CANCER

Prostate cancer

Prostate cancer is a malignant tumour, which develops in the prostate gland. It is the most commonly encounter form of male tumour.

The frequency of illnesses grows starting from 50 years of age, and then increases quite rapidly up to 90 years of age. After the age of 60 years, one man in three is likely to suffer from prostate cancer, while after reach the age of 70 years, 40% of men have this disease. Among men who reach the age of 90 years, cancer cells can be found in the prostate of almost all of them.

The initial stages of prostate cancer develop slowly and almost without symptoms. Several years can pass from the initial illness to the first symptoms. This explains why the majority of men fail to pay proper attention to this.

Since cancer of the prostate gland usually grows quite slowly, some men (particularly older men or those who have other serious health problems) may not require any treatment at all. Instead, a doctor may choose the so-called observation (waiting) tactic. This means that the cancer will be carefully observed (keeping track of the level of PSA in the blood), without using any treatment, e.g. an operation or radiation therapy.  The waiting tactic does not mean that you will be left without attention. On the contrary, the doctor will carefully observe its development. Your PSA level has to be determined and the prostate gland will have to be examined every three or six months through palpation, in addition to which a biopsy of the gland will have to be conducted every year. If you experience any complaints or the tumour starts to grow faster, you will have to consider undergoing active therapy.

Symptoms

In its early stages, prostate cancer may exist without symptoms. In later stages, symptoms increase.

The tumour can narrow the urinary tract, which hampers the flow of urine and reduces the stream of urine, which most frequently occurs during the late stages of the tumour. A feeling of discomfort will arise in the small pelvis. Metastases in bones can cause pain or precipitate pathological breaks.

It is obligatory for men over the age of 45 years or men above 40 years whose relatives have had prostate cancer to undergo PSA analysis and visit a urologist.

Diagnostics

A urologist’s consultation – it is very important to discuss the necessary diagnostic examinations with the urologist treating you, in order to determine the precise stage of the tumour and to choose the treatment tactic that is most appropriate for you.

Prostate-specific antigen (PSA) is an immunoreactive substance, which only forms in prostate tissue and is not found anywhere else. An increase in its amount within blood serum can indicate prostate cancer, an increase in the size of the prostate or bacterial prostatitis. One must be careful if the PSA level exceeds 4 ng/ml.

Digital rectal examination (DRE), touching the prostate with a finger through the rectum determines its form, dimensions and relations with surrounding organs. It is possible to feel its structural changes – denser, firmer, soften, inconsistent and knotty. DRE can be unpleasant and painful if the anal muscle is rapidly stretched.

Trans rectal sonography is a special ultrasonographic probe with which the prostate is viewed through the rectum. Using ultrasonography, a doctor will evaluate structural changes and the density of the prostate gland.

Prostate biopsy involves the use of a thin needle specially prepared for this purpose to remove 10 to 12 tissue samples from the prostate through the rectum under the control of ultrasonography. A biopsy is carried out if suspicions have arisen about the existence prostate cancer or PSA level in the blood is over 4 ng/ml.

Skeletal scintigraphy is used to determine the spread of the tissue within bones.

Magnetic resonance for the small pelvis is used to determine the spread of the tumour within the prostate and pelvic lymph nodes.

Computer tomography for the small pelvis and bones determines the spread of the tumour’s metastases within the bones and small pelvis.

Positron emission tomography / Computer tomography/ (PET / DT) is the very latest global examination method, which is used to discover metastases in lymph nodes and bones. Since 2016, this examination has also been available in Latvia. A PET/CT examination checks the whole body and provides precise information about the spread of a disease within the body and malignant changes in bones, tissue and organs. A PET/CT makes it possible to diagnose prostate cancer metastases precisely and early, and to determine the spread of a tumour within the body. PET/CT is also used to clarify the effectiveness of treatment received and to plan subsequent therapy, as well as to diagnose the reoccurrence of tumours early.

It is vital that the examination should be carried out properly at a specialised centre, where such examinations are described and has a radiologist, who specialises in urological pathologies.

Stages

Stage I – the tumour is at a very early stage with low risk and is located in a very small part of the prostate. Viewed under a microscope, the tissue cells are not aggressive.

Stage II – the tumour is still small and is located within both lobes, while aggressive tissue can be seen under the microscope.

Stage III – the tumour is growing outside the boundaries of the prostate and growing into the testicles and adjoining tissue.

Stage IV – the tumour is growing or taking root within adjoining organs such as the bladder, rectum or bones, lymph nodes or lungs contain tumour metastases.

Treatment

Treatment of a prostate tumour is dependent on the stage of the tumour.

If you have prostate cancer, before choosing a treatment method, you should consider several aspects, i.e. you age, general state of health, treatment goal and your attitude to the side effects of treatment. For example, some men cannot imagine their lives with urine incontinence or impotence. In turn, others focus not on the potential side effects, but rather on their desire to completely destroy the cancer cells. However, each situation is unique, and is influenced by many factors. Therefore, primarily each patient should turn to professional and experienced specialists so that through an assessment of each specific case, doctors can offer the most effective form of treatment.

• Active observation

This is used for prostate cancer with a low risk. The patient regularly monitors the PSA level in the blood and visits a urologist (once every 3 – 6 months). The risk that the tumour will spread and progress is very low. In the event of a rapid increase in PSA, radical treatment is required.

Surgical treatment

Surgical treatment is used in stages I and II, and sometimes during stage III. An operation is performed on patients whose forecast life expectancy is over 10 years. During the operation, the prostate and the seminal vesicles are removed completely. In the case of a high risk tumour, the adjoining lymph nodes are also removed. After the operation, urine incontinence may develop along with erectile dysfunction.

Surgical treatment methods

• An incision in the lower part of the abdomen – the operation is carried out through a 10−15 cm large incision in the lower part of the abdomen. This is the oldest surgical method.
• Robot assisted surgery – surgical instruments are inserted into the abdominal cavity through small incision in skin. The instruments are fastened to a mechanised manipulator guided by an experienced urologist using video control. The tumour is evacuated through a 3−5 cm large skin incision.
• Laparoscopic arm assisted surgery − surgical instruments are placed in the abdominal cavity through small skin incisions, instruments manually guided by an experienced urologist with the help of video control. The tumour is removed through a 3−5 cm large skin incision.

The oncological results of surgical treatment are roughly the same for all methods. The quality of the operation is determined by the urologist’s operation experience and knowledge.

If the prostate cancer is located outside the boundaries of the organ has metastasized (stages III−IV). Metastases in lymph nodes or other soft organs. During these stages, an operation is irrelevant, because it is not possible to remove the tumour and any complex manipulation will weaken the body even further. Since the grown the tumour is precipitated by men’s gender hormones, the main goal is to eradicate their impact on the prostate. This can be achieved in two ways: firstly, by suppressing the formation of men’s gender hormone in eggs; and secondly by preventing this hormone from accessing prostate cancer cells.

Radiation therapy

Radiation therapy is treatment with high energy rays (such as X-ray rays) to kill or weaken the cancer cells. Rays can be transmitted from a source outside the body (external radiation) or from radioactive materials, placed inside the tumour itself (internal radiation or brachytherapy).

Sometimes, radiation therapy is chosen as the first treatment method for low degree prostate cancer, which has not spread outside the prostate or only affects adjoining tissue. Occasionally, it is used is not all cancer tissue is removed during an operation or if the cancer is recurrent in nature after operation therapy. Possibilities of recovery after radiation therapy as after operational therapy. If the cancer is already at an advanced stage, radiation therapy can help to reduce the size of the tumour and pain.

External radiation therapy involves exposing the prostate from the outside to radiation. Radiation therapy is an alternative method to surgery, with which to treat prostate cancer radically. This method is recommended for older patients or patients who do not want to undergo surgical treatment.

Each radiation session lasts for a few minutes. Ordinarily, a patient will undergo five sessions a week as an outpatient, which are subsequently repeated for a total of seven to nine weeks. Treatment itself is fast and painless.

Nowadays, external radiation is chosen much more rarely than before. The latest technology allows a doctor to be more successful in treating the prostate gland, without subjecting surrounding healthy tissue to the impact of radiation. These methods are intended to increase effectiveness and reduce side effects.

Radiation therapy also entail complications, which, thanks to the improvement of equipment, have been reduced to a minimum. An infection of the bladder is possible, which manifests itself as frequent and painful urination. If the colon is affected, then painful diarrhoea is possible, sometimes even including a mixture of blood. However, this discomfort is fleeting and does not affect all patients.

ROBOTIC RADIOSURGERY WITH A CYBERKNIFE or hypo fractionated radiation therapy is an type of external radiation therapy that is now recognised as the most effective and safest method for treating low or moderate risk primary prostate cancer, which has the least effect on the patient’s quality of life. It is used for treating tumours during stages I and II. Treatment on its own is fast and painless. Each radiation session lasts for 45−60 minutes. Usually, the patient undergoes five treatment sessions over the course of one week spent as an outpatient.

This method is recommended for patients for whom surgical treatment is unsuitable and in cases when the side effects of surgical treatment could significantly affect the quality of a man’s life. The results of 10 years of studies into this method indicate equal effectiveness in ensuring the control of the reoccurrence of a tumour, compared with surgical treatment and more effectiveness than external radiation treatment.

The hypo fractionated radiation therapy also tends to result in complications, but compared to surgical treatment or external radiation therapy, it is reduced to a minimum. An infection of the urinary tract is possible, which manifests itself and more frequent and unpleasant urination. In individual cases, mild diarrhoea is possible. Usually, this discomfort disappears a month after treatment.

Robotic radiosurgery with CyberKnife can also be used on tumours during Stages III and IV. If prostate cancer is discovered at a time, when it has already spread outside the prostate capsule, it is possible to combine robotic radiosurgery with classical treatment methods including surgical treatment as well as external radiation therapy. In the case prostate cancer that has been previously treated, it is found to have become recurrent or individual metastases are found in the bones, soft tissue or elsewhere, robotic radiosurgery provides high local control of reoccurrence and makes it possible to delay the commencement of hormone substitution therapy.

Internal prostate radiation or brachytherapy, when radioactive seedlings (metallic radioactive seeds), which have long-term effects are entered into the prostate and around it. This method has less marked side effects that external radiation therapy, because adjoining organs are less affected. This method is more recent and is effective for treating tumours during stages I and II. Anaesthesia is necessary to use this method.

• Hormone therapy

The goal of hormone therapy is to reduce the level of male gender hormones (androgen) – including testosterone – in the blood. Androgens, which mainly form in the testicles cause heightened growth of prostate cancer cells. Reducing the level of androgens, the prostate cancer is reduced. Alternatively, its growth is significantly slowed. Cancer can be controlled with hormone therapy, but not eradicated. If hormone therapy is continually used for 3-4 years, the so-called hormone refractory state often sets in, as a result of which the tumour cells become insensitive to hormones. It is then necessary to switch chemotherapy.

• Chemotherapy

Chemotherapy means the use of medicines that kill cancer cells. More often than not, these medicines are injected into a vein. Some medicines are also in tablet form. When the medicine ends up in the circulation of a patient’s blood, it spreads throughout the body and kills cancer cells.

In the case of prostate cancer, chemotherapy is chosen when cancer cells have spread throughout the body and hormone therapy is not effective. This is not standard therapy during the early stages of prostate cancer. Studies are being conducted which prove the effectiveness of a short-term course of chemotherapy after the prostate has been operated on.

Just as with hormone therapy, chemotherapy does not treat cancer in full. It cannot be used to destroy all cancer cells, but it can slow down the growth of the tumour and reduce symptoms, thus providing a higher quality of life.