A prostate cancer diagnosis changes everything, and yet for most men diagnosed today, particularly those whose cancer is found early through PSA screening, it need not change everything for the worse. Prostate cancer in its early stages is one of the most curable cancers in all of oncology with five-year survival rates for localized disease over 99 percent. The problem, and the critical need for screening, is that most early prostate cancers cause no symptoms at all.
Understanding prostate cancer means knowing what it is, what it is not, how it is detected before the development of symptoms, and the full range of treatment options at each stage. That means knowing the difference between a cancer that can be safely watched and a cancer that requires immediate, aggressive treatment. And it means knowing that decisions about treatment for prostate cancer are decisions about values and priorities, quality of life, side effect tolerance, family planning, and personal philosophy – not simply clinical staging.
Prostate cancer is the malignant change of the prostate gland epithelial cells, most commonly the acinar cells of the peripheral zone. This results in uncontrolled proliferation of cells which, if left untreated, can invade beyond the prostate capsule, spread to lymph nodes and metastasise to bone and distant organs. It is the commonest male cancer after skin cancer, but is among the most curable when detected in a localised stage by PSA screening.
The overwhelming majority of prostate cancers, about 95 percent, are adenocarcinomas that arise from the glandular epithelium. Their grade is assessed using the Gleason grading system and its modern equivalent, the Grade Group (GG) classification. GG1 (Gleason 3+3=6) is the least aggressive cancer, and GG5 (Gleason 5+5=10) is the most aggressive. The grade group is one of the most important factors in treatment decision – making , GG1 cancers can often be managed with active surveillance rather than immediate treatment , while GG4 and GG5 cancers require aggressive treatment.
The one thing to remember about prostate cancer symptoms is that early prostate cancer that is curable seldom causes any symptoms. There are typically no symptoms of prostate cancer until the disease has grown large enough to block the urethra or has spread outside of the prostate, and cure may be more difficult or impossible. The basic rationale for PSA testing is that it detects cancer before it produces symptoms.
Weak or Slow Urine Stream
PSA-based prostate cancer screening is the only reliable way to detect prostate cancer at its earliest, most curable stage, before the development of symptoms. The evidence is clear: men diagnosed with localised prostate cancer detected by PSA screening have markedly better outcomes than men diagnosed with symptomatic disease.
What Is PSA Test & Why It Is Important for Early Detection
Radiation therapy is a definitive treatment for localised and locally advanced prostate cancer . High energy radiation destroys the cancer cells’ ability to divide . Radiation gives cancer control rates equivalent to surgery for early-stage cancer. For locally advanced disease, it is combined with hormone therapy for best results.
External Beam Radiation Therapy (EBRT) & IMRT for Prostate Cancer
Brachytherapy – Internal Radiation Seed Implant for Prostate
Stereotactic Body Radiotherapy (SBRT) & CyberKnife
Radiation After Surgery – Adjuvant & Salvage Radiotherapy
Side Effects of Radiation & How They Are Managed
Androgen deprivation therapy (ADT) is the treatment of choice for locally advanced and metastatic prostate cancer. Prostate cancer cells, like normal prostate cells, are stimulated to grow by male hormones (androgens), especially testosterone. When the androgen stimulus is removed, prostate cancer cells cease to divide and begin to die in a programmed fashion.
What Is Androgen Deprivation Therapy (ADT) & How It Works
No, prostate cancer isn’t always a fatal disease. And for most men diagnosed today, it isn’t fatal. If prostate cancer is found only in the prostate (localized) by PSA testing, more than 99% of men will be alive 5 years after diagnosis with the right treatment and more than 98% will be alive 10 years after diagnosis. Even locally advanced prostate cancer treated with radiation and hormone therapy has excellent long term survival. Only metastatic prostate cancer, where the cancer has spread to the bones or other distant organs, has a more guarded prognosis, and even in this case modern treatment significantly extends survival. The trick is catching it early. Prostate cancer caught in a screening before it causes any symptoms is one of the most curable cancers in all of oncology.
The most common method of pathological grading of prostate cancer is the Gleason score which is based on the microscopic appearance of the cancer when viewed by a pathologist . It runs from 6 (least aggressive) to 10 (most aggressive). A simplified modern equivalent of the Grade Group system (1-5) is the lowest grade GG1 (Gleason 6), the highest GG5 (Gleason 9-10). Grade Group has a huge effect on prognosis and treatment decisions, GG1 and many GG2 cancers can be managed with active surveillance but GG4 and GG5 need immediate aggressive treatment. The most important information you can get after a prostate biopsy is to know your Grade Group.
Active surveillance (AS) is a management strategy for low-risk, low-grade prostate cancer (usually Grade Group [GG] 1, sometimes GG2) whereby the cancer is closely observed with serial PSA testing, repeat mpMRI, and periodic rebiopsy, with curative treatment initiated only if the cancer shows evidence of progression to a higher grade or increasing volume. This is based on evidence that many low-grade prostate cancers will not harm during a patient’s lifetime, and that the side effects of immediate treatment (erectile dysfunction, incontinence) can be avoided or delayed without compromising cancer-specific survival. Long-term data from major international active surveillance cohorts show that 85 to 90 percent of carefully selected patients avoid curative treatment for 10 or more years and have cancer-specific survival equivalent to immediate treatment.
Radical prostatectomy is surgical removal of the entire prostate gland, seminal vesicles, and regional lymph nodes when indicated. It is the main surgical curative treatment for localised prostate cancer. The standard minimally invasive approach is laparoscopic radical prostatectomy which involves using a camera and long-handled instruments through small keyhole incisions. The cancer control is equivalent to open surgery but with significantly less blood loss, less post-operative pain, shorter hospital stay (two to three days) and faster return to normal activity. Surgical technique considerations include ensuring negative margins (no cancer at the edge of the specimen) and using a nerve-sparing technique when oncologically safe to preserve erectile function.
In most prostate cancers, hormone therapy (ADT) controls the disease, it does not cure it. ADT suppresses testosterone to castrate levels, causing prostate cancer cells to stop growing and many to die, resulting in dramatic PSA responses and clinical improvement. But almost all prostate cancers eventually adapt to the low-testosterone environment and start growing again, a condition known as castration-resistant prostate cancer (CRPC). The exception is when ADT is used as an adjunct to radiation therapy for localised/locally advanced disease , in this setting the combination is potentially curative . ADT as a single agent for non-metastatic disease may result in prolonged PSA suppression and delayed progression, but is not generally considered curative.
Yes, prostate cancer can spread (metastasise) to lymph nodes, most commonly pelvic and para-aortic, to bone, especially the lumbar spine, sacrum, pelvis, ribs and long bones, and less commonly to the liver, lungs and brain. Bone metastases of prostate cancer are usually osteoblastic, causing dense, sclerotic lesions on bone scan. Bone pain, especially back or hip pain in a man with a history of prostate cancer or elevated PSA, is an urgent need for staging investigation. PSA level, Gleason grade and clinical stage are related to the risk of metastasis and this is the reason that aggressive staging and treatment is required in high risk prostate cancers to reduce the risk of spread.
The diagnosis of prostate cancer was revolutionized by multiparametric MRI (mpMRI) of the prostate. In any man with an elevated PSA, prior to biopsy mpMRI identifies suspicious areas within the prostate using the PI-RADS scoring system (1 to 5). Lesions with PI-RADS 1 and 2 have a very low probability of cancer and often biopsy can be deferred. “Lesions PI-RADS 4 and 5 are highly suspicious for cancer and need targeted biopsy.” MRI-fusion targeted biopsy The use of MRI in combination with real-time ultrasound when performing biopsy significantly increases the accuracy of cancer detection, finds more clinically significant cancers, finds fewer insignificant cancers, and requires fewer biopsy cores. Now, at his clinic in Indore, Dr. Vikas Singh says mpMRI is standard practice before any prostate biopsy.
The duration of treatment is entirely contingent on the treatment chosen. Laparoscopic radical prostatectomy is one operation, requires two to three days in hospital and takes four to six weeks to recover from. External beam radiation therapy usually involves 28 to 44 daily treatments (five days a week for six to nine weeks). SBRT (stereotactic radiation) is 5 sessions in one-two weeks. Brachytherapy seed implant is a one-day procedure. Hormone therapy may be given as an injection every one, three or six months, or as a daily tablet. This may be for six months (neoadjuvant before radiation) or for life (metastatic disease). The total treatment time therefore ranges from a single operative day up to months or years of systemic therapy.
Yes, prostate cancer has a significant hereditary component. Men with one first degree relative (father or brother) with prostate cancer are at about twice the population risk. Men are three to five times at risk if two or more first degree relatives are affected. There are certain genetic mutations that greatly increase the risk: BRCA2 mutations confer a five-fold increased risk of prostate cancer and are associated with more aggressive disease; BRCA1 mutations pose a lesser, but still increased risk. Lynch syndrome (hereditary colorectal cancer syndrome) is associated with an increased risk of prostate cancer. Men with a strong family history of prostate, breast or colorectal cancer may want to speak to their urologist about genetic testing and early PSA screening.
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