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 causes prostate cancer?

The exact causes of prostate cancer are not known. Several risk factors for developing prostate cancer have been identified, but which of these risk factors cause a prostate cell to become cancerous is not fully known. For a cancer to develop, changes must occur in the chemicals that make up the DNA, which makes up the genes in the cell. The genes control how the cell works, for example, how quickly the cell grows, divides into new cells, and dies, as well as correcting any mistakes that occur in the DNA of the cell to keep the cell working normally. Cancer occurs when certain genes that either control the growth or death of the cell are affected, which results in abnormal cell growth and/or death. Genes are inherited (passed on from parents to their children) and thus some changes in the genes (gene mutations) that increase the risk of developing cancer may be inherited. For prostate cancer, approximately 5%-10% of prostate cancers are due to inherited gene changes. Several inherited genes have been identified that increase the risk of prostate cancer, including RNASEL, BRCA 1, and BRCA 2, DNA mismatch genes, HPC1, and HoxB13. Gene changes may also be acquired (develop during the course of your life). These changes are not passed on to children. Such changes may occur when a cell is normally undergoing growth and division. It is thought that at times during normal cell growth, risk factors may affect the DNA of the cell.

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Prostate cancer facts

• The prostate is a gland that is a part of the male reproductive system that wraps around the male urethra at its exit 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 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;
  • dribbling;
  • 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 one to two 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.

Prostate Cancer Symptoms & Signs

Many of the symptoms of prostate cancer relate to the enlargement of the gland, so they are not specific to prostate cancer and can be caused by other conditions like benign prostatic hyperplasia, which enlarges the prostate gland. Very early prostate cancer may also be small and not produce any specific symptoms. Other symptoms of prostate cancer localized to the prostate can include

• a weak or interrupted urine stream,
• blood in the urine,
• a frequent need to urinate (urinary frequency

What are the risk factors for prostate cancer?

Certain risk factors may predispose a person to prostate cancer. These include the following:

• Age: Sixty percent of cases of prostate cancer arise in men over 65 years of age. The disease is rare in men under 40.
• Race or ethnicity: African-American men and Jamaican men of African ancestry are diagnosed with prostate cancer more often than are men of other races and ethnicities. Asian and Hispanic men are less likely to develop prostate cancer than are non-Hispanic white males.
• Family history: Prostate cancer can run in families. A man whose father or brother has or had prostate cancer is twice as likely to develop the disease. The younger the family member is when he is diagnosed with prostate cancer, the higher the risk is for male relatives to develop prostate cancer. The risk of developing prostate cancer also increases with the number of relatives affected.
• Nationality: Prostate cancer is more common in North America, Europe (especially northwestern countries in Europe), the Caribbean, and Australia. It is less common in Asia, Africa, and South and Central America. Multiple factors, such as diet and lifestyle, may account for this.
• Genetic factors: Mutations in a portion of the DNA called the BRCA2 gene can increase a man's risk of getting prostate cancer, as well as other cancers. This same mutation in female family members may increase their risk of developing breast or ovarian cancer. However, very few cases of prostate cancer can be directly attributed to presently identifiable genetic changes. Other inherited genes associated with an increased risk of prostate cancer include RNASEL, BRCA 1, DNA mismatch genes, HPC1, and HoxB13.
• Other factors: Diets high in red meats and fatty foods and low in fruits and vegetables appear to be associated with a higher risk of developing prostate cancer. Obesity is also linked to a higher risk of the disease. Increased calcium intake and dairy foods may increase the risk of prostate cancer.

Smoking, a history of sexually transmitted diseases, a history of prostatitis (inflammation of the prostate), and a history of vasectomy have not been proven to play a role in causing prostate cancer. The role of fish oil in risk of prostate cancer remains under investigation.

What are the signs and symptoms of prostate cancer?

A patient with early prostate cancer is usually asymptomatic. However, late stage disease and sometimes early stage disease may have the following signs and symptoms:

• Frequent urination, during the day and/or at night
• Difficulty in starting (hesitancy), maintaining, or stopping the urine stream
• A weak or interrupted urine stream
• Straining to urinate
• Inability to urinate (urinary retention)
• Loss of control of urination
• Difficulty urinating when standing, requiring sitting during urination
• Pain with urination or ejaculation
• Blood in the urine or in the semen
• Abnormal rectal examination

Many symptoms of early cancer of the prostate can also be attributed to benign (noncancerous) conditions of the prostate, including benign prostatic hypertrophy (BPH), or infection in the prostate gland or urinary system.

Signs and symptoms of advanced prostate cancer (late stage prostate cancer) that has already spread from the prostate gland to elsewhere in the body (called metastatic prostate cancer) include

• a new dull, then progressively severe, pain in the bones, especially the low back;
• unexplained weight loss;
• fatigue;
• increasing shortness of breath while doing activities previously well tolerated;
• low-impact fracture of bone(s) without a lot of trauma (or broken bone[s] from minor trauma); and
• swelling of the legs related to obstruction of the lymph tissue by prostate cancer.

It is always best to find and diagnose prostate cancer at an early stage and hopefully still confined to its site of origin. At that point, treatments can cure it. When prostate cancer is widespread or metastatic, it can be treated, but it cannot be cured.

What specialists identify and treat prostate cancer?

There are several different types of specialists involved in the identification and treatment of prostate cancer.

1. The primary provider (PCP) may be the initial medical doctor to discuss prostate cancer screening and/or become concerned about the risk of prostate cancer (because of abnormal rectal examination and/or elevated PSA or family history of prostate cancer [brother or father or multiple family members diagnosed with prostate cancer at < 60 years of age]) during your routine evaluations or due to symptoms and refer you to a urologist for further evaluation.
2. Urologists are the specialists who will initially be involved in the diagnosis of prostate cancer and will perform the prostate biopsy. Depending on the grade and stage of the prostate cancer at the time of the diagnosis, additional specialists may be involved in your care. Urologists perform surgical-based treatments for prostate cancer (radical prostatectomy), minimally invasive treatments (cryotherapy, brachytherapy), and prescribe medications (hormonal therapy).
3. Medical oncologists are medical doctors who specialize in the treatment of cancer. Medical oncologists treat prostate cancer with a variety of medical therapies, including chemotherapy, immune/vaccine, and hormonal therapy.
4. Radiation oncologists are specialists who treat cancer with ionizing radiation. This radiation may be given externally (external beam radiation therapy) or internally through the placement of small radioactive pellets into the prostate (brachytherapy).
5. Often urologists, medical oncologists, and radiation oncologists work together in a multidisciplinary team to review your case and you may meet with one, two, or all of these physicians at some point during your prostate cancer treatment.