A Guide to Prostate Cancer
Because cancer is a daunting word, let alone journey, we’ve created this guide to help you understand what it may mean for you or your loved ones.
Prostate and Prostate Cancer
The prostate is a gland in the male reproductive system. About the size of a ping-pong ball, it is located just below the bladder and in front of the rectum. The gland surrounds the urethra, the tube that carries urine and semen through the penis. It contains several small glands, whose main purpose is to produce the milky white part of semen. This super fluid acts as a vehicle protecting your sperm during the big swim.1
Prostate cancer is a disease in which some prostate cells have lost control of growth and division, and are no longer healthy.
Cancerous prostate cells:
- Grow uncontrollably
- Have an abnormal structure
- Have the ability to move to other parts of the body (aka ‘invasiveness’)
We don’t mean to scare you, but in a word — probably. Research shows that around 70% of men over 70 have at least some cancerous cells in their prostate. So, if you have a male reproductive system, you’ll most likely develop prostate cancer if you live long enough. The good news is that prostate cancer is slow-growing and can remain untreated for years without posing substantial risk. Most men never experience symptoms and only 11.6% are diagnosed during the course of their lives. Although it is the second most common cancer amongst men, more men die with prostate cancer than from it.1
Depends on your risk level. Diagnostic procedures of the prostate can be quite invasive, and many prostate cancers end up diagnosed as “insignificant”, which means that they pose a low risk of harm to the patient. For this reason, screening is deemed most crucial for men at high risk of prostate cancer and those experiencing symptoms. However, all men between the ages of 55 and 69 should make an informed decision with their doctor about whether or not to get screened. If you are at high risk, consideration of screening should begin at 40.1
There is no single cause of prostate cancer, but some factors can increase the risk of developing prostate cancer in some men. A risk factor is something that increases the likelihood of developing cancer. Risk factors can be environmental, behavioural, or genetic. Most cancers result from a combination of many risk factors, but sometimes cancer develops in men who do not carry any risk factors commonly recognized by doctors.3
- Have a family history of the disease. If someone in your family has had prostate cancer, you are more than two times as likely to have the disease.
- Eat a diet high in red meat content.
- Are African-American. African-American men are 60% more likely to develop prostate cancer than any other ethnicity. African-American men are diagnosed at a statistically younger age with more aggressive tumours, and their mortality rate is 2.4 times higher than men of other ethnicities.
- Are over 55 years old.
There is no sure way to prevent prostate cancer, but there are things you can do to improve your overall health that may affect prostate cancer development. Lifestyle recommendations for prostate cancer prevention are the same as most information given related to general health advice3:
- Eat a heart-healthy diet that’s plant-based and low in fat and dairy content.
- Maintain a healthy weight by reducing your daily caloric intake.
- Exercise most days of the week, for about 30 minutes.
- Don't smoke.
Any change in urinary patterns can be a sign of something happening with your prostate. If your bathroom breaks become more frequent, your stream is weak or strained, or you feel you have to urinate but cannot produce urine, speak to your doctor. Keep in mind, however, that more frequent urination does not necessarily indicate prostate cancer. It is important to consider that prostate cancer often does not have symptoms early on in its development, and sometimes symptoms that resemble prostate cancer are related to other benign prostatic diseases. The prostate enlarges with age and can lead to a condition with similar symptoms called benign prostatic hyperplasia (BPH).2
Despite technological advancements, the primary method for screening is the good old digital rectal exam (DRE). It’s a valuable way to get a quick and dirty assessment of the prostate. Gloved and lubricated, the doctor will slip a finger into the rectum and feel around for a spot that’s firmer than the tissue surrounding it. While the test is basic, a negative result doesn’t rule out cancer. The test helps indicate whether or not there is a need for further inquiry. Some cold lubricated comfort - the exam only takes about 10 seconds.1
The prostate specific antigen (PSA) is a slippery protein, produced in the prostate, that liquifies semen and allows your sperm to swim freely. The PSA test is a secondary measure to screen for prostate cancer. Since PSA circulates throughout the body, this test is less invasive than the DRE and only requires a sample of blood. Any PSA level above 2.5 ng/mL indicates a need for further testing. However, assessments of a ‘normal’ PSA must take into account factors like age, prostate size, previous tests, other medical conditions, medications, and infections.1
There was a time when a high PSA was a one way street to biopsy, surgery or even radiation, but now it’s understood as a highly sensitive biomarker of potential prostate issues, not solely prostate cancer. The test is rather controversial as it can detect high PSA amounts at very low concentrations, which can lead to overdiagnosis and overtreatment. A high PSA does not necessarily mean cancer; research shows an astounding 75% of cases are false positives and what’s more troubling, 20% are false negatives. Due to the sensitivity of the test, your results may differ within a week, so talk to your doctor and get retested.1
Currently, PSA is the best biomarker of your prostate health, but because it is not specifically indicative of prostate cancer, the race is on to identify scores that are. Keep in mind, FDA requirements for lab tests aren’t as demanding as those for new drugs, so ask your doctor if a test is commonly accepted or if you’re the next guinea pig.1
You’ve probably heard of magnetic resonance imaging (MRI). This high tech method takes live pictures of the inner workings of your prostate. More advanced types of MRI allow doctors to selectively identify harmful cancers like high grade aggressive tumors. This helps mitigate over diagnosis and treatment of low- grade tumors. Although great in theory, MRI does have its shortcomings; the high price tag and the associated costs of the machine (the scan must be read by a trained radiologist) make it less accessible than a urologist’s finger. Also, however unlikely, a false negative for high grade cancer is possible.1
Traditionally, 12 biopsy samples (cores) are taken using a thin hollow needle. Guided by ultrasound imaging technology, the procedure may be performed transrectally, through the urethra or the perineum. So far, this is the only way to confirm prostate cancer. The most common diagnostic approaches are systematic (or blind) biopsy and fusion (or targeted) biopsy.4
The ultrasound probe (transducer) emits and receives high frequency sound waves that bounce around your insides. Software analyzes these echo patterns to generate live 2D grayscale images. These images are like a map, depicting the size and orientation of the prostate in relation to its surrounding tissue.5
During a systematic or transrectal ultrasound guided (TRUS) biopsy, you may choose to be sedated or given local anesthesia before a lubricated ultrasound probe is inserted into your rectum. Using the ultrasound image as a reference, the doc will ready the needle, aim and fire. The process continues until 10- 12 samples (cores) are systematically taken from different areas of the prostate. Although the urologist is guided by the ultrasound, this method is considered “blind” because the appearance of prostate cancer is pretty ambiguous, so they do their best by trying to sample the gland in a systematic way.6
Blindly and uniformly sampling less than 1% of the prostate is far from perfect, but it’s the current approach for most doctors. We’re here to change that.
Fusion combines targets identified on previously taken MRI scans with live ultrasound imaging. A 3D construct of the prostate is created using data points acquired from the MRI and an ultrasound sweep. This 3D interactive model acts as a map and the projected needle path becomes the compass that directs clinicians to areas of suspicion for biopsy.7
Prior to the biopsy, your MRI scans will be annotated with details like regions of interest, shape contours and landmarks. Similar to TRUS, you may be sedated or given local anesthesia before probing time. With the ultrasound machine connected to our Fusion Bx device, our software will overlay the MRI scans with the live ultrasound to create a live 3D model of the prostate and the marked areas of suspicion. Because MRI has a greater detection accuracy, Fusion software allows doctors to take fewer targeted samples and reference your biopsy history for future monitoring.8
Not necessarily. The treatment path you take depends on the potential development of the tumor. To understand your risk profile, the urologist assesses different facets of the tumor which are calculated using imaging and biopsy data. The first is its aggressiveness. This is measured on a scale called the Gleason Grading System. The second is its stage which is scored on the TNM system. This determines the location of the tumor (T), if it’s spread to nearby lymph nodes (N) and if it has spread (metastasized) to other parts of the body. A high Gleason grade and/or advanced stage likely means it’s time to move forward with severe interventions.1
To best guide you, your doctor will consider other factors such as your age, genetics, overall health and willingness to endure potential side effects of a given treatment. In all cases, get a second opinion. Most men with newly-diagnosed prostate cancer should be seen in consultation with a radiation oncologist and a urologist. A multidisciplinary prostate cancer care team can provide you with a full view of the available treatments and outcomes.2
If the prostate cancer is not clinically significant or invasive, your doctor may not recommend any treatment at all. Active surveillance is a management strategy built to closely monitor the cancer via DRE, PSA and imaging in order to avoid unnecessary side effects of treatment. Curative treatment may only be prescribed if the cancer shows signs of progression.1
This stealthy method uses targeted non-ionizing ultrasonic waves to create heat that destroys prostate cancer cells. The procedure is minimally invasive and has minimal potential side effects. HIFU has been recently approved by the FDA for prostate tissue ablation.2
This involves the partial or complete removal of the prostate, called a prostatectomy, by a surgeon or a robot, or overseen by one. This option is suitable for men who’s aggressive risk it too high, or his tumor risk is low, but just prefers peace of mind.2
Radiation interferes with cell division by zapping the cells in a localized area with high energy rays. Because both normal and cancerous cells are affected, the treatment is given in small doses over a period of eight weeks. Men with low risk tumors may only require radiation, whereas those with more risky tumors may couple radiation with androgen deprivation therapy (ADT); a series of drugs that prevent the production of testosterone. This causes the prostate to shrink and the cancer cells go dormant, making them easier to eliminate.1
The common side effects of surgery and radiation are incontinence and erectile dysfunction, which can last for weeks, months, even years. But fear not, you can always talk to your doctor and get a prescription for the little blue pill. Most men will experience both, but the severity will depend on the aggressiveness of the tumor and the intensity of treatment. Active surveillance can be a stressful waiting game, which carries its own risks. There’s a chance the tumor grows in unexpected ways. Each treatment has its downfalls, so talk to your doctor to figure out what’s best for you.1
1 Sullivan, E. An Optimist’s Guide To Your Prostate. Esquire. May 2018. Available at: https://www.esquire.com/lifestyle/health/a19834135/prostate-cancer-samir-tanej
2 Prostate Cancer Canada. About Prostate Cancer. 2018. Available at: http://www.prostatecancer.ca/Prostate-Cancer/About-Prostate-Cancer
3 Canadian Cancer Society. Risk factors for prostate cancer. 2018. Available at: http://www.cancer.ca/en/cancer-information/cancer-type/prostate/risks/?region=on
4 Canadian Cancer Society. Transrectal Ultrasound (TRUS). 2018. Available at: http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/transrectal-ultrasound-trus/?region=on
5 Harvey CJ, Pilcher J, Richenberg J, Patel U, Frauscher F. Applications of transrectal ultrasound in prostate cancer. Br J Radiol. 2012;85 Spec No 1(Spec Iss 1):S3-17.
6 John Hopkins Medicine. Targeted Biopsy: A Smarter Way to Take Prostate Tissue Samples. Clinical Connection. January 2017. Available at: https://clinicalconnection.hopkinsmedicine.org/news/targeted-biopsy-a-smarter-way-to-take-prostate-tissue-samples
7 Ferrari, N. Improved magnetic resonance imaging (MRI) may aid detection of prostate cancer. Harvard Health. March 2009. Available at: https://www.health.harvard.edu/blog/improved-magnetic-resonance-imaging-mri-may-aid-detection-of-prostate-cancer-200903105
8 Bjurlin MA, Rosenkrantz AB, Taneja SS. MRI-fusion biopsy: the contemporary experience. Transl Androl Urol. 2017;6(3):483-489.