Prostate Cancer

You may have heard about prostate glands, Prostate Specific Antigen (PSA) tests and screening guidelines without giving them much thought. When it comes to prostate cancer prevention, it is time to do more than just listen.

Prostate cancer is one of the highest prevalent cancers in India. While it typically affects men over 65 years, however, of late, there have been reports of an increasing number of younger men (between the age group of 35 – 44 and 55-64) residing in metropolitan cities suffering from prostate cancer. In the initial stages, Prostate cancer often goes unnoticed as symptoms may include burning sensation during urination, increased frequency of urination and difficulty in passing urine.

A few major contributing factors identified towards an increased incidence of Prostate cancer are improper diet, obesity, genetic alterations and old age.

What is a Prostate Gland?

The prostate is a walnut-shaped, exocrine gland( Glands which produce secretions) in men located at the base of the bladder. It is a part of the male reproductive system. The prostate produces fluid that nourishes and moves sperms on their journey to fuse with a female egg, to beget human life. It is the prostate that contracts and forces the semen out during orgasm.

In addition, urethra, a tube through which urine and sperm exit the body, also passes through the prostate gland (the median lobe). Therefore, an enlarged prostate (because of benign or malignant changes) affects the flow of urine.  It can constrict and limit the flow of urine through the urethra (as it passes through the median lobe and median and lateral lobes of the Prostate are most affected by benign/ malignant changes in the gland) because of physical effects.

The prostate is an exocrine gland, which means its fluids and secretions are for use outside our body. The prostate, prostate-specific antigen (PSA) excretes protein that helps semen in retaining its liquid state. Surplus of this protein in the blood is the first signs of prostate cancer. Prostate cancer usually develops very slowly and, although not lethal in most patients, a small percentage of prostate cancers are very aggressive.

The disease usually does not produce symptoms in the early stages when it is most treatable. By the time symptoms, like pain when urinating occur, the cancer is likely to have advanced, demonstrating the following symptoms:

• Increased frequency of urination, especially at night
• Sudden erectile dysfunction,
• Urinary Incontinence.
• An interrupted or weak urinary stream
• Urine leak while coughing or laughing
• Inability to stand up and urinate
• Experiencing discomfort while sitting due to an enlarged prostate
• Burning or painful sensation during ejaculation or while urinating
• Blood in semen or urine

Advanced prostate cancer symptoms include:

• Stiffness or pain in bones of the pelvic region, ribs, upper thighs, lower back areas
• Loss of appetite and weight
• Nausea, vomiting, or fatigue
• Swelling of lower extremities
• Weakness or paralysis in the lower limbs, often along with constipation

Currently, the primary screening tool is the prostate-specific antigen (PSA) test, which measures blood levels of a protein produced by the prostate gland. Elevated PSA levels do not necessarily mean cancer; this warrants further investigations. These investigations may include:

• A Digital Rectal Examination (DRE), where a doctor manually checks for any prostate abnormalities with his/her finger
• A biomarker examination to check the body tissues, blood or urine of an individual with cancer

If these diagnostic tests show abnormal results, additional tests may include:

• A PCA3 test that examines the urine for the PCA3 gene that is found only in prostate cancer cells
• A trans-rectal ultrasound scan that provides images of the affected area.
• A biopsy (harvesting of a small tissue sample for further investigation) from some areas of the prostate for study under a microscope. These actually help confirm the stage of cancer, whether it has spread and what treatment may be suitable.

To track metastasis (spread of cancer), doctors use a CT scan, bone or MRI scan.

If you opt for PSA testing and it produces suspicious results, your doctor may order a second PSA. If PSA levels are confirmed high, your doctor may then recommend periodic PSA testing to monitor for rising

PSA levels as well as a digital rectal examination (DRE) to check for prostate tumours.

If PSA levels increase or a lump can be diagnosed, your doctor will most likely recommend imaging tests and/or a biopsy to diagnose and stage the disease. If the presence of prostate cancer is confirmed, your doctor may recommend continued surveillance, or one of the many precisely targeted treatment methods available:

• Brachytherapy (internal radiotherapy) places sealed radiation units called “seeds” near the tumor to destroy malignant tissue with the lowest radiation dose possible.
• External Beam Radiotherapy focuses beams of radiation on the affected area to eradicate cancer cells while minimizing damage to healthy tissues nearby.
• Prostatectomy removes a part or all of the prostate gland. An open prostatectomy is a traditional surgery requiring an incision to reach the prostate.
• Robotically Assisted Laparoscopic Prostatectomy uses a smaller incision and typically results in less pain, shorter hospital stay and faster recovery.
• Androgen Deprivation Therapy blocks hormones responsible for tumour growth from reaching the prostate. This method may be used if surgery or radiation is not an option, or to help shrink the tumour before another treatment.
• Proton Beam Therapy is the latest mode of delivery of Radiation therapy wherein Proton particles generated via a cyclotron and travelling at high speed are bombarded on the tumour cells. The main benefit of using Proton therapy is minimal/ negligible damage to the surrounding healthy tissue.

Outlook

Early diagnosis and treatment is the key to conquering any cancer and Prostate cancer is no exception. If prostate cancer is diagnosed before it spreads to other organs (called metastasis), the 5-year survival rate can be as high as 99 per cent. The same, after fifteen years, reduces to 96 per cent. And, if the cancer spreads (or metastasizes), the 5-year survival rate is just 29 per cent.

Regular screening can help detect prostate cancer early – when it can be treated without major morbidity. If you are a man, and above 45 years, discuss your risk for the disease with your doctor and decide on screening.