Prostate Cancer - Symptoms and Treatment Options

Prostate cancer forms in the male reproductive gland called the prostate gland.  According the National Cancer Institute, 192,280 new prostate cancer cases were reported in the United States in 2009, with deaths directly attributable to the disease totaling 27,360.  This cancer affects one-in-ten men and is the most common non-skin cancer.  While the largest percentage of men who are diagnosed with the disease are over the age of 65, all men should be aware of the diet an lifestyle factors that put them at risk of developing the disease.

While more than 70 percent of those diagnosed with prostate cancer are over the age of 65, a disproportionate amount of these men are African American.  This dramatic difference in the number of incidents of prostate cancer, in different demographics, has been observed in various populations. Which suggests that genetics and dietary factors may increase one’s risk of developing the cancer. However, the scientific research has not being conclusive in explaining this anomaly.

As a result of the fact that the prostate surrounds the urethra, any increase in its size can cause some problems with urinations, erections or ejaculation.  However, having these symptoms is not a positive diagnosis of prostate cancer. A common condition, known as benign prostatic hyperplasia (BPH) can also cause these symptoms. While BPH is not a cancer or a threat to life, it can be treated with medicine or surgery to relieve the symptoms.  If the cancer is caught early most men wont experience any of the common symptoms of having an enlarged prostate. Here are some common prostate cancer symptoms:

• Frequently needing to urinate, especially at night
• Difficulty starting or stopping urination
• Weak urine flow
• Painful or burning urination
• Difficulty in having an erection
• Pain during ejaculation
• Blood in the urine or semen; or
• Frequent pain or stiffness in the lower back, hips or upper thighs.

Screening and diagnosis

Screening for prostate cancer can be done in a physician’s office using a prostate specific antigen (PSA) test or a digital rectal exam (DRE).  During a DRE the physician inserts a gloved finger into the rectum to check for any irregularity in the texture, size or shape of prostate. The procedure is usually pain free, if the prostate is not enlarge or cancerous.

Prostate specific antigen is a protein that is produced by the prostate and released in small amounts into the bloodstream.  When the prostate develops a problem, more and more PSA is released until is reaches a level where it can be easily detected by a PSA blood test.  PSA levels are usually rated as follows:

• Results under 4 ng/mL -  normal
• Results between 4 and 10 ng/mL - intermediate
• Results greater than 10 ng/mL - high

If the PSA test raises suspicion that prostate cancer is present, or if the test is inconclusive, a biopsy of the prostate can be done to determine if prostate cancer is present. 

Should the presence of prostate cancer be confirmed, the patient has several treatment options to choose from.  The best prostate cancer treatment depends on several factors such as the age of the patient, how advanced the cancer is and whether the cancer has spread.  In any case these are the generally accepted methods of treating prostate cancer:

Radical prostatectomy is a major surgery that’s used to completely remove the prostate gland and some surrounding tissue. The operation is performed under general and local anesthesia and is used to treat prostate cancer with the hope of preventing its spread to other parts of the body. Generally speaking, there are two main options for doing this surgery: an open surgery or a minimal invasive technique called laparoscopic surgery.

Open Surgery -Though doctors often do the open surgery by hand, a few do it with robotic assistance called robot-assisted prostatectomy. Depending on the specifics of a case, a surgeon may elect to make an incision in the lower belly (called the retropubic approach) or make an incision in the groin area between the anus and scrotum (called the perineal approach). The recovery times for this procedure may be shorter than the retropubic approach, but the choice as to which approach will be used depends on the location of the cancer in the gland and the size of the growth, among other factors.

Laparoscopic Surgery - Laparoscopic surgery is a minimal invasion surgical technique in which a surgeon uses a laparoscope and special instruments to remove the prostate through a small incision made in the belly.  The surgeon is able to see inside the patient with the use of video cameras, which are used to project images onto a video monitor. Because this is a minimal invasion technique, patients tend to loose less blood and recover more quickly than patients on whom an open surgery is performed.

Benefits Of Laparoscopic Surgery -While the laparoscopic technique does not allow for the same level of dexterity, as what can be accomplished in a open surgery, the surgeon’s control over the laparoscope and cameras is greatly improved where Robot Assisted Surgery is available and used. Robotic prostatectomy, as it is sometimes called, requires the skills of a specially trained surgeon and very specialized equipment. While the laparoscopic surgical technique is more challenging to execute by the surgeon, it offers significant advantages to the patient that include:

• Less post operative discomfort
• Shorter recovery times
• Shorter hospital stays and
• Less internally and externally scarring.

Side effects of prostatectomy surgery - As is the case with many major surgical procedures, there are risks inherent in just having the procedure done. Such issues include: problems that can arise from the use of anesthesia during the surgery, there is also a small risk of heart attack, stroke, blood clots in the legs, infection, and post-operative bleeding. Other common side effects, specific to having prostate cancer, may include impotence and incontinence.

Studies show that up to half of the men who undergo radical prostatectomy experience problems with their bladder after the surgery, while between 15% and 50% reported having problems up to a year after the surgery. On the other hand up to 80% may experience erectile problems after the surgery. The good news is that most of these functions will return in the months that follow the surgery but how quickly the functions returns and to what extent depend on:

• How old the man was at the time of the surgery
• The extent to which the nerves that control the function where affected and
• Whether the man could have an erection before the surgery

The objective of a prostatectomy is to remove the prostate gland and any surrounding tissue that may be diseased, or may contribute to the re-occurrence of the cancer. This procedure often necessitates the cutting of nerves or the removal of tissue that are essential to the performance of certain important bodily functions, such as bladder control or achieving an erection. Whether or not the surgeon plans to operate in such a way to preserve these functions, the risk still exists that there will be significantly side effects.

Radical prostatectomy might not be the best treatment option for prostate cancer in every case but it is a well-established procedure that has been used successful to treat prostate cancer in many patients.

Cryotherapy, or cryosurgery, as it is sometimes called, is a more recently developed prostate cancer treatment option. The procedure is a minimally invasive one that was developed in the 90’s and works by freezing the prostate and the cancer cells within. During a cryotherapy surgery, pins are inserted into the prostate through the perineum (the area between the scrotum and anus), the pins are then used to freeze the cancerous portions of the prostate; this will completely destroy any frozen tissue and the cancer cells within it. Unfortunately, this procedure may also damage the nerves that are associated with sexual functions.

Cryotherapy is a minimal invasion technique that can be used in conjunction with other treatment options or used when other treatment options have failed. It is also an option that can be used when the patient wants to avoid the longer recovery times that are associated with using other options, such as open surgery radical prostatectomy.

Side effects of Cryotherapy - Cryotherapy can be done as an outpatient surgery under local or general anesthesia. The main side effect associated with cryotherapy is impotence. In order to properly treat the cancer it is sometimes necessary to freeze some tissue outside the prostate, which can affect the nerves that are responsible for regulating an erection. In many cases, if the nerve bundles are not damaged, the symptoms will go away in a matter of weeks. Side effects of cryotherapy surgery include:

• Blood in the urine
• Swelling of the Scrotum
• Impotence
• Urinary leakage
• Prostatic slough (damage to the urethra)
• Mild urinary urgency
• Mild pelvic pains
• Recovery times of Cryotherapy

Being a minimum invasion procedure, Cryosurgery patients usually experience relatively short recovery times. In most cases the patient will be up and about the same day, but he may experience some discomfort.

Success Rates of Cryotherapy - Cryosurgery has some of the highest success rates of any prostate cancer treatment option. According to E. Fuller Torrey and Carlton Stoiber in their book “Surviving Prostate Cancer…” the cancer recurrence rate, after two years, was 40 percent for low-risk patients, 55 percent for intermediate-risk patients and 64 percent for high-risk patients. These numbers were measured using the PSA score, and may not reflect the results that can be obtained from using modern cryotherapy techniques.

Brachytherapy is a minimal invasion prostate cancer treatment option. This treatment option seeks to kill the cancer cells by exposing them to radiation. The procedure may use one of two prostate radiation options that include: a localized radiation therapy using a high dose rate (HDR), also known as temporary brachytherapy or permanent seed implants. 

Permanent Seed Implant Brachytherapy - Permanent seed implant brachytherapy works by radiating the cancer cells from inside the gland with a low dose rate over several weeks, after which the seeds remain in the gland permanently. The procedure uses either radioactive Iodine (I -125) or palladium (Pd-103) that’s about the size of a grain of rice. Usually, the patient doesn’t notice the presence of the seeds and in most cases he can go home the same day. 

HDR Brachytherapy - On the other hand, HDR involves treating the cancer cells with a series of radiation treatment, delivered by way of tiny plastic catheters that are inserted into the prostate.  This treatment option is effective because it can precisely focus the radiation on the cancer, and away from sensitive areas, such as the nerve bundle that’s responsible for regulating an erection. Once the treatment is complete, the catheters can be easily removed from the prostate. The major advantage of this method, over the permanent seed method, is that a higher dose of radiation can be delivered at once and so the cancer’s response to the treatment can be more quickly assessed.

Side Effects Of Brachytherapy - Most side effects will be urinary related issues.  After the procedure is performed patients may feel the need to urinate more frequently than is the norm and in some instance the man may not be able to urinate at all.  This is because the needles, that were used to insert the seeds, may cause the prostate to swell or become enlarged after the implantation.  Some patients may require a catheter for about seven days but usually the swelling goes away and the patient will start to experience normal bladder action after about 3 months.  Other side effects may include blood in the urine and semen. In a few cases, patients may have erectile problems, however, the risk of this happening is very low. 

Brachytherapy is usually recommended for men who have localized cancer that is confined to the prostate gland.  It is also popular among those who desire to have a noninvasive treatment option, with a reduced chance of incontinence and impotence. Even though the risk of impotence increases with age, most patients will experience the same level of potency they had, before the procedure was done.

The number of men who use herbal therapies to treat prostate cancer is between 10 to 22 percent, according to a number of studies. Perhaps herbal alternatives are popular with men because it has been observed that the Chinese, who use lots of herbs, have low incidences of cancer. While one might be jumping-the-gun in ascribing a strong correlation between the use of herbs and low incidences of cancer, it can’t be denied that diet and lifestyle has a major impact on incidences of prostate cancer in any population.

Herbs Commonly Used -The herb that is most commonly used by men, to treat prostate cancer is the saw palmetto.  It is an extract from the dwarf palm, which is grown in the southeastern United States.  It is believed that Native Americans used extracts from the herb to treat urinary problems.  It is said that saw palmetto has the ability to block the production of testosterone, and by the extension, the growth of prostate cancer cells. Studies have shown that it does increase urine flow, reduces urinary urgency and decreases urinary obstruction. Other herbal alternatives that are used to treat prostate problems include: yohimbe, kava, jin bu huan and PC-SPES.

Side Effects -The book “100 Questions & Answers About Prostate Cancer,” highlights PC-SPES as an effective herbal preparation that has been used to treat localized and advanced prostate cancer. PC-SPES was first marketed in 1996.  PC stands for prostate cancer and spes is a Latin word that means hope. However, E. Fuller Torrey and Carlton Stoiber, in their book “Surviving Prostate Cancer…” state that PC-SPES has been known to cause breast enlargements, which is nearly universal in persons taking PC-SPES. Other side effects include: thromboembolism (blood clots in the leg) and a mysterious bleeding condition.

Men who are considering taking herbal preparations to treat any cancer should be aware that they could experience serious side effects when the herbs interact with other medications they are taking.  It is of utmost importance that a doctor be consulted before taking herbal remedies. The risk of having complications, from the use of some herbal supplements, is heightened by the fact that there is no regulation of the manufacturing of these supplements.  This is so, because manufacturers of herbal supplements are not required by law to be regulated, once they don’t claim the product is a treatment option for a specific disease or medical condition. 

E. Fuller Torrey and Carlton Stoiber list the following side effects of using herbal preparations as follows:

• Liver failure from the use of kava
• Hepatitis from jin bu huan supplements
• Seizures caused by using supplements derived from the yohimbe plant.

Hormone therapy is a prostate cancer treatment option that treats the cancer by depriving it of the male hormone androgen, which it needs to grow. This treatment option is also known as androgen deprivation therapy. It must be noted that hormone therapy can only slow down the growth of cancer cells, but not stop them. Therefore, it is sometimes used with other treatment options.

There are two broad classes of hormone treatment therapy: orchiectomy (surgical castration) or drugs treatment such as Luteinizing Hormone-Releasing Hormone (LHRH) antagonists.

Orchiectomy is best, and most often used in cases where the patient has advanced prostate cancer. The procedure involves the removal of the testicles from the scrotum which results in a drastic fall in the amount of testosterone that is produced by the man. This is because the testicles account for more than 95 percent of testosterone production, with the adrenal gland also producing a small amount.

Hormone Therapy Side effects -The removal of large amounts of testosterone from the body can cause lots of problems and side effects, many of which are similar to those that a menopausal woman will have. However, most of these symptoms can be resolved with hormone replacement therapy. The Encyclopedia of Surgery lists the following as side effects of having an orchiectomy:

• Loss of sexual desire (This side effect can be treated with hormone injections or gel preparations.)
• Impotence
• Hot flashes
• Fatigue
• Loss of sensation in the groin or the genitals
• Osteoporosis (Men who are taking hormone treatments for prostate cancer are at greater risk of osteoporosis.)
• Weight gain of 10–15 lb (4.5–6.8 kg)
• Mood swings or depression
• Enlargement and tenderness in the

In some cases, it might be better to not treat the cancer immediately, but rather, to wait to see how it progresses.  This option is sometimes appropriate because prostate cancer is usually slow to develop, and the patient my not want to risk having the side effects inherent in treating the cancer. In some cases, where the life expectancy of the patient is low, due to his age or the presence of another life threatening disease, watchful waiting may also be considered.

In a Swedish study of 695 men diagnosed with prostate cancer between 1989 and 1999, half of the men were place on a watchful waiting list and the others had prostate surgery.  After follow-ups had been done (on average 6.1 years), the men who were on the watchful waiting list had the following results:

• In 31 percent of the cases, the cancer had spread outside the prostate
• In 16 percent of the cases, the cancer had spread to other organs
• In 9 percent of the cases, the cancer had killed the man

The men who had had surgery faired as follows:

• In 12 percent of the cases, the cancer had spread outside the prostate
• In 10 percent of the cases, the cancer had spread to other organs
• In 5 percent of the cases, the cancer had killed the man

Another study of 767 Americans aged 55 to 74, who all elected watchful waiting, found that 96 percent had died after 20 years.  The study also showed the percentage chance of a man dying from prostate cancer within 20 years based on his Gleason score.  The scores and percentages are as follow:

• Gleason score of 5 = 10 percent of chance of dying
• Gleason score of 6 = 27 percent of chance of dying
• Gleason score of 7 = 51 percent of chance of dying
• Gleason score of 8 to 10 = 66 percent of chance of dying

While prostate cancer usually progresses slowly, the cancer maybe larger, or its growth rate more aggressive, than was expected.  In such cases, the advantage of treating the cancer early may be lost.  Men often choose watchful waiting because of the embarrassing side effects that treating the cancer can have. Others may choose the wait-and-see approach, because of the presence of another, more serious, life threatening disease that could kill them before the prostate cancer.  However, watchful waiting is generally considered appropriate in these cases:

• Where there is a short life expectancy
• The patient has another life threatening illness
• The patient has small tumors, a low Gleason score, and a low PSA level

Source: E. Fuller Torrey, and Carlton Stoiber. Surviving Prostate Cancer: What You Need to Know to Make Informed Decisions. Yale University Press, 2008