Posts Tagged ‘Bladder Cancer’
Note:
This website is not intended as a substitute for professional medical advice and does not address specific treatments or conditions specific to any patient. All health and treatment decisions must be made in consultation with your physician(s), utilizing your specific medical information. The information on this website is subject to change.
WHAT IS THE BLADDER?
The bladder is a hollow organ in the lower abdomen that stores urine. The kidneys filter waste from the blood and produce urine, which enters the bladder through two tubes called ureters. Urine leaves the bladder through another tube, the urethra. In women, the urethra is a short tube that opens just in front of the vagina. In men, it is longer, passing through the prostate gland and then the penis.
Bladder Cancer
WHAT IS BLADDER CANCER?
Cancer is a group of diseases. More than 100 different types of cancer are known, and there are different types of bladder cancer. They all have one thing in common: abnormal cells grow and destroy body tissue.
Healthy cells that make up the body’s tissues grow, divide, and replace themselves in an orderly way. This process keeps the body in good repair. Sometimes, however, some cells lose the ability to control their growth. They grow too rapidly and without any order. Too much tissue is made, and tumors begin to form. Tumors can be benign or malignant.
Benign tumors are not cancer. They do not spread to other parts of the body and are seldom a threat to life. Often, benign tumors can be removed by surgery, and they are not likely to return.
Malignant tumors are cancer. They can invade and destroy nearby healthy tissues and organs. Cancer cells can also break away from the tumor and enter the bloodstream and lymphatic system. That is how cancer can spread to other parts of the body. This spread is called metastasis . Even if cancer is removed from the bladder, the disease sometimes returns, because cancer cells may have already spread.
Most bladder cancers develop in the inside lining of the bladder. The cancer often looks like a small mushroom attached to the bladder wall. It may also be called a papillary tumor. Often, more than one tumor is present.
Bladder cancer is a fairly common form of cancer in the United States. Whites contract bladder cancer twice as often as blacks, and men are affected two to three times as often as women. Most bladder cancers occur after the age of 55, but the disease can also develop in younger people.
WHAT ARE THE RISK FACTORS FOR BLADDER CANCER?
While it is unknown why one person gets bladder cancer and another doesn’t, it is established. that the disease is not contagious. No one can “catch” bladder cancer from another person. Scientists do not know exactly what causes this disease, but research does show that some people are more likely to develop it than others. A number of factors contribute to this higher risk.
Smoking is a major risk factor. Cigarette smokers develop bladder cancer two to three times more often than do non-smokers. Quitting smoking reduces the risk of bladder cancer, lung cancer, several other types of cancer, and a number of other diseases as well.
Workers in some occupations are at higher risk of developing bladder cancer because of exposure to carcinogens (cancer- causing substances) in the workplace. These workers include people in the rubber, chemical, and leather industries, as well as hairstylists, machinists, metal workers, printers, painters, textile workers, and truck drivers.
WHAT ARE THE SYMPTOMS OF BLADDER CANCER?
The most common warning sign of bladder cancer is blood in the urine. Depending on the amount of blood present, the color of the urine can range from faintly rusty to deep red. Pain during urination can also be a sign of bladder cancer. A need to urinate often or urgently may be another warning sign. Often, bladder tumors cause no symptoms.
When symptoms do occur, they are not sure signs of cancer. They may also be caused by infections, benign tumors, bladder stones, or other problems. It is important to see a doctor to determine the cause of the symptoms. Any illness should be diagnosed and treated as early as possible.
HOW IS BLADDER CANCER DIAGNOSED?
To diagnose bladder cancer, a personal and family medical history is taken and a thorough physical examination is conducted. Sometimes, the doctor can feel a large tumor during a rectal or vaginal exam. In addition, urine samples are checked under the microscope to see whether any cancer cells are present.
Often, the doctor orders an x-ray called an intravenous pyelogram (IVP). This test allows the doctor see the kidneys, ureters, and bladder on an x-ray. An IVP normally causes little discomfort, although a few patients experience nausea, dizziness, or pain from the procedure.
The doctor may also look directly into the bladder with an instrument called a cystoscope. In this test, a thin, lighted tube is inserted into the bladder through the urethra. If the doctor sees any abnormal areas, samples of tissue can be removed through the cystoscope. This is called a biopsy. A pathologist examines the tissue under a microscope to see whether cancer cells are present. A biopsy is needed to make a definite diagnosis of bladder cancer.
WHAT IS THE TREATMENT FOR BLADDER CANCER?
Treatment for bladder cancer depends on a number of factors. Among these are how quickly the cancer is growing; the number, size, and location of the tumors; whether the cancer has spread to other organs; and the patient’s age and general health.
Staging:
Before treatment begins, it is important to know exactly where the cancer is located and whether it has spread from its original location. Staging procedures include a complete physical exam and additional blood tests and scans.
A CT (or CAT) scan may be performed. A CT scan is a series of x-rays put together by a computer to form a detailed picture. Ultrasound is a procedure that creates pictures of the inside of the body using high-frequency sound waves. The echoes make an image on a video screen that is much like a television. Sometimes, a magnetic resonance imaging (MRI ) is performed, in which a cross-sectional image (like a CT scan) is produced on a screen with the use of a powerful magnet instead of x-rays.
Methods of Treatment
Early (superficial) bladder cancer (in which the tumors are found on the surface of the bladder wall) generally can be treated using the cystoscope in a procedure called transurethral resection (TUR). The cystoscope can remove all or part of a tumor or destroy it with an electric current.
When several tumors are present in the bladder or when there is a risk that the cancer will recur, TUR may be followed by treatment with drugs. The doctor may put a solution containing the bacillus Calmette-Guerin (BCG), a form of biological therapy , directly into the bladder. Chemotherapy (anticancer drugs) may also be inserted directly into the bladder.
Radiation therapy (also called radiotherapy) may be needed when the cancer cannot be removed with TUR because it involves a larger area of the bladder. X-rays destroy the ability of cancer cells to grow and divide. Internal radiation therapy, with the radioactive material placed in the bladder, may be combined with external radiation, which comes from a machine located outside the body.
For internal radiation therapy, radioactive material is inserted into the bladder through the cystoscope. This puts cancer-killing rays as close as possible to the site of the cancer while sparing most of the healthy tissues around it. The patient is hospitalized for this treatment for approximately 4 to 7 days.
For external radiation treatments, the patient goes to the hospital or clinic each day. Usually, treatments are given 5 days a week for 5 to 6 weeks. This schedule helps to protect normal tissue by spreading out the total dose of radiation.
When the cancer involves much of the surface of the bladder or has grown into the bladder wall, standard treatment is to remove the entire bladder. This surgery is called a radical cystectomy. In this operation, the surgeon removes the bladder as well as nearby organs. In women, this operation includes removing the uterus, fallopian tubes, ovaries, and part of the vagina. In men, the prostate and seminal vesicles are removed. Research is under way to find treatments that spare the bladder.
When cancer involves the pelvis or has spread to other parts of the body, the doctor may suggest chemotherapy, the use of anticancer drugs that travel through the bloodstream to reach cancer cells in all parts of the body. Drugs used to treat cancer are either given by mouth or injected into a muscle or a blood vessel. Chemotherapy is usually given in cycles, a treatment period, followed by a rest period, then another treatment period, and so on.
The patient usually receives chemotherapy as an outpatient at the hospital, at the doctor’s office, or at home. Sometimes, the patient may need to stay in the hospital for a short while.
WHAT ARE THE SIDE EFFECTS OF BLADDER CANCER TREATMENT?
The methods used to treat bladder cancer are very powerful. It is hard to limit the effects of treatment so that only cancer cells are destroyed; healthy tissue may also be damaged. That is why treatment can cause unpleasant side effects. Side effects depend on the type of treatment used and on the part of the body being treated.
When the bladder is removed, the patient needs a new way to store and pass urine. Various methods are used. In one, the surgeon uses a piece of the person’s small intestine to form a new pipeline. The ureters are attached to one end, and the other end is brought out through an opening in the wall of the abdomen. This new opening is called a stoma. (It is also called an ostomy or urostomy.) A flat bag fits over the stoma to collect urine, and it is held in place with a special adhesive. A specially trained nurse or enterostomal therapist will show the patient how to care for the ostomy.
A newer method uses part of the small intestine to make a new storage pouch (called a continent reservoir) inside the body. The urine collects there and does not empty into a bag. Instead, the patient learns to use a tube (catheter) to drain the urine through a stoma. Other methods are being developed that connect a pouch made from the small intestine to a remaining part of the urethra. When this procedure is possible, a stoma and bag are not necessary because urine leaves the body through the urethra.
Radical cystectomy causes infertility in both men and women. This operation can also lead to sexual problems. In the past, nearly all men were impotent following this procedure, but improvements in surgery have made it possible to prevent this in many men. In women, the vagina may be narrower or shallower, and intercourse may be difficult.
During radiation therapy, patients may become very tired as the treatment continues. Resting as much as possible is important. Radiation treatment to the lower abdomen may cause nausea, vomiting, or diarrhea . Usually, certain foods or medications can ease these problems. Radiation therapy can also cause problems with fertility and can make sexual intercourse uncomfortable.
Chemotherapy causes side effects because it damages not only cancer cells but other rapidly growing cells as well. The side effects of chemotherapy depend on the specific drugs that are given. In addition, each patient reacts differently. Chemotherapy commonly affects blood-forming cells and cells that line the digestive tract. As a result, patients may have side effects such as a lowered resistance to infection, loss of appetite, loss of hair, nausea and vomiting, less energy, and mouth sores. These are short-term side effects that usually end after treatment stops. When drugs are put directly into the bladder, these side effects may be limited. However, it is common for the bladder to be irritated.
Loss of appetite can be a serious problem for patients during therapy. Patients who eat well may be better able to withstand the side effects of their treatment, so good nutrition is an important part of the treatment plan. Eating well means getting enough calories to prevent weight loss and having enough protein to build and repair muscles, organs, skin, and hair. Many patients find that eating several small meals and snacks during the day is easier than trying to eat three large meals.
Side effects during cancer treatment vary for each patient. They may even be different from one treatment to the next in the same person. Attempts are made to plan treatment to minimize problems. Fortunately, most side effects are temporary. Doctors, nurses, and dietitians can explain the side effects of cancer treatment and can suggest ways to deal with them.
WHAT HAPPENS AFTER TREATMENT FOR BLADDER CANCER?
Regular follow-up exams are very important after treatment for bladder cancer. The bladder needs to be checked with a cystoscope, any superficial tumors that may have recurred are removed. The urine is checked for cancerous cells and a chest x-ray, an IVP, or other tests may be performed.
A patient who has had bladder cancer should be closely monitored for several years, because bladder tumors can come back. If the cancer does recur, early detection is important so that additional treatment can be started.
HOW CAN PATIENTS COPE WITH BLADDER CANCER?
The diagnosis of bladder cancer can change the lives of cancer patients and the people who care about them. These changes in daily life can be difficult to handle. It is natural for patients and their families and friends to have many different and sometimes confusing emotions.
Patients and their loved ones may feel frightened, angry, or depressed. These are normal reactions that people have when diagnosed with a serious health problem. Others in the same situation have found that they cope with their emotions better if they can talk openly about their illness and their feelings with those who care about them.
Concerns about what the future may hold, as well as worries about tests, treatments, hospital stays, and medical bills, are common. Talking with doctors, nurses, or other members of the health care team may help to calm fears and ease confusion. Patients can take an active part in decisions about their medical care by asking questions about bladder cancer and their treatment choices. Patients, family, or friends often find it helpful to write down questions to ask the doctor as they think of them. Taking notes during visits to the doctor helps them remember what was said. Patients should ask the doctor to explain anything that is not clear.
Patients have many important questions, and the doctor is the best person to answer them. Most people ask about the extent of their cancer, how it can be treated, and how successful the treatment is likely to be. The doctor is the best person to give advice about treatment, working, or limiting daily activities. Patients may also wish to discuss concerns about the future, family relationships, and finances. They may find it helpful to speak with a nurse, social worker, counselor, or a member of the clergy.
Sharing feelings with loved ones can help everyone feel more at ease, opening the way for others to show their concern and offer their support. Many patients feel that it helps to talk with others who are facing problems like theirs. Patients can meet other cancer patients through self-help and support groups such as those described in the next section.
WHAT SUPPORT CAN BLADDER CANCER PATIENTS SEEK?
Learning to live with the changes brought about by having cancer is easier for patients and those who care about them when they have helpful information and support services. Often, the social worker at the hospital or clinic can suggest local and national groups that will help with emotional support, financial aid, transportation, home care, and rehabilitation.
If a patient has problems with a urostomy, the doctor, nurse, or enterostomal therapist can help. Adjusting to a stoma can be a lot easier with the advice and support of someone who has had the same problem. Many people have had bladder surgery, and several organizations offer assistance.
WHAT DOES THE FUTURE HOLD FOR BLADDER CANCER?
Each year, more than 50,000 people in the United States find out they have bladder cancer. The outlook for patients with early bladder cancer is very good. The chances of recovery from more advanced bladder cancer are improving as researchers continue to look for better ways to treat this disease.
Doctors often talk about “surviving” cancer, or they may use the word “remission” rather than “cure.” Even though many bladder cancer patients recover completely, doctors use these terms because bladder cancer can recur. It is normal for patients to be concerned about their future. Sometimes they use statistics they have heard to try to figure out their chance of being cured. It is important to remember, however, that statistics are averages. They are based on the experiences of large numbers of patients, and no two cancer patients are alike. Only the doctor who takes care of the patient knows enough about his or her case to discuss the patient’s chance of recovery (prognosis).
Scientists at hospitals and medical centers all across the country are studying bladder cancer. They are trying to learn what causes the disease and how to prevent it. They are also looking for better ways to diagnose and treat it.
The National Cancer Institute is supporting many studies of new treatments for bladder cancer. When laboratory research shows that a new treatment method has promise, it is used to treat cancer patients in clinical trials. These trials are designed to answer scientific questions and to find out if a new treatment is both safe and effective. Patients who take part in clinical trials make an important contribution to medical science and may have the first chance to benefit from improved treatment methods.
The Ostomy Rehabilitation Program of the American Cancer Society (ACS) and the United Ostomy Associations of America offer both emotional support and educational material.
BLADDER CANCER AT A GLANCE
* While the exact cause(s) of bladder cancer is not known, risk factors have been identified.
* The most common warning sign of bladder cancer is blood in the urine.
* The diagnosis of bladder cancer is supported by findings of the medical history and examination, blood, urine, and x-ray tests, and confirmed with a biopsy (usually during a cystoscope exam).
* Treatment of bladder cancer depends on the growth, size, and location of the tumor as well as the age and health of the patient.
Note:
This website is not intended as a substitute for professional medical advice and does not address specific treatments or conditions specific to any patient. All health and treatment decisions must be made in consultation with your physician(s), utilizing your specific medical information. The information on this website is subject to change.
WHAT IS THE PROSTATE GLAND?
The prostate gland is an organ that is located at the base or outlet (neck) of the urinary bladder. The gland surrounds the first part of the urethra. The urethra is the passage through which urine drains from the bladder to exit from the penis. One function of the prostate gland is to help control urination by pressing directly against the part of the urethra that it surrounds.
Another function of the prostate gland is to produce some of the substances that are found in normal semen, such as minerals and sugar. Semen is the fluid that transports the sperm. A man can manage quite well, however, without his prostate gland.
In a young man, the normal prostate gland is the size of a walnut. During normal aging, however, the gland usually grows larger. This enlargement with aging is called benign prostatic hypertrophy (BPH), but this condition is not associated with prostate cancer. Both BPH and prostate cancer, however, can cause similar problems in older men. For example, an enlarged prostate gland can squeeze or impinge on the outlet of the bladder or the urethra, leading to difficulty with urination. The resulting symptoms commonly include slowing of the urinary stream and urinating more frequently, particularly at night.
Illustration of the Prostate Gland
WHAT IS PROSTATE CANCER?
Prostate cancer is a malignant (cancerous) tumor (growth) that consists of cells from the prostate gland. The tumor usually grows slowly and remains confined to the gland for many years. During this time, the tumor produces little or no symptoms or outward signs (abnormalities on physical examination).
As the cancer advances, however, it can spread beyond the prostate into the surrounding tissues (local spread). Moreover, the cancer also can metastasize (spread even farther) throughout other areas of the body, such as the bones, lungs, and liver. Symptoms and signs, therefore, are more often associated with advanced prostate cancer.
WHAT CAUSES PROSTATE CANCER?
The cause of prostate cancer is unknown, but the cancer is thought not to be related to benign prostatic hypertrophy (BPH). The risk (predisposing) factors for prostate cancer include advancing age, genetics (heredity), hormonal influences, and such environmental factors as toxins, chemicals, and industrial products. The chances of developing prostate cancer increase with age. Thus, prostate cancer under age 40 is extremely rare, while it is common in men older than 80 years of age. As a matter of fact, some studies have suggested that among men over 80, between 50 and 80 percent of them may have prostate cancer!
Genetics (heredity), as just mentioned, plays a role in the risk of developing a prostate cancer. For example, black American men have a higher risk of getting prostate cancer than do Japanese or white American men. Environment, diet, and other unknown factors, however, can modify such genetic predispositions. For example, prostate cancer is uncommon in Japanese men living in their native Japan. However, when these men move to the United States, their incidence of prostate cancer rises significantly.
Prostate cancer is also more common among family members of individuals with prostate cancer. Thus, a person whose father, grandfather, or even uncle has prostate cancer is at an increased risk for also developing prostate cancer. To date, however, no specific prostate cancer gene has been identified and verified (genes, which are situated on chromosomes within the nucleus of cells, are the chemical compounds that determine specific traits in individuals).
Testosterone, the male hormone, directly stimulates the growth of both normal prostate tissue and prostate cancer cells. Not surprisingly, therefore, this hormone is thought to be involved in the development and growth of prostate cancer. The important implication of the role of this hormone is that decreasing the level of testosterone should be (and usually is) effective in inhibiting the growth of prostate cancer.
Environmental factors, such as cigarette smoking and diets that are high in saturated fat, seem to increase the risk of prostate cancer. Additional substances or toxins in the environment or from industrial sources might also promote the development of prostate cancer, but these have not yet been clearly identified.
WHAT ARE THE SYMPTOMS OF PROSTATE CANCER?
In the early stages, prostate cancer often causes no symptoms for many years. As a matter of fact, these cancers frequently are first detected by an abnormality on a blood test (the PSA, discussed below) or as a hard nodule (lump) in the prostate gland. Usually, the doctor first feels the nodule during a routine digital (done with the finger) rectal examination (note in the diagram that the prostate gland is right in front of the rectum).
As the cancer enlarges and presses on the urethra, the flow of urine diminishes and urination becomes more difficult. Patients may also experience burning with urination or blood in the urine. As the tumor continues to grow, it can completely block the flow of urine, resulting in a painfully obstructed and enlarged urinary bladder.
In the later stages, prostate cancer can spread locally into the surrounding tissue or the nearby lymph nodes, called the pelvic nodes. The cancer then can spread even farther (metastasize) to other areas of the body. The doctor on a rectal examination can sometimes detect local spread into the surrounding tissues. That is, the physician can feel a hard, fixed (not moveable) tumor extending from and beyond the gland.
Prostate cancer usually metastasizes first to the lower spine or the pelvic bones (the bones connecting the lower spine to the hips), thereby causing back or pelvic pain. The cancer can then spread to the liver and lungs. Metastases (areas to which the cancer has spread) to the liver can cause pain in the abdomen and jaundice (yellow color of the skin) in rare instances. Metastases to the lungs can cause chest pain and coughing.
HOW IS PROSTATE CANCER DIAGNOSED?
Prostate cancer is diagnosed from the results of a biopsy of the prostate gland. If the digital rectal exam of the prostate or the PSA blood test is abnormal, a prostate cancer is suspected. A biopsy of the prostate is usually then recommended. The biopsy is done from the rectum (trans-rectally) and is guided by ultrasound images of the area. A small piece of prostate tissue is withdrawn through a cutting needle. A pathologist then examines the tissue under a microscope for signs of cancer in the cells of the tissue.
When prostate cancer is diagnosed on the biopsy tissue, the pathologist will then grade each of two pieces of the tissue from 1 to 5 on the Gleason scale. The scale is based on certain microscopic characteristics of the cancerous cells and reflects the aggressiveness of the tumor. The two scores are then added together. Sums of 2 to 4 are considered low, indicating a slowly growing tumor. Sums of 5 and 6 are intermediate, representing an intermediate degree of aggressiveness. Sums of 7 to 10 are considered high, signaling a rapidly growing tumor with the worst prognosis (outcome).
Gleason scores can be helpful in guiding treatment that is based, at least in part, on the aggressiveness of the tumor. The principal application of the Gleason score, however, is in predicting the risk for death from a prostate cancer. Thus, recent studies have shown that men with Gleason scores of 2 to 4 face a minimal risk (4 to 7%) of death from prostate cancer over the ensuing 15 years, while men with scores of 8 to 10 face a high risk (60 to 87%) of death from prostate cancer over the 15 year period.
HOW IS THE STAGING OF PROSTATE CANCER DONE?
The staging of a cancer refers to determining the extent of the disease. Once a prostate cancer is diagnosed on a biopsy, additional tests are done to assess whether the cancer has spread beyond the gland. For this assessment, biopsies of the surrounding organs, such as the rectum or urinary bladder, or of the nearby (pelvic) lymph nodes might be done. In addition, imaging tests are usually performed. For example, radionuclide bone scans can determine if there is a spread of the tumor to the bones. Additionally, CAT scans (coaxial tomography) and MRIs (magnetic resonance imaging) can determine if the cancer has spread to adjacent tissues or organs such as the bladder or rectum or to other parts of the body such as the liver or lungs.
In brief, doctors do the staging of prostate cancer based primarily on the results of the prostate biopsy, possibly other biopsies, and imaging tests. In staging a cancer, doctors assign various letters and numbers to the cancer, depending on which of the classifications for staging they use. The numbers and letters in the different classifications define the volume or amount of the tumor and the spread of the cancer. The stage of the prostate cancer, therefore, helps to predict the expected course of the disease and determine the choice of treatment.
Two main systems are used to stage prostate cancer. In the American urologic staging system, stage A describes a minimal cancer that can neither be palpated (felt) on physical examination nor seen by imaging techniques. Such a tumor is so small that it can be detected only by viewing it under a microscope. Stage B refers to a larger cancer that may be palpated, but that still is confined (localized) to the prostate gland. Stage C indicates local spread beyond the prostate into the surrounding tissues. Stage D1 signifies a spread to the nearby (pelvic) lymph nodes and D2 is for distant spread (metastasis), for example, to the bones, liver, or lungs.
The other main system for staging prostate cancer is called the tumor, nodes, and metastasis (TNM) classification. In this system, T1 and T2 are equivalent to stage A and B (respectively) in the American urologic system. T3 describes cancer that extends just beyond the capsule (coat) of the prostate, and T4 describes cancer that is fixed to the surrounding tissues. N1 is equivalent to Stage D1 and M1 is equivalent to D2.
WHAT ARE THE TREATMENT OPTIONS FOR PROSTATE CANCER?
Deciding on treatment can be daunting, partly because the options for treatment today are far better than they were ten years ago, but also because not enough reliable data are available on which to base the decisions. Accordingly, scientifically controlled, long term studies are still needed to compare the benefits and risks of the various treatments.
To decide on treatment for an individual patient, doctors categorize prostate cancers as organ-confined (localized to the gland), locally advanced (a large prostate tumor or one that has spread only locally), or metastatic (spread distantly or widely). The treatment options for organ-confined prostate cancer or locally advanced prostate cancer usually include surgery, radiation therapy , hormonal therapy, cryotherapy, combinations of some of these treatments, and watchful waiting. A cure for metastatic prostate cancer is, unfortunately, unattainable at the present time. The treatments for metastatic prostate cancer, which include hormonal therapy and chemotherapy , therefore, are considered palliative. By definition, the aims of palliative treatments are, at best, to slow the growth of the tumor and relieve the symptoms of the patient.
Other factors considered in choosing treatment include the age, general health, and preference of the individual and the Gleason score and stage of the cancer. The results of the PSA test sometimes also can help to decide on the treatment. For example, a borderline elevation of the PSA (4-10), if shown to be due to a prostate cancer, suggests that the cancer is confined to the gland. If other tests also point to an organ-confined tumor, surgery or possibly radiation can be considered to attempt a cure. In contrast, a very high PSA (for example, over 30 or 40) raises the possibility of metastases. If the metastases are then confirmed by other tests, the treatment options would be limited to hormonal therapy or chemotherapy.
PSA tests also should be done periodically after treatment to help assess the results of treatment. For example, an increasing PSA suggests growth or spread of the cancer, despite the treatment. In contrast, a decreasing PSA indicates improvement. As a matter of fact, a post-treatment PSA of zero may indicate complete control or cure of the cancer.
WHAT ABOUT SURGICAL TREATMENT FOR PROSTATE CANCER?
The surgical treatment for prostate cancer is commonly referred to as a radical or total prostatectomy, which is the removal of the entire prostate gland. Since 1990, the radical prostatectomy has been the most common treatment for prostate cancer in the United States. This operation is done in about 36% of patients with organ-confined (localized) prostate cancer. The American Cancer Society estimates a 90% cure rate nationwide when the disease is confined to the prostate and the entire gland is removed. The potential complications of a radical prostatectomy include the risks of anesthesia, local bleeding, impotence (loss of sexual function) in 30%-70% of patients, and incontinence (loss of control of urination) in 3%-10% of patients.
Great strides have been made in lowering the frequency of the complications of radical prostatectomy. These advances have been accomplished largely through improved anesthesia and surgical techniques. The improved surgical techniques, in turn, stem from a better understanding of the key anatomy and physiology of sexual potency and urinary continence. Specifically, the recent introduction of nerve-sparing techniques for the prostatectomy has helped to reduce the frequency of impotence and incontinence.
If post-treatment impotence does occur, it can be treated by sildenafil (Viagra) tablets, injections of such medications as alprostadil (Caverject) into the penis, various devices to pump up or stiffen the penis, or a penile prosthesis (an artificial penis). Incontinence after treatment often improves with time, special exercises, and medications to improve the control of urination. Occasionally, however, incontinence requires implanting an artificial sphincter around the urethra. The artificial sphincter is made up of muscle or other material and is designed to control the flow of urine through the urethra.
WHAT ABOUT RADIATION THERAPY FOR PROSTATE CANCER?
The goal of radiation therapy is to damage the cancer cells and stop their growth or kill them. This works because the rapidly dividing (reproducing) cancer cells are more vulnerable to destruction by the radiation than are the neighboring normal cells. Clinical trials have been conducted using radiation therapy for patients with organ-confined (localized) prostate cancer. These trials have shown that radiation therapy resulted in a rate of survival (being alive) at 10 years after treatment that is comparable to that for radical prostatectomy. Incontinence and impotence can occur as complications of radiation therapy, as with surgery, although perhaps less often than with surgery. More data are needed, however, on the risks and benefits of radiation therapy beyond 10 years, especially because late recurrences (reappearances) of the cancer can sometimes occur after radiation.
Choosing between radiation and surgery to treat organ-confined prostate cancer involves considerations of the patient’s preference, age, and co-existing medical conditions (fitness for surgery), as well as of the extent of the cancer. Approximately 30% of patients with organ-confined prostate cancer are treated with radiation. Sometimes, oncologists combine radiation therapy with surgery or hormonal therapy in efforts to improve the long-term results of treatment in the early or later stages of prostate cancer.
Radiation therapy can be given either as external beam radiation over perhaps 6 or 7 weeks or as an implant of radioactive seeds (brachytherapy) directly into the prostate. In external beam radiation, high energy x-rays are aimed at the tumor and the area immediately surrounding it. In brachytherapy, radioactive seeds are inserted through needles into the prostate gland under the guidance of transrectally taken ultrasound pictures. Brachy, from the Greek language, means short. The term brachytherapy thus refers to placing the treatment (radiation therapy) directly into or a short distance away from the cancerous target tissue. The theoretical advantage of brachytherapy over external beam radiation is that delivering the radiation energy directly into the prostate tissue should minimize damage to the surrounding tissues and organs. The actual advantages or disadvantages of brachytherapy as compared to external beam radiation, however, are still being studied.
WHAT ABOUT HORMONAL TREATMENT FOR PROSTATE CANCER?
The male (androgenic) hormone is called testosterone. It stimulates the growth of cancerous prostatic cells and, therefore, is the primary fuel for the growth of prostate cancer. The idea of all of the hormonal treatments (medical and surgical), in short, is to decrease the stimulation by testosterone of the cancerous prostatic cells. Testosterone normally is produced by the testes in response to stimulation from a hormonal signal called LH-RH. The LH-RH stands for luteinizing hormone-releasing hormone and is also called gonadotropin-releasing hormone. This hormone comes from a control station in the brain and travels in the blood stream to the testes. Once there, the LH-RH stimulates the testes to produce and release testosterone.
Hormonal treatment, also referred to as androgenic deprivation (depriving the prostate of testosterone), can be accomplished surgically or medically. The surgical hormonal treatment is removal of the testes in an operation called an orchiectomy or a castration. This surgery thus removes the body’s source of testosterone. The medical hormonal treatment involves taking one or two types of medication. One type is referred to as the LH-RH agonists. They work by competing with the body’s own LH-RH. These drugs thereby inhibit (block) the release of LH-RH from the brain. The other type of drug is referred to as anti-androgenic, meaning that these drugs work against the male hormone. That is, they work by blocking the effect of testosterone itself on the prostate.
Today, most men electing hormonal treatment choose medication over surgery, probably because they view surgical castration as more devastating cosmetically or psychologically. Actually, however, the effectiveness and side effects of medical hormonal treatment as compared to surgical hormonal treatment are very much the same. Both types of hormonal treatment usually effectively eliminate stimulation of the cancer cells by testosterone. Some tumors of the prostate, however, do not respond to this form of treatment. They are referred to as androgen-independent prostate cancers. The principal side effects of all of these hormonal treatments (that is, the side effects of androgenic deprivation) are enlarged breasts (gynecomastia) that often are tender, flushing (like hot flashes), and impotence.
The LH-RH agonists, leuprolide (Lupron) or goserelin (Zoladex), are given as monthly injections in the doctor’s office. The anti-androgenic drugs, flutamide (Eulexin) or bicalutamide (Casodex), are oral capsules that are used usually in combination with the LH-RH agonists. The LH-RH agonists are often effective alone. The anti-androgenic drugs are added, however, if the cancer progresses despite the use of the LH-RH agonists. The hormonal treatments may have value, as well, when combined with radiation therapy. Studies are currently being conducted to determine if hormonal therapy enhances the therapeutic effect of radiation.
Generally, hormonal treatment is reserved for individuals who have advanced prostate cancer with local spread or metastases. Occasionally, an individual with organ-confined (localized) prostate cancer will receive hormonal treatment because he has severe associated medical problems or simply because he refuses to undergo surgery or radiation. Hormonal treatment is used in less than 10 percent of men with organ-confined (localized) prostate cancer. Remember that the intent of hormonal therapy usually is palliative. This means that the goal is to control the cancer rather than cure it because a cure is not possible.
WHAT IS CRYOTHERAPY FOR PROSTATE CANCER?
Cryotherapy is one of the newer treatments that is being evaluated for use in the early stage of prostate cancer. This treatment kills the cancer cells by freezing them. The freezing is accomplished by inserting a freezing liquid (for example, liquid nitrogen or argon) through needles directly into the prostate gland. The procedure is accomplished under the guidance of ultrasound images. Actually, cryotherapy is not a new technique. Rather, it is a modification of a procedure that was tried previously, but had an unacceptably high rate of complications. Thus, cryotherapy was used in the 1960s to freeze the lining of the stomach to treat ulcers, but was discontinued because it also severely damaged the lining of the stomach.
At present, cryotherapy is recommended for patients with locally advanced prostate cancer who, for whatever reason, are not candidates for the more established treatments. Cryotherapy is further being studied to determine which other patients might benefit from this treatment. For example, studies are underway to establish whether cryotherapy is beneficial as an initial treatment for organ-confined (localized) prostate cancer. The effectiveness of cryotherapy in eliminating prostate cancer, however, has not yet been proven. We do know that sometimes the freezing liquid fails to kill all of the cancer cells. Moreover, the potential side effects of this treatment include damage to the urethra and bladder. This damage can cause obstruction (blockage) of the urethra, fistulas (abnormal tunnels) that leak urine, or serious infections.
WHAT IS CHEMOTHERAPY FOR PROSTATE CANCER?
Chemotherapeutic agents, or chemotherapy, are anti-cancer drugs. They are used as a palliative treatment (palliation) in patients with advanced cancer for whom a cure is unattainable. Recall that the goal of palliation is simply to slow the tumor’s growth and relieve the patient’s symptoms. Chemotherapy is not ordinarily used for organ-confined or locally advanced prostate cancers because a cure in these cases is possible with other treatments. Currently, chemotherapy is used only for advanced metastatic prostate cancers that have failed to respond to other treatments.
Several chemotherapeutic agents have been used effectively to palliate metastatic prostate cancer. One such agent is estramustine (Emcyt). Another agent, mitoxantrone (Novantrone), has been shown to be effective in combination with prednisone for palliating androgen-independent prostate cancer. As mentioned previously, metastatic tumors that have not responded specifically to hormonal therapy are referred to as androgen-independent (hormone-refractory) prostate cancers.
The more common side effects of chemotherapy include weakness, nausea, hair loss , and suppression of the bone marrow. The suppression of marrow, in turn, can decrease the red blood cells (causing anemia ), the white blood cells (leading to infections), and the platelets (resulting in bleeding).
New chemotherapeutic agents for prostate cancer are continually being studied for their effectiveness and safety in cancer centers throughout the United States and elsewhere. For example, cancer specialists (oncologists) have been evaluating paclitaxel (Taxol) or docetaxel (Taxotere) for metastatic prostate cancer (these two drugs are effective in palliating metastatic breast cancer). Another one of the newer chemotherapeutic agents under investigation for androgen independent prostate cancer is Suramin.
WHAT ABOUT HERBAL OR OTHER ALTERNATIVE MEDICINE TREATMENTS FOR PROSTATE CANCER?
Alternative medicine, also called integrative or complementary medicine, includes such non-traditional treatments as herbs, dietary supplements, and acupuncture . A major problem with most herbal treatments is that their composition is not standardized. Moreover, the way herbal treatments work and their long-term side effects usually are not known.
One new treatment for prostate cancer, new at least in the United States, is an herbal medicine called PC Spes. The name comes from PC, which stands for prostate cancer, and Spes, which is the Latin word for hope. In some initial trials of PC Spes in men who have failed the traditional treatments (hormonal therapy and chemotherapy) for advanced prostate cancer, this herbal medicine appeared to be promising. More rigorous studies are ongoing to evaluate more fully the risks and benefits of this treatment.
WHAT IS WATCHFUL WAITING?
Watchful waiting is observing a patient while no treatment is given. Such a patient usually has an organ-confined tumor and no symptoms. Understand, however, that although watchful waiting involves no actual treatment, the patient still needs close follow-up and monitoring. The follow-up involves frequent visits to the doctor, perhaps every three to six months. The visits include questions about new or worsening symptoms and digital rectal examinations for any change in the prostate gland. In addition, blood tests are done to watch for a rising PSA and imaging studies can be conducted to detect the spread of the cancer. If the history, examinations, or any of the tests signal the possibility of an advancing cancer, the watchful waiting usually is discontinued and treatment is recommended.
This option of watchful waiting actually has been chosen over a therapeutic intervention, such as surgery or radiation, in up to 30% of patients who have organ-confined (localized) prostate cancer. The main reason for taking a course of watchful waiting is that prostate cancers generally grow more slowly than most other cancers. Thus, many localized prostate cancers found at an early stage can take years or sometimes even decades to spread locally and metastasize. Therefore, watchful waiting seems to make sense for organ-confined (localized) prostate cancers in men who are elderly. It is also a reasonable decision in men who have tiny (seen only with a microscope) tumors and a low PSA (for example, in the 4-10 range or lower). Additionally, watchful waiting often is the most appropriate choice in men who are ill with other serious medical diseases, such as heart or lung disease, poorly controlled high blood pressure, diabetes, AIDS, or other cancers.
Watchful waiting in prostate cancer, however, remains controversial. Some medical authors have stated outright that it is not a good choice. They point out that few doctors would just watch other cancers to see whether they would spread without treatment. Furthermore, the treatment for an individual could become less effective in the future if and when the cancer does progress. Finally, one expert summarized some recently published information on watchful waiting. He indicated that among men with organ-confined (localized) prostate cancer, the development of distant spread (metastasis) and death from the cancer was 50 percent higher in those who received no treatment than in those who underwent surgical removal of the prostate (radical prostatectomy).
CAN PROSTATE CANCER BE PREVENTED?
No specific measures are known to prevent the development of prostate cancer. At present, therefore, we can hope only to prevent progression of the cancer by making early diagnoses and then attempting to cure the disease. Early diagnoses can be made by screening men for prostate cancer. Screening is done, as mentioned previously, by routine yearly digital rectal examinations beginning at age 40 and the addition of an annual PSA test beginning at age 50. The purpose of the screening is to detect early, tiny, or even microscopic cancers that are confined to the prostate gland. Early treatment of these malignancies (cancers) can stop the growth, prevent the spread, and possibly cure the cancer.
Based on some research in animals and people, certain dietary measures have been suggested to prevent the progression of prostate cancer. For example, low fat diets, particularly avoiding red meats, have been suggested because they are thought to slow down the growth of prostate tumors in a manner not yet known. Soybean products, which work by decreasing the amount of testosterone circulating in the blood, also reportedly can inhibit the growth of prostate tumors. Finally, other studies show that tomato products (lycopenes), the mineral selenium, and vitamin E might slow the growth of prostate tumors in ways that are not yet understood.
WHAT WILL BE THE FUTURE TREATMENTS FOR PROSTATE CANCER?
The treatment of organ-confined prostate cancer to date has involved cutting out, radiating, or freezing the gland in trying to cure the disease. In more advanced cases, the goal has been to control the cancer for at least some time by using hormonal treatment or chemotherapy. Earlier diagnosis and improved treatment techniques in recent years have certainly led to better results. In addition, other treatments are being sought. For example, microwave treatment of the prostate is being used for benign prostatic hypertrophy (enlargement of the prostate, BPH) in a minimally invasive (minimal cutting or probing), outpatient (outside the hospital) procedure. Studies may soon begin to evaluate this technique as a treatment for prostate cancer.
The key to curing prostate cancer, however, ultimately will come from an understanding of the genetic basis of this disease. Genes, which are chemical compounds located on the chromosomes, determine the characteristics of individuals. Accordingly, investigators at research centers have focused on identifying and isolating the gene or genes responsible for prostate cancer. For example, studies are being conducted in men who have a family history of prostate cancer to try to uncover the genetic links of the disease. The investigators ultimately will try to block or modify the offending genes so as to prevent or alter the disease. Finally, perhaps a vaccine to either prevent or treat prostate cancer will be developed in the future.
PROSTATE CANCER AT A GLANCE
* Prostate cancer is the second leading cause of deaths from cancer among US men.
* While the causes of prostate cancer are still unknown, some risk factors for the disease, such as advancing age and a family history of prostate cancer, have been identified.
* Prostate cancer is often initially suspected because of an abnormal PSA blood test or a hard nodule (lump) felt on the prostate gland during a routine digital (done with a finger) rectal examination.
* The digital rectal examination (starting at age 40) and the PSA blood test (starting at age 50) should be done at yearly intervals to screen men for prostate cancer.
* Refinements in the PSA test, including the PSA ratio, age-specific PSA, and PSA velocity or slope have improved the accuracy of the test.
* If one of the screening tests is abnormal, the diagnosis of prostate cancer should be suspected and a biopsy of the prostate gland is usually done.
* The diagnosis of prostate cancer is made when cancerous prostatic cells are identified in the biopsy tissue under a microscope.
* In some men, prostate cancer is life threatening, while in many others, it can exist for many years without causing health problems.
* The choice of treatment for prostate cancer depends on the size, aggressiveness, and extent or spread of the tumor, as well as on the age, general health, and preference of the patient.
* The many options for treating prostate cancer include surgery, radiation therapy, hormonal treatment, cryotherapy, chemotherapy, combinations of some of these treatments, and watchful waiting.
* Research is underway to identify the genes that cause prostate cancer.
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