Cancer

Prostate cancer is the most common form of cancer in men. It is primarily diagnosed in men over 65, although it may begin much earlier. While most prostate cancers are found in the peripheral zone, they may occur anywhere in the prostate. Most pathologists use a Gleason Grading System to assess the tumour progression. The more distorted and aggressive the cancer looks, the higher the Gleason grade, and the more aggressive the cancer behaves in the body. A score from 2 to 4 is very low on the cancer aggression scale; scores from 5 to 6 are mildly aggressive; a score of 7 indicates that cancer is moderately aggressive; scores from 8 to 10 indicate that the cancer is highly aggressive.

Screening and Testing

Prostate Cancer is often curable when diagnosed and treated properly. Starting at age 50 (or sooner, if you have a history of prostate cancer in your family), the following tests should be a part of a regular (six monthly) physical examination by your doctor:

Digital Rectal Exam (DRE)
The doctor inserts his lubricated finger into the rectum to feel for lumps on the prostate, which is normally smooth. Nobody likes this test but it can a life saver.

If the digital rectal exam, PSA, or other indicators (such as urinary symptoms) point to the possibility of prostate cancer, the following tests may be performed.

Prostate Specific Antigen (PSA) Test
This blood test helps identify the possible presence of prostate cancer by checking for Prostate Specific Antigen (a protein substance produced by the prostate gland), which is present in high levels in many people who have prostate cancer. The lower the score, the better. A score below 4 is desirable, and a score below 2 is even better.

Free PSA
The free PSA test is another tumour marker. It's newer than the regular PSA test. Free PSA is a special version of PSA, specifically, its the inactive form of the antigen. Regular PSA tests are used to screen patients for prostate cancer, but free PSA can provide extra information, especially in determining whether a biopsy should be performed. (The term free obviously doesn't refer to the test itself!). Unlike regular PSA test, the value is expressed as the free PSA divided by the total PSA, and a low percentage score is bad. Generally scores of 20 percent and above are considered good, while scores of 15 percent and below mean the chances of cancer are high.

Urine Flow Study
Sometimes the doctor will ask a patient to urinate into a special device that measures how quickly the urine is flowing. A reduced flow often suggests BPH.

Biopsy
Procedure where tissue samples from the prostate are removed to be checked for cancer. Prostate biopsy is recommended when a digital rectal examination reveals a lump or some other abnormality in the prostate. In addition, if blood tests reveal that the levels of certain markers, such as PSA, are above normal, the doctor may order a biopsy.

Prostate biopsies can be performed in three different ways. They can be performed by inserting a needle through the perineum (the area between the base of the penis and the rectum), by inserting a needle through the wall of the rectum, or by cytoscopy. Before the procedure is performed, the patient may be given a sedative to help him relax. Patients undergoing cytoscopy may be given either general anesthesia or local anesthesia. The doctor will ask the patient to have an enema before carrying out the biopsy. The patient is also given antibiotics to prevent any possible infection. Prostate biopsy performed with a needle is a low-risk procedure. The possible complications include some bleeding into the urethra, an infection, or an inability to urinate.

Needle biopsy via the perineum
The patient lies either on one side or on his back with his knees up. The skin of the perineum is thoroughly cleansed with an iodine solution. A local anesthetic is injected at the site where the biopsy is performed. Once the area is numb, the doctor makes a small (1 in) incision in the perineum. The doctor places one finger in the rectum to guide the placement of the needle. The needle is then inserted into the prostate, a small amount of tissue is collected, and the needle is withdrawn. The needle is then re-inserted into another part of the prostate. Tissue may be taken from several areas. Pressure is then applied at the biopsy site to stop the bleeding. The procedure generally takes 15-30 minutes and is usually done in a physician's office or in a hospital operating room. Though it sounds painful, it typically causes only slight discomfort.

Needle biopsy via the rectum
This procedure is also done in the physician's office or in the hospital operating room, and is usually done without any anaesthetic. The patient is asked to lie on his side or on his back with his legs in stirrups. The doctor attaches a curved needle guide to his finger and then inserts the finger into the rectum. After firmly placing the needle guide in the rectum, the biopsy needle is pushed along the guide, through the wall of the rectum and into the prostate. The needle is rotated gently, prostate tissue samples are collected and the needle withdrawn.

Cystoscopy
In this exam, the doctor inserts a small tube through the opening of the urethra in the penis. This procedure is done after a solution numbs the inside of the penis so all sensation is lost. The tube, called a cystoscope, contains a lens and a light system, which help the doctor see the inside of the urethra and the bladder.
This test allows the doctor to determine the size of the gland and identify the location and degree of the obstruction.

If your biopsy/ tissue samples show the presence of prostate cancer, the pathologist assigns each tissue sample a grade, indicating how far the cells have travelled along the path from normal to abnormal. The grade offers a good clue to your tumour's behaviour: a tumour with a low grade is likely to be slow-growing, while one with a high grade is more likely to grow aggressively or already to have spread outside the prostate (metastasised). The most widely used grading method for prostate cancer is known as the Gleason grading system

Ultrasound
A test that uses sound waves to check for the presence of tumours. An external ultrasound may be used in addition to the internal ultrasound.

Imaging Tests

Radionuclide Bone Scan
A bone scan may be performed in addition to a biopsy, to check whether cancer may have spread to the bones. The procedure involves an intravenous injection of a small amount of a radioactive material. The radioactive substance settles in damaged bone tissue throughout the entire skeleton. Areas of bone damage will be more radioactive and will appear as "hot spots" in your skeleton.
These areas may suggest metastatic cancer is present, but arthritis or other bone diseases can also cause the same pattern. To distinguish among these conditions, other imaging tests such as simple x-rays, CT, or MRI or bone biopsies may be used to better evaluate these hot spots.

Conventional Treatments

Generally, conventional treatment for prostate cancer is determined by the stage of the cancer.

Surgery

Radical Prostatectomy
If the radiation is limited to the prostate, radical prostatectomy (the removal of the entire prostate gland and the accompanying seminal vesicles. In this surgical procedure the prostate is removed and a catheter is inserted to drain urine, blood, and tissue out of the bladder. If a patient is too old or too ill to undergo this surgery a catheter may be inserted on a permanent basis. The main disadvantage of surgery is that it requires a lot of recovery time (at least four weeks). During your recovery, you may have some temporary problems with incontinence. And if you don't have nerve-sparing surgery, it is likely that you'll be permanently impotent. Other risks include urinary incontinence, significant blood loss that requires a transfusion, pain from surgery, blood clots in legs, lymphoceles in the pelvis, infection in the incision or pelvis, nerve damage from lying on the table in the wrong position, swelling in legs from the removal of the lymph nodes, injury to the rectum etc.

TURP (Trans-urethral resection of the prostate)
In the surgical procedure TURP (Trans-urethral resection of the prostate) the surgeon removes a part of the prostate. TURP may cause sterility, impotence, and incontinence. A TURP is usually performed under a general anaesthetic so that the man is asleep and feels no pain throughout the procedure. Typically, no food and drink is allowed for about six hours before a general anaesthetic. However, some anaesthetists allow a few sips of water until two hours beforehand.

A TURP usually involves a hospital stay of around four days. The operation itself takes about an hour.
Once the anaesthetic has taken effect, the surgeon inserts a thin, tube-like telescope (a resectoscope) into the urethra. The resectoscope includes a camera and specially adapted surgical instruments. This allows the surgeon to see the prostate clearly. A wire loop attachment that carries an electric current is used to "chip away" at the prostate. The same instrument, with a different type of electric current, is used to stem any bleeding.

During the operation, the bladder is flushed with a sterile solution to remove the chippings of prostate tissue. A catheter (a thin flexible tube) is then inserted through the urethra into the bladder.

What to expect afterwards

As the anaesthetic wears off, there may be some pain and the anaesthetist may prescribe painkillers.
There may be a drip in the arm to prevent dehydration. This will be removed once enough fluid is being drunk.

A urinary catheter will be in place. This system allows fluid to pass into and out of the bladder simultaneously.

One or more bags, usually hanging above the bed, store liquid that runs slowly into the bladder via the catheter. A mixture of urine and this flushing liquid then flows out of another section of the catheter and is collected in a jar or bag beside the bed. With the catheter in place, many men feel as though their bladder is constantly full.

When the urine in the catheter runs clear, which is usually within two to three days, the catheter will be removed. Urinating normally may sting a bit at first and the urine may be cloudy. To start with, there may be a constant urge to urinate and it may be difficult to control the flow. There may be leaks or dribbles of urine. This usually goes away within 24 hours.

Once home, further painkillers may be taken if needed, as advised by the hospital. Drinking at least two litres of fluid a day will help flush out the bladder and assist recovery. It is common to have occasional blood clots (red-brown or purple flecks) in the urine. Also leaks of urine can happen when coughing or straining for a number of weeks. To help with this an absorbent liner can be worn inside the underpants.

The hospital or a GP should be contacted immediately if heavy bleeding returns, there is a high temperature, if it’s not possible to urinate, or if the level of pain increases.

A full recovery from a TURP normally takes from four to six weeks. After this, normal activities, including sex, can be resumed, but heavy work or strenuous activity should be avoided for three months.

Deciding to have a TURP

TURP is generally a very safe surgical procedure. For most men the benefits, in terms of improved symptoms, are greater than the disadvantages. However, in order to give informed consent, anyone deciding whether or not to have a TURP needs to be aware of the possible side-effects and the risk of complications.

Side-effects

Side-effects are the unwanted but usually mild and temporary effects of a successful procedure. Examples include feeling sick as a result of the general anaesthetic and some discomfort from the catheter. In addition to these, there are some specific side-effects can be expected for this operation.
• The urine will contain blood for several days – this will gradually clear.
• Most men find that a lasting side-effect of a TURP is dry orgasm (retrograde ejaculation). This happens because the surgery makes it possible for semen to travel back up into the bladder rather than out through the penis at the time of orgasm. However, this should not interfere with sex and, after recovery from the operation, most men return to the same level of sexual activity as before the treatment.

Complications

Complications are unexpected problems that can occur during or after the operation. Most people are not affected. The complications of this operation include excessive bleeding, a urinary tract infection or an unexpected reaction to the anaesthetic. It is also possible for too much water to be absorbed from the fluid used to flush the bladder during the operation. This can temporarily upset the balance of salts in the blood, which can be harmful, particularly for people who already have heart or kidney problems. The condition is sometimes known as TURP syndrome.

Rarely, it is also possible to develop a blood clot (known as a deep vein thrombosis or DVT) in the veins of the leg. This clot can break off and travel to the lungs to cause a blockage. In the majority of cases, this is treatable, but it can be a dangerous condition. People having surgery are routinely given medicines or compression stockings to wear during the operation to help prevent a DVT.

A TURP can sometimes cause longer-term problems. These can include:
• reduced fertility – this happens to about 1 in 10 men who have a TURP
• persistent urinary incontinence, even after the initial recovery period - this happens to about 1 in 100 men who have a TURP
• some men continue to have problems emptying their bladder completely
• in a small number of cases, men may develop erection problems

Cryosurgery

Cryosurgery (which is also known as cryotherapy or cryoablation) refers to the procedure in which cancer cells are frozen. Some of the primary disadvantages include tissues surrounding the prostate being damaged. If healthy tissue is damaged, significant side effects such as urethral burning, incontinence, and rectal problems can occur. Another disadvantage involves the nerve bundles that control erections often unavoidably get frozen during the procedure, which can lead to impotence.

Radiation Therapy

Radiation therapy can be performed externally with, with external beam radiation therapy (EBRT), or internally, with brachytherapy (a procedure where radioactive seeds are either permanently or temporarily inserted into the prostate. A major disadvantage of radiation is that it may cause impotence and urinary incontinence. The buildup of scar tissue can cause impotence for a year (or more) after treatment. Radiation can also cause other problems with the bladder and rectum. Other side effects include hair loss, weakness and tiredness.

Chemotherapy

Anti-cancer drugs that are given (either orally, intravenously, or by injection) to attach the cancer cells. The primary disadvantage of chemotherapy is the side effects, which may be severe. Side effects can include nausea and vomiting, loss of appetite, weight loss, hair loss, and extreme fatigue.

Hormone Therapy

See ‘Looking after your Prostate’. Synthetic hormones often have unpleasant side effects that one doesn’t encounter with nature identical hormones which the body recognises.