Prostate Cancer: Overview

Do I Need Screening?

Prostate cancer comes in many forms. Often, it grows slowly and may not be aggressive. However, other times it can spread much quicker and behave more aggressively. Because prostate cancer in one man can behave differently than in another there is a serious debate among the top doctors and medical society’s in the United States regarding screening.

However, the United States Preventive Services Taskforce (USPSTF) recommends that for men between the ages of 55-69 years at average risk the decision to screen should be an individual one. What the USPSTF means is that men should have a discussion with their primary care physician about the benefits and harms of prostate cancer screening. Other groups such as the American Urologic Association (AUA) also recommend a shared decision-making process. Some physicians may feel more strongly about screening for prostate cancer than others.

Most doctors agree that men over the age of 70 do not need screening. Although, again there is some debate over who is too old to be screened and each decision should be a personal choice after discussion with your primary care physician. What we can say is that all men should discuss prostate cancer screening with their physician to determine if it is the right choice and aligns with your values and preferences. One doctor tells SurvivorNet to ask your primary care physician what they would recommend for their father or loved ones when it comes to screening for prostate cancer.

Men who are at higher risk for this cancerthose who have a family history of the disease or certain inherited gene mutations, and African American menshould discuss this with their physician as it may help inform the decision on  screening.

The experts SurvivorNet asked suggested that men consider factors like their family history, genes, and age when making the decision about whether, and when, to screen. Ask your doctor what makes sense in your circumstance.

When should you get screened for prostate cancer? Dr. Edwin Posadas, director of the Translational Oncology Program at Cedars-Sinai Medical Center, has the answers. 

If you do choose to be screened it is important to know what is involved. Screening consists of a test to measure prostate-specific antigen (PSA) in the blood and a digital rectal exam (DRE) that allows the doctor to check your prostate for lumps. This exam may be uncomfortable, but it is briefit shouldn’t last for more than a minute. Based on the results of your PSA and DRE, your doctor may recommend additional testing including a biopsy or imaging such as a prostate MRI.

What are the Symptoms of Prostate Cancer?

It might sound odd, but paying attention to the way you urinate can help you know when to seek help. Finding that you’re peeing more often or waking up in the middle of the night to use the bathroom may indicate that you should make a doctor’s appointmentthough these may be signs of another problem, such as a urinary tract infection or diabetes. In any case, having to urinate more often at night should prompt a conversation with your doctor.

Because symptoms aren’t obvious, Dr. Edwin Posadas tells you what clues might signal that you have prostate cancer

Other warning signs of prostate cancer are:

• Blood in your urine
• Trouble getting an erection
• Pain or burning when you urinate
• Pain in your back, hips, thighs, or other bones
• Unexplained weight loss
• Fatigue

Getting a Diagnosis

A PSA test and digital rectal exam can alert your doctor to the possibility that you might have cancer. These two tests are either performed as part of prostate cancer screening or if the doctor thinks you may have prostate cancer based on any symptoms you have. Although everyone will have these tests done the only way to definitively diagnose prostate cancer is with a biopsy.

That involves the doctor removing a small piece of prostate tissue and then sending it out to a lab for testing.
There are several ways a doctor, who is usually a urologist, may get a biopsy. The most common is called a transrectal ultrasound-guided biopsy. In this procedure, a transrectal ultrasound a probe that uses sound waves to take a picture of your prostate is inserted into the rectum to allow your doctor to visualize your prostate and help with the biopsy.
There are other ways a doctor may get a biopsy including an MRI-fusion biopsy where an MRI helps the doctor target areas of the prostate that look like cancer. What type of biopsy is right for each patient is an individualized decision between you and your doctor.

Once your biopsy is completed the doctor will send the tissue to another doctor called a pathologist to assess if the biopsy has cancer cells. In addition to determining if cancer is present the pathologist will also assign a score to the cancer that tells your doctor how aggressive it is. This score is called the Gleason score and it ranges from 6-10. To make understanding this score easier it is converted into a grade group as below. Your doctor may use the Gleason score and Grade Group when discussing your biopsy results with you.

• Gleason 3+3=6 is Grade Group I
• Gleason 3+4=7 is Grade Group II
• Gleason 4+3=7 is Grade Group III
• A Gleason score that adds to 8 is Grade Group IV
• A Gleason score that adds to 9 OR 10 is a Grade Group V

After your biopsy, depending on your specific risk factors, your doctor may order additional tests such as a bone scan or pelvic MRI. However, whether you need these tests is based on your situation.

How Do Doctors Stage Prostate Cancer?

Once your doctor has established that you do have prostate cancer, the next step is to learn its stage. The stage tells how far the cancer has spread, and knowing it can help your doctor decide on the right treatment for you.

The staging system doctors typically used for prostate cancer is called TNM, and it’s based on five factors:

• The extent of the main tumor
• Whether it has spread to any lymph nodes
• Whether it has spread (metastasized) to other parts of your body
• Your PSA level at the time of diagnosis
• The grade (based on your Gleason score), which is how aggressively your cancer is likely to behave

Prostate cancer has four stages, each of which is broken down further with a letter based on its extent.

Stage I

The doctor can’t feel the tumor or see it with an imaging test such as transrectal ultrasound. It was found during transurethral resection of the prostate (TURP) or biopsy. The cancer has not spread to nearby lymph nodes or to other parts of your body. Your Gleason score is 6 or less, and your PSA level is less than 10.

OR

The doctor can feel the tumor by digital rectal exam (DRE) or see it with imaging, and it is in one half or less of only one side (left or right) of your prostate. The cancer has not spread to nearby lymph nodes or elsewhere in the body. The Gleason score is 6 or less, and the PSA level is less than 10.

OR

You’ve had surgery to remove your prostate, and the tumor was only in the prostate. The cancer has not spread to nearby lymph nodes or elsewhere in your body. The Gleason score is 6 or less, and the PSA level is less than 10.

Dr. David Wise, NYU Langone medical oncologist, explains how Gleason score affects treatment and prognosis

Stage IIA

The doctor can't feel the tumor or see it with imaging. It was either found during TURP, or was diagnosed by needle biopsy. The cancer has not spread to nearby lymph nodes or elsewhere in your body. The Gleason score is less than or equal to 6, and the PSA level is at least 10, but less than 20.

OR

The doctor can feel the tumor by DRE or see it with imaging. The tumor is in one half or less of only one side of the prostate. Or, the prostate has been removed with surgery, and the tumor was only in the prostate. The cancer has not spread to nearby lymph nodes or elsewhere in the body. The Gleason score is less than or equal to 6, and the PSA level is at least 10 but less than 20.

OR

The doctor can feel the tumor with DRE or see it on imaging. It is in more than half of one side of the prostate or in both sides of the prostate. The cancer has not spread to nearby lymph nodes or elsewhere in your body. The Gleason score is less than or equal to 6, and the PSA level is less than 20.

Stage IIB

The cancer has not yet spread outside the prostate. Your doctor might feel it with DRE or see it with imaging. The cancer has not spread to nearby lymph nodes or elsewhere in your body. The Gleason score is 7, and the PSA level is less than 20.

Stage IIC

The cancer has not yet spread outside the prostate. Your doctor might feel it with DRE or see it with imaging tests. The cancer has not spread to nearby lymph nodes or elsewhere in the body. The Gleason score is 7 or 8, and the PSA level is less than 20.

Stage IIIA

The cancer has not yet spread outside the prostate. It might be felt by DRE or seen with imaging. The cancer has not spread to nearby lymph nodes or elsewhere in your body. The Gleason score is 8 or less, and the PSA level is at least 20.

Stage IIIB

The cancer has grown outside the prostate and might have spread to the seminal vesicles, or into other tissues next to the prostate, such as the urethral sphincter (the muscle that helps control urination), rectum, bladder, and/or wall of the pelvis. It has not spread to nearby lymph nodes or elsewhere in your body. The Gleason score is 8 or less, and the PSA can be any value.

Stage IIIC

The cancer might be growing outside the prostate and into nearby tissues. It has not spread to nearby lymph nodes or elsewhere in the body. The Gleason score is 9 or 10, and the PSA can be any value.

Stage IVA

The tumor might be growing into tissues near the prostate. The cancer has spread to nearby lymph nodes, but has not spread to other parts of your body. The Gleason score and the PSA can be any value.

Stage IVB

The cancer might be growing into tissues near the prostate and might have spread to nearby lymph nodes. It has spread to other parts of the body, such as distant lymph nodes, bones, or other organs. The Gleason score and the PSA can be any value.

What Are Your Treatment Options?

After your treating team has all of the information (PSA, Gleason Score, prostate exam, and the results of any imaging scans), your doctor will use it to categorize your cancer into one of several groups, called risk groups. These include:

• Low risk
• Intermediate risk
• High risk

There are several subgroups within these categories that your doctor may mention. Which risk group your cancer falls into will determine what treatment options are available to you. Men with low-risk and very low-risk disease may be candidates for active surveillance, while men with high-risk disease may be treated with radiation therapy and androgen deprivation therapy (hormonal therapy).

In addition to your risk group, your doctor will also consider other factors, including:

• Your age
• Your overall health
• Your life expectancy
• Your goals for treatment

A combination of all of this information will allow your treating team to discuss all of the options that are available for treating your specific cancer.

Medical oncologist Dr. David Wise explains how your Gleason score will help guide your treatment, and predict your outlook

Common treatment options for men with prostate cancer include:

• Surgery
• Radiation therapy
• Active surveillance
• Combination radiation therapy with hormonal therapy
• Surgery followed by radiation therapy

The reality is that most treatments are effective at curing the cancer. However, they each have different side effects that your doctors should discuss with you. We encourage and recommend that if you are diagnosed with prostate cancer, you get an opinion from a urologist (surgeon) and a radiation oncologist to hear all of your options before choosing a treatment. We also recommend you get a second opinion from another institution. Given the many treatment choices, doctors at some centers may do things quite differently than others.

We believe it is important to understand all of your options and hearing from other doctors at different institutions is helpful. The good news is that we have a lot of great options to treat men with this cancer. It can sometimes be overwhelming to pick what is best for you.

Knowing whether or not to treat prostate cancer isn't an easy decision, says Dr. Geoffrey Sonn 

Surgery

Surgery is an option for men with any risk group of prostate cancer that hasn’t spread outside of the prostate gland. Typically, the type of surgery used is called a radical prostatectomy. The surgeon removes the entire prostate, along with some tissue around it, including the seminal vesicles that release fluid into the semen. Your doctor can perform this through a traditional open procedure with one large incision, or through several small incisions, called laparoscopic surgery.

Surgery has side effects including erectile dysfunction and urinary incontinence. The risk for these depends on the type of surgical approach and factors specific to your cancer. Sometimes, men who have surgery will need radiation therapy after surgery if the surgeon could not remove all of the prostate, your PSA does not become undetectable or you have a high risk genetic profile if the tissue is sent for testing. Men with High Risk and Very High Risk prostate cancer are more likely to require radiation after surgery than men with lower risk disease.

Radiation Therapy

Radiation, like surgery, is an option for men with any risk group. It uses high-energy x-rays to treat cancer. You might get this treatment alone if your cancer is still early stage and confined to your prostate gland, together with hormone therapy if your cancer is more advanced or has spread outside your prostate, or to relieve symptoms like bone pain and control cancer that has spread more widely. You can get radiation in a few different ways.

External beam radiation therapy (EBRT) aims the radiation at your body from a machine. You’ll usually get this treatment five days a week for several weeks. Newer techniques including stereotactic body radiotherapy (SBRT) aim more focused beams of radiation at the tumor, to spare surrounding healthy tissues, and may allow treatment in a shorter time. Like surgery, radiation also has side effects. EBRT like surgery can also cause erectile dysfunction although it is much less likely to cause issues with urinary incontinence. However, it can cause issues with bowel function and urine flow.

Brachytherapy implants small seeds containing radiation directly into your prostate. This type of radiation works best in men with smaller prostates. If your prostate is very large, your doctor might give you hormone therapy first to shrink it. You’ll get brachytherapy in a hospital, while under anesthesia. Usually, the seeds are permanent and continue to release small doses of radiation, ensuring that the cancer is treated. Some centers now use a form of brachytherapy that does not require permanent seeds. In this procedure, the radiation is put into the prostate and removed while the patient is under anesthesia. Brachytherapy also has side effects including erectile dysfunction and issues with urine flow.

Androgen Deprivation Therapy

Androgens are male hormones that fuel the growth of prostate cancer. Androgen deprivation therapy (ADT), also known as hormone therapy, reduces levels of these hormones your body makes, to slow the cancer’s growth. You might get this treatment if your cancer has spread or comes back after treatment, or to shrink the tumor before surgery. You’ll get this treatment as injections, implants placed under your skin, or pills. ADT can cause fat gain, muscle loss, fatigue, and hot flashes in some men.

Active Surveillance

Often prostate cancer grows very slowly. And some men, especially those who are older, may not need aggressive treatment. Active surveillance means the doctor watches the cancer carefully, with a PSA blood test every 6 months and a digital rectal exam about once a year. You may also get prostate biopsies and imaging tests every 1 to 3 years. Depending on the results of these tests, your doctor may decide to start you on treatment. We want to stress that Active surveillance is NOT watchful waiting. Active surveillance is a treatment and as the name implies is active! About one-third to half of men who choose active surveillance will eventually require definitive treatment such as surgery or radiation therapy.

Surgery and Radiation Therapy

Radiation therapy can be used after surgery, to get rid of any cancer cells that were left behind. Getting radiation along with surgery is called adjuvant therapy. This is sometimes used when the surgeon is unable to remove all of the cancer, tests after surgery show that the cancer is high risk, or the PSA is at detectable levels after surgery.

Nerve-sparing surgery could help you preserve your sexual function, says Weill Cornell urologic oncologist, Dr. Jim Hu 

Advanced-Stage Prostate Cancer Treatment

If prostate cancer has metastasized (spread to other parts of your body), your doctor might suggest hormone therapy, chemotherapy, radiation therapy, or a combination of these therapies. Anti-androgen therapy or hormone therapy is the backbone of treatment for metastatic prostate cancer. Prostate cancer uses testosterone to grow, and these therapies turn your body’s testosterone off, slowing cancer growth. In addition to hormone therapy, your doctor may recommend chemotherapy. This treatment uses strong drugs to kill cancer cells throughout the body. Fortunately for men with metastatic disease, there are many new drugs available that have the potential to keep the cancer under control for many years. These include androgen deprivation therapy, chemotherapy, targeted agents, immunotherapy, and Radium-223 treatments. Sometimes, if one treatment stops working your doctor may switch to another that works better at keeping your cancer under control.

Your doctor may also discuss the use of radiation therapy. Radiation therapy in advanced disease can be used to eliminate any pain or issues your cancer is causing. In some cases, your doctor may consider giving radiation to the prostate, as well as to cancer cells that have spread throughout your body.

The goal of treatment for men with metastatic prostate cancer is to prevent symptoms and control the cancer for as long as possible. Given the many new advances in treating prostate cancer, men with metastatic disease can live for many years after their diagnosis with good quality of life.

Stanford Medicine radiation oncologist Dr. Patrick Swift explains the benefits of high-dose brachytherapy

Finishing your treatment can come with a sense of relief and excitement. Be proud of what you’ve accomplished, but remain vigilant. It is possible for prostate cancer to return after treatment.

You’ll have follow-up visits with your doctor to monitor you for new symptoms and address any long-term side effects of your cancer treatment. It’s important to keep all of these appointments so that, if your cancer does return, you’ll be ready to start treating it right away.