Prostate Cancer Treatment in Delhi, India

Prostate cancer is a type of cancer that develops in the prostate, a small, walnut-sized gland located below the bladder in men. Prostate cancer occurs when malignant (cancerous) cells develop in the tissues of the prostate. It is one of the most common cancers in men. It is usually seen in men after the age of 50 years but the risk increases with increasing age. Prostate cancer can spread to local tissues around the prostate, to lymph nodes and distant sites, most commonly bones.

The type of prostate cancer helps tell which type of cell the cancer started in. The most common type is adenocarcinoma of the prostate, which starts in the gland cells of the prostate. Doctors use the information about prostate cancer type, along with how abnormal the cancer cells look under the microscope (the grade of the cancer) and the size of the cancer to decide which treatment is best for the patient. Here are the types of prostate cancers an individual might develop.

Adenocarcinoma of the Prostate

This is the most common type, accounting for the vast majority of prostate cancer cases. Adenocarcinoma originates in the gland cells of the prostate and typically grows slowly. It often resembles normal prostate tissue when viewed under a microscope.

There are two main types of adenocarcinoma of the prostate:

• Acinar Adenocarcinoma of the Prostate: This is the most common type of prostate cancer, accounting for over 95% of cases. It develops in the gland cells that line the prostate gland.
• Ductal Adenocarcinoma of the Prostate: Ductal adenocarcinoma starts in the cells that line the tubes (ducts) of the prostate gland. It tends to grow and spread more quickly than acinar adenocarcinoma.

Transitional Cell Carcinoma of the Prostate

Transitional Cell Carcinoma, also known as Urothelial Carcinoma, is a type of cancer that predominantly affects the urothelial cells lining the urinary tract. It is most commonly associated with bladder cancer, where the urothelial cells line the inner surface of the bladder. However, in rare instances, transitional cell carcinoma can develop in the prostate gland, where these cells may exist in smaller quantities.

Squamous Cell Carcinoma of the Prostate

These cancers originate from flat, thin cells that form the surface lining of the prostate. Unlike the more common adenocarcinoma of the prostate, squamous cell carcinomas tend to exhibit a faster growth rate and a higher tendency to spread to surrounding tissues and distant organs. Squamous cell carcinoma of the prostate is relatively rare, making up a small proportion of all prostate cancer cases. However, due to its aggressive nature, it often requires a different approach to diagnosis and treatment.

Small Cell Prostate Cancer

Small cell carcinoma of the prostate is a less common and more aggressive type. It is composed of small, tightly packed cancer cells and tends to grow and spread rapidly. Small cell carcinoma usually requires different treatment approaches compared to adenocarcinoma.

Though the exact causes of prostate cancer are unknown; the following factors may increase the risk of prostate cancer: Some of the key factors associated with an increased risk of prostate cancer include:

• Old Age: Prostate cancer is more common in older men, with the risk increasing as men age.
• Family History: Having close relatives, such as a father or brother, with prostate cancer raises an individual's risk.
• Swelling or Inflammation of the Prostate: Chronic inflammation of the prostate, known as prostatitis, may contribute to an elevated risk of developing prostate cancer.
• Obesity: Obesity is linked to a higher risk of aggressive prostate cancer.
• Eating High Fatty Food: Diets high in red and processed meats, along with a low intake of fruits and vegetables, may increase the risk of prostate cancer.
• Smoking: Smoking is associated with an elevated risk of various cancers, including prostate cancer.
• Low Level of Vitamin D: Some studies suggest that low levels of vitamin D may be linked to an increased risk of prostate cancer, although more research is needed to establish this relationship definitively.

It's important to note that while these factors may increase the risk of prostate cancer, many men with these risk factors do not develop the disease, and some men without these risk factors do. Regular screenings, early detection, and consulting with a healthcare professional are crucial for assessing individual risk and making informed decisions about prostate cancer prevention and treatment.

Symptoms of prostate cancer are initially not different from non-cancerous enlargement of prostate (BPH). However, when it becomes advanced additional symptoms can occur. Some of the common symptoms of prostate cancer are:

• Frequent Urination.
• Facing difficulties in starting or stopping when trying to urinate or urinating.
• Constant need of urination, especially at night.
• A painful or burning sensation while urinating or ejaculating.
• Blood in urine or semen.
• Erectile dysfunction.
• Change in bowel habits.
• Unexplained weight loss.
• Fatigue
• Back pain, hip pain or pelvic pain.

These symptoms can also be caused by other conditions, such as benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate. However, if a person experiences any of these symptoms, it is important to see a doctor to rule out prostate cancer.

Early detection and treatment of prostate cancer are essential for improving outcomes. If a person has any concerns about their risk of prostate cancer, they should talk to their doctor. Their doctor can help them assess their risk and make recommendations for reducing their risk and screening for the disease.

If prostate cancer is suspected, initial evaluations include a physical examination and specific tests to determine the need for further diagnostics.

Prostate-specific Antigen (PSA) Test

This blood test measures PSA levels, a protein produced by the prostate. Elevated PSA levels can result from various prostate conditions, including cancer. The test considers PSA values, changes over time (PSA velocity), and levels relative to prostate size to guide the decision for a biopsy.

Free PSA Test

A variation of the PSA test measures "free" PSA, the unbound form of the protein. The ratio of free PSA to total PSA can help assess the likelihood of malignant conditions like prostate cancer.

Digital Rectal Exam (DRE)

In a DRE, a physician uses their finger to physically examine the prostate. While not highly precise, it can identify irregularities in the prostate. DRE is less effective in detecting early prostate cancer.

Biomarker Tests

Biomarkers are substances found in blood, urine, or tissues that signal cancer presence. Tests like the 4Kscore and Prostate Health Index (PHI) predict the likelihood of high-risk prostate cancer.

Genomic Testing

Genomic tests, such as Oncotype Dx Prostate, Prolaris, Decipher, and ProMark, provide additional insights for managing prostate cancer. They are valuable when deciding treatment approaches for certain low-risk or intermediate-risk localised prostate cancer cases, especially in the context of active surveillance or post-surgery considerations (prostatectomy). Biomarker results should always be assessed alongside other available information.

Biopsy

To conclusively diagnose prostate cancer, a biopsy is performed. Typically guided by transrectal ultrasound (TRUS), this procedure extracts small samples of prostate tissue for microscopic examination. Biopsy specimens are collected from various areas of the prostate to ensure a comprehensive analysis. The entire procedure typically takes 20 to 30 minutes, and around 12 to 14 tissue samples are obtained.

Patients are encouraged to consult with their healthcare providers to gain a comprehensive understanding of the significance of biomarker tests, the potential implications for their treatment plans, and how these tests may or may not impact their prostate cancer management. In cases where PSA or DRE results indicate abnormalities, further tests are employed to definitively confirm the presence of prostate cancer.

The treatment choices for prostate cancer are determined by various factors, such as how quickly the cancer is growing, whether it has spread to other body parts, overall health of the patient, and the potential benefits and side effects of the treatment. There are many different treatment options available in India, and the best treatment for each patient will depend on their individual circumstances. Commonly prescribed treatments include:

Surgery

Prostate cancer surgery, known as radical prostatectomy, involves the removal of the prostate gland, surrounding tissue, and a few lymph nodes. It is a treatment option for prostate cancer that is localised within the prostate. In some cases, surgery is combined with other treatments to address advanced prostate cancer.

Surgeons access the prostate through two primary techniques:

• Robot-Assisted Laparoscopic Prostatectomy: This minimally invasive approach involves creating small incisions in the abdomen. Surgical instruments are connected to a robotic device, which is inserted through these incisions. The surgeon controls the robot from a console, guiding the instruments. Most prostate cancer surgeries are conducted using this method.
• Retropubic Surgery: In this less common approach, the surgeon makes a single long incision in the lower abdomen to access and remove the prostate gland. This technique may be necessary in specific situations.

Both methods are aimed at effectively treating prostate cancer, with the choice of technique depending on the patient's individual circumstances and the stage of the cancer.

If cancer has not spread outside the prostate gland, radical prostatectomy is performed, in which a surgeon removes the entire prostate gland along with the tissues around it. Such surgery can be carried out by laparoscopic approach or by robotic approach leading to less patient discomfort and faster recovery.

Radiation Therapy

Radiation uses high-energy x-rays, gamma rays or particles to destroy cancer cells. Radiation therapy can be divided into external beam radiation and brachytherapy (internal radiation). In external radiation therapy, high-energy x-ray beams are directed at a tumour from outside the body. In case of internal radiation, doctors for prostate cancer treatment in India will place a radioactive source directly inside or near the tumour.

Hormone Therapy

Hormone therapy is used for reducing the level of male hormones (androgens) as well as restrain them from affecting the prostate cancer cells. It is also called Androgen Deprivation Therapy (ADT) and Androgen Suppression Therapy. Lower androgen levels lead to shrinkage in the size of the prostate cancer and restrict their growth.

Chemotherapy

Chemotherapy is becoming increasingly prominent in the realm of prostate cancer treatment, particularly in cases of high-grade prostate cancer. In this treatment approach for prostate cancer, specific drugs are administered to the patient either through injections into the bloodstream or oral medications. These drugs have the primary purpose of targeting and effectively eliminating cancer cells while also working to reduce the size of the tumour. High-grade prostate cancer is characterised by cancer cells that are more aggressive and tend to grow and spread at a faster rate, making it essential to employ advanced treatment strategies like targeted drug therapies to combat the disease effectively.

Vaccination

Sipuleucel-T (Provenge) is a cancer vaccination given to boost the body's immune system to attack the prostate cancer cells. This vaccine is specifically made for every patient with the help of their white blood cells.

Active Surveillance

In many cases, prostate cancer grows slowly, and therefore, immediate medical intervention may not be required. Watchful waiting or active surveillance approach is applicable for low-grade prostate cancers. It means that the cancer is monitored closely by keeping a tab on the changing symptoms and doing regular testing to decide the need for further treatment.

Just as prostate cancer treatment affects physically, it also affects the way the patient thinks and feels. While a patient will be happy to know that it is the end of the treatment, deep inside there will be a fear of its recurrence. Just as it is essential to take care of the body after the treatment, it is essential to take care of the emotions too. It is the time to take care of your mental health, and the following tips would help:

 
• Share your feelings with your loved ones.
• Eat a balanced diet.
• Maintain a healthy weight.
• Add any physical activities, like yoga, exercise, etc., to your daily routine.
• Vent out both your positive and negative emotions.
• Keep yourself busy in those activities which can take your mind off your fears.
• Rest well.

You may expect the worst when it’s time for your next follow-up appointments after prostate cancer treatment. However, don’t let that feeling stop you from going. Make use of the time to discuss your current health state and ask questions about any signs or symptoms that worry you.

Your doctor may also conduct some tests to get a better idea of your current health state. Ask about your fear of recurrence and what signs to watch for. Follow-up appointments help you know more about your health which will undoubtedly give better control over the situation.

1. Is prostate cancer curable?

Prostate cancer can often be treated successfully, especially when detected early. However, a complete cure may not always be possible, and some cases may require ongoing treatment to manage the disease effectively.

2. How can I lower my risk of developing prostate cancer?

While it is not possible to completely prevent prostate cancer, certain measures can help reduce the risk. These include maintaining a healthy diet and healthy weight, engaging in regular physical activity, and minimising exposure to potentially harmful chemicals and toxins.

3. What is PSA, and why is it used for prostate cancer screening?

PSA stands for prostate-specific antigen, which is a protein produced by the prostate gland. A PSA is a simple blood test which is commonly used as a screening tool for prostate cancer, as elevated levels of PSA in the blood can indicate the presence of the disease.

4. What is a biopsy, and why is it performed to diagnose prostate cancer?

A biopsy involves taking a small sample of tissue from the prostate for microscopic examination. This procedure is the most reliable way to diagnose prostate cancer, as it allows doctors to analyse the tissue for the presence of cancer cells.

5. Can prostate cancer recur after treatment?

In some cases, prostate cancer may recur after initial treatment, especially if the cancer was not completely eradicated or if it was advanced at the time of diagnosis. Regular monitoring and follow-up check-ups are crucial for detecting any recurrence.

6. What is the most common treatment for localised prostate cancer?

The most common treatment for localised prostate cancer is typically a choice between active surveillance, surgery (prostatectomy), or radiation therapy.

7. What is the best way to remove prostate cancer?

The primary methods for the removal of prostate cancer include radical prostatectomy (surgery), radiation therapy, and sometimes, hormone therapy.

8. How common is prostate cancer?

Prostate cancer is one of the most prevalent cancers in men, with the risk increasing with age. It is the second most common cancer worldwide.

9. What stage of prostate cancer requires surgery?

Surgery is generally recommended for localised prostate cancer, which typically corresponds to Stages I and II.

10. Is benign prostatic hyperplasia serious?

Benign prostatic hyperplasia (BPH) is generally not considered a serious condition. However, it can cause urinary problems and discomfort.

11. What are the warning signs of prostate enlargement?

Warning signs of prostate enlargement (often due to BPH) include frequent urination, difficulty starting and stopping urination, weak urine stream, and a feeling of incomplete bladder emptying.

12. Are prostate problems always a sign of prostate cancer?

Not all prostate problems are indicative of prostate cancer. Many prostate issues, such as benign prostatic hyperplasia (BPH) or prostatitis, are not cancerous.

13. How can I prevent prostate cancer?

Preventative measures for prostate cancer include maintaining a healthy lifestyle, a balanced diet, regular exercise, and early detection through screenings.

14. What is the prognosis (outlook) for people with prostate cancer?

The prognosis for people with prostate cancer varies depending on factors such as the stage, grade, and individual characteristics of the cancer. Many cases have a favourable outlook when detected and treated early.

15. Can you refer me to another prostate cancer specialist for a second opinion?

Seeking a second opinion from another prostate cancer specialist is advisable to ensure comprehensive assessment and treatment options.

16. What are the treatment options for 4th stage prostate cancer?

Treatment options for 4th stage (metastatic) prostate cancer may include hormone therapy, chemotherapy, targeted therapy, immunotherapy, or palliative care.

17. How to decide between radiation and surgery for localised prostate cancer?

The choice between radiation and surgery for localised prostate cancer depends on various factors, including the cancer's stage, the patient's overall health, and personal preferences. Both options have their advantages and considerations.

18. What is the success rate of TURP surgery?

The success rate of Transurethral Resection of the Prostate (TURP) surgery depends on factors such as the patient's specific condition and the skill of the surgeon. Typically, it is an effective procedure for relieving urinary symptoms associated with an enlarged prostate. Success rates may vary, but many patients experience improved urinary function.

Reviewed by Dr. Debashish Chaudhary - Principal Consultant, Surgical Oncology, Cancer Care / Oncology, Gastrointestinal & Hepatobiliary Oncology, Gynecologic Oncology, Breast Cancer on 15-Dec-2023.

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