Prostate Cancer: Diagnosis, Treatment, and How to Prevent It

A diagnosis of prostate cancer can be daunting, and you may wonder what is next once you have been given the grim news.

Here is the rundown on diagnosing, staging and treating the disease.

What is prostate cancer?

Prostate cancer is a form of cancer that begins in the gland cells of the prostate. The prostate, which sits under the bladder, is a walnut-sized gland that helps in fertilization and carries semen that nourishes and transports sperm.

Age is the biggest risk factor in developing prostate cancer. The risk increases with age, and peaks around age 68.

Prostate cancer diagnosis

Prostate cancer is the No. 1 cancer found in men and is the second-leading cause of cancer-related death in men. It is important to get screened early, even if you are not experiencing symptoms. Screenings typically happen during a visit with your primary care physician.

If you’re at average risk, you’re encouraged to start screenings at age 55. Black men are encouraged to start screenings at age 45 because they are at a higher risk of getting the disease and have a two times higher mortality rate.

The types of tests used to diagnosis prostate cancer may include:

• Blood tests. The PSA blood test measures a protein in the blood called the prostate-specific antigen (PSA). Only the prostate and prostate cancers make PSA. A high PSA may signal that something is wrong, and a doctor may request more tests, including a digital rectal exam.
• Digital rectal exam (DRE). During this physical exam, a doctor will put a lubricated gloved finger into the rectum and feel for an abnormal shape, consistency or thickness of the prostate. A digital rectal exam is often used in conjunction with a PSA blood test. Together, the tests may help find prostate cancer early.
• Biopsy. If a patient is confirmed to have a repeated high PSA, they may be referred to a urologist for a biopsy. During a biopsy, a needle is inserted into the prostate to collect tissue. The tissue is then analyzed in a lab to determine whether cancer cells are present.
• MRI/ultrasound fusion biopsy. This test combines an MRI scan with an ultrasound image to help urologists target the area of the prostate that needs to be biopsied and guide the needle to the precise spot. These types of biopsies help target the tumors that need treatment, reduce the number of repeat biopsies and allow for earlier diagnosis and treatment.

Prostate cancer treatments

To determine treatment options, doctors need to establish whether the cancerous cells have spread in the prostate or beyond.

In localized prostate cancer, the cancer has not spread outside the prostate. In locally advanced prostate cancer, the cancer has spread to nearby organs outside the prostate. Risk groups — based on PSA, DRE and biopsy results — are assigned before the patient undergoes any treatment and are important factors in determining prognosis, risk and treatment options.

• Low-risk group. The tumor is confined to the prostate, and the PSA is less than 10. There is also a subset called very low risk in which fewer than 3 biopsy tissue samples contain cancer cells and the cancer was not detectable during a digital rectal exam.
• Intermediate-risk group. The tumor is confined to the prostate, and the PSA is between 10 and 20.
• High-risk group. The tumor is outside the prostate and the PSA is greater than 20. There is also a subset called very high risk in which the tumor has extended into the seminal vesicles or the rectum or bladder.

Below are the major treatment options for patients with prostate cancer:

• Active surveillance. An option for men who have a low risk of prostate cancer. During active surveillance, men receive repeat MRIs and biopsies over time, to monitor PSA levels.
• Radical prostatectomy surgery. This is for patients whose tumor is only in the prostate, and it is an option for all risk groups. During this procedure, the prostate, surrounding tissue and seminal vesicles are removed. The main types of radical prostatectomy include:
• Open radical prostatectomy: A cut is made in the lower abdomen or the area between the anus and scrotum. Surgery is performed through the incision.
• Radical laparoscopic prostatectomy: Several small cuts are made in the wall of the abdomen. A laparoscope, which is a thin, lighted tube that has a video camera, is inserted through a cut to guide the surgery.
• Robot-assisted laparoscopic radical prostatectomy: Several small cuts are made in the wall of the abdomen. The surgeon then uses robotic arms to insert a tool with a camera through one opening and surgical instruments through another opening. The camera gives the surgeon a 3D view of the prostate and allows them to complete the surgery using the robotic arms and a computer monitor near the operating table.
• Radiation therapy. A cancer treatment that uses high-energy X-rays and other forms of radiation to keep cancer cells from growing or to destroy them. This is an option for all risk groups. The different types of radiation therapy include:
• External radiation therapy. This occurs when a machine outside the body sends radiation toward the area of the body with cancer.
• Conformal radiation. A therapy that uses a computer to take a 3D picture of the tumor and alters the radiation beams to fit the tumor. This allows a high dose of radiation to reach the tumor while causing less damage to healthy tissue.
• Intensity-modulated radiation therapy (IMRT). This is the most common type of external beam radiation therapy for prostate cancer. A computer-driven machine moves around the patient to deliver radiation. The intensity of the beams can be adjusted to allow doctors to deliver an even higher radiation dose to the cancer while limiting the doses of radiation reaching nearby healthy tissue.
• Image-guided radiation therapy (IGRT). The scanner allows the doctor to take pictures of the prostate before giving the radiation, to make aiming adjustments.
• Proton beam radiation therapy. This therapy focuses beams of protons on the cancer instead of X-rays. Unlike X-rays, which release energy before and after they hit their target, protons release energy after traveling a certain distance and cause minimal damage to tissue they pass through.
• Internal radiation therapy (brachytherapy). Brachytherapy places small radioactive pellets or seeds directly into the prostate. This therapy is generally only used in men with early-stage prostate cancer that is slow-growing.
• Hormone therapy. This treatment uses surgery or drugs to stop testosterone from being made or from reaching prostate cancer cells. Testosterone fuels the growth of prostate cancer cells. Hormone therapy is often given with radiation if a patient has intermediate or high-risk prostate cancer. The duration depends on risk group. If someone has an intermediate risk, its four to six months, while high-risk patients will receive hormone treatment for 18 to 36 months.
  • Orchiectomy (surgical castration). During this procedure, the surgeon removes the testicles, which is where most of the androgens (testosterone and DHT) are made. This causes most prostate cancers to stop growing or shrink for a period of time.
  • Luteinizing hormone-releasing hormone (LHRH) agonists. These drugs are injected under the skin to lower the amount of testosterone made by the testicles. The testicles stay in place but will shrink over time. Treatment with these drugs can be considered a form of medical castration.
  • Luteinizing hormone-releasing hormone antagonists. LHRH antagonists can be used to treat advanced prostate cancer. These drugs lower testosterone levels more quickly and don’t cause tumor flare like the LHRH agonists do. Treatment with these drugs can also be considered a form of medical castration.

Prostate cancer prevention

As we tell our patients at Duke Cancer Center, there are ways to lower your risk for prostate cancer. They include:

• Early screenings
• Eat a healthy diet (increase fish, tomato and cruciferous vegetable intake, reduce red meat intake)
• Maintain a healthy weight
• Exercise regularly
• Do not smoke
• Avoid toxins
• Be aware of genetic risk factors and family history