1. PSA Testing – Prostate Cancer Information
Prostate Specific Antigens (PSA) tests are used in conjunction with DRE (digital rectal examinations) to evaluate your prostate for any abnormalities. The PSA result is age-specific. Consult your urologist for its correct interpretation.
Essentials of PSA
Your doctor often uses a PSA test to screen for prostate cancer. An elevated PSA by itself does not always mean that cancer is present. It simply alerts your doctor to evaluate your prostate.
There are other medical conditions that can cause your PSA level to increase. These conditions include an enlarged prostate (Benign Prostatic Hyperplasia, or BPH), and inflamed prostate (prostatitis), or a urinary tract infection.
A PSA test should always be combined with DRE to assess prostate health.
In the blood stream, PSA can be either free-floating or attached to other proteins. Men with cancer often have lower levels of free PSA than do those whose elevated PSa has other causes. Free PSA tests have been available for several years and can potentially be used to pinpoint patients who may be harboring cancer.
The introduction of total and free PSA has been extremely helpful. The lower the percent free PSA, the greater the likelihood of prostate cancer. Evaluating the free PSA level is extremely beneficial in men with serum PSA concentrations between 4 and 10 ng/mL, in that 29% of negative biopsies would be spared while retaining a 95% sensitivity.
In younger men with PSA between 2 and 4 ng/mL, a much more aggressive appproach is taken in terms of getting an early biopsy. In older patients, 4 ng/MLis recoginized as cutoff.
PSA velocity, which measures the rate of rise compared to the previous PSA level, is also taken as an indicator for further diagnostic testing.
If your PSA level is high what should be done next?
Your doctor may repeat the test or perform additional tests to see if there is any reason to suspect cancer of the prostate.
2. Risk factors for prostate cancer:
A man’s risk for prostate cancer is as follows:
Increasing age (50 years and above)
History of prostate cancer in the family
A diet consistently high in fat
Men at high risk for developing prostate cancer should begin screening at age 40.
3. Signs and symptorms for prostate cancer:
Most early prostate cancer causes no symptoms and may be detected by abnormalities in the PSA and DRE evaluations. However, you need to know that the signs and symptoms of prostate cancer may include:
Weakening or slowing of your urinary stream
Pain in the pelvis, hips, spine, or ribs
These signs and symptoms may also be present in other condition such as BPH, so it is important to evaluated your prostate with a PSA test and/or DRE and consider other risk factors mentioned above, such as age, race, and family history.
4. Treatment options for Prostate Cancer patiens
Determining which treatment option is best for you is dependent on your prostate cancer profile. Your prostate profile is based on the following factors:
-Age and expected actuarial survival
-Medical condition and risk factors
-Presence of significant illnesses, such as myocardial infarction, strokes, diabetes, etc.
-Presence of metastasis
-Status of DRE (rectal exam)
Depending on your prostate profile, the following treatment options will be offered to you:
If your prostate cancer profile is overwhelmingly positive and you have 7-10 years of expected healthy lifestyle, surgery will be recommended. The most common types of prostate surgery include:
Radical Robotic Prostatectomy:
With the advent of the da Vinci™ robot, Tulane University Health Science Center was among the first in the United States to acquire this advanced therapeutic option for management of prostate cancer. This technical innovation provides the surgeon with 3-D high definition viewing capabilities which enhances the surgical procedure so as to maintain quality of life issues which are of major concern to patients for management of their prostate cancer.
Besides drastically decreasing pain and blood loss, the robotic prostatectomy greatly enhances the technical aspects of the procedure because the surgeon has the option of up to 10x magnification which greatly facilitates the nerve-sparing option which is now preferred in most patients who have early diagnosis of prostate cancer.
The surgeons on the Tulane Urology robotic team not only provide this state-of-the-art option here in New Orleans but also have traveled extensively teaching this new art of surgery in several states around the country.
In addition, Tulane Urology is the only approved fellowship training site in the entire Gulf South.
Brief Description of the Procedure
After pre-operative discussion and adequate consent, the patient is given general anesthesia.
Laparoscopic trocars or ports are inserted into the abdomen to introduce a 3-D camera and the robotic working instruments. Additional trocars help the bedside surgeon to insert instruments, suture material, drains, etc.
The magnification, as mentioned above, greatly improves the vision of the surgeon and thus the surgical procedure is more precise as compared to most open radical retropubic prostatectomy.
The robotic procedure usually takes slightly longer than the open surgical procedure. However, the increased time includes the robot set-up time, instrument turnover or change time, etc.
Most patients stay in the hospital overnight and are sent home after having a regular breakfast.
Pain management: most patients are managed postoperatively using anti-inflammatory agents such as ibuprofen (Advil™, Nuprin™).
As with all new technology, robotic surgery involves a significant learning curve. The importance of experience in robotic surgery is critical in procedures such as radical prostatectomy because the nerve-sparing approach is crucial to maintain quality of life as well as ensuring that the surgical margins are negative. This latter point is important as far as cancer control is concerned.
It is recommended that potential patients check with their urologist about his/her experience using the da Vinci™ robot for radical prostatectomy. We believe a well-informed consumer can make the right choices.
Click here to read an article published in USA Today in May 2007 about the importance of experience in performing robotic radical prostatectomy.
In summary, the advantages are:
– better visualization in 3-D
– less invasive
– less painful
– quicker recovery
– quicker return to normal activity.
Radical Open Retropubic Prostatectomy
In this procedure, the prostate, seminal vesicles and surrounding lymph nodes are removed through an incision made in the abdomen. This incision is made from the belly button downwards. Depending on your biopsy results and your overall prostate cancer profile, your urologist will discuss the possibility of performing a nerve-sparing radical prostatectomy. Such a procedure removes the prostate and lymph nodes but spares nearby nerves. If these nerves are spared, it lowers the risk of impotence (not being able to have an erection of the penis) after surgery.
Radical Perineal Prostatectomy
Tulane is among the most experienced clinics in the country in performance of radical perineal prostatectomy. This approach is through an incision made in the perineum (between the scrotum and the anus). Those urologists who are specially trained in this low-morbidity approach offer this procedure. Recovery is usually quicker and return to normal activity is easier using this approach.
However, the lymph nodes will need to be evaluated using a minimally invasive laparoscopic approach.
Prior to the introduction of the da Vinci™ robot, Tulane Urology performed laparoscopic prostatectomy for the management of prostate cancer. This option is still used at several medical centers around the world. Ask your urologist about best surgical treatment option for you. Very often if both your PSA and Gleason score are low, there is no need for a pelvic lymph node dissection. The advantage of surgery includes removal of the prostate gland, which can effectively be monitored by serial PSA exams in the future. Radical prostatectomy has been shown to offer the best surgical long-term effectiveness to control your prostate cancer.
The disadvantages of surgery (Prostatectomy) include:
bleeding, transfusion requirement in a small percentage of patients, urinary tract infection (A catheter drains your bladder for approximately two weeks), urinary incontinence, and impotency (it is now well known that the degree of impotency following radical prostatectomy depends on various factors). Under similar circumstances, the younger the patient, the higher the likelihood of preserving potency. Conversely, the older you are, the less likely it is that you will be able to maintain your potency in a satisfactory manner. Following prostate removal, you will have lack of ejaculation, since the prostate contributes significantly to your ejaculation, thus you will be sterile after the procedure. However, approximately 30-50% of patients will have erections satisfactory to perform sexual intercourse. Patients may also require the assistance of oral medications, such as Viagra™; injectables, such as Caverject™; a vacuum erection device (VED); or implantation of a penile prosthesis that can be inflated prior to sexual intercourse.
Potency preservation is possible with a nerve-sparing prostatectomy. However, not all patients are candidates for potency-sparing prostatectomy. It depends on your prostate cancer profile.
b. Radiation Therapy
This treatment option employs high-energy x-rays to destroy cancer cells. Such high-energy x-rays are delivered by the following methods:
External Beam Radiation Therapy
Directs high-energy x-rays from a machine outside the body onto the area affected by the cancer. Usually this involves a base-line evaluation to be followed by approximately six weeks of treatment. Treatments are given Monday through Friday and last a few minutes for each session. Since the x-ray beams have to travel through the skin onto the prostate (see figure), because of male anatomy, the x-ray beam very often has to travel through the bladder and the rectum. Side-effects include: radiation cystitis (inflammation of the bladder) and radiation proctitis (inflammation of the rectum). Most patients get relief from this within a few weeks after the radiation is completed.
Sometimes the radiation oncologist will suspend radiation if the side effects are significant and will resume it once these symptoms have subsided. Click here for location and contact information.
Also known as internal radiation therapy, this procedure involves small radioactive seeds placed directly into the prostate. Brachytherapy is performed under anesthesia and is a team effort between the urologist, the radiation oncologist, and the radiation physicist so as to provide safe application of this treatment. This procedure also involves mapping and evaluating the prostate in order to estimate the number of radioactive seeds needed for a given brachytherapy procedure.
Advantages of brachytherapy include fewer complications from treating adjacent organs, such as the bladder and the rectum. Long-term studies are pending to see the overall effectiveness of brachytherapy. However, short-term data is promising.
Your radiation oncologist can answer further questions on radiation therapy, including brachytherapy.
Radioactive iodine and palladium are used to deliver the energy into the prostate.
3-D Conformal Radiation Therapy
This is a newer type of radiation therapy which focuses high-energy x-ray beams very precisely, with less effect on normal surrounding organs.
c. Hormone Therapy
Most prostate cancers are hormone-dependent and use the male hormone testosterone to grow. Hormonal therapy works by lowering the amount of testosterone available in the body to act on the prostate and thus it slows the cancer growth. Hormonal therapy is given by medication, which decreases or blocks testosterone in the body or by removing the testicles (orchiectomy). Hormone therapy is usually given either to shrink the prostate or in cases where the cancer has spread beyond the confines of the prostate gland.
This procedure uses liquid nitrogen to freeze the prostate. The treatment is delivered through tiny incisions made in the perineum (Between the scrotum and the anus). Several small metallic tubes are inserted while you are under anesthesia, and liquid nitrogen is instilled into the prostate. This drops the temperature in the prostate to way below freezing. Usually the cycles are repeated, and this process is meant to kill the cancerous cells. The entire prostate is treated.
Who are candidates for Cryosurgery?
The ideal candidates are those who have failed radiation treatment (either external beam or brachytherapy). In certain cases, patients may choose this as a primary treatment, however one should carefully consider the side effects and complications of cryosurgery and whether your insurance policy will reimburse for this procedure. At many institutions and health care plans, this procedure is still considered investigational Once again, please consult your urologist and locate a center nearest you that performs cryosurgery to get all of the facts and details.
This treatment modality employs strong drugs to destroy cancerous cells in the body. It can be given in the vein (intravenously) or by mouth. Often a combination of several drugs may be given to make this treatment more effective. Chemotherapy is usually used in men with advanced prostate cancer who are no longer responding to hormone therapy.
PSA Testing – Prostate Cancer Information