Understanding Prostate Cancer -- Diagnosis & Treatment

How Do I Know If I Have Prostate Cancer?

Two tests are used to look for prostate cancer: a digital rectal exam and a PSA blood test.

The PSA blood test looks for something called prostate-specific antigen in the blood. Who should have a PSA test and when is controversial:

  • The U.S. Preventive Services Task Force does not recommend regular PSA tests. The task force say the tests may find cancers that are so slow growing that treatment, which can have serious side effects, would offer no benefit.
  • The American Cancer Society (ACS) recommends a discussion between the doctor and patient about the pros and cons of PSA tests. Men shouldn't get the test unless their doctor has given them this information, says the ACS. The ACS recommends that the discussion start at age 50 for most men at average risk for prostate cancer, or age 40 to 45 for those at high risk of prostate cancer.
  • The American Urologic Association (AUA) also recommends men talk with their doctor about the pros and cons of the PSA test. The AUA says men who want to be tested should start at age 40.

PSA levels in blood are higher if there is prostate cancer, making it a valuable tool in finding early prostate cancer. But PSA levels can also be high from infection or inflammation in the prostate or from an enlarged prostate.

It is important to discuss this test with your doctor before having one. A high PSA level does not mean that you have cancer; a normal PSA level does not mean you don't have cancer.

If PSA levels are high or have gone up since the last PSA test, your doctor will do a biopsy of the prostate gland using a small ultrasound probe inserted in the rectum (transrectal ultrasound). Tissue samples will be tested for cancer.

If cancer is found, the doctor will do abdominal and pelvic X-rays to see if the cancer has spread outside the prostate. A CT scan and a bone scan may also be done.

For men who have high PSA levels but biopsies don’t find cancer, there is a urine test known as a PCA-3 that looks for cancer. This test can prevent the need for repeat biopsies in some men.

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What Are the Treatments for Prostate Cancer?

Once the decision is made to treat prostate cancer, your doctor will decide the type of treatment. Decisions about how to treat this cancer are complex, and it makes sense for men to seek a second opinion before making a treatment decision. Treatment may include doing nothing, a single therapy, or some combination of radiation, surgery, hormone therapy, and rarely chemotherapy. The choice depends on many things. Prostate cancer that hasn’t spread usually can be cured with surgery or radiation.

Watchful Waiting

Since prostate cancer can grow slowly and may not be fatal in many men, some patients -- after discussing the options with their doctors -- opt for "watchful waiting." Watchful waiting means not treating it. Instead, the doctor regularly checks the prostate cancer for signs that it is becoming more aggressive. Watchful waiting recommended for men who are older or have other life-threatening conditions. In these cases, a less aggressive cancer may be growing so slowly that it's not likely to be fatal.

Surgery

The standard operation, a radical retropubic prostatectomy, removes the prostate and nearby lymph nodes. In most cases, surgeons can remove the gland without cutting nerves that control erections or the bladder, making impotence or incontinence much less common than in the past. Depending on the man's age and the amount of surgery needed to remove all the cancer, nerve-sparing operations allow about 40%-65% of men who were able to get erections before surgery to be able to do so after surgery without the need for erectile dysfunction treatments.

Laparoscopic robotic prostatectomy is a surgery using a laparoscope aided by robotic arms. This operation is now the most popular form of radical prostatectomy in the United States.

After surgery, most men have temporary urine leakage, called incontinence, but they usually regain complete urinary control over time. If it is severe or lasts a long time, incontinence can be managed with special disposable underwear, exercises, condom catheters, biofeedback, penile clamps, implants around the urethra, or a urethral sling.

After surgery or radiation, men may have impotence. Treatment for this side effect includes drugs such as tadalafil (Cialis), sildenafil (Viagra), andvardenafil (Levitra). Other treatments include teaching the man to perform a painless self-injection into the penis (of a drug called Caverject), or vacuum pumps. These treatments work in 15% to 40% cases of impotence after surgery and 50% to 75% cases of impotence after radiation. A penile prosthesis is only used when all other options have failed.

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Radiation

Radiation is often the main treatment for prostate cancer that has not spread. It may also be given as follow-up to surgery. Radiation may also be used, in advanced cases, to relieve pain from the spread of cancer to bones. Incontinence and impotence also occur with radiation. Radiation to the pelvis may also be done if PSA levels rise after surgery.

An advanced form of radiation, known as intensity modulated radiation therapy (IMRT), can increase the dose of radiation to the prostate with fewer side effects to the surrounding tissues. Proton beam therapy can increase the radiation dose to the prostate even more. But proton therapy has not been proven to be superior to IMRT. A more focused form of radiation, known as stereotactic radiation, is being used for early forms of prostate cancer. This treatment also has not been shown to improve the outcome of prostate cancer. Stereotactic radiation for prostate cancer is still new.

Radioactive seeds (brachytherapy) deliver radiation to the prostate with little damage to surrounding tissues. During the procedure, the tiny radioactive seeds, each like a grain of rice, are implanted in the prostate gland using ultrasound guidance. The implants remain in place permanently and become inactive after many months. In some patients, brachytherapy may be used with traditional radiation. In some patients, if the prostate gland is too large for brachytherapy, hormone therapy can shrink the prostate to allow brachytherapy to be done.

Hormone Therapy

Hormone therapy is the recommended treatment for advanced prostate cancer. Since testosterone can make prostate cancer grow, hormone therapy works by tricking the body to stop making testosterone, thus stopping or slowing the cancer's growth. Even advanced cases that cannot be cured may be controlled for many years with hormone therapy. But there is a higher risk of heart disease with this treatment. Fractures are also a risk due to thinning of bone. Medications are given to reduce the risk of osteoporosis and fractures.

Testosterone can also be removed from the bloodstream by surgically removing the testicles (orchiectomy) or by giving female hormones such as estrogen or other drugs that block testosterone production. Estrogen therapy is no longer used routinely. Patients generally prefer the testosterone-blocking drug treatment because it is effective, less invasive, and causes fewer side effects than surgery or female hormone drugs.

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Other Treatments

Chemotherapy is effective for some men with advanced prostate cancer who didn’t do well on hormone therapy. When the hormonal treatments stop working, the drugs Zytiga (abiraterone) or Xtandi (enzalutamide) have proven effective.

The goal of prostate cancer treatment is long-term survival, and that is likelier in men diagnosed with early prostate cancer. All prostate cancer survivors should be examined regularly and have their PSA and testosterone levels monitored closely.

WebMD Medical Reference Reviewed by Sujana Movva, MD on March 14, 2015

Sources

SOURCES: 

Prostate Cancer Foundation. 

Prostate Cancer Research Institute. 

National Library of Medicine. 

National Prostate Cancer Coalition. 

U.S. Preventive Services Task Force.

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