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Prostate Cancer Treatment in India

Prostate Cancer

Prostate cancer is a disease which only affects men. Cancer begins to grow in the prostate – a gland in the male reproductive system. 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. he prostate is below the bladder and in front of the rectum. The size of the prostate changes with age. In younger men, it is about the size of a walnut, but it can be much larger in older men. Just behind the prostate are glands called seminal vesicles that make most of the fluid for semen. The urethra, which is the tube that carries urine and semen out of the body through the penis, goes through the center of the prostate.

Types of prostate cancer

Almost all prostate cancers are adenocarcinomas. These cancers develop from the gland cells (the cells that make the prostate fluid that is added to the semen).

Other types of prostate cancer include:

  • Sarcomas
  • Small cell carcinomas
  • Neuroendocrine tumors (other than small cell carcinomas)
  • Transitional cell carcinomas

Causes of Prostate Cancer

  • Family history
  • Gene changes
  • Diet
  • Obesity
  • Smoking
  • Chemical exposures
  • Inflammation of the prostate
  • Sexually transmitted infections
  • Vasectomy

Symptoms of Prostate Cancer?

There are no warning signs of early prostate cancer. Once a tumor causes the prostate gland to swell, or once cancer spreads beyond the prostate, the following symptoms may happen:

  • A frequent need to urinate, especially at night
  • Difficulty starting or stopping a stream of urine
  • A weak or interrupted urinary stream
  • Leaking of urine when laughing or coughing
  • Inability to urinate standing up
  • A painful or burning sensation during urination or ejaculation
  • Blood in urine or semen

Symptoms of Advanced Prostate Cancer

  • Paralysis or weakness in the lower limbs, usually with constipation
  • Stiffness, deep or dull pain in the upper thighs, pelvis, lower back or ribs.  This is often followed by pain in the bones of those areas
  • Swelling of the lower extremities
  • Fatigue, vomiting or nausea
  • Loss of appetite and weight

Stages of Prostate Cancer

Stage Stage grouping Stage description
I T1, N0, M0Gleason score 6 or less

PSA less than 10

The doctor can’t feel the tumor or see it with an imaging test such as transrectal ultrasound (it was either found during a transurethral resection or was diagnosed by needle biopsy done for a high PSA) [T1]. The cancer is still within the prostate and has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Gleason score is 6 or less and the PSA level is less than 10.
OR
T2a, N0, M0Gleason score 6 or less

PSA less than 10

The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound and is in one half or less of only one side (left or right) of the prostate [T2a]. The cancer is still within the prostate and has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Gleason score is 6 or less and the PSA level is less than 10.
IIA T1, N0, M0Gleason score of 7

PSA less than 20

The doctor can’t feel the tumor or see it with imaging such as transrectal ultrasound (it was either found during a transurethral resection or was diagnosed by needle biopsy done for a high PSA level) [T1]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor has a Gleason score of 7. The PSA level is less than 20.
OR
T1, N0, M0Gleason score of 6 or less

PSA at least 10 but less than 20

The doctor can’t feel the tumor or see it with imaging such as transrectal ultrasound (it was either found during a transurethral resection or was diagnosed by needle biopsy done for a high PSA) [T1]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor has a Gleason score of 6 or less. The PSA level is at least 10 but less than 20.
OR
T2a or T2b, N0, M0Gleason score of 7 or less

PSA less than 20

The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound and is in only one side of the prostate [T2a or T2b]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. It has a Gleason score of 7 or less. The PSA level is less than 20.
IIB T2c, N0, M0Any Gleason score

Any PSA

The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound and is in both sides of the prostate [T2c]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor can have any Gleason score and the PSA can be any value.
OR
T1 or T2, N0, M0Any Gleason score

PSA of 20 or more

The cancer has not yet spread outside the prostate. It may (or may not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound [T1 or T2]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor can have any Gleason score. The PSA level is at least 20.
OR
T1 or T2, N0, M0Gleason score of 8 or higher

Any PSA

The cancer has not yet spread outside the prostate. It may (or may not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound [T1 or T2]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Gleason score is 8 or higher. The PSA can be any value.
III: T3, N0, M0Any Gleason score

Any PSA

The cancer has grown outside the prostate and may have spread to the seminal vesicles [T3], but it has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor can have any Gleason score and the PSA can be any value.
IV T4, N0, M0Any Gleason score

Any PSA

The cancer has grown into tissues next to the prostate (other than the seminal vesicles), such as the urethral sphincter (muscle that helps control urination), rectum, bladder, and/or the wall of the pelvis [T4]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The tumor can have any Gleason score and the PSA can be any value.
OR
Any T, N1, M0Any Gleason score

Any PSA

The tumor may or may not be growing into tissues near the prostate [any T]. The cancer has spread to nearby lymph nodes [N1] but has not spread elsewhere in the body [M0]. The tumor can have any Gleason score and the PSA can be any value.
OR
Any T, any N, M1Any Gleason score

Any PSA

The cancer may or may not be growing into tissues near the prostate [any T]and may or may not have spread to nearby lymph nodes [any N]. It has spread to other, more distant sites in the body [M1]. The tumor can have any Gleason score and the PSA can be any value.

Diagnosis of Prostate Cancer

Most prostate cancers are first found during screening with a prostate-specific antigen (PSA) blood test or a digital rectal exam (DRE).A number of tests are performed for diagnosing prostate cancer that include

Medical history and physical exam

If your doctor suspects you might have prostate cancer, he or she will ask you about any symptoms you are having, such as any urinary or sexual problems, and how long you have had them. You might also be asked about possible risk factors, including your family history.

PSA blood test

The prostate-specific antigen (PSA) blood test is used mainly to screen for prostate cancer in men without symptoms). It’s also one of the first tests done in men who have symptoms that might be caused by prostate cancer.

Transrectal ultrasound (TRUS)

For this test, a small probe about the width of a finger is lubricated and placed in your rectum. The probe gives off sound waves that enter the prostate and create echoes. The probe picks up the echoes, and a computer turns them into a black and white image of the prostate. The procedure often takes less than 10 minutes

Prostate biopsy

If certain symptoms or the results of tests such as a PSA blood test or DRE suggest that you might have prostate cancer, your doctor will do a prostate biopsy.A biopsy is a procedure in which small samples of the prostate are removed and then looked at under a microscope. A core needle biopsy is the main method used to diagnose prostate cancer.

Suspicious results

Sometimes when the prostate cells are seen, they don’t look like cancer, but they’re not quite normal, either. These results are often reported as suspicious.

Prostatic intraepithelial neoplasia (PIN): In PIN, there are changes in how the prostate cells look, but the abnormal cells don’t look like they’ve grown into other parts of the prostate (like cancer cells would). PIN is often divided into 2 groups:

  • Low-grade PIN: the patterns of prostate cells appear almost normal
  • High-grade PIN: the patterns of cells look more abnormal

Imaging tests to look for prostate cancer spread

Imaging tests use x-rays, magnetic fields, sound waves, or radioactive substances to create pictures of the inside of your body.

Bone scan

If prostate cancer spreads to distant sites, it often goes to the bones first. A bone scan can help show whether cancer has reached the bones.

Computed tomography (CT) scan

A CT scan uses x-rays to make detailed, cross-sectional images of your body

Magnetic resonance imaging (MRI)

Like CT scans, MRI scans show detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. A contrast material called gadolinium may be injected into a vein before the scan to better see details.

Lymph node biopsy

In a lymph node biopsy, also known as lymph node dissection or lymphadenectomy, one or more lymph nodes are removed to see if they have cancer cells. This isn’t done very often for prostate cancer, but can be used to find out if the cancer has spread from the prostate to nearby lymph nodes.

Treatment of Prostate Cancer

Depending on the situation, the treatment options for men with prostate cancer might include:

Because prostate cancer often grows very slowly, some men (especially those who are older or have other serious health problems) might never need treatment for their prostate cancer. Instead, their doctors may recommend approaches known as watchful waiting or active surveillance

Surgery is a common choice to try to cure prostate cancer if it is not thought to have spread outside the prostate gland. The main type of surgery for prostate cancer is a radical prostatectomy. In this operation, the surgeon removes the entire prostate gland plus some of the tissue around it, including the seminal vesicles. A radical prostatectomy can be done in different ways.

Open approaches to radical prostatectomy

In the more traditional approach to doing a prostatectomy, the surgeon operates through a single long skin incision to remove the prostate and nearby tissues. This type of surgery, sometimes referred to as an open approach. There are 2 main ways to do this operation.

Radical retropubic prostatectomy

For this operation, the surgeon makes an incision (cut) in your lower abdomen, from the belly button down to the pubic bone. You will either be under general anesthesia (asleep) or be given spinal or epidural anesthesia (numbing the lower half of the body) along with sedation during the surgery.

Radical perineal prostatectomy

In this operation, the surgeon makes the incision in the skin between the anus and scrotum

Laparoscopic approaches to radical prostatectomy

Laparoscopic approaches use several smaller incisions and special long surgical tools to remove the prostate. The surgeon either holds the tools directly, or uses a control panel to precisely move robotic arms that hold the tools. This approach to prostatectomy has become more common in recent years.

Laparoscopic radical prostatectomy

For a laparoscopic radical prostatectomy (LRP), the surgeon inserts special long instruments through several small incisions to remove the prostate. One of the instruments has a small video camera on the end, which lets the surgeon see inside the abdomen.

Robotic-assisted laparoscopic radical prostatectomy

In this approach, also known as robotic prostatectomy, the laparoscopic surgery is done using a robotic interface (called theda Vinci system). The surgeon sits at a control panel in the operating room and moves robotic arms to operate through several small incisions in the patient’s abdomen. Robotic prostatectomy has advantages over the open approach in terms of less pain, blood loss, and recovery time

Radiation therapy uses high-energy rays or particles to kill cancer cells. Radiation may be used:

  • As the first treatment for cancer that is still just in the prostate gland and is low grade. Cure rates for men with these types of cancers are about the same as those for men treated with radical prostatectomy.
  • As part of the first treatment (along with hormone therapy) for cancers that have grown outside the prostate gland and into nearby tissues.
  • If the cancer is not removed completely or comes back (recurs) in the area of the prostate after surgery.
  • If the cancer is advanced, to help keep the cancer under control for as long as possible and to help prevent or relieve symptoms.

The 2 main types of radiation therapy used for prostate cancer are:

  • External beam radiation

In EBRT, beams of radiation are focused on the prostate gland from a machine outside the body. This type of radiation can be used to try to cure earlier stage cancers, or to help relieve symptoms such as bone pain if the cancer has spread to a specific area of bone.

  • Brachytherapy (internal radiation)

Brachytherapy (also called seed implantation or interstitial radiation therapy) uses small radioactive pellets, or “seeds,” each about the size of a grain of rice. These pellets are placed directly into your prostate

Cryotherapy (also called cryosurgery or cryoablation) is the use of very cold temperatures to freeze and kill prostate cancer cells. Despite it sometimes being called cryosurgery, it is not actually a type of surgery.

Hormone therapy is also called androgen deprivation therapy (ADT) or androgen suppression therapy. The goal is to reduce levels of male hormones, called androgens, in the body, or to stop them from affecting prostate cancer cells

Chemotherapy (chemo) uses anti-cancer drugs injected into a vein or given by mouth. These drugs enter the bloodstream and go throughout the body, making this treatment potentially useful for cancers that have spread (metastasized) to distant organs.

Unlike traditional vaccines, which boost the body’s immune system to help prevent infections, this vaccine boosts the immune system to help it attack prostate cancer cells. The vaccine is used to treat advanced prostate cancer that is no longer responding to initial hormone therapy but that is causing few or no symptoms.