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The prostate is a walnut-sized organ that is part of the male reproductive system. It is located below the bladder and in front of the rectum. It surrounds part of the urethra, the tube that carries urine from the bladder to outside the body. The gland’s main function is to produce fluid for semen, which nourishes and transports sperm cells.
When prostate cells grow abnormally and form a mass, it is called a tumor. Some tumors are benign (not likely to be life-threatening) and others are malignant (cancerous and potentially life-threatening). Over the course of a man’s lifetime, some prostate cells may become cancerous. Sometimes, the cancer can be very small, localized, and confined within the prostate. In other cases, the cancer is present in more than one site of the prostate, often involving both sides of the gland. Through a process called metastasis, some cancer cells can spread outside the prostate to nearby regional lymph nodes or organs in the pelvic area. They eventually can spread to more distant parts of the body through the blood and lymph systems–most often to the bones. Determining whether the cancer is confined to the prostate or whether it has spread either locally or to more distant sites is often done by cross-sectional imaging and is very important in selecting treatment.
Most prostate cancers in the United States are identified through prostate-specific antigen (PSA) screening or digital rectal examination (DRE). Prostate-specific antigen is a protein in the blood produced by prostate cells. It is widely used as a screening test for prostate cancer. Your PSA level can be measured with a simple blood test. The higher the PSA level, the more likely that prostate cancer is present. In a DRE, a doctor inserts a gloved, lubricated finger into a man’s rectum to feel for any irregular or abnormally firm area in the prostate. While most prostate cancers are indicated by PSA results, some cancers produce little PSA but can be detected by DRE.
An elevated PSA may suggest an increased risk of prostate cancer; however, elevations of PSA can also occur in benign conditions. The decision to proceed to biopsy of the prostate is based on a combination of factors, such as PSA, DRE, family history, age, race and other comorbidities and should be done only after discussing the risks and benefits with a physician.
Deciding how to treat prostate cancer can be a confusing process. Each treatment has its own mix of benefits, risks and impacts on quality of life. The good news is that several treatments are very successful for many prostate cancer patients, either in providing a cure or keeping the cancer under control for many years. However, your physician cannot always tell you specifically which treatment to choose, because for most men, the choice is significantly influenced by personal preferences.
In addition to the tumor risk factors described above, treatment choice is influenced by factors such as:
• Your age and life expectancy
• Your general health and specific medical conditions
• Cost and practical considerations
• Attitudes about cure and/or living with cancer
• Your needs, concerns, values and social relationships
• Your feelings about specific side effects
As appropriate, you and your physicians may choose a combination of treatments.
Below are brief examples of treatment options for localized prostate cancer:
As previously discussed, many prostate cancers do not pose an immediate risk to health and may not require treatment. Active surveillance is a way to monitor low risk prostate cancer (cancer that is not an immediate risk to your health or well-being) with a plan of timely intervention should the tumor progress.
A radical prostatectomy is surgery to remove the entire prostate gland and seminal vesicles after a diagnosis of prostate cancer is made. Sometimes, this also entails removal of the regional lymph nodes, depending on a number of factors.
Radiation therapy is done with the intent of curing the disease by killing cancer cells.. Radiation can be given as external beam radiation therapy (EBRT) and/or as brachytherapy (temporary or permanent radiation seed implants). This treatment is sometimes coupled with hormone therapy because most prostate cancers are driven by testosterone. Hormone therapy attempts to establish very low levels of testosterone in an effort to control the cancer progression.
Brachytherapy (Seed Implants)
With brachytherapy, radiation is given from inside the body, with radioactive seeds placed permanently in the prostate or with narrow, seed-filled tubes that are placed temporarily for one or two days.
This procedure, used to treat localized prostate cancer, kills the cancer cells in the prostate by freezing them.
What If Initial Treatment Is Not Sufficient or Your Cancer Recurs?
While the diagnosis and treatment of prostate cancer has improved significantly in recent years, the cancer can still recur. Not surprisingly, clinical studies show the likelihood is higher the more advanced the disease was at initial diagnosis, and the more time that passes since diagnosis and treatment. While differences emerge between different types of treatment, many other factors also come into play such as the original staging, Gleason score, extent of the cancer, and age of the patient. Various statistical tools called nomograms help assess this risk.
There are usually a number of treatment options that men in such situations can consider to successfully treat or control the cancer. Choosing among them will require a new decision-making process. It is still essential that you and your physician continue to monitor your PSA on a quarterly basis for some period of time, no matter how successful your treatment has seemed to be.
The National Comprehensive Cancer Network Guidelines for Patients with Prostate Cancer are meant to help patients talk to their physicians about the best treatment options for their disease. (The NCCN Guidelines are written by experts from 26 of the world's leading cancer centers.)
For more information, UCSF Urology has prepared several information documents on this disease. Please see below for selected information.