prostate cancer

Issue

Vol. 1 No. 1 (2024)

Date Log

Submitted
May 23, 2024
Accepted
June 29, 2024
Published
June 25, 2024

Understanding Prostate Cancer: Causes, Risks, Diagnosis, and Treatment

https://doi.org/10.69512/ajphi.v1i01.47
Gauri Adhikari, MD
Nepalese Army Institute of Health Sciences-College of Medicine, Nepal
Binaya Dhakal, MD
Nepalese Army Institute of Health Sciences-College of Medicine, Kathmandu, Nepal
Pradeep Khatiwada, MD
B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Corresponding Author(s) : Gauri Adhikari, MD

gauryadhikary@gmail.com

The American Journal of Patient Health Info, Vol. 1 No. 1 (2024)

Abstract


  1. Prostate cancer is the most common cancer among men after skin cancer.

  2. Most men who get prostate cancer don't die from it. More than 90% of men diagnosed with prostate cancer survive for at least five years. If detected early, while the tumor has not spread outside of the prostate, the survival rate is nearly 100% with treatment.

  3. Early-stage prostate cancer rarely causes symptoms, symptoms develop after the disease progresses.

  4. Prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) are common screening methods for prostate cancer. However, whether or not to use these screening techniques is still controversial.

  5. Active surveillance is a strategy for managing low-risk prostate cancer without immediate treatment. The idea is to avoid unnecessary side effects by carefully watching how the cancer develops over time.

Keywords

Prostate cancer Prostate Specific Antigen Digital Rectal Examination
Adhikari, MD, G., Dhakal, MD, B., & Khatiwada, MD, P. (2024). Understanding Prostate Cancer: Causes, Risks, Diagnosis, and Treatment. The American Journal of Patient Health Info, 1(1). https://doi.org/10.69512/ajphi.v1i01.47
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References
  1. About Prostate Cancer | Prostate Cancer Overview [Internet]. www.cancer.org. Available from: https://www.cancer.org/cancer/types/prostate-cancer/about.html
  2. Rawla P. Epidemiology of Prostate Cancer. World Journal of Oncology. 2019 Apr 20;10(2):63–89. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6497009/
  3. Prostate Cancer Causes, Risk Factors, and Prevention [Internet]. www.cancer.org. Available from: https://www.cancer.org/cancer/types/prostate-cancer/causes-risks-prevention.html
  4. Al-Fayez S, El-Metwally A. Cigarette smoking and prostate cancer: A systematic review and meta-analysis of prospective cohort studies. Tob Induc Dis 2023;21:19.
  5. NHS. Prostate cancer - Symptoms [Internet]. nhs.uk. 2018. Available from: https://www.nhs.uk/conditions/prostate-cancer/symptoms/
  6. David MK, Leslie SW. Prostate Specific Antigen (PSA). PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557495/
  7. Prostate cancer - Diagnosis and treatment - Mayo Clinic [Internet]. Mayoclinic.org. ; 2022 [cited 2024 Jan 20]. Available from: https://www.mayoclinic.org/diseases-conditions/prostate-cancer/diagnosis-treatment/drc-20353093
  8. Prostate Cancer: Advancements in Screenings [Internet]. 2020. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/prostate-cancer-advancements-in-screenings
  9. Tagai EK, Miller SM, Kutikov A, Diefenbach MA, Gor RA, Al-Saleem T, et al. Prostate Cancer Patients’ Understanding of the Gleason Scoring System: Implications for Shared Decision-Making. Journal of Cancer Education. 2018 Jan 15;34(3):441–5.
  10. Prostate Cancer Treatment | Surgery, Radiation, & Chemotherapy [Internet]. Cancer.org. 2024 [cited 2024 Jan 20]. Available from: https://www.cancer.org/cancer/types/prostate-cancer/treating.html
  11. Mayo Clinic. Prostate cancer - Diagnosis and treatment - Mayo Clinic [Internet]. Mayoclinic.org. 2018. Available from: https://www.mayoclinic.org/diseases-conditions/prostate-cancer/diagnosis-treatment/drc-20353093
  12. Mayo Clinic. Prostate cancer - symptoms and causes [Internet]. Mayo Clinic. Mayo Clinic; 2022. Available from: https://www.mayoclinic.org/diseases-conditions/prostate-cancer/symptoms-causes/syc-20353087
  13. Chapman CH, Burns JA, Skolarus TA. Prostate Cancer Surveillance After Radiation Therapy in a National Delivery System. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2019;36(Suppl 1):S16–21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411359/
  14. Prostate Cancer: Age-Specific Screening Guidelines [Internet]. ww.hopkinsmedicine.org. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/prostate-cancer-age-specific-screening-guidelines
  15. Prostate Cancer, Nutrition, and Dietary Supplements (PDQ®)–Patient Version - NCI [Internet]. www.cancer.gov. 2012. Available from: https://www.cancer.gov/about-cancer/treatment/cam/patient/prostate-supplements-pdq
  16. Talvitie AM, Ojala H, Tammela T, Pietilä I. Prostate cancer-related sexual dysfunction – the significance of social relations in men’s reconstructions of masculinity. Cult Health Sex 2024;26(6):763–77.
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Gauri Adhikaria, Binaya Dhakala, Pradeep Khatiwadab

a Nepalese Army Institute of Health Sciences-College of Medicine, Kathmandu, Nepal

b B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Background

Prostate cancer develops in the prostate gland, an important part of the male reproductive system. The prostate gland lies below the bladder, surrounds the urethra, and is in front of the rectum. The prostate gland secretes fluid that mixes with semen during ejaculation.

Prostate cancer, besides skin cancer, is the most common cancer in American men. According to the American Cancer Society, about one man in eight has been estimated to be diagnosed with prostate during his lifetime, and it is more common in older men and non-Hispanic Black men. 1

Benign Growth and Cancerous Growth of Prostate

The benign and cancerous growth of the prostate are two distinct conditions with varying implications for health. Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland commonly occurring in older men and is non-cancerous. It is primarily due to hormonal changes and typically results in urinary symptoms such as increased frequency and urgency. While it can be uncomfortable, BPH is not life-threatening.

In contrast, prostate cancer is the uncontrolled growth of malignant cells within the prostate gland. Unlike BPH, prostate cancer can be life-threatening, especially if it spreads to other parts of the body. Distinguishing between these conditions is crucial, and a proper diagnosis is important to determine the course of action.

Risk Factors of Prostate Cancer

The most common risk factors include:

Figure 1.

  • Age: Your risk of prostate cancer increases significantly with age. It is relatively rare in men under 40 but becomes more common as they age. The majority of cases are men over the age of 65. 2
  • Family History: A family history of prostate cancer can elevate an individual's risk. The risk is higher if a close male relative, like a father or brother, has had prostate cancer. The risk increases further if multiple family members have been affected. 3
  • Genetics: BRCA1 and BRCA2 are commonly implicated genes in ovarian and breast cancers. These mutations have also been found to be associated with an increased risk of prostate cancer in men. 3
  • Race and Ethnicity: Prostate cancer is more commonly seen in African American men than in men of other races. It tends to occur at a younger age and be more aggressive in this group. On the other hand, Asian and Hispanic men have a lower risk compared to Caucasians. 4
  • Occupational Exposure: Some studies have suggested that exposure to certain chemicals and toxins, such as cadmium and Agent Orange, may be associated with an increased risk of prostate cancer. 3
  • Sexually Transmitted Infections(STIs): Some research has suggested a potential link between STIs and an increased risk of prostate cancer. 3
  • Smoking: While the evidence is not as strong as for some other cancers, some studies have shown smoking is associated with an increased risk of prostate cancer in terms of prognosis, with a worse prognosis among smokers. 4

Symptoms of Prostate Cancer

Early prostate cancer often shows no symptoms. As prostate cancer spreads, it may cause the following symptoms:

Figure 2.

1. Urinary Changes

Changes in urinary habits are one of the first noticeable symptoms of prostate cancer. These include:

  • Increased frequency of urination, especially at night (nocturia).
  • Difficulty starting or stopping urination.
  • Weak urine flow or interrupted urine flow.
  • Pain or burning sensation during urination.
  • Blood in the urine (hematuria) or semen.

2. Erectile Dysfunction

You can have difficulty achieving or maintaining an erection may occur, though this can also be due to other factors such as age or other medical conditions.

3. Pain and Discomfort

Advanced prostate cancer may cause pain in the pelvic area, lower back, hips, or upper thighs. This pain may be dull, deep, or sharp and can be intermittent or continuous.

4. Blood in Semen or Ejaculate

This can be a symptom of prostate cancer, though it can also be caused by other conditions such as infections or inflammation of the prostate (prostatitis). 5

5. Bone Pain

Prostate cancer that has spread (metastasized) to the bones can cause a nagging kind of bone pain, particularly in the spine, hips, pelvis, or other bones. This pain may be severe and worsen at night.

6. Diagnosis of Prostate Cancer

The diagnosis of prostate cancer involves steps to determine whether a patient has malignant growth in the prostate gland. Following are the tests that your doctor might suggest:

Figure 3.

1. Blood Tests for Prostate Cancer

The Prostate-Specific Antigen (PSA) test measures the protein levels produced by the prostate gland, serving as a vital tool in screening for and monitoring prostate cancer. Typically recommended for men over 50, the PSA test can detect the cancer in its early stages; that is when treatment is most effective. 6While a normal PSA level is generally considered four nanograms per milliliter or lower, various factors can influence PSA levels, leading to false positives and false negatives. Consequently, an elevated PSA reading often triggers further diagnostic steps, such as a digital rectal examination (DRE) and a prostate biopsy, to ascertain the presence of cancer. 6However, the use of PSA screening has sparked debate due to its limitations and the potential for overdiagnosis. One should undergo PSA testing after carefully discussing it with a healthcare provider, considering individual risk factors and the overall benefits and risks associated with the test. 6

2. Digital Rectal Examination for Prostate Cancer

During a DRE, a healthcare provider, typically a urologist or primary care physician, inserts a gloved lubricated finger into the patient's rectum to feel the prostate gland. The examination is relatively quick, lasting only a few seconds. While it may be slightly uncomfortable, it is generally not painful. 7The primary purpose of a DRE is to check the shape, size, and texture of the gland and to check for any abnormalities that may be indicative of prostate cancer or other prostate-related conditions. It is often used as part of a comprehensive evaluation for prostate cancer. While a DRE can identify some abnormalities, it has limitations. It can miss small or deep-seated tumors, and the assessment of the prostate's condition is subjective, varying from one healthcare provider to another. 7

3. Prostate Biopsy

A prostate biopsy is an important medical procedure done to diagnose prostate cancer definitively. It is typically recommended when there are elevated PSA levels or suspicious findings during a DRE. During a prostate biopsy, your urologist or radiologist uses a thin, specialized needle to extract small tissue samples from the prostate gland, typically through the rectum or perineum. These tissue samples are then analyzed to determine the presence of cancer cells and to assess their aggressiveness using the Gleason score.8Biopsy is considered the gold standard for prostate cancer diagnosis, but it's not without its potential risks, which can include bleeding, infection, or discomfort. The decision to undergo a prostate biopsy should be made in close consultation with a healthcare provider, considering individual risk factors, potential benefits, and the need for accurate diagnosis when prostate cancer is suspected. 8

Staging and Grading of Prostate Cancer

Staging and grading are essential components of diagnosing and characterizing prostate cancer. Staging, often determined by the TNM system, assesses the extent of cancer's spread. It categorizes prostate cancer into stages, ranging from localized (confined to the prostate) to advanced (spread to other organs or lymph nodes).

Grading, on the other hand, is typically evaluated using the Gleason score, which examines the appearance of cancer cells in a biopsy sample. Lower Gleason scores indicate less aggressive cancer, while higher scores signify a more aggressive form.

These two factors, staging and grading, are crucial for treatment decision-making, as they help healthcare providers understand the severity of the disease and its potential to grow and spread, ultimately guiding the choice of the most appropriate treatment for each individual diagnosed with prostate cancer. 9

Treatment of Prostate Cancer

Treatment options for prostate cancer differ for different individuals depending on factors like the stage and aggressiveness of the cancer, the patient's overall health, and individual preferences.

Figure 4.

  • Active Surveillance: Active surveillance is an approach to managing low-risk or early-stage prostate cancer that closely monitors the cancer's progression rather than immediately pursuing aggressive treatment. It is typically recommended for men with small, low-grade tumors that are unlikely to grow rapidly or cause an immediate threat. Individuals on active surveillance undergo periodic check-ups, including regular PSA tests, DREs, and occasional prostate biopsies, to monitor any changes in the cancer's behavior. If there are signs that the cancer is becoming more aggressive or progressing, treatment options may be reconsidered. 6
  • Surgery (Prostatectomy): Radical prostatectomy is a surgical procedure that removes the entire prostate gland. It can be performed traditionally as open or using minimally invasive methods like laparoscopy or robotic-assisted surgery. This option is often recommended for early-stage or more aggressive prostate cancers. 10
  • Radiation Therapy: This therapy uses high-energy beams to destroy the cancer cells in the gland. It can be given externally (external beam radiation therapy) or internally (brachytherapy). Radiation therapy is one of the most important treatment options for localized prostate cancer and is often used in combination with other treatments for more advanced cases. 10
  • Hormone Therapy: Hormone therapy aims to reduce the levels of male hormones (androgens), which are like the fuel for the growth of the cancer cells in the prostate. This is also known as androgen deprivation therapy. This therapy is often used in combination with radiation therapy for intermediate or high-risk cases and can be the main line of treatment for advanced or metastatic prostate cancer. 11
  • Chemotherapy: Chemotherapy may be recommended for prostate cancer that is at its advanced stage and no longer responds to other modalities of treatment like hormone therapy. It involves using drugs to target and kill cancer cells throughout the body. 10
  • Targeted Therapies: Targeted therapies are drugs that specifically target molecules or pathways involved in cancer growth. They are typically used for advanced or metastatic prostate cancer. 11
  • Cryotherapy: Cryotherapy is also known as cryosurgery or cryoablation. It is a minimally invasive option for localized prostate cancer. It uses extreme cold temperatures to freeze and destroy cancerous tissue in the prostate. During the procedure, thin, needle-like probes are inserted into the prostate, guided by ultrasound imaging. 11
  • High-Intensity Focused Ultrasound (HIFU): HIFU uses ultrasound waves to generate heat and destroy cancerous tissue in the prostate. It is another treatment option for localized prostate cancer. 11

Complications of Prostate Cancer Treatment

Impotence and sexual dysfunction can be caused by prostate cancer and its therapies, including surgery, radiation therapy, and hormone therapy. Some prostate cancer therapies, especially radiation therapy, can cause bowel issues, including diarrhea, rectal bleeding, proctitis, and rectum inflammation. Hormone treatment, frequently used to treat advanced prostate cancer, can have undesirable side effects, including hot flashes, libido loss, weight gain, and osteoporosis (thinning of the bones). Prostate cancer often has complications, one of which is cancer-related tiredness. Some prostate cancer therapies might make you more likely to get secondary malignancies like leukemia or bladder cancer. 12

Monitoring Following Prostate Cancer Therapy

After the treatment of prostate cancer, you will have to make follow-up appointments with your doctor. Your doctor will perform DRE, PSA tests, and imaging studies to assess the effectiveness of the treatment effectiveness and detect signs of recurrence or side effects. For those at higher risk of metastasis to bones, bone scans may be conducted. Monitoring extends to evaluating symptoms, maintaining overall well-being, and addressing quality of life. 13

What Happens if Prostate Cancer is Left Untreated?

Leaving prostate cancer untreated can have serious consequences, as the cancer may continue to grow and potentially spread to other parts of the body. Here are the potential outcomes of untreated prostate cancer:

Figure 5.

  • Metastasis: Untreated prostate cancer may metastasize, which means it can spread to distant sites in the body, most commonly the bones. This can cause you to have bone pain, fractures, and other complications. 12
  • Worsening Symptoms: As cancer advances, urinary symptoms such as difficulty urinating, frequent urination, and blood in the urine may become more pronounced and uncomfortable.
  • Pain and Discomfort: Metastatic prostate cancer can cause significant pain and discomfort, especially in the bones. This discomfort may also be present in the pelvic area or your upper thighs.
  • Decreased Life Expectancy: Left untreated, prostate cancer may become life-threatening. While the course of the disease varies, advanced prostate cancer can significantly reduce life expectancy.
  • Limited Treatment Options: Delaying treatment can limit the effectiveness of available treatment options and reduce the chances of a successful outcome.

Prostate Cancer Screening

The timing for prostate cancer screening is a subject of discussion among medical experts, and the decision should be individualized. A general guideline for when to consider seeing a doctor for prostate cancer screening is:

  • If you are between 45-69 years of age.
  • African American.
  • Have a family history of prostate cancer.
  • Have symptoms suggestive of prostate cancer. 14

Prostate Health Supplement

Prostate health supplements are products containing various ingredients that are believed to boost the health of the prostate gland. Common ingredients include saw palmetto, beta-sitosterol, lycopene, selenium, zinc, vitamin D, Pygeum, and nettle root. These supplements claim to aid in maintaining prostate health. Although certain components might alleviate urinary tract symptoms linked to prostate problems, the overall research on their effectiveness is often limited. 15

Prostate Cancer and Sexual Health

Prostate cancer and sexual health are connected, and the treatments for prostate cancer can affect a man's sexual function. Procedures like surgery and radiation may lead to issues such as erectile dysfunction, where achieving or maintaining an erection becomes challenging. Hormone therapy, another treatment option, can impact libido or sexual desire. The diagnosis of prostate cancer can have emotional consequences, affecting intimacy and relationships. Communication with your doctor is key, and rehabilitation programs or counseling may be recommended to address these challenges. Open discussions with partners and seeking emotional support play a crucial role in navigating the changes in sexual health associated with prostate cancer and its treatment. 16

Questions To Ask Your Doctor

  1. Are there any lifestyle changes to help manage prostate cancer?
  2. What are the signs that the cancer may be returning or progressing?
  3. How will the treatments affect my daily life and activities?
  4. What is the expected recovery time after surgery?
  5. Are there any support groups or resources for prostate cancer patients?

References

  1. About Prostate Cancer | Prostate Cancer Overview [Internet]. www.cancer.org. Available from: https://www.cancer.org/cancer/types/prostate-cancer/about.html
  2. Rawla P. Epidemiology of Prostate Cancer. World Journal of Oncology. 2019 Apr 20;10(2):63–89. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6497009/
  3. Prostate Cancer Causes, Risk Factors, and Prevention [Internet]. www.cancer.org. Available from: https://www.cancer.org/cancer/types/prostate-cancer/causes-risks-prevention.html
  4. Al-Fayez S, El-Metwally A. Cigarette smoking and prostate cancer: A systematic review and meta-analysis of prospective cohort studies. Tob Induc Dis 2023;21:19.
  5. NHS. Prostate cancer - Symptoms [Internet]. nhs.uk. 2018. Available from: https://www.nhs.uk/conditions/prostate-cancer/symptoms/
  6. David MK, Leslie SW. Prostate Specific Antigen (PSA). PubMed. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557495/
  7. Prostate cancer - Diagnosis and treatment - Mayo Clinic [Internet]. Mayoclinic.org. ; 2022 [cited 2024 Jan 20]. Available from: https://www.mayoclinic.org/diseases-conditions/prostate-cancer/diagnosis-treatment/drc-20353093
  8. Prostate Cancer: Advancements in Screenings [Internet]. 2020. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/prostate-cancer-advancements-in-screenings
  9. Tagai EK, Miller SM, Kutikov A, Diefenbach MA, Gor RA, Al-Saleem T, et al. Prostate Cancer Patients’ Understanding of the Gleason Scoring System: Implications for Shared Decision-Making. Journal of Cancer Education. 2018 Jan 15;34(3):441–5. Available from: https://pubmed.ncbi.nlm.nih.gov/29333577/
  10. Prostate Cancer Treatment | Surgery, Radiation, & Chemotherapy [Internet]. Cancer.org. 2024 [cited 2024 Jan 20]. Available from: https://www.cancer.org/cancer/types/prostate-cancer/treating.html
  11. Mayo Clinic. Prostate cancer - Diagnosis and treatment - Mayo Clinic [Internet]. Mayoclinic.org. 2018. Available from: https://www.mayoclinic.org/diseases-conditions/prostate-cancer/diagnosis-treatment/drc-20353093
  12. Mayo Clinic. Prostate cancer - symptoms and causes [Internet]. Mayo Clinic. Mayo Clinic; 2022. Available from: https://www.mayoclinic.org/diseases-conditions/prostate-cancer/symptoms-causes/syc-20353087
  13. Chapman CH, Burns JA, Skolarus TA. Prostate Cancer Surveillance After Radiation Therapy in a National Delivery System. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2019;36(Suppl 1):S16–21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6411359/
  14. Prostate Cancer: Age-Specific Screening Guidelines [Internet]. ww.hopkinsmedicine.org. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/prostate-cancer-age-specific-screening-guidelines
  15. Prostate Cancer, Nutrition, and Dietary Supplements (PDQ®)–Patient Version - NCI [Internet]. www.cancer.gov. 2012. Available from: https://www.cancer.gov/about-cancer/treatment/cam/patient/prostate-supplements-pdq
  16. Talvitie AM, Ojala H, Tammela T, Pietilä I. Prostate cancer-related sexual dysfunction – the significance of social relations in men’s reconstructions of masculinity. Cult Health Sex 2024;26(6):763–77. Available from: https://www.researchgate.net/publication/373657500_Prostate_cancer-related_sexual_dysfunction_-_the_significance_of_social_relations_in_men's_reconstructions_of_masculinity

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