Prostate Cancer

The prostate is a small, walnut-sized, gland located below your bladder that surrounds your urethra. It produces some of the fluid that makes up semen, the fluid that comes out at the time of ejaculation. As men age the prostate grows and can cause obstruction or blockage of the urine stream; this is referred to as benign prostatic hyperplasia, or BPH.

Unfortunately, cancer can also develop in the prostate. Prostate cancer is the most commonly diagnosed form of cancer in American males. It is relatively rare in men under age 45 years, but risk increases with age. Nearly two-thirds of prostate cancers are diagnosed in men over the age of 65 years. According to Us Too (www.ustoo.org), a prostate cancer education and support group, each year over 230,000 men are diagnosed with prostate cancer and approximately 30,000 men die from it. If it is detected early, it is highly treatable. However, some men don’t know they have prostate cancer until it has progressed. As a result, prostate cancer is now the second leading cause of cancer death in the US.

Prostate cancer often has no symptoms in the early stages and causes symptoms only when it is more advanced.  Because of this, doctors often use screening to determine a patient’s risk of prostate cancer. 

Screening recommendations have changed over the years, but many urologists advocate screening for prostate cancer starting at age 55. Screening consists of both a PSA (prostate specific antigen) test, which is a blood test, and a prostate exam, which is a finger exam in your rectum. This is recommended every 1-2 years. Urologists generally don’t recommend screening after age 70.

Although we don’t yet know exactly what causes prostate cancer, scientists have identified some risk factors—most notably age, genetics, race, diet and lifestyle.

Risk of prostate cancer increases with age. The average age of diagnosis is 70 years, with most cases found in men over age 55 years.

Your risk of prostate cancer doubles if you have one close relative (such as a brother or father) with the disease, and your risk increases even more if you have 2 close relatives who have been diagnosed with prostate cancer.

Race also can affect your risk: prostate cancer is more common in African American men than white, Asian, or American Indian men.

While you cannot change your age, heritage or family history to lower your risk, you can change your diet and lifestyle. Researchers believe that obesity increases your risk of prostate cancer.  Research has also consistently found that plant elements such as those found in tomatoes, cruciferous vegetables like broccoli, soy and other fiber-rich foods like whole grains, may be protective against prostate cancer, while dairy, red meat and chicken all may increase the risk of prostate cancer.

Smoking may also increase your risk of developing and dying from prostate cancer.

Most men are diagnosed with prostate cancer due to findings on a screening prostate exam or PSA blood test.  Diagnosis can only be made with a biopsy (sampling) of the prostate tissue. The tissue that is sampled will be looked at under a microscope by a pathologist, who will determine whether there is prostate cancer present and will give it a “score” referring to how abnormal the cells of the prostate look.

Currently, there are many treatment options for prostate cancer, including watchful waiting, active surveillance, surgery, radiation therapy, cryosurgery, hormone therapy, and chemotherapy. You will need to discuss with your doctor (and, if appropriate, with your partner) which option is right for you. The Urology Care Foundation has a good website with information on the different treatment modalities at www.urologyhealth.org. Remember: there is no single best treatment for every man.

Watchful waiting: “Watchful waiting” refers to no active treatment or surveillance of prostate cancer.  This is often an option for men who choose no treatment, are very old or with life-threatening medical conditions.  Your physician would monitor you for symptoms of prostate cancer and you may be treated for these if they arise.

Active surveillance: “Active surveillance” is a treatment option in which men are followed “actively” with lab tests and repeat biopsies to track their cancer.  At any point, a patient can choose to go ahead with treatment.  One benefit of this treatment option is that you do not experience the treatment-related side effects that you would with another type of treatment.  One drawback is that the cancer may progress while on this plan.

Surgery: Surgery for prostate cancer is called a “radical prostatectomy.”  “Radical” in this context means complete, and indicates that it is being done for cancer.  This is different than prostate surgery that is done for prostate symptoms not caused by cancer. Prostate cancer surgery is generally most effective in men with early disease—in other words, in men whose prostate cancer has not grown outside of the prostate gland. Candidates for this treatment must be healthy enough to undergo major surgery. There are a few different surgical approaches that your surgeon might use. In the radical retropubic prostatectomy, your surgeon will make an incision through your lower abdomen. During a radical laparoscopic prostatectomy, the same procedure is done through small incisions across your abdomen.  This can be done with the help of an operating robot and is sometimes called a “robotic prostatectomy.” You will want to speak with your doctor about which approach is right for you.

With either approach, your entire prostate will be removed as well as the part of the urethra (tube that urine travels through) in the middle of the prostate.  Seminal vesicles, the small pockets that hold semen and are attached to the prostate, are also removed.  Sometimes the lymph nodes in the pelvis are also removed.  The bottom part of the bladder is sewn back to the urethra after the prostate is removed. A catheter, or urine drainage tube, is placed through the urethra and into the bladder and stays in place for several days to let these stitches heal.

Outside of the risks of surgery, we generally talk about two main “side effects” of this type of surgery: urinary incontinence (leakage of urine), and impotence (erectile dysfunction, or ED)—not being able to have an erection that is strong enough for sex. The majority of men who have had this surgery will experience temporary or permanent incontinence and ED. Both of these issues may improve in time following surgery and recovery, and there are treatments or procedures for both of these problems.

Sometimes this surgery is further described as “nerve-sparing” or “non nerve-sparing.” This refers to the nerve tissue that runs alongside the prostate. Your surgeon may try to save these nerves on one or both sides of the prostate because we believe that this helps with recovery of function after surgery. Sometimes, your surgeon will decide not save these nerves, usually because of the concern for cancer growing into the nerves and the desire to remove all the cancer. Sometimes, though your surgeon may try to save the nerves, they cannot be saved, either due to scarring around the prostate or your particular cancer.  It is important to remember that nerve-sparing alone does not fully dictate your erections after surgery.  Even if the majority of the nerves are preserved in the surgery, temporary or permanent ED can still occur.  Similarly, it is not impossible to regain erections after non nerve-sparing prostatectomy. 

How strong erections are after surgery depends on several factors including age, extent of cancer and how strong erections were before surgery.  At least half of all men that have a radical prostatectomy will have some degree of ED for the first 1-2 years after.

Other sexual changes following radical prostatectomy include “dry orgasm” (orgasm feeling without ejaculation or release of semen) and shortening of the penis. 

Dry orgasm is due to the removal of the seminal vesicles (the small pockets attached to the prostate that hold semen).  This cannot be reversed and is permanent. 

Shortening of the penis may be due to nerve or blood vessel damage and scarring or “fibrosis.”  The amount of shortening can vary depending on the person.  Some experts believe that penile shortening can be reduced by starting oral, injection, intraurethral and/or traction or vacuum therapy a few weeks after surgery.

For more information about satisfying sex after cancer treatment, click here.

After surgery, your surgeon will expect your PSA to go down to zero.  You will need to continue to monitor PSA.  If the PSA rises after surgery, it could mean that cancer has returned. Prostate cancer can return even if the whole prostate is removed.  Other types of treatment may be recommended in that case.

Cryotherapy: Cryotherapy treats prostate cancer by freezing it.  Cryotherapy can treat just an area of the prostate or the whole gland.  Using needles that are placed in the perineum, the area between your legs, behind the scrotal sac, the prostate is frozen and thawed several times with liquid nitrogen, killing the cancer cells. Cryotherapy is a newer technology and does not have as much long-term data as surgery or radiation with regard to survival, but could be a good option for some patients.

Sometimes this is used as a first treatment for prostate cancer and sometimes it is used after other types of treatment have been tried.

Cryotherapy can also cause erectile dysfunction in the long-term.  Short-term side effects may include difficulty urinating or pain and bleeding. Rarely, it can cause serious damage to the urethra (the tube that urine travels through), the bladder or the rectum.

After this procedure, you will need to continue to monitor PSA.  If the PSA rises, it could mean that cancer has returned. Other types of treatment may be recommended in that case.

Radiation: Radiation therapy describes any type of treatments for prostate cancer using radiation. External beam radiation therapy, uses high-powered x-rays to penetrate deep into the body. Another type, called brachytherapy, places radioactive pellets (“seeds”) into the body. The radiation damages the prostate cancer cells as well as the non-cancerous prostate tissue. Each approach has benefits and drawbacks. Your doctors will help determine if—and which type of—radiation therapy is most appropriate for your specific cancer.  Sometimes radiation is done in combination with hormone therapy.

After radiation therapy, patients can have sexual side effects including erectile dysfunction (ED) and less amount of semen with ejaculation. It is unclear why radiation causes these issues, but it may be due to damage to the nerves and blood vessels in the pelvis.  Higher doses of radiation are more likely to cause these side effects. Also, if a patient has other risk factors for ED such as diabetes, heart disease, high blood pressure, obesity or they are a smoker, their risk of sexual problems after radiation goes up.

Urinary symptoms such as needing to urinate or defecate more frequently or urgently, or blood in the urine or stool can also occur.

Rarely, patients may have tumors or other cancers that grow in an area that was treated with radiation, like the bladder.

Side effects from radiation tend to increase with time and are generally not as severe at the time of the treatment, though this varies from person to person.

After radiation, you will need to continue to monitor PSA.  If the PSA rises, it could mean that cancer has returned. Other types of treatment may be recommended in that case.

Hormone therapy: The goal of hormone therapy is to reduce the testosterone level in the body and try to “starve” the prostate cancer so that it stops growing or shrinks. This treatment can reduce symptoms of prostate cancer, but it does not cure prostate cancer by itself. Usually, with time, the prostate cancer will “learn” how to grow without testosterone and that treatment isn’t effective anymore.  Sometimes hormone therapy is given in combination with another therapy, like radiation. There are a variety of ways to reduce the testosterone level, ranging from medications to surgically removing the testicles.

Reducing the level of testosterone in the body causes a variety of side effects including tiredness, irritability, weight gain, sleeping problems, lower sex drive and erection problems. 

PSA will be monitored to gauge how well the treatment is working.

Chemotherapy: Chemotherapy uses a variety of drugs to destroy cancer cells. Chemotherapy is typically reserved for patients whose cancer has spread outside of the prostate, and for whom other options of cancer treatment are not longer working. Chemotherapy is an aggressive treatment that is associated with many side effects, so you should always discuss all of your treatment options with your doctor.

PSA will be monitored to gauge how well the treatment is working.

Condition overview written by Elizabeth Phillips, MD

Prostate Cancer Survivorship and Mental Health

Unfortunately, feelings of anxiety, depression, and unhappiness with one’s sex life are common among men who have been treated for prostate cancer. These feelings do not seem to always be associated with poor sexual functioning, but more the ability to enjoy one’s sex life. 

Given that the majority of men will not die from their prostate cancer, preserving quality of life after prostate cancer therapy is very important. For some men, sexual problems are temporary and penile rehabilitation may help. For others, the issues are long-term. Either way, the adjustment can be frustrating, affect men’s self-esteem, and be a challenge for partners as well.

The good news is that there are many options to address quality of life during and after cancer treatment. Counseling and sex therapy can be very transformative for cancer-survivors and their partners.  Sex counselors or therapists can offer solutions or products to help make sex more fun and enjoyable and can help open and explore new avenues of activity and communication that refresh the sexual relationship.

Support groups often help at various stages of diagnosis, treatment and survivorship.  Some may find it helpful to discuss their experiences with like-minded individuals who are having similar experiences. In a support group, men can vent their frustrations and offer each other practical solutions, all in a safe community.

Partners are a vital part of any cancer treatment plan and a big part of the recovery and survivorship.  Resources exist for partners experiencing cancer as well and can be very supportive and helpful. 

Maintaining communication and social activity is important.  Often men will withdraw from friends, family and partners due to inability or discomfort with opening up.  They may feel too overwhelmed. They may also worry about how those close to them will react. While its ok to go at your own speed with social engagements, it can be very therapeutic to engage in social activities and redirect the mind, even for a few hours.

Exercise and healthy lifestyle are paramount in cancer recovery and survivorship. For many, staying physically active does wonders for relieving anxiety and depression.

Regrettably, feelings of depression and suicide risk seem to affect patients with urologic cancers more so than other cancers. Of those who died of suicide undergoing urologic cancer treatment over a 22 year period, the majority were prostate cancer patients. Prostate cancer patients tend to be at greatest risk long after the diagnosis, with the highest incidence being at least 15 years after diagnosis. Rates among white patients was higher than African Americans. If you are having feelings of despair or thoughts of hurting yourself or ending your life, please reach out to your doctors or someone close to you for help.