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Prostate Cancer
By Dr. Christopher L. Amling
Who’s at Risk
Prostate cancer is a very common cancer in older men. One in six American men (about 17 percent) will develop prostate cancer sometime during their lifetime. The older a man gets, the more likely he is to get prostate cancer. However, there are a few other risk factors besides age. African-American men are more likely to be diagnosed at a younger age and with a more aggressive cancer. And a man has who has family members with prostate cancer has a higher risk for getting the disease, too.
Symptoms
If you’re a caregiver for your father and he is of an age that prostate cancer screening is suggested, talk to his doctor about screening. Most men with early-stage prostate cancer have no symptoms. That’s why screening is so important. Screening allows us to find these cancers when they’re still curable. In many situations, once symptoms develop, the cancer is at a more advanced stage and is more difficult to control or cure.
The symptoms of advanced prostate cancer mimic the symptoms of benign enlargement of the prostate, which is an extremely common problem in older men. When men age, the size of the prostate increases, squeezing the urine channel and causing difficulty with urination. This can include:
- Having a weaker stream.
- Getting up to urinate frequently at night.
- Incomplete emptying of the bladder.
- Having trouble stopping or starting the urine stream (called intermittency).
All of these problems can be a sign of either an enlarged prostate or cancer. Occasionally, blood in the urine can be a sign of prostate cancer. In advanced forms, the cancer often spreads to the bones, so a man in this situation may have bone pain or weight loss. But remember, early-stage prostate cancer has no symptoms.
Screening and Diagnosis
PSA
The most common tool for screening is a PSA (prostate specific antigen) blood test. In the past we recommended that men have an annual PSA beginning at age 50. Now we’re suggesting that all men start screening in their 40s, with high-risk populations beginning annual screening at age 40. Men who don’t have high risk factors should have their initial PSA in their early 40s. If their early PSA is normal, their doctor may have them take another test less often than annually, until they reach age 50. At that point, they should begin coming in for annual screening.
DRE
We also use a DRE (digital rectal exam) to see if we can detect a nodule on the prostate, which may indicate cancer. We use the DRE in conjunction with the PSA to screen because some men with prostate cancer have normal PSA levels and their cancer is only detectable by finding an abnormal prostate during examination.
Biopsy
If the PSA or DRE show a possibility of cancer, the man needs to undergo a prostate biopsy for a diagnosis. This is a very common outpatient procedure. An ultrasound device is inserted into the rectum and the biopsy is performed with a spring-loaded needle device that samples the prostate tissue so it can be pathologically assessed to determine whether prostate cancer is present.
Treatment
Watchful Waiting
When a man is first diagnosed with prostate cancer, there are many things we need to consider in terms of defining what the appropriate treatment approach should be. One of the first things to decide is whether he has a cancer that can be watched – we call this active surveillance or watchful waiting. Many men who are diagnosed with prostate cancer have less aggressive tumors that can be best treated with regular monitoring of the PSA,regular DREs and occasional repeat biopsy. This might be the best treatment approach for men with low-risk prostate cancers, particularly those men who are older and have other medical problems that might threaten life expectancy or make curative treatment unnecessary.
Curative Options
For younger men, the wait-and-see approach is not usually the best option because often they have the kinds of cancers that, given time, will progress or spread to the point that they are less curable. In patients who choose a curative treatment, there are several options:
Surgical Removal of Prostate
This is called a radical prostatectomy and can be done either through an open incision (open prostatectomy) or by using a robotic-assisted laparoscopic approach.
The laparoscopic procedure uses the da Vinci robotic surgical system and offers many advantages, including:
- Quicker recovery
- Shorter hospital stay
- Less blood loss
- Equal, with potentially superior, results in terms of preservation of quality of life factors such as urinary continence and erectile function.
Radiation Therapy
Surgery is a less commonly used option if the patient is older, particularly in his late 70s. In these cases, radiation is the primary treatment approach. Radiation can be given via an external beam or via an internal approach referred to as brachytherapy or prostate seed implants.
Hormone Therapy
Testosterone can stimulate the growth of the cancer cells. Hormone therapy is used to try to stop the body’s production of testosterone, or in some cases, to prevent the body’s ability to use testosterone. Unfortunately, the cancer cells can sometimes eventually thrive without testosterone. Intermittent hormonal treatment can be equally effective as continuous therapy and at the same time limit the side effects associated with this treatment.
Chemotherapy
This treatment can be effective but can have many side effects, so it’s usually reserved for those whose cancer has spread and who are resistant to hormone therapy.
Progress in the Fight against Prostate Cancer
With screening and better treatment of prostate cancer, we have seen a steady reduction in prostate cancer death rates.. I’m happy to be able to say that the five-year survival rate for men diagnosed in the early stage is now near 100 percent. We are working hard to find more effective treatments for those who have prostate cancer in the later stages. There are many other procedures and drug therapies being tested and refined, so more and better options will be coming available.
Dr. Christopher L. Amling is Professor and Head of Urology at Oregon Health & Science University. He specializes in urological oncology. Dr. Amling received his medical degree at OHSU, did his urology residency at Duke University Medical Center in Durham, N.C., and completed a fellowship in urologic oncology at the Mayo Clinic in Rochester, Minn. Before coming to OHSU, he held the position of Professor and Head of Urology at the University of Alabama at Birmingham.
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