Prostate Cancer

Prostate cancer is one of the top ten cancers among men in India. According to Globocan, in 2018, there were 25,696 new cases and 17,184 deaths due to prostate cancer in India.

TYPES OF PROSTATE CANCER

Prostate cancer may be classified in several ways by a doctor:

Based on cell type:

• • Acinar adenocarcinoma: It is the most common type of prostate cancer (90% of cases) and develops in the outer gland cells of the prostate.
  • Ductal adenocarcinoma: It develops in the cells that line the tubes of the prostate gland. The form of cancer tends to grow faster than acinar adenocarcinoma.
  • Transitional cell (urothelial) cancer: It develops in the cells of the urethra (tube connecting the bladder to the outside).
  • Squamous cell cancer: It develops from flat cells that cover the prostate, and grows faster than adenocarcinomas.
  • Small cell cancer: It is made up of small round cells and is very rare (less than 2% of all cases).

Based on the spread of cancer:

• • Localised prostate cancer: The cancer is contained within the prostate gland and may be low-risk, intermediate-risk or high-risk prostate cancer depending on the risk of spreading.
  • Locally advanced prostate cancer: The cancer has spread beyond the prostate gland. It may have spread into the tissue around the prostate or organs such as the rectum.
  • Metastatic prostate cancer: The cancer has spread to another part of the body, most commonly the lymph nodes or to the bones, but can also spread to other organs.

These are diagnosed by the pathologist based on microscopic study of sample from the tumor.

STAGING OF PROSTATE CANCER:

If you are diagnosed with prostate cancer, your doctor will run more tests to determine the extent (stage) of your cancer. Your cancer's stage is an important input in deciding on your treatment. Prostate cancer staging is complicated and this is a simplified version but your doctor will be able to explain it to you in more detail:

• • Stage I: The tumour is not apparent on rectal examination or imaging, involves half of one lobe of the prostate or less with no regional lymph node metastasis or distant metastasis (spread to other organs).
  • Stage II: The tumour involves more than one half of a lobe but not both lobes OR involves both lobes with No regional lymph node or distant metastasis.
  • Stage III: The tumour extends through the prostate capsule (outer covering) with no regional lymph node or distant organ metastasis.
  • Stage IV: The tumour is fixed or invades surrounding structures with metastasis in regional lymph node and/or metastasis to distant organs.

Sources: Cancer India; European Society of Medical Oncology (ESMO); 

SCREENING & DIAGNOSIS OF PROSTATE CANCER

• • Clinical examination: The clinician will ask for symptoms of prostate cancer such as passing urine more frequently or difficulty passing urine, leaking of urine, blood in the urine or erection-related problems. A digital rectal examination is also carried out with a gloved finger in the rectum to feel the prostate gland for any lumps or abnormalities.
  • Prostate-specific Antigen (PSA) test: This is a blood test used to screen patients for prostate cancer. It measures the amount of a specific protein in the blood called prostate-specific antigen. This protein can be produced by both cancerous and noncancerous tissue in the prostate. High levels of PSA may indicate the presence of prostate cancer. However, many other conditions, such as an enlarged or inflamed prostate, can also increase PSA levels.
  • Biopsy: If the digital rectal examination and PSA tests are suspicious, a sample of tissue will be taken from the prostate gland to look for cancer cells. The procedure is called transrectal ultrasound scan guided (TRUS) biopsy, in which an ultrasound scanner is inserted into the rectum and a fine needle is then used to take samples of tissue from the prostate gland. These are then sent to the laboratory where the pathologist will examine the samples under the microscope to confirm the diagnosis and provide details on the characteristics of the cancer cells.
  • Radiological Tests: CT scan- It is a type of x-ray that lets doctors visualise internal organs in cross-section to help in staging. MRI scan - It uses magnetic fields and radio waves to produce detailed images and help with staging and to search for spread to distant organs in the body. PET scan - It involves injecting a radioactive substance into a vein and can help find areas of cancer that an MRI or CT scan may miss, especially when it spreads to other parts of the body. Bone scan - This is a scan to look for spread of cancer to the bones.

TREATMENT OF PROSTATE CANCER

The management of cancer depends on various factors, including the stage of the cancer, additional health issues, age etc. Surgery, radiation or chemotherapy may be used.

• • Active surveillance and watchful waiting: This involves only the close monitoring of the cancer and is an option for low- or intermediate-risk localised prostate cancer. The blood PSA levels and prostate biopsies or MRI scans are carried out often. The aim is to manage, rather than cure, the cancer.
  • Surgery: The removal of the prostate gland is radical prostatectomy, which aims to completely remove the prostate gland, surrounding tissues and lymph nodes. A variant is nerve-sparing prostatectomy in which the prostate tissue is removed without removing the nerves that control erection but can only be done when the cancer is not growing close to the nerves. Radical prostatectomy is major surgery, and may not be suitable for men with slowly growing prostate or those with contraindications to surgery. Other types of surgery include transurethral resection of the prostate (removal of the inner part of the prostate) or removal of the testicles both of which can help relieve the symptoms or control the spread of the cancer. Side effects: Problems controlling the flow of urine, leakage of urine, erection issues, swelling in the genital region or in the legs etc.
  • Radiotherapy: Radiotherapy uses ionising radiation to destroy the DNA of cancer cells. It may be external beam radiotherapy (from a machine outside the body) or brachytherapy (radioactive source placed inside the prostate gland). This form of therapy is recommended for localised or locally advanced prostate cancer. Side effects: fatigue, skin irritation, bladder inflammation, diarrhoea, blood in urine or semen, loss of pubic hair, etc.
  • Hormone therapy: Prostate cancer requires testosterone to grow. Hormone therapies block the actions of testosterone. This reduces the risk of prostate cancer recurring after treatment with surgery or radiotherapy as well as slows the growth of advanced cancer. There are three types of therapy: Androgen deprivation therapy (stops the testicles from producing testosterone and are given by injection or implanted), Anti-androgens (oral medications that prevent testosterone from reaching the cancer cells) Abiraterone (new type of therapy that blocks the formation of testosterone). Men who are treated with antiandrogen therapy or orchiectomy are at an increased risk of bone loss and bisphosphonate drugs are prescribed to lessen the risk of fractures. Side effects: fractures, loss of sex drive, erection problems, hot flushes, decreased body hair, loss of muscle bulk, hypertension, urinary tract infections, anaemia, blood in urine, fatigue, joint pain, acne etc. Side effects depend on the agent used.
  • Chemotherapy: It is indicated in some patients who are fit enough to receive it. When taken by mouth or injected, the drugs enter the bloodstream and can reach cancer cells throughout the body and is known as systemic chemotherapy. When chemotherapy is placed into an organ, or a body cavity it affects cancer cells in those areas (regional chemotherapy). The type of therapy depends on the type and stage of the cancer. Side effects: Depend on the agent used but commonly include hair loss, anaemia, anorexia, diarrhoea, nail disorders, nerve damage, mouth ulcers, risk of bleeding etc. 
  • Cryosurgery: This is also known as cryoablation and involves freezing and heating tissue to kill the cancer cells. Small needles are inserted in the prostate with the help of ultrasound guidance and the cold gas is placed in the needles causes the surrounding tissue to freeze. A second gas is then introduced to reheat the tissue. These cycles of freezing and thawing kill the cancer cells.
  • Palliative care: It is to describe care interventions to manage the symptoms of cancer and side effects of treatment of prostate cancer. Specialists also offer support in coping with the prognosis and preparation for end-of-life care. Palliative care in prostate cancer may include management of pain, diarrhoea, urinary incontinence, nutritional problems, leg swelling and bedsores etc.

Sources: European Society for Medical Oncology (ESMO); Mayo Clinic; National Cancer Institute; 

MULTI-DISCIPLINARY TEAM (MDT): Unlike most other diseases, cancer treatment requires an integrated approach from several specialists, each with their own expertise. This team of specialists who would work together on your cancer, is referred to as the Multi-Disciplinary Team (MDT). Many global organisations have recognized the importance of a MDT for cancer treatment, as it improves coordinated care to you, as a patient. Your MDT would include specialists from the following:

• • Medical Oncologist: Specialist that decides the optimum course and agent for chemotherapy
  • Urologist: A surgeon specialised in operating on conditions related to the urinary tract
  • Radiologist: A specialist who interprets MRI, X-rays and CT scans
  • Pathologist: A specialist who studies tissues under the microscope and provides insights regarding cancer cells that help decide treatment
  • Radiation Oncologist: Specialist that decides the optimum course and agent for radiotherapy
  • Palliative care specialist: Helps patients deal with the physical and psychological symptoms involved with the diagnosis and management of prostate cancer.

Some hospitals that take an organ-based approach to cancer, have a separate department for Reproductive cancers. These teams comprise of specialists who have dedicated training in cancers occurring in female and male reproductive organ cancers.

TUMOR BOARD: A tumor board is a meeting where your Multi-Disciplinary Team discusses cancer cases and shares knowledge. The board’s goal is to determine the best possible cancer treatment and care plan for an individual patient. Having fresh perspectives from other doctors makes it much easier to come up with that plan.

In some hospitals, all cancer cases are discussed at the Tumor Board, while in other hospitals the Tumor Board focuses on cases where a doctor seeks inputs from other specialists on the patient’s case. It’s OK to ask your doctor if or why your case was discussed at a tumor board. Or if it wasn’t, why not? In some cases, a patient’s treatment plan is very straightforward using standard treatment guidelines, and the doctor may feel a tumor board review isn’t needed. However, you can request that one be done.

SUPPORT GROUPS: These are offline or online groups that connect patients suffering from cancer. Do find out about a support group around you. The hospital where you are being treated may have a support group that you could join.

Sources:  Mayo Clinic

Choosing your oncologist and hospital is a very important decision, we recommend you make the time to research your options. We profile doctors and hospitals based on the range of services they offer to treat prostate cancer. Use our search tools to guide your choice of a medical provider. You may get in touch with us for any assistance during selection or booking process.

If you’ve been diagnosed with cancer, you need to find an oncologist to begin your treatment. An oncologist is a doctor who specializes in treating cancer. For prostate cancer, you can start by visiting a medical oncologist. Choose someone you are not only confident about but also comfortable with.

TIPS TO FIND AN ONCOLOGIST

1. 1. Look for Specialists: Look for doctors who treat your specific type of cancer - prostate cancer. You may need to work with more than one type of oncologists – surgical, medical or radiation oncologists.
   2. Gather Feedback: Discuss with friends and family, especially those who’ve taken similar treatment before. Online communities are a quick way to get feedback from others who’ve experienced your type of cancer before.
   3. Check the doctor’s credentials: Find out if the doctor has received any advanced training. There may be super-specialists available for reproductive cancers, who have received dedicated training on treating prostate cancer. If doctor’s credentials are not available easily, you have the right to ask for it from the doctor directly.
   4. Review doctor’s experience: Check how long the doctor has been practicing after completion of formal oncology education. How many patients with your type of cancer – prostate cancer – does the doctor see every year? In case of surgeons, studies have proven that higher volumes of surgeries lead to better outcomes.
   5. Find out hospital affiliations: Which hospitals does the doctor practice in? The availability of a multiple types of doctors at the hospital where you get treated is important. Find out what support staff is available at the hospital e.g. dietitian, counselor, home healthcare facilities etc.

TIPS TO FIND A HOSPITAL 

1. 1. Lookout for hospitals with lot of experts: Look for hospitals that offer a multi-disciplinary approach to prostate cancer treatment. This means each you receive inputs from many cancer experts. You will be helped by specialists including surgeons, medical oncologists, radiation oncologists, oncology nurses and other supporting staff. Find out if the hospital has a dedicated team for reproductive cancers? Does the hospital have Tumor Board reviews – how often are they conducted and will your case be discussed there if you wish?
   2. Work with a major cancer hospital, even if it is far: Most experts in high-volume centers are willing to work with your local doctors. Usually, part of the treatment (for example, surgery) can be executed in the major center and the post-surgery treatment is executed locally.
   3. Research hospital’s Prostate Cancer volumes: How many cases of prostate cancer are treated in the hospital every year? High volume centers with multiple specialists available for reproductive cancers may have better expertise and specialized medical infrastructure required.
   4. Consider Clinical Trials Availability: Ask whether the doctor or hospital has access to clinical trials and if you are eligible for any. Clinical trials are research studies that test new ways to treat cancer that you can be involved with. By being involved, you can help improve treatments and outcomes for future patients.
   5. Insurance Acceptance: Check if the hospital accepts your insurance. Check if the hospital has a desk that can assist you with claims.

Sources: Rogel Cancer Center; Cancer.Net