What is Prostate Cancer?

Prostate cancer which is also referred to as Cancer of the Prostate [ CaP] is a malignant transformation of the cells of the prostate gland into cells with the ability to proliferate uncontrollably, erode into surrounding tissues/organs, and the potential to spread to other parts of the body.

It is about the most common cancer in men and the leading cause of cancer-related death in men. It is estimated to affect about 127 to 180 in every 100,000 men in Nigeria. And the mortality rate in Nigeria, as of 2014, was estimated to be as high as 80%. And this is largely due to late presentation and diagnosis.

Cancer of Prostate case study

The urgency in his steps as he hurried to the restroom was unmistakable. This was the 4th time the 65-year-old CEO had excused himself from the ongoing meeting.

As he banged the door behind him, he could still hear the murmuring from the board members he left behind. With trembling hands, he unzipped his trousers and brought out his junk to pee. Then began the wait, as the urine refused to come.

For the past 6 months, he had been having some difficulty urinating. His urine flow had been reduced, coming out in trickles, like a child’s. He had to strain forcefully, sometimes grunting with effort, to be able to urinate.

As time passed, he started having pain in his lower tummy, burning sensation on urination and making use of the toilet more frequently than he used to.

Over the last few weeks, he had started losing appetite, and as a consequence, he had also started losing weight, so much that people were beginning to ask him if he was alright. He had made a mental note to visit his GP, but something more important always seemed to come up whenever it was time.

After some 15 to 30 seconds of waiting, the urine finally came as a crimson fluid from his urethral opening; he was peeing blood! And that was when he knew that it was high time, he went to see a doctor. Whatever it was that made him pee blood must definitely be a serious issue.

Structure and Function of the Prostate

The prostate gland is an organ– about the size of a walnut, measuring 4cm in length, and 5cm in width– situated in the male pelvis.

It lies immediately below the bladder, surrounding the urethra [the tube through which urine from the bladder flows to the outside] like a fist wrapped around a tube.

Its function is to produce prostatic fluid, which is a major component of the seminal fluid [semen]. It also plays a role in ejaculation.

The prostate gland, under the influence of Testosterone, grows bigger with age. This may lead to the formation of a non-cancerous, but troublesome growth called Benign Prostatic Hyperplasia [BPH], which has symptoms similar to that of CaP.

Risk Factors of Prostate Cancer

Unfortunately, most of the major risk factors for CaP are NON-MODIFIABLE. This means they are factors that are constant if they are present; and no degree of precautions, or lifestyle modifications, would change them.

These factors include the following.

Age: The likelihood of developing CaP increases with age. Most cases of CaP occur after the ages of 45 to 55.
Race: CaP is commoner blacks, especially those of African descent. Also, more aggressive cases are seen in the black African population.
Family History: The history of CaP in a first-degree relative, increases one’s history of developing CaP by 2 to 3 folds.

Also, the presence of the BRCA [Breast Cancer] genes, 1 and 2, in first-degree female relatives, increases one’s chances of developing CaP. Other Risk Factors

These include.

Obesity
Smoking
Prostatitis [inflammation of the prostate]
Dietary factors like a high intake of red meat and high-fat dairy products; and low intake of fruits and vegetables, are also considered risk factors.

Symptoms of Prostate Cancer

For the purpose of convenience and easier understanding, the symptoms of Ca Prostate can be divided into the following.

General Symptoms Of Cancers

This include:

Weight loss
Loss of appetite
Excessive sweating, especially at night
Low-grade fever
Weakness

Symptoms Of Prostate Enlargement

Difficulty urinating; having to strain forcefully before urine starts flowing well.
Presence of blood in the urine.
Hesitancy; having to wait for long before urine starts flowing.
A weak stream of urine.
Incomplete emptying; feeling as if there’s leftover urine inside the bladder after urination.
Terminal dribbling; having [more than the usual few] drops of urine leak and stain the trousers after urinating, and one is about to zip up.
Frequent urination, including excessive nighttime urination.
Painful urination.
Urgency; the uncontrollable urge to rush and go and ease oneself.
Urge incontinence; having urine leak before one gets to the toilet.
Low back pain.

Note that these symptoms [of Prostate enlargement] are roughly the same symptoms seen in the aforementioned BPH , as well as other non-prostate-related problems affecting the urinary tract [like urethral stricture]. Hence the need for a review by a Urologist, to know which is which.

Complications of Prostate Cancer

CaP could lead to the following complications.

Erectile dysfunction [impotence]
Kidney failure
Paralysis of both legs
Fracture of the spine
Excruciating bone pains
Death.

Prevention/Screening for cancer of the prostate

With an estimated mortality rate of about 80%, Prostate cancer is one of those disease where “prevention is better than cure” is more than just a mantra.

Unfortunately, most of the major risk factors are non-modifiable, so primary prevention is almost impossible, and as such of little or no use.

Fortunately, however, most cancers of the prostate are slow-growing tumors, and as such regular screening can detect them early enough so that they can be nipped in the bud, and cured before considerable damage is done.

So, EARLY DETECTION THROUGH ROUTINE SCREENING, what is called SECONDARY PREVENTION, is the mainstay of “prevention” [where prevention here means, prevention of the progression of the disease to incurable forms]

Screening Schedule For CaP

The available modalities for screening for CaP include;

DRE: Digital Rectal Examination. This is a procedure in which an examiner inserts a lubricated, gloved finger into one’s anus to access the prostate, in order to assess its size and other important physical characteristics.
PSA: Prostate Specific Antigen. This is a blood test that is used to predict the likelihood of one having, or developing, CaP. A PSA level 0 to 4ng/ml is NORMAL; 4 to 10 ng/ml is INDETERMINATE; while anything above 10ng/ml is suggestive of a DISEASED PROSTATE, which could be BPH or CaP, and thus requires further evaluation.

[Note however, that even though a PSA level of less than 4ng/ml is “normal,” people can still develop CaP with it; the only thing is that it is RELATIVELY less likely, and almost impossible.

According to Medscape, the risk of developing CaP with a PSA of less than 1ng/ml is only 8%; with a level of 1 to 4 ng/ml it climbs to 25%; and with a PSA level of > 10ng/ml, the odds skyrockets to 50%.]

Men are advised to be going for the above two screening exercises once every 1 to 2 years after the age of 55. However, those with a very strong family history are advised to start as early as 45.

After the first screening exercise, if the PSA level is less than 2.5ng/ml, screening is recommended to be done every two years. But if it is more than 2.5ng/ml, it is recommended to be done yearly.

Diagnosis of Prostate Cancer

Definitive diagnosis is made by sending a sample of prostate tissue, obtained through a minor surgical procedure called Trucut biopsy, to a lab for histological analysis.

Treatment of Prostate Cancer

Depending on the stage at which the diagnosis of CaP is made, there are several treatment modalities available, including surgical, and bon surgical modalities.

Cure is possible if the cancer is detected early enough while still confined within the prostate gland, and with no evidence of eroding into surrounding tissues, or distant spread. In that case, removal of the prostate gland, with the surrounding structures [lymph nodes] in some cases, may effect “cure.”

In cases of a localized disease, that has affected surrounding structures, but with no distant spread, radiation therapy, and Androgen-deprivation [i.e hormone] therapy, may also come in handy.

Surgical Options For Prostate Cancer

Depending on the stage, the surgical options include;

– Radical Prosatectomy [removal of the prostate and surrounding structures]

– Orchiechtomy [removal of both testicles, as testosterone produced from the testes is what feeds the tumor. Hence this is a surgical form of hormone therapy]

Non-Surgical Options for of Prostate Cancer

These include;

Chemotherapy
Radiotherapy
Hormone therapy

Conclusion

With an estimated mortality rate of 80%, prostate cancer is the leading cause of cancer deaths in males.

With most of the major risk factors being non-modifiable, efforts directed at conscious prevention is of little, or no use.

Early detection, through routine screening– what is called secondary prevention, remains the key to successful treatment.

Men are therefore advised to be going for routine screening, with DRE and PSA, after the 55 year mark.