Prostate with the seminal vesicle is a part of the male reproductive system. It has the shape of a walnut. The prostate is situated below the urinary bladder and in front of the rectum in the male pelvis. It provides nourishment for the sperms.
Prostate cancers are one of the common cancers in males. It is dependent on the male sex hormone called androgen. It usually occurs in older males.
The patient usually presents with decreased urinary flow, increased frequency of urination at night, urge to pass urine, incomplete evacuation of the bladder. These urinary problems are collectively called Lower urinary tract symptoms (LUTS). Other symptoms include blood in urine and pain while urinating. In advanced conditions, there might be bone pain or breathing difficulty.
When the patient presents with such symptoms to a Urologist, a thorough clinical examination is done. The urologist usually performs a digital rectal examination to examine the prostate. After this, specific tests are done to confirm the diagnosis. Prostate-Specific Antigen (PSA), is a blood test which is usually elevated in prostate cancers. It is one of the tests, which is used in screening. The confirmatory test is the biopsy. A biopsy is generally done under sonography guidance through the rectum. This tissue is sent for microscopic examination to get the histology. This examination also shows the aggressiveness of the tumor, also known as Gleason's score. After the biopsy report, we need to see the extent of the spread of cancer by process of staging. For staging, a CT scan can be done. MRI is preferred to assess the local extent of the disease. Bone scans are done to evaluate the spread of bones. Nowadays, a special scan called PSMA PET CT scan is done, which can show the spread of prostate cancers.
Based on the PSA, Gleason's score, and local spread, the cancer is classified into Low risk, Intermediate risk or High risk. Risk stratification determines the treatment modality.
Treatment
Treatment usually dependents on risk stratification, age and stage of cancer. There are various treatments for prostate cancers. They are:
These therapies are either used alone or in combination depending on the risk stratification and stage of cancer.
1. Watchful Waiting
The survilence is an option when it is very early stage and very low-risk cancer of the prostate. This observation method is a valid option in very elderly patients. However, this approach requires a frequent assessment of PSA, with or without a biopsy.
2. Surgery
Surgical removal is one of the oldest treatment options for the treatment of prostate cancers. Surgery involves removal of the prostate, seminal vesicle, with or without the nodes. This procedure is called radical prostatectomy. The traditional method of surgery is by opening the pelvis and performing the surgery. As there was technological advancement, Laparoscopic surgery was introduced. This technique involved removing the tumor without cutting open the pelvis, but by using keyholes. With more technological advancements, Robotic surgery was introduced. In Robotic surgery, a surgeon can single-handedly perform the surgery sitting remotely and controlling the robot. He has more mobility and can get a 3-dimensional visualization of the surgery. The hospital stay has decreased considerably through this technique.
Surgery is indicated mostly in early stages but can be done in other stages too. It is sometimes combined with Hormonal therapy, especially in intermediate and high-risk conditions. Sometimes, if PSA is rising after surgery, the patient may require radiation with or without hormonal therapy.
In certain metastatic cancers of the prostate, removal of testes is done surgically. This procedure is called an orchidectomy. Orchidectomy can be a replacement for hormonal therapy.
3. External Beam Radiation Therapy (EBRT)
EBRT is one of the most important treatments in prostate cancers. It can be used in all stages of prostate cancers. In all stages, when surgery is not possible or if the patient is not willing, radiation can be used as a treatment option. With the advent of the latest technologies of radiation like Intensity Modulated Radiation Therapy (IMRT) and Image-Guided Radiation Therapy (IGRT), dose-escalation can be done safely with sparing of normal tissue. These techniques have also reduced the acute and long-term toxicities.
For early-stage prostate cancers, there is a radiation technique called
Stereotactic Body Radiation Therapy (SBRT). SBRT involves delivering very high doses of radiation over a very short period of time. The entire course of treatment is completed in 5 to 7 days. There are various machines for the delivery of SBRT. These include Cyberknife, X – Knife (TruBeamStx) etc.
In intermediate and high-risk prostate cancers, when radiation therapy is indicated, it is usually combined with Hormonal treatment. This type of therapy is delivered over 4 to 8 weeks.
In certain conditions, radiation is delivered after surgery for raising PSA values, called as salvage radiation therapy. This post-surgery radiation is delivered over 5 to 6.5 weeks. Palliative radiation can be given for painful bone metastasis for pain relief.
4. Brachytherapy and Permanent radioactive seed implants
Brachytherapy is a type of radiation in which the radiation source is placed within or very near the tumor. This procedure is used alone or in combination with external beam radiation therapy. In one type of the procedure, rigid tubes through the pelvis piercing the prostate are inserted. After this, the radioactive source is guided through these tubes for delivering the radiation.
In low-risk prostate cancers, permanent radioactive seeds like Iodine or gold are placed throughout the prostate. These seeds stay within the prostate permanently and deliver high doses of radiation. Brachytherapy techniques can also be used as a boost after external beam radiotherapy.
5. Hormonal Therapy
Prostate cancers are essentially male sex hormone (androgen) dependent. Therefore, to counter the effect of androgen, hormonal therapy is administered. It is usually given along with radiation or surgery for intermediate and high-risk prostate cancers. In these conditions, it is started before radiation or surgery and continued for a maximum of 2 years.
In metastatic prostate cancers, it can replace orchidectomy (removal of testes) as a single modality therapy. In these conditions, it can also be combined with chemotherapy.
6. Chemotherapy /Targeted therapy /Immunotherapy
Chemotherapy is the primary treatment in metastatic prostate cancers. These are drugs, which are given through the veins. It might be a single drug or combination of drugs. It is also given in metastatic prostate cancers to decrease the cancer burden so that local therapy like radiation can be initiated on a later date. Chemotherapy is given over 1 or 2 days and repeated every 3 to 4 weeks. Usually, six such cycles are delivered.
Targeted and immunotherapy is usually given in metastatic prostate cancers when the patient has failed multiple lines of chemotherapy. Immunotherapy activates the immune system to target the cancer cells.
7. Alpha therapy /PSMA Therapy
These are the latest nuclear medicine therapies for the treatment of metastatic prostate cancers. It is usually administered in extensive metastases which ahs failed all lines of therapies. In this technique, radioactive substances are injected into the blood, which has an affinity to the cancer cells. It targets these cancer cells using alpha rays. It is very targeted and specific for prostate cancers. It still awaits approval by various agencies. It is presently tried on an experimental basis.
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