and are at very low risk. And our criteria have remained the same since 1995.”

They screen out men whose tumors have features that could be signs of faster-growing or more extensive disease. Then they follow them very closely. If a man in the program has any evidence of disease progression in tissue samples taken during the annual biopsies, then treatment will be recommended.

Carter says about one in four men in the Johns Hopkins active surveillance program will have disease that progresses to the need for treatment. “We can say,” Carter tells WebMD, “that at two to three years, it’s not likely a man in this program is going to lose the window of opportunity for cure.”

Researchers in Sweden followed a population of men with early-stage prostate cancer for an average of 12.5 years. They found that men with tumors that were small, confined within the prostate, and not of an aggressive type had “excellent” survival. That finding was valid regardless of what age the man was diagnosed. None of the men in the study had cancer that was detected by prostate-specific antigen (PSA) testing. PSA testing is a relatively recent and controversial method for screening for prostate cancer. Part of the controversy stems from the fact it may pick up very early cancers that might not otherwise cause problems.

In a second study, the same group of men were followed even longer. After an average follow-up of 21 years, 91% of the men had died. Sixteen percent of the deaths could be attributed to prostate cancer. Most of the cancers grew slowly for the first 10 to 15 years of the study. But after 15 years of watchful waiting, there was a substantial increase in the number of men who had progression of their cancers. In addition, more of the men developed metastatic prostate cancer. Also, more died from the prostate cancer itself than in the earlier years of the study. The researchers said that the findings support early treatment of prostate cancer. Early treatment is especially beneficial for men who at the time of diagnosis have an estimated life expectancy of 15 years or longer.

Does hormonal therapy or androgen deprivation have a role in localized prostate cancer?

Hormonal therapy, or androgen deprivation, uses drugs or surgery to block the action of testosterone and other hormones on prostate cancer. There is new evidence to suggest it does not offer any survival advantage for men with disease that is confined to the prostate gland. It may, in fact, be harmful compared with expectant management alone.

Androgen deprivation does, however, play an important role in treating men with locally advanced and metastatic prostate cancer. This is the focus of the next section of this article.
What are the options for locally advanced, recurrent, or metastatic prostate cancer?

Locally advanced cancer is called stage III cancer. It refers to cancer that has spread beyond the margins of the prostate gland into the seminal vesicles and/or nearby lymph nodes. Recurrent cancer refers to a previously treated cancer that has returned. The return is usually signaled by a rise in prostate-specific antigen in the bloodstream after radical prostatectomy or radiation therapy. Metastatic or stage IV cancer refers to the spread of prostate cancer cells through the lymphatic system or bloodstream to other parts of the body. For instance, it might spread to the chest wall or bones.

Neither locally advanced, recurrent, nor metastatic prostate cancer can generally be cured with current treatments. But there are several treatments that provide long-term control of the cancer. Many men live for years or even decades with a good quality of life on these therapies. In addition, there are several promising therapies for advanced-stage prostate cancer that are now being studied.

Men with more advanced cancers are often treated with a combination of therapies. This includes surgery, radiation, hormone therapy, and chemotherapy. For instance, some studies show that men with locally advanced prostate cancer have better overall survival with radiation therapy combined with hormone therapy. They also have longer survival free of disease progression when compared to men with radiation therapy alone.

The man’s age and his general overall health will be taken into consideration when planning a treatment strategy. For instance, for older men and those with other illnesses, the risks of surgery for advanced prostate cancer may outweigh the benefits.
Can surgery help with advanced prostate cancer?

In general, surgery cannot completely remove cancerous tissue in men with stage III prostate cancer. Instead, the role of surgery may be to “debulk” the tumor. That means to remove as much tissue from the tumor as possible. Surgery may also be used to remove cancerous lymph nodes or to relieve symptoms such as urine retention. Often, surgery is used in combination with radiation therapy and/or hormonal therapy. Men with urinary symptoms such as painful or difficult urination caused by an enlarged prostate or large tumor may benefit from surgery to open a constricted urethra.

What are the complications and side effects of surgery for advanced prostate cancer?

As with surgery for early-stage prostate cancer, surgery for more advanced cancers can have significant side effects. Those include erectile dysfunction, urinary incontinence, and fecal incontinence.
Can radiation therapy be used for advanced prostate cancer?

External-beam radiation therapy can help control the growth of localized tumors. It can also help men live longer without symptoms of disease. Brachytherapy (radiation seeding) is technically difficult to do in large prostate tumors. So it is less often used in men with advanced disease.

External beam radiation can also be an effective method for controlling disease that recurs after radical prostatectomy. The radiation is directed to the part of the body where the diseased prostate was removed. Brachytherapy cannot be used in this case because the gland has been taken out. That leaves no place to embed the seeds.

Some men’s tumors are not diagnosed until they have reached stage III or higher. When that’s the case, whether radiation therapy will be effective depends on the status of regional lymph nodes. If the nodes are removed and appear to be disease-free, the chance for long-term survival is much better than if they have cancerous cells.
What are the complications and side effects of radiation in treating advanced stage prostate cancer?

Common complications of radiation therapy include erectile dysfunction and urinary incontinence.

Impotence and urinary problems may occur in men treated with radiation therapy.

Other complications may include:

* Short-term bladder infections
* Infections of the lining of the anus
* Intestinal infections

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