Prostate Cancer

Prostate cancer can be viewed as unusual compared to other cancers, being that in many cases it doesn’t spread to other parts of the body. It grows very slowly and may not cause a patient problems for years. Proper management of prostate cancer can lead to good health and quality of life for several years. In the U.S., about 1 in 8 men will develop prostate cancer at some point in their lives.

Types & Stages

Almost all prostate cancers are adenocarcinomas. These cancers develop from the gland cells in the prostate (the cells that make the prostate fluid that is added to the semen). The main subtypes of adenocarcinoma of the prostate are: 

• Acinar adenocarcinoma (conventional adenocarcinoma), which accounts for virtually all prostatic adenocarcinomas. Acini cells line the prostate’s fluid-secreting glands. The cancer starts growing in the back (periphery) of the prostate near the rectum and may be felt during a doctor’s digital rectal exam. The disease increases PSA levels.
   
• Prostatic ductal adenocarcinoma (PDA) is a rarer but more aggressive form of adenocarcinoma. It develops in the cells lining the tubes and ducts of the prostate gland. When it occurs, it frequently develops along with acinar adenocarcinoma. This cancer type doesn’t necessarily increase PSA levels, making it harder to detect.

There are other prostate cancers, but they’re incredibly rare given the overwhelming diagnoses of prostatic adenocarcinomas. Some of these include:

• Transitional cell carcinoma or urothelial cancer, which may either start in the urethra or bladder and spread to the prostate or, very rarely, vice-versa.
   
• Neuroendocrine tumors or carcinoids, which don’t produce PSA, appearing in the nerve and gland cells that make and release hormones into the bloodstream.
   
• Small cell carcinoma, the most aggressive type of neuroendocrine cancer in the prostate that develops in small round cells of the neuroendocrine system.
   
• Squamous cell carcinoma, a very rare, fast-growing form of prostate cancer that starts in the flat cells that cover the prostate glands.
   
• Prostate sarcoma (also called soft-tissue prostate cancer), which develops outside the prostate glands in the soft tissue — the muscle and nerves — of the prostate.

Signs & Symptoms

Prostate cancer may not cause symptoms at first. Most prostate cancers are found at an early stage. This means that the cancer is only in the prostate. An early-stage prostate cancer often doesn't cause symptoms. But you may experience:

• Frequent urination
• Weak urine flow
• Blood in the urine
• Blood in the semen
• Needing to urinate more often
• Trouble getting started when trying to urinate
• Waking up to urinate more often at night

Visit a doctor if you are experiencing any of the above symptoms to determine the cause of the problem and a proper diagnosis. If you are a man aged 45 or over, be proactive about your health. For information about screening for prostate cancer or to make an appointment with a Stony Brook urologist, call (631) 444-4000.

Diagnosis

Prostate cancer is often detected during the course of a routine prostate exam and/or the PSA blood test, but diagnosing it may require other procedures.

• PSA blood test for prostate cancer. PSA—or prostate-specific antigen test—is a protein found in prostate cells that helps to keep semen liquified. Most cases of prostate cancer develop in these cells, so an elevated PSA count may be a sign of prostate cancer. However, PSA results are more of an indicator than a firm diagnostic tool. There’s not a certain PSA score that means a man has prostate cancer. Instead, there are various ranges that are considered average for different age groups. If the PSA score is elevated for your age, further testing may be recommended. 
  
  PSA levels are measured as ng/mL. According to the American Cancer Society:
  • Men with a PSA level between 4 and 10 have about a 25% chance of having prostate cancer.

  • Men with a PSA level higher than 10 have more than a 50% chance of having prostate cancer.

    Not all men with high PSA levels have prostate cancer. High levels may also be caused by a urinary tract infection, prostatitis or benign prostatic hyperplasia, all of which are noncancerous conditions. Conversely, men with a low PSA level may still develop prostate cancer. PSA tests are not an indication of how aggressive the prostate cancer may be. Many prostate cancers are slow-growing and don’t require immediate treatment.

• Digital rectal exam.  In addition to the PSA blood test, your doctor may perform a digital rectal examination (DRE). For this exam, your doctor inserts a gloved lubricated finger into the rectum to gently feel for any bumps or lumps on the prostate that could indicate cancer. The DRE isn’t typically painful and usually takes a few seconds.
   
• Prostate biopsy. Depending on the results of the PSA and DRE, the doctor may order a prostate biopsy. A biopsy may be performed through the wall of the rectum (known as a transrectal biopsy) or through the skin between the scrotum and anus (transperineal biopsy). Numerous tissue samples may be taken from different parts of the prostate. Samples are sent to a pathologist to examine under a microscope.
   
• Prostate ultrasound is an imaging test that uses sound waves to make pictures of the prostate. To get ultrasound pictures of the prostate, a healthcare professional puts a thin probe into the rectum. The probe uses sound waves to create a picture of the prostate gland. When an ultrasound is done this way, it's called a transrectal ultrasound.
   
• Prostate MRI, magnetic resonance imaging, uses a magnetic field and radio waves to make pictures of the prostate. 

Treatment

Treatment of prostate cancer will be determined by the stage and grade of cancer, and your overall health. It can include: 

• Active surveillance (monitoring) would be the approach for a small, non-aggressive tumor.
   
• Robotic prostatectomy, which is surgery to remove the entire prostate gland and seminal vesicle. At Stony Brook, we offer robotic-assisted minimally invasive surgery using the da Vinci® Surgical System for staging and treatment. It offers doctors increased depth perception, magnification and the ability to use different instruments than in laparoscopic minimally invasive surgery. There are also significant benefits over traditional surgery, including faster recovery, fewer wound complications and less postoperative pain.
   
• External-beam radiation therapy cures the disease by killing cancer cells. When a patient has this type of treatment, the radiation comes from a large machine and is aimed at the cancer. The machine moves around you without touching you.
   
• Brachytherapy (seed implants) is radiation therapy given from inside the body. An intracavitary implant is a cancer treatment in which your radiation oncologist places radioactive sources directly into the prostate using a specially designed applicator.
   
• Cryosurgery uses extreme cold to destroy the cancer cells in the prostate by freezing them.

Causes & Risk Factors

Factors that can increase the risk of prostate cancer include:

• Older age; it's most common after age 50.
   
• Race and ethnicity. In the U.S., Black people have a greater risk of prostate cancer than do people of other races and ethnicities. Healthcare professionals aren't exactly sure why. In Black people, prostate cancer also is more likely to grow quickly or be advanced when detected.
   
• Family history of prostate cancer. If a blood relative, such as a parent or sibling, has been diagnosed with prostate cancer, your risk may be increased. The risk also may be increased if other close relatives have had prostate cancer. This includes your grandparents and your parents' siblings.
   
• Family history of DNA changes. Some DNA changes that increase the risk of cancer are passed from parents to children. The DNA changes called BRCA1 and BRCA2 can cause a higher risk of prostate cancer. 
   
• Obesity. In people with obesity, prostate cancer is more likely to grow quickly and more likely to come back after treatment.
   
• Smoking. People with prostate cancer who smoke may have a higher risk of the cancer coming back and also have a higher risk of the cancer spreading beyond the prostate.

Screening

Prostate cancer screening tests look for prostate cancer in people who don't have any symptoms of the disease. Tests typically include a prostate-specific antigen (PSA) blood test and a digital rectal exam. Most experts recommend talking with your doctor about prostate cancer screening around age 50.

Stony Brook Medicine’s Department of Urology and Stony Brook Cancer Center, in accordance with the National Comprehensive Cancer Network guidelines, recommend screenings for:

• Men 45-75 years of age who are at average risk of developing prostate cancer.
• Men 40-75 years of age who are at high risk of developing prostate cancer.

Participants must meet our guidelines in order to be eligible.