Prostate Cancer Treatment

What is prostate cancer?

Prostate cancer (PC) is a cancer of prostate gland, which is situated at the mouth of the bladder. Its function is to provide nutrition in semen to sperms and also one protein called Prostate Specific Antigen (PSA), which helps in liquefying the semen for better mobility of sperms.

What is the risk of having this cancer in me?

Although the lifetime risk of having microscopic prostate cancer for a man of 50 years is 42%, the risk of his dying of prostate cancer is about 3%. In North America, about 100 men in 1 lakh of population would suffer from prostate cancer and this number is 5 /100000 in Asia. Though the risk is less but due to sheer population of India, we do see many cases in the age group of 55 to 70 years.

What are the symptoms?

Prostate cancer in itself would not cause symptoms to begin with but in advanced stage, it may lead to obstruction in passage of urine or blood in urine. Symptoms are invariably caused by benign prostate enlargement ( BPH).

What does cause cancer in prostate?

Like any other cancers, there is no proven cause for cancer, but there are reasons for increasing the risk of having it. One may follow measures given below to reduce the risk of developing prostate cancer.
1. Regular exercise
2. Regular sex
3. Avoiding excess consumption of red meat
4. Stop smoking and tobacco chewing
5. Maintain a healthy weight and avoid a pot belly

What should I do to diagnose this cancer early?

To detect any cancer at its early stage, one should have screening test to pick it before it starts producing symptoms. For prostate cancer there are no symptoms to begin with, therefore screening with PSA test is recommended. In the united states and other countries, men between the age of 55 to 70 years are advised to have their PSA testing done in consultation with the Urologist and if they have any male members in the house who has suffered from prostate cancer then PSA testing is done even at the age of 45 years.
In India, we do opportunistic screening only i.e. men coming to see Urologist for urinary symptoms or men having executive health check are advised to have PSA tested after a consultation.

What is PSA screening?

Since the introduction of the PSA test in 1986, screening to detect prostate cancer at the early stage has been a norm in the USA and other western countries. This led to detection of prostate cancer As of now, almost 95% of the prostate cancers in North America are detected at the early stage. Prostate cancer is globally the most common cancer after skin cancer and second leading cause of cancer related death in men.
As in India, we don’t screen asymptomatic men, we detect prostate cancer at advanced stage in more than 50-60% time. There has been increase in number of prostate cancers being detected at early stage due to Executive health check up and availability of robots across India.

What are the tests to confirm the diagnosis?

Rectal examination: done by your primary physician or Urologist to feel the prostate for any hardness or nodule. Urologist will pass a finger through the anus into the rectum and feel for the prostate.

Blood PSA:

PSA (prostate specific antigen), which is tested in the blood is a useful marker to detect this cancer at the early stage. Most of the labs are doing free PSA, which has a very limited role to play and rather add to the unnecessary cost to the patients. (Agnihotri S et al. Indian J Med Res. 2014 Jun; 139(6):851-6)

Though the threshold level of PSA for biopsy in asymptomatic men has been 4 ng/ml, based on data from India, we have raised this threshold to 5.4 ng in symptomatic men with normal rectal examination. (Agnihotri S et al Indian J Med Res. 2014 Jun; 139(6):851-6)

PSA is a very nonspecific marker and its high value does not always mean presence of prostate cancer. One should not jump the gun and start worrying if they find their PSA levels to be more than 4ng. High PSA could be due to BPH (benign prostatic hyperplasia), infection in the prostate and Ejaculation by Sexual activity or masturbation could also lead to rise in PSA. So, one should try to pay attention to these factors before they get their PSA test done.

MRI of prostate:

This should be done as a part of diagnostic work up, whenever there is rise in PSA and abnormal rectal examination after consultation with your Urologist. Main purpose of this test is to identify the extension of the disease beyond the prostate and to look for lymph nodes. New parameter described to categorize the abnormal lesions in the prostate by scoring them from 1 to 5, which is called PIRAD scoring, may help in taking decision on delaying the biopsy. MRI could be biometric or multiparametric and one should leave this to the Urologist to decide. MRI should preferably be done before the biopsy or if biopsy has been done then preferably 6-8 weeks after the biopsy.

What is prostate biopsy?

This is done with an instrument passed thought the anus to your rectum under local anesthesia. With the help of a Gun and a needle, small pieces (10-12 in number) of prostate from suspicious areas are removed and send to pathologist.

This procedure is little uncomfortable and sometimes leads to pain and blood in urine for few days. You should have a clean rectum before going in for biopsy. Urologist will give you a course of antibiotics.

What are the stages of the cancer?

There are 3 ways prostate cancer can be staged.

Group 1: Localized prostate cancer: Localized to the prostate gland and treatment is with a curative intention i.e. to get rid of the cancer from the body entirely.

Group 2: Locally advanced prostate cancer: This may need an additional form of therapy in terms of Hormonal or Radiation therapy along with surgery.

Group 3: Metastatic prostate cancer: Here disease is beyond cure that means one has to live with the cancer, which could be controlled for years together with the help of Hormonal treatment and chemotherapy.

What are the treatment options?

For Group 1 Radical prostatectomy (Robotic/laparoscopy/open) or Radical Radiotherapy. Both the options have their pros and cons and Surgery is always preferred if patients have obstructive symptoms.
For Group 2 Radical prostatectomy (Robotic/laparoscopy/open) or Radical Radiotherapy along with Hormonal treatment.
For Group 3 Hormonal and or chemotherapy.

What about Robot assisted Radical prostatectomy?

If cost is not a factor, then robotic surgery is the best way to remove the entire prostate harboring cancer. Again, the role of a surgeon sitting on the robot is important than the robot itself. Robot is just a tool to help surgeon perform a better surgery ( please read the section on robotic surgery) Open surgery is also safe and effective way to remove the prostate, except that it has little longer hospital stay by 2 days and has little more blood loss in comparison to robotic surgery.

What are the problems I may have after the surgery?

Surgical removal of the prostate comes with 2 likely complications.

Sexual impotence: There could a possibility that you may lose your potency (ability to have an erect penis to perform sexual act). Impotency depends on the stage of the disease. In localized prostate cancer if a man is potent before surgery then he may have 60% chance that he will regain his potency at one year.
There are ways and means to regain potency after one year depending upon the status of the cancer. Unfortunately even if you regain your potency, you may not ejaculate (there will not be any semen discharge through urethra at orgasm, which is called dry orgasm).

Urinary Incontinence: There is a stop valve (called sphincter in medical parlance), which prevents spontaneous and involuntary passage of urine (incontinence). As prostate sits on this stop valve, surgical removal of the prostate may weaken this and results in urine leak. This leak may be there initially and 90% would be continent by 3 months and only 1-3% may leak urine even after one year.

For those patients there are mechanisms, unfortunately surgical only to control the leak.

Is there any role of endoscopic or laser surgery?

These surgeries are mostly done to treat benign prostate hyperplasia ( BPH). This can still be done in prostate cancer patient, when he has metastatic disease and has obstructive urinary symptoms i.e. difficulty in passing urine or blood in urine etc. In that case we need to do channeling through the prostate to create a passage by using the endoscope and laser or electric energy.

What is the best option for patients in group 3 (metastatic cancer)?

The standard of care treatment for metastatic prostate cancer is Androgen Deprivation Therapy (ADT), where in we eliminate the production of testosterone hormone, which is the main fuel for prostate cancer cells to grow. More than 95% of patients get good response to this treatment and their PSA comes back to near normal. Unfortunately this response is short lived and despite low levels of testosterone, prostate cancer cells find alternative ways to get food and start growing again. We then call it castrate resistant prostate cancer (CRPC).

What is the treatment for CRPC?

Newer drugs you should discuss with your Urologist are Abiraterone, Docetaxel, Enzalutamide, Denosumab, and Immunotherapy etc., which could be used either alone or in combination to give you extra months of life and quality too.

Research publication on prostate cancer

NMR spectroscopy of filtered serum of prostate cancer: A new frontier in metabolomics.
Kumar D, Gupta A, Mandhani A, Sankhwar SN.
Prostate. 2016 May 16. doi: 10.1002/pros.23198

Functional genetic variability at promoters of pro-(IL-18) and anti-(IL-10) inflammatory affects their mRNA expression and survival in prostate carcinoma patients: Five year follow-up study.
Dwivedi S, Goel A, Mandhani A, Khattri S, Sharma P, Misra S, Pant KK.
Prostate. 2015 Nov;75(15):1737-46. doi: 10.1002/pros.23055. Epub 2015 Aug 17.