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Doctors review images of a prostate with cancer. Options other than radiation, chemotherapy or surgery exist - here are some questions to ask while considering the best approach to treatment.
This week, Governor Jerry Brown made headlines with the announcement that he is undergoing radiation treatment for “localized” prostate cancer.
The federal Centers for Disease Control and Prevention reports that prostate cancer is the most common cancer found in American men of all races.
Even so, there's a lot of confusion about biopsies and treatment options. So we spoke with Stuart Holden, M.D., director of Louis Warschaw Prostate Cancer Center at Cedars-Sinai Medical Center in Los Angeles and Mark S. Litwin, MD Chair of the Department of Urology at UCLA and compiled answers to these 18 Frequently Asked Questions about prostate cancer.
1. What is prostate cancer?
It’s a disease of the prostate gland of the male reproductive system.
The American Cancer Society has an in-depth overview here.
2. What is the prostate gland and what function does it play?
The prostate is a walnut-sized gland that’s located inside a man’s body between his bladder and rectum. The prostate gland contains cells that make some of the seminal fluid that nourishes and carries sperm. The urethra – the tube that carries urine - runs through the gland’s center. That's why changes in a man’s urinary or sexual function might indicate prostate cancer.
3. Does a diagnosis of prostate cancer mean an automatic death sentence?
Not at all. Most prostate cancer is slow growing, so those afflicted with it are often more likely to die from old age or from other causes of death than from prostate cancer.
4. How common is prostate cancer in the United States?
Very common. Nationwide, prostate cancer is the most common cancer among men of all races, according to the federal Centers for Disease Control and Prevention. (CDC)
It’s estimated that 30 percent of American men ages 50 and older - or about 10 million men - have prostate cancer, says Dr. Holden.
But most men with prostate cancer are unaware they have it. That's because the vast majority of cases are "slow-growing pussy cats that men die with, not of," says Dr. Litwin.
5. How many U.S. men die each year of prostate cancer?
The disease ranks second to lung cancer as the leading cause of cancer deaths among men in the U.S., the CDC reports.
While that sounds ominous, the CDC puts the actual number of U.S. deaths from prostate cancer at about 28,000 a year. Drs. Holden and Litwin say when compared to the millions who are believed to be living with the disease, the death rate is proportionately very small.
“The risk of death from prostate cancer for the average Joe is extraordinarily low,” Dr. Litwin says.
6. What are some typical symptoms?
They include blood in a man’s urine or semen; problems with urinary function including weak urine flow; and difficulty with starting or holding back urination.
The cancer can also show symptoms through problems with sexual function that include difficulty getting an erection and painful ejaculation.
But for most men, prostate cancer is a silent disease. The most typical indicators include abnormal readings on PSA blood tests, which measure the protein produced by the prostate gland.
Another way doctors detect prostate cancer is by feeling a nodule or lump in the prostate during a digital rectal exam.
The Prostate Cancer Foundation provides an overview of symptoms.
7. Does a high PSA blood test or lump on my prostate mean I have prostate cancer?
No. All it means is that there is a suspicion of prostate cancer. A biopsy is required before you can determine that cancer is present.
The CDC offers this information about PSA tests.
8. Should I get a biopsy if I have an abnormal PSA reading or a lump in my prostate?
That depends. Until recently, the automatic next step was for your doctor to order a biopsy.
These days, however, leaders in the field are opting to first consider a patient’s age and health before ordering a biopsy. If the patient is too elderly or too sick with other illnesses for a prostate diagnosis to add value to his life, it’s more likely his doctor will to forego a biopsy.
If you don't fall into those categories, a biopsy is the recommended next step.
9. What happens during a prostate cancer biopsy?
The doctor places an ultrasound probe into the rectum, which provides an image of the prostate. Local anesthesia is injected. Then a hollow-bore needle is inserted, usually through the rectum wall, into the prostate gland.
Typically, about a dozen samples of tissue - about the size of a one-inch length of lead from a mechanical pencil - are taken from the prostate.
“Those samples go to the pathologist who studies them under a microscope and tells us if it’s cancer or a benign growth,” Dr. Litwin says.
10. Do biopsies pose any health risks?
They can. Among the risks is blood infection because the needle must pass through the rectum.
“The rectum is not the most sterile area of the body,” says Dr. Litwin. “For that reason we always give people antibiotics around the time of the biopsy.”
But Drs. Litwin and Holden say the risk of blood infections is minimal.
11. What if my biopsy results in a cancer diagnosis?
Your doctor will next consider stage and grade of the tumor.
The stage of a prostate tumor refers to whether it’s confined to the prostate or has spread to other sites in the body. The confined variety of prostate cancer, also known as “localized” or “early-stage” prostate cancer, is the type that Governor Jerry Brown’s office has reported.
The grade or severity of the cancer is then measured on a 10-point scale that provides a ranking known as a “Gleason’s score.” The higher the Gleason’s score, the more severe the cancer.
12. Do the stage and grade of a prostate tumor affect treatment decisions?
Yes. They have huge implications on decisions that a patient and doctor will make together regarding which treatment method is best.
13. What are the treatment options?
There are three main options: active surveillance, surgery, and radiation.
14. What is “active surveillance” and what does it entail?
This treatment option involves the patient foregoing – at least initially - surgery or radiation for “active” surveillance of the tumor. This is a fairly new treatment approach recommended for those with slow-growing tumors as a way to avoid surgery and radiation.
Dr. Holden says those who opt for “active surveillance” will undergo regular PSA blood tests, digital rectal exams and repeated biopsies.
Those diagnosed with prostate cancer can now sign onto the world's first online medical data base for men with the disease. The interactive data base allows them to track progression of the disease before seeking aggressive treatments.
15. What does prostate cancer surgery involve?
Today, prostate surgery typically involves removal of the entire prostate gland. But new imaging methods under study at UCLA might change that.
The new technology combines ultrasound and MRI imaging that researchers say may allow doctors to see, then target suspicious growths on a patient’s prostate gland for more accurate biopsies. By contrast, in prostate biopsies doctors can’t see the tumor.
The American Cancer Society offers more information.
16. What does radiation treatment involve?
Dr. Holden says doctors often recommend external beam radiation for early-stage, localized prostate cancer. The treatments usually last between six to seven weeks, which each treatment session lasting about five minutes.
“Basically, it’s completely external and like having your picture taken,” says Dr. Holden.
Advances in radiation treatment, which allows for focused beams to target the just the prostate, reduce the risks and have made it more effective.
The American Cancer Society offers more about radiation treatment for prostate cancer.
17. What are the potential side effects of surgery or radiation treatment?
Surgery and radiation pose serious side effects, most notably incontinence and impotence. An individual’s likelihood of suffering either or both depends on age, health and existing sexual functionality before surgery.
Dr. Holden says the incidence of sexual dysfunction is about equal with both treatments. “Roughly 50 percent of men with either treatment retain sexual function, assuming they had good sexual function to begin with,” he says.
Surgery, by contrast, initially poses more urinary tract problems than radiation, he says. “However, some of the men develop more urinary dysfunction eight or 10 years after radiation treatment,”Dr. Holden says. “So over the long run, radiation catches up.”
18. What’s new in prostate cancer research?
The Prostate Cancer Foundation offers a list of advances in prostate cancer research.