Despite
the intense publicity in the past ten years regarding prostate cancer(CaP) screening,
still many men do not take advantage of these simple screening procedures. A
yearly visit to your physician, or perhaps preferably your urologist with a
simple digital exam of the rectum(DRE) and a PSA blood test can detect prostate
cancer early, in it’s most curable stages most of the time. I suspect that
of the 40,000 men dying each year in the U.S. of prostate cancer, very few of
them were having yearly examinations. These examinations should start preferably
by age 40 for the DRE with the PSA tests starting at age 50 unless you are at
higher risk, in which case the PSA testing will also start at around age 40.
Who is at higher risk? African American men, and those men of any ethnic background
who have a family history of CaP.
When
the urologist is in a position to have some reason to suspect that you could
have prostate he cancer a biopsy will usually be recommended. This is generally
an office procedure that takes less than 10 minutes. There is some very temporary
discomfort associated with the biopsy, but it generally does not last any time
at all. If the biopsy reveals CaP, there will be a GRADE assigned to it called
the Gleason score. This is a scoring of the severity of the cancer and does
have some prognositic significance. The score can be between 2 and 10, with
the vast majority being either 6’s or 7’s. The prognosis, or the seriousness
if you will, of the 7, is greater than with the 6, or of course with a 5 or
a 4 etc. We occasionally STAGE the tumors as well. This refers to testing to
try to see whether there is any evidence of spread away from the prostate itself.
If the Gleason score is not very high, and/or the PSA not very high, X-rays,
CT scans and bone scans are not often done. If for any reason the urologist
suspects there could be spread, any and all of these tests can be done. We rarely
do these tests when the PSA is less than 10 however because the yield is so
low.
Once
a diagnosis is made that you have CaP it is time to look at treatment options.
We first try to assess whether it appears the patient is potentially curable
or not. If there is evidence of spread of the disease, the cancer cannot be
cured, but can certainly be treated. If we believe that cure is possible we
are looking at two options; surgery or radiation therapy. Surgical removal of
the prostate (Radical Prostatectomy-see below for post operative considerations)
generally offers the greatest chance for permanent cure. In this operation the
entire prostate is removed. The hospitalization for this operation is typically
3 to 5 days, and time off from normal activities, about 3 weeks. The potential
downsides of the surgery are basically two; a small number of men will lose
bladder control, usually less than 3-5%. More than half the men will have a
decrease in their erection capabilities. Both of these potential effects are
almost always curable with other treatments. (See incontinence, impotence, artificial
sphincter this web site). Radiation therapy is commonly offered to men over
the age of 70 or so, or those who we feel might not be able to undergo the surgery.
There are two commonly used forms of radiation therapy; brachytherapy or radioactive
seed implantation, or external beam radiotherapy. Both of these have their places
in the management of men with CaP. When radiation therapy is contemplated, the
radiation therapy physician will often want the patient to be on hormone treatments
for some period of time prior to the radiation treatment. More on hormone therapy
below, but, the reason this is often recommended is that accumulated data seems
to indicate a definite benefit for some men as far as the success of radiation
therapy. Side effects of radiation are the same as for surgery, but bothe consequences,
impotence and incontinence, are less common than with surgery. The ill effects
of radiation can affect the structures nearby the prostate, and these effects
can sometimes pose problems for the patient. Your radiation oncologist will
gov over this with you in detail prior to beginning therapy. The greatest drawback
of radiation is that it does not offer the same long-term cure rates as does
surgery.
In the
situation where the prostate cancer has spread beyond the prostate, cure is
not possible, but a lot can be done to prolong life, put the cancer into remission,
and improve the quality of life of the CaP patient. First line therapy is
hormone treatment. Male hormone, testosterone is the driving force stimulating
prostate cancer. For this reason, hormone treatments are aimed at lowering
the level of male hormone in the patient. Commonly used combinations include
the Injectable drugs Lupron or Zoladex, often combined with pills taken daily
such as Casodex, Nilandron or Eulixin. Surgical removal of the testicles,
orchiectomy, will accomplish the same goal as these medical therapies, and
is considerably less expensive. These treatments can be continued for long
periods of times, months and even years. When the hormone treatments are no
longer effective, other methods of chemotherapy can be used, and this is a
constantly changing field of medicine. Unfortunately, although a lot of chemotherapy
agents have been used, none of them is highly successful. Certainly none are
as effective as hormone manipulation. Certain effects of CaP can occur in
later stages such as bone pain, and we have very specific methods to manage
these problems.
We now
do very well in our management of CaP, and only about 25% of men diagnosed
with CaP will die of the cancer. The remainder die of other causes totally
unrelated…heart disease, strokes, accidents etc. However, one of the
most troubling problems we as urologists face is the fact that so many men
do not take advantage of the simple yearly screening. If you will simply see
your doctor once a year and have the DRE and PSA tests, the chance of your
demise due to CaP is very low.
No discussion
of prostate cancer would be complete without looking at preventive issues.
Some drugs and supplements may be helpful in prevention. There is solid evidence
that Selenium at a dose of 200 micrograms per day helps prevent CaP. Other
benefits are seen from Vitamins C,D and E. A diet low in saturated fats, high
in lycopenes and soy seems to be of benefit. Finally there may be benefit
from the prescription drugs Vioxx and Proscar(see BPH this web site) Neither
of these has yet to be proven, but the evidence is there. Of all of these
options, selenium seems to be a “no-brainer,” it’s cheap, safe,
and the data in support of it’s use is quite strong.
Most
men will go home about 3-4 days after surgery. By the time you go home you will
be eating a regular diet, you will have very little discomfort, and you will
be starting to feel good again. Your major nuisance will be your catheter which
I will leave in your bladder usually for a couple of weeks. The main precaution
that I want you to observe is…..DON’T DO ANYTHING THAT COULD CAUSE
YOUR CATHETER TO BE PULLED OUT!! You can see, I feel this is very important.
The catheter needs to stay put to allow proper healing where the bladder and
urethra have been stitched together. For these reasons I really don’t want
you going out in the car, to the mall, to eat, to visit etc. I know it may be
a little boring to stay home for 2 weeks, but I don’t want you to chance
anything. What can you do? Limited exercise, walking around outside is fine,
but nothing extensive. I will send you home with pain pills if you need them,
antibiotics for a short time. You may eat a regular diet, and drink fluids as
before. Avoid constipation…use a mild laxative if needed. Things that would
mean a call to me might include significant pain or swelling anywhere, fever,
pain or swelling in the legs, significant blood in the urine, or anything that
seems improper to you. I will see you at about 2 weeks after you leave the hospital.
At this time I nearly always remove the catheter. There will almost always be
a little urine leakage when the catheter comes out. For this reason I want you
to bring one adult diaper with you for that visit. We will put it on you to
wear under your underwear when you go home. As soon as bladder control returns
to normal, throw away the diapers. Any questions not answered here will be answered
for you by Dr. Mobley or the staff.