PROSTATE CANCER (An Overview)
Courtesy Salt Lake Research Clinic, Salt Lake City LIVING WELL Magazine
Prostate cancer is the most commonly diagnosed malignancy in men. One in six will be diagnosed with this disease at some point during their lifetime. The important issues regarding prostate cancer that will be discussed in this article are risk factors, detection, stage and grade of the tumor, treatment options (and their potential adverse side effects) and screening programs.
Men who have a family history of a close relation (father, grandfather, paternal uncle, or brother) who has been diagnosed with prostate cancer are of greater risk to develop this disease, especially if the relative was diagnosed before the age of 60. Black males have, for as yet unknown reasons, a significantly higher risk than white men. Asian men have the lowest risk of all racial categories. The importance of these data is that testing for prostate cancer should be done earlier in the high risk groups. Ordinarily, testing for prostate cancer begins at age 50. In high risk males, it was my practice to begin testing in the form of PSA blood test and digital rectal exam (DRE) at age 40.
When I started my Urology training in the mid-1970s, 30-40% of men had metastatic disease at the time of diagnosis. That means that percentage had no hope of being cured and most of them died of their disease. With current testing methods the vast majority of newly diagnosed have organ confined disease, i.e., no evidence of cancer cells outside the prostate. The actual diagnosis is almost always made by performing a needle biopsy of the prostate. This is an office procedure done under local anesthesia. The biopsy is performed by way of an ultrasound probe that has been passed through the anal opening into the rectum. The needle is directed through a notch on the side of the probe through the rectal wall into the tissue of the prostate. Six to 12 biopsy core will be obtained in this manner from various regions within the prostate. The indication for the biopsy will usually be an abnormal rise in the PSA levels and/or abnormality on the DRE.
STAGE AND GRADE OF TUMOR
Two of the most important factors with regard to treatment options are the stage and grade of the tumor. The stage of any tumor simply describes the degree of progression. Low grade tumors are those involving a small portion of the prostate. Larger or multifocal lesions would be staged at a higher level (especially if both lobes of the prostate show cancer cells). If extension of the tumor to adjacent structures such as the rectum or the pelvic wall is indicated by DRE or ultrasound findings, then a still higher stage has been reached. The highest stage describes cancers that have spread throughout the body. Grading of a tumor is based on the microscopic examination of the tumor cells by a pathologist. Some cells may have certain characteristics that suggest a more malignant tumor and a much higher likelihood of spread. High grade tumors are dangerous and often treated more aggressively.
After a complete clinical evaluation and the results of the prostate biopsy are available, it is time for a thoughtful assessment of the data. Patients with relatively low grade/stage cancers, especially those who are older than 70 or in poor health would certainly strongly consider a course of “watchful waiting.” Since these tumors are often slow to progress, many of these patients will “outlive” their cancer and will ultimately die from causes unrelated to prostate disease. These patients, however, need to commit to a regimen of frequent laboratory and physical evaluations lest their tumors progress to the point where treatment becomes advisable. For those younger patients and those with aggressive tumors, more definitive therapy might be warranted. Detailed descriptions of all the therapeutic options are beyond the scope of this article. The most common therapies offered to those patients where intervention is deemed necessary are radical prostatectomy (surgical removal of the prostate gland) or radiation therapy administered via external beam or radioactive seeds placed within the prostatic tissue. Much is being done in the field of research with the advancement of new technologies, such as cryotherapy and high intensity focused ultrasound (HIFU). The critical issue in this therapeutic option decision-making process is that the patient be fully informed and an active participant.
There has been much controversy regarding large scale prostate cancer screening programs in recent months. It is uncertain whether these screening efforts benefit prostate cancer victims in terms of longer survival or better quality of life. After spending most of my adult life treating prostate cancer, I choose to check my PSA level and undergo a DRE on an annual basis. What I do with that information is based on all the factors presented in this article. Other patients, having been counseled concerning the pros and cons of screening, may choose a different course and I feel they have every right to do so.
Dr. Richardson is currently conducting clinical trials involving new medication regimens and noninvasive surgical techniques at Salt Lake Research Clinic and can be reached at 801-288-9778 or fax at 801-288-9778.