Your cancer

Living with the disease

Prostate Cancers

What is it ?

Prostate cancer is the most common cancer in men in the United States with more than 190,000 cases and the 2nd most deadly cancer in men, after lung cancer, with more than 30,000 deaths per year (according to Cancer Statistics, 2020). The risk is strongly correlated to age with highly variable prognoses. If the diagnosis is most often made at the localized stage, there are aggressive forms, metastatic from the outset.

Prostate cancer cells are derived from the epithelial cells of the prostate.

These cells secrete Prostate-Specific Antigen (PSA), the level of which is part of the screening for this disease as well as the cornerstone of its long-term follow-up.

The growth of tumor cells is stimulated by androgens and particularly testosterone. This makes prostate cancer one of the hormone-dependent cancers, like certain types of breast and endometrial cancer.

Note also that there are hereditary predisposition to prostate cancer (especially due to mutation in the BRCA2 gene).

Prostate cancers

There are several histologies (type of tissue affected) of prostate cancer.
The most common of these, totaling more than 95% of cases, is prostatic adenocarcinoma.
There are also the rarer neuroendocrine carcinomas, whose treatment typically
requires surgery and / or chemotherapy.

When discussing prostate cancer, the emphasis focuses on different presentations of the disease:

Extent of cancerous lesions

When localized : the tumor is confined to the prostate gland only.

Locally advanced : the tumor extends regionally around the prostate gland but has not spread beyond the pelvis.

Metastatic : the tumor has spread to other areas of the body. Most often, prostate cancer cells migrate to the bones and lymph nodes, but visceral damage is also possible to critical organs (e.g. liver, lung and more rarely the brain).

Response to the treatment

Hormone-sensitive response : effective response to hormonal treatment, or castration, first-line (physical or chemical).

Hormone-resistant : the cancer does not respond to castration (primary resistance) or progresses after a period of response to first-line hormonal treatment (secondary resistance).

The hormone-dependent nature of this cancer leads to frequent use of anti-androgen hormone therapy at different stages of the disease.

Hormone therapy drastically decreases the secretion of testosterone and therefore involves an increased cardiovascular risk. This is especially due to weight gain and high blood pressure. It is imperative to combine hormone therapy with hygienic and dietary measures (e.g., regular physical activity, balanced diet) and specialized cardiological monitoring in the event of increased risk factors. Doing so can limit the likelihood of complications unrelated to the cancer itself.

Prostate cancer most often metastasizes to the bone

Should this occur, specific steps should be taken to manage these lesions. In the event of symptomatic metastases and / or resistance to castration, an anti-resorptive bone treatment may be indicated associated with vitamin-calcium supplementation. Hormone therapy can also induce secondary osteoporosis, which must be addressed.

Prostate cancer is a genitourinary condition

Treatment for prostate cancer can be responsible for sexual disorders: postoperative or post-irradiation erectile dysfunction, libido and erection disorders, reduction in the size of the genitals under hormonal therapy, etc. Management by a professional in oncosexology is possible and various solutions are available.

Management by a professional in oncosexology is possible

Ask your doctor, various solutions are available.

Symptoms

Prostate cancer is most often without obvious symptoms (asymptomatic.) Depending on the stage of the disease, the symptoms are different.

When in a localized stage,signs may appear but not be specific. Further, they may be linked to other non-cancerous pathologies of the prostate. Examples include benign prostatic hypertrophy (a prostatic adenoma or ‘large prostate’) or prostatitis (inflammation or infection of the prostate).

Common indications are of a urinary origin :

Dysuria

Difficulty urinating with decreased urine output

Pollakiuria

Frequent urination, nocturnal rises

Urinary urgency

Urgent needto go urinate

Acute urine retention

Totalinability to urinate

Macroscopic hematuria

Blood in the urine

Hematospermia

Blood in the ejaculate
In the metastatic stage, the disease is most
often exhibited by bone symptoms :

Bone pain

Spinal cord compression with back pain / lumbar pain

Continence disorders

Motor deficit of the lower limbs

A general deterioration of the patient’s condition

Unusual fatigue, weight loss

Screening

Screening is critically important because of the asymptomatic nature of the disease. It is important to monitor prostate health and consider additional tests to determine if biopsies are necessary.

PSA is an indicator of specific activity of the prostate. Annual monitoring of PSA typically begins from age 50, and even earlier for those with family history. A high level or a continuous increase of this marker will typically initiate further tests, which include clinical examination (digital rectal examination for prostate induration) and a prostate MRI (Magnetic Resonance Imaging) scan. In cases where the patient has a pacemaker, a contrast ultrasound can replace the MRI.

Diagnostic Process

Only prostate biopsies performed under the best conditions, targeting suspicious areas on MRI by image fusion, allow a correct diagnosis to be made. Aggressiveness of the cancer is based on the Gleason score applied to the biopsy results, which ranges from 6 (good prognosis) to 10. Tumor size is another prognostic factor, based on MRI review and cancer biopsies.

The initial diagnosis determines treatment options, with the aggressiveness of the cancer factored in. Bone scintigraphy, CT scan or sometimes Positron Emission Tomography (PET) scan may be indicated, and especially in locally advanced forms.

Risk factors

The main risk factors for prostate cancer are :

Age

Endocrine disruptors
(such as chlordecone)
Family history

Treatments

With biopsies that indicate a mildly aggressive cancer, active surveillance may
be a viable option. This approach would include evaluation by MRI and biopsies in the first year, with additional treatment in case of progression.

With potentially progressive localized prostate cancer,several options are possible
including surgery or radiation therapy. 

Surgical treatment is called a prostatectomy. This consists of removing the prostate, the seminal vesicles and, if necessary, the neighboring lymph nodes that drain the prostate. Prostatectomy is indicated in localized tumors but becomes more questionable with locally advanced tumors. (Tumor spread to the seminal vesicles and/or lymph nodes.) Typical complications after surgery are incontinence (the frequency of which has markedly decreased due to improved surgical techniques) and sexual disorders, particularly erectile dysfunction. The surgical techniques are equivalent whether in conventional surgery or robot-assisted laparoscopy.

Radiation therapy uses radiation kill tumor cells in the prostate and possibly the seminal vesicles and lymph node areas. The specifics of these radiation treatments (intensity, number of sessions, etc.) depend on the cancer stage. The prostate is located and identified, and the irradiation delivered with care to protect neighboring organs. In aggressive forms, hormonal treatment can be combined to reduce the risk of recurrence.

Other treatment options are sometimes possible, including brachytherapy, focused ultrasound and other less established techniques. It is therefore not always easy for the patient to choose the course of action and a second opinion may be necessary. The most complete picture is therefore critical so that the patient can participate in their therapeutic choice. 

Despite the treatment, recurrence of the tumor is possible, and usually indicated by a rise in PSA level. A PET scan or prostate-specific membrane antigen (PSMA) test can tell if this is a localized recurrence accessible to a new local treatment.

In the event of recurrence after prostatectomy, radiation therapy is a likely treatment option.

In the event of recurrence after radiation therapy, the therapeutic choices are not well established. Prostatectomy can be considered, but the consequences can be more serious. Other treatments are offered such as stereotaxic radiation therapy localized on recurrence, brachytherapy, or other treatments such as focused ultrasound, cryotherapy, etc.

In some instances, certain lymph node or bone recurrences are accessible to radiation therapy.

In the event of metastatic prostate cancer, treatment is based on hormonal therapy. This involves pituitary stimulation aimed at stopping the production of testosterone by the testes, possibly in conjunction with an anti-androgen treatment.

In some cases, chemotherapy or immunotherapy may be considered. In these metastatic forms, local treatment of the prostate by radiation therapy may improve survival. Additionally, new hormonal therapies have made it possible to significantly improve survival in advanced tumors.

Endoscopic surgery is sometimes necessary to unblock the prostatic urethra or repermeabilize the ureters in some locally advanced forms.

Finally, as with any cancer diagnosis, the chosen therapeutic strategy must be approached with a multidisciplinary perspective and the proper medical team.