Updated August 2021
The American Cancer Society estimates that prostate cancer is going to affect approximately 248,530 men in the US in 2021. That is an increase of over 80,000 cases from 2018. About 34,130 men will die from prostate cancer this year. It is estimated that about 1 in 8 men will be diagnosed with prostate cancer during their lifetime.
What is the prostate and how does it work?
The prostate is a walnut sized organ that is located deep in the pelvis and adjacent to the bladder and rectum. The urethra, the tube that carries urine from the bladder, passes through the prostate gland. The seminal vesicles are a set of organs that along with the prostate contribute to the male reproductive system. The role of the prostate and seminal vesicles is to contribute fluid to the semen. Sperm moves from the testicles through the vas deferens and gets deposited in the urethra along with fluid from the prostate and seminal vesicles. This combination of fluids comprises the ejaculate.
How is prostate cancer detected?
Prostate cancer screening consists of a blood test called the prostate specific antigen, or PSA, and a digital rectal exam, or DRE. The American Urological Association recommends PSA screening in men ages 55 to 69 years after a thorough discussion with their physician regarding risks and benefits of screening. Men at increased risk of prostate cancer, such as those with a family history or of African American race may be screened between age 40 to 54. Also, men older than 69 with a greater than 10-year life expectancy may benefit from screening.
What are the signs and symptoms of prostate cancer?
Prostate cancer is often asymptomatic, especially in its early stages. It is therefore known as the “silent killer”. Occasionally patients may experience urinary symptoms such as urinary urgency and frequency if the prostate is enlarged but this is not a specific to prostate cancer.
How is screening performed?
Screening is encouraged in men of the following demographic:
· Any man age 55-69
· African American starting at age 45
· Family history of prostate cancer starting at age 45
Screening may be performed earlier if there are risk factors and you should discuss this with your urologist. Screening consists of a blood test known as prostate-specific antigen (PSA) and a digital rectal exam (DRE). The PSA test may be elevated due to several reasons including infection or inflammation and prostate cancer. This number should be interpreted by your urologist who may recommend further investigation into the reason of the elevation. The DRE is performed to palpate the shape, thickness, and contour of the prostate. Abnormal shape, symmetry, or nodules, may prompt further investigation.
What can be done about an abnormal screening exam?
Your urologist will discuss any abnormal results with you to determine a jointly formed plan. This may consist of repeat lab work, MRI of the prostate, a prostate biopsy, close surveillance, or a combination of approaches. For instance, your demographic information and exam results may be compared to population data to determine the percentage risk that prostate cancer may be detected on a biopsy. Other tests such as the 4K Score may help guide the decision for a biopsy as well. Once the risks and benefits of a biopsy are discussed, a jointly formed plan can be developed between you and your urologist.
What does a prostate biopsy entail?
Generally speaking, a biopsy is a procedure where tissue is taken from your body and looked at under the microscope to determine if any abnormalities such as cancer exist. A prostate biopsy is generally a 10-15-minute procedure. You may be given an antibiotic by your doctor prior to the procedure to help prevent any infections. An ultrasound device is used to locate the prostate similar to a Digital Rectal Exam (DRE). Your physician will then inject local anesthetic solution around your prostate to make the procedure more comfortable for you. Depending on whether this is your first or repeat biopsy, different number of samples are obtained. The transperineal prostate biopsy is considered the best approach to a prostate biopsy as it reduces risk of infection and improves detection rates. Your surgeon will usually have results of the biopsy back within 1-2 weeks post biopsy.
What are complications of a prostate biopsy?
Complications are rare but you should expect to see some blood in your urine for a few days and your ejaculate for up to several weeks after the biopsy. This is self-limiting and will resolve with time. Infection requiring antibiotics is also rare but may require additional antibiotics by your physician. The risk of infection is significantly reduced by the transperineal biopsy technique. In one large patient registry, the rate of infection-related hospitalization following transrectal prostate biopsy was 0.6% but it can be as high as 5% if the transrectal biopsy technique is used.
How is prostate cancer classified?
If prostate cancer is discovered on your biopsy, your physician will discuss the Gleason Score and grade with you. In other words, the pathologist assigns “grades” to the biopsy samples. The Gleason Score is a measure of how quickly the cells are likely to grow and spread outside the prostate. The Gleason score is assigned to the most abnormal and second most abnormal cells. If the score adds up to Gleason 6, then prostate cancer is diagnosed. Prostate cancer can be classified as Gleason 6, 7, 8, 9, and 10. The higher the Gleason score the more aggressive the tumor.
A newer nomenclature has been developed to make the diagnosis easier to understand.
Gleason 3+3 or 6 is labeled Grade Group 1
Gleason 3+4 or "favorable 7" is labeled Grade Group 2
Gleason 4+3 or "unfavorable 7" is labeled Grade Group 3
Gleason 4+4 is labeled Grade Group 4
Gleason 9 and 10 are labeled Grade Group 5
Depending on these results, your urologist may recommend further testing such as imaging studies to further define your overall disease burden.
What treatment options are available?
There are different ways to approach prostate cancer depending on the amount and aggressiveness of tumor that was discovered.
· Watchful Waiting
This approach is the least involved and refers to monitoring the cancer without getting regular tests or biopsies. It essentially allows the cancer to take on its natural course.
· Active Surveillance
This approach is aimed at less aggressive cancers and at patients who do not wish to actively treat the disease. It involves routine laboratory testing and repeat biopsies to track the progression of the disease.
Radical Prostatectomy
This is a surgical approach to the cancer that is aimed at removing the prostate, nearby vesicles, tissues, and lymph nodes. Robotic Prostatectomy is the gold standard for those who seek cure from their cancer using a surgical approach. In experienced hands it has the best overall results. Risks of surgery are bleeding, infection, and potential injury to surrounding structures. Depending on the experience of your surgeon you may experience erectile dysfunction and/or some degree of urinary incontinence after surgery. Dr. Shakuri-Rad has been named a Master Surgeon in Robotic Surgery by the Surgical Review Corporation and has some of the best outcomes in the world.
· Radiation Therapy
Radiation can be done in two ways depending on your biopsy results. External beam radiation may involve multiple rounds of radiation that is aimed at killing cancer cells from outside-in. Brachytherapy or “seeds” is a form of radiation where small radioactive pellets are placed inside your prostate with the hope of killing the cells from inside-out. If radiation therapy fails to control the cancer, then surgical approaches may become much more challenging and the healing process may be impaired. Radiation therapy may also adversely affect surrounding tissues and have chronic consequences such as radiation cystitis and proctitis which are irreversible. It is a great tool to use for those cancers that return after a patient has undergone robotic prostatectomy. Patients who undergo robotic prostatectomy rarely need additional treatments.
· Cryotherapy
This approach is aimed at freezing the prostate tissue to kill cancer cells. This approach is considered experimental by some and are only effective for a subset of patients.
· High-Intensity focused Ultrasound (HIFU)
This is an investigation treatment aimed at killing cancer cells by using sound waves. Like cryotherapy, this is in its early stages and may not be considered appropriate for most patients.
· Systemic Therapy
Systemic therapy may consist of hormonal therapy, chemotherapy, or immunotherapy. This is reserved for advanced or non-localized prostate cancers. Your surgeon will review these options with you if necessary.
As always, the information above is meant to be informative and does not replace your physician's recommendations or judgement. Each individual case has to be evaluated carefully to determine the best course of action. Call or use our contact page to request an appointment to further discuss your unique case.