prostate cancer
A malignant tumor of the prostate gland . It is almost always an adenocarcinoma.
SEE: benign prostatic hypertrophy ; brachytherapy; prostatectomy.
Incidence: In 2024 nearly 300,000 Americans will be diagnosed with prostate cancer, and more than 35,000 will die of the disease.
Incidence is 60% higher in African Americans than in Caucasians or Hispanics and lowest in Asians. The highest mortality is also in African Americans. Other risk factors include family history, having had a vasectomy, eating a diet high in fats and red meats and low in fruits and vegetables, and demonstrating reduced levels of vitamins D and E, lycopene, and selenium.
Causes: Although the cancer may have many causes, it is a hormone-sensitive tumor (testosterone).
Symptoms and Signs: The disease is often asymptomatic, or it may present with symptoms similar to those of benign prostatic hypertrophy (difficulty in urinating, urinary hesitancy, frequency, dribbling, steam reduction or interruption, and nocturia); symptoms of urinary tract infection; or in cases in which the cancer has spread to bone, localized or generalized bone pain. Prostate cancer can also spread locally or metastasize via the lymphatic system to lung, liver, and brain.
Diagnosis: Prostate cancer is diagnosed by ultrasound-guided biopsy.
Treatment: Because prostate cancer is a tumor whose growth is encouraged by male hormones, many of the treatments for the disease center on reducing levels of and rogens. These include gonadotropin-releasing hormone agonists (such as leuprolide and goserelin), other antiand rogenic drugs (such as flutamide or bicalutamide), and urologic surgery (bilateral orchiectomy, i.e., castration). If prostate cancer spreads despite chemical or surgical castration, chemotherapeutic drugs known to be active against prostate cancer can be employed (such as docetaxel). Prostate cancers can also be treated by implanting radioactive seeds in the tumor (radium-223) or by external beam radiation therapy.
Impact on Health: Ninety-three percent of those diagnosed survive at least 10 years, and 77% of men with the disease survive at least 15 years.
Patient Care: Most professional medical societies recommend that men over the age of 50 or men with a strong family history of the disease discuss prostate cancer screening with their primary care providers. The available options include blood tests to assess levels of prostate specific antigen (PSA), digital rectal examination (DRE), or assessment of the gland with ultrasonography. Mass screening for prostate cancer is not recommended by any major professional group because it may result in false-positive diagnosis, unnecessary or complicated treatments, or unnecessary anxiety. However, those men at high risk (esp. African Americans) should begin annual testing at 45. Screening should begin at 40 for men at highest risk (several first-degree relatives having prostate cancer at early ages).
When prostate cancer is suggested by screening tests, biopsies are required to confirm the diagnosis, usually with guided imagery via transrectal ultrasound. Further studies may include MRIs, CTs, and bone scans to see if the disease has spread. Once diagnosed, prostate cancer is differentiated as stages 1 to 4, with the higher stages indicating more advanced or widespread disease, and is graded on the Gleason score from 2 to 10, with lower numbers indicating cells more closely resembling normal cells (well differentiated) and higher numbers increasingly abnormal (poorly differentiated). Stage, grade, age, and overall health help determine treatment although all treatment options should be explored.
Patient support and education vary with the stage of the disease and the therapies to be provided. For example, for patients with early (low-grade or low-stage) disease, or for those with limited life expectancy and significant co-morbid diseases who choose expectant care (watchful waiting) to avoid the rigors of treatment and potential adverse reactions, teaching should focus on symptoms requiring prompt intervention and on the need for follow-up visits for repeat PSA and DRE, usually every 6 months. If the patient chooses external beam radiation, he is taught the most common side effects (localized skin irritation, diarrhea, urinary urgency, frequency, hesitancy and pain, erectile dysfunction, fatigue, and bone marrow suppression). If the patient chooses brachytherapy, he is taught that the radioactive seeds will be placed in the prostate while he is under sedation. Radiation precautions are needed, including following the approved method of lost seed disposal. A condom must be used when sexual activity is resumed after 2 weeks. The most common side effects are irritation and obstruction of the urinary tract. Patients who have received brachytherapy should immediately report inability to void, rectal bleeding, rectal irritation, or diarrhea to the health care providers.
Cryosurgery in which liquid-nitrogen probes are inserted into the prostate eradicates the malignant cells. Complications include erectile dysfunction, urinary incontinence, and formation of fistulas between the bladder and the rectum. Radical prostatectomy is the most effective surgery for improving long-term survival. The entire prostate, seminal vesicles, regional lymph nodes, and part of the bladder neck are removed. All patients should be taught from an early age about their risks for prostate cancer and encouraged to have regular screening at the appropriate age.