Cancer of Prostate Gland 

Prostate Cancer is a malignancy of the prostate gland that usually starts in the peripheral zone (region closest to the rectal wall). The prostate gland is a walnut-sized gland situated just below the urinary bladder in men. These glands help to secrete a thin opalescent and slightly alkaline fluid that comprises approximately 70 % of the seminal volume. This fluid provides lubrication and nutrition to the sperm.

Prostate cancer is one of the top ten leading cancers in India. As per statistics, the incidence rate of prostate cancer in India is 9-10/ 100,000 population. This rate is higher than countries like Africa but lower than the United States and Europe. Diagnosing prostate cancer in its early stages increases the chances of successful treatment. Let us now understand the Cancer of Prostate Gland -Symptoms, Causes and Risk Factors

Stages: What are the Stages of Prostate Cancer?

The pathologist uses the TNM staging system to describe the spread of prostate cancer by elaborating on the tumor (T), lymph node (N), and metastasis (M) to the lymph nodes, bones, and other organs. As per this system, there are four stages of prostate cancer, namely :

• Stage I – In this stage, the cancer is localized within the prostate gland and is small. It grows slowly and has a PSA level (Prostate-specific antigen) of less than 10. The detection of cancer at this stage increases the chances of complete recovery.
• Stage II – The cancer is relatively larger but is yet to grow outside the prostate gland. It is further subdivided into stage IIA ( the cancer is localized to one half or less than one side of the gland ), IIB, and IIC ( cancer is localized to one or both sides of the prostate gland ). The PSA level is usually above 10 but below 20 in this stage. Stage II cancer, when left untreated, is more likely to spread when compared to stage I cancer.
• Stage III – In this stage, cancer has spread outside the prostate gland and reached the bladder and rectum but not the lymph nodes or distant organs in this stage. The chances of recurrence are higher for cancers diagnosed at this stage than the earlier stage tumors. It is further subdivided into stage IIIA, IIIB, and IIIC depending on the regions where cancer has spread to.
• Stage IV – In this stage, cancer has spread to the nearby lymph nodes or to distant organs like bones. Most stage IV cancers cannot be cured but can be treated by using hormone therapy or chemotherapy. It is also subdivided into stage IVA and IVB cancer.

Types: Are there any Types?

The most common type is prostatic adenocarcinoma. This is because this type arises from the glandular type cells that are predominantly found in the prostate gland. In most cases, the cancer cells are less aggressive and grow more slowly when compared to the cells found in other cancers. However, when prostate cancer spreads to the other regions of the body, it is termed “metastatic prostate cancer.”

• Metastatic Prostate cancer – It is an advanced form of cancer wherein the cancer cells break away from the original tumor and travel through the blood to reach the lymph nodes, ribs, pelvic bones, and spine. Around 50 % of the men diagnosed with local prostate cancer have a higher chance of getting metastatic cancer in their lifetime.
• Recurrent prostate cancer – Recurrence of the malignancy in the prostate area or other areas of the body after treatment is called recurrent prostate cancer. Studies have shown that men with prostate cancer involving the lymph nodes of the pelvic region are more likely to have a recurrence, especially if the tumor size is big.

Other rare and uncommon types of prostate cancer are :

• Small cell Prostate Carcinoma – It is a rare type of cancer that accounts for less than 1 % of all prostate cancers. These carcinomas invade the regions outside the prostate, such as the regional lymph nodes and distant organs, unlike conventional prostatic adenocarcinoma.
• Neuroendocrine Prostate cancer – It is a rare and aggressive type of prostate cancer that may arise as a mechanism of resistance in patients who were previously treated for prostatic adenocarcinoma using hormonal therapies. It has been characterized by the conversion of hormone-sensitive tumors to hormone-resistant ones. 
• Transitional cell Prostate carcinoma – This type arises from the prostatic urethra’s primary carcinoma but is often found secondary to bladder cancer. This cancer is distinguished by the fibrosis and necrosis of the entire prostatic urethra, prostatic duct, and the nearby acini.

Causes: What Causes Prostate Cancer?

The exact etiology of prostate cancer is unknown. However, a combination of genetics and environmental toxins like radiations and certain chemicals are known to cause it. It has been observed that mutations in the DNA of the normal prostate cells lead to the production of abnormal cells that divide more rapidly than normal cells. These abnormal cells, in turn, accumulate and become malignant over a period of time. In hereditary prostate cancer, heritable genetic changes such as mutations of genes like BRCA2, BRCA2, ATM, PALB2, and CHEK2 increase the likelihood of development. Acquired gene mutations can also cause prostate cancer, and this is associated with a higher level of androgens like testosterone and other hormones like insulin-like growth factor 1 (IGF-1) in the individual.

Symptoms- Are there any Symptoms of Prostate Cancer?

Prostate cancer is usually asymptomatic in its early stages. The symptoms present in its later stages are:

· Difficulty in micturition or difficulty in passing urine and other urinary problems like urine hesitancy and interrupted urine flow due to the pressing of the prostate tumor on the urethra.

· Increased urge to urinate and frequent urination at night due to the persistent contractions of the bladder even when it contains a small amount of urine. This is due to the irritation of the bladder wall by the prostate tumor.

· Burning sensation while passing urine.

· In cases where cancer has spread to the bones, there is bone pain, which could either be generalized or localized pain.

· Other common signs of include

• • • Blood in the semen.
    • Erectile dysfunction.
    • Discomfort in the pelvis.
    • The weakness of legs.
    • Inconsistency while passing stool.
    • Shortness of breath.

Risk Factors: What can put me at risk of Prostate Cancer?

·        Age – Older people (especially> 50 years old) are at higher risk. A large percentage of men who are diagnosed with prostate cancer are over 65 years.

·        Race – Black men are at higher risk as compared to white men. Hispanic men comparatively have the least risk.

·        Sedentary lifestyle – Physical inactivity increases the PSA levels and levels of male sex hormones in the body, raising the likelihood of developing prostate cancer.

·        Consumption of unhealthy, fatty, and oily food – Excessive consumption of red meat, processed meat, saturated animal fat, egg yolks, butter, and whole milk is found to aggravate prostate cancer.

·        Men’s height and weight – Taller men, obese men, and men with bigger body mass indexes have a higher risk of developing prostate cancer. The reasoning behind this correlation remains unknown.

·        Family history – The chances of getting prostate cancer is higher if the father, brother, or any first degree relative of the patient was or is diagnosed with prostate cancer.

·        High calcium and phosphorus intake – Consumption of a large amount of phosphorus alone have been shown to increase the chances of developing high-grade and lethal prostate cancer. Consumption of calcium alone for longer periods is also found to increase the likelihood of developing prostate cancer.

Diagnosis- How is Prostate Cancer diagnosed?

Prostate cancer is initially screened by a Prostate-specific antigen (PSA) blood test or by a digital rectal exam (DRE). These tests help to identify cancer in its early stages itself.

• PSA blood test – The patient’s blood sample is taken and analyzed for prostate-specific antigen, a protein that is made by the normal and cancerous cells of the prostate gland. It helps to diagnose prostate cancer in men without symptoms and also to determine the stage of cancer. This test is also often employed to determine the effectiveness of the treatment.
• Digital rectal exam – In this exam, any abnormalities in the shape, size, and texture of the prostate gland are discovered. To perform this exam, the doctor inserts a gloved and lubricated finger into the rectum for examining the prostate that is just adjacent to the rectum.

If the results of the screening tests reveal any abnormality in the prostate, the doctor suggests further tests. This includes :

• Transrectal ultrasound – A small probe that resembles a cigar in its size and shape is inserted into the rectum for evaluation of the prostate by using sound waves. It is a painless procedure and helps to distinguish benign prostatic hyperplasia from prostate cancer. 
• Prostate biopsy – A core needle biopsy is usually done by a urologist to analyze a small sample of the prostate tissue. A thin hollow needle is inserted either through the rectum wall or through the skin between the anus and the scrotum to remove a small cylinder of the prostate tissue. Doctors often take 12 core samples from different parts of the prostate for carrying out the biopsy.
• Transrectal magnetic resonance imaging (MRI) –  A probe inserted into the rectum near the prostate gives off radio waves to get clearer images of the prostate and the nearby tissues. It is usually done when cancer has spread outside the prostate to the surrounding tissues. 

Several tests are done to find out if the cancer cells have spread from the prostate to the other parts of the body. This includes :

• Bone scan – A radioactive material is injected intravenously to find out if the cancer cells have spread to the bones.
• Pelvic lymphadenectomy – It is a surgical procedure to remove the lymph nodes, and these are then analyzed by a pathologist to detect the presence of cancerous cells.
• Seminal vesicle biopsy – A needle is used to remove the semen from the seminal vesicles, and this is analyzed by a pathologist to detect any cancerous cells’ presence.
• ProstaScint scan – A radioactive material is injected intravenously, and this attaches to the prostate cancer cells. This radioactive material shows up as a bright spot in the other regions of the body where there are a lot of prostate cancer cells.
• Other tests like MRI scan and CT scan – These help to make a series of detailed pictures of the inside of the body.

Treatment- How is Prostate Cancer treated?

The different types of treatment adopted for treating prostate cancer are :

• Active surveillance – The patient’s condition is actively monitored until the symptoms appear or change without providing any treatment. This is most often used in older men who have not manifested any symptoms. During this period, the diagnostic tests are carried out, and treatment is given only when cancer begins to grow.
• Radiation therapy – High energy x-rays and other types of radiations are used to kill the cancerous cells in the prostate gland. In external radiation therapy, a machine is used to send the radiation towards the tumor. In internal radiation therapy, a radioactive substance is inserted into the prostate by using needles or catheters.
• Hormone therapy – In this therapy, hormones are removed, or their actions are blocked to stop the cancerous cells from growing. Antiandrogens like flutamide, luteinizing hormone-releasing hormone agonists like leuprolide, estrogen, and drugs like ketoconazole are frequently administered to the patient to treat prostate cancer.
• Chemotherapy – This involves using drugs like abiraterone acetate, goserelin acetate, nilutamide, and radium 223 dichlorides, among others, to stop the growth of the cancer cells and to prevent them from multiplying. They are given either intravenously or orally.
• Immunotherapy – This is a biologic therapy that uses substances made by the body or in the laboratory to enhance the immune system of the patient. In turn, it directly boosts or restores the body’s natural defense against cancer. Sipuleucel-T is an example of an immunological agent that is used for treating metastatic prostate cancer.
• Bisphosphonate therapy – This therapy is adopted to reduce bone disease when prostate cancer has spread to the bones. It is especially prescribed for men who were treated using antiandrogen therapy as they are at an increased risk of bone loss. The drugs used include clodronate and zoledronate, and these slow the growth of bone metastases. 
• Surgery is done when the patient is in good health, and other treatment options fail to elicit any effect. The commonly adopted surgical procedures are :

1. 1. 1. 1. Radical prostatectomy – In this surgery, the prostate gland, surrounding tissues, and the seminal vesicles are removed. It can be done via an incision or by using a laparoscope.
         2. Pelvic lymphadenectomy – The lymph node is removed and analyzed by a pathologist to detect any cancerous cells’ presence. If cancerous cells are present in the lymph nodes, the doctor does not remove the prostate gland but removes the cancerous lymph nodes.
         3. Transurethral resection of the prostate (TURP) – A resectoscope is inserted through the urethra and is used to remove the excess prostate tissue. It is done to relieve the symptoms caused by prostate cancer before other treatments are adopted. 

Prevention- Lifestyle changes to prevent prostate cancer?

Various factors result in the development of different types of cancer, but there is no proven way to prevent the onset of cancer. However, by taking the following precautions, the onset of prostate cancer can be delayed.

· Avoid unhealthy foods, especially foods rich in animal fat. Eating healthy vegetables and fiber-rich food helps to reduce the chances of developing prostate cancer. Lycopene present in tomatoes is believed to reduce the risk, but this is not yet proven.

· Exercising regularly and avoiding a sedentary lifestyle.

· Avoid or limit the consumption of tobacco in any form.

· Reduce the amount of dairy product intake, especially whole milk and butter.

· Maintain healthy body weight.

FAQs :

1. Is prostate cancer curable?

• Patients with stage I, II, and III are curable as there are many treatment options available. However, when the patient is diagnosed with stage IV prostate cancer, treatments can only extend the patient’s life but not completely cure them.

2. What is the survival rate of prostate cancer?

• The 5-year survival rate of men with local prostate cancer is roughly 100 %, but for those with metastatic cancer, it lies at 31 %. The average 5-year survival rates of prostate cancer diagnosed at later stages are approximately 28 %. 

3. What is the cost of treatment?

• The cost of medical evaluation and surgery alone is estimated to be roughly 4 lakhs. Hormone therapy, if needed, costs around 2.5 lakhs, while radiation therapy is estimated to cost around 4 lakhs.

4. Which hospitals to get treatment?

• Top 38 Accredited Cancer Hospitals from India
• Best Oncologists/Oncosurgeons in India

5. Does age and gender play a role?

• Older men above the age of 50 are at a higher risk of developing prostate cancer than younger men.

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