What is prostate cancer?
The male has a gland that is responsible for forming an important part of our seminal fluid so that it can be a vehicle for the sperm that are formed in the testicles.
This gland, which is located between the bladder and the base of the penis, like all living tissue and formed by cells, can be altered in its growth and suffer a series of damages in the nuclei of the cells. In this way, it loses control of its growth and causes this uncontrolled tissue to advance locally and at a distance, forming metastases.
In short, it is the application of the concept of “cancer” that we all know colloquially, but applied to the prostate gland in men, which has very specific repercussions in its development.
Prostate cancer is the most frequent cancer in men, although fortunately it is not the first in mortality. In global terms, lung cancer and colorectal cancer are more deadly.
It is estimated that approximately 246,700 new cases of prostate cancer will have been diagnosed in Spain by 2021, mainly in the population over 65 years of age, but there are some cases between 45-55 years of age, which it is important to diagnose early.
Many prostate cancers are slow-growing (10-15 years) and go with aging. For this reason, we must be clear that the diagnosis of prostate cancer is not a death sentence and that it is possible to live with it, and many times one dies of causes completely different from the prostate cancer diagnosed a few years ago.
What are the causes of its appearance?
Cancer appears because there has been damage to the nucleus of the prostate cells, which alters the control of cell growth. This disorder alters the structure and functioning of the gland and causes it to migrate to other organs.
Prostate cancer is hormone-dependent, that is, it needs the male hormone testosterone. Therefore, it is a genuinely male cancer, and it appears with age in most cases, because the more years the prostate cells are in contact with testosterone, the more likely it is that these mutations will appear.
It should be remembered that 85% of these mutations or prostatic cell damage are spontaneous, that is, they have not been inherited from our parents, but the other 15% can be hereditary or familial. In these cases, it may debut before the usual age and appear at an early age. Hence the need to be aware of the need for prostate examinations after the age of 45, especially if there is a family history.
What are its symptoms?
In general, prostate cancer is silent, and when it shows symptoms (bone pain, renal insufficiency, general fatigue, or blood in the urine in abundance), it is because the cancer is advanced and, therefore, there will be fewer treatment options, so it is not necessary to wait for symptoms to remember prostate cancer.
It is important not to confuse these symptoms with the usual symptoms of what we commonly call “prostate problems”. That is, when we go to the bathroom a lot to urinate, loose stream or feeling of poor voiding, these symptoms are usually due to a completely different disease, called Benign Prostatic Hyperplasia, which is very common and, fortunately, their solutions are much more bearable for the patient.
How is it diagnosed?
It must be diagnosed in prostate check-ups, which normally include three tests:
- Digital rectal examination: the explorer performs a touch with the finger of his hand through the rectum to touch the prostate, to assess the consistency, size and any other abnormality. You should not be “afraid or shy” of this test, it is not usually painful unless you have hemorrhoids or anal stricture. It is basic and very useful for the early diagnosis of prostate cancer and should not be delayed because of illogical fears.
- Systemic prostatic antigen (PSA): this is a blood test in which a protein produced exclusively by the prostate is analyzed, and which, over the years, we have learned that its value in blood should be between 0-4 ng/ml. When it is higher than this, the possibility of performing a prostate biopsy must be assessed.
- Urological ultrasound: this is performed by means of an ultrasound scanner to assess the size of the prostate, the contours of the bladder and the situation of the kidneys.
With these three tests, a decision must be made as to whether it is necessary to perform a prostate biopsy, which is the essential and rarely waived test for the diagnosis of prostate cancer. This is a relatively simple test, which is performed under local anesthesia and on an outpatient basis, in which samples of prostate tissue are taken through an ultrasound machine, which is introduced through the rectum, so that the pathologist can study them under the microscope and tell us what type of cells he sees, and what degree of cellular changes he sees. That is to say, what degree of aggressiveness he sees in the prostatic cells.
The pathologist who studied these tissues the most was D. Gleason, and he gave a classification. Few changes and less aggressiveness, will be Gleason 6, while many changes and more aggressiveness, will be Gleason 9-10.
Although they are all prostate cancer, they have nothing to do with a Gleason 6 to a Gleason 9-10. In the first case, nothing needs to be done or simply observed. On the other hand, in the second case, every effort must be made to stop it.
Hence, the importance of having a prostate biopsy, to know the prognosis and what to expect over the years if you suspect you may have prostate cancer.
What is the treatment?
First of all, prostate cancer is slow-growing in the vast majority of cases (10-15 years to cause death), therefore, there will be cases in which no treatment is necessary, depending on the patient’s situation (other important diseases that condition his life in the short-medium term, advanced age…).
We must be clear, when we talk to our patients about this disease, that, on numerous occasions, the patient will die of a cause other than the diagnosis of prostate cancer and, therefore, therapeutic abstention (i.e., doing nothing) is a plausible, reasonable decision that benefits the patient.
However, if by consensus and having explained the situation to the patient, curative treatments can be proposed in appropriate cases, these can be based on two options, which are already well contrasted and have been followed for years.
- Surgery
This consists of radical prostatectomy. This is a surgical technique in which the prostate gland and seminal vesicles are removed, and the bladder and urethra are reattached to the penis. This surgical technique can be performed by different approaches: open or suprapubic surgery, which has been routinely performed since the late 1990s; surgery by laparoscopic approach and surgery by Robot-assisted laparoscopic approach.
The three approaches, in expert hands, show very similar results in terms of tumor disease control and functional results. However, with robotic-assisted laparoscopic surgery, having a great vision through the three-dimensional camera and the precision of the robot’s movements, the results of continence and erectile dysfunction recovery are somewhat better than the rest of the more conventional techniques. But it should not be forgotten that stress urinary incontinence and erectile dysfunction may be the norm in the first months after surgery.
- Radiotherapy
Another possibility of curative treatment is radiotherapy, which is the application of ionizing energy by means of devices emitting this energy on the tissue whose growth is to be stopped.
With the new technological equipment, which modulates the energy according to the type and contour to be radiated (intensity modulated radiation therapy equipment, IMRT), the results have been improved and the surrounding tissues, i.e. bladder and rectum, are less damaged.
However, there is still damage to surrounding tissues with “rectal and bladder burns” (rectitis and radicular cystitis due to radiotherapy), which are not easily managed and can worsen the quality of life of these patients. In fact, in patients who are anticoagulated, it is not advisable to undergo radiotherapy because of the risk of bleeding over the years with the anticoagulant treatment.
There are other treatments such as focal therapies (with new energies), which are far from being considered standard treatments and can be applied normally.
In short, prostate cancer is a very common cancer, and in many cases it goes with aging, but it is by no means a death sentence. In many cases, it is not necessary to give treatment and in many others it is necessary to decide on the most appropriate treatment, because there are different types of aggressiveness. It is not necessary to give the same treatment to all patients, but to select the type of treatment according to the particularities of the patient and his life expectancy.
By performing early prostate check-ups from the age of 45 if there is a family history and from the age of 50 onwards in general, it is possible for urology specialists to give our patients the recommendations and therapeutic actions in prostate cancer that will improve their quality of life and their life expectancy.