Prostate cancer

Prostate cancer

Prostate cancer is one of the most frequent pathologies in men. It rarely occurs in men under the age of 50 and is strongly associated with family history; for instance, in families with patients with prostate cancer the likelihood that a first-degree relative (son, brother, etc.) may become affected roughly doubles.
There are slightly fewer than 240,000 cases per year in the USA, while, in Italy, it is estimated that there are just over 23,000.
In the USA there are more than 2,500,000 men living with prostate cancer.

What is a tumor?
A tumor is a process that may take on several different forms of development, but, for simplicity, we can imagine that a group of cells designed to have a specific task in the body lose their distinctive characteristics at some point and begin to replicate rapidly without any precise order or purpose. The faster this process is the more the tumor tends to have aggressive characteristics. As this neoplastic process continues we may have a dissemination of cells that expand beyond the limits of the organ from which they originate, (contiguous extension) or they may move through the lymph or blood, giving rise to metastases.

What is the prostate?
The prostate is a chestnut-shaped gland in men that is located below the bladder and wraps around the duct through which urine and seminal fluid are ejected from the body, i.e. the urethra.
The main task the prostate performs is to provide some elements that enrich the seminal fluid.

What disorders does prostate cancer give?
Prostate cancer, especially when diagnosed early DOES NOT GIVE ANY DISTURBANCES IN PARTICULAR.

  • this means that it is not true that those who suffer from urinary disorders have a significantly greater than average risk of developing prostate cancer
  • this means that it is not true that those who do not have trouble do not run any risk of developing prostate cancer

In more advanced forms, prostate cancer may actually give urinary symptoms such as difficulty in emptying the bladder or blood in the urine, but it occurs in a very small percentage of subjects.

The prognosis of prostate cancer
The prognosis of prostate cancer is, all in all, GOOD!

Like with many cancers, the earlier it is diagnosed the better. In the USA, 80.9% of patients are diagnosed when the disease is at an early localized stage (that is within the prostate).

The probability of overall survival in the USA (where the habit of making early diagnosis is more widespread than in Italy) is 99.2%.

If the disease is localized probability of 5-year survival rises to 100%. However, if the first diagnosis is the metastatic form (i.e. it is disseminated) this probability drops to 27.9%. [SOURCE: National Cancer Institute – SEER – USA]

Early diagnosis of prostate cancer

There is a very high probability of curing prostate cancer if it is diagnosed early; not only that, but, in addition to high survival, being able to diagnose prostate cancer early means patients can be provided with the “bare minimum” treatment to ensure the disease is cured; sometimes, in selected patients, no treatment is necessary but only close monitoring: “active surveillance” aimed at following the development of the disease with the physicians ready to intervene if really necessary.

Otherwise, an excellent prognosis can still be guaranteed while maintaining the patient’s quality of life thanks to more and more avant-garde treatments, including robotic radical prostatectomy.

How is diagnosis made:

In subjects aged over 50 it is a good idea to carry out a urological examination and a PSA test. In addition to the so-called total PSA test, there are other alternatives such as free PSA, PSA density, etc. that can be evaluated by a urologist to determine whether or not to carry out any further tests.

Depending on the values of PSA and / or results of a digital rectal examination there may be indications to perform a prostate biopsy.

NB: transrectal ultrasound controls are widespread although it is not recommended they be performed repeatedly. Transrectal ultrasound is useful for gaining various types of information (shape and volume of the prostate, the volume of the adenoma, etc) which is also very important, but has not, to date, proven to add anything to the diagnosis of prostate cancer.

It is advisable to use it when a prostate biopsy is required, in order to guide the needle to the correct “prostatic quadrant”.

What is a prostate biopsy?

A biopsy is a procedure that, through the guidance of the ultrasound probe, allows samples of prostate tissue to be obtained and then analyzed by an anatomopathologist.

Today numerous samples are obtained, usually between 10 and 18, while performing biopsies under local anesthesia.

The biopsy technique envisages the insertion of the ultrasound probe into the patient’s rectum and, after local anesthesia, the insertion of a needle via the rectum (transrectal technique, the most common) or via the perineum, between the patient’s scrotum and anus.

It is a procedure that causes mild but tolerable discomfort.

Read and understand what prostate biopsy is:

One of the most delicate and stressful moments for a patient is when he receives the results of the histological examination (i.e. the examination of the tissue samples which were analyzed).

The histological examination tells us whether there are cancer cells in the tissue that has been subjected to an examination under a microscope.

  • If there are no cancer cells: the word “cancer” or “adenocarcinoma” does not appear on the report. In this case we are sure that there are no cancer or dysplastic cells in the tissue in question. This is of course a very favorable result, but it does not mean no further tests should be carried out, because the tissue sampled in a prostate biopsy is only part of the prostate and does not totally exclude the possibility that there may be small foci of tumor cells in the unsampled prostate. (This explains why many men who have had a negative biopsy sometimes find they must undergo a second or even a third and a fourth, rarely more than that)
  • If there are cancer cells: to understand the “severity” of the problem, we need to understand the level of aggressiveness of the disease. This is expressed, in addition to other parameters, by the so-called Gleason score which is presented as the sum of two values. In the majority of cases 3 +3 = 6. In this case it is localized prostate cancer with a high probability of cure. Along with the outcome of the PSA and the rectal examination, the Gleason score provides the urologist with the most important information to be able to give the patient the best therapeutic indications.

Intermediate aggressive forms are Gleason 3 +4 and 4 +3, while Gleason 4 +4 up to 5+5 are the most aggressive forms.

  • If there is no sign of the presence of cancer, but there appear terms like: a) PIN (intraepithelial neoplasia) b) ASAP: (Atypical Small Acinar Proliferation), this refers to forms that are not clearly cancerous, but neither is the tissue completely healthy. Without going into the technical details of what PIN and ASAP are, when there is one or the other or even both in the results of a biopsy we have a situation of absence of obvious tumor, but a high probability of diagnosis in a subsequent biopsy. It is important in this case to plan a subsequent biopsy a short period of time after the previous one.

NB: Clearly if a confirmed tumor is concomitant the presence of PIN or ASAP does not change the therapeutic choices

The staging of prostate cancer

Once the analysis of the biopsy has revealed that cancer cells are present in the sample tested, it will be important to understand the aggressiveness and extent of the disease that we are facing.

We are able to obtain some initial information from the parameters we already have.

PSA (if

Gleason Score (if

Rectal examination (if the urologist who has visited us has told us that nodules could not be felt then we are at low risk).

If the above factors identify low risk, no further tests are required and we can proceed with choosing the treatment for the case.

If the above factors identify intermediate or high risk further tests should be carried out to determine whether there is a risk that the disease has spread to the lymph nodes (a CT scan is carried out for this) or to the bones (a bone scintigraphy is carried out for this).

In particularly advanced forms, other issues may arise that must be identified and treated by the urologist.