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Prostate Cancer Signs Symptoms & Carcinoma Tumor Treatment | Does Prostate Cancer Spread?

Mens Health

What is a prostate carcinoma or Cancer?

Prostate Cancer Signs Symptoms & Carcinoma Tumor Treatment | Does Prostate Cancer Spread? Prostate cancer is a malignant tumor of the prostate gland of the male. Its often slow growth sets it apart from other malignant tumors. Prostate cancer is the most common cancer among men in Germany, with more than 60,000 new cases annually.

Before the age of 50, the cancer of the prostate gland is rare. If prostate cancer occurs at a young age of the father, brother, uncle or grandfather, early detection examinations are advisable earlier than the usual 45 years, for example, already at 35. Prostate Cancer Signs Symptoms & Carcinoma Tumor Treatment | Does Prostate Cancer Spread?

Prostate and surrounding organs (Schematic representation)
Prostate Cancer Signs Symptoms & Carcinoma Tumor Treatment | Does Prostate Cancer Spread?

The prostate (circled in red) encloses the urethra in a ring just below the bladder outlet. Behind the prostateis the rectum, from where the prostate gland in the early detection by the doctor with his finger is felt. The prostate belongs to the reproductive organs of the man. In it, a part of the seminal fluid arises, another part are the two seminal vesicles (purple), which rest on the outside of the prostate. The testes (testes) produce much of the male sex hormone testosterone, which controls the growth and function of the prostate.

The tumor initially spreads within the prostate. As growth progresses, however, it can break through the connective tissue capsule that surrounds the organ and grow into adjacent tissue. This can then affect seminal vesicles, bladder and rectum.

As the duration of the disease increases, so does the likelihood that cancer cells will spread throughout the body via lymph or bloodstream and form metastases. These can be, for example, in the lymph nodes of the pelvis, but also in other organ systems of the body. By far the most commonly affected are the bones (spine, rib and pelvic bones). But metastases can also occur in the liver and lungs.

Almost all men survive a disease of prostate cancer, if it is detected so early that it is still limited to the prostate gland. The number of (diagnosed) new cases of prostate cancer has been increasing for several decades, with no increase in mortality. The relative 5-year survival – a measure of the survival probability of prostate cancer patients – has now increased to about 93 percent.

Clearly distinguished from prostate cancer is the benign enlargement of the prostate gland ( benign prostatic hyperplasia, BPH ), which can cause problems especially with urination, but is always limited to the prostate.

Symptoms of Prostate Cancer

The problem: There are no typical symptoms that point to a prostate cancer clearly and early. In most cases, prostate cancer develops in the outer glandular zone. The result: To narrow the internal urethra with disturbances in urination, it usually comes only when the tumor is already large and has spread throughout the entire organ. Therefore, it is particularly important that men perceive the screening tests offered.

Warning signs of a late, often far advanced stage can be for example:

  • Difficulty urinating
  • Blood in the urine or seminal fluid
  • Pain in ejaculation, in the back , pelvis or in the hip area
  • Erectile Dysfunction

If such symptoms occur, then immediately consult the family doctor or urologist. Only physicians can decide whether the described symptoms are harmless or give rise to further investigations.

Prostate cancer: Early Sign

The goal of early Sign measures is to make the diagnosis on time. Namely, at a time when a growing tumor causes no discomfort, it is still small and especially localized. Because then the treatment and thus chances of recovery are greatest.

Specialists in urology recommend all men over 40 have their prostate examined once a year. This is also the current guidelines of the German Society of Urology. The statutory health insurance companies usually pay an annual screening test for prostate cancer, but only from the age of 45 years. If the prostate cancer facility is possibly in the family, it may be important to start regular cancer screening much earlier – for example, from the age of 35. Patients should seek individual advice from their doctor. In justified cases, the statutory health insurance usually pays.

Palpation of the prostate

The screening examination of the prostate gland belongs to the screening test. The doctor also examines the external genital organs, palpates the lymph nodes in the groin and asks the patient’s history and any complaints. Then he examines the prostate with his finger over the rectum (digital rectal examination). Prostate cancers are most common in the part of the gland that faces the rectum. The doctor looks for irregularities and indurations that suggest a suspected carcinoma. But not every prostate cancer can be determined in this way. Especially small tumors are not noticeable during the palpation examination.

PSA test

For the so-called PSA test, a laboratory test that is also carried out in the case of prostate cancer suspected, legally insured men currently usually pay for themselves if the test is purely for early detection, ie without justified suspected cancer, carried out (cost about 30 euros). If prostate cancer is suspected, the costs of the PSA test will be borne by the statutory health insurance companies.

The PSA is a protein that is formed by the glandular cells of the prostate. In small amounts, the PSA also enters the blood. So the doctor takes blood from the man, which is examined in the laboratory. The normal PSA level in healthy men is in the range of zero to two and one-half billionths of a gram (nanogram, ng) per milliliter (ml) of blood. In prostate cancer, the PSA concentration in the blood is usually increased.

But it is true that increasing PSA alone is not a sure sign of cancer. Because there are many more reasons for a changed PSA value. A prostate inflammation (prostatitis), a benign enlargement of the prostate (benign prostatic hyperplasia, BPH), a previous palpation or cycling prior to blood collection, for example, also in the height chase the PSA level. Research shows that only one in four men with a PSA between four and ten nanograms per milliliter actually has prostate cancer.

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Conversely, just as elevated PSA levels may not always indicate prostate cancer, “normal” PSA levels do not fully exclude prostate cancer. Therefore, in addition to the absolute value, the slew rate between different PSA measurements is important.

Intensive is currently being searched for improvements or alternatives to the PSA test and research. However, the previously tested procedures are not yet ready for practical use.

Prostate cancer: diagnosis

If there is a suspected cancer of the prostate gland, the doctor will first examine the prostate via the rectum as with the screening test (digital rectal examination). Blood for the determination of the PSA value should under no circumstances immediately follow, but should be taken either before the palpation examination or at a separate appointment.

If there is a reasonable suspicion of prostate cancer, only tissue sampling (biopsy) can ultimately confirm this fear or preclude the diagnosis of cancer with high probability.

Often, however, a nuclear spin examination (“multiparametric magnetic resonance tomography”, abbreviated mpMRT) of the prostate is performed today. This allows a better statement as to whether a malignant prostate cancer, an inflammation or a benign enlargement is present. Thus, some patients whose prostate change turns out not to be suspicious of cancer can be spared the biopsy. Since the mpMRT examination is not widely accepted as a standard prostate cancer test, please check with your health insurance company in advance to see if it will cover the costs of the examination.

If a prostate cancer is actually present, the doctors next determine with various further diagnostic measures, what size of the tumor has already reached and where it may have spread already. In addition, they try to estimate how cancerous the tumor is.

The biopsy

During biopsy, a puncture needle is stung from the rectum – occasionally also from the perineum – into different parts of the prostate . At least six, but usually ten to twelve tissue samples are taken. With the help of an ultrasound probe, which is inserted into the rectum via the anus, the doctor can visualize the prostate and surrounding tissue structures on a screen (transrectal ultrasound – TRUS) and thus control the removal of prostate tissue in a targeted manner.

In the presence of magnetic resonance imaging of the prostate gland, the cancerous area suspected in the prostate can be punctured by means of a so-called fusion biopsy. The data obtained in the previous MRI are recorded in the ultrasound machine used for biopsy, and then this stove or even several foci can be exactly hit. This fusion biopsy using a special ultrasound device is much faster than a biopsy directly in the MRI device and is thus gentler for the person affected.

Tissue examination with microscopic and molecular biological methods not only serves to diagnose tumors, but also provides physicians with important information about the nature and behavior of the tumor. This is crucial for treatment planning.

Further diagnostic measures

Further diagnostic measures – and thus the treatment planning – depend on how far the tumor has spread locally, whether it is more or less malignant and whether metastases have already formed in the nearby lymph nodes of the pelvis or in other parts of the body. For clarification, the following procedures are used, depending on the situation:

  • With the help of the transrectal ultrasound examination, it can be checked whether the tumor has already broken through the connective tissue capsule which surrounds the prostate or whether it has already grown into the seminal vesicles.
  • With the help of so-called skeletal scintigraphy (bone scintigraphy), it can be determined whether the tumor has already affected the bones. This examination is useful if the PSA value (see chapter on early detection) is more than 20 nanograms per milliliter or if there is any other evidence of bones in the bones. For this purpose, small amounts of a radioactive substance are injected into the bloodstream, which accumulates particularly in diseased bones. A camera, which registers the radioactive radiation, then locates the suspected metastases areas.
  • General blood tests are among the further examinations that almost all patients have to overcome before further treatment planning. They serve above all the examination of the state of health, for example to determine the anesthesia capability before an operation.

Currently, diagnostic procedures such as magnetic resonance tomography – possibly associated with tissue analysis via spectroscopy – and new methods such as positron emission tomography (choline-PET), which is used to search for metastases in high-risk patients, are not yet standard diagnostic procedures ,

Classification of malignant prostate tumors

Prostate carcinomas usually originate from gland cells and therefore belong to the group of so-called adenocarcinomas. The treatment plan depends to a large extent on the biological characteristics of a diagnosed tumor, how extensive and “malignant” it is or threatens to become. The physicians receive information about this from the tissue samples taken.

The classification of the tumor occurs in two ways:

1. Gleason-Score:
In prostate cancer, the plays after the American doctor. Donald Gleason named the scale for describing the malignancy of tumors (Gleason score) the largest role. The affected visible cells from a tissue sample are divided into groups. The two cell types that occur most frequently and form the largest groups are evaluated, according to a scale between 1 (largely similar to healthy cells) and 5 (strongly different, comparatively very malignant). Taken together, the two values ​​give the Gleason score. 

2. TNM rating
This system takes into account with the letter T the tumor size as well as the local extent, with the letter N the lymph node involvement and with the letter M the metastases, ie secondary tumors. Numbers after each letter more accurately indicate the size and extent (T1-4), the presence or absence of affected lymph nodes (N0 or N1), and the presence or absence of metastases (M0 or M1).

For example, T1 N0 M0 refers to a tumor that was detected at the time of diagnosis only in the punch biopsy or as a random finding in tissue shavings after surgical treatment of benign prostatic hypertrophy (BPH). T3 means that the tumor breaks through the prostate capsule. N1 stands for lymph node metastases, and the abbreviation M1b stands for bone metastases. An exact assessment of the T-stage is possible only after the surgical removal of the tumor. In the pathologist’s report, a small “p” stands before the numbers for “pathologically secured”. Prostate Cancer Signs Symptoms & Carcinoma Tumor Treatment | Does Prostate Cancer Spread?

Prostate cancer: Causes and Risk Factors

Older

With age, the risk of contracting prostate cancer increases. Over 80 percent of all men diagnosed with prostate cancer are over 60 years old.

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Physicians estimate that about 60 percent of all 60-year-old men have prostate cancer due to studies on the deceased. In the vast majority of cases, however, these are very small and non-malignant early forms of prostate cancer, which need not be treated.

Genetic predisposition

It is estimated that the proportion of genetic prostate cancer is between five and ten percent. It has been known for some time that men whose fathers or brothers are affected by prostate cancer are twice as likely to be affected by it themselves, compared to the rest of the male population. At the same time, the probability of being affected earlier by prostate cancer increases.

Anyone who believes that he is hereditary may turn to specific human genetic counseling centers. There, it is determined how high the probability of contracting prostate cancer. It should be noted that prostate cancer can be inherited both by the father and by the mother. For this reason, people seeking advice should look at the families of both parents to see if their brothers or fathers have prostate cancer.

Nutrition, smoking

Whether the diet – especially a very high-fat and high-calorie diet – plays a role in the development of prostate cancer is not clear. It is known, however, that overweight increases the risk of many cancers.

The connection between smoking and increased occurrence of prostate cancer is confirmed.

Prostate cancer: Therapy

The treatment depends on how malignant and how extensive the tumor is.

Locally limited prostate cancer

In early stages (T1 and T2), when the cancer is still confined to the prostate and has not metastasized (metastasis), healing is possible through complete removal of the tumor during surgery. Alternatively, radiotherapy is an option . It too can lead to healing.

In older patients with small, non-malignant tumors, it may also be easy to see if the tumor grows at all and only then to start treatment. However, this procedure called “active monitoring” requires the regular determination of the PSA , regular palpation and ultrasound examinations of the prostate gland and, if necessary, the renewed removal of tissue samples. If very old or ill men no longer require surgery or radiotherapy, they can be treated with palliative medication. A cure is not possible in this way. 

As the newest treatment option, the so-called focal therapy of small tumors is offered at a few centers, which are then selectively switched off while preserving the entire organ.

Advanced prostate cancer

For example, if the tumor has spread across the prostate into the rectum or seminal vesicles (T3 and T4) and yet does not form secondary tumors in lymph nodes or other organs (N0, M0), either surgery or a combination of radiation and hormone therapy lead to healing. With surgery, however, the survival rates of these locally advanced tumors are better. Elderly and ill men, who do not want to undergo surgery or radiation, can either wait under medical supervision to see how the tumor develops or can be treated with medication. A cure is not possible in this way. Prostate Cancer Signs Symptoms & Carcinoma Tumor Treatment | Does Prostate Cancer Spread?

Tumor with metastases

If the tumor has already formed secondary tumors in lymph nodes or other organs, only therapy with antihormonal drugs or removal of the testes (orchiektonime) can be considered. This is followed by chemotherapy after about four months.

Therapy methods of Prostate Cancer

Man is sitting on sofa

surgery

If the carcinoma is still confined to the prostate , it is usually attempted to completely remove it with surgery and increase the chance of healing. In so-called prostatectomy , the seminal vesicles and, depending on the risk, the lymph nodes of the pelvis are removed in addition to the prostate itself. The latter happens because these lymph nodes are the most likely station for metastases. After removal of the prostate, the urethra is re-attached to the bladder, allowing bladder emptying to proceed in the normal way.

An alternative to open surgery is endoscopic surgery or keyhole surgery through several small incisions. These days, as a rule, a surgical robot is used, via which the instruments pushed into the cymbal can be operated from a control console.

Unwanted consequences of radical prostatectomy can not always be avoided despite all care: The most common are the loss of erectile function (impotence) and unwanted urination ( urinary incontinence ). Transient urinary incontinence is relatively common and usually lasts for a few weeks or months. Permanent incontinence occurs in about 1 to 10 percent of operated patients, depending on the center and surgeon (see also: aftercare and rehabilitation). 

Limitation or loss of erectile function(Impotence) occurs when prostatectomy violates the nerve cords responsible for the erection. They run right and left along the prostate and between the prostate and the rectum. Depending on how far a tumor has spread, the nerve bundles can be spared during the operation.

Prostatectomy is a very demanding operation. Here it is of utmost importance to choose a center or a surgeon with a lot of experience. It has been proven that the success of the operation depends strongly on the frequency with which it is performed at a center and by a specific surgeon. The center should perform at least 100, the surgeon concerned at least 50 “radical prostatectomies” per year. You should also inquire about the results of your surgeon; If he can not give you exact numbers, you should get a second opinion.

Man is sitting on sofa

Radiotherapy

In radiotherapy, high-energy radiation is localized to the tumor area. It is intended to kill the malignant cells by damaging their genetic material (DNA).

For small, prostate-restricted tumors, radiation may be an alternative to surgery. If the tumor is no longer confined to the prostate, but has spread to the bladder or pelvis , for example , radiation is given high priority – usually in combination with hormone therapy. In addition, radiation is often used to target bone metastases.

Often, the tumor region is irradiated externally ( external irradiation ). The total dose of radiation is divided into small single doses over several weeks. It can take several months for the PSA to drop significantly.

Under certain conditions, alternatively, tiny radioactive metal rods can be introduced into the prostate, so that the irradiation takes place from the inside ( brachytherapy ).

Although the neighboring organs are largely spared by modern radiation techniques, complaints such as inflammation of the bladder or the intestine can occur. As a result of radiation therapy, half or more of the patients may experience impotence. Urinary incontinence is rare after radiotherapy. It has also been observed that after exposure to radiation, the risk of colon cancer increases. Therefore, affected patients should take the offered pre and post care examinations very conscientiously.

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Focal radiation therapy

This is a new therapeutic approach, which is usually offered at centers. Under certain conditions, small, limited and not particularly malignant tumors are eliminated on an outpatient basis while preserving the entire organ. Laser, ultrasound and refrigeration processes are used. Potency and continence remain mostly undisturbed, however, the permanent freedom from tumors in the context of ongoing studies must still be demonstrated.

Hormone Treatment

Hormone treatment, along with radiation, may be considered as part of a healing approach to locally advanced prostate cancer. It can either take place before the irradiation (neoadjuvant), with the aim of reducing the size of the tumor. Or it follows the irradiation (adjuvant) to prevent any residual tumor from growing. If prostate cancer has metastasized, hormone therapy followed by chemotherapy is the drug of choice. Palliatively, hormone therapy may also be used in patients with prostate-limited tumors, if surgery or radiation is not possible, for example, for health reasons.

The aim of the treatment is to inhibit the production and effects of the male sex hormone testosterone. Because testosterone maintains the growth of much of the cells of prostate cancer. The antihormonal therapy inhibits growth – but only as long as the medication is taken.

Three methods of hormone treatment are used:

1. suppress testosterone formation

Either the testes – where testosterone is formed – are surgically removed – which is very rarely practiced. Or affected men take medications that inhibit testosterone formation in the testicles. Several chemical substances are used, including the LHRH analogues or GnRH agonists on the one hand and the GnRH antagonists on the other hand. LHRH analogs and GnRH antagonists work for one to six months after ingestion. Hot flashes and sweats are possible side effects of the resulting hormone change, but can be controlled with drugs. In addition, there is a decrease in sexual drive and impotence. The risk of cardiovascular disease and diabetes may also increase.

2. Prevent testosterone effect

Another class of drugs, the anti-androgens, prevent testosterone from coupling to the tumor cell and exerting its effect. Anti-androgens may be used in some circumstances in addition to LHRH analogs. Thus, the tumor is completely shielded from growth-stimulating hormones, which are still present in small amounts despite the analogue therapy. Anti-androgens are also used as a complete alternative to LHRH analogues because their side effects are lower. The use of anti-androgens can cause gastrointestinal disorders and liver function. Frequently, the mammary glands also swell painfully. Possible, but not the rule, is a reduction in sexual pleasure and potency.

3. Blockage by female hormones

Female sex hormones (estrogens), administered in high doses, can also block testosterone production in the testes. However, significant side effects are observed, including the cardiovascular system and blood clotting. This therapy variant is therefore no longer used as a priority.

Chemotherapy

For example, chemotherapy is combined with hormone therapy in the presence of secondary tumors. In doing so, the doctors use medicines which prevent the cells of the tumor from dividing and thus multiplying, causing them to die and thus preventing the growth of the tumor. These drugs are called cytostatic drugs. However, they do not only affect the tumor but all rapidly renewing tissues in the body. Typical side effects of many cytotoxic drugs include transient blood cell disorders or hair loss, as well as nausea and vomiting . Prostate cancers respond to cytostatic drugs – but not as sensitive as some other cancers. The treatment does not bring any definitive cure, but may delay the course of the disease.

Pain Management

As the disease progresses, the pain experienced is often the main problem for the affected men. Pain relief may also be chemo or radiotherapy, but the focus is on the treatment with painkillers.

For painful bone metastases, targeted radiation can bring relief. As a result, the damaged, fracture-prone bones can be strengthened again at the same time. Even with the administration of high-dose estrogens or certain radioactive substances that accumulate in diseased bone and irradiate it from the inside, can be achieved regressions of the bone tumors and thus a pain relief (radionuclide therapy).

Prostate cancer: aftercare and rehabilitation

Aftercare has the following functions:

  • recognize in time when the disease recurs to initiate new treatments. Medical follow-up visits take place every three months during the first two years. In the case of new bone pain or “rheumatic” complaints, experts strongly advise you to consult the attending physician immediately. After all, prostate cancer often forms secondary tumors in the skeleton that can cause such symptoms.
  • Find, treat and relieve complications, side effects of the therapy and comorbidities.
  • To help the patient, as part of a follow-up care to get psychological and social problems under control. This can already begin in the clinic, where doctors, social services or psychologists give advice. In addition, counseling centers and support groups provide information and opportunities for contact with other patients.

After hospitalization, follow-up treatment or treatment is often recommended to speed recovery. In special follow-up hospitals, the situation of those affected is discussed. There, they also get advice on how best to deal with the potential consequences of cancer treatment, such as urinary incontinence or impotence.

urinary incontinence

Urinary incontinence is the inability to hold the urine. This disorder is usually temporary, but in rare cases permanent. The cause is the failure of the shutter mechanism at the bladder outlet. Most under physical stress, coughing, sneezing or pressing, small amounts of urine leak uncontrollably. 

Absorbent inserts can catch the urine. Often, the disorder can be resolved by a consistent pelvic floor exercise. In chronic incontinence, various surgical procedures can bring improvement, such as the implantation of an artificial sphincter.

Limited Sexuality

The good news: The production of male sex hormones is not affected by surgery. This means: pleasure and orgasm abilities are maintained. However, erectile dysfunction can occur. Temporal-related disorders can be the result of injury, permanent problems resulting from the removal of nerves during surgical procedures. Sometimes, however, psychological problems are behind it. 

If sexual activity is limited, it is distressing for many. Support from the sexual partner, especially through open, understanding conversations, can be of great help here. “Prostate Cancer Signs Symptoms & Carcinoma Tumor Treatment | Does Prostate Cancer Spread?”

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