Dr Irfan Ahmed
Consultant Urologist & Cancer Surgeon
Horizon Hospital, Lahore
Prostate is an ovoid shaped approximately 20 gm gland which lies at the base of the bladder in males. It encircles the first part of the urethra. The apex of the prostate is continuous with the striated urethral sphincter, the muscle which helps in continence. Prostate gland plays an important role during reproductive years of life.
Cancer of prostate gland is the leading cancer diagnosis and second most common cause of cancer-related death in men in US.
Worldwide prostate cancer is the fourth most common cancer in men.
In the last two decades, earlier diagnosis and treatment, when the disease is still localized has led to marked decrease in the mortality rate from this disease.
Prostate cancer is predominantly a disease of elderly with more than 75% of cancers being diagnosed in men older than 65 years of age. The incidence however has increased in men age 50 – 59 years.
Prostate cancer risk is determined by both genetic and environmental factors. Approximately 10 % prostate cancers are inherited. Men with one first degree relative with prostate cancer has a twofold risk of developing cancer, while men with two or more affected first degree relatives have a 5-11 fold risk respectively.
Dietary fat is supposed to increase the risk where as selenium, vit E and lycopene decrease the incidence of this disease.
- Prostate cancer rarely causes any specific symptoms early in the course of the disease.
It can present with the lower urinary tract symptoms like:
- difficulty in voiding,
- poor flow,
- incomplete emptying,
- increased frequency,
- urgency and passage of more urine during the night.
- It may also present with ejaculatory problems like haematospermia or erectile dysfunction.
- The cancer when advances locally, it may obstruct the kidneys and when it spreads distally it usually affects the proximal ends of long bones and axial skeleton. In such cases the patient may present with features of renal obstruction & impairment or bone symptoms which could be pain, anaemia or pathological fracture.
- The diagnosis is suspected on the basis of symptoms,
- digital rectal examination (DRE) and
- blood test (PSA) which is specific for prostate cancer.
- The diagnosis is confirmed by biopsy performed with the aid of transrectal ultrasound or obtained through transurethral resection of the prostate.
Once the diagnosis is confirmed the next important step prior to any treatment is staging of the disease to find out its extent whether the disease is localized, locally advanced or spread distally.
It is done by bone scan and in selected cases by pelvic MRI scan.
After the diagnosis and the staging work-up is completed, the treatment plan is made which varies widely between the patients.
The treatment for symptomatic metastatic or advanced disease is only palliative and is usually in the form of androgen blockade offered by oral tablets, injectables or surgical castration.
The decision making regarding the treatment is of paramount importance when it is diagnosed early and the disease is localized to prostate gland as it is potentially curable.
The treatment offered in such cases mainly depends upon the patient’s age, co-morbidities and nature of the disease as determined by histology.
Two main modalities of treatment for localized disease are
Radical Surgery (Radical Prostatectomy) and
Treatment with Radical Radiation.
Hormonal treatment is not given in these cases other than in combination with radiation treatment in selected case. The injudicious use of hormones could be more detrimental than useful in this situation.
Radical Prostatectomy in selected cases has an edge over the radiation treatment in terms of long term cancer control. It carries a minor risk of incontinence and erectile dysfunction but provides good cancer control, accurate staging and helps in further treatment planning if required.
I will strongly recommend elderly male patients who suffer from lower urinary tract symptoms to seek help early, particularly if there is first degree relative who suffers from prostate cancer.
I also urge that all those involved in the diagnosis or management of this disease should make an attempt towards early diagnosis and referral to the specialist centres for Radical Treatment.