A malignant tumor (almost always an adenocarcinoma) of the prostate gland. Other than skin cancers, it is the most common neoplasm in men. In 2008, the American Cancer Society estimated that 186,320 American men would be diagnosed with prostate cancer and that 28,660 would die as a result. Nonetheless, 93% of those diagnosed survive at least 10 years, and 77% of men with the disease survive at least 15 years.

Figure: PROSTATE CANCER




See: benign prostatic hypertrophy; brachytherapy; prostatectomy

ETIOLOGY
Although the cancer may have many causes, it is a hormone (i.e., testosterone) sensitive tumor.

SYMPTOMS
The disease often is asymptomatic, or it may present with symptoms similar to those of benign prostatic hypertrophy, such as difficulty urinating, urinary hesitancy, frequency, dribbling, steam reduction or interruption, and nocturia; symptoms of urinary tract infection; or in cases in which the cancer has spread to bone, localized or generalized bone pain. Prostatic cancer can spread locally or metastasize via the lymphatic system to lung, liver and brain in addition to bone.

DIAGNOSIS
About two thirds of those diagnosed are over age 65. Incidence is 60% higher in black men than in whites or Hispanics, and lowest in Asians. The highest mortality rate also is in black men. Other risk factors include family history, having had a vasectomy, eating a diet high in fats and red meats and low in fruits and vegetables, and demonstrating reduced levels of vitamins D & E, lycopene and selenium.

PATIENT CARE
Most professional medical societies recommend that men over the age of 50 or men with a strong family history of the disease discuss prostate cancer screening with their primary care providers. The available options include blood tests to assess levels of prostate specific antigen (PSA), digital rectal examination (DRE), or assessment of the gland with ultrasonography. Mass screening for prostate cancer is not recommended by any major professional group because it may result in false-positive diagnosis, unnecessary or complicated treatments, or unnecessary anxiety. However, those men at high risk (including black men) should begin annual testing at 45. Screening should begin at 40 for men at highest risk (several first-degree relatives having prostate cancer at early ages).

When prostate cancer is suggested by screening tests, biopsies are required to confirm the diagnosis, usually employing guided imagery via transrectal ultrasound. Further studies may include MRIs, CTs and bone scans to see if the disease has spread. Once diagnosed, prostate cancer is differentiated as stages 1 to 4, with the higher stages indicating more advanced or widespread disease, and is graded on the Gleason grading system from 2 to 10, with lower numbers indicating cells more closely resembling normal cells (well-differentiated) and higher number increasingly abnormal (poorly differentiated). Stage, grade, age, and overall health aid in determining treatment, although all treatment options should be explored.

Patient support and education vary with the staging of disease and the therapies to be provided. For example, in patients with early (low-grade or low stage) disease or those with limited life expectancy and significant co-morbid diseases who choose expectant care (watchful waiting) to avoid the rigors of treatment and potential adverse reactions, teaching should focus on symptoms that may require prompt intervention, and on the need to remember follow-up visits for repeat PSA and DRE – usually every 6 months. If the patient chooses external beam radiation, he is taught the most common side effects, including localized skin irritation, diarrhea, urinary urgency, frequency, hesitancy and pain, erectile dysfunction, fatigue, and bone marrow suppression. If the patient chooses brachytherapy, he is taught that the radioactive seeds will be placed in the prostate while he is under procedural sedation. Radiation precautions are needed, including following the approved method of lost seed disposal. A condom must be used when sexual activity is resumed after 2 weeks. The most common side effects are irritation and obstruction of the urinary tract. Patients who have received brachytherapy should immediately report inability to void, rectal bleeding, rectal irritation, or diarrhea to the health care providers.

Cryosurgery eradicates malignant cells by freezing them. In this minimally invasive procedure, the patient is anesthetized and then liquid-nitrogen probes are inserted into the prostate. Complications can include erectile dysfunction, urinary incontinence, and fistula formation between the bladder and the rectum. The most effective surgical procedure to improve the potential for long-term survival is radical prostatectomy, which can be performed via laparoscopic, retropubic or perineal approach. The entire prostate, seminal vesicles, regional lymph nodes and part of the bladder neck are removed. All male patients should be taught from an early age about their risks for prostate cancer, and encouraged to have regular screening at the appropriate age.