Contents
About prostate cancer
Prostate Cancer represents a significant
problem in men’s health. It is estimated that 1
in 6 men will be diagnosed with prostate cancer
at some point in their lives. Prostate Cancer is
the leading cancer in males and more than 4000
men are diagnosed yearly with prostate cancer in
South Africa. One of the contributing factors to
these alarming figures is that many men are
unaware of the risks they face with regards to
this disease and that many are currently
diagnosed with advanced stages of the disease.
These realities and statistics are directly
related to awareness and education programs
available to the public at large.
The newly
formed non-profit Section 21 Prostate Cancer
Foundation of South Africa is dedicated to the
fight against prostate cancer and to the
promotion of prostate health and prostate cancer
awareness concentrating on the following focus
areas.
- To promote awareness of prostate cancer
by raising community awareness of the
disease resulting in the early detection and
more effective treatment
- To promote the continuing education of
health care professionals about prostate
cancer
- To assist in the formation of prostate
cancer support & advocacy groups by
providing information, support and
counseling to those affected by prostate
cancer
- To facilitate and enhance & support
prostate cancer research dedicated to
improving treatment and to finding a cure
for prostate cancer
It is the intention to reach out and to
attract corporate business, the pharmaceutical
industry, interested urologists, oncologists,
radiotherapists, allied medical associations as
well as prominent figures in the community to be
part of the foundation in varying capacities.
This will ensure both intellectual and financial
support from a diverse population to further the
aims and ideals of the Prostate Foundation.
These aims and objectives would be
achieved by the facilitation and co-operation
amongst all stakeholders be they medical
fraternity, corporate business or the general
public.
What is the prostate?
The
prostate is a gland which forms part of the male
reproductive system and when healthy is about
the size and shape of a walnut. It is found
between the pubic bone and rectum and surrounds
the upper part of the urethra (the tube that
carries urine out of the bladder). The prostate
produces part of the seminal fluid which helps
transport sperm out of the man's body during
orgasm ejaculation.
Men over the age of
50 should go for an annual prostate check-up.
Men with a family history of prostate cancer
should go for an annual checkup from the age of
40.
Growth of the prostate
Male hormones (androgens) make the prostate
grow. At birth the prostate is normally the size
of a pea and at puberty it grows to its adult
size which is about the size of a walnut.
When men reach their 40's to 50's the prostate
gland can begin to grow under the influence of
testosterone. If the prostate grows too large,
it squeezes the urethra. This may slow or stop
the outflow of urine from the bladder.
The symptoms of prostate problems such as BPH
are similar to those of prostate cancer.
Benign Prostatic Hyperplasia (BPH)
An
abnormal increase in the numbers of
non-cancerous cells in the central part of the
prostate
OR
Benign Prostatic
Hypertrophy (BPH)
An abnormal increase in
the size of non-cancerous cells in the central
part of the prostate
Understanding prostate
cancer
Understanding cancer
Cancer
begins in the body’s cells which are the
building bocks that make up our tissues. Our
tissues make up the organs of our bodies.
Under normal circumstances, cells grow and
divide to create new cells as the body needs
them. When the cells grow old, these old cells
die. New ones then take their place.
At times this process is upset and for
some reason extra cells are created to form a
mass of tissue or a tumour.
Tumours can
be benign (non-cancerous) or malignant
(cancerous).
What is prostate cancer?
Prostate cancer is a disease in which cancer
develops in the tissues of the prostate gland.
The cancer occurs when cells of the prostate
begin to multiply out of control. These cells
may spread, which in medical terms is known as
metastasis.
Metastasis means that the
cells spread from the prostate to other parts of
the body, especially the lymph nodes and the
bones. Even when the disease has spread to other
parts of the body, it is still known and treated
as prostate cancer, as that is the primary
source of the cancer. Doctors also call the new
or metastasized tumor, "distant" disease.
Prostate cancer is a slow growing cancer
compared with other cancers.
Incidence and epidemiology of prostate cancer
In medical terms "incidence" refers to the
frequency with which a disease appears in a
particular population or area. Epidemiology
deals with the study of the causes,
distribution, and control of disease in
populations.
Populations
In the USA it is estimated that one in six men
will be diagnosed with prostate cancer during
their lifetime. It is the most commonly
diagnosed solid organ cancer in South African
men. According to the South African National
Cancer Registry (1999), the incidence of
prostate cancer in South Africa is increasing at
approximately 3% every year.
Rates of
prostate cancer vary widely across the world. It
is least common in parts of Asia, more common in
Europe, and most common in the United States.
Incidence
Prostate cancer is rare
in men under the age of 40. After the age of 50
the incidence rises steeply, and by the age of
80 almost 80% of men will have prostate cancer,
even if it is only a small focus of cancer cells
in some. Generally the peak age incidence is
around 65, however this also depends on the life
expectancy, which varies among race groups.
Rates of prostate cancer vary widely across the
world. It is least common in parts of Asia, more
common in Europe, and most common in the United
States. A non smoking man is more likely to
develop prostate cancer than colon, bladder,
melanoma, lymphoma and kidney cancer combined.
Men are 35% more likely to be diagnosed with
prostate cancer than women are to be diagnosed
with breast cancer
While one man in six
may develop prostate cancer during his lifetime,
only one man in 34 will die of this disease.
This is because prostate cancer is not as
aggressive as other cancers, and because it
occurs most often in elderly men who may have
other diseases that are more likely to cause
their death.
Risk factors
The
cause of prostate cancer, as in most cancers in
general, is not entirely known. There are
however, some risk factors that can be taken
into consideration which are thought to increase
the chances of developing prostate cancer.
Studies have identified the following areas as
risk factors:
Age:
The older
you are, the more likely you are to be diagnosed
with prostate cancer. The disease is less common
in men younger than 40 years of age. If you are
50 or older your risk increases.
Race:
There are racial differences across the globe
which could be due to social and geographical
influences. The lowest incidence rates are seen
in Asia, Africa, Central and South America. In
the USA, prostate cancer is twice as common
among African-American men as among white men.
The apparently lower incidence rates in Africa
are most probably due to the disease not being
diagnosed or reported. In South Africa, prostate
cancer appears to be equally common in men of
all race groups.
Diet: Studies
have shown that certain foods may protect
against prostate cancer, including tomatoes
which contain lycopene. Vitamin E, selenium, soy
and Omega-6 fatty acids are also thought to have
benefits. Dietary factors which may increase the
risk of prostate cancer include saturated fat
and red or grilled meat.
Family
history:
A man’s risk is higher if a
family member such as a father or brother has
had prostate cancer. Studies show that men with
a family history of prostate cancer are likely
to present with the cancer six to seven years
earlier than patients without a family history.
Men with single first degree relatives
i.e. a father, brother or son, with a history of
prostate cancer are twice as likely to develop
the disease, while those with two or more
relatives have a nearly four times greater
chance of being diagnosed. The risk is increased
further if the family member is diagnosed before
the age of 65.
Lifestyle:
Doctors suggest that maintaining a healthy
weight and participating in regular physical
activity reduces the risk of developing prostate
cancer.
Symptoms
It is
important to remember that many symptoms listed
here may not necessarily mean you have prostate
cancer. They could be due to Benign Prostatic
Hyperplasia (BPH), an infection known as
prostatitis, or other health problems. However,
it is also important to know that, in its early
stages, prostate cancer usually does not cause
any symptoms at all. Consult a doctor as soon as
possible and do not wait for the onset of
symptoms.
When symptoms of Benign
Prostatic Hyperplasia or malignant prostate
cancer occur, they may include:
- A need to urinate frequently, especially
at night.
- Difficulty in starting to urinate or
holding back urine.
- Inability to urinate.
- Weak or interrupted flow of urine.
- Painful or burning urination.
- Painful ejaculation.
- Blood in urine or semen.
- Frequent pain in the lower back.
What causes these symptoms?
These
symptoms are usually caused because the tumour
is blocking the flow of urine or pressing on the
urethra.
Diagnosis and
screening
Thoughts of a cancer diagnosis can be
quite stressful. Fear of the unknown can add to
this stress. You will feel more at ease about
your doctor’s appointment and what to expect by
educating yourself about the various tests
available to screen for prostate cancer.
An initial prostate examination will
most likely begin with your doctor asking about
your personal and medical history, followed by a
physical examination and blood tests which may
include:
- Digital rectal exam (DRE)
- Urine test to check for blood/infection
- Blood tests
DRE
The doctor inserts a gloved,
lubricated finger into the rectum and feels the
prostate through the rectal wall to check for
hard or lumpy areas.
PSA Blood test
The PSA test
measures the blood level of prostate-specific
antigen (PSA), a protein produced by the
prostate and released in small amounts into the
blood. In normal circumstances, very little PSA
should be found in the blood. Rising levels of
PSA in the blood indicate a problem with the
prostate, which could be cancer but could also
be an enlarged prostate (BPH) or infection
(prostatitis).
If you have previously been diagnosed
and treated with prostate cancer your doctor
will monitor your PSA on a regular basis.
The PSA test together with a DRE is the best
option for early detection.
Additional PSA terminology your doctor may use:
- PSA density: determined by dividing the
PSA level by the size or volume of the
prostate.
- PSA doubling time: refers to the time
during which PSA measured in blood doubles.
- PSA velocity measures how quickly the
PSA level rises over a period of time.
If the PSA velocity is increased, it means there
is a higher risk of developing prostate cancer.
How good is the PSA blood test?
The PSA test indicates the risk that you may
have prostate cancer. This is helpful for your
doctor as it can guide him/her in their decision
about whether you should have further tests.
PAP
The PAP test measures the
Prostatic Acid Phosphatase (PAP) in the blood.
The PAP level usually rises only after the
cancer has metastasized (spread to other parts
of the body).
Other Tests
Transrectal ultrasound (TRUS)
In this
procedure, an ultrasound (sonar) probe is
inserted into the rectum to check for
abnormal areas. The probe sends out sound
waves at ultra-high frequency, hence the
name ultrasound. The waves bounce off the
prostate and the echoes are used to create a
picture called a sonogram.
- Cystoscopy
In this procedure a thin,
lighted tube is used to look into the
urethra and bladder.
- Transrectal biopsy
This test is
normally used to guide a prostate biopsy so
that a pathologist can examine the removed
cells or tissues to check for cancer cells.
It is the most accurate way to diagnose
prostate cancer. While the patient is
anaesthetized a needle is inserted through
the rectum into the prostate. A small tissue
sample is taken from many areas of the
prostate. Ultrasound may be used to guide
the needle.
Staging
Staging
is the process where doctors determine and
evaluate how far the cancer has spread. It is
important for your doctor to know the stage of
the cancer as it will assist in determining the
type of treatment you will receive. Doctors will
predominantly talk about your cancer in three
categories - localised, locally advanced or
metastatic. Generally speaking, there are four
stages of prostate cancer which fall into these
three categories.
Localised prostate
cancer
• Stage I:
The cancer is
in a very early stage and cannot be felt with a
digital rectal exam (DRE). The tumour is usually
found because of an elevated PSA level, or when
surgery is performed for a BPH diagnosis. The
cancer is only in the prostate.
• Stage
II:
The cancer can be felt during DRE and is more
advanced, but has not spread outside the
prostate.
Locally advanced prostate cancer
•
Stage III:
The cancer has spread outside the
prostate. It may be in the seminal vesicles. It
has not spread to the lymph nodes.
Metastatic prostate cancer
• Stage IV:
The cancer may have spread to nearby muscles and
organs and possibly to the lymph nodes. It may
have spread to other parts of the body such as
the bones.
• Recurrence
When treatment is finished and the cancer can no
longer be detected, the cancer could come back
or recur. This could happen in the prostate or
any other part of the body.
Grading
Grading measures how
abnormal the cancer cells appear when a biopsy
is looked at under the microscope. When your
biopsy is sent to a pathology laboratory, a
pathologist looks closely at the difference in
the definition or shape of the healthy cells
compared to the cancerous cells. The healthier
cells are well defined and fairly uniform in
shape while the cancer cells are more irregular
looking. A grade is given to these cells.
The grade indicates how quickly the cancer
can spread or metastasize. There are two grades
to consider, low-grade and high-grade.
- Low-grade cancer cells are only slightly
abnormal in appearance, and grow slowly.
- High-grade cells usually vary in size
and shape. Without treatment they spread
quickly.
Treatment
A
prostate cancer diagnosis may bring an onset of
fear, panic or distressing thoughts. However
since this is a slow growing cancer, there is no
need to rush into making quick decisions about
your treatment.
To ensure that you receive the most
effective treatment for your prostate cancer,
your doctor will take the stage and grade of the
cancer into consideration, along with your age
and other health factors. The more precise your
diagnosis the more specific your treatment will
be. Armed with this information, you and your
doctor can make the right decisions about your
treatment.
Prostate cancer will usually
follow the path of surgery, radiotherapy,
hormonal therapy and sometimes chemotherapy,
however each patient is different and your
doctor will determine what is best for you.
Watchful waiting
Watchful waiting means
that your doctor will not treat your disease
immediately. Instead, your condition will be
monitored by your doctor very closely through
regular DRE’s and PSA tests. Should your
symptoms increase or change your doctor may
decide that treatment is necessary.
This approach may seem inappropriate to many
prostate cancer patients and their families,
however it may be the best and most sensible
option, particularly if you are older or have
serious health problems. Watchful waiting can
also delay side effects from surgery or
radiation. Your doctor may also suggest watchful
waiting if you are diagnosed with an early stage
and slow growing prostate cancer.
Surgery
Surgery is the most common
treatment for prostate caner and can be used to
remove all or part of the prostate. Removal of
the prostate is known as a prostatectomy.
Surgery for early stage disease will usually
include a radical prostatectomy which involves
the surgical removal of the entire prostate
gland including some surrounding tissue. There
are a number of surgical and prostectomy
procedures for prostate cancer.
- Radical retropubic prostatectomy:
The removal of the entire prostate and
seminal vesicles through an incision, or cut
in the lower abdomen. Sometimes the nearby
lymph nodes are also removed (this is called
a pelvic lymph node dissection). After the
prostate has been removed, the urethra is
stitched directly to the bladder so urine is
able to flow.
- Radical perineal prostatectomy:
The removal of the entire prostate
through a cut in the perineum, or the space
between the scrotum and the anus. Nearby
lymph nodes may be removed through a
separate cut in the abdomen.
- Laparoscopic prostatectomy:
The removal of the entire prostate through
several (three to five) small incisions,
through which a thin, lighted tube (a
laparoscope) and other instruments are
placed to remove the prostate.
- Transurethral resection of the
prostate (TURP):
The doctor removes
the central part of the prostate with a
long, thin device that is inserted through
the bladder tube (urethra). The outside or
peripheral part of the prostate is not
removed. TURP may not remove all of the
cancer, which usually occurs in the outside
part of the prostate, but it can remove
tissue that blocks the flow of urine.
- Cryosurgery:
The prostate
cancer is placed under sub zero temperatures
(frozen) with probes inserted through the
perineum.
- Pelvic lymphadenectomy:
This
is sometimes done during prostatectomy. The
doctor removes lymph nodes in the pelvis to
see if cancer has spread to them. If there
are cancer cells in the lymph nodes, the
disease may have spread to other parts of
the body. In this case, the doctor may
suggest other types of treatment however
most patients selected for radical
prostatectomy these days have such a low
risk of pelvic metastases that lymph node
dissection can be omitted.
Radiation therapy
Radiation therapy,
also known as radiotherapy, is commonly used in
prostate cancer treatment and uses radiation to
kill the prostate cancer cells. Two different
kinds of radiation therapy are used in prostate
cancer treatment: radiation therapy and
brachytherapy.
- Radiation therapy (external
radiation)
This is a standard form of radiation therapy
that uses a machine to aim high-energy rays at
the cancer.
- Brachytherapy (internal radiation)
Brachytherapy for prostate cancer is given using
small radioactive rods called "seeds" implanted
directly into the tumour. Each "seed" is smaller
than a grain of rice and is precisely placed
into the prostate via needles that enter through
the skin behind the testicles. These "seeds" are
basically small amounts of radiation that affect
a small area of the prostate. Over a period of
months the "seeds" give off radiation to the
surrounding area which kills the prostate
cancer. By the end of one year, the radioactive
material degrades and the remaining radioactive
"seeds" become harmless. Hormonal therapy
The male hormones (androgens) stimulate the
normal prostate (and also prostate cancer) to
grow. The most abundant androgen is
testosterone. Stopping the production of
testosterone, or blocking its action on the
cells, prevents the cancer cells or tumour from
growing.
There are several types of
hormonal therapy:
- Antiandrogens
Antiandrogens
are drugs which block the action of
testosterone on the cancer cells by blocking
the hormone receptors.
- LH-RH Agonists
LH-RH stands
for luteinizing hormone-releasing hormone.
LR-RH agonists are drugs which stop the
testicles from producing testosterone.
- Orchiectomy
Testicles make
most of the body’s testosterone. An
orchiectomy is when surgery takes place to
remove the testicles in order for the
testosterone levels to drop.
PSA blood test during Hormone Therapy
If you are receiving hormone therapy for
prostate cancer your PSA levels should be low.
Your doctor will explain your PSA levels to you
and how your treatment can affect these levels.
Chemotherapy
Chemotherapy refers to drugs which can kill
cancer cells. It cannot be focused to any
particular area of the body and is primarily
used to treat prostate cancer when the disease
has become resistant to hormones. Prostate
cancer chemotherapy is almost always used for
advanced prostate cancer.
Chemotherapy in prostate cancer has advanced
greatly over the past three years with the
creation of new and more effective chemotherapy
drugs. In some men, the earlier use of
chemotherapy has been helpful in slowing the
advancement of the disease.
Talk to your doctor about chemotherapy
options which are best suited to your disease.
Palliative care
Palliative care or
treatment reduces the severity of cancer
symptoms or slows down the cancer’s progress.
This type of treatment is not aimed at cure but
rather at improving quality of life by reducing
pain and easing physical and psychological
problems. Palliative care also supports the
partners and family of patients.
Bisphosphonate treatment
Bone
disease
In advanced cancer, the disease often spreads to
the bones, causing bones to weaken.
Bisphosphonates can help reduce the risk of your
bones weakening and therefore reduce the risk of
fractures and other complications.
Bone pain Bisphosphonates can also assist in
reducing cancer related bone pain and reduce the
levels of calcium in your blood which can occur
when bones are damaged.
Talk to your doctor about a bisphosphonate
treatment that will help reduce your bone
complications from your prostate cancer and
allow you to get on with your normal activities
as much as possible.
Side Effects
Prostate cancer treatments have improved
greatly over the years and therefore side
effects have become less severe. You should
however educate yourself about the possible side
effects you may experience. Although you doctor
plans your treatment precisely and carefully, it
is extremely difficult to prevent side effects
with most treatments. All people respond
differently to treatment and therefore not every
man will experience the same side effects.
Side effects of Surgery
Impotence
The nerves that cause erection of the penis run
very close to the outside of the prostate.
Damage to these nerves during radical
prostatectomy can cause loss of erections
(impotence). If the cancer is not very large,
these nerves can be spared during surgery, thus
reducing the risk of erectile dysfunction. Pills
and injections are available in South Africa to
treat impotence.
Incontinence
Normally there are two closure mechanisms
(sphincters) that prevent leakage of urine from
the bladder (incontinence). With radical
prostatectomy one of these sphincters (the
internal one) is removed, so if the other
(external) sphincter is not strong, or is
damaged during surgery, there is a risk of
incontinence.
Blocked outflow of
urine
The prostate has a rich blood
supply therefore blood transfusion may be
necessary. Sometimes scar tissue may develop
where the prostate has been removed, thus
blocking the outflow of urine.
Side effects of Radiation therapy
As
your treatment continues, you may feel ongoing
tiredness.
External radiation may cause:
- Bowel dysfunction - diarrhea or frequent
stools; faecal incontinence or the inability
to control bowel movements; and rectal
bleeding
- Bladder dysfunction – passing urine more
frequently, inability to hold back the
urine, discomfort or difficulty in passing
urine, or blood in the urine – this is
usually temporary and long-term bladder
problems are rare
- Erectile dysfunction (impotence) – if
this does occur, it usually does so a few
years after the radiotherapy
- Skin – may become dry, red and tender
- Hair loss – only in the pelvic area, but
may not necessarily occur
Side Effects of Hormone Therapy
Because Hormone therapy affects the
testosterone levels, it is important to discus
the potential side effects with your doctor
prior to treatment. Ask you doctor for advice
about how to adjust your lifestyle after hormone
therapy.
Some side effects
experienced include:
- Decreased sexual desire and erectile
dysfunction
- Hot flushes
- Anaemia
- Fatigue
- Weight loss
- Weight gain
Side effects of Chemotherapy
These side effects depend on the type of
chemotherapy administered, but can include
tiredness, nausea and vomiting, hair loss, loss
of appetite, fatigue and weight loss. Don’t be
afraid to talk about your side effects with your
nurse or doctor. There are many supportive care
treatments available to help treat side effects.
Maintaining your Health
Looking after
your health during treatment is important and
will assist with your recovery. Take the time to
understand your disease and treatment and don’t
be afraid to ask questions.
Regular
Check-ups and appointment
Protect your
health by having regular check-ups and
scheduling appointments with your doctor to
follow up and monitor your health. Expect to
have further tests and examinations to evaluate
your health to ensure that you are responding
well to treatment.
Nutrition
Good nutrition is important. Eating well will
ensure you feel better and have more energy. It
also means you will get enough calories to
prevent weight loss, regain strength, and
rebuild normal tissue.
You may find it difficult to eat during
treatment or even lose your appetite. Talk to a
dietician who can give you advice for healthy
eating during your treatment or ask your nurse
or doctor for advice in this area.
Exercise
Regular, gentle exercise such as
walking or swimming can help keep your energy
levels up and also reduce pain levels. Don’t
forget to inform your doctor of any exercise you
are doing and if you feel unwell during exercise
let your nurse or doctor know.
Quality of Life
Most men with
prostate cancer can live a productive lifestyle
and enjoy a good quality of life. Because every
person is different and responds differently to
treatment, the outcome of your treatment cannot
be guaranteed; however, by working together with
your doctor you should be able to control your
disease and live life to its fullest.
Questions to ask your
doctor before surgery or treatment
- What tests are going to be done for an
accurate diagnosis?
- How long will the biopsy take? Will I be
awake? Will it hurt?
- How long will it take to get the biopsy
results?
- If I do have cancer, what will happen
next?
- Has the cancer spread to any other
areas?
- What stage of prostate cancer do I have?
- What type of treatment do you recommend?
- What are the risks from the
chemotherapy, from radiation, and from
surgery?
- How will I feel during treatment?
- What are the side effects of my
treatment?
- When will my treatment start? How often
will I have treatments? When will the
treatment end?
- What is the survival rate with or
without treatment?
- What effects will this condition have on
sexual activity? On urinary continence?
- How long will it be before I can return
to my normal activities?
- How will my prostate cancer be monitored
after treatment? How often will I need
check-ups?
|