What is the prostate?
The prostate is an exocrine gland of the male reproductive system, and exists directly under
the bladder, in front of the rectum.
An exocrine gland is one whose secretions end up outside the body e.g. prostate gland
and sweat glands.
It is approximately the size of a walnut.
The urethra - a tube that goes from the bladder to the end of the penis and carries urine
and semen out of the body - goes through the prostate.
There are thousands of tiny glands in the prostate - they all produce a fluid that forms
part of the semen.
This fluid also protects and nourishes the sperm.
When a male has an orgasm the seminal-vesicles secrete a milky liquid in which the semen
travels.
The liquid is produced in the prostate gland, while the sperm is kept and produced in the
testicles.
When a male climaxes (has an orgasm) contractions force the prostate to secrete this fluid into
the urethra and leave the body through the penis.
Urine control.
As the urethra goes through the prostate: the prostate gland is also involved in urine
control (continence) with the use of prostate muscle fibers.
These muscle fibers in the prostate contract and release, controlling the flow of urine
flowing through the urethra.
The Prostate Produces Prostate-specific antigen (PSA).
The epithelial cells in the prostate gland produce a protein called PSA (prostate-specific
antigen).
The PSA helps keep the semen in its liquid state.
Some of the PSA escapes into the bloodstream.
We can measure a man's PSA levels by checking his blood.
If a man's levels of PSA are high, it might be an indication of either prostate cancer
or some kind of prostate condition.
It is a myth to think that a high blood-PSA level is harmful to you - it is not.
High blood PSA levels are however an indication that something may be wrong in the prostate.
Male hormones affect the growth of the prostate, and also how much PSA the prostate produces.
Medications aimed at altering male hormone levels may affect PSA blood levels.
If male hormones are low during a male's growth and during his adulthood, his prostate gland
will not grow to full size.
In some older men the prostate may continue to grow, especially the part that is around
the urethra.
This can make it more difficult for the man to pass urine as the growing prostate gland
may be causing the urethra to collapse.
When the prostate gland becomes too big in this way, the condition is called Benign Prostatic
Hyperplasia (BPH).
BPH is not cancer, but must be treated.
Prostate cancer.
In the vast majority of cases, the prostate cancer starts in the gland cells - this is
called adenocarcinoma.
In this article, prostate cancer refers just to adenocarcinoma.
Prostate cancer is mostly a very slow progressing disease.
In fact, many men die of old age, without ever knowing they had prostate cancer - it
is only when an autopsy is done that doctors know it was there.
Several studies have indicated that perhaps about 80% of all men in their eighties had
prostate cancer when they died, but nobody knew, not even the doctor.
Experts say that prostate cancer starts with tiny alterations in the shape and size of
the prostate gland cells - Prostatic intraepithelial neoplasia (PIN).
Doctors say that nearly 50% of all 50-year-old men have PIN.
The cells are still in place - they do not seem to have moved elsewhere - but the changes
can be seen under a microscope.
Cancer cells would have moved into other parts of the prostate.
Doctors describe these prostate gland cell changes as low-grade or high-grade; high grade
is abnormal while low-grade is more-or-less normal.
Any patient who was found to have high-grade PIN after a prostate biopsy is at a significantly
greater risk of having cancer cells in his prostate.
Because of this, doctors will monitor him carefully and possibly carry out another biopsy
later on.
Classification of prostate cancer.
It is important to know the stage of the cancer, or how far it has spread.
Knowing the cancer stage helps the doctor define prognosis - it also helps when selecting
which therapies to use.
The most common system today for determining this is the TNM (Tumor/Nodes/Metastases).
This involves defining the size of the tumor, how many lymph nodes are involved, and whether
there are any other metastases.
When defining with the TNM system, it is crucial to distinguish between cancers that are still
restricted just to the prostate, and those that have spread elsewhere.
Clinical T1 and T2 cancers are found only in the prostate, and nowhere else, while T3
and T4 have spread outside the prostate.
There are many ways to find out whether the cancer has spread.
Computer tomography will check for spread inside the pelvis, bone scans will decide
whether the cancer has spread to the bones, and endorectal coil magnetic resonance imaging
will evaluate the prostatic capsule and the seminal vesicles.
The Gleason Score.
A pathologist will look at the biopsy samples under a microscope.
If cancer tissue is detected, the pathologist then grades the tumor.
The Gleason System of grading goes from 2 to 10.
The higher the number, the more abnormal the tissues are compared to normal prostate tissue.
Two numbers are added up to get a Gleason score:
A number from 1 to 5 for the most common pattern observed under the microscope.
This is the predominant grade and must be more than 51% of the sample.
A number from 1 to 5 for the second most common pattern.
This is the secondary grade and must make up more than 5% but less than 50% of the sample.
A Gleason score of 7 can have two meanings.
If the predominant grade is 3 and the secondary grade is 4, the Gleason score is 7.
If the predominant grade is 4 and the secondary grade is 3, the Gleason score is also 7.
However, the first example, with a predominant score of 3, has a less aggressive cancer than
the second example, with a predominant score of 4.
It is crucial that the tumor is graded properly, as this decides what treatments should be
recommended.
Causes of prostate cancer.
It is not known exactly what causes prostate cancer, although a number of things can increase
your risk of developing the condition.
These include: Age – risk rises as you get older and most
cases are diagnosed in men over 50 years of age.
Ethnic group – prostate cancer is more common among men of African-Caribbean and African
descent than in men of Asian descent.
Family history – having a brother or father who developed prostate cancer under the age
of 60 seems to increase the risk of you developing it.
Research also shows that having a close female relative who developed breast cancer may also
increase your risk of developing prostate cancer.
Obesity – recent research suggests that there may be a link between obesity and prostate
cancer.
Exercise – men who regularly exercise have also been found to be at lower risk of developing
prostate cancer.
Diet – research is ongoing into the links between diet and prostate cancer.
There is evidence that a diet high in calcium is linked to an increased risk of developing
prostate cancer.
In addition, some research has shown that prostate cancer rates appear to be lower in
men who eat foods containing certain nutrients including lycopene, found in cooked tomatoes
and other red fruit, and selenium, found in brazil nuts.
However, more research is needed.
Symptoms of prostate cancer.
Prostate cancer does not normally cause symptoms until the cancer has grown large enough to
put pressure on the urethra.
This normally results in problems associated with urination.
Symptoms can include: Needing to urinate more frequently, often
during the night.
Needing to rush to the toilet.
Difficulty in starting to pee (hesitancy).
Straining or taking a long time while urinating.
Weak flow.
Feeling that your bladder has not emptied fully.
Many men's prostates get larger as they get older due to a non-cancerous condition known
as prostate enlargement or benign prostatic hyperplasia.
Symptoms that the cancer may have spread include bone and back pain, a loss of appetite, pain
in the testicles and unexplained weight loss.
Treatments for prostate cancer.
The following treatments are separated into early stage and advanced stage prostate cancers.
Early stage prostate cancer.
If the cancer is small and contained - localized - it is usually managed by one of the following
treatments:
Watchful waiting - not immediate treatment is carried out.
PSA blood levels are regularly monitored.
Radical prostatectomy - the prostate is surgically removed.
Brachytherapy - radioactive seeds are implanted into the prostate.
Conformal radiotherapy - the radiation beams are shaped so that the region where they overlap
is as close to the same shape as the organ or region that requires treatment, thus minimizing
healthy tissue exposure to radiation.
Intensity modulated radiotherapy - beams with variable intensity are used.
An advanced form of conformal radiotherapy usually delivered by a computer-controlled
linear accelerator.
Treatment recommendations really depend on individual cases.
In general, if there is a good prognosis and the cancer is in its early stages, all options
can be considered.
However, they all have their advantages and disadvantages.
The patient should discuss available options thoroughly with his doctor.
More advanced prostate cancer.
If the cancer is more aggressive, or advanced, the patient may require a combination of radiotherapy
and hormone therapy.
Radiotherapy requires treatment on an everyday basis for up to about eight weeks.
Radical surgery is also an option - the prostate is removed.
Traditional surgery requires a hospital stay of up to ten days, with a recovery time that
can last up to three months.
Robotic keyhole surgery has the advantage just a couple of days in hospital, followed
by a much shorter recover period.
However, even robotic keyhole surgery may not be ideal for very elderly patients.
In advanced prostate cancer hormone therapy is very effective in slowing down, and even
stopping the growth of cancer cells.
Even if the hormone therapy stops working after a while, there are still other options
the patient will be able to discuss with his doctor, such as participating in clinical
trials.
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