Prostate Cancer - Facts & Treatment
CANCER OF THE PROSTATE: FACTS AND TREATMENT
Fletcher C. Derrick, Jr., M. D. - Urology Offices
641 St Andrews Blvd
Charleston, South Carolina 29407
It is estimated that about 180,000 men in the United States
will be diagnosed as having cancer of the prostate per year.
This number will probably rise simply because men have become
more aware of prostate cancer and are seeking examinations and
treatment sooner. As recently as fifteen years ago, when the
diagnosis of cancer of the prostate was made, the cancer had
already spread outside the prostate gland, making cure virtually
impossible. With 1, increased awareness, 2, the PSA (prostatic
specific antigen), a blood test which is specific for prostate
diseases and particularly cancer of the prostate, 3, patients
coming in for the rectal examination, and 4, ultrasound of the
prostate, ( a painless rectal examination of the prostate done
in the office), Urologist are finding the cancer earlier.
If the cancer is found in the early stages, and if by all
testing it has not spread outside of the prostate gland itself, with
surgical removal of the prostate, there is a 93% , 10 year
disease specific survival.
WHO GETS CANCER OF THE PROSTATE?
Cancer of the prostate occurs in men, rarely before the age
of 50 and very often after the age of 80. It has been estimated
that if all men over the age of 80 were tested, as many as 70%
would be found to have prostate cancer. The cancer that occurs
in the 80 plus year old man seems to be a less aggressive cancer
than those in the younger men. Because of this fact, Urologist
feel that if the cancers that occur in the younger men can be
found early enough, then a good chance of cure can be offered.
The incidence of cancer of the prostate is about 1 in 10 or
11 men. If a man has a grandfather, father, or brother
who had cancer of the prostate, then the incidence doubles to
about 1 in 5 or 6 men. Men of the Black race have a
higher incidence of prostate cancer: about 1 in 9.
WHEN, AND WHO SHOULD BE TESTED FOR CANCER OF THE PROSTATE?
All men in the 50 - 55 age group should go for PSA and rectal
exam by their Urologist or Family Physician, and then have the
All Black men and men with a family history of cancer of the
prostate should have their testing starting as early as 40 years
of age, continuing thereafter on a yearly basis.
As a service to the community, Urologist at various hospitals
participate in PROSTATE AWARENESS WEEK. This is usually in
September of each year. If patients do not have a regular Family
Physician or Urologist they can go for the exam and PSA at these
times. This testing is free, and if the test are suspicious or
positive, a Urologist can be found who will help with further
testing and determining if the patient has cancer or not.
HOW ACCURATE IS THE PSA?
The PSA is very specific for prostate disease. It can be
elevated with 1, cancer, 2, so called benign prostate
hypertrophy, (which is very common in the aging male), and even
3, acute prostatitis. We do not recommend that the PSA be done
as a screening test alone. A rectal exam of the prostate is
necessary also, for the most accurate assessment of the gland
and any problems which may be present. The "split PSA"
method is now being done in those cases where the PSA is between
4 and 10 with no nodule or irregularity on the prostate exam.
WHAT CAUSES CANCER OF THE PROSTATE?
There is no known specific cause of cancer of the prostate.
Several theories exist, from excessive smoking to excessive fat
in the diet. The most likely reason is some changing hormonal
pattern or some genetic influence in the aging male.
WHAT ARE THE SYMPTOMS OF CANCER OF THE PROSTATE?
Very early cancer of the prostate has no symptoms. Although
not specific, certain symptoms may include:
1. Frequent urination.
2. Weak urinary stream.
3. Painful urination.
4. Pain in the prostate area just before or just after
5. Blood in the urine or semen.
6. Persistent pain in the low back or hips.
7. Loss of sex drive.
Some of these symptoms are indications of late cancer of the
prostate, or can be symptoms of other problems. I stress once
again the importance of the yearly PSA and rectal examination,
and visiting a physician if you have any of the above symptoms.
HOW IS THE DIAGNOSIS OF CANCER OF THE PROSTATE MADE?
The diagnosis is made by examining tissue taken from the
prostate by either a needle biopsy of the prostate or through an
operating type cystoscope. The Urologist will most likely
perform a transrectal ultrasound of the prostate, This procedure
is usually done in the office. It is uncomfortable but is
usually not painful. Certain instructions will be given to you
prior to and after the ultrasound exam.
AFTER THE DIAGNOSIS IS MADE, WHAT IS THE NEXT STEP?
Once the diagnosis is made, the Urologist will probably order
some other testing, usually a bone scan and CT scans or in some
cases a MRI scan. Sometimes, testing of the bone marrow is
Testing the lymph nodes may also be indicated and this may
require an operation or use of the laparoscope. All of this
testing is done to determine if the cancer is still confined to
the prostate or has spread to some other part of the body. These tests are necessary because once the type, location, and
extent of the cancer is known by the Urologist, then a treatment
plan can be recommended. The technical terms for these tests are staging and grading of the cancer.
Staging is the extent of the cancer in your prostate
gland or body.
Stage A or T1: Cancer that is usually not felt by exam, may
or may not have an elevated PSA, or is discovered when tissue is
removed at surgery of the prostate.
Stage B or T2: A nodule felt at rectal exam, but with the
cancer still confined to the prostate gland. May of may not have
an elevated PSA.
Stage C or T3: The cancer has grown into nearby tissues of
the bladder or rectum.
Stage D or T4 or M1: The cancer has spread to some other part
of the body...in the case of cancer of the prostate, most often
bones or lymph nodes.
Grading is done by the Pathologist as he looks at the
cancer specimens under the microscope.
The Gleason's grading system is used by most Pathologist,
grading the cancer from 1-5. Grade 1, is the most favorable
cancer, Grade 5, is the most malignant.
The stage and grade of the cancer must be known in order to
discuss a treatment plan.
WHAT FACTORS DETERMINE A TREATMENT PLAN?
Age of the patient.
Health of the patient.
Stage of the cancer.
Grade of the cancer.
Bone scan, CT, MRI etc results.
Lymph node or bone marrow results.
Desires of the patient and his family.
USING THE ABOVE FACTORS, HOW DO WE START TREATMENT?
As a general rule, men 70 years of age or younger, in good
health, with low to medium grade cancer confined to the prostate
gland, are best treated with surgical removal of the prostate.
Now I quickly remind you that other factors play a part in the
decision, and each patient must be treated individually. A good
conversation between the patient and his family, and his
Urologist, is the best way to start to try to understand the
problem and what will be best for each person.
WHAT TREATMENT PLANS ARE AVAILABLE?
1. Close observation with treatment later when troublesome
2. Total surgical removal of the prostate and seminal
Laparoscopic Surgery with or without the Robot.
3. Radiation treatment:
Brachytherapy, (placement of internal seed).
External beam radiation.
4. Cryoablation of the prostate (freezing).
5. Hormone therapy.
WHAT CAN ONE EXPECT IF CLOSE OBSERVATION IS DONE?
This depends on the grade and stage of the cancer and the
general condition of the patient. Close observation is usually
recommended for patients who are elderly, in poor health and/or
the cancer poses no immediate problem. Said another way, this
type treatment may depend on the life expectancy of the patient.
If other health problems are more likely to cause problems
before the cancer of the prostate does, then, "no treatment
right now", may the best treatment for the cancer.
WHAT CAN ONE EXPECT WITH TOTAL REMOVAL OF THE PROSTATE GLAND
There are two methods of total prostate removal: 1, Radical
retropubic prostatectomy, and 2, Radical perineal prostatectomy.
In the retropubic type, a midline abdominal incision is made
below the naval. The lymph nodes can be examined through the
same incision. In the perineal type, separate incisions may be
done on the abdomen to take some lymph nodes for testing, and if
they are negative then the prostate is removed through an
incision between the scrotum and the rectum. In
Laparoscopic Surgery, healing time and hospital time will be
shortened. The Robot is being used by many medical centers
With the radical prostatectomy, by either method, there is a
large possibility that a man will lose his potency; not his sex
drive, but his ability to get an erection. There is a variation
on the operation which is called a "nerve sparring"
prostatectomy, after which a man may have his potency preserved
about 50% of the time.
I always tell my patients, that even if they lose potency
while we are curing the cancer with the necessary surgery, there
are several methods of regaining an erection.
After radical prostatectomy, there is also about a 2-3%
chance that one will have some trouble with urinary control. I
always tell my patients that 95% of them will have 95% control
within 3 months. There are exceptions to this guideline...some
dry in a week...others taking 4-6 months to gain complete
control. If one does not gain complete control, there are
medications which may help, collagen implants, microcarbon
implants and even a silicone sphincter implant available.
WHAT CAN ONE EXPECT IF X-RAY TREATMENT IS DONE?
External beam radiation therapy usually is given daily for
about 30-35 treatments. One may feel lousy and weak during the
treatment. If needles and radiation seed are used, you may have
an incision or in some centers, the needles and seed are placed
through the skin. At times a combination of seed and external
beam therapy is used.
There is less chance of impotency with radiation therapy, but
the long term effects of the radiation on the bladder and rectum
can be very annoying. A combination of surgery and radiation
therapy is sometimes necessary.
Radiation therapy is also useful in treating areas of spread,
particularly painful bone sites.
WHAT IS THE STATUS OF CRYOABLATION (FREEZING) OF THE PROSTATE
CANCER? (Also see the page on Cryoablation of the
About 25 years ago, some investigation was done on freezing
of prostate cancer. The results were unpredictable. With a newer
technique using Argon and ultrasound guided probes, freezing of
prostate cancer is once again being used. At this writing, 10
year data is available. Some recent
reports are very favorable and lead us to believe cryoablation
will be better than radiation. We are using the technique of
freezing twice with a thaw in between. The side effects of
freezing can be some degree of impotence, temporary numbness of
the penis, but only a small chance of incontinence, since the
new technique also includes placement of thermal probes to
monitor vital areas. The one good aspect of freezing is that it
only requires an overnight stay in the hospital and one can
return to work in a few days. As of July 1, 1999, insurance
companies and Medicare are paying for the treatment, since they
no longer consider it an investigational therapy. As of
July 1, 2001, Medicare will pay for Cryoablation of the Prostate
for salvage in radiation failure patients
IF NEEDED, HOW DOES ONE RECEIVE HORMONE THERAPY?
Since testosterone is the "gasoline that feeds the fire
of cancer of the prostate", there are several methods of
lowering or eliminating the hormone. 1, orchiectomy, (removal of
the testicles), 2, female hormones by either "shot" or
pill, 3, a new type hormone which stops the pituitary gland from
stimulating the testes, (Zolodex or Lupron), 4, antiandrogens,
medications which act against testosterone (Eulexin, Casodex, or
With any of the hormone treatments, one can experience hot
flashes, and some breast development. Also, with the hormone
therapy, sex drive and potency will disappear.
Hormones are occasionally used prior to surgery, x-ray
treatment, and cryoablation to "down-stage" the
WHEN IS CHEMOTHERAPY USED?
Chemotherapy is used when the hormone therapy seems to not be
working. Several different drugs have been used with varying
results, some very good and some not so good.
WHAT CHANCE OF CURE DOES ONE HAVE WITH CANCER OF THE
If one has low grade, low stage cancer of the prostate,
according to the latest results of several centers in the United
States, the following can be stated:
1. Surgery: A 93% 10 year disease specific survival.
2. Close observation: Usually recommended for patients who
are older or have other serious medical problems. A 70-75% 8-10
year survival. Bear in mind that left untreated, cancer of the
prostate will probably spread within 3-5 years. At that time
hormone therapy can put the cancer in remission for another 3-5
years. Most patients who select observation as their form of
treatment die with the cancer, not of it.
3. Radiation: External beam irradiation seems to give about a
60% 10 year, disease specific survival. This may have improved
with conformal treatment and with the "Cyberknife". The newer applications of using
Iodine-131 and Paladium-203 seeds into the prostate are showing
results of 73% to 83% 10 year survival without cancer.
4. Cryoablation (freezing) : The treatment results are being
followed very closely, but the most recent data indicates that
it will better than external beam radiation therapy alone and as
good as or better than the seed implantation, interpreted (82-85%)
10 year survival without recurrence).
WHAT SHOULD ONE DO WHEN HE IS TOLD HE HAS CANCER OF THE
Of course, consult with the Urologist who made the diagnosis.
In my opinion, one of the best things one can do is to get a
second opinion. This second opinion may be the best time and
money you will every spend. Nothing may change in your mind
about the proposed treatment, but you will at least be exposed
to a second approach and to a second personality.
Dr. Derrick is a Board Certified Urologist and a Fellow of
The American of Surgeons with many years experience treating
cancer of the prostate and other diseases of the male
reproductive and urinary systems. He is Clinical Professor of
Urology at The Medical University of South Carolina with a
private practice in Charleston, South Carolina. He was formerly
Professor and Chairman of Urology at George Washington
University in Washington, D. C.
Original: August 1993
Revised: March 14, 2008