Prostate Cancer

Incidence

  • Most common non-skin cancer in men in the US
  • Second to lung cancer as cause of cancer deaths in men.
  • 1 in 6 lifetime risk of developing prostate cancer.
  • Approximately 240,000 men diagnosed annually.

Risk Factors

  • Age
  • Ethnicity (African American>Caucasian>Asian)
  • Heredity/Family History
  • Diet (Western diet: high fat/red meat)
  • Smoking
  • Obesity

Types of Prostate Cancer

  • Adenocarcinoma (most common)
  • Mucinous Adenocarcinoma
  • Small Cell Carcinoma
  • Ductal Carcinoma

Route of Spread

  • Local extension of cancer out of prostate into surrounding organs (bladder, rectum, etc.)
  • Metastatic spread:
    • Lymphatic – spread to lymph nodes via invasion into lymphatic channels.
    • Hematogenous – spread other areas of the body via the blood system.

Associated Symptoms

  • Most patients are symptom free at the time of diagnosis. (This is due primarily to the detection/diagnosis of prostate cancer at very early stages as a result of PSA testing.)
  • Change in urinary symptoms (difficulty voiding, hesitancy, incompletely emptied bladder, etc.)
  • Blood in urine or semen
  • New onset back or bone pain

Diagnosis of Prostate Cancer

  • PSA testing
  • Prostate examination: detection of a “lump” or hard area of the prostate.
  • Staging of prostate cancer will typically involve nuclear bone scanning, CT scanning and prostate MRI with endo-rectal coil.

Staging (TNM)

From the AJCC 6th edition (2002) and UICC 6th edition.

Evaluation of the (primary) tumor (‘T’)

  • TX: cannot evaluate the primary tumor
  • T0: no evidence of tumor
  • T1: tumor present, but not detectable clinically or with imaging
    • T1a: tumor was incidentally found in less than 5% of prostate tissue resected (for other reasons)
    • T1b: tumor was incidentally found in greater than 5% of prostate tissue resected
    • T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA
  • T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate
    • T2a: the tumor is in half or less than half of one of the prostate gland’s two lobes
    • T2b: the tumor is in more than half of one lobe, but not both
    • T2c: the tumor is in both lobes but within the prostatic capsule
  • T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2)
    • T3a: the tumor has spread through the capsule on one or both sides
    • T3b: the tumor has invaded one or both seminal vesicles
  • T4: the tumor has invaded other nearby structures

Evaluation of the regional lymph nodes (‘N’)

  • NX: cannot evaluate the regional lymph nodes
  • N0: there has been no spread to the regional lymph nodes
  • N1: there has been spread to the regional lymph nodes

Evaluation of distant metastasis (‘M’)

  • MX: cannot evaluate distant metastasis
  • M0: there is no distant metastasis
  • M1: there is distant metastasis
    • M1a: the cancer has spread to lymph nodes beyond the regional ones
    • M1b: the cancer has spread to bone
    • M1c: the cancer has spread to other sites (regardless of bone involvement)

Prostate Cancer Grade:

  • Gleason grading system:A Gleason score is given to prostate cancer based upon its microscopic appearance. This score is determined by the   pathologist who examines the biopsy tissue. Prostate cancers with a higher Gleason score are more aggressive and have a worse prognosis. (This system was initially described by Dr Donald Gleason, a pathologist from Minneapolis.)
    • How does the scoring system work?
      • The pathologist assigns a grade to the most common cancer pattern (primary grade), and a secondary grade to the next most common tumor pattern. The two grades are then added together to get a Gleason Score. (For example, if the most common tumor pattern was grade 3, and the next most common tumor pattern was grade 5, the Gleason Score would be 3+5 = 8.)
    • In recent years, pattern score 3 has been used to depict the least aggressive pattern of prostate cancer. Pattern 4 represents a moderately aggressive cancer and pattern 5 depicts a very aggressive cancer.
    • Gleason scoring and prognosis:
      • Gleason 3+3=6 represents a low risk or slow growing cancer (best prognosis).
      • Gleason 3+4 or 4+3 =7 represents an intermediate grade cancer.
      • Gleason 8, 9. or 10 represent a very aggressive cancer (poorest prognosis).

Treatment Options

Active Surveillance:

  • This option is based on a principle that some prostate cancers will not progress (become more aggressive, proliferate, or spread) in a man’s lifetime and thus may not require treatment.
  • Caution: Only certain patients can be enrolled in Active Surveillance. For more information click here. (LINK)

Radiation Therapy:

  • Brachytherapy/seed implantation
  • Intensity Modulated Radiation Therapy (IMRT)
  • Proton Beam Radiation Therapy
  • High Dose Response (HDR)

*For more information on radiation therapy options, please consult a Radiation Oncologist.

Surgery:

  • Radical Prostatectomy- complete surgical removal of the prostate and seminal vesicles with/without removal of regional lymph nodes and reconstruction of urinary tract.
    • Robot-assisted Laparoscopic Radical Prostatectomy (RALP) Click for more info
    • Open Radical Prostatectomy

High Intensity Focused Ultrasound (HIFU):

  • A minimally invasive procedure that applies focused sonic energy to locally heat and destroy prostate cancer. This novel therapy is not yet available in the US.

Hormone Therapy:

  • Hormone therapy (also called androgen deprivation treatment) removes, blocks, or adds hormones to treat prostate cancer.
  • Prostate cancer growth is regulated by the presence of the male hormone testosterone. By reducing or blocking the effect of this hormone, prostate cancer growth/progression can be halted/reduced.

Prognostic Factors

  • Gleason Grade
  • Stage of Cancer
  • PSA at time of diagnosis
  • Overall health of patient at time of diagnosis

Survival

In general, survival of prostate cancer is excellent (5 year survival for men with localized prostate cancer is 100%; 10 year survival for localized prostate cancer is approximately 95%). This is due to several factors:

  • With the advent and use of PSA testing, most prostate cancers are diagnosed at a very early stage (cancers are confined to prostate).
  • Therapies such as surgery and radiation are very effective in eradicating the primary cancer.



Male prostate anatomy lateral view

About Prostate Cancer

Incidence
Risk Factors
Types of Prostate Cancer
Route of Spread
Associated Symptoms
Diagnosis of Prostate Cancer
Staging of Prostate Cancer
Prostate Cancer Grade
Treatment Options
Prognostic Factors
Survival
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Gleason System Grading Images

Gleason 3 plus 3 total 6
Gleason 3 plus 3 total 6 (3 + 3 = 6)

Gleason 3 plus 4 total 7
Gleason 3 plus 4 total 7 (3 + 4 = 7)

Gleason 4 plus 4 total 8 no2 Gleason 4 plus 4 total 8 (4 + 4 = 8)

Gleason 5 + 5  total 10 solid pattern of cellsGleason 5 plus 5 total 10 (5 + 5 = 10)