Prostate Cancer

Prostate cancer is cancer that affects the prostate gland located near the bladder and between the male genital organs.

Prostate cancer is the second most common cancer in men, after skin cancer, and the second leading cause of cancer death in men, after lung cancer.

As with many types of cancer, early detection and treatment improve the prospects for cure. Additionally, prostate cancer is a type of cancer that grows slowly.

When it develops very late in life, as is frequently the case, the impact of the disease may be minimal. In fact, many men with prostate cancer eventually die from causes unrelated to the cancer itself.

Therefore, diagnostic procedures and treatments for prostate cancer must be carefully planned by each man with his urologist to avoid excessive procedures that do not improve quality of life.

The prostate is one of the male sex glands. It is a small gland (about the size of a walnut) and serves to produce seminal fluid, which forms part of semen or sperm. It is located above the rectum and below the urinary bladder.

The prostate surrounds the urethra (the tube that carries urine from the bladder to the penis) like a kind of "float," at the point where the urethra connects to the bladder. Therefore, when the prostate enlarges, there are difficulties with urination or sexual relations.

Prostate cancer occurs more frequently in older men. The prostate continues to grow during most of a man's life, so it is very common to develop after age 60 a benign condition called "enlarged" prostate or benign prostatic hyperplasia (BPH), which is much more common than prostate cancer. Many of the signs and symptoms of BPH are the same as those of prostate cancer.

The main risk factors for prostate cancer development are:

• Age: Prostate cancer rarely occurs before age 55. Most men diagnosed are 65 years or older. Prostate cancer is becoming more common, possibly because men are living longer.
• Black race: African Americans living in America have the highest rate of prostate cancer in the world, for unknown reasons.
• Family history (father, brother, uncle) of prostate cancer.
• Presence of genes associated with cancer.
• Other unconfirmed factors that could play a role in this type of cancer are:
  • Diet high in animal fats and low in vegetables, especially cruciferous vegetables (broccoli, cauliflower, cabbage).
  • Consumption of omega-3 fatty acids (promote body inflammation if not balanced with omega-6).
  • Alcohol consumption.
  • Obesity.
  • Smoking.
  • Infections, especially trichomonas that cause chronic inflammatory conditions called prostatitis.

It is unclear whether other factors such as sexually transmitted infections, chemical substances, or vasectomy are associated with prostate cancer.

There is no known recommendation that serves to prevent prostate cancer.

However, it has been observed that people who consume lycopene in their diet (tomato and watermelon) and phytoestrogens such as those found in soy could have lower risk of prostate cancer.

Coffee and vigorous physical activity are also associated with fewer cases of prostate cancer.

In its earliest stage, prostate cancer may not produce signs or symptoms. As the tumor grows, certain signs or symptoms may be noticed, including:

• Difficulty starting or stopping urination.
• Reduced force of urine stream.
• Dribbling at the end of urination.
• Painful or burning urination.
• Urinating small amounts frequently, especially at night.
• Painful ejaculation.
• Blood in the urine.
• Blood in the semen.
• Inability to urinate.
• Persistent pain in the lower back, pelvis, or upper thighs.

There are several ways to detect prostate cancer:

1. Digital rectal examination. Also called digital prostate examination. By inserting a gloved finger into the rectum, the physician palpates the prostate surface through the intestinal wall. The normal prostate has characteristic size, shape, and consistency. Alterations such as suspicious masses, abnormal textures, or hardness will lead to further investigations.
2. Prostate-specific antigen (PSA). It is a protein produced in the prostate that may be elevated when cancer is present. PSA levels in blood can help the physician monitor a patient with prostate problems.
3. Prostate puncture/biopsy. The only way to determine if a suspicious mass is prostate cancer is to examine microscopically a tissue sample taken from the area. This sample can be extracted with a needle placed directly into the prostate through the rectum or perineum (the space between the scrotum and anus). This procedure is called a fine-needle aspiration (FNA) or a needle biopsy. A biopsy can also be obtained through surgery.
   If cancer exists, several other procedures, including X-rays, laboratory tests, and computerized diagnostic radiology procedures will be useful in determining the extent of the disease.

Although the PSA test is a valuable tool, defining a precise protocol for when to perform it has proven complicated.

Likewise, the digital rectal examination is dependent on the experience of the physician performing it and should always be compared with the prostate-specific antigen test.

If a man has symptoms of prostate abnormalities, he should undergo these examinations at any age.

In men without symptoms, the decision to perform these tests is somewhat more complex.

It should be taken into account that an elevated result on the PSA test or an abnormal finding on digital rectal examination may lead to invasive procedures such as rectal biopsies, surgeries, or radiotherapy that, in some cases, may cause sequelae in the urinary system, rectum, or even cause sexual impotence.

Additionally, there is a risk of unnecessary treatments being performed in young men if it is erroneously concluded that there was cancer, or that diagnosis occurs too late when the tumor has already metastasized and no treatment is useful.

Given this complexity, numerous urology associations have proposed using the PSA test mandatorily in asymptomatic men at high risk of developing aggressive prostate cancer at early ages, especially starting at age 40.

For these cases, an annual urological evaluation including digital rectal examination along with the PSA test is recommended, particularly in these groups:

• Black men.
• Men with BRCA2 gene variants (and, to a lesser extent, BRCA1).
• Men with direct family history, such as a father or brother diagnosed with prostate cancer.

On the other hand, American associations suggest that asymptomatic men between 55 and 69 years old who do not belong to these risk groups should consult with their physician to evaluate the advisability of performing the test, with it being essential that they understand the possibility of obtaining false results, both positive and negative.

In Europe, these examinations are evaluated starting at age 50.

Ultimately, the decision to undergo the examinations rests with the man himself and could be done annually or every two years.

Likewise, preventive digital rectal examination or PSA testing is not recommended after age 70, as it does not improve survival because prostate cancer grows very slowly at this age, and the risk of complications may be increased if excessive medical procedures are performed.

The different stages in which prostate cancer can be found are:

Stage I (A). Prostate cancer at this stage cannot be felt and does not cause any symptoms. The cancer is found only in the prostate and is detected incidentally.

Stage II (B). Cancer cells are found only in the prostate gland. The tumor can be detected through needle biopsy or simple digital rectal examination.

Stage III (C). Cancer cells have spread outside the lining (capsule) of the prostate to surrounding tissues.

Stage IV (D). Spread (by metastasis) to lymph nodes (near or distant from the prostate) or to organs and tissues located far from the prostate -bones, liver, or lungs-.

Recurrence. The cancer reappears after being treated. It may reappear in the prostate or in another part of the body.

T.N.M. CLASSIFICATION. Prostate cancer can also be classified using T (tumor size), N (degree of spread to lymph nodes), and M (extent of spread to other parts of the body).

Prostate cancer treatment is highly individualized, and many factors must be considered, especially:

• The stage of the disease.
• The patient's general medical history.
• Age.
• Overall health status.
• Life expectancy.

1. SURGERY. Surgery for prostate cancer ranges from removing only the cancerous growth to removal of the entire prostate and surrounding lymph nodes.

   Radical prostatectomy. This involves removal of the prostate and part of the surrounding tissue. Surgery can be performed through an incision in the space between the scrotum and anus (perineal prostatectomy) or through an incision in the lower abdomen (retropubic prostatectomy). Radical prostatectomy is performed only if the cancer has not spread outside the prostate.

   In some cases of advanced prostate cancer, removal of the testicles may be indicated, as these two glands are the main producer of the male hormone testosterone in the body, which stimulates prostate cancer growth.

   The main side effects of prostate removal are impotence (inability to have or maintain an erection) and urinary incontinence (inability to control urinary function). These are usually temporary, but in some cases may be permanent.

2. TRANSURETHRAL RESECTION. This involves removal of prostate cancer using an instrument that is inserted into the prostate through the urethra. This operation is sometimes performed to relieve symptoms caused by the tumor before applying another treatment, or in men who cannot tolerate radical prostatectomy due to age or other disease.

3. CRYOSURGERY. A type of surgery in which cancer is destroyed by freezing.

4. OTHER THERAPIES. In addition to surgery, one or more of the following may be indicated to treat prostate cancer:

   • Ionizing radiation (Radiotherapy).
   • Anti-cancer medications ("poisons") (Chemotherapy).
   • Hormones (Hormone therapy).
   • Biological therapy or Immunotherapy (use of the body's immune system to fight cancer).

Hormone therapy or Androgen Deprivation Therapy (ADT). Male hormones (especially testosterone) can contribute to prostate cancer growth. To stop cancer growth, female hormones (estrogens) or medications called LHRH agonists that reduce the amount of male hormones can be administered. The reason is the same as sometimes leads to removal of the testicles (orchiectomy) in order to prevent them from producing testosterone. This treatment is generally used in men with advanced prostate cancer.

The purpose of biological therapy or biological response modifier therapy (BRM) is to try to get your own body to fight the cancer. This uses materials produced by the body itself (or identical laboratory syntheses) to strengthen, direct, or restore the body's natural defenses against disease.

Prostate cancer treatment depends on the stage of your disease, your age and overall health, and is highly individualized.

In each case, the most sensible options of surgery, radiation therapy, hormone therapy, and biological therapies will be combined. Chemotherapy has not proven to be of great utility in prostate cancer.

The 5-year survival rate is 85% for patients with prostate cancer whose cancers are discovered at an early stage, and the overall prostate cancer survival rate has increased to more than 70% in the last 30 years.

In prostate cancer survivors who have undergone surgery or androgen deprivation hormone therapy, one of the main goals is to improve quality of life. For this, the following is recommended:

• Personalized physical training provided by specialists for at least one year.
• Diet recommendations, weight maintenance, not smoking, and avoiding alcohol.
• Preventing diseases such as diabetes, high blood cholesterol, and bone decalcification (osteoporosis).
• Providing comprehensive rehabilitation for possible side effects such as urinary incontinence and erectile dysfunction.
• Providing psychological and social support.