Understanding Prostate Cancer & Your Treatment Options
Western States HIFU in Los Angeles, California
“I’ve Been Diagnosed with Prostate Cancer.”
Prostate cancer is both scary and confusing. When faced with a diagnosis of prostate cancer, you will find a lot of information about your prostate cancer diagnosis, what prostate cancer is, and your treatment options for prostate cancer. Making a decision can be tough, so we suggest reading about a prostate cancer diagnosis, and take it seriously. We’ve compiled information to help you make an informed decision about treating your prostate cancer.
What is Prostate Cancer?
To begin with – prostate cancer IS cancer. Many articles these days say it may be less aggressive than other cancers. However, any diagnosis of cancer should be taken seriously. It is still cancer.
Let’s begin with an explanation of what prostate cancer is. Then we’ll progress to understanding how it is diagnosed, how it is categorized by stages and what treatments are available.
The human body has between 50 to 100 trillion living cells. Most cells grow, divide and die in a regular, healthy manner. Cancer begins when the cells begin to grow out of control, causing abnormal cell growth. Over time, a mass of cells develops and is called a tumor or cancer. Because cancer cells do not have the control that normal cells have, they can grow outside of the area they start in and can travel to other parts of the body. For example, in cases of advanced prostate cancer, tumor cells can spread to a patient’s bones and other distant areas.
Risk Factors of Prostate Cancer
It is difficult to pinpoint an exact cause for any form of cancer. However, there are common risk factors that have been identified with prostate cancer.
Some of the risk factors for prostate cancer include:
- Age – the chances of developing prostate cancer increase with age. Although it is rare under the age of 40, the youngest reported case of prostate cancer occurred in a 33-year-old patient. 60% of all cases are diagnosed in men aged 60 or older.
- Genetics – men of African descent have a higher risk of getting prostate cancer than do Asian or Caucasian men. In recent years, there has been a lot of focus on the genetic basis of prostate cancers. Several specific genes have been identified.
- Heredity – a person whose father, brother or other paternal relatives (grandfather, uncle, cousin) has prostate cancer is at an increased risk of also developing prostate cancer. In fact, the risk doubles.
- Hormonal influences – this is controversial. While, in the past, testosterone was thought to increase the development of prostate cancer, recent studies suggest that this is not true. Indeed, one study concluded that higher testosterone may be protective against prostate cancer.
- Environment/diet/lifestyle – living in certain areas (like North America), eating large amounts of saturated fats, smoking and exposure to some chemicals and industrial toxins may increase the risk of getting prostate cancer.
- Obesity – several mechanisms have been postulated, but, it seems clear that obesity increases the risk of getting prostate cancer and it may be diagnosed at a more advanced stage.
- Vitamins – vitamin E, once thought to protect men from prostate cancer, is now believed to be a causative factor. Selenium, a trace element, may also be a risk factor.
- Medications – medicines used for BPH treatment or hair loss, such as finasteride (Proscar) and dutasteride (Avodart), Jalyn and Propecia have been shown to cause a more aggressive form of prostate cancer in some patients.
Stages of Prostate Cancer
Prostate cancer is divided into four stages. There are subdivisions of each stage, to help define the location of the severity of the advancement of the tumor.
- T1a – tumor cells found in less than 5% of tissue cut out during a TURP
- T1b – tumor cells found in more than 5% of tissue cut out during a TURP
- T1c – tumor found on a needle biopsy done because of an elevated PSA level
- T2a – tumor involving ½ or less of one side of the prostate
- T2b – tumor involving more than ½ of one side but not extending to the other side
- T2c – tumor involving both sides of the prostate
- T3a – tumor growing through the capsule of the prostate
- T3b – tumor growing into the adjacent seminal vesicles
- T4 – tumor growing into tissues beyond the seminal vesicles
The higher the stage of prostate cancer, the lower the likelihood of recovery. That it is why it is important to have a simple, annual prostate cancer screening that includes a brief examination and a PSA blood test. Screening can save your life!
There are other staging systems. These include the Partin tables and the CAPRA scale. Both take in to account a patient’s age, tumor type and amount, PSA level and other factors to predict the likelihood of a successful treatment.
The Gleason grade is a system used by pathologists to determine the potential aggressiveness of a prostate cancer. The grade is made up of 2 numbers, ranging from 2 to 5. By adding them together the Gleason grade is calculated. For example, a Gleason 7 cancer could be made of 3+4 cells or 4+3 cells. The first # represents the majority of the cancer cells; the second # represents the secondary pattern. Higher numbers correlate with the more aggressive behavior of prostate cancer and higher mortality.
Is Genetic Testing Useful for Predicting Prostate Cancer?
More and more attention is being placed on genetic testing to predict 1) the likelihood a patient having prostate cancer and 2) how aggressive your prostate cancer is. There is a multitude of genetic tests including Prolaris, Confirm MDx, Oncotype Dx, Decipher, and PTEN. While they purport to predict long-term growth and spread potentials of prostate cancers, long-term data may be lacking so accurate treatment plans based upon these results may not provide an accurate picture of your particular cancer.
That’s why it is so important to see a recognized cancer expert like Dr. Pugach. As one of the most experienced prostate cancer specialists, Dr. Pugach will incorporate the results of genetic testing with all of your clinical data to give you an accurate picture of your prostate cancer risk and the aggressiveness of your cancer. Dr. Pugach does not look at any piece of clinical information without taking into account the entire picture. You and your cancer are unique and he treats every patient as an individual.
CAPRA and Partin Tables
These are statistical tools that look at the Gleason grade of prostate cancer, a patient’s PSA level, the amount of cancer and other factors to determine the likelihood of cancer has spread outside the prostate and the potential for a cancer cure.
Signs and Symptoms of Prostate Cancer
Most cases of prostate cancer do not produce any symptoms in early stages so, like most other cancers, cancer cells can multiply and spread silently beyond the prostate before it is diagnosed.
The current theory of prostate cancer is that a man has it for 10 years or more before it can be diagnosed. That’s how long it takes from the development of the first cancer cell until it doubles, then doubles again and again and again… after 10 years there are about 1 billion cancer cells in the prostate. At that point, a man’s PSA rises or an abnormal area in the prostate can be felt on a rectal examination.
So, early detection is usually only possible when a man does not have signs and symptoms of prostate enlargement. That’s why an annual screening examination is so important!
If a man does have signs and symptoms of prostate cancer, they may include:
- Blood in your urine
- Dull pain in your lower pelvic area
- General pain in your lower back, hips or other bone areas
- Urgency of urination
- Difficulty starting urination
- Pain during urination
- Loss of appetite and weight
- Painful ejaculation
- Persistent bone pain
- Weak urine flow and dribbling
- Intermittent urine flow
- A sensation that your bladder is not empty
- Frequent urination during the night
If My PSA Blood Test Is Elevated Does That Mean I Have Prostate Cancer?
Not necessarily. PSA increases for 3 principal reasons: 1) you have prostate cancer; 2) you have prostatitis (inflammation of the prostate); 3) you have a large, benign prostate gland. An elevated PSA blood level says a person MAY have prostate cancer. Other types of PSA tests, including one known as “free PSA”, may give additional information about the possibility of having prostate cancer.
What Type of PSA Testings are Commonly Used?
There is conflicting information available on what PSA results mean. It is important to educate yourself on the various types of PSA tests and what the results mean. A standard PSA test measures the total PSA in your blood. However, PSA has many different forms and sub-types. The two most common and practically available forms that should be measured annually are:
- Bound: PSA is attached to a protein in the blood. This is the TOTAL PSA. It should not exceed 2.5 in men up to age 65, and should not be more than 4.0 in men over the age of 65.
- Unbound: PSA is not attached to a protein in the blood. This is FREE PSA.
The proportions of free and bound PSA are different in men with prostate cancer, compared to men who have benign prostate disease. It is a general opinion that a higher amount of free PSA in a test means a lower chance of cancer. Levels above 25% are typically thought to be normal. Levels below this may be an early sign of prostate cancer, even when the total (bound) PSA is normal.
Diagnosing Prostate Cancer
The only way to diagnose prostate cancer is a prostate biopsy. While certain imaging tests (MRI, CT scan, bone scan) may help improve the accuracy of a biopsy. The most significant imaging test there is a multiparametric MRI. If a particular area that is suspicious for prostate cancer is seen, Dr. Pugach can perform a targeted fusion biopsy.
Only a biopsy can accurately determine if there is cancer and how aggressive it is. A biopsy is done as an office procedure. An ultrasound probe is used to take images of the prostate. Through that probe, a numbing medicine is injected around the prostate so you will feel almost nothing during the short, 10-minute biopsy procedure. The samples are evaluated by an experienced pathologist and a diagnosis is usually possible within just a few days.
Targeted Fusion Biopsy
At Western States HIFU, Dr. Pugach is one of a handful of doctors in the country with his own, advanced URONAV targeting system. URONAV “fuses” the MRI images into our advanced office ultrasound system to all biopsies of the MRI target(s). This minimizes tissue trauma and dramatically improves the accuracy of a biopsy. While only a few urology practices have this system, we believe this is the new ”standard” and we are proud to be a leader in this field!
Can Prostate Cancer be Diagnosed Without a Biopsy?
No. While some people believe this is true – including some physicians – no diagnosis of prostate cancer can be made without a tissue sample. A prostate biopsy is typically done via a transrectal or transperineal approach. In cases of advanced prostate cancer, biopsies can also be done of lymph nodes or bones where the cancer may have spread. Other tests, like MRI and ultrasound imaging, can show where a prostate cancer may be located, but a tissue diagnosis is the only way to confirm if cancer is present. A biopsy also allows us to characterize your cancer in many important ways – aggressiveness, extent, location, etc. This information is important in planning prostate cancer treatment.
Does a Biopsy Spread Prostate Cancer?
Once again, the answer is no. After decades of performing millions of biopsies of many body parts – prostates, breasts, kidneys, livers, bones, etc., there has never been evidence of tumor spread along a biopsy site. However, the question remains as to whether prostate biopsies can spread cancer within the prostate. That is why this is a concern for patients on Watchful Waiting or Active Surveillance (see below) since they have to undergo multiple repeat biopsy procedures on an ongoing basis.
Dr. Robert Pugach’s urology office is located in Los Alamitos. For patients who live out-of-the-area and for international patients who want to discuss prostate cancer treatment options with Dr. Pugach, we offer telephone or online/virtual consultations.