Prostate cancer

Background information

Prostate cancer is a malignancy that arises from cells in the prostate. The prostate is a gland that occurs only in men and forms a part of the male reproductive system where it contributes to the production of semen (sperm). It is situated in the pelvis minor right below the urinary bladder covering the urethra. Being adjacent to the rectum, it can be examined digitally through the rectum

Cancer is essentially caused by genetic mutations or changes at the DNA (gene) level. The information contained in DNA determines, among others, the structure of a cell, its functions and interactions with other cells. Changes at the DNA level cause the mutated cell to stop cooperating with other, healthy cells, stop performing its functions and escape the close control of the organism. Being out of control, the mutated cells start growing exponentially to create a tumour, invade and destroy neighbouring tissue and form metastases (develop new foci of cancer away of its original site).

Prostate cancer develops from cells that form the prostate. The most frequent form of PC is adenocarcinoma prostatae. Less frequent PC types include neuroendocrine carcinomas, ductal carcinomas and sarcomas.

Prostate cancer should be distinguished from benign prostatic hyperplasia (BPH) which is an age-related disease, most commonly occurring in men of around 50 years of age. That condition develops slowly and is characterised by a gradual growth of the prostate that presses against the urethra and impedes urination. Troublesome as it is, BPH is a purely local disease and does not lead to any metastases. BPH is not a malignant tumour.

Statistics

Prostate cancer is the second most common cancer type in Poland following lung cancer. Approximately 10,000 men are diagnosed with PC every year, and approx. 4,000 die from it.

Clinical picture – symptoms

Early stage prostate cancer may show no clinical symptoms. Most early stage cases are diagnosed in the symptomless phase based on PSA determination in a blood test and per rectum exam. Some patients have some lower urinary tract symptoms, such as:

• polyuria at day,
• urges to urinate at night, even several times,
• sudden bladder pressure and incontinence,,
• pain when urinating
• trouble starting while urinating
• decreased flow of urine,
• urges to urinate,,
• trouble stopping while urinating
• dripping from the urethra after urination,
• total blockage of urine,

Those symptoms usually result from the concurrent BPH However, they may also indicate prostate cancer, therefore, must not be ignored and always require medical consultation.

Sometimes, the first symptoms of PC are skeletal pains. These result from cancer metastases and prove the disease to be at a high stage.

Diagnostics

The basic diagnostic procedure for prostate cancer is PSA determination. Unfortunately, that marker is not specific for PC, as its concentration also grows in BPH and prostate infections. The commonly adopted upper limit of PSA concentration in serum is 4ng/ml; however, PC may also occur with lower levels.

Final diagnosis is made based on histopathology of a sample collected by ultrasonography-guided transrectal biopsy of the prostate. Such analysis should be performed in the case of elevated serum PSA or suspicion of PC based on per rectum exam or ultrasonography.

Biopsy is the only way to know for sure. Is is usually carried out under the guidance of transrectal ultrasonography (TRUS). The procedure involves the insertion of an ultrasonic probe, in the form of a thin cylinder, into the rectum. Thus, the physician can visualise the prostate and select a place to collect a sample tissue. Biopsy is made by means of a special needle by piercing the prostate at several points. The procedure is too burdensome for the patient and does not require anaesthesia. Nonetheless, the patient must properly prepare himself by emptying his rectum by means of a rectal enema and antibiotic cover. Unfortunately, TRUS-guided biopsy is not a perfect tool. Sometimes, the procedure must be repeated. Such re-take may for instance be ordered if no cancer cells are found while PSA concentration remains high.

Tissue collected by biopsy are examined microscopically by a pathologist. Based on the microscopic examination, the pathologist determines whether cancerous cells are present in the collected specimen. If such cells are detected, cancer type and stage of malignancy are assessed. Vast majority of all PC cases (at least 95%) are adenocarcinomas, but other types, such as small cell carcinomas, ductal carcinomas or lymphomas may also occur.

The stage of PC is determined according to the Gleason score. GS ranges from 2 to 10. The higher the score, the more malignant the cancer: GS below 6 stands for low malignancy; 6 – 7, moderate; and above 7, indicates high malignancy.

Histopathological diagnosis is essential for decisions on further diagnostics and treatment. Moreover, rare types of PC are treated differently than the typical ones adenocarcinomas.

Further diagnostic tests are selected on a case-by-case basis. The attending doctor may order further tests based on the clinical situation, PSA level and histopathology results. Those tests are aimed to establish how extensive the disease is and if the process is limited to the prostate (local disease).

Risk factors

Exact reasons for the development of prostate cancer are yet to be discovered. What we know is that the occurrence of this kind of cancer is mostly associated with older age and genetic factors (i.e. families with BRCA gene mutations and related risk of breast and ovarian cancer in women and prostate cancer in men).

Treatment

The choice of a treatment method depends on a number factors: clinical stage, risk assessment (based on PSA concentration and Gleason score), patient’s age and expected survival time.

There are three main methods to manage that type of cancer: surgery (prostate resection), radiotherapy and systemic treatment (hormonal therapy or traditional chemotherapy).

Surgery is primarily used in patients whose expected survival time is longer than 10 years (not recommended for men at a very old age), and the tumour does not go beyond the anatomical borders of the prostate.

Radiotherapy (either the so-called radioteletherapy, i.e. radiation from an external source located outside patient’s body, or brachytherapy i.e. radiation from a source placed within the prostate) is mainly applied in men with more advanced disease but without metastases.

In the case of advanced prostate cancer where the so-called radical treatment (surgery or radiotherapy) is impossible, hormonal therapy is usually a recommended option. Prostate cancer cells usually stimulated to grow by testosterone; therefore, hormonal treatment is aimed to reduce the impact of testosterone on the tumour. The outcome can be achieved in several ways. First, bilateral removal of the testicles should be considered – a simple and safe method, but not accepted by many men for psychological reasons. Second, there medicines which can reduce the impact of testosterone on cancer cells (androgenic block). Hormonal therapy is often used in combination with radiotherapy, the combination increasing the aggregate efficacy. In the course of time the effectiveness of hormonal therapy decreases, as PC cells become “resistant to castration”. In that case, a decision is usually taken to use another method, namely chemotherapy, or switch to new medicines. Patients with advanced PC are also treated with radiotherapy of metastatic foci in the bones.

There is a group of patients who are not given any treatment after PC diagnosis, but only closely observed by regular PSA determination with possible repeats. Treatment with the above mentioned methods is only started if the control tests prove the disease to clearly progress. Such strategy has been shown not to have any adverse impact on prognosis. Certainly, this method may only be proposed to patients who meet specific conditions (e.g. Low PSA concentration, low Gleason score, etc.).

Tips for prostate cancer patients treated with ionising radiation (radiotherapy)

• Following radiotherapy your body will not become radioactive;
• You do not pose any health threat to your family, including children;

Radiotherapy sessions for PC are absolutely painless, they require, however, for the patient to be laid on a therapeutic table and stay there for ten to twenty minutes. Due to a high precision of radiation, it is very important that the patient remain totally immobile during the procedure.

Healthy tissue exposed to radiation may become irritated leading to the following symptoms:

• pain and burning when urinating
• urination disorders (frequent urination in small amounts);
• bloodstained urine;
• stomach ache, intestinal contrition, bloating or diarrhoea;

The above symptoms may but do not have to occur.

IT IS IMPORTANT NOT TO IGNORE ANY SYMPTOMS, AND REPORT THEM TO A NURSE OR DOCTOR. THOSE SYMPTOMS MAY BE MITIGATED OR ELIMINATED.

To reduce adverse effects during radiotherapy

YOU SHOULD:

• Eat small but frequent meals;
• Try to eat and drink slowly;
• Drink room temperature drinks between meals;
• If problems deteriorate, try a liquefied diet – broth, fruit teas, linseed oil;
• Drink up to two litres of liquids a day (e.g. still mineral water);

EXCLUDE FROM YOU DIET:

• Milk meals
• Milk
• Cottage cheese
• Cream
• Yoghurt (natural and fruit)
• Buttermilk
• Bonny clabber
• Raw fruit and vegetables
• Buttermilk
• Peas
• Beans
• Cabbage
• Mushrooms
• Fizzy drinks
• Alcohol

Remember: Remember: your diet should be rich in potassium (bananas, potatoes, apricots).

HYGIENE:

• There are no contraindication to take showers during radiotherapy;
• Only make sure not to wash off the markings;
• Wash the crotch region with lukewarm water using soap with acid PH or mild child soap;
• Relieving effect can be achieved by using intimate care wipes (e.g. Bobas, Pampers);
• Dry your skin by patting it with a soft towel;
• Wear only cotton underwear; wash it in the soap you use;
• Do not apply any cosmetic to that region, unless recommended by your doctor;
• Do not remove hair from the crotch region.
• If any redness appear on your skin, apply appropriate agents;
• Empty your bowels regularly;

If any problems appear, you will receive adequate medicine to control them. Diarrhoea may occur around week four of the therapy. It is very important that you exclude milk from your diet. If problems persist, we will give you medicine that will help to solve it.

REMEMBER:

• Do not heat nor coll the treated area;
• Use your prescribed pain killers;
• Try to relax as much as possible and do not do any hard physical work;
• Comply to the set dates of follow-up visits, it is important not to interrupt treatment;
• For any questions regarding the disease and treatment, contact your doctor, nurse or radiation technologist. These are the only persons who are able to give you advice.

SMOKING AND DRINKING ALCOHOL DURING RADIOTHERAPY REDUCES THE CHANCE FOR RECOVERY FROM CANCER AND INCREASES RADIATION TOXICITY IN THE COURSE OF THERAPY!!!