Prostate Cancer

Prostate Cancer

For many men, “prostate cancer” are two of the scariest words they will ever hear. One in nine men will be diagnosed with the disease during his lifetime. While more than 31,000 die from it every year, the very experienced prostate cancer specialists at Urology Partners offer a range of state-of-the-art detection and treatment options to help men successfully battle prostate cancer.

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Nearly 175,000 U.S. men are diagnosed with prostate cancer each year.

What is prostate cancer?

Located deep inside the groin between the base of the penis and the rectum, the golf-ball-sized prostate gland produces seminal fluid which mixes with sperm from the testes to help sperm travel. Prostate cancer occurs when healthy cells in the prostate begin to mutate and grow out of control. When the abnormal cells clump together, they form a cancerous tumor. Researchers still don’t have all the answers about what triggers changes to prostate cells, but know that genetics, family history, ethnicity, a high-fat diet and obesity are all risk factors.

Early detection and treatment are crucial because most men do not experience symptoms until the cancer has spread (metastasized) beyond the prostate to other areas of the body. Once prostate cancer has metastasized, symptoms can include frequent urination, painful urination, difficulty urinating, blood in the urine or semen, painful ejaculation, dull pain in the lower pelvic area or general pain in the lower back, hips and upper thighs.


How is prostate cancer diagnosed?

There are several steps involved in screening for and diagnosing prostate cancer, including PSA testing, digital rectal exam (DRE), and biopsy.

PSA testing

A simple blood test to detect the presence of prostate-antigen antibody (PSA)—a protein produced by the prostate—is the first step toward monitoring the health of the prostate. The first PSA test provides patients and physicians with an important baseline that can be monitored over time to track a suspicious rise in level. Generally, levels measuring less than 2.5 are considered within normal range, but a rise in PSA greater than 0.35 per year or a doubling within a year raises suspicions about cancer.

The higher the PSA level, the greater the risk for prostate cancer. High PSAs should be confirmed with a repeat blood test to ensure an underlying medical condition—an enlarged prostate, prostatitis, benign prostatic hyperplasia, urinary tract infection, urine retention or recent ejaculation—isn’t responsible for the high level. The doctor will evaluate the test results and determine whether the PSA level is appropriate for a man's age, ethnicity and other relevant health factors. While some criticize PSA testing, prostate cancer deaths have declined 44 percent since the test was introduced in 1991.

When a man has an elevated PSA, one of the many questions that arise is how to get it back down to normal levels. If only one PSA test is above normal, it is a good idea to repeat the test. There is roughly 20 percent variability in PSA readings which can be secondary to many issues with PSA leaking into the bloodstream. If a man has urinary symptoms that could indicate an infection, antibiotics may be an appropriate next step, but antibiotics are not helpful in simply lowering PSA levels. For men with an underlying medical condition that may elevate PSA, blood should be drawn several weeks later for a repeat PSA. Because PSA is a marker that indicates something could be wrong in the prostate, supplementsand medications are not the answer. The PSA test is an excellent way to confirm suspicions about a prostate issue, and if levels continue to remain elevated, discussion with a physician is the next step.

Digital rectal exam

Since the prostate is not easily visible, a digital rectal exam (DRE) allows the physician to feel the prostate by inserting a gloved finger into the rectum. If the prostate feels hard, lumpy or has any abnormal areas, it could be a warning sign for prostate cancer. While a DRE is often a source of apprehension for many men, the exam takes only a few seconds and causes mild discomfort. A DRE test, along with PSA testing, is an important part of regular prostate cancer screening.

Biopsy

Although results from a PSA test and DRE are the first indicators that prostate cancer may be present, a transrectal ultrasound (TRUS) guided biopsy or magnetic resonance imaging (MRI) fusion-guided biopsy are conducted to confirm a diagnosis.

TRUS-guided biopsy

Under local anesthetic, a lubricated ultrasound probe is placed in the rectum allowing the physician to see the shape and size of the prostate—along with any apparent abnormalities or shadows that may indicate cancer. After the prostate gland is injected with numbing anesthetic, slim needles are used to gather samples from several zones of the prostate including suspicious-looking areas (although not all prostate cancers are visible). The collected tissue samples are sent to a pathologist who will examine them to determine if cancer is present.

MRI

Magnetic Resonance Imaging (MRI) has been used for many years to evaluate soft tissue, but has only become mainstream for prostate imaging over the last seven years. Because the prostate is a very dense organ, it was very difficult to visualize with previous MRI machines. Now newer, more powerful magnets—the 3 Tesla (3T)—have significantly improved the images collected.

In 2012, the PI-RADS (v.1) imaging grading system was introduced. This grading system enables radiologists and urologists to grade abnormal areas in the prostate. The PI-RADS scale ranges from 1 to 5 with 5 being the highest rating and indicating areas most likely to harbor a focus of intermediate or high-grade prostate cancer. While the MRI is roughly 80 percent accurate in finding intermediate to high- grade prostate cancer, it often misses lower-grade prostate cancer. This is currently rarely an issue, though, as many of these men are candidates for active surveillance to follow these low-risk cancers without treatment.

Not all MRIs are built the same, so it is extremely important to discuss your MRI with your UP urologist. Urology Partners currently recommends Gateway Imaging in Arlington because they have the MRI and software specifications to produce high-quality images that are compatible with our inVivo Uronav fusion biopsy software system.

MRI fusion-guided biopsy

TRUS-guided biopsies don’t always deliver definitive answers. There have been many cases where men with PSA levels of 20 or 30 have undergone several biopsies that repeatedly come back negative. Their cancer could not be located due to limitations of the TRUS technology. In an effort to get a clearer picture of the prostate and suspicious areas, many men have a prostate MRI before their biopsy.

During an MRI fusion-guided biopsy, the physician marks suspicious lesions on the high-resolution MRI image and enters them in a computer using specialty software. The MRI image is carefully layered over the ultrasound image to provide better visualization and more precise targeting of suspicious areas. The software maps the areas where samples are collected in case future biopsies are required. MRI fusion-guided biopsy is beneficial for any man with an abnormal prostate MRI.


Not all prostate cancer is the same.

Many prostate cancer tumors are low-grade, slow-growing cancers that may not pose an immediate health risk, while others are aggressive, high-grade cancers that can grow rapidly and quickly spread beyond the prostate. Once a biopsy has confirmed the presence of prostate cancer, cancer grading and cancer staging are used to determine which type of cancer a man is facing.

Cancer grading

Grading refers to the way cancer looks under a microscope. When abnormal-looking cancer cells are found, the pathologist ranks them according to the degree of visible change. While early-stage or low-grade cancer cells may look only slightly different from healthy cells, high-grade cancer cells look dramatically different. Each of the tissue samples collected during a biopsy is assigned a number according to the Gleason Grade from 3 to 5 if cancer is present. The number 3 indicates the “least aggressive” grade of prostate cancer, while the number 5 represents the “most aggressive” grade of the disease.

To make things a little more complex, all prostate cancers will get a Gleason score from 6-10 and each score has parentheses. This enables the pathologist to relay if there are different Gleason Grades in the biopsy core. The two most common Gleason Grades (3 to 5) from the set are added together to determine the overall Gleason score—from (3+3) to (5+5). In each sample given to the pathologist, the amount of Gleason 3, 4 or 5 is given a percentage and the Gleason Grade with the highest percentage goes first. For example, a Gleason score of 7 (3+4) has a higher percentage of Gleason 3 than 4, so it is placed first in the parentheses. The most common overall Gleason score is 6 (3+3), but scores can range from 6 to 10. Gleason score 6 is generally referred to as a lower score. Gleason 7 is an intermediate score. Gleason 8, 9 and 10 are considered higher scores. In cases where the Gleason score is on the high side, additional tests such as an MRI or bone scan will be conducted to help stage the prostate cancer more accurately.

Cancer staging

Staging refers to how much the cancer has grown and spread. Is it confined locally within the prostate? Has it spread beyond the prostate and into the lymph nodes, or metastasized to the bones? In cases where the Gleason score is on the high side, additional tests such as an MRI, CT scan or bone scan will be conducted to help stage the prostate cancer more precisely. Based on these reports, the American Joint Committee on Cancer TNM (Tumor, Node, Metastasis) Staging System is used to describe how far the cancer has spread. The TNM system is based on three important pieces of information:


T category: the size and extent of the primary tumor

T1a - cancer found in 5% of TURP specimens

T1b - cancer found in more than 5% of TURP specimens

T1c - cancer found on prostate needle biopsy only because of elevated PSA


T2a - cancer found in less than 50% of one side of the prostate

T2b - cancer found in more than 50% of one side of the prostate

T2c - cancer found in both sides of the prostate


T3a - cancer has spread outside the prostate, but not to seminal vesicles

T3b - cancer has spread to the seminal vesicles


T4 - cancer has grown into the nearby tissues such as bladder or pelvic sidewall


N category: whether the cancer has spread to nearby lymph nodes

Nx - lymph nodes have not been assessed for cancer

N0 - no cancer in nearby lymph nodes

N1 - cancer has spread to nearby lymph nodes


M category: the absence or presence of distant disease metastasis

Mx - it is unknown if cancer has spread to distant sites

M0 - cancer has not spread to distant sites

M1 - cancer has spread to distant sites

M1a - cancer has spread to distant lymph nodes

M1b- cancer has spread to bones

M1c - cancer has spread to distant organs

There are actually two types of staging for prostate cancer—the clinical and pathologic staging. Clinical staging is the doctor's best estimate regarding the extent of the prostate cancer based on the results of a physical exam, digital rectal exam (DRE), lab tests, prostate biopsy and imaging tests. Pathologic staging is based on the examination of tissue removed during surgery. Pathologic staging is likely to be more accurate than clinical staging because it enables physicians to get firsthand knowledge about the extent of the cancer.

 

Treatment Depends on Several Factors

While every individual’s cancer case is unique, Urology Partners follows treatment guidelines established by the National Comprehensive Cancer Network (NCCN).
The NCCN system takes Gleason Grade, cancer stage, PSA and the presence or absence of lymph node and bone involvement into consideration before recommending treatment based
on a man’s risk category—very low risk, low risk, intermediate risk or high risk.

Active Surveillance Robot-Assisted Laparoscopic Radical Prostatectomy Intensity-Modulated Radiation Therapy Cryosurgery



Active Surveillance


active surveillanceTen to 20 years ago, about one-third of men diagnosed with prostate cancer already had metastatic cancer that had spread to their bones or lymph nodes. Now that number is just one or two percent because more men are diagnosed in the very early stages of prostate cancer. Because they are diagnosed much earlier, not all men need immediate treatment. Rather than undergoing surgery or radiation treatments immediately after a prostate cancer diagnosis, some men can be actively monitored for a period of time.

During active surveillance, men have a PSA test every three to six months, and see their urologist to determine if there have been any significant changes.  Research shows that men who are good candidates for active surveillance—and who opt to participate in it as a first step in their treatment—have outcomes that are just as good as men who undergo radiation or surgery right away. Biopsies and prostate MRIs are routinely recommended as followup in the years after the original diagnosis to ensure that there is no evidence of higher-grade cancer that may require treatment.



Robot-Assisted Laparoscopic Radical Prostatectomy


robot assisted prostatectomyThe surgical removal of the entire prostate gland and seminal vesicles is a treatment option for men with intermediate or high-risk cancer that has not spread beyond the prostate. Unlike open radical prostatectomy that requires a large incision in the abdomen, Urology Partners surgeons use the da Vinci Surgical® System to perform a robot-assisted laparoscopic radical prostatectomy.

The procedure requires only small abdominal incisions to accommodate a slim robotic arm controlled by the surgeon. A high-definition camera provides a clear, magnified view of the patient’s anatomy, and precision tools give the surgeon the delicate control needed to remove cancerous tissue without damaging surrounding nerves.

In experienced hands, patients who undergo a robot-assisted prostatectomy lose less blood, heal more quickly, have a shorter hospital stay and return to normal activities more quickly.

Today, survivor rates 15 years post-prostatectomy are as high as 93 percent. Urology Partners has some of the most experienced robotic surgeons in the United States—skilled surgeons who have been performing robotic surgery since its early inception in 2002.



Intensity-Modulated Radiation Therapy


radiationIntensity-modulated radiation therapy (IMRT) kills cancerous tissue by damaging its DNA and halting its growth cycle. Using state-of-the-art technology, this targeted approach pinpoints the exact location and shape of the prostate cancer tumor to deliver a very precise dose of radiation. The focused radiation destroys cancer cells while avoiding adjacent healthy tissue and organs—including the bladder and rectum. With no incision, no pain and no recovery time, most men can go about their daily lives with minimal disruption. Treatment sessions last minutes, not hours.



Cryosurgery


CryosurgeryThis minimally invasive alternative to other surgical and radiation treatments is an option for men with localized prostate cancer. Slim cryoprobes deliver cycles of extremely cold and warm temperatures that repeatedly freeze and thaw cancerous cells within and around the prostate gland—ultimately destroying them.

Ultrasound technology guides the strategic placement of the probes into and around the prostate while minimizing damage to surrounding tissue. With two or more cycles, cancerous cells are destroyed, while the other tissue is either absorbed by the body or remains as scar tissue. Because the procedure is relatively short (usually 1 to 1.5 hours), men experience fewer side effects and enjoy faster recovery. Unlike radiation therapy or a radical prostatectomy, cryosurgery can be repeated if necessary.



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