Prostate Cancer
Prostate cancer is a type of cancer that affects the prostate gland, which is a small gland in the male reproductive system. It is the second most common cancer in men worldwide and typically affects older men. Risk factors for prostate cancer include age, family history, and certain genetic mutations.
Symptoms of Prostate Cancer
Prostate cancer in its early stages often does not cause any noticeable symptoms. As the cancer grows and spreads, symptoms may include:
Weak or interrupted urine flow
Difficulty starting and stopping urination
Pain or burning during urination
Blood in urine or semen
Frequent urination, especially at night
Pain in the back, hips, or pelvis
Erectile dysfunction
Unexplained weight loss or fatigue
It’s important to note that these symptoms can also be caused by other conditions, so it’s essential to get a proper medical evaluation to determine the cause. If you have any concerns about prostate cancer, it’s best to talk to your doctor.
Causes of Prostate Cancer
- Increasing age is a primary risk factor for prostate cancer, with the majority of cancers being seen in elderly men above 60 years of age.
- Younger men who are diagnosed with prostate cancer tend to have an aggressive disease with a tendency to spread faster.
- Prostate cancers have a genetic component. They are hereditary in nature & men with a positive family history on either side, especially in a first degree relative, have an increased risk of developing prostate cancer.
- Men with a family history of breast cancer, male breast cancer, colorectal cancer, ovarian, pancreatic cancer, malignant melanoma, have an increased risk of prostate cancer.
- Men who are carriers for the high risk, hereditary, cancer-causing mutations in the DNA repair genes like BRCA2, ATM, CHEK2, RAD51, HRD pathway defects, are all at an increased risk for prostate cancer.
- Smoking and alcohol intake are both associated with an increased risk for prostate cancer.
- Vitamin D deficiency is associated with an elevated risk for prostate cancer.
- There appears to be a significant association between arsenic exposure and prostate cancer development.
Prostate Cancer Treatment
- Prostate cancer can be detected incidentally in the early stages when it is localised, through routine sonography or elevated PSA, or through urinary symptoms when it is locally advanced.
- The treatment of prostate cancer depends on the stage at which it is diagnosed, prostate cancer is classified into low, intermediate, and high risk.
- If the cancer is confined within the prostate gland, treatment options are: active surveillance, robotic radical prostatectomy, or external beam radiotherapy.
- Locally advanced prostate cancer may require a combination of surgery, radiotherapy, and androgen deprivation therapy.
Androgen deprivation therapy consists of GnRH agonist injections and anti-androgens which are used to suppress testosterone production. - Metastatic prostate cancer is an advanced stage disease and may require a combination of treatments including chemotherapy, radiation, and androgen deprivation therapy.
- Molecular tests in the form of Next Generation Sequencing are necessary for all prostate cancer patients to detect hereditary cancer-causing mutations which can guide the treatment.
Treatment Options for Localized Prostate Cancer
Active Surveillance
Close monitoring with scans and PSA level checks is used if the cancer is low-grade and low-risk.
Robotic Radical Prostatectomy
Surgical removal of the prostate gland using a minimally invasive technique which ensures rapid recovery and minimal blood loss.
External Beam Radiotherapy
Non-invasive, non-surgical treatment to kill prostate cancer using IMRT/IGRT/Proton beam radiation techniques.
Brachytherapy
The technique of radiation where a radioactive source is directly implanted into the prostate gland.
Read About: Prostate Cancer Journey: Targeted Therapy
Five Warning Signs Of Prostate Cancer
- An elevated PSA level detected during a routine health check, especially levels above 10ng/ml should prompt an immediate evaluation of the prostate.
- A routine pelvic sonography showing an enlarged prostate with a high PSA must be investigated.
- Urinary complaints like hesitancy, increased frequency of urination, nocturia, urgency, blood in the urine, sudden inability to pass urine can all be symptoms of a prostate cancer.
- An increasing loss of appetite, weight loss, weakness and fatigue must be investigated.
- Sudden onset back pain causing lower limb weakness with difficulty in passing urine can indicate bone metastases involving the vertebra and causing spinal cord compression.
- Bony pain, gradually increasing in intensity, sudden onset, and severe, or a spontaneous fracture, can both be symptoms of metastasis.
Types of Prostate Cancer
- Adenocarcinoma: This is the most common type of prostate cancer and accounts for more than 90% of all cases.
- Small Cell Prostate Cancer: This is a rare type of prostate cancer that is aggressive and fast-growing.
- Prostate sarcoma: This is a rare type of prostate cancer that develops in the connective tissue of the prostate gland.
- Neuroendocrine tumors of the prostate: This is a rare type of prostate cancer that arises from neuroendocrine cells in the prostate.
- Prostatic ductal adenocarcinoma: This is a rare type of prostate cancer that arises in the ducts of the prostate gland.
It is important to note that prostate cancer can also be classified based on the stage and aggressiveness of the disease. Early-stage prostate cancer is usually slow-growing and less likely to spread, while advanced-stage prostate cancer is more aggressive and has a greater risk of spreading.
Locally Advanced Prostate Cancer
If there is spread of the cancer into the surrounding tissues and organs, the above treatment options of Radical Prostatectomy and/or External Beam Radiotherapy can be utilized. However, depending on the extent of spread, a combination of surgery followed by radiotherapy may be needed, or other drugs may have to be added.
- Radical Prostatectomy can be done followed by androgen deprivation therapy. Androgen deprivation refers to suppression of testosterone production. It consists of using a tablet called Abiraterone Acetate which is an anti-androgen, which is combined with a steroid tablet, prednisolone. If surrounding organs and/or draining lymph nodes are involved with the cancer, then external beam radiotherapy is also added to the treatment regimen.
- External beam radiotherapy in combination with Brachytherapy can be used as a curative treatment option. This requires addition of androgen deprivation therapy, tablet Abiraterone Acetate, in combination with tablet prednisolone, a low dose steroid.
- Androgen deprivation therapy consists of GnRH agonist injections- Leuprolide, or a GnRH antagonist Relugolix, given orally. It may be combined with anti-androgens like Abiraterone Acetate or Enzalutamide. This therapy suppresses testosterone production in the testis and blocks its stimulatory effect on the prostate cancer cells.
- There are clinical trials ongoing to assess the benefits of adding chemotherapy to surgery and radiation, in patients with extensive spread into the surrounding tissues in prostate cancer. Preliminary results appear to show a benefit in those with high-risk disease.
Read about: Uterine Cancer
All prostate cancer patients must undergo molecular tests in the form of Next Generation Sequencing, to look for underlying high risk, hereditary cancer-causing mutations like BRCA1 & BRCA2. The tests also detect the prostate cancers deficient in homologous recombination repair (HRR). The presence of HRR deficiency or detection of the BRCA mutations allows the use of oral tablets called PARP inhibitors in the treatment regimen, thus improving the treatment response and reducing the risk of a recurrence. Other mutations which are cancer causing and may be detected are ATM, CHEK2, PALB2, FANCA, RAD51B, BRIP1 which can be treated with targeted therapy.
Metastatic Prostate Cancers:
This refers to prostate cancers that have spread into the bones, lymph nodes, lungs, liver, etc. Once metastatic, the cancer cannot be cured, but it can be controlled using a combination of targeted therapy options with or without chemotherapy.
A molecular profiling of the biopsy specimen, using next generation sequencing is essential to detect any underlying targetable mutations like BRCA or HRR deficiencies. Both can be treated using PARP inhibitors.
A PSMA PET-CT Scan is needed to document the extent of spread, along with a baseline PSA level, done pre-treatment, to help monitor the response to treatment.
- The initial treatment involves suppressing the testosterone production by performing a surgical castration ( bilateral orchidectomy-removal of the testis) or a medical castration by giving a GnRH Agonist-injection Leuprolide. Both these therapies work to block the stimulatory effect of testosterone on the prostate cancer cells, thereby suppressing the cancer and its ill effects.
- Injection Denosumab or Zoledronic Acid must be added to treat bony metastasis if present.
- Painful, bony lesions which are refractory to pain-killers can receive local radiation for pain control.
- An anti-androgen, usually tablet Abiraterone Acetate with tablet Prednisolone, or tablet Enzalutamide is added post bilateral orchidectomy or with the injection Leuprolide. The 2 therapies act in conjunction to suppress and then maintain cancer control.
- These therapies will control the prostate cancer for a period of time. Monitoring is essential by performing regular PSMA scans and checking PSA levels.
- When disease progression is detected, the treatment line must be changed. Chemotherapy must be added to the Leuprolide and Abiraterone or Enzalutamide combination. A Taxane- injection Docetaxel, is usually the first option. In case of non-response or progression on therapy, another chemotherapy drug- Cabazitaxel can be used.
- If a repeat biopsy done at the time of progressive disease, shows a poorly differentiated cancer, then chemotherapy using a Taxane and a Platinum gives a good response.
- If the cancer shows mismatch repair deficiency or a high tumour mutational burden, then an Immunotherapy drug like Pembrolizumab can be utilized in the treatment regimen.
- If HRR deficiency or BRCA mutations are detected, PARP inhibitors can be given for the cancer treatment.
Diagnosis of Prostate Cancer
- A diagnosis of Prostate cancer is usually an incidental finding, as it remains asymptomatic in the initial stages.
- An elevated PSA on a routine check-up is the commonest abnormality detected. Generally, a PSA level greater than 4ng/ml warrants an investigation.
- It should be followed by ultrasonography of the abdomen and pelvis. Finding an enlarged prostate along with its sonography appearance determines the next course of action.
- At times, the patient may have urinary symptoms or pain related to cancer, thus leading to its detection on sonography and through an elevated PSA.
- A digital rectal examination is usually performed along with a sonography. Finding a nodule, induration over the gland, or asymmetry of the prostate points towards a malignancy.
- This must be followed by a Transrectal Ultrasound Guided Biopsy of the Prostate. The histopathology will then confirm the diagnosis.
- Once the diagnosis is made, a PSMA PET-CT Scan must be done, to assess the extent of the invasion of cancer. The scan helps determine whether the prostate cancer is localized or metastatic.
Prostate Cancer: Prevention and awareness
A regular health check done annually along with specific screening for prostate cancer is the most effective way to detect the cancer in its initial stage.
There are no specific medications or surgery available to prevent a prostate cancer from developing.
All men must be made aware that they carry a risk for prostate cancer as they grow older. Smoking, tobacco intake, alcohol consumption, obesity, a family history of prostate, breast, ovarian, uterine, colon cancer all increase the risk for a future development of prostate cancer.
Screening for prostate cancer must begin for all men at age 50. For those at a high risk due to a positive family history or if the patient is a carrier for the hereditary, cancer-causing mutations like the BRCA genes, screening must begin at age 40.
Annual PSA levels should be monitored along with a yearly sonography of the prostate. These 2 tests are quite effective as screening tools. Any abnormality should prompt further evaluation.
Survival Rates of Prostate Cancer
The survival rates of prostate cancer can vary depending on various factors such as the stage of the cancer, the patient’s age, overall health, and the type of treatment received.
As of 2023, the overall 5-year relative survival rate for prostate cancer is 99%. This means that 99% of men diagnosed with prostate cancer are expected to live at least 5 years after their diagnosis.
It is important to note that the survival rate can be higher or lower depending on the individual case and that early detection and treatment are key to improving survival rates.
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Frequently Asked Questions
Prostate cancer cannot be prevented. It can be detected at an early stage, treated and cured.
An elevated PSA level, urinary complaints like urgency, hesitancy, increased frequency of urination, sudden inability to pass urine, unexplained bony pain not responding to pain killers, loss of appetite, weight loss, weakness and fatigue, back pain, spontaneous fracture, can all be signs of prostate cancer.
Yes, prostate cancer can be completely cured if detected early & treated appropriately.
Older age, high risk mutations like BRCA, ATM, CHEK2, Lynch Syndrome, a family history of prostate, breast, uterine or ovarian cancer, smoking, alcohol, tobacco intake are all causes of prostate cancer.
Urinary complaints like nocturia, urgency, hesitancy, increased frequency of urination, hematuria, back-ache, bony pain not responding to pain-killers can all be the initial signs of prostate cancer.
Adenocarcinoma is the commonest type of prostate cancer. Neuroendocrine carcinoma is the other type of prostate cancer that may occur in a lesser frequency.
A PSA level followed by a sonographic evaluation of the prostate and a biopsy of the prostate are the tests for prostate cancer.
Surgery, radiation, anti- androgen therapy, injectable and oral, are all effective treatments for prostate cancer.
Depending on the stage of the prostate cancer, radiation can cure the cancer completely. In advanced stages, radiation can be given for pain control.
It is very rare to get a prostate cancer at such a young age. Usually prostate cancer develops above the age of 40.
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About Dr. Sujata Vasani
Dr. Sujata Vasani is a Hemato-Oncologist with 18+ years of experience in her field. She currently has her own clinic at Kemps Corner and is an Honorary Consultant at these renowned hospitals – Saifee, Breach Candy, Bhatia, Cumballa, and Dalvi.
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