Articles on Prostate Cancer
What should I know about prostate cancer?
- The prostate is a walnut-shaped gland that is a part of the male reproductive system that wraps around the male urethra at it exits from the bladder.
- Common problems are benign (noncancerous) enlargement of the prostate called BPH (benign prostatic hyperplasia), acute and chronic infections of the prostate (acute and chronic bacterial prostatitis), and chronic inflammation of the prostate that is not related to bacteria (chronic prostatitis [non-bacterial]).
- Prostate cancer is common in men over 50 years of age, with the risk of developing prostate cancer increasing with aging. Certain populations are at increased risk for developing prostate cancer, particularly African-Americans and men with a first-degree relative, father or brother, diagnosed with prostate cancer at a younger age.
- Symptoms of prostate problems (and prostate cancer) include urinary problems such as
- decreased force of urine stream;
- difficulty starting (hesitancy);
- the need to strain to urinate;
- stopping/starting of the urine stream (intermittency);
- frequent urination;
- pain or burning during urination,
- erectile dysfunction;
- painful ejaculation;
- blood in urine or semen and/or deep back, hip, pelvic or abdominal pain;
- other symptoms may include weight loss, bone pain and lower extremity swelling.
- Prostate cancer screening consists of periodic laboratory testing, usually every 1-2 years, which includes a prostate specific antigen (PSA) test and digital rectal examination. Prostate cancer screening is not for everyone and the pros/cons should be discussed with a primary care provider and/or urologist (specialist who treats problems with the urinary system).
- A concern for prostate cancer is raised when blood testing, PSA, is abnormally increased and/or an abnormal area of the prostate is felt on a rectal examination.
- Prostate cancer is definitively diagnosed by removal of small cores of prostate tissue (prostate biopsies), which are then examined under the microscope by a pathologist.
- Treatments for prostate cancer may include observation, active surveillance, surgery (radical prostatectomy), radiation therapy (external beam or placement of radioactive pellets into the prostate), hormone therapy, chemotherapy, immune/vaccine therapy, and other medical therapies that can affect prostate cancer cell growth.
- Prostate cancer is a leading cause of cancer and cancer death in males; in some men, identifying it early may prevent/delay spread and death from prostate cancer.
What is prostate cancer?
Prostate cancer is cancer of prostate gland. The prostate gland is a walnut-sized gland present only in men, found in the pelvis below the bladder. The prostate gland wraps around the urethra (the tube through which urine exits the body) and lies in front of the rectum. The prostate gland secretes part of the liquid portion of the semen, or seminal fluid, which carries sperm made by the testes. The fluid is essential to reproduction.
Prostate cancer is one of the most common types of cancer that develops in men and is the third leading cause of cancer deaths in American men, behind lung cancer and colorectal cancer. In 2017, the American Cancer Society estimated that 161,360 men will be newly diagnosed with prostate cancer and 26,730 men will die from the disease -- though many of them had lived with the disease for years prior to their deaths.
Prostate cancer is comprised nearly always of adenocarcinoma cells -- cells that arise from glandular tissue. Cancer cells are named according to the organ in which they originate no matter where in the body we find such cells. Thus, if prostate cancer cells spread in the body to the bones, it is not then called bone cancer. It is prostate cancer metastatic to the bones. Metastasis is the process of cancer spread through the blood or lymphatic system to other organs/areas throughout the body. Prostate cancer more commonly metastasizes to lymph nodes in the pelvis and to the bones.
What tests do health care professionals use to diagnose prostate cancer?
The diagnosis of prostate cancer ultimately is based on the pathologist's review of tissue removed at the time of the prostate biopsy. An abnormal PSA and/or abnormal digital rectal examination often are present and are the indications for the prostate biopsy.
Digital rectal examination (DRE): As part of a physical examination, your doctor inserts a gloved and lubricated finger into your rectum and feels toward the front of your body. The prostate gland is a walnut or larger sized gland immediately in front of the rectum, and beneath your bladder. The back portion of prostate gland can be felt in this manner. Findings on this exam are compared to notes about the patient's prior digital rectal examinations.
Prostate specific antigen (PSA) blood test: The PSA blood test measures the level of a protein found in the blood that is produced by the prostate gland and helps keep semen in liquid form. The PSA test can indicate an increased likelihood of prostate cancer if the PSA is at an increased or elevated level or has changed significantly over time, but it does not provide a definitive diagnosis. Prostate cancer can be found in patients with a low PSA level, but this occurs less than 20% of the time.
Prostate biopsy: A biopsy refers to a procedure that involves taking of a sample of tissue from an area in the body. Prostate cancer is only definitively diagnosed by finding cancer cells on a biopsy sample taken from the prostate gland.
The pathologist's report on the biopsy sample showing prostate cancer will contain much detailed information. The size of the biopsy core and the percentage of involvement of each core will be reported. Most importantly the prostate cancer present will be assigned a numerical score, which is usually expressed as a sum of two numbers (for example, 3 + 4) and is referred to as the Gleason Score. This characterizes the appearance of the cancer cells and helps predict its likely level of aggressiveness in the body. A Gleason score of 6 or less indicates a low grade prostate cancer, whereas scores of 8-10 indicate a high-grade prostate cancer. A new prostate cancer grading system was developed in 2014 to help assess risk and assign a Gleason grade group. This grade group is particularly useful in Gleason score 7, where the predominant cell type could be a 4 or a 3, which may impact prostate cancer risk.
- Gleason grade group 1: Gleason score < 6
- Gleason grade group 2: Gleason score 3+4= 7
- Gleason grade group 3: Gleason score 4+3 = 7
- Gleason grade group 4: Gleason 4+4 =8, 3+5 = 8 and 5+3 = 8
- Gleason grade group 5: Gleason score 9 and 10
The Gleason score and the extent of involvement of the biopsy core expressed as a percentage, as well as the PSA level as well as your general state of health and otherwise estimated life expectancy, all help to allow doctors to make their best recommendations for you regarding how your cancer should be treated.
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What are the stages of prostate cancer?
The American Joint Commission on Cancer (AJCC) system for prostate cancer staging is as follows:
- T designations refer to the characteristics of the prostate cancer primary tumor.
- T1 prostate cancers cannot be seen on imaging tests or felt on examination. They may be found incidentally when surgery is done on the prostate for a problem presumed to be benign, or on needle biopsy for an elevated PSA.
- T1a means that the cancer cells comprise less than 5% of the tissue removed.
- T1b means that cancer cells comprise more than 5% of the tissue removed.
- T1c means that the tissue containing cancer was obtained by needle biopsy for an elevated PSA.
- T2 prostate cancers are those that can felt (palpated) on physical examination of the prostate gland (on digital rectal exam) or that can be visualized with imaging studies such as ultrasound, X-ray, or related studies. The prostate gland is comprised of two halves or lobes. The extent of involvement of those lobes is described here.
- T2a means the cancer involves one half of one lobe of the prostate or less.
- T2b means the cancer involves more than half of one lobe but does not involve the other lobe of the prostate.
- T2c means that the cancer has grown into or involves both lobes of the prostate.
- T3 prostate cancers have grown to the extent that the tumor extends outside of the prostate gland. Adjacent tissues, including the capsule around the prostate gland, the seminal vesicles, as well as the bladder neck, may be involved in T3 tumors.
- T3a means that the cancer has extended beyond the capsule (the outer edge) of the prostate gland but not into the seminal vesicles.
- T3b means that the cancer has invaded into the seminal vesicles.
- T4 prostate cancers have spread outside of the prostate gland and have invaded adjacent tissues or organs. This may be determined by examination, biopsy, or imaging studies. T4 prostate cancer may involve the pelvic floor muscles, the urethral sphincter, the bladder itself, the rectum, or the levator muscles or the pelvic wall. T4 tumors have become fixed to or invaded adjacent structures other than the seminal vesicles.
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What are the treatment options for prostate cancer?
Treatment options for prostate cancer are many, and while this is an advantage in that prostate cancer is such a common disease in men, it can also be a cause of great confusion. The following overview presents some information about these options, but it is not a complete explanation of any of these. You can find more information on treatment options in the NCCN Clinical Practice Guideline for Patients on Prostate Cancer for 2017 and the Physician Data Query (PDQ) web site of the National Cancer Institute, as well as information from the American Urological Association, and the American Cancer Society.
Conventional medical treatment options for prostate cancer include the following (see our in-depth articles for each of the treatments below for more detail):
- Active surveillance
- Surgery (radical prostatectomy [RRPX]: open, laparoscopic, robotic, perineal)
- Radiation therapy (external beam therapy [EBRT] and brachytherapy)
- Focal therapy, including cryotherapy
- Hormonal therapy
- Immunotherapy/vaccine and other targeted therapies
- Bone-directed therapy (bisphosphonates and denosumab)
- Radiopharmaceuticals (radioactive substances used as drugs)
- Research techniques including high-intensity focused ultrasound (HIFU) and others
Several new biomarkers have been developed in an effort to improve decision making in men considering active surveillance and in treated men considering adjuvant therapy or treatment of recurrence. These include Oncotype DX, Prolaris, and ELAVL1.
The NCCN treatment recommendations based on risk stratification are as follows:
Very low risk
- Life expectancy < 10 years -- observation
- Life expectancy 10-20 years -- active surveillance
- Life expectancy > 20 years -- active surveillance, EBRT, brachytherapy, or RRPX
- Life expectancy < 10 years -- observation
- Life expectancy > 10 years -- active surveillance, EBRT, brachytherapy, or RRPX
- Life expectancy < 10 years -- observation; EBRT +/- ADT (4-6 months), +/- brachytherapy; brachytherapy
- Life expectancy > 10 years -- RRPX +/- lymph node dissection EBRT +/- ADT (4-6 months) +/- brachytherapy; brachytherapy
- EBRT + ADT (2-3 years); EBRT + brachytherapy +/- ADT; RRPX in select individuals
Very high risk
- EBRT + long-term ADT; EBRT + brachytherapy +/- long-term ADT; RRPX + lymph node dissection ADT or observation in select patients
What is the prognosis for prostate cancer?
The prognosis for prostate cancer varies widely and depends on many factors, including the age and health of the patient, the stage of the tumor when it was diagnosed, the aggressiveness of the tumor, and cancer's responsiveness to treatment, among other factors.
- The 5-year survival rate for most men with local or regional prostate cancer is 100%.
- Ninety-eight percent are alive at 10 years.
- For men diagnosed with prostate cancer that has spread to other parts of the body, the 5-year survival rate is 30%.
Is it possible to prevent prostate cancer?
For a disease as common as prostate cancer, a condition which one man in six will be diagnosed with in their lifetime, the ideal approach is to prevent men from getting prostate cancer.
Two clinical trials referred to as the Prostate Cancer Prevention Trial (PCPT) and the subsequent Reduction by Dutasteride of Prostate Cancer Events (REDUCE) trial were conducted over the past two decades. These studies demonstrated that both finasteride and dutasteride (Propecia and Avodart), when used in men between 50 and 75 years of age, reduced the incidence of prostate cancer by 28% and 23% respectively as compared to similar men taking a placebo.
The reduction in the overall incidence of prostate cancer was significant. The use of these drugs and their FDA-approval for prevention has been slow to come in part because of the lingering concern over the high-grade prostate cancer risk. Men in these trials got less prostate cancer if treated with these drugs, but the prostate cancers that they did get were more often high-grade (had higher Gleason scores) and thus appeared to be at risk for behaving more aggressively. Men with a family history of prostate cancer or other high risk factors, and in fact any man, should discuss the use of these drugs for this purpose.
Vitamin E and selenium were not effective in the prevention of prostate cancer in the SELECT trial. Vitamin E supplementation may have increased the incidence of prostate cancer.
- Lycopene was also ineffective as a preventive agent.
- Pomegranate juice had no meaningful impact on prostate cancer prevention.
- Green tea had some early results suggestive of a possible protective effect, and a larger trial is under way.
Vitamin D and its derivatives have been studied in prostate cancer. There is no evidence that vitamin D protects against prostate cancer. The vitamin D derivative, calcitriol, has some therapeutic utility against this disease, and is still under study.
Prostate cancer is the most common cancer in men (after skin cancer), and the third leading cause of death from cancer in men. The biology of prostate cancer is better understood today than it was in the past. The natural history of the disease and its staging have been well defined. There are numerous potentially curative approaches to prostate cancer treatment when the disease is localized. Treatment options also exist for prostate cancer that has spread. Ongoing research continues to search for treatments for metastatic prostate cancer.
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American Cancer Society (ACS). <http://www.cancer.org/cancer/prostatecancer/index>.
American Urological Association. "Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline." 2017. <http://www.auanet.org/guidelines/clinically-localized-prostate-cancer-new-(aua/astro/suo-guideline-2017)>.
Byrd, E.S., et al. AJCC Cancer Staging Manual, 7th Ed. New York, NY: Springer, 2009.
The James Buchanan Brady Urological Institute. Johns Hopkins Medicine.
Lu-Yao, G.L., P.C. Albertson, D.F. Moore, et al. "Fifteen-year outcomes following conservative management among men aged 65 years or older with localized prostate cancer." Eur Urol 68.5 (2015): 805-811.
Mottet, Nicolas, et al. "Updated Guidelines for Metastatic Hormone-Sensitive Prostate Cancer: Abiraterone Acetate Combined With Castration Is Another Standard." European Urology 73 (2018): 316-321.
National Comprehensive Cancer Network
"Prostate Cancer." Memorial Sloan Kettering Cancer Center.
Top Prostate Cancer Facts Related Articles
Early-Stage Prostate Cancer Treatment
If prostate cancer is detected early and appears to be slow-growing, invasive procedures, chemotherapy, radiation and other approaches can sometimes do more harm than good. Many prostate cancer treatments come with side effects, like incontinence or impotence, so it’s in the patient’s interest to put off invasive treatments as long as is medically safe. Active surveillance is where doctors "watch and wait" for changes that could prompt medical intervention.
How Is Prostate Cancer Diagnosed?
Prostate cancer is largely a disease of men over 40, so it’s around this age doctors recommend the first prostate screening. The first exam is a blood test to determine if there are abnormal prostate specific antigen (PSA) levels in your blood – PSA is produced by the prostate. If the PSA is high, your doctor will perform a digital rectal exam, during which the doctor feels your prostate from inside your rectum with a gloved finger. Other diagnostic tests include an endoscopic biopsy of tumor tissue for analysis in a lab.
Prostate cancer is the most common cancer in men after skin cancer. Risk factors include age, family history, ethnicity, and diet. Prostate cancer is diagnosed by digital rectal exam, prostate specific antigen (PSA) test, and prostate biopsy.
Symptoms may include frequent need to urinate, incontinence, pain, blood in the urine, fatigue, and more. Prognosis and treatment depend on cancer staging. Watchful waiting, surgery, radiation, cryotherapy, and other management strategies are available. Research and clinical trials strive to find new and better treatments for prostate cancer.
Prostate Cancer Treatment: Chemotherapy, Bone-Targeted and Immune Therapy
Doctors may introduce chemotherapy and immune therapy if other measures fail to cure a case of prostate cancer. However, unlike with other forms of cancer, chemotherapy isn’t the first choice for early prostate cancer. Immune therapy uses the body's own immune system to attack the prostate tumor, while bone-targeted therapy aims to preserve bone and prevent metastasis.
Prostate Cancer Treatment: Focal Therapy and Other Experimental Treatments
Several new and experimental treatments for prostate cancer are under study, including treatments that use ultrasound, lasers, tissue-freezing gas, and new ways of administering radiation. These new methods are types of focal therapy, that is, treatment focused on the cancer cells in the prostate, rather than systemic therapy that administers medications or other treatments to the whole body with the aim of treating the prostate.
Prostate Cancer (Prostatic Cancer) Symptoms and Causes
Difficulty with urination – frequency, weak stream, trouble getting started, etc. – is usually the first sign of prostate cancer. But these and other early symptoms of prostatic cancer can also come from benign prostate conditions, so diagnostic testing is important, including PSA tests and digital rectal exam.
Prostate Cancer Treatment: Radiation, Brachytherapy and Radiopharmaceuticals
Radiation treatment for prostate cancer is a powerful tool at doctors’ disposal. Using radiation vs. surgery or other invasive treatments to kill cancer cells may still cause side effects, but ideally they are less severe. Radiation therapy can be performed via external beam therapy (EBRT) or the placement of radioactive seeds into the prostate (prostate brachytherapy) or using radioactive drugs (radiopharmaceuticals).
Prostate Cancer Treatment: Radical Prostatectomy Surgery
Radical prostatectomy, or surgical removal of the entire prostate gland, isn’t typically the first choice in prostate cancer treatment. Sometimes a radical approach is necessary to keep the cancer from metastasizing, however. Some cases are too severe or diagnosed too late for drugs or radiation to have much effect. In these cases, treatment teams may opt for a radical prostatectomy, despite potential side effects like impotence and incontinence.
Prostate Cancer Staging and Prognosis
The prognosis for prostate cancer, as with any cancer, depends on how advanced the cancer has become, according to established stage designations. The patient's PSA score at diagnosis, as well as their Gleason score (the grading system used to determine the aggressiveness of prostate cancer) determines the prognosis and final stage designation. Prostate cancer has a high survival rate in general, but your chances depend on the stage of the cancer.
Prostate Cancer Treatment: Hormonal Therapy
Prostate cancer is highly sensitive to, and dependent on, the level of the male hormone testosterone, which drives the growth of prostate cancer cells. Testosterone belongs to a family of hormones called androgens, and today front-line hormonal therapy for advanced and metastatic prostate cancer is called androgen deprivation therapy (ADT).