Prostate Cancer: Types, Symptoms, Treatment and Prevention

Originating in the prostate gland, a small walnut-shaped gland that nourishes and transports sperm, prostate cancer is one of the most common types of cancer affecting men worldwide, particularly those over the age of 50 years. Despite its prevalence, many men are not aware of its causes, risk factors, symptoms, and treatment options. Understanding these aspects, exploring the available management and prevention strategies is crucial for making informed health decisions. That’s why in this comprehensive guide, we provide an in-depth look at prostate cancer, covering all that you need to know about this disease, including its types, symptoms, diagnosis, treatment and prevention measures.

What is Prostate Cancer?

Prostate cancer is characterized by uncontrolled growth of gland cells in the prostate. While some prostate cancers grow slowly and may need minimal or no treatment, others are more aggressive and can spread quickly to other parts of the body. It is therefore important, especially for older men, to watch out for the early signs and symptoms of this disease and have regular screenings, as there may be no noticeable symptoms during early stages.

What are the Types of Prostate Cancer?

Prostate cancer can be classified into several types based on the cells involved and the aggressiveness of the cancer. Understanding the different types is important for determining the most appropriate treatment and management strategies. Here are the main types of prostate cancer:

Adenocarcinoma

This is the most prevalent type of prostate cancer, accounting for more than 95% of cases. It originates in the glandular cells of the prostate that produce prostate fluid, which is a component of semen. Adenocarcinomas can be further classified based on their growth patterns with acinar adenocarcinoma being the most common subtype. Ductal adenocarcinoma, although less common tends to be more aggressive.

Small Cell Carcinoma

Small cell carcinoma is a rare type of prostate cancer that tends to grow and spread more quickly than other types. It originates from neuroendocrine cells and is typically not associated with elevated PSA levels which can make it more challenging to detect early. Due to its aggressive nature, treatment often involves a combination of chemotherapy, radiation therapy, and sometimes surgery.

Squamous Cell Carcinoma

This type of prostate cancer is very rare and does not originate from the glandular cells of the prostate. Squamous cell carcinoma is typically more aggressive and less responsive to hormone therapy compared to adenocarcinoma. It often presents with urinary symptoms and may require a different treatment approach, including surgery and radiation.

Transitional Cell Carcinoma

This type of cancer starts in the cells lining the urethra (the tube that carries urine from the bladder to the outside of the body) and can spread into the prostate. Transitional cell carcinoma is rare and is often associated with bladder cancer. Treatment usually involves addressing both the primary site and any spread to the prostate.

Neuroendocrine Tumours

These are a group of rare tumours that arise from the neuroendocrine cells in the prostate. They can range from relatively slow-growing tumours to very aggressive forms like small cell carcinoma. Treatment options vary based on the specific type and aggressiveness of the tumour.

Sarcomas

Prostate sarcomas are extremely rare and originate from the connective tissues of the prostate. They tend to be aggressive and may require treatments such as surgery, radiation, and chemotherapy.

What are the Risk Factors and Causes of Prostate Cancer?

While the exact cause of prostate cancer is not well understood, certain risk factors can increase its likelihood. These risk factors can be broadly categorized into those that are non-modifiable (cannot be changed) and those that are modifiable (can be influenced by lifestyle choices).

Non-modifiable Risk Factors

• Age: Prostate cancer is rare in men under 40, but the risk increases significantly after age 50. The majority of prostate cancer cases are diagnosed in men over the age of 65.
• Family history: Having a first-degree relative (father, brother or son) with prostate cancer more than doubles the risk. The risk is even higher if multiple family members are affected or if a family member was diagnosed at a young age.
• Genetics: Certain inherited genetic mutations can increase the risk of prostate cancer. Mutations in the BRCA1 and BRCA2 genes, commonly associated with breast and ovarian cancer, also elevate the risk of prostate cancer. Other genetic conditions, such as Lynch syndrome, can also increase the risk.
• Race or ethnicity: Prostate cancer is more common in African American men than in men of other races. African American men are also more likely to develop prostate cancer at a younger age and have more aggressive forms of the disease. In addition, men of Asian and Hispanic descent have a lower risk compared to Caucasian men.
• Geography: Prostate cancer incidence rates vary by region, with higher rates observed in North America, Europe, Australia and the Caribbean and lower rates in Asia, Africa and South America. Environmental, dietary and lifestyle factors are believed to play a role.

Modifiable Risk Factors

• Diet: A diet high in red meat and high-fat dairy products and low in fruits and vegetables may increase the risk of prostate cancer. Consuming a balanced diet rich in plant-based foods may help lower the risk.
• Obesity: Obesity has been linked to an increased risk of developing advanced prostate cancer. Maintaining a healthy weight through regular physical activity and a balanced diet can reduce this risk.
• Physical activity: Regular physical activity is associated with a lower risk of prostate cancer. Exercise helps maintain a healthy weight and improves overall health, potentially lowering cancer risk.
• Smoking: While the link between smoking and prostate cancer is less clear than for other cancers, some studies suggest that smoking may increase the risk of aggressive prostate cancer. Quitting smoking can improve overall health and reduce the risk of various cancers.
• Chemical exposure: Exposure to certain chemicals, such as those used in farming or in the rubber manufacturing industry, may increase the risk of prostate cancer. Reducing exposure to harmful chemicals and following safety guidelines in the workplace can help mitigate this risk.

Possible Causes and Biological Mechanisms

The development of prostate cancer is believed to result from a combination of genetic, hormonal, and environmental factors:

• Hormonal influence: Androgens, the male hormones such as testosterone, play a crucial role in the growth and function of the prostate. High levels of androgens or changes in androgen metabolism may contribute to the development of prostate cancer.
• Genetic changes: Genetic mutations and alterations in specific genes that control cell growth and division can lead to the uncontrolled growth of prostate cells, resulting in cancer. Research is ongoing to better understand the genetic basis of prostate cancer.
• Inflammation and infections: Chronic inflammation of the prostate (prostatitis) and infections, such as sexually transmitted infections, have been suggested as potential risk factors. The link between inflammation and prostate cancer is still under investigation.
• Environmental and lifestyle factors: Diet, physical activity, chemical exposures, and other lifestyle factors can influence the risk of developing prostate cancer. A healthy lifestyle may help reduce the risk and improve overall health.

While some risk factors for prostate cancer such as age, genetics, and family history, cannot be changed, adopting a healthy lifestyle can help reduce the risk.

What are the Symptoms of Prostate Cancer?

The symptoms of prostate cancer can vary depending on the stage and extent of the disease. In the early stages, prostate cancer often does not cause any symptoms. As the cancer progresses, symptoms may become more apparent, producing various symptoms such as:

Erectile and Ejaculatory Symptoms

• Difficulty achieving or maintaining an erection (erectile dysfunction)
• Painful ejaculation
• Decreased semen volume

Lower Extremity Symptoms

• Swelling or discomfort in the lower limbs
• Numbness or weakness in the legs or feet

Urinary Symptoms (In Advanced-stage Prostate Cancer)

• Difficulty starting urination
• Weak or interrupted urine flow
• Frequent urination, especially at night
• Pain or burning during urination
• Blood in the urine
• Inability to urinate or complete bladder emptying

Other Advanced-stage Prostate Cancer Symptoms

• Pain in the bones, especially the hips, back, or ribs
• Unexplained weight loss
• Fatigue and weakness

Recognizing these symptoms and seeking medical attention early can significantly improve the chances of successful treatment and management of prostate cancer.

When to See a Doctor?

Consulting a doctor for further evaluation is advisable if the symptoms don’t go away or if the person is at a high risk of developing prostate cancer. Even if your symptoms do not seem severe, it is important to seek medical advice if they persist or worsen over time. Early evaluation and diagnosis can lead to better outcomes and more effective treatment.

In addition, if you have a family history of prostate cancer or other cancers, or if you have known genetic mutations (e.g., BRCA1 or BRCA2) that increase the risk of prostate cancer, it is important to discuss this with your healthcare provider.

How is Prostate Cancer Diagnosed?

Diagnosing prostate cancer typically involves a combination of screening tests, diagnostic procedures, and imaging studies to confirm the presence of cancer and assess its extent. Here are the primary methods used to diagnose prostate cancer:

Screening Tests

• Prostate-Specific Antigen (PSA) test: The PSA test measures the level of PSA in the blood. Elevated levels can indicate prostate cancer, though high levels can also be caused by benign prostatic hyperplasia (BPH) or inflammation. This test is a common screening tool, especially for men over the age of 50 or those with risk factors for prostate cancer.
• Digital Rectal Exam (DRE): During a DRE, a healthcare provider inserts a gloved, lubricated finger into the rectum to feel the prostate gland for abnormalities such as lumps or hard areas. It is important to note that while the DRE can detect abnormalities, it is often used in conjunction with the PSA test for better accuracy.

Diagnostic Procedures

• Prostate biopsy: If screening tests suggest the possibility of prostate cancer, a biopsy is typically performed to confirm the diagnosis. In a prostate biopsy, small samples of prostate tissue are removed using a thin needle, usually guided by transrectal ultrasound (TRUS). The tissue samples are then examined under a microscope by a pathologist to determine the presence and grade of cancer cells.
• Transrectal Ultrasound (TRUS): TRUS involves inserting a small probe into the rectum that emits sound waves to create an image of the prostate. It is often used to guide the biopsy needle and can also provide information about the size and structure of the prostate.

Imaging Studies

• Magnetic Resonance Imaging (MRI): MRI can provide detailed images of the prostate and surrounding tissues. The doctor may also prescribe multiparametric MRI (mpMRI) which combines different MRI sequences to better characterize prostate lesions and is often used for targeted biopsies and to evaluate the extent of cancer.
• Computed Tomography (CT) scan: CT scans create detailed cross-sectional images of the body and can help determine if cancer has spread to other organs and are more commonly used for staging rather than initial diagnosis.

Bone Scan

A bone scan can detect whether prostate cancer has spread to the bones, a common site for metastasis. During this test, a small amount of radioactive material is injected into the bloodstream, which collects in areas of abnormal bone growth and is detected by a special camera.

Positron Emission Tomography (PET) Scan

PET scans can identify cancer spread by highlighting areas of increased metabolic activity. PET scans are sometimes used in conjunction with CT scans (PET-CT) to get more comprehensive information.

Additional Tests

• Urine Tests: Tests such as the PCA3 (Prostate Cancer Antigen 3) test can help in assessing the likelihood of prostate cancer.
• Genetic Testing: Genetic tests can identify specific mutations associated with a higher risk of prostate cancer, such as BRCA1 and BRCA2 mutations. These tests can be particularly useful for men with a strong family history of prostate cancer or other cancers.

Diagnostic Pathway

The diagnostic process for prostate cancer often starts with screening tests (PSA and DRE), followed by a biopsy if abnormalities are detected. Imaging studies are used to further evaluate the extent of the disease and assist in staging.

How is Prostate Cancer Graded and Staged?

Understanding the grade and stage of prostate cancer is crucial for determining the most appropriate treatment and predicting the likely course of the disease. Here’s a detailed look at how prostate cancer is graded and staged:

Grading of Prostate Cancer

Prostate cancer is graded based on how the cancer cells look under a microscope, which gives an indication of how quickly the cancer is likely to grow and spread. The most commonly used grading system is the Gleason score.

Gleason Score

• Grade Group 1 (Gleason score 6 or less): The cancer cells look similar to normal prostate cells and are likely to grow slowly.
• Grade Group 2 (Gleason score 7): The cancer cells are more abnormal and moderately aggressive.
• Grade Group 3 (Gleason score 7): Indicates a more aggressive form of cancer.
• Grade Group 4 (Gleason score 8): The cancer cells are very abnormal and are likely to grow and spread more quickly.
• Grade Group 5 (Gleason score 9-10): The most aggressive form of prostate cancer, with a high likelihood of rapid growth and spread.

The Gleason score is determined by adding the two most common patterns of cells observed in the biopsy samples, each scored on a scale of 1 to 5. For example, if the most common pattern is graded 3 and the second most common is graded 4, the Gleason score would be 3+4=7.

Staging of Prostate Cancer

Staging describes the extent of cancer spread in the body. The most widely used system for staging prostate cancer is the TNM (Tumour, Node, Metastasis) system, which takes into account the size and extent of the tumour (T), the involvement of nearby lymph nodes (N), and the presence of metastasis (M).

TNM system

• T (Tumour):

○T1: The tumour is not palpable and is usually found incidentally during surgery for another condition or through a biopsy due to an elevated PSA level.

○T2: The tumour is confined to the prostate and can be felt during a digital rectal exam (DRE).

○T3: The tumour extends beyond the prostate capsule and may involve the seminal vesicles.

○T4: The tumour has spread to nearby tissues such as the bladder, rectum, or pelvic wall.

• N (Nodes):

○N0: No regional lymph node involvement.

○N1: The cancer has spread to nearby lymph nodes.

• M (Metastasis):

○M0: No distant metastasis.

○M1: The cancer has spread to distant parts of the body, such as bones, liver, or lungs.

Staging Groups

• Stage I: Cancer is confined to the prostate, not palpable, and with a low Gleason score.
• Stage II: Cancer is still confined to the prostate but may be palpable and has a higher Gleason score.
• Stage III: Cancer has spread beyond the prostate capsule to nearby tissues.
• Stage IV: Cancer has spread to nearby lymph nodes or distant parts of the body.

Prognostic Factors

In addition to the TNM stage and Gleason score, other factors influence the prognosis and treatment approach, including:

• PSA Level: The level of prostate-specific antigen in the blood at diagnosis.
• Percentage of Positive Biopsy Cores: The proportion of biopsy samples that contain cancer.
• Genomic Testing: Testing for specific genetic mutations that may influence treatment decisions.

By accurately grading and staging prostate cancer, healthcare providers can develop a tailored treatment plan that offers the best chance for successful management and improved quality of life.

What is Early-stage Prostate Cancer?

Early-stage prostate cancer refers to cancer that is confined to the prostate gland and has not spread to other parts of the body. It is typically classified as Stage I or Stage II prostate cancer. Early-stage prostate cancer often grows slowly and may not cause noticeable symptoms, which is why regular screening is important for early detection.

Characteristics of Early-stage Prostate Cancer

Stage I prostate cancer

• Tumour: The cancer is small and localized within the prostate. It may not be detectable through a digital rectal exam (DRE) but could be found incidentally during a procedure for another condition or through a prostate-specific antigen (PSA) test.
• PSA levels: Typically, PSA levels are relatively low.
• Gleason score: The Gleason score is usually 6 or lower, indicating a less aggressive form of cancer.

Stage II prostate cancer

• Tumour: The cancer is still confined to the prostate but is larger than in Stage I and may be detectable through a DRE.
• PSA levels: PSA levels may be higher than in Stage I.
• Gleason score: The Gleason score ranges from 6 to 7, indicating a moderate to slightly higher risk of progression compared to Stage I.

Prognosis of Early-stage Prostate Cancer

The prognosis for early-stage prostate cancer is generally very good, with high survival rates. Many men with early-stage prostate cancer live for many years without the disease progressing. Regular follow-up and monitoring are essential to ensure that any changes in the cancer's status are detected early and managed appropriately.

How is Prostate Cancer Managed or Treated?

The management and treatment of prostate cancer depend on several factors, including the stage and grade of the cancer, the patient’s age and overall health, and personal preferences. Here are the main approaches to managing and treating prostate cancer:

Active Surveillance

Suitable for men with very low-risk or low-risk prostate cancer, active surveillance involves closely monitoring the cancer without immediate treatment. During the surveillance period, PSA tests, digital rectal exams (DRE) and biopsies are conducted at regular intervals to track cancer progression, and treatment is initiated only if the cancer is progressing.

Radiation Therapy

• External Beam Radiation Therapy (EBRT): EBRT involves the use of high-energy rays or particles to kill cancer cells. Typically given five days a week for several weeks, the therapy is suitable for localized prostate cancer and as an option for men who prefer a non-surgical approach.
• Brachytherapy (Internal Radiation Therapy): This therapy involves placing radioactive seeds or pellets directly into the prostate using a permanent (low-dose rate) or temporary (high-dose rate) implant. It causes less damage to surrounding tissues compared to EBRT.

Hormone Therapy

Androgen Deprivation Therapy (ADT): This therapy is used to reduce the levels of male hormones (androgens) that can promote cancer growth, which can be achieved through medications (such as luteinizing hormone-releasing hormone (LHRH) agonists or antagonists) or surgical removal of the testicles (orchidectomy). ADT is often used in advanced-stage prostate cancer or in combination with radiation therapy for high-risk cases.

Chemotherapy

Chemotherapy involves the use of drugs to kill rapidly dividing cancer cells, and is typically used for advanced prostate cancer that has spread to other parts of the body and is not responding to hormone therapy. Common chemotherapy drugs for prostate cancer include docetaxel and cabazitaxel.

Targeted Therapy

Targeted therapy uses drugs that specifically target cancer cells with certain genetic mutations or abnormalities. PARP inhibitors (such as olaparib) are used for prostate cancers with specific genetic mutations, such as BRCA1 or BRCA2.

Immunotherapy

Uses the body’s immune system to fight cancer. Under this, the doctor may prescribe Sipuleucel-T (Provenge), a vaccine used to treat advanced prostate cancer by stimulating the immune system to attack prostate cancer cells.

Focal Therapies

• Cryotherapy (Cryosurgery): Involves freezing and destroying prostate cancer cells and is used for localized prostate cancer or cancer that recurs after radiation therapy.
• High-Intensity Focused Ultrasound (HIFU): Uses focused ultrasound waves to heat and destroy cancer cells and is generally an option for localized prostate cancer.

Surgery

• Radical prostatectomy: This involves the removal of the entire prostate gland and some surrounding tissue including the seminal vesicles. It is suitable for men with localized prostate cancer who are in good health and have a longer life expectancy. It can be performed using either open surgery, laparoscopic surgery or robot-assisted laparoscopic surgery but robot-assisted laparoscopic surgery is the gold standard. It is a minimally invasive surgery where the robotic arms, are easily able to reach deep into the pelvis where the prostate is located, through small incisions. Its helps in removal of prostate with great precision due to its three dimensional magnified image and improved range of motion offered by the robotic arms. We at Max hospitals have the latest da Vinci Robotic System which leads to shorter operative time, minimal blood loss, less pain and faster recovery of the patient. Most of our patients go back home within 48 to 72 hours post procedure.
• Transurethral Resection of the Prostate (TURP): Used to relieve symptoms caused by an enlarged prostate rather than to treat cancer itself, this surgery involves removing part of the prostate tissue through the urethra.

Palliative Care

• Focuses on relieving symptoms and improving quality of life for patients with advanced prostate cancer. This can involve pain management, psychological support, and other supportive care measures.

Choosing the Right Treatment

The choice of treatment depends on various factors, including:

• The stage and grade of the cancer.
• The patient’s age, overall health and life expectancy.
• The potential side effects and impact on quality of life.
• Personal preferences and values.

A multidisciplinary team of healthcare providers, including urologists, oncologists, radiologists and other specialists, typically collaborate to develop a personalized treatment plan for each patient. Regular follow-up and monitoring are essential to assess the effectiveness of the treatment and make necessary adjustments.

Final Words

Prostate cancer is a complex disease that requires careful attention and specialized medical care. While early detection and timely treatment are crucial for managing the disease effectively and improving outcomes, understanding the risk factors, recognizing the symptoms and being informed about the various treatment options can empower men to take control of their health. If you have any concerns about prostate cancer or are at higher risk, it is advisable to consult with a specialist as soon as possible. Max Hospitals, with a team of experienced oncologists and advanced medical facilities, is committed to providing personalized care and cutting-edge treatment solutions for all types of cancer, including prostate cancer. Don't hesitate to reach out to Max Hospitals for expert advice and comprehensive care tailored to your specific needs.