Prostate Cancer Treatment in India
What is Prostate?
The prostate is a walnut-sized gland that forms part of the male reproductive system. The gland is made of two lobes, or regions, enclosed by an outer layer of tissue. As the diagrams show, the prostate is located in front of the rectum and just below the bladder, where urine is stored. The prostate also surrounds the urethra, the canal through which urine passes out of the body.
Scientists do not know all the prostate’s functions. One of its main roles, though, is to squeeze fluid into the urethra as sperm move through during sexual climax. This fluid, which helps make up semen, energizes the sperm and makes the vaginal canal less acidic.
What is BPH?
It is common for the prostate gland to become enlarged as a man ages. Doctors call this condition benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy. The prostate normally gets bigger as men grow older. This causes BPH (benign prostatic hyperplasia) which can lead to problems passing urine because the prostate can press on the urethra. BPH is a problem that often must be treated, but it is not cancer. The growth of the prostate depends on the male sex hormone, testosterone, which is made by the testes. Benign prostate enlargement usually begins on the outer surface of the prostate. It may cause the following symptoms:
- a hesitant, interrupted, weak stream
- urgency and leaking or dribbling
- more frequent urination, especially at night
What is Cancer?
Cells are the basic building blocks of our body. Our bodies constantly make new cells: to help us to grow, to replace worn-out cells, or to heal damaged cells after an injury. But sometimes something goes wrong with this process and cells grow in an uncontrolled way. This uncontrolled growth may develop in to a lump called a tumour.
A tumour can be benign (not cancer) or malignant (cancer).
A benign tumour does not spread outside its normal boundary to other parts of the body. However, if a benign tumour continues to grow at the original site, it can cause a problem by pressing on nearby organs.
A malignant tumour is made up of cancer cells. When it first develops, this malignant tumour may not have invaded nearby tissue. As the tumour grows, it invades surrounding tissue. A cancer that has not spread to other parts of the body is called primary cancer.
Sometimes cells move away from the original (primary) cancer and invade other organs and bones. When these cells reach a new site, they may continue to grow and form another tumour at that site. This is called a secondary cancer or metastasis.
What is Prostate Cancer?
Prostate cancer develops when the cells in the prostate gland grow more quickly than in a normal prostate, forming a malignant lump or tumour.Most prostate cancers grow slower than other types of cancer. Early (or localized) prostate cancer is growth that has not spread beyond the prostate. Some prostate cancers may spread to other parts of the body, such as the bones and lymph nodes. This is called advanced prostate cancer.
What causes Prostate Cancer?
Research has shown that men with certain risk factors are more likely than others to develop prostate cancer. A risk factor is something that may increase the chances of developing a disease.
Studies have found the following risk factors for prostate cancer:
Age: Age is the main risk factor for prostate cancer. This disease is rare in men younger than 45. The chance of getting it goes up sharply as a man gets older. In the United States, most men with prostate cancer are older than 65.
Family history: A man’s risk is higher if his father or brother has prostate cancer.
Race: Prostate cancer is more common in African-American men than in white men, including Hispanic white men. It is less common in Asian and American Indian men.
Certain prostate changes: Men with cells called high-grade prostatic intraepithelial neoplasia (PIN) may be at increased risk for prostate cancer. These prostate cells look abnormal under a microscope.
Diet: Some studies suggest that men who eat a diet high in animal fat or meat may be at increased risk for prostate cancer. Men who eat a diet rich in fruits and vegetables may have a lower risk.
What are the symptoms of Prostate Cancer?
Early curable prostate cancer rarely causes symptoms. This is because the cancer is not large enough to put pressure on the urethra.
If the cancer grows and spreads beyond the prostate (advanced prostate cancer), it may cause the following problems:
• pain or burning when urinating
• difficulty in, or increased frequency of, urinating
• blood in the urine or semen
• pain in the lower back, hips or upper thighs.
These symptoms are common to many conditions and may not be advanced prostate cancer. If you are concerned about prostate cancer and/or experiencing any of these symptoms, speak to your doctor.
How is Diagnosis of Prostate Cancer done?
Your doctor will confirm the diagnosis with a number of tests. You may have some or all of the following tests.
Prostate specific antigen blood test
Prostate specific antigen (PSA) is a protein made by normal prostate cells and cancerous prostate cells. The PSA is measured using a blood test. The test may tell your doctor that there might be a problem with the prostate gland. A high PSA does not necessarily mean you have cancer. A number of factors can increase PSA levels in your blood.These include inflammation in the prostate, benign prostate enlargement or prostate cancer. Only one in three men with an elevated PSA level will have cancer.As the meaning of your PSA level is not clear cut, this blood test is normally used with other tests to diagnose prostate cancer. Some men who have prostate cancer have normal PSA levels.
Digital rectal examination
This examination is usually the first test done. The doctor inserts a gloved finger into the rectum and feels the part of the prostate next to the rectum. This examination gives the doctor a general idea of the size and condition of the gland.
Rectal Ultrasound and Prostate Biopsy
If there is a suspicion of prostate cancer, your doctor may recommend a test with rectal ultrasound. In this procedure, a probe inserted in the rectum directs sound waves at the prostate. The echo patterns of the sound waves form an image of the prostate gland on a display screen. To determine whether an abnormal-looking area is indeed a tumor, the doctor can use the probe and the ultrasound images to guide a biopsy needle to the suspected tumor. The needle collects a few pieces of prostate tissue for examination with a microscope.
If the biopsy shows you have prostate cancer, a number of other tests may be carried out. You may have one of these tests or a combination. The tests will estimate the extent of the cancer in your prostate and if it has spread to other parts of the body. This is called staging.
Blood samples may be taken regularly to check your health and to see if the prostate cancer has spread.
A bone scan may be taken to see if the prostate cancer has spread to your bones.
A CT (computerised tomography) scan is a type of x-ray procedure. It uses x-ray beams to take pictures of the inside of your body and can assess if the cancer has spread to the lymph nodes of the pelvis and abdomen.
In some cases of more advanced prostate cancer, an MRI can help to confirm if the cancer is contained within the prostate. This is sometimes performed with a probe in the rectum.
How can problems of prostate be treated?
Your urologist and radiation oncologist will advise you on the best treatment after considering your age, general health, how fast the prostate cancer is growing (the grade) and whether it has spread (the stage). The side effects you are prepared to accept are also important.
The treatments for localised prostate cancer include surgery and radiotherapy. If the cancer has spread beyond the prostate, hormone therapy may be used. You may have one of these treatments or a combination.
Your doctor may suggest surgery if you have early prostate cancer, are fit for surgery and expect to live longer than 10 more years. There are several different types of surgery used to treat prostate cancer.
Removal of the whole prostate and the nearby glands that store semen, the seminal vesicles, is called a radical prostatectomy. This surgery is usually done through a 10-12 cm cut in your lower abdomen. After the prostate is removed, the urethra is rejoined to the bladder.You will need to stay in hospital for three to seven days. A thin tube (catheter) will be used to collect urine in a bag. You may need a catheter for six to 14 days after the surgery.You should be able to return to work and activities such as heavy lifting within four to six weeks depending on your type of work.
Nerve-sparing surgery involves removal of the prostate and preservation of the erection nerves. These nerves can only be saved if the cancer has not spread along the nerves. Problems with erections are common for one to three years after nerve-sparing surgery but information, support, medication and aids can improve the situation.
For some patients, an alternative to open surgery is to remove the prostate via keyhole surgery. This is called a laparoscopic prostatectomy or a robot-assisted laparoscopic prostatectomy.
In this procedure, several small cuts are made in the skin, and a small tube is passed into the abdomen. A very small telescope, with a camera attached (the laparoscope) is passed through it to allow the surgeon to see inside the abdomen. The prostate is cut away and removed through the tube.
If the prostate can’t be taken out because of more extensive cancer, symptoms such as the need to urinate more often can be relieved by removing blockages in the urinary tract. This operation is called transurethral resection of the prostate (TURP). It is also used to treat benign prostate enlargement.
A telescope-like instrument is passed through the opening in the penis and up the urethra to remove the blockage. The operation only takes about an hour but usually requires a couple of days in hospital.
Side effects of surgery
• Nerve damage: The nerves needed to have an erection and the muscle used to control bladder function are found near the prostate. These may be damaged during surgery, causing bladder control problems and erection difficulties.
• Impotence: Most men will experience problems getting and maintaining an erection (impotence) after surgery. Recovery of erections often takes up to two years. Impotence can cause ongoing problems in about 30-70% of men. The extent of the problem may depend on your age, general health, type of surgery and quality of erections before treatment. Fortunately, there are a number of strategies to help you manage impotence.
• Bladder control: A radical prostatectomy may mean you have difficulty controlling your bladder, leading to leakage and the need for pads. This usually improves within a year of the surgery. Advances in surgical techniques have made major urine control problems very uncommon. You can also do pelvic floor exercises to improve control.
• Effect on fertility: Infertility will occur because the tubes from the testicles (vas deferens) are sealed. A normal orgasm is still possible but without the ejaculation of semen (dry ejaculation). If you still wish to have children you should speak with your doctor before treatment about the possibility of storing your sperm or other options.
External beam radiotherapy
External beam radiotherapy uses high-energy x-rays to kill cancer cells or injure them so they cannot multiply. Radiotherapy is usually considered if you have early cancer and are otherwise in good general health. It may be used instead of surgery or in combination with surgery. The x-rays are aimed at the cancer in your prostate from an external machine. Treatment is planned to ensure as little harm as possible to the normal tissue surrounding the prostate.
Brachytherapy is a type of targeted internal radiotherapy where the radiation source is placed directly within a tumour. This allows high doses of radiation to be given with minimal effect on nearby tissues such as the rectum. Brachytherapy can be given at either a low-dose rate, by inserting permanent radioactive seeds, or a high-dose rate, through temporary needle implants. Brachytherapy is not suitable for men with significant urinary symptoms.
High intensity focused ultrasound (HIFU) and cryotherapy are less established treatments for localised prostate cancer. At this stage they are regarded as emerging options which most centres reserve for those patients who are unsuitable for or who refuse surgery or radiotherapy. High Intensity Focused Ultrasound also called as HIFU is a state-of-the-art technology developed to treat cancerous cells without harming the healthy cells. HIFU uses acoustic ablation technique. This technique utilizes the power of ultrasound to destroy cancerous cells with pinpoint accuracy for prostate cancer treatment. The cancerous cells in the prostate gland are destroyed with the high temperature which is generated by focusing sound waves in a targeted area. HIFU procedure for prostate cancer treatment is a very simple procedure which requires shorter time to perform. Since it is non-ionizing, it can also be used as a salvage technique if other treatments for treating prostate cancer fail. During the procedure, the doctor uses continuously updated real-time images of the prostate gland on a computer screen. This helps the doctor to map out and execute the entire treatment plan and to customize treatment for maximum safety and effectiveness.
Prostate cancer needs the male hormone, testosterone, to grow. Slowing the production of testosterone may also slow the growth of the cancer or shrink it. This is called hormone treatment. Hormone treatment will not cure prostate cancer. It can help with symptoms such as pain caused by the cancer spreading.
It will put the cancer into temporary remission. This treatment is often given for several months before radiotherapy and may be continued following radiotherapy to increase the effectiveness of the treatment.
Injections of luteinising hormone-releasing hormone (LHRH) are used to control the production of testosterone. LHRH is given as a monthly, three-monthly or six-monthly injection. It will not cure the cancer but will often slow its growth for years.
Palliative treatment is available for all people who have cancer symptoms, whatever their stage of treatment. It is particularly important for people who have advanced cancer, who cannot be cured but want to live comfortably.
Your doctor will discuss palliative treatment for specific problems caused by the cancer, such as pain. Treatment can include radiotherapy, chemotherapy and pain-relieving medications. Palliative treatment can help with pain management – it is not just for people who are about to die.
After treatment: follow-up
After treatment, you will need regular checkups with your doctor.
What if the prostate cancer comes back?
If your PSA levels start to rise and the cancer has not spread beyond the prostate, this may mean you still have cancer cells in the prostate area. If this happens, you may be given more treatment. This is called salvage treatment. If you have had surgery, radiotherapy may be offered. If you have had radiotherapy you may be offered surgery, brachytherapy, cryotherapy or ultrasound treatment (HIFU).If the cancer has spread beyond the prostate, hormone treatment is the usual treatment option.
Managing side effects
Treatment for prostate cancer may damage nerves and muscles near the prostate and the bowel and this may cause side effects. The side effects of treatment include impotence, urinary incontinence, changes in bowel habits, infertility and loss of interest in sex. Side effects will vary from person to person. Some men will have no side effects; others may experience a few. Side effects may last from a few weeks to three years.
After treatment for prostate cancer, most men lead active lives by managing the side effects.
There are many ways to reduce or manage the discomfort that side effects cause, and most go away in time.
The quality of erections usually changes as men get older. Erections may be short-lived or difficult to achieve. Erection problems are also common in men who have had surgery and radiotherapy for prostate cancer because these treatments can damage nearby nerves and blood flow.
Not being able to control the flow of urine is called urinary incontinence. It is a common temporary side effect of surgery, but for a few men it is permanent. The effects of incontinence vary. Some men may lose a few drops when they cough, sneeze, strain or lift. Others have more severe problems requiring the use of incontinence pads. It is usually worse after treatment, and better within a year.
Bladder problems can be managed in a variety of ways. You can:
• Use aids to help cope with any urine loss and protect your skin. Some available aids include absorbent pads, sheets and chair covers.
• Ask a doctor or nurse about ‘training’ your bladder. This can help you to go to the toilet less often and to pass more urine when you go to the toilet.
• Exercise the muscles in your pelvis (pelvic floor muscles) to help stop or reduce leakage.
Don’t restrict your intake of fluids because you are afraid of leakage. It’s important to drink plenty of water as concentrated urine can irritate the bladder, cause constipation and may lead to urinary infections.
If incontinence lasts longer than a year, it is unlikely to improve. You should then talk to your urologist about other treatments to fix the incontinence. Two successful options include slings or an artificial sphincter.
Rarely, radiotherapy may damage the lower bowel (rectum), leading to bleeding, diarrhoea or loss of bowel control. A bowel specialist (colorectal surgeon) will treat these side effects with suppositories or treatments applied to the bowel. Ask your radiation oncologist for more information.
After surgery, radiotherapy or hormone therapy for prostate cancer, most men become infertile. Loss of fertility may not be a problem for many men diagnosed with prostate cancer as they are usually older and have finished having children. If you want to have children, it is best for you and your partner to talk about these issues with your doctor before treatment commences. You may be able to store sperm before treatment starts for use at a later date. Ask your doctor about the options.
Protect yourself from Prostate Cancer
You can help to protect yourself from the Prostate Cancer by following these simple tips:
Cut down on meat: Prostate cancer – a hormone-based disease – may be strongly linked to the consumption of meat which contains higher levels of hormone-disrupting chemicals. Try to eat meat no more than three times a week. It’s best to eat white meat, and lean cuts of red meat with equal portions of fish. Opt for hormone-free organic cuts where possible.
Don’t fry food: Diets which are high in dairy products – milk, cheese, butter and saturated animal fats – are also associated with a higher incidence of prostate cancer. Avoid trans-fats, found in margarine, vegetable shortening, and processed vegetable oils. If you are overweight, start a diet to reduce your risk.
Eat more fruit: Eat five to nine daily servings of organic fresh fruit and vegetables. Eat plenty of rich red tomato sauces. Try to include soya in your diet – soya milk, tofu or soya yoghurts. These are all high in antioxidants, which protect our cells against the damaging effects of free radicals and can help prevent cancers.
Take vitamins: Recommended daily supplements for prostate protection include: Vitamin A, C, D and; Selenium and Flaxseed oil.
Stop smoking: Giving up cigarettes will also protect your zinc levels.
Avoid using garden fertilisers and pesticides: Many these contain hormone-disrupting chemicals.
Exercise: Because very little research has been conducted into prostate cancer, the power of exercise, though known to be beneficial in boosting the body’s immune system, is still largely uncertain. What scientists do know is that exercise can prevent cancer because it enhances natural immunity by improving circulation, blood pressure and the efficiency and strength of the heart.It also improves the antioxidant defences of our cells, which can help to counter the potentially damaging effects of oxidants, and which can lead to the genetic mutations that lie behind the development of cancers.