Prostate gland is a small walnut-shaped gland in men only that produces seminal fluid which nourishes and transports sperm. Diseases of the prostate are usually of the older people for example benign prostatic hyperplasia or prostatic cancer. Prostate cancer is one of the most common malignancies of men in the world whose incidence gradually increases with age. As per GLOBOCON 2018 data, it comprised 7.1% of new cancer cases detected worldwide. And it accounted for 3.8% of all cancer related deaths.
Risks of prostate cancer
Like any other malignancy the etiology is multifactorial with host, environment and genetic factors all playing a role. However, the most important risk factor is increasing age. Most diagnoses occur in men who are 60 or older. Black race is more prone to develop prostate cancer as compared to white race. There is also a genetic predisposition for prostate cancer as well as if there is presence of the BRCA1 and 2 gene in the family history.
Since the prostate gland is present very closely with the urinary tract most of the symptoms are related to micturition. The patient may present with trouble in urination (difficulty or pain), decreased force in the stream of urine, increased need to urinate (particularly at night), blood in urine or semen, discomfort in the pelvic area and erectile dysfunction.
Since cancer cells are known to spread (metastasize), sometimes a patient with prostate cancer presents with bone pain most commonly pain in the spinal area or hip area. Sometimes prostate enlargement may be found incidentally during per rectal examination and the patient may be completely asymptomatic. If an individual has the above-mentioned risk factors or symptoms, they should review with a urologist immediately.
Early screening for prostate cancer
Cancer screening means searching for cancer before it causes any symptoms. The goal of screening for prostate cancer is to find cancers that may be at high risk for spreading if not treated. Consecutively, to find them early before they spread. Since it is a common malignancy for aged males, screening is an important part. A few countries have adopted routine screening programs for prostate cancer. However, it is controversial.
Screening for prostate cancer is done by a blood test called Prostate Specific Antigen or PSA and a Digital Rectal Examination (DRE). Prostate-specific antigen (PSA) is a protein produced by both cancerous (malignant) and noncancerous (benign) prostate tissue. Prostate cancer cells usually make more PSA than do benign cells, causing PSA levels in your blood to rise. PSA levels can also be raised with certain medications finasteride (Propecia, Proscar) and dutasteride (Avodart) and infections like prostatitis or in benign conditions like Benign Prostatic Hypertrophy (BPH).
Prostate cancer screening
The advantages of screening are for all to see; however, the downside is that sometimes it may lead to overdiagnosis and overtreatment. Since some prostate cancers are slow growing, may never extend beyond the prostate, nor become symptomatic and may not even warrant any treatment.
The American Cancer Society (ACS) recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer or not. Take this decision after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening.
- Age 50 for men who are at average risk of prostate cancer and have 10 more years of life-expectancy.
- Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father or brother) diagnosed with prostate cancer at an early age (younger than age 65).
- Age 40 for men at even higher risk (those with more than one first-degree relative who had prostate cancer at an early age).
In 2017, the USPSTF issued an updated statement suggesting that men aged 55 – 69 years should know about the benefits and harms of PSA-based screening. As, this might be in link with a small survival benefit, leading to a grade C recommendation.
Prostate cancer in India
The Indian Council of Medical Research (ICMR) in their draft consensus released in 2022 stated that “As per the available evidence population-based screening cannot be recommended in the Indian population in any age group”. This is based on the fact that there has been no improvement in prostate cancer specific survival. And furthermore, overall survival by routine population-based screening as per a Cochrane Meta-analysis.
Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue. Therefore, men who have a life expectancy less than 10 to 15 years should know that screening for prostate cancer is unlikely to be beneficial.
Ultimately, whether to have prostate cancer screening or not is something you should decide after discussing it with your doctor. Here, consider your risk factors and weigh your personal preferences.
Prostate cancer biopsy
Once there is suspicion the patient undergoes certain tests like Ultrasonography, Magnetic Resonance Imaging (MRI) followed by collecting a sample of cells from the prostate by doing a prostatic biopsy. When a biopsy confirms the presence of cancer, the next step is to determine the level of aggressiveness (grade) of the cancer cells. The most common scale that evaluate the grade of prostate cancer cells is namely a Gleason score. A score of 6 indicates a low-grade prostate cancer. A score of 7 indicates a medium-grade prostate cancer. Scores from 8 to 10 indicate high-grade cancers. Genomic testing analyses your prostate cancer cells to determine which gene mutations are present.
Once diagnosed, the Stage and Risk Stratification of the disease, determines the treatment. Treatment options include active surveillance, waitful watching, surgery, radiotherapy, hormonal therapy, chemotherapy and immunotherapy.
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