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Prostate Cancer

The prostate is a small walnut shaped well defined gland located below the bladder and next to the rectum. It is a part of the male reproductive system. It is located directly below the bladder and surrounds the urethra. The prostate produces the seminal fluid, which transports semen during ejaculation.

Incidence of prostate cancer

Prostate cancer is the most commonly diagnosed cancer in men over the age of 65, but it can also be found in younger men. It is estimated that one out of every six men will be diagnosed with prostate cancer during his lifetime. Over the past two decades, the incidence of prostate cancer has increased rapidly and is now the most frequent cancer amongst men in Western Europe. It is unclear why this is the case, but it could be due to improved screening for the disease. This is an advantage not only when it comes to early intervention, choice of treatment and long-term survival. But also, if the tumor grows beyond the gland, new methods of diagnosis and therapy may increase the chances of cure.

Causes of prostate cancer

Prostate cancer occurs when cells in the prostate grow out of control. These multiplying cells may form a tumor within the gland or may spread to other parts of the body (metastasize). Prostate cancer usually takes years to develop before being large enough to detect.

Preventive Check-Up

Early detection of prostate cancer is the key factor in initiating proper treatment that will result in cure of the disease. As long as the cancer is limited to the prostate gland, there is a good chance of eliminating it. Once it passes the border of the gland, it becomes more difficult to treat.

Generally, it is recommended that men of a specified age should receive regular cancer prevention check-ups from a urologist. In the UK and in Spain, it is recommended that men 50 years or older may undergo annual screening should there be no positive history of prostate cancer. In France and Germany, annual check-ups are recommended beginning with the age of 45.

For screening recommendations in your specific country, please contact your physician.

Diagnosis

In general, various diagnostic tools are used in combination to achieve high diagnostic reliability:

Prostate Specific Antigen (PSA)
PSA is a protein that is produced by the prostate. Its concentration in human blood is measured by the PSA test. While men normally have a relatively low level of PSA in their blood, an elevated PSA level indicates an abnormal situation in the prostate, but does not automatically mean that prostate cancer is present. It also may be the result of benign enlargement or other conditions. However, if the PSA level is elevated, further clinical evaluation should be performed.

Digital Rectal Examination (DRE)
When performing a DRE a urologist examines the prostate by inserting a lubricated and gloved finger inside the rectum and palpates the prostate through the rectal wall. Due to the close proximity of the rectum to the prostate, abnormalities of the gland can be felt. A DRE is very useful in detecting prostate cancer, but only if the tumor has a palpable size and location. Otherwise false negatives can be recorded. It is therefore recommended to conduct this examination in combination with a PSA test.

Transrectal Ultrasound (TRUS)
The prostate can be visualized on an ultrasound screen using a transrectal ultrasound probe inserted into the rectum. In this way, the physician obtains a precise picture of the gland. The image can then be examined.

Biopsy and Gleason Score
Small samples of prostate tissue are removed in biopsy form with a special needle. The tissue is examined microscopically and the result graded according to the Gleason pattern (ranging from 2 to 10). The score is a measure of the histologic difference between cancer cells and normal cells and describes how aggressive the tumor cells are. Biopsy is the only definitive confirmation of prostate cancer.

Treatment Options

Treatment Option 1: Permanent Brachytherapy – Seed Implantation
Prostate seed implantation is an effective and well-tolerated method to cure prostate cancer. Its cure rates are comparable to the ones of EBRT and prostatectomy for early stage prostate cancer.

In this treatment, small radioactive Iodine-125 sources (seeds) are placed inside the prostate. Each seed has a length of 4.5 mm and a diameter of 0.8 mm and emits a specific low dose of radiation to its surrounding tissue inside the prostate. By placing the seeds homogeneously throughout the organ, the prostate is covered with the designated dose required to destroy the cancerous cells. Since irradiation is mainly localized around the radioactive source, neighboring tissues are spared.

The seed implantation procedure is as follows:

  • The patient is anaesthetised and an ultrasound probe is inserted into the rectum.
  • A treatment planning system calculates the number of seeds as well as their exact location based on the ultrasound prostate image. It guarantees an optimal dose distribution, with minimal exposure of surrounding tissue and organs at risk to radiation.
  • The physician inserts the implantation needles into the prostate and implants the seeds. The optimal placement is continuously monitored by ultrasound and fluoroscopy. The complete procedure takes approximately 50 – 70 minutes.
  • After the treatment is completed, the patient may leave the clinic on the same day and resume his normal activities a few days later.
  • As Iodine-125 has a short half-life, the seeds emit radiation only for a certain period of time. Since the rate of emitted energy is low, there is limited risk of irradiation outside of the body.

Please also see our corresponding seed implantation films:

Seed Implantation Film (English)

Compared to other treatment methods, prostate seed implantation may offer the following advantages:

  • Quicker physical recovery after the medical intervention, including mobility the day after implantation and fast return to daily activities
  • Shorter hospital stay (often performed as outpatient treatment)
  • Minimal treatment time (only one session)
  • Better preservation of urinary continence, erectile and rectal function in comparison to other treatment options, resulting in enhanced quality of life

Treatment Option 2: Active Surveillance
Since prostate cancer often grows at a slow pace, physicians may not necessarily offer immediate treatment, instead the cancer is monitored at regular intervals. This treatment form may be preferable for low risk tumor patients as well as for elderly patients with relatively feeble health, in order to avoid surgical or hormonal treatment. If there are any changes in tumor characteristics, the physician is able to react instantly.

Treatment Option 3: Radical Prostatectomy
The prostate gland, the seminal vesicles and the organ-specific lymph nodes are surgically removed (open, laparoscopic or robotic-assisted). Radical prostatectomy can be performed on low, intermediate and high risk prostate cancer and is an inpatient treatment.

Treatment Option 4: Hormone Therapy
This non-surgical treatment method involves decelerating the growth of the prostate cancer by depriving the body of testosterone (the male sex hormone). It is not a curative procedure and is sometimes combined with percutaneous radiation therapy or brachytherapy.

Treatment Option 5: Percutaneous Radiation Therapy
In radiation therapy, the cancer cells are exposed to high doses of radiation. Cancer cells are much more susceptible to radiation than healthy tissue. There are two main types of percutaneous radiation therapy available:

  1. During External Beam Radiation Therapy (EBRT) a so-called linear accelerator emits a high energy X-ray beam onto the targeted tumorous tissue. External beam radiation is delivered in daily fractions five days a week for approximately six to seven weeks which requires frequent visits to the hospital.
  2. During Proton Beam Therapy accelerated protons enter the body and deposit the prescribed dose inside the tumor. This treatment method requires more than 20 fractions.

Treatment Option 6: HDR Brachytherapy
For prostate cancer that is diagnosed before it has spread outside the prostate gland, and the tumor stage is T1 or T2 HDR brachytherapy is becoming more and more the treatment of choice. It may be given as the only treatment (called HDR monotherapy) or it may be used in combination with external radiation therapy. HDR brachytherapy has been found to be highly effective to virtually all stages of localized prostate cancer.

The HDR brachytherapy procedure is performed under anesthesia in a specialized radiation suite. Depending on the size of the tumor, a series of long needles are placed into the prostate using a template.

The exact placements of the needles have been calculated using advanced specialized software. During the procedure, the physician may use a trans-rectal ultrasound probe to ensure accurate needle placement. Upon completion of each HDR treatment sessions, the needles are removed.

The most important advantages of HDR brachytherapy for prostate cancer are:

  • Short duration of the treatment (only one to two procedures).
  • Exact knowledge of radiation dose distribution before treatment is given.
  • High accuracy and precision of tumor-specific radiation dose delivery.
  • Optimal radiation dose uniformity across the tumor (absence of low dose regions/ “cold” spots).
  • Preservation of the structure and function of other (adjacent) organs.
  • Few side effects, both short-term and long-term, due to targeted therapy.
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