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Prostatectomy

Prostate cancer is a disease in which malignant (cancer) cells form in the tissues of the prostate. The prostate is a gland in the male reproductive system located just below the bladder and in front of the rectum. It is about the size of a walnut and surrounds the urethra (the tube that empties urine from the bladder). The prostate gland produces fluid that is one of the components of semen.1

Statistics

Prostate cancer is the most common non-skin malignancy in men2 and is responsible for more deaths than any other cancer, except for lung cancer. However, microscopic evidence of (prostate?) cancer is found at autopsy in many if not most men. The American Cancer Society (ACS) estimated that about 218,890 new cases of prostate cancer were diagnosed in the United States during 2007. About 1 man in 6 will be diagnosed with prostate cancer during his lifetime, but only 1 man in 34 will die of it. A little over 1.8 million men in the United States are survivors of prostate cancer.3

Prognosis & Treatment

Treatment options and prognosis depend on the stage of the cancer, the Gleason score4, and the patient's age and general health. With greater public awareness, early detection is on the rise and mortality rates are declining. Additionally, new advances in medical technology are enabling cancer patients to return to active and productive lives after their treatment.


  1. "General Information about Prostate Cancer," National Cancer Institute, www.cancer.gov.
  2. "What are the Key Statistics About Prostate Cancer?," National Cancer Institute, www.cancer.gov.
  3. "The Prostate Cancer Outcomes Study: Fact Sheet," National Cancer Institute, www.cancer.gov.
  4. Gleason score: A system of grading prostate cancer tissue based on how it looks under a microscope. Gleason scores range from 2 to 10 and indicate how likely it is that a tumor will spread.. National Cancer Institute, http://www.cancer.gov

The prostate gland, a key part of the male reproductive system, is linked closely with the urinary system. It is a small gland that secretes much of the liquid portion of semen, the milky fluid that transports sperm through the penis during ejaculation. 1

diagram of prostate

The prostate is located just beneath the bladder, where urine is stored, and in front of the rectum. It encircles, like a donut, a section of the urethra. The urethra is the tube that carries urine from the bladder out through the penis. During ejaculation, semen is secreted by the prostate through small pores of the urethra's walls. 2

The prostate is made up of three lobes encased in an outer covering, or capsule. It is flanked on either side by the seminal vesicles, a pair of pouch-like glands that contribute secretions to the semen. Next to the seminal vesicles run the two vas deferens, tubes that carry sperm from the testicles. The testicles, in addition to manufacturing sperm, produce testosterone, a male sex hormone that controls the prostate's growth and function. 3

Male hormones cause the prostate gland to develop in the fetus. The prostate continues to grow as a boy progresses to manhood. If male hormone levels are low, the prostate gland will not grow to full size. In older men, the part of the prostate around the urethra often persists in growing. This causes BPH (benign prostatic hyperplasia), which can result in urination problems. 4


  1. "General Information About Prostate Cancer," National Cancer Institute, www.cancer.gov. URL: http://www.cancer.gov/cancertopics/pdq/treatment/prostate/patient
  2. "The Prostate," National Cancer Institute, www.cancer.gov. URL: http://www.cancer.gov/cancertopics/wyntk/prostate/page2
  3. "General Information About Prostate Cancer," National Cancer Institute, www.cancer.gov. URL: http://www.cancer.gov/cancertopics/pdq/treatment/prostate/patient
  4. "What is Prostate Cancer," American Cancer Society, www.cancer.org. URL: http://www.cancer.org/docroot/CRI/content/CRI_2_2_1X_What_is_prostate_cancer_36.asp

When you or a loved one is diagnosed with prostate cancer, the most important thing you can do is learn everything you can about available treatment options. The good news is that prostate cancer is one of the most treatable cancers. The prognosis for curing the cancer and long term survival is excellent when the cancer is caught early and treated effectively.

About one third of American men will have microscopic traces of prostate cancer by age 50. Half to three-quarters of all men will have some cancerous changes in their prostate glands by age 75. More than half of all men will have some cancer in their prostate by age 80.1

Every patient’s prostate cancer should be treated based on their individual situation, including whether to actively treat the cancer and what method to use.

Active treatment usually begins a few weeks to months after diagnosis. During this time, you should meet with various doctors to learn about your treatment options. It's also a good idea to include your spouse or partner in your decision-making process. After all, a diagnosis of cancer and the treatment choices you make affect both of you.2


  1. National Cancer Institute, Facts About Prostate Cancer: http://www.cancer.gov/cancertopics/types/prostate

The causes of prostate cancer, as with other cancers, are broad and complex. There is no single perspective on what causes prostate cancer. There are, however, certain factors that are associated with an increased risk of developing prostate cancer.

Age & Genetics

What is known is that prostate cancer is somewhat rare in men under 50 years old, with the risk of developing prostate cancer increasing thereafter. By the time they are 80, more than half of all men will have some cancerous growth, which may or may not require treatment.

Prostate cancer seems to run in some families, suggesting an inherited or genetic factor. Having a father or brother with prostate cancer doubles a man's risk of developing this disease. The risk is even higher for men with several affected relatives, particularly if their relatives were young at the time of diagnosis. Scientists have identified several inherited genes that seem to increase prostate cancer risk.

Some inherited genes increase risk for more than one type of cancer. For example, inherited mutations of the BRCA1 or BRCA2 genes are the reason that breast and ovarian cancers are much more common in some families. The presence of these gene mutations also increases prostate cancer risk. But they are responsible for a very small percentage of prostate cancer cases.

Ethnic origin appears to play a part: men of African heritage seem to be at highest risk, and men of Asian descent are the lowest.

Diet & Lifestyle

Lifestyle choices, diet and exposure to environmental toxins are thought to play a part in the development and speed of prostate cancer.

Diets high in red meat, calcium (dairy products) and bad cholesterol (LDL) are thought to significantly increase prostate cancer risk. Diets high in grain carbohydrates can also affect insulin levels, which may result in obesity. Combined with dietary contributors towards obesity, a lifestyle with little exercise may also lead to development of prostate cancer. Men with a body mass index (BMI) of 32.5 or higher are 30% more likely to die from prostate cancer, while men with a BMI of 35 are 60% more likely to have a recurrence of prostate cancer in 3 years.

Diets that are rich in raw foods and vegetables are known to help prevent prostate cancer. Antioxidant foods help reduce “free radicals” in the body, which damage cell structure and may be a trigger for cancer development. Some common antioxidants include lycopene (found in tomatoes), pomegranate, mangosteen, wheatgrass and seabuckthorn, though the field of antioxidant discovery and research is ever-changing.

There is also research suggesting dietary or supplemented sources of omega 3 and 6 fatty acids, found predominantly in fish, can help prevent cancer, as well as having positive effects on the brain and cardiovascular function. Additionally, supplementation of selenium, vitamin D and vitamin E are thought to be beneficial in preventing prostate cancer as they can lower PSA levels and inhibit tumor growth.

Visit the National Prostate Cancer Coalition's website for more information on preventing prostate cancer: http://zerocancer.org/ .

Early prostate cancer usually causes no symptoms and is found by a PSA (prostate-specific antigen) test and/or DRE (digital rectal exam). Some advanced prostate cancers can slow or weaken your urinary stream or make you need to urinate more often. Non-cancerous diseases of the prostate, such as BPH (benign prostatic hyperplasia) often cause these symptoms.1

If the prostate cancer is advanced, you might also develop hematuria (blood in your urine) or impotence (difficulty having an erection). Pain in your pelvic bone, spine, hips or ribs is also possible, as advanced prostate cancer commonly spreads to the bones. Other diseases, however, can also cause these same symptoms. 2

When symptoms do occur, they may include:

  • Frequent urination, especially at night
  • Inability to urinate
  • Trouble starting or holding back urination
  • A weak or interrupted flow of urine
  • Painful or burning urination
  • Blood in the urine or semen
  • Painful ejaculation
  • Frequent pain in the lower back, hips or upper thighs 2

For more information on diagnosis, consult the section below on Screening & Testing.


  1. "General Information About Prostate Cancer," National Cancer Institute, www.cancer.gov. URL: http://www.cancer.gov/cancertopics/pdq/treatment/prostate/patient
  2. "Early Prostate Cancer: Questions and Answers," National Cancer Institute, www.cancer.gov. URL: http://www.cancer.gov/cancertopics/factsheet/detection/PSA

There are two primary methods used to initially detect abnormalities in the prostate that may be cancerous.

The first is the prostate-specific antigen (PSA) blood test. Prostate cancer can often be found early by testing the amount of prostate-specific antigen in your blood. PSA levels can be high not only in men who have prostate cancer, but also in men with an enlarged prostate gland or infections of the prostate. PSA tests may be very useful for early cancer diagnosis. However, PSA tests alone do not always reveal whether cancer is present.

Prostate cancer may also be found when your doctor does a digital rectal examination (DRE). Because your prostate gland lies just in front of your rectum, the doctor can feel if there are any nodules or areas of abnormal hardness in your prostate. These indicate the need for further testing to see if there is a cancer.

If you have yearly examinations and either one of these test results becomes abnormal, any cancer that you may have has probably been found at an early, more treatable stage.

Since about 1990, when the use of early detection tests for prostate cancer became relatively common, the prostate cancer death rate has dropped. But it has not been proven that this is a direct result of screening. Studies are underway to try to prove that early detection tests for prostate cancer in large groups of men will lower the prostate cancer death rate. Until that information is available, whether you have the test is something for you to decide in consultation with your doctor. Factors to consider are your age and general health. If you are young and develop prostate cancer, it will probably shorten your life if it is not caught early. If you are older or in poor health, then prostate cancer may never become a major problem because it is generally a slow-growing cancer.

Neither of the available screening tests for prostate cancer is infallible. Screening tests check for disease in a person who shows no symptoms. Most men with mildly elevated PSA do not have prostate cancer, and many men with prostate cancer have normal levels of PSA. Also, the digital rectal exam can miss many prostate cancers.

For more information on diagnosis, consult the section below on Screening & Testing.

There is no standard or routine screening test for prostate cancer. Some screening tests are used because they have been shown to be helpful both in finding cancers early and decreasing the chance of dying from these cancers. Other tests are effective in detecting cancer in some cases, though their efficacy in actually decreasing the risk of death from cancer has yet to be proven.

Scientists study screening tests to find those with the fewest risks and most benefits. Cancer screening trials also are meant to show whether early detection decreases a person's chance of dying from the disease. For some types of cancer, finding and treating the disease at an early stage may result in a better chance of recovery.

Tests to detect prostate cancer include:

1. Digital Rectal Exam (DRE)

During a DRE, the doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel the prostate for lumps or anything else that seems unusual. Learn more .

2. Prostate-Specific Antigen (PSA) Test

This test measures the level of PSA in the blood. PSA is a substance made mostly by the prostate that may be found in an increased amount in the blood of men who have prostate cancer. The level of PSA may also be high in men who have an infection or inflammation of the prostate or benign prostatic hyperplasia (enlargement of the prostate gland). Learn more .

Scientists are studying the combination of PSA testing and using a digital rectal exam as a way to get more accurate results from screening tests. Some cancers never cause symptoms or become life-threatening, but if found by a screening test, the cancer may be treated. It is not known if treatment of these cancers would extend life longer than if no treatment were given, and treatments for cancer may have serious side effects. Follow-up tests, such as a biopsy, may also be done to diagnose cancer.

3. Transrectal Ultrasound (TRUS)

Transrectal ultrasound uses sound waves to make an image of the prostate on a video screen. For this test, a small probe is placed in the rectum. It gives off sound waves, which enter the prostate and create echoes that are picked up by the probe. A computer turns the pattern of echoes into a black and white image of the prostate. The procedure takes only a few minutes and is done in a doctor's office or outpatient clinic. You will feel some pressure when the TRUS probe is placed in your rectum, but it is usually not painful. Learn more .

4. Biopsy

A biopsy is a procedure in which a sample of tissue is removed and then examined under a microscope. The doctor will use transrectal ultrasound (TRUS) for guidance and insert a narrow needle through the wall of your rectum into several areas of your prostate gland. The needle then removes a cylinder of tissue, usually about 1/2-inch long and 1/16-inch across, that is sent to the laboratory to see if cancer is present. Learn more .

5. Grading

Healthy prostate cells are uniform in size and shape, neatly arranged in the patterns of a normal gland. As cancer spreads, cells lose their uniform appearance. They change from normal, well-differentiated tissues to more disorganized, poorly differentiated tissue. Eventually, a tumor develops. If your biopsy shows the presence of prostate cancer, the pathologist assigns each tissue sample a grade, indicating how far the cells have traveled along the path from normal to abnormal. Learn more .

6. Staging

The process used to find out if cancer has spread within the prostate or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. Learn more .

A staging system is a standardized system of indicating the extent to which a cancer has spread. Staging describes the extent or severity of an individual's cancer based on the size of the original (primary) tumor and the extent to which it has spread within the body. While there are several different staging systems for prostate cancer, the most widely used system in the United States is called the TNM System. It is also known as the Staging System of the American Joint Committee on Cancer (AJCC).1

General Information on Staging

Staging is based on knowledge of the manner in which cancer develops. Cancer cells divide and grow to form a mass of tissue called a tumor. As tumor growth progresses, it can invade nearby organs and tissues. Cancer cells may also break away from the tumor, entering the bloodstream or lymphatic system. By moving through the bloodstream or lymphatic system, cancer can spread from the primary site to form new tumors in other organs. The spread of cancer is called metastasis. 2

Purpose of Staging

Staging aids the cancer diagnosis and treatment process in significant ways:

  • Staging helps doctors in effectively planning a patient's treatment.
  • The stage can be used to estimate a patient's prognosis (likely outcome or course of the disease).
  • Knowing the stage aids in identifying clinical trials (research studies) that may be suitable for a particular patient. 3

Staging helps researchers and health care providers exchange information about patients, providing a common language for diagnosis, treatment and clinical trials.

Tests to Determine Prostate Cancer Stage

The following tests and procedures may be used in the staging process for prostate cancer:

TEST/PROCEDURE

EXPLANATION

Radionuclide bone scan

A procedure to check if there are rapidly dividing cells, such as cancer cells, in the bone. A very small amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones and is detected by a scanner. 4

MRI (magnetic resonance imaging)

A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI). 5

Pelvic lymphadenectomy

A surgical procedure to remove the lymph nodes in the pelvis. A pathologist views the tissue under a microscope to look for cancer cells. 6

CT scan (CAT scan)

A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. 7

Seminal vesicle biopsy

The removal of fluid from the seminal vesicles (glands that produce semen) using a needle. A pathologist views the fluid under a microscope to find out if cancer is present. 8

The results of these tests are viewed together with the results of the original tumor biopsy to determine the prostate cancer stage.

Staging Prostate Cancer Using the TNM System

The TNM System describes the extent of the primary tumor (T stage), whether the cancer has spread to nearby lymph nodes (N stage), and the absence or presence of distant metastasis (M stage). The TNM System has been accepted by the International Union Against Cancer (IUAC) and the American Joint Committee on Cancer (AJCC). 9 The stages described below are based on the most recent version of the AJCC staging manual. The clinical stage is based on your tests before surgery, such as your PSA results and your doctor's assessment of the cancer from the DRE. If you have surgery, your doctors can determine the pathologic stage, based on the surgery and examination of the removed tissue. There are 4 categories for describing the prostate tumor's (T) stage, ranging from T1 to T4.10

STAGE

EXPLANATION

T1

Your doctor can't feel the tumor or see it with imaging such as transrectal ultrasound.

T1a

The cancer is found incidentally during a transurethral resection (often abbreviated as TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed.

T1b

The cancer is found after TURP but is present in more than 5% of the tissue removed.

T1c

The cancer is found by needle biopsy that was done because of an elevated PSA.

T2

Your doctor can feel the cancer when a digital rectal exam (DRE) is done, but it still appears to be confined to the prostate gland.

T2a

The cancer is in one half or less of only one side (left or right) of your prostate.

T2b

The cancer is in more than half of only one side (left or right) of your prostate.

T2c

The cancer is in both sides of your prostate.

T3

The cancer has begun to spread outside your prostate and may involve the seminal vesicles.

T3a

The cancer extends outside the prostate but not to the seminal vesicles.T3b: The cancer has spread to the seminal vesicles.

T4

The cancer has spread to tissues next to your prostate (other than the seminal vesicles), such as your bladder's sphincter (muscles that help control urination), your rectum, and/or the wall of your pelvis.

Stage Grouping

For many cancers, TNM combinations correspond to one of five stages. Once the T, N, and M categories have been determined, this information is combined, along with the Gleason score, in a process called stage grouping. The overall stage is expressed in Roman numerals from I (the least advanced) to IV (the most advanced). 11 This is done to help determine treatment options and the outlook for survival or cure. The following graphics, reproduced courtesy of the National Cancer Institute, show the urologic organs and prostate cancer stages. 12

STAGE I

 

STAGE II

In stage I, cancer is found in the prostate only. It cannot be felt during a digital rectal exam (DRE) and is not visible by imaging. It is usually found accidentally during surgery for other reasons, such as benign prostatic hyperplasia. Stage I prostate cancer may also be called stage A1 prostate cancer. 13

 

In stage II, cancer is more advanced than in stage I, but has not spread outside the prostate. Stage II prostate cancer may also be called stage A2, stage B1, or stage B2 prostate cancer.14

STAGE III

 

STAGE IV

In stage III, cancer has spread beyond the outer layer of the prostate to nearby tissues. Cancer may be found in the seminal vesicles. Stage III prostate cancer may also be called stage C prostate cancer. 15

 

In stage IV, cancer has metastasized (spread) to lymph nodes near or far from the prostate or to other parts of the body, such as the bladder, rectum, bones, liver, or lungs. Metastatic prostate cancer often spreads to the bones. Stage IV prostate cancer may also be called stage D1 or stage D2 prostate cancer. 16


  1. "Staging: Questions and Answers," National Cancer Institute. www.cancer.gov. URL: http://www.cancer.gov/cancertopics/factsheet/Detection/staging
  2. Ibid.
  3. Ibid.
  4. "How is Prostate Cancer Staged?," American Cancer Society, www.cancer.org. URL: http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_prostate_cancer_staged_36.asp
  5. Ibid.
  6. Ibid.
  7. Ibid.
  8. Ibid.
  9. "Staging: Questions and Answers," National Cancer Institute. www.cancer.gov. URL: http://www.cancer.gov/cancertopics/factsheet/Detection/staging
  10. "How is Prostate Cancer Staged?," American Cancer Society, www.cancer.org. URL: http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_How_is_prostate_cancer_staged_36.asp
  11. Ibid.
  12. "Stages of Prostate Cancer," National Cancer Institute. www.cancer.gov. URL: http://www.cancer.gov/cancertopics/pdq/treatment/prostate/Patient/page2
  13. Ibid.
  14. Ibid.
  15. Ibid.
  16. Ibid.