Prostate cancer treatment

Prostate cancer treatment

What is Prostate Cancer?

Prostate cancer is a cancer that occurs in the prostate. The prostate is a small walnut-shaped gland in males that produces the seminal fluid that nourishes and transports sperm.

Prostate cancer is one of the most common types of cancer. Many prostate cancers grow slowly and are confined to the prostate gland, where they may not cause serious harm. However, while some types of prostate cancer grow slowly and may need minimal or even no treatment, other types are aggressive and can spread quickly.

Prostate cancer that's detected early — when it's still confined to the prostate gland — has the best chance for successful treatment.

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Before Prostate Cancer Treatment

Symptoms

Prostate cancer may cause no signs or symptoms in its early stages.

Prostate cancer that's more advanced may cause signs and symptoms such as:

. Trouble urinating

. Decreased force in the stream of urine

. Blood in the urine

. Blood in the semen

. Bone pain

. Losing weight without trying

. Erectile dysfunction

When to see a doctor

Make an appointment with your doctor if you have any persistent signs or symptoms that worry you.

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Causes

It's not clear what causes prostate cancer.

Doctors know that prostate cancer begins when cells in the prostate develop changes in their DNA. A cell's DNA contains the instructions that tell a cell what to do. The changes tell the cells to grow and divide more rapidly than normal cells do. The abnormal cells continue living, when other cells would die.

The accumulating abnormal cells form a tumor that can grow to invade nearby tissue. In time, some abnormal cells can break away and spread (metastasize) to other parts of the body.

Risk factors

Factors that can increase your risk of prostate cancer include:

. Older age. Your risk of prostate cancer increases as you age. It's most common after age 50.

. Race. For reasons not yet determined, Black people have a greater risk of prostate cancer than do people of other races. In Black people, prostate cancer is also more likely to be aggressive or advanced.

. Family history. If a blood relative, such as a parent, sibling or child, has been diagnosed with prostate cancer, your risk may be increased. Also, if you have a family history of genes that increase the risk of breast cancer (BRCA1 or BRCA2) or a very strong family history of breast cancer, your risk of prostate cancer may be higher.

. Obesity. People who are obese may have a higher risk of prostate cancer compared with people considered to have a healthy weight, though studies have had mixed results. In obese people, the cancer is more likely to be more aggressive and more likely to return after initial treatment.

Complications

Complications of prostate cancer and its treatments include:

. Cancer that spreads (metastasizes). Prostate cancer can spread to nearby organs, such as your bladder, or travel through your bloodstream or lymphatic system to your bones or other organs. Prostate cancer that spreads to the bones can cause pain and broken bones. Once prostate cancer has spread to other areas of the body, it may still respond to treatment and may be controlled, but it's unlikely to be cured.

. Incontinence. Both prostate cancer and its treatment can cause urinary incontinence. Treatment for incontinence depends on the type you have, how severe it is and the likelihood it will improve over time. Treatment options may include medications, catheters and surgery.

. Erectile dysfunction. Erectile dysfunction can result from prostate cancer or its treatment, including surgery, radiation or hormone treatments. Medications, vacuum devices that assist in achieving erection and surgery are available to treat erectile dysfunction.

Prevention

You can reduce your risk of prostate cancer if you:

. Choose a healthy diet full of fruits and vegetables. Eat a variety of fruits, vegetables and whole grains. Fruits and vegetables contain many vitamins and nutrients that can contribute to your health.

Whether you can prevent prostate cancer through diet has yet to be conclusively proved. But eating a healthy diet with a variety of fruits and vegetables can improve your overall health.

. Choose healthy foods over supplements. No studies have shown that supplements play a role in reducing your risk of prostate cancer. Instead, choose foods that are rich in vitamins and minerals so that you can maintain healthy levels of vitamins in your body.

. Exercise most days of the week. Exercise improves your overall health, helps you maintain your weight and improves your mood. Try to exercise most days of the week. If you're new to exercise, start slow and work your way up to more exercise time each day.

. Maintain a healthy weight. If your current weight is healthy, work to maintain it by choosing a healthy diet and exercising most days of the week. If you need to lose weight, add more exercise and reduce the number of calories you eat each day. Ask your doctor for help creating a plan for healthy weight loss.

. Talk to your doctor about increased risk of prostate cancer. If you have a very high risk of prostate cancer, you and your doctor may consider medications or other treatments to reduce the risk. Some studies suggest that taking 5-alpha reductase inhibitors, including finasteride (Propecia, Proscar) and dutasteride (Avodart), may reduce the overall risk of developing prostate cancer. These drugs are used to control prostate gland enlargement and hair loss.

However, some evidence indicates that people taking these medications may have an increased risk of getting a more serious form of prostate cancer (high-grade prostate cancer). If you're concerned about your risk of developing prostate cancer, talk with your doctor.

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Diagnosis

Screening for prostate cancer

Testing healthy men with no symptoms for prostate cancer is controversial. There is some disagreement among medical organizations whether the benefits of testing outweigh the potential risks.

Most medical organizations encourage men in their 50s to discuss the pros and cons of prostate cancer screening with their doctors. The discussion should include a review of your risk factors and your preferences about screening.

You might consider starting the discussions sooner if you're a Black person, have a family history of prostate cancer or have other risk factors.

Prostate screening tests might include:

. Digital rectal exam (DRE). During a DRE, your doctor inserts a gloved, lubricated finger into your rectum to examine your prostate, which is adjacent to the rectum. If your doctor finds any abnormalities in the texture, shape or size of the gland, you may need further tests.

. Prostate-specific antigen (PSA) test. A blood sample is drawn from a vein in your arm and analyzed for PSA, a substance that's naturally produced by your prostate gland. It's normal for a small amount of PSA to be in your bloodstream. However, if a higher than usual level is found, it may indicate prostate infection, inflammation, enlargement or cancer.

Diagnosing prostate cancer

If prostate cancer screening detects an abnormality, your doctor may recommend further tests to determine whether you have prostate cancer, such as:

. Ultrasound. During a transrectal ultrasound, a small probe, about the size and shape of a cigar, is inserted into your rectum. The probe uses sound waves to create a picture of your prostate gland.

. Magnetic resonance imaging (MRI). In some situations, your doctor may recommend an MRI scan of the prostate to create a more detailed picture. MRI images may help your doctor plan a procedure to remove prostate tissue samples.

. Collecting a sample of prostate tissue. To determine whether there are cancer cells in the prostate, your doctor may recommend a procedure to collect a sample of cells from your prostate (prostate biopsy). Prostate biopsy is often done using a thin needle that's inserted into the prostate to collect tissue. The tissue sample is analyzed in a lab to determine whether cancer cells are present.

Determining whether prostate cancer is aggressive

When a biopsy confirms the presence of cancer, the next step is to determine the level of aggressiveness (grade) of the cancer cells. A doctor in a lab examines a sample of your cancer cells to determine how much cancer cells differ from the healthy cells. A higher grade indicates a more aggressive cancer that is more likely to spread quickly.

Techniques used to determine the aggressiveness of the cancer include:

. Gleason score. The most common scale used to evaluate the grade of prostate cancer cells is called a Gleason score. Gleason scoring combines two numbers and can range from 2 (nonaggressive cancer) to 10 (very aggressive cancer), though the lower part of the range isn't used as often.

Most Gleason scores used to assess prostate biopsy samples range from 6 to 10. A score of 6 indicates a low-grade prostate cancer. A score of 7 indicates a medium-grade prostate cancer. Scores from 8 to 10 indicate high-grade cancers.

. Genomic testing. Genomic testing analyzes your prostate cancer cells to determine which gene mutations are present. This type of test can give you more information about your prognosis. But it's not clear who might benefit most from this information, so the tests aren't widely used. Genomic tests aren't necessary for every person with prostate cancer, but they might provide more information for making treatment decisions in certain situations.

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Determining whether the cancer has spread

Once a prostate cancer diagnosis has been made, your doctor works to determine the extent (stage) of the cancer. If your doctor suspects your cancer may have spread beyond your prostate, one or more of the following imaging tests may be recommended:

. Bone scan

. Ultrasound

. Computerized tomography (CT) scan

. Magnetic resonance imaging (MRI)

. Positron emission tomography (PET) scan

Not every person should have every test. Your doctor will help determine which tests are best for your individual situation.

Your doctor uses the information from these tests to assign your cancer a stage.

During Prostate Cancer Treatment

Prostate cancer stages

Knowing the stage of prostate cancer can help a person understand what to expect, and it will inform decisions about treatment. We list the stages below:

 

. Stage 0: Precancerous cells are present, but they only affect a small area and are slow growing.

. Localized (stage 1): Cancer is only present in the prostate gland. Effective treatment is possible at this stage.

. Regional (stages 2–3): Cancer has spread to nearby tissues.

. Distant (stage 4): Cancer has spread to other parts of the body, such as the lungs or bones.

Types of prostate cancer

Most cases of prostate cancer are a type of cancer called an adenocarcinoma. This is a cancer that grows in the tissue of a gland, such as the prostate gland.

Prostate cancer is also categorized by how fast it grows. It has two types of growths:

. Aggressive, or fast growing

. Nonaggressive, or slow growing

With nonaggressive prostate cancer, the tumor either doesn’t grow or grows very little over time. With aggressive prostate cancer, the tumor can grow quickly and may spread to other areas of the body, such as the bones.

Treatment

Your prostate cancer treatment options depend on several factors, such as how fast your cancer is growing, whether it has spread and your overall health, as well as the potential benefits or side effects of the treatment.

Immediate treatment may not be necessary

Low-grade prostate cancer may not need treatment right away. For some, treatment may never be needed. Instead, doctors sometimes recommend active surveillance.

In active surveillance, regular follow-up blood tests, rectal exams and prostate biopsies may be performed to monitor progression of your cancer. If tests show your cancer is progressing, you may opt for a prostate cancer treatment such as surgery or radiation.

Active surveillance may be an option for cancer that isn't causing symptoms, is expected to grow very slowly and is confined to a small area of the prostate. Active surveillance may also be considered for someone who has another serious health condition or who is of an advanced age that makes cancer treatment more difficult.

Surgery to remove the prostate

Surgery for prostate cancer involves removing the prostate gland (radical prostatectomy), some surrounding tissue and a few lymph nodes.

Surgery is an option for treating cancer that's confined to the prostate. It's sometimes used to treat advanced prostate cancer in combination with other treatments.

To access the prostate, surgeons may use a technique that involves:

. Making several small incisions in your abdomen. During robot-assisted laparoscopic prostatectomy, surgical instruments are attached to a mechanical device (robot) and inserted through several small incisions in your abdomen. The surgeon sits at a console and uses hand controls to guide the robot to move the instruments. Most prostate cancer operations are done using this technique.

. Making one long incision in your abdomen. During retropubic surgery, the surgeon makes one long incision in your lower abdomen to access and remove the prostate gland. This approach is much less common, but may be necessary in certain situations.

Discuss with your doctor which type of surgery is best for your specific situation.

Radiation therapy

Radiation therapy uses high-powered energy to kill cancer cells. Prostate cancer radiation therapy treatments may involve:

. Radiation that comes from outside of your body (external beam radiation). During external beam radiation therapy, you lie on a table while a machine moves around your body, directing high-powered energy beams, such as X-rays or protons, to your prostate cancer. You typically undergo external beam radiation treatments five days a week for several weeks. Some medical centers offer a shorter course of radiation therapy that uses higher doses of radiation spread over fewer days.

External beam radiation is an option for treating cancer that's confined to the prostate. It can also be used after surgery to kill any cancer cells that might remain if there's a risk that the cancer could spread or come back. For prostate cancer that spreads to other areas of the body, such as the bones, radiation therapy can help slow the cancer's growth and relieve symptoms, such as pain.

. Radiation placed inside your body (brachytherapy). Brachytherapy involves placing radioactive sources in your prostate tissue. Most often, the radiation is contained in rice-sized radioactive seeds that are inserted into your prostate tissue. The seeds deliver a low dose of radiation over a long period of time. Brachytherapy is one option for treating cancer that hasn't spread beyond the prostate.

In some situations, doctors may recommend both types of radiation therapy.

Freezing or heating prostate tissue

Ablative therapies destroy prostate tissue with cold or heat. Options may include:

. Freezing prostate tissue. Cryoablation or cryotherapy for prostate cancer involves using a very cold gas to freeze the prostate tissue. The tissue is allowed to thaw and the procedure repeats. The cycles of freezing and thawing kill the cancer cells and some surrounding healthy tissue.

. Heating prostate tissue. High-intensity focused ultrasound (HIFU) treatment uses concentrated ultrasound energy to heat the prostate tissue and cause it to die.

These treatments may be considered for treating very small prostate cancers when surgery isn't possible. They may also be used to treat advanced prostate cancers if other treatments, such as radiation therapy, haven't helped.

Researchers are studying whether cryotherapy or HIFU to treat one part of the prostate might be an option for cancer that's confined to the prostate. Referred to as "focal therapy," this strategy identifies the area of the prostate that contains the most aggressive cancer cells and treats that area only. Studies have found that focal therapy reduces the risk of side effects. But it's not clear whether it offers the same survival benefits as treatment to the entire prostate.

Hormone therapy

Hormone therapy is treatment to stop your body from producing the male hormone testosterone. Prostate cancer cells rely on testosterone to help them grow. Cutting off the supply of testosterone may cause cancer cells to die or to grow more slowly.

Hormone therapy options include:

. Medications that stop your body from producing testosterone. Certain medications — known as luteinizing hormone-releasing hormone (LHRH) or gonadotropin-releasing hormone (GnRH) agonists and antagonists — prevent your body's cells from receiving messages to make testosterone. As a result, your testicles stop producing testosterone.

. Medications that block testosterone from reaching cancer cells. These medications, known as anti-androgens, usually are given in conjunction with LHRH agonists. That's because LHRH agonists can cause a temporary increase in testosterone before testosterone levels decrease.

. Surgery to remove the testicles (orchiectomy). Removing your testicles reduces testosterone levels in your body quickly and significantly. But unlike medication options, surgery to remove the testicles is permanent and irreversible.

Hormone therapy is often used to treat advanced prostate cancer to shrink the cancer and slow its growth.

Hormone therapy is sometimes used before radiation therapy to treat cancer that hasn't spread beyond the prostate. It helps shrink the cancer and increases the effectiveness of radiation therapy.

Chemotherapy

Chemotherapy uses drugs to kill rapidly growing cells, including cancer cells. Chemotherapy can be administered through a vein in your arm, in pill form or both.

Chemotherapy may be a treatment option for treating prostate cancer that has spread to other areas of the body. Chemotherapy may also be an option for cancers that don't respond to hormone therapy.

Immunotherapy

Immunotherapy uses your immune system to fight cancer. Your body's disease-fighting immune system may not attack your cancer because the cancer cells produce proteins that help them hide from the immune system cells. Immunotherapy works by interfering with that process.

Prostate cancer immunotherapy can involve:

. Engineering your cells to fight cancer. Sipuleucel-T (Provenge) treatment takes some of your own immune cells, genetically engineers them in a laboratory to fight prostate cancer and then injects the cells back into your body through a vein. It's an option for treating advanced prostate cancer that no longer responds to hormone therapy.

. Helping your immune system cells identify cancer cells. Immunotherapy drugs that help the immune system cells identify and attack the cancer cells are an option for treating advanced prostate cancers that no longer respond to hormone therapy.

Targeted drug therapy

Targeted drug treatments focus on specific abnormalities present within cancer cells. By blocking these abnormalities, targeted drug treatments can cause cancer cells to die.

Targeted therapy drugs may be recommended to treat advanced or recurrent prostate cancer if hormone therapy isn't working.

Some targeted therapies only work in people whose cancer cells have certain genetic mutations. Your cancer cells may be tested in a laboratory to see if these drugs might help you.

Alternative medicine

No complementary or alternative treatments will cure prostate cancer. However, complementary and alternative prostate cancer treatments may help you cope with the side effects of cancer and its treatment.

Nearly everyone diagnosed with cancer experiences some distress at some point. If you're distressed, you may feel sad, angry or anxious. You may experience difficulty sleeping or find yourself constantly thinking about your cancer.

Several complementary medicine techniques may help you cope with your distress, including:

. Art therapy

. Dance or movement therapy

. Exercise

. Meditation

. Music therapy

. Relaxation techniques

. Spirituality

Discuss your feelings and concerns with your doctor. In some cases, treatment for distress may require medications.

After Prostate Cancer Treatment

After surgery

After your operation you will wake up on the recovery room. Once it’s safe to do so, you usually go back to the ward. Recovery rooms and wards are busy and often noisy places that some people find strange and disorienting. You'll feel drowsy because of the anaesthetic and painkillers.

. Tubes and drains

When you wake up, you may have several tubes in you. This can be frightening, so it helps to know what they’re for.

You may have:

. A drip to give you fluids usually through a vein in your arm

. A small wound drain to drain any blood or fluid if you’ve had a radical prostatectomy

. A tube into your bladder (catheter) to measure how much urine you pass. 

The catheter stays in for a couple of weeks if you’ve had a radical prostatectomy.  After removal of the inner part of the prostate gland (TURP) it stays in for a couple of days.  Sometimes you need the catheter to stay in place for a while after you go home. Before you leave hospital your nurse will show you how to look after it.

You may also have an oxygen mask on.

. Painkillers

It’s normal to have pain for the first week or so. You have painkillers to help.

Tell your doctor or nurse as soon as you feel any pain. They need your help to find the right type and dose of painkiller for you. Painkillers work best when you take them regularly.

Immediately after surgery you might have painkillers through a drip into the bloodstream that you control. This is called patient controlled analgesia (PCA).

Or you might have painkillers through a small thin tube that is put into your back. This tube is connected to a pump that gives you a constant dose of painkiller. This is called an epidural.

You get painkillers to take home. Follow the instructions your nurse gives you about how often and when to take them. Contact your doctor if you still have pain or if it gets worse.

After keyhole surgery you will only need painkillers to take by mouth.

. Eating and drinking

Your team will let you know when you can start eating and drinking again.

. Your wound

After a radical prostatectomy, you have dressings over your wounds. You have 1 wound if you had open surgery. You may have several smaller wounds if you had keyhole (laparoscopic) surgery. After a couple of days your nurse changes the dressings and cleans your wounds.

Your stitches or clips stay in for at least 10 days. The nurse usually takes them out before you go home. You can go home with the stitches in if your wound is still healing and you are otherwise well. The practice nurse, district nurse or hospital nurse then takes them out. This might be at home, at your GPs, or you may need to go back to the hospital.

Before you go home the nurse gives you information about how to care for the wound.

Getting up

Your nurses and physiotherapists help you to move around as soon as possible. They check you’re doing your breathing and leg exercises. This helps you recover.

You might be sitting in a chair within 12 hours of your operation. The day after, you’ll be walking around your bed. And within a few days you’ll be able to walk along the hospital corridor.

Making progress

During the first few days after your operation, you’ll start to feel better. The drips and drains will come out, you’ll start eating and can move about better.

. You’ll begin to feel like you’re making progress.

. Most people go home about 3 to 7 days after an open radical prostatectomy.

. After robotic surgery you will go home within 24 to 48 hours.  

Going home

You’ll need help when you first go home. The dietitian will talk to you and your family about what to eat. It can take some time to find what works for you.

You’re likely to feel very tired for several weeks and sometimes months after your surgery. It helps to do a bit more every day.

Try:

. Sitting for less time each day

. Walking around the house a bit more each day

. Building up to walking outside

What you can do depends on how fit you were before your surgery and any problems you have afterwards. Talk to the physiotherapist or your doctor if you’re unsure about what you should be doing.

Contact your doctor or specialist nurse if you have any problems or symptoms you’re unsure about. You’ll have follow up appointments to check your recovery and fix any problems. They’re also your opportunity to raise any concerns you have.

Follow up

You’ll have follow up appointments to check your recovery and sort out any problems. They’re also your opportunity to raise any concerns you have about your progress.

Your first checkup is around 6 weeks after your operation. Then you have one every 6 months for 2 years. Then once a year after that.

Outlook

Males with early stage prostate cancer have a good chance of effective treatment and survival.

Based on past statistics, the ACS expect the following percentages of people, on average, to survive for at least another 5 years after diagnosis:

. Localized or regional cancer: Nearly 100% will survive at least another 5 years.

. Distant: Around 30% will survive at least 5 more years if the cancer has affected other parts of the body.

With treatment, the overall 5 year survival rate for prostate cancer is 98%. Many people live longer than this, however.

The best way to detect prostate cancer in the early stages is to attend regular screening. Anyone who has not yet attended screening should ask their doctor about the options.

10 common Questions about prostate cancer

1What is the best treatment for early stages of prostate cancer?
Initial treatment options may include: Hormone therapy, possibly along with chemotherapy. External beam radiation (sometimes along with brachytherapy), plus hormone therapy. Radical prostatectomy in some men whose cancer has not spread to the lymph nodes or other parts of the body.
2What are the odds of beating prostate cancer?
According to the American Cancer Society: The relative 5-year survival rate is nearly 100% The relative 10-year survival rate is 98% The 15-year relative survival rate is 91%
3How long can you live with metastatic prostate cancer?
For men with distant spread (metastasis) of prostate cancer, about one-third will survive for five years after diagnosis.
4Is Stage 4 prostate cancer fatal?
Stage 4 prostate cancer is an uncommon diagnosis. Most often, prostate cancer is diagnosed at an earlier stage, when the cancer is confined to the prostate. Treatments may slow or shrink an advanced prostate cancer, but for most men, stage 4 prostate cancer isn't curable.
5What are the 5 early warning signs of prostate cancer?
Early warning signs of prostate cancer Burning or pain during urination. Difficulty urinating, or trouble starting and stopping while urinating. More frequent urges to urinate at night. Loss of bladder control. Decreased flow or velocity of urine stream. Blood in urine (hematuria) Blood in semen.
6Can you die from stage 2 prostate cancer?
If prostate cancer is truly confined to the prostate, it is curable with surgery or radiation. ... This is because many prostate cancers are slow growing and men will sometimes die from other causes before they succumb to prostate cancer.
7What are the four stages of prostate cancer?
The main stages of prostate cancer range from I (1) through IV (4). Some stages are split further (A, B, etc). As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage IV, means cancer has spread more.
8Is prostate cancer a painful death?
Many people worry about being in pain when they are dying. Some people do get pain if their prostate cancer presses on their nerves or makes their bones weak. But not everyone dying from prostate cancer has pain.
9What are five symptoms that are associated with prostate cancer?
Prostate Cancer: Symptoms and Signs Frequent urination. Weak or interrupted urine flow or the need to strain to empty the bladder. The urge to urinate frequently at night. Blood in the urine. Blood in the seminal fluid. New onset of erectile dysfunction. Pain or burning during urination, which is much less common.
10What is the most aggressive form of prostate cancer?
Ductal prostate cancer is usually more aggressive than common prostate cancer.

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