Prostate Cancer

Prostate anatomy and function

The prostate is a small, walnut-sized gland in men. It is located below the bladder and surrounds the upper portion of the urethra (where urine exits). The function of the prostate is to secrete fluids that make up part of the semen. The prostate may be a source of many health problems in men, the most common being benign prostatic hyperplasia (BPH), prostatitis (infection of the prostate), and cancer.

What is prostate cancer?

Prostate cancer is an important health problem in the United States due to its high significance. It is different from most cancers in that a percentage of men, particularly older men with a shorter life expectancy, may have a silent form of this cancer, meaning it will not cause symptoms or progress beyond the prostate gland during their lifetime. Sometimes this cancer can be small, slow growing and present limited risk to the patient. Other times, it can progress rapidly. Clinically important prostate cancers can be defined as those that threaten the well-being or life span of a man.

What causes prostate cancer?

What causes prostate cancer is a subject of intensive research. It is likely that prostate cancer occurs due to many reasons. Predominately a disease of elderly men, the diagnosis of prostate cancer is rare before age 40 but increases dramatically thereafter.

What are the risk factors for prostate cancer?

• Family history – Men with a family history of prostate cancer are at an increased risk of developing the disease. The risk correlates with the number of first-degree relatives (father, brother or uncle) affected by prostate cancer and the age at onset.
• African-American Ethnicity – African-Americans are in the highest risk group, with an incidence of more than 200 cases per 100,000 black men. AA men also tend to present with more advanced disease and have poorer overall prognosis than Caucasian or Asian men.
• Obesity – It has been clearly shown that obesity is associated with increased risk for death from prostate cancer. Thus, the simplest advice for avoiding death from prostate cancer is to prevent obesity and if you are obese, to lose weight and keep it off.

The intake of other certain dietary factors may also reduce the risk of developing prostate cancer. Such substances include lycopene and fish oil. Lycopene is an antioxidant that may protect cells from becoming cancerous.

Who should be screened for prostate cancer?

The easiest thing you can do to detect prostate cancer and catch it early, is be diligent about getting screened. Screening involves a blood test called a PSA and prostate exam (also known as a digital rectal exam). This can be done by your primary care physician or a urologist.

The following guidelines are per AUA (American Urological Association) recommendations:

• Men under the age of 55 with no risk factors do not need to be screened.
• For men younger than age 55 years at higher risk (e.g. positive family history or African American race), decisions regarding prostate cancer screening should be individualized.
• Age 55-70, who are low risk, get screened every 1-2 years.
• Over the age of 70 can continue to be screened if life expectancy is greater than 10 years.

If your doctor feels that a screening test was suspicious, he or she may check your PSA more frequently until it is stable.

Why is there a debate about screening?

There is questioning among healthcare professionals regarding the over-diagnosis and overtreatment of prostate cancer. However, screening to see if cancer is present is still important. If the doctor suspects cancer, then he may decide to proceed with a prostate biopsy. We recognize that not all patients need to be treated if they have prostate cancer. For example, an elderly patient (>age 80) with a small amount of prostate cancer may not necessarily be affected by the cancer due to its slow growing nature. In certain patient populations, treatment may lead to more harm than good. Each patient has a different story, and while we recommend routine screening, further diagnosis and treatment is at the doctor’s discretion based on each individual case.

Are there symptoms associated with prostate cancer?

There are usually no symptoms associated with prostate cancer, especially in the early stages of the disease. If symptoms do occur, they include urinary problems, pelvic pain, blood in the semen or urine, and bone pain. Again, it is rare to have these symptoms unless the prostate cancer is very advanced and/or has spread to the body.

How is prostate cancer diagnosed/detected?

Currently, digital rectal examination (DRE) and prostate specific antigen (PSA) are used for prostate cancer detection. The American Urological Association recommends that healthy men ages 55-70 should have prostate cancer screening with a DRE and PSA test every two years. Men with risk factors such as family history or African-American ethnicity should be screened yearly, starting at an earlier age. We recommend continual screening for men over the age of 70 if life expectancy is greater than 10 years.

• DRE (digital rectal exam): The DRE is performed with the provider inserting a gloved finger into the rectum and examining the prostate gland, noting any abnormalities in size, contour, or consistency.
• PSA (prostate specific antigen): The PSA test is a blood test usually performed in addition to DRE and increases the likelihood of prostate cancer detection. The test measures the level of PSA, a substance produced only by the prostate, in the bloodstream. While PSA is specific to the prostate, it is not specific for prostate cancer necessarily. PSA may be elevated in benign prostate enlargement or inflammation of the prostate as well. Therefore, PSA density, PSA velocity, PSA age-specific reference ranges and use of free-to-total PSA ratios increase the ability to detect cancer.
• PCA-3 Test: PCA-3 is a cancer marker, specific for prostate cancer. In some cases, this newer test may allow the patient to avoid having a prostate biopsy. This test is ordered when PSA is high or the patient has a high risk of prostate cancer. It is a urine test, performed by vigorously massaging the prostate through DRE. The patient then urinates out prostate cells, which are sent for analysis. A positive value warrants further investigation.
• PHI Test: The Prostate Health Index is a newer test that combines 3 prostate tests to potentially increase the ability to screen out which individuals may have prostate cancer and therefore need a biopsy, while reducing the number of men who may need further (unnecessary) testing.
• Genetic Tests: There are a number of new genetic tests available that assess the aggressive nature of individual prostate cancers. These tests help us to determine what type of prostate cancer treatment would be appropriate. They are also very useful for patients who have already had prostate cancer treatment, and would like to know the risk of recurrence of the cancer. Some genetic tests look at how cells replicate (cell cycle progression), others evaluate specific tumor markers for prostate cancer, and some tests evaluate down to level of DNA and chromosomes that can activate or silence genes (DNA methylation). These tests are always used in correlation with the PSA blood test, patient’s health, and medical/family history. They do not decide treatment; however they help the provider plan for future management and outcomes.
• MRI of prostate: Prostate MRI is another way to detect prostate tumors and masses, along with the digital rectal exam (DRE). The doctor can decide how he would like to use this information. It can be used prior to a biopsy to see if any tumor is present. MRI can also be done after prostate cancer has been diagnosed to determine if there is any extension directly outside of the prostate capsule. This information is helpful during surgery.
• Prostate Biopsy: Biopsy is usually performed when there is a high suspicion of prostate cancer (elevated PSA, mass on DRE, positive PCA-3). It is a 15-minute procedure, done under ultrasound guidance. The prostate is numbed using Lidocaine. You should not feel anything after we numb the prostate. A sampling of tissue is collected from different areas of the prostate. This tissue is then sent to a pathologist to be examined. The pathologist assigns the biopsy sample a “Gleason Score.” The Gleason Score is a tool used to grade prostate cancer. You will be prescribed an antibiotic to take before, during, and after the procedure to reduce the chance of infection. Other precautions used before the biopsy to lower infection rate include an enema and clear liquid diet the night before the procedure. Some things you may experience after the prostate biopsy include: light rectal bleeding, blood in the semen, burning with urination, pain or discomfort in the groin, no intercourse for one week. Also, avoid straining with bowel movement and heavy lifting for 48 hours.

These are minor issues that will resolve in one-two days. If you experience fever (greater than 101.4 F), chills, nausea, or vomiting, immediately call our office or go to the emergency room.

Click here to get more information on the prostate biopsy procedure.

Surgery (Laparoscopic da Vinci Robotic Prostatectomy)

Dr. Shaw is proud to be amongst the first surgeons in the Central Texas area to offer da Vinci Robotic Prostatectomy. Trained at Tulane in New Orleans in 2000, he has been performing the Robotic-Assisted Prostatectomy procedures in Austin since 2004. A radical robotic prostatectomy is done to remove the entire prostate and seminal vesicles. For patients with prostate cancer confined to the prostate, the chance of cure with surgery alone at 10 years (with an undetectable PSA) is more than 90 percent. Most patients are able to leave the hospital within 48 hours with five small incisions no bigger than a dime, and minimal pain. Although the incidence of operative complications with radical prostatectomy is quite low, the primary postoperative side effects are urinary incontinence and erectile dysfunction.

The surgery itself is an inpatient procedure, about two-three hours long, and requires at least 24 to 48 hours in the hospital afterwards. It is performed under general anesthesia, so you will be asleep through the whole procedure. With the advent of robotics, we perform the surgery with smaller incisions and quicker recovery. The robot is controlled by the surgeon from about 10 feet away. The fine movements of the robotic arms allow the surgery to be performed at an optimal level. The prostate is removed, along with nearby structures called the seminal vesicles. We do our best to preserve nerves around the prostate; however, this depends on the extent and location of the cancer. The urethra is then re-anastomosed to the bladder, and the incisions are closed. The prostate and seminal vesicles are sent to pathology to be analyzed, and we will review that report with you at your follow up visit.

Before the surgery:

• Once you decide to proceed with a prostatectomy, you will speak with our surgical scheduler to pick a date and time for your surgery.
• We will have you do pre-op clearance either with your primary care doctor or at the hospital. This usually involves blood work for labs, urine analysis and culture, EKG, and chest x-ray.
• You will visit with a physical therapist that specializes in rehabilitation of the pelvic floor muscles. This is done before and after surgery to help you regain urinary continence after the surgery.
• Aspirin and other blood thinning products such as NSAIDs, fish oils, and vitamin E should be stopped one week before your surgery. If you are on other medications such as Coumadin, warfarin, Plavix, etc. these medications will be stopped under the direction of your prescribing physician.
• The day before your surgery, you may have a light breakfast in the morning with a clear liquid diet the rest of the day.

Some things to expect after surgery:

• You will go home with a catheter in place. This is placed in the operating room, and empties the bladder into a bag. The catheter will be removed at your post-operative visit in our clinic.
• You will be on post-operative antibiotics for about three days.
• Recovery may take anywhere from four-six weeks. Refrain from vigorous activity for one week. You can then slowly start to increase activity level, about 10 pounds per week.
• Pain should be minimal by the time you are discharged from the hospital. You will receive pain medications while you are there, and may only need Ibuprofen or Tylenol at home.
• You can begin showering normally after discharge from the hospital.
• Stitches are absorbable and will dissolve on their own.
• You may notice blood in the urine. This is normal, and will decrease over the next several days.
• Leakage of urine is a very common and expected effect of surgery. With pelvic floor physical therapy, this significantly improves within two-three months, and most patients are completely continent (can hold their urine) by six months.
• Rectile dysfunction is another very common effect of surgery, since some of the nerves surrounding the prostate are removed. When you are near recovery, you may begin erectile rehabilitation. At one of your post-operative visits, we will discuss the options for treatment. This usually involves the use of medications. If erectile function is important to you, it is imperative that you begin therapy soon after recovery from surgery. The longer you wait, the less likely the nerves are to respond to achieve erection. Click here to learn more about the treatment options for erectile dysfunction.

At Austin Urology Institute, we utilize a comprehensive prostate cancer program to ensure that our patients and family are well educated in the Laparoscopic Robotic da Vinci Prostatectomy Care Pathway to ensure optimum expectations and outcomes.

Radiation

Radiation therapy is appropriate for the primary treatment of localized prostate cancer, and secondary treatment for cancer recurring within the region of the prostate. These therapies are typically reserved for patients who are not candidates for surgery, or who do not wish to have surgery. Radiation is performed by a radiation oncologist, and involves a number of sessions depending on the type of radiation you choose.

• EBRT (External Beam Radiation Therapy): These X-rays destroy tumor cells by damaging their DNA. There is a brief exposure to the radiation, typically lasting several minutes. Once the prostate cancer treatment is over, there is no radiation in the patient’s body. The treatment is completely non-invasive, so there is no discomfort to the patient during the delivery of the radiation. EBRT is typically given once per day, five days per week. Primary treatment for localized prostate cancer usually requires about eight weeks of treatment.
• Brachytherapy: Is also referred to as “seed therapy” or a “prostate implant.” Brachytherapy involves the insertion of tiny radioactive “seeds” into the prostate. The seed implant is an outpatient procedure, performed under anesthesia. The radioactivity of the seeds slowly decays during several weeks to months after the procedure, and there are few long-term risks associated with this treatment.

Once radiation is done for the prostate, surgical removal of the prostate becomes very difficult, and is not usually offered as a treatment option. However, it can be used if prostate cancer recurs after surgery. Side effects of radiation are similar to those of surgery and include erectile dysfunction and urinary leakage.

Active Surveillance

Prostate cancer is often a slowly progressive disease. Tumor (grade, volume, PSA, stage) and patient (age and comorbidities) measures can be used to identify men at lower risk of disease progression during intermediate periods of follow-up. For men with lower risk cancer or for those for whom avoidance of sexual, urinary, and/or bowel complications are a primary consideration, active surveillance may also be considered. Surveillance includes close follow-up of PSA levels, DREs (digital rectal exams), and prostate biopsies if necessary. Certain hormonal medications that decrease testosterone can also be used to help keep the prostate cancer from growing.

After Treatment

After surgical prostate cancer treatment, we closely monitor your PSA levels to ensure that there is no recurrence of cancer. An ultrasensitive PSA is checked every six months for two years, then annually afterwards if there is no evidence of recurrence.

What if my cancer recurs?

If cancer recurs after surgical removal of the prostate, radiation or medical treatment may be advised. Radiation treatment involves EBRT (external beam radiation) and brachytherapy, described above. This is appropriate for patients who have not had prior radiation to the prostate. Medical treatment includes the use of hormonal therapies that are made to reduce levels of testosterone. In a patient with residual prostate cancer, excess testosterone may fuel the cancer and cause it to grow. Medical therapy is appropriate for either patients who have had either surgery or radiation of the prostate.

Can I prevent prostate cancer?

There is controversy about true prevention. The best thing you can do is follow the screening guidelines, and maintain your health through diet and exercise. As clinical studies, which found that supplements such as vitamin E and selenium do not prevent prostate cancer, point out – there is no current short-cut that can replace a healthy lifestyle.

What is the outlook/prognosis for prostate cancer?

When caught early and treated, patients with prostate cancer have a high chance of being cancer free after surgery. This will depend on the grade and extent of the cancer, as well as the patient’s other medical problems. While prostate cancer is considered a slow-growing cancer, it is still important to follow-up and have proper screening done.

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