Prostate cancer

Treatment of prostate cancer significantly differs from the clinical approach to all other malignant neoplasms. A rather favorable course of the disease in the majority of very elderly men does not manifest itself in characteristic symptoms against the background of many chronic conditions, it is revealed almost inadvertently, not interfering with life and not threatening with death.

The most reliable cancer diagnostics

The presence of a malignant prostate tumor is signaled by an increase in the marker called prostate-specific antigen or PSA. The recent keenness on total coverage of the male population of all ages with regular PSA level analyses resulted in a clinical frustration. Every sixth person with a normal level of antigen not exceeding 4 ng/ml shows up malignant cells during a biopsy, but when the glandular tissue cells undergo malignization, the marker increase is by no means guaranteed.

The marker concentration in blood increases not only with the tumor, but also after a usual digital examination of the prostate, its inflammatory conditions and local vascular catastrophes (prostate infarction).

Today, diagnostics requires repeated study of PSA and its forms, as well as a digital examination of the organ and an obligatory transrectal biopsy of the suspicious area (TRUS). Only a histological examination of the tissue specimen allows diagnosis of prostate cancer.

What is meant by observation?

In some situations, observation without treatment is suggested with a small malignant tumor until clear signs of progression appear.

Observation involves abandonment of therapy with regular and serious examination, from repeated blood sampling for PSA to an annual biopsy. In this case, biopsy is necessary to establish the dynamic life characteristice of the cancer node, when the activity of the pathological process is determined by the change in the cells. Cancer aggressiveness is expressed by Gleason score, where a higher number means a more active oncological process.

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In what cases observation is possible without treatment?

Observation is recommended for very elderly men, whose life is already complicated by a variety of ailments that do not promise a long life, at least a decade. Another reason is when the existing prostate tumor is not only manifested by scanty manifestations due to its minimal size, but also has a low potential for aggressiveness. Every third to fourth patient who has celebrates the 75th birthday has very little chance of dying from prostate cancer or even experiencing its significant clinical symptoms.

As a rule, in men of young and mature age the expectant tactic is not applied due to the more aggressive course of the malignant process.

Formally, such an approach is feasible with a stage 1 tumor in a man over 75 years old with a Gleason score less than 7 and PSA below 10 ng/ml. Individual options are possible, the essence being that prostate cancer sort of exists in parallel without interfering with a man’s life and not making him really ill.

Advantages and disadvantages of observation without therapy

What does the patient get from expectant tactics, other than regular visits for examination?

  • First, it is the preservation of the existing quality of life, because any cancer treatment, even a very effective one, does not pass without any trace and is always fraught with complications that limit the patient’s physical capabilities.
  • Second, in the process of observing the neoplasm life, the cancer growth rate is found out for certain, making it possible to avoid unnecessary and excessive therapy at low rates of progression.
  • Third, it saves money.

But the patient who does not get a therapy, even if temporarily, does not become calmer, for the cancer progression cannot be stopped without treatment, and this causes mental discomfort.

There is no guarantee that further treatment will not be required, and it will be more complicated and serious than it would have been at the first detection of the disease. Surgical elimination of malignant tissue with nerve saving (to maintain sexual activity) may already be technically impossible due to the increase in lesion scope.

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When is the operation necessary?

To carry out surgery at the first stage, the man’s desire to undergo treatment and recover is quite enough. Each more or less healthy man with a tumor process localized only in the gland itself and without metastases to other organs has the right to undergo an operation called radical prostatectomy (RPE). Cancer release beyond the organ can be an obstacle to surgical intervention.

What types of surgery are possible with prostate cancer?

Currently, nerve-saving surgery is widely used that allows to preserve existing sexual activity, if the erectile function was not lost earlier for some reason, such as ischemic heart disease and vascular atherosclerosis.
Laparoscopic or robotic RPEs allow earlier restoration of the patient’s activity, but the procedure of the operation itself is more difficult for the surgeon and takes longer than the traditional prostatectomy.

A RPE with perineal incision also entails minimal trauma and minor blood loss with undoubtedly greater opportunities for the operating surgeon. The patient’s recovery with perineal access to the affected organ is quite quick.

A typical approach with tissue incision behind the pubic allows surgery of tumors that are large in size and have metastases in the lymphatic nodes of the small pelvis adipose tissue, though it is associated with a slightly higher percentage of unavoidable complications due to the scope of intervention with a sufficiently large cancer lesion.

When is it possible to abstain from prostate cancer surgery?

Surgical and radiation therapy of prostate cancer respond with similar results in relapse rates and life expectancy, which gives reasons to consider both methods quite radical.

As a rule, irradiation is offered when it is technically difficult to remove a large tumor conglomerate, or if it has spread outside the glandular tissue. Radiation therapy is also possible with a significantly greater degree of the process aggressiveness.

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Features of the surgery and radiation therapy consequences

There are certain difficulties in the follow-up, while after surgical removal of prostate cancer it is less burdensome and the interpretation of analyzes is simple. Irradiation does not allow destruction of all prostate tissue that produces PSA, which significantly complicates a practical assessment of the achieved result and interpretation of examination data at further observation.

The difference is also observed in the consequences of treatment, as after irradiation, the complications will become more pronounced over time, while after surgery, the complications are most pronounced initially and gradually decrease, and man will sooner or later learn to coexist with the inevitable chronic consequences.

Drug therapy of cancer prostate

As the main drug therapy for advanced and metastatic prostate cancer, hormonal drugs are used, or rather, anti-hormonal ones that block production of own testosterone or its access to tumor cells. Testosterone and other androgens are used by malignant cells for their own reproduction and growth.

The level of testosterone can be drastically and irrevocably reduced only by removal of the testicles called bilateral orchectomy, and temporarily stopped by introduction of a special substance, which is called chemical castration. The drug representing an analogue of the natural gonadotropin-releasing hormone suppresses the production of androgens only for the duration of treatment, and long-lasting forms intended for many months of action are already widely available.

The third method of hormonal effect is regular intake of antiandrogens that block testosterone from entering the affected cell. Several drugs of equal efficacy and diverse toxicity have been developed. Even with a good therapeutic result, adverse reactions are inevitable, but their severity and spectrum are very individual.

In the absence of a positive tumor reaction to hormone drugs, chemotherapy is applied, though its possibilities are not so good.

Specialists of the clinic masterly apply all known methods of prostate cancer treatment. They will select the best method at any stage, and suggest a program to minimize adverse effects and speed up recovery.

This text is based on the materials of NCCN (National Cancer Comprehensive Network).

Reference list:

  1. Fadeev Andrey Vasilyevich Prostate cancer: etiology, diagnostics, treatment (In Russian). // Bulletin of Russian Scientific Center of Roentgen-Radiology. 2009. No. 9.
  2. Borshch v. Yu., Varenpov G.I., Zakhmatov Yu. M. et al. Transurethral resection for prostate cancer (In Russian) // Materials of the Plenum of the Board of the Russian Society of Urology. Мoscow, 1999, pp. 212–214.
  3. Bukharkin B.v. , Podregulskiy К. E. Prostate cancer (In Russian) // Journal of Clinical Oncology, 1999, Vol. 1, No. 1, pp. 10–13.
  4. Goldobenko G.v. Radiation therapy for patients with prostate cancer (In Russian).
  5. Kushlinskiy N.Е., Solovyev Yu. N., Trapeznikova М. F. Prostate cancer (In Russian) // RAMS Publ., 2002.
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