Prostate Cancer

The prostate is part of a man's reproductive system. It's an organ located in front of the rectum and under the bladder. The prostate surrounds the urethra, the tube through which urine flows.

A healthy prostate is about the size of a walnut. If the prostate grows too large, it squeezes the urethra. This may slow or stop the flow of urine from the bladder to the penis.

The prostate is a gland. It makes part of the seminal fluid. During ejaculation, the seminal fluid helps carry sperm out of the man's body as part of semen.

Male hormones (androgens) make the prostate grow. The testicles are the main source of male hormones, including testosterone. The adrenal gland also makes testosterone, but in small amounts.

Cancer that forms in tissues of the prostate (a gland in the male reproductive system found below the bladder and in front of the rectum). Prostate cancer usually occurs in older men.


Risk Factors

When you're told you have prostate cancer, it's natural to wonder what may have caused the disease. But no one knows the exact causes of prostate cancer. Doctors seldom know why one man develops prostate cancer and another doesn't.

However, research has shown that men with certain risk factors are more likely than others to develop prostate cancer. A risk factor is something that may increase the chance of getting a disease.

Studies have found the following risk factors for prostate cancer:

  • Age over 65: Age is the main risk factor for prostate cancer. The chance of getting prostate cancer increases as you get older. In the United States, most men with prostate cancer are over 65. This disease is rare in men under 45.
  • Family history: Your risk is higher if your father, brother, or son had prostate cancer.
  • Race: Prostate cancer is more common among black men than white or Hispanic/Latino men. It's less common among Asian/Pacific Islander and American Indian/Alaska Native men.
  • Certain prostate changes: Men with cells called high-grade prostatic intraepithelial neoplasia (PIN) may be at increased risk of prostate cancer. These prostate cells look abnormal under a microscope.
  • Certain genome changes: Researchers have found specific regions on certain chromosomes that are linked to the risk of prostate cancer. According to recent studies, if a man has a genetic change in one or more of these regions, the risk of prostate cancer may be increased. The risk increases with the number of genetic changes that are found. Also, other studies have shown an elevated risk of prostate cancer among men with changes in certain genes, such as BRCA1 and BRCA2.

Having a risk factor doesn't mean that a man will develop prostate cancer. Most men who have risk factors never develop the disease.


Symptoms

A man with prostate cancer may not have any symptoms. For men who do have symptoms, the common symptoms include:

  • Urinary problems
    • Not being able to pass urine
    • Having a hard time starting or stopping the urine flow
    • Needing to urinate often, especially at night
    • Weak flow of urine
    • Urine flow that starts and stops
    • Pain or burning during urination
  • Difficulty having an erection
  • Blood in the urine or semen
  • Frequent pain in the lower back, hips, or upper thighs

Most often, these symptoms are not due to cancer. BPH, an infection, or another health problem may cause them. If you have any of these symptoms, you should tell your doctor so that problems can be diagnosed and treated.


Detection and Diagnosis

Your doctor can check for prostate cancer before you have any symptoms. During an office visit, your doctor will ask about your personal and family medical history. You'll have a physical exam. You may also have one or both of the following tests:

  • Digital rectal exam: Your doctor inserts a lubricated, gloved finger into the rectum and feels your prostate through the rectal wall. Your prostate is checked for hard or lumpy areas.
  • Blood test for prostate-specific antigen (PSA): A lab checks the level of PSA in your blood sample. The prostate makes PSA. A high PSA level is commonly caused by BPH or prostatitis (inflammation of the prostate). Prostate cancer may also cause a high PSA level. See the NCI fact sheet The Prostate-Specific Antigen (PSA) Test: Questions and Answers.

The digital rectal exam and PSA test are being studied in clinical trials to learn whether finding prostate cancer early can lower the number of deaths from this disease.

The digital rectal exam and PSA test can detect a problem in the prostate. However, they can't show whether the problem is cancer or a less serious condition. If you have abnormal test results, your doctor may suggest other tests to make a diagnosis. For example, your visit may include other lab tests, such as a urine test to check for blood or infection. Your doctor may order other procedures:

  • Transrectal ultrasound: The doctor inserts a probe into the rectum to check your prostate for abnormal areas. The probe sends out sound waves that people cannot hear (ultrasound). The waves bounce off the prostate. A computer uses the echoes to create a picture called a sonogram.
  • Transrectal biopsy: A biopsy is the removal of tissue to look for cancer cells. It's the only sure way to diagnose prostate cancer. The doctor inserts needles through the rectum into the prostate. The doctor removes small tissue samples (called cores) from many areas of the prostate. Transrectal ultrasound is usually used to guide the insertion of the needles. A pathologist checks the tissue samples for cancer cells.

You may want to ask the doctor these questions before having a transrectal ultrasound or biopsy:

  • Where will the procedure take place? Will I have to go to the hospital?
  • How long will it take? Will I be awake?
  • Will it hurt? Will I need local anesthesia?
  • What are the risks? What are the chances of infection or bleeding afterward?
  • How do I prepare for it? Will I need to avoid taking aspirin to reduce the chance of bleeding? Will I need an enema before the procedure?
  • How long will it take me to recover? Will I be given an antibiotic or other medicine afterward?
  • How soon will I know the results? If a biopsy is done, will I get a copy of the pathology report?
  • If I do have cancer, who will talk to me about the next steps? When?

Treatment

Men with prostate cancer have many treatment options. The treatment that's best for one man may not be best for another. The options include active surveillance (also called watchful waiting), surgery, radiation therapy, hormone therapy, and chemotherapy. You may have a combination of treatments.

The treatment that's right for you depends mainly on your age, the grade of the tumor (the Gleason score), the number of biopsy tissue samples that contain cancer cells, the stage of the cancer, your symptoms, and your general health. Your doctor can describe your treatment choices, the expected results of each, and the possible side effects. You and your doctor can work together to develop a treatment plan that meets your medical and personal needs.

You may want to ask your doctor these questions before choosing your treatment:

  • What is the grade of the tumor?
  • What is the stage of the disease? Has the cancer spread? Do any lymph nodes show signs of cancer?
  • What is the goal of treatment? What are my treatment choices? Which do you recommend for me? Why?
  • What are the expected benefits of each type of treatment?
  • What are the risks and possible side effects of each treatment? How can side effects be managed?
  • What can I do to prepare for treatment?
  • Will I need to stay in the hospital? If so, for how long?
  • How will treatment affect my normal activities? Will it affect my sex life? Will I have urinary problems? Will I have bowel problems?
  • What will the treatment cost? Will my insurance cover it?
  • Would a clinical trial (research study) be appropriate for me?
  • Can you recommend other doctors who could give me a second opinion about my treatment options?

Active Surveillance

You may choose active surveillance if the risks and possible side effects of treatment outweigh the possible benefits. Your doctor may suggest active surveillance if you're diagnosed with early stage prostate cancer that seems to be slowly growing. Your doctor may also offer this option if you are older or have other serious health problems.

Choosing active surveillance doesn't mean you're giving up. It means you're putting off the side effects of surgery or radiation therapy. Having surgery or radiation therapy is no guarantee that a man will live longer than a man who chooses to put off treatment.

If you and your doctor agree that active surveillance is a good idea, your doctor will check you regularly (such as every 3 to 6 months, at first). After about one year, your doctor may order another biopsy to check the Gleason score. You may begin treatment if your Gleason score rises, your PSA level starts to rise, or you develop symptoms. You'll receive surgery, radiation therapy, or another approach.

Active surveillance avoids or delays the side effects of surgery and radiation therapy, but this choice has risks. For some men, it may reduce the chance to control cancer before it spreads. Also, it may be harder to cope with surgery or radiation therapy when you're older.

If you choose active surveillance but grow concerned later, you should discuss your feelings with your doctor. Another approach is an option for most men.

You may want to ask your doctor these questions before choosing active surveillance:

  • If I choose active surveillance, can I change my mind later on?
  • Is it safe for me to put off treatment?
  • How often will I have checkups? Which tests will I need? Will I need a repeat biopsy?
  • How will we know if the prostate cancer is getting worse?
  • Between checkups, what problems should I tell you about?

Surgery

Surgery is an option for men with early (Stage I or II) prostate cancer. It's sometimes an option for men with Stage III or IV prostate cancer. The surgeon may remove the whole prostate or only part of it.

Before the surgeon removes the prostate, the lymph nodes in the pelvis may be removed. If prostate cancer cells are found in the lymph nodes, the disease may have spread to other parts of the body. If cancer has spread to the lymph nodes, the surgeon does not always remove the prostate and may suggest other types of treatment.

There are several types of surgery for prostate cancer. Each type has benefits and risks. You and your doctor can talk about the types of surgery and which may be right for you:

  • Open surgery: The surgeon makes a large incision (cut) into your body to remove the tumor. There are two approaches:
    • Through the abdomen: The surgeon removes the entire prostate through a cut in the abdomen. This is called a radical retropubic prostatectomy.
    • Between the scrotum and anus: The surgeon removes the entire prostate through a cut between the scrotum and the anus. This is called a radical perineal prostatectomy.
  • Laparoscopic prostatectomy: The surgeon removes the entire prostate through small cuts, rather than a single long cut in the abdomen. A thin, lighted tube (a laparoscope) helps the surgeon remove the prostate.
  • Robotic laparoscopic surgery: The surgeon removes the entire prostate through small cuts. A laparoscope and a robot are used to help remove the prostate. The surgeon uses handles below a computer display to control the robot's arms.
  • Cryosurgery: For some men, cryosurgery is an option. The surgeon inserts a tool through a small cut between the scrotum and anus. The tool freezes and kills prostate tissue. Cryosurgery is under study. See the section on Taking Part in Cancer Research.
  • TURP: A man with advanced prostate cancer may choose TURP (transurethral resection of the prostate) to relieve symptoms. The surgeon inserts a long, thin scope through the urethra. A cutting tool at the end of the scope removes tissue from the inside of the prostate. TURP may not remove all of the cancer, but it can remove tissue that blocks the flow of urine.

You may be uncomfortable for the first few days or weeks after surgery. However, medicine can help control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.

The time it takes to heal after surgery is different for each man and depends on the type of surgery. You may be in the hospital for one to three days.

After surgery, the urethra needs time to heal. You'll have a catheter. A catheter is a tube put through the urethra into the bladder to drain urine. You'll have the catheter for 5 days to 3 weeks. Your nurse or doctor will show you how to care for it.

After surgery, some men may lose control of the flow of urine (urinary incontinence). Most men regain at least some bladder control after a few weeks.

Surgery can damage the nerves around the prostate. Damaging these nerves can make a man impotent (unable to have an erection). In some cases, your surgeon can protect the nerves that control erection. But if you have a large tumor or a tumor that's very close to the nerves, surgery may cause impotence. Impotence can be permanent. You can talk with your doctor about medicine and other ways to help manage the sexual side effects of cancer treatment.

If your prostate is removed, you will no longer produce semen. You'll have dry orgasms. If you wish to father children, you may consider sperm banking or a sperm retrieval procedure before surgery.

You may want to ask your doctor these questions before choosing surgery:

  • What kinds of surgery can I consider? Which operation do you recommend for me? Why?
  • How long will I be in the hospital after surgery?
  • How will I feel after the operation?
  • If I have pain, how can we control it?
  • Will I have any lasting side effects? What is the chance that the surgery will cause incontinence or impotence?
  • Is there someone that I can talk with who has had the same surgery that I'll be having?
  • How often will I need checkups?

Radiation Therapy

Radiation therapy is an option for men with any stage of prostate cancer. Men with early stage prostate cancer may choose radiation therapy instead of surgery. It also may be used after surgery to destroy any cancer cells that remain in the area. In later stages of prostate cancer, radiation treatment may be used to help relieve pain.

Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the treated area.

Doctors use two types of radiation therapy to treat prostate cancer. Some men receive both types:

  • External radiation: The radiation comes from a large machine outside the body. You will go to a hospital or clinic for treatment. Treatments are usually 5 days a week for several weeks. Many men receive 3-dimensional conformal radiation therapy or intensity-modulated radiation therapy. These types of treatment use computers to more closely target the cancer to lessen the damage to healthy tissue near the prostate.
  • Internal radiation (implant radiation or brachytherapy): The radiation comes from radioactive material usually contained in very small implants called seeds. Dozens of seeds are placed inside needles, and the needles are inserted into the prostate. The needles are removed, leaving the seeds behind. The seeds give off radiation for months. They don't need to be removed once the radiation is gone.

Side effects depend mainly on the dose and type of radiation. You're likely to be very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay active, unless it leads to pain or other problems.

If you have external radiation, you may have diarrhea or frequent and uncomfortable urination. Some men have lasting bowel or urinary problems. Your skin in the treated area may become red, dry, and tender. You may lose hair in the treated area. The hair may not grow back.

Internal radiation therapy may cause incontinence. This side effect usually goes away.

Both internal and external radiation can cause impotence. You can talk with your doctor about ways to help cope with this side effect.

You may find it helpful to read the NCI booklet Radiation Therapy and You.

You may want to ask your doctor these questions before choosing radiation therapy:

  • Which type of radiation therapy can I consider? Are both types an option for me?
  • When will treatment start? When will it end? How often will I have treatments?
  • Will I need to stay in the hospital?
  • What can I do to take care of myself before, during, and after treatment?
  • How will I feel during treatment? Will I be able to drive myself to and from treatment?
  • How will we know the treatment is working?
  • How will I feel after the radiation therapy?
  • Are there any lasting effects?
  • What is the chance that the cancer will come back in my prostate?
  • How often will I need checkups?

Hormone Therapy

A man with prostate cancer may have hormone therapy before, during, or after radiation therapy. Hormone therapy is also used alone for prostate cancer that has returned after treatment.

Male hormones (androgens) can cause prostate cancer to grow. Hormone therapy keeps prostate cancer cells from getting the male hormones they need to grow. The testicles are the body's main source of the male hormone testosterone. The adrenal gland makes other male hormones and a small amount of testosterone.

Hormone therapy uses drugs or surgery:

  • Drugs: Your doctor may suggest a drug that can block natural hormones:
    • Luteinizing hormone-releasing hormone (LH-RH) agonists: These drugs can prevent the testicles from making testosterone. Examples are leuprolide, goserelin, and triptorelin. The testosterone level falls slowly. Without testosterone, the tumor shrinks, or its growth slows. These drugs are also called gonadotropin-releasing hormone (GnRH) agonists.
    • Antiandrogens: These drugs can block the action of male hormones. Examples are flutamide, bicalutamide, and nilutamide.
    • Other drugs: Some drugs can prevent the adrenal gland from making testosterone. Examples are ketoconazole and aminoglutethimide.
  • Surgery: Surgery to remove the testicles is called orchiectomy.

After orchiectomy or treatment with an LH-RH agonist, your body no longer gets testosterone from the testicles, the major source of male hormones. Because the adrenal gland makes small amounts of male hormones, you may receive an antiandrogen to block the action of the male hormones that remain. This combination of treatments is known as total androgen blockade (also called combined androgen blockade). However, studies have shown that total androgen blockade is no more effective than surgery or an LH-RH agonist alone.

Hormone therapy causes side effects such as impotence, hot flashes, and loss of sexual desire. Also, any treatment that lowers hormone levels can weaken your bones. Your doctor can suggest medicines that may reduce your risk of bone fractures.

An LH-RH agonist may make your symptoms worse for a short time at first. This temporary problem is called "flare." To prevent flare, your doctor may give you an antiandrogen for a few weeks along with the LH-RH agonist.

An LH-RH agonist such as leuprolide can increase body fat, especially around the waist. The levels of sugar and cholesterol in your blood may increase too. Because these changes increase the risk of diabetes and heart disease, your health care team will monitor you for these side effects.

Antiandrogens (such as nilutamide) can cause nausea, diarrhea, or breast growth or tenderness. Rarely, they may cause liver problems (pain in the abdomen, yellow eyes, or dark urine). Some men who use nilutamide may have shortness of breath or develop heart failure. Some may have trouble adjusting to sudden changes in light.

If you receive total androgen blockade, you may have more side effects than if you have just one type of hormone treatment.

If used for a long time, ketoconazole may cause liver problems, and aminoglutethimide can cause skin rashes.

Doctors usually treat prostate cancer that has spread to other parts of the body with hormone therapy. For some men, the cancer will be controlled for two or three years, but others will have a much shorter response to hormone therapy. In time, most prostate cancers can grow with very little or no male hormones, and hormone therapy alone is no longer helpful. At that time, your doctor may suggest chemotherapy or other forms of treatment that are under study. In many cases, the doctor may suggest continuing with hormone therapy because it may still be effective against some of the cancer cells.

You may want to ask your doctor these questions before choosing hormone therapy:

  • Which kind of hormone therapy can I consider? Would you recommend drugs or surgery? Why?
  • If I have drugs, when will treatment start? How often will I have treatments? When will treatment end?
  • If I have surgery, how long will I need to stay in the hospital?
  • How will I feel during treatment?
  • What can I do to take care of myself during treatment?
  • How will we know the treatment is working?
  • Which side effects should I tell you about?
  • Will there be lasting side effects?
  • How often will I need checkups?
Chemotherapy

Chemotherapy may be used for prostate cancer that has spread and no longer responds to hormone therapy.

Chemotherapy uses drugs to kill cancer cells. The drugs for prostate cancer are usually given through a vein (intravenous). You may receive chemotherapy in a clinic, at the doctor's office, or at home. Some men need to stay in the hospital during treatment.

The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:

  • Blood cells: When chemotherapy lowers the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of drug. There are also medicines that can help your body make new blood cells.
  • Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may change in color and texture.
  • Cells that line the digestive tract: Chemotherapy can cause a poor appetite, nausea and vomiting, or diarrhea. Your health care team can give you medicines and suggest other ways to help with these problems.

Other side effects include shortness of breath and a problem with your body holding extra water. Your health care team can give you medicine to protect against too much water building up in the body. Also, chemotherapy may cause a skin rash, tingling or numbness in your hands and feet, and watery eyes. Your health care team can suggest ways to control many of these problems. Most go away when treatment ends.

  • You may want to ask your doctor these questions before choosing chemotherapy:
  • Why do I need this treatment?
  • Which drug or drugs will I have?
  • How do the drugs work?
  • What are the expected benefits of the treatment?
  • What are the risks and possible side effects of treatment? What can we do about them?
  • When will treatment start? When will it end?
  • How will treatment affect my normal activities?
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