This blog is an assignment for nursing school, however, the information and research provided is being done by a woman who married a man with a strong family history of prostate cancer.
I married a man who is approaching the age at which his father and both grandfathers were first diagnosed with prostate cancer... there is no better time to educate ourselves about what exactly prostate cancer is and what we are going to do to fight it...
First things first:
What is a prostate?
its part of the MALE reproductive system
its a gland: it makes fluid that adds to semen to help protect sperm
semen is the fluid that comes with ejaculation
it surrounds the urethra (a tube that passes urine)
When we are researching a disease, one of the first things I wanted to know besides how likely you are to get it is.. how many other people have it? How many people die from it? Is it worse in the United States.. is it worse in my state?
First.. some definitions:
Incidence: number of new cases per year Mortality: number of deaths per year
And some graphs:
How the US compares to other countries when it comes to incidence of prostate cancer:
from CDC website 2011
In words:
• The incidence rate for
the United States is 128.3, that is out of 100,000 males, 128 of them have prostate cancer in 2011
Incidence rates are
highest...
in the Northeast U.S. Census region (144.3), followed by the Midwest
(130.0) and South (124.7)
• The death rate for the
United States is 20.8, that is out of 100,000 males, 20 died from prostate cancer in 2011.
Death
rates are highest...
in the South U.S. Census region (21.0), followed by the
Midwest (20.9), West (20.7),
and Northeast (20.3)
Incidence by Race in the US:
from CDC in 2011
What we can see from this graph:
Incidence of prostate cancer is higher in Black Americans than other races
BUT some positives...
from 1999-2010..
incidence in black men with prostate cancer decreased by 3.8% and all men by 3.4%!
A few other graphs to show how Prostate Cancer compares to Other Cancers
Incidence among men: #1
from CDC statistics, 2011
Mortality rate from cancer among men: #2
from CDC statistics 2011
Perhaps the most important statistics are the following on how prostate cancer incidence increases with age...
● 20 to 30
years, 2 to 8 percent of men with occult cancer
● 31 to 40
years, 9 to 31 percent
● 41 to 50
years, 3 to 43 percent
● 51 to 60
years, 5 to 46 percent
● 61 to 70
years, 14 to 70 percent
● 71 to 80
years, 31 to 83 percent
● 81 to 90 years, 40 to 73 percent
From these statistics we can see that in the US Prostate Cancer is a problem of all ages and we need to focus on educating the male population about screenings especially in their retirement years!
Since we don't have a specific cause, we can look at what we know about all cancers and some common links amongst men who have prostate cancer.
What CAUSES prostate cancer?
A: no exact cause has been found
What CAUSES any cancer?
A: a mutation or abnormal DNA (genetic material that is responsible for making new cells)
Further...
What else we know:
cells grow old, get worn out and die
our body knows how to make new ones by making a copy of the old one and dividing the cell into two cells
Two types of cells that help with Cell Division (i.e.: making new cells)
Oncogenes: these are the part of DNA that helps cells grow, divide and stay alive
Tumor suppressor genes: these are part of DNA that have three functions:
helps to slow down cell division
repair mistakes
cause cells to die that may be bad for our body
These two types of genes could be turned ON or turned OFF and contribute to mistakes in DNA.
Just like any human activity, the faster you try to do something, the more likely you are to make a mistake... i..e: The faster the cells grow and divide the more likely there will be a mistake...
A video of how cells grow and divide and how cancer grows!
Another video: what is happening at the level of the DNA to cause a mutation!
What are some specific genes that have can have mutations that are linked to Prostate Cancer?
RNASEL: if this gene has a mutation, it will let abnormal cells live longer
BRCA 1 and BRCA 2: if these genes have mutations, there is a problem in DNA repair
MSH 2 and MCH 1: if these genes have mutations there are problems with fixing a mismatch when DNA is copied incorrectly.
OTHER RISK FACTORS:
ALERT: All of the following "Risks" have had mixed results in research.. this means that there is NOT ENOUGH EVIDENCE to definitively say they cause cancer.
ie: do not make drastic lifestyle changes before speaking to your doctor about your concerns
1. AGE: the older you are, the more likely to have prostate cancer (not often diagnosed under 40)
2. RACE: African-Americans are more likely to be diagnosed than any other race
3. FAMILY HISTORY: most at risk if your brother has it, less at risk if your father has it but considered a higher risk if multiple family members have it (father and brother)
4. GENETIC CHANGES: see above description of specific genes
5. DIET: linked to diet high in red meat, high fat dairy products with little fruits and veggies
***do NOT stop eating certain foods without consulting a doctor***
6. HORMONE LEVELS: increased risk for people with elevated levels of testosterone or insulin-like growth factor
7. INFLAMMATION: it is thought that if the more the prostate is inflamed, the more damage there is to cells, the more often they divide and repair and as stated before, the more you divide the more likely you are to make a mistake
What we know based on current research is that there is a strong genetic component that causes prostate cancer. Most men will have prostate cancer at some point before they die but it is the progression and type of prostate cancer that affects mortality.
So.. how do they diagnose?
SIGNS or SYMPTOMS:
Generally there are NO signs that you have prostate cancer... sometimes you can have problems with urination, difficulty peeing, blood in your urine, or incontinence.. in advanced stages you may have fatigue or experience pain in your joints or bones
What they will check FIRST: a prostate exam includes a licensed provider placing their gloved finger into the anus and feeling for the prostate...
FURTHER EXPLANATION:
if there is concern, NEXT step: blood test
What the blood test looks for is an elevated Prostate Specific Antigen (PSA)
Normal levels:
40 to 49 years — 0 to 2.5 ng/ml
●50 to 59 years — 0 to 3.5 ng/mL
●60 to 69 years — 0 to 4.5 ng/mL
●70 to 79 years — 0 to 6.5 ng/mL
Depending on the level and your risk factors... you may be placed on a WATCH
ACTIVE SURVEILLANCE: re-check PSA levels every 3 months to monitor
** PSA enters the blood by leaking from the prostate, this can be due to trauma to the prostate (like from riding a bike) or from infection and is not always a sign of cancer..
If significant concern they will complete a biopsy: use a needle to get a tissue sample from prostate
Pathology of a Biopsy:
I. A Gleason Score: based on 2 tissue samples taken from the prostate
Do the cancerous cells taken from (biopsied from) the prostate all look like one another or do they look very different from one another?
Score 2-4: look like all the other cells i.e.: well differentiated
Score 5-7: look like other cells but some that do not i.e.: moderately differentiated
Score 8-10: do not look the same at all i.e.: poorly differentiated
The LOWER the score the LOWER the risk of progressive cancer.
II. Classification of the Cancer: based on how it has spread within or outside of the prostate
T1c: no symptoms of cancer, found by chance looking for something else
T2a, T2b: cancer cells limited to half of one lobe or one lobe of the prostate
T2c: cancer cells in both lobes
T3a, T3b: cancer cells spread through one wall or through both walls of the prostate
T3c: cancer cells spread through the walls and to the seminal vesicles (another reproductive part)
T4: cancer cells have spread and invaded other structures
III. PSA levels: prostate specific antigen in the blood.
Normal levels:
40 to 49 years — 0 to 2.5 ng/mL
●50 to 59 years — 0 to 3.5 ng/mL
●60 to 69 years — 0 to 4.5 ng/mL
●70 to 79 years — 0 to 6.5 ng/mL
RISK ANALYSIS CHART:
What happens when it is detected, how do we know how progressive it will be?
Low
Intermediate
High
Very High
Grade
T1c, T2a
T2b-T2c
T3a
T3b, T4
Gleason Score
≤ 6
7
8-10
PSA level
≤ 10
10-20
> 20
THE HIGHER THE RISK.. the MORE ADVANCED and progressive disease will be.
Although we can identify the risk for quick progression of the disease, we do not know exactly how long it will take. Maintaining a healthy diet, getting exercise and maintaining a healthy sleep cycle to combat fatigue will inevitably help live a longer more fulfilling life with prostate cancer.
What are the symptoms he might feel that we might seek a medical provider? What are the signs the provider will find physically that make him suspect prostate cancer? It is important to understand that most prostate cancers are asymptomatic, that is.. there are no signs or symptoms. It is often diagnosed after general screenings rather than based on symptoms of concern. Remember the prostate is part of the male reproductive system and it surround the urethra, if it becomes enlarged it can have an impact on how men pee. IF there are symptoms they are related to these two systems and may include:
difficulty urinating or holding back urine
increased frequency of urinating
weak urine flow or very little flow
painful or burning urination
difficulty having an erection
painful ejaculation
blood in urine or semen
in advanced stages there may be pain or stiffness in the lower back, hips or upper thighs
*it is important that these symptoms are also symptoms of other diseases including sexually transmitted infections
Signs: what the doctor will find during digital-rectal prostate exam that leads more testing:
enlarged prostate (depending on age for what is normal)
"No other disease condition with the incidence of localized prostate cancer has so many treatment alternatives with so few certainties in the outcome." Donna L. Berry, PhD, AOCN, FAAN
Few certainties, too many treatment options, where will we begin? How will we know what to choose and if this is the right option for him?
Options range from Non-Invasive to Surgery..
Least Invasive:
Active Surveillance:
monitor PSA every 3 months and re-evaluate
repeat biopsy after 1st year, then every 4-5 years
Issues to address:
frequent visits to the doctor's office
increased anxiety/worry that levels have increased
possible need for further treatment options
Why choose this method:
most men want to retain their quality of life and avoid side effects as long as possible
More invasive: Radiation Therapies:
External Beam Radiation Therapy:
daily targeting of infected tissue with radiation for about 6 weeks
Complications/ Side Effects:
fatigue
sexual dysfunction
irritated bladder (usually short term)
irritated bowel
Brachytherapy:
radiation "seeds" are implanted into infected prostatic tissue, limiting extension to other tissues
Complications/Side Effects:
irritative bladder
sexual dysfunction
need to reduce closeness to pregnant women and infants
Why choose this option?
men with a more advanced prostate cancer who wish to control
Most invasive: Surgery
Prostatectomy:
removal of the prostate, seminal vesicles, and prostatic portion of urethra
Complications/ Side Effects:
incontinence
sexual dysfunction
**more practice = fewer complication rates, choose your MD carefully**
Treatment of Stage IV: Bone Metastasis
spread of cancer to areas of the skeleton, commonly: vertebra, ribs, skull and ends of long bones
Hormonal Control/ Orchiectomy
androgen ablation: removing male hormones through removal of testes
androgen blockade: add anti-androgen to block adrenal androgens
Complications/ Side Effects:
hot flashes
emotional dysfunction
fatigue
loss of libido
impotence
What to consider when discussing treatment options:
age (with less than 10 years life expectant, active surveillance is recommended)
quality of life (how important is maintaining a sexual relationship, can you manage fatigue?)
stage of cancer (advanced stages require more invasive therapies)
*Ask your doctor for a P3P, a questionnaire called Personal Patient Profile for Prostate Cancer
-helps sort out treatment options by discovering what it most important to you
A Video from Physician right here in Seattle: What you can expect from your doctor...
UpToDate Comparison of Treatments:
External
beam radiation therapy
Effective long-term
cancer control with high-dose treatments
Very low risk of
urinary incontinence
Available for cure
of patients over a wide range of ages and in those with significant
comorbidity
Brachytherapy
Cancer control rates
appear equal to surgery and EBRT for organ-confined tumors
Quicker than EBRT
(single treatment)
Available for cure
of patients over a wide range of ages and in those with some comorbidity
Radical
prostatectomy
Effective long-term
cancer control
Predictions of
prognosis can be more precise based on pathologic features in specimen
Pelvic lymph node
dissection is possible through the same incision
PSA failure is easy
to detect
Active
surveillance
Reduces
overtreatment
Avoids or postpones
treatment-associated complications
