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Prostate cancer is a condition marked by the uncontrolled multiplication of anomalous cells within the prostate gland. This disease can progress slowly, showing no symptoms for years, or rapidly, leading to metastases. Symptoms usually manifest in the advanced stages and can resemble other conditions, such as prostatitis and benign prostatic hyperplasia. The primary risk factor for prostate cancer is age, specifically being over 50 years old. The widespread occurrence of prostate cancer after this age, coupled with the excellent chances of eradication in the early stages, highlights the importance of early diagnosis.
The DRE is a simple diagnostic procedure that checks the health of the prostate and identifies any alterations by touch. The doctor uses a gloved and lubricated finger to palpate the prostate and surrounding tissues through the wall of the rectum. The exam evaluates the size, firmness, and consistency of the prostate gland; any pain caused by contact or pressure on the prostate; and hard areas or nodules, which may suggest the presence of one or more tumors. However, tumors may cause alterations that are difficult to detect upon palpation, making the determination of the blood level of prostate specific antigen (PSA) a complementary test to the DRE.
PSA is an enzyme produced by the prostate gland that maintains the fluidity of sperm after ejaculation. It can be measured in the blood via a common blood test. Neoplastic cells produce high quantities of PSA, so determining PSA levels in the blood can increase the chances of detecting the presence of a tumor, even in the early stages. After treatment, the PSA test is often used to check for any signs of recurrence. However, the test is not accurate enough to exclude or confirm the presence of the disease. PSA levels can be increased by various factors, including benign prostatic hyperplasia, prostatitis, advanced age, and ejaculation within 48 hours of the test. A high PSA value signals a probable prostate anomaly, but it cannot alone be considered a sure indicator of prostate carcinoma.
If a clinical suspicion of prostate cancer emerges from the urological examination and PSA values, a transrectal prostate ultrasound may be requested. This test provides more precise data on the morphology of the prostate, but it cannot be considered a completely reliable diagnostic test. The definitive diagnosis comes from a prostate biopsy, the only tool currently validated for the diagnosis of cancer.
If symptoms and test results raise suspicion of cancer, a urologist may perform a prostate biopsy. This investigation can definitively determine the presence of tumor cells in the prostate tissue. The procedure, performed under local anesthesia, involves taking small samples from different areas of the prostate gland. The biopsy samples are analyzed under a microscope to look for any neoplastic cells and establish the grade of the tumor.
A positive result confirms the presence of prostate cancer. A pathologist assigns a Gleason score to the neoplastic cells found in the biopsy specimen, based on their microscopic appearance. The grade ranges from 2 to 10 and describes how likely the tumor is to metastasize. The lower the Gleason score, the less aggressive the cancer is and the less likely it is to spread. If the biopsy is negative, the presence of tumor cells cannot be 100% ruled out. Therefore, the patient will enter a surveillance phase with further periodic checks.
The staging of prostate cancer depends on the ability of the tumor to invade neighboring tissues, the tumor's ability to metastasize to lymph nodes or other parts of the body, the grade (Gleason score), and the PSA level. Doctors identify the stage of prostate cancer using the TNM (tumor, lymph node, and metastasis) system. This system allows three different risk classes to be attributed to the disease: low, intermediate, and high risk. Sometimes, a simpler numerical staging system is used.
The stages of prostate cancer are:
If prostate cancer is diagnosed at an early stage, the chances of survival are generally good. However, if prostate cancer is diagnosed when it has reached stage IV, the patient has a 30% chance of living for at least another five years.
Treatment for prostate cancer depends on individual circumstances, including the stage of the cancer, the Gleason score, the PSA level, the symptoms, the patient's age, and their general health conditions. For many cases of prostate cancer, treatment may not be necessary right away. The goal of therapy is to cure or control the tumor, so as not to reduce the patient's life expectancy.
Active surveillance involves a period of observation, which aims to avoid unnecessary treatment of harmless tumors, while still providing timely intervention for men who need it. Active surveillance involves regular follow-up tests to monitor the progression of prostate cancer: blood tests, rectal exams, and biopsies. When evidence shows that the disease is progressing, treatment, such as surgery or radiotherapy, may be opted for.
Radical prostatectomy involves the surgical removal of the prostate gland, some surrounding tissues, and some lymph nodes. This treatment is an option for the treatment of localized prostate cancer and locally advanced carcinoma. The procedure can be performed by robotic laparoscopic surgery, retropubic surgery, perineal surgery, or laparoscopic prostatectomy.
Radical prostatectomy, like any operation, carries some risks and side effects, including urinary incontinence and erectile dysfunction. In extremely rare cases, post-operative problems can lead to patient death.
Radiotherapy involves the use of radiation to kill cancer cells. The radiation source can be external or inserted directly into the prostate. In the latter case, we are talking about brachytherapy, an intervention indicated primarily in patients in a low or intermediate risk class. Side effects of radiation therapy may include tiredness, painful and frequent urination, urinary incontinence, erectile dysfunction, diarrhea, and pain during defecation.
Hormone therapy is often used in combination with radiation therapy, to increase the chances of successful treatment or to reduce the risk of recurrence. Furthermore, it can be used in men with advanced prostate cancer to relieve symptoms, reduce tumor mass, and slow the proliferation of neoplastic cells.
Other treatment options include orchiectomy (surgical removal of the testicles), cryotherapy (freezing prostate tissue to kill cancer cells), high intensity focused ultrasound (HIFU), and chemotherapy. The choice of treatment depends on the stage of the cancer, the patient's general health, and the potential benefits and side effects of each treatment.