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Ung thư và Phòng ngừa : Glossary
Prostate cancer
[2007-09-21 10:30] (1,072)

Synonyms

 

Prostatic malignant tumor

Prostatic adenocarcinoma

 

Definition

 

Prostate cancer is a malignant tumor which starts at the perimeter of the prostate gland. As the tumor grows, it expands to the inside portion of the prostate gland. Like other cancers, prostate cancer can metastasize or be transmitted to the lungs, bones, and to other organs. Initially, prostate cancer does not cause any urologic symptoms but as the cancer progresses important urological problems including urinary tract suppression or urinary tract blockage may be encountered. In addition, compared to other types of cancers, prostate cancer can cause serious complications due to its frequent metastasis to the spine and pelvic bones. Prostate cancer is currently the most frequently occurring cancer in American males and has the second highest mortality rate. Due to its increasing incidence, prostate cancer is becoming the focus of interest.

 

Symptoms

 

In the early stages, the size of prostate cancer is small and there is nearly no symptoms present in most cases. Most cases of prostate cancer are diagnosed by an elevation in Prostate Specific Antigen (PSA), accidental localization of hard nodes during the digital rectal examination, or finding of cancer cells in the tissue which was initially suspected to have prostate hyperplasia. However, if prostate cancer had progressed into its later stages and was associated with prostatic hyperplasia, the following symptoms could be experienced: difficulty in urinating, frequent urination, hematuria, pain during urination, narrow stream of urination, and discomfort in defecating. In addition, if prostate cancer was transmitted or had metastasized to other organs, especially the pelvic bones or spinal bones, the patient may have severe ostalgia, severe lower limb paralysis or pathologic fractures.

 

Cause, conditions and physiological

 

The cause of prostate cancer has not been clearly identified. However, the incidence of prostate cancer varies depending upon race, or family genetics. Also, an environmental factor has been known to be related to its causes and a high fat diet has been postulated to contribute to the incidence of prostate cancer.

 

Diagnosis

 

There is nearly no symptoms at the early stages of prostate cancer. If the patient with prostate cancer is experiencing a symptom, he may have the advanced form of cancer or a metastatic cancer which was spread to the other organs. Because of this, the early diagnosis of prostate cancer is important.

 

- Digital rectal examination: This test involves palpating the prostate gland, with the doctor inserting his second finger into the patient’s anus. The test is mostly conducted with the patient bending at the waist while in the standing position or with the patient. lying on one side of a bed and drawing his knees to the abdomen. This examination takes approximately 5-10 seconds without causing pain. Both the American Cancer Society (ACS) and American Urological Association (AUA) recommended the digital rectal examination and the measurement of Prostate specific antigen (PSA) level for people more than 50 years old. Generally, if a biopsy was conducted after nodes were found by digital rectal examination, the accuracy for the diagnosis of prostate cancer by a digital rectal examination ranges from 21~53%. If an abnormal finding was noted through digital rectal examination, a tissue biopsy may be required to diagnose prostate cancer. But there are many cases of prostate cancer which were not detected by the digital rectal examination. In other words, the digital rectal examination alone is difficult to use in diagnosing prostate cancer. In addition, half of prostate cancers diagnosed by the digital rectal examination have histopathological advanced cancer. Also, the digital rectal examination is dependent upon the examiner’s skill. Therefore, other methods such as the serum PSA measurement are absolutely necessary. Other than prostate cancer the following may manifest as hardened nodes during digital rectal examination: prostate tuberculosis, prostatic stone, prostatitis, and prostate hyperplasia. Under these circumstances, urine test, prostate gland juice test, serum PSA level test and transrectal ultrasound guided prostate biopsy are necessary.

 

- Serum Prostate Specific Antigen (PSA): PSA is a type of digestive enzyme produced by the epithelial cells of the prostate gland, which is needed to dilute sperm. Although there are some differences depending upon the method of measurement, the generally regarded normal level is estimated to be less than 4ng/ml. The elevation of PSA is more helpful in screening for prostate cancer than digital rectal examination, and its value is more important for patients who are expected to live longer than 10 years. The incidence of prostate cancer is low in our nation. In the US, the possibility of having the cancer as the PSA value exceeds more than 4ng/ml is 25-30%. If PSA value is more than 10ng/ml, the risk of having prostate cancer has been known to be greater than 50%. So, the risk of having prostate cancer increases as the PSA value increases. Based on this, a yearly PSA test is recommended for all men more than 50 years old. However, the PSA value alone can not be used to differentiate between prostate cancer and prostatic hyperplasia. One fourth of prostatic hyperplasia patients, have abnormal serum PSA levels of more than 4ng/ml. If prostatitis or severe infection is accompanied by prostate hyperplasia, the PSA level could increase to values greater than 20ng/ml. If leukocyte count is found to be increased during a urine test, the PSA level has to be retested after treatment with antibiotics for 2~3 weeks. In general cases of prostatic hyperplasia, if the above conditions are not present, the PSA level rarely shows more than 10ng/ml. Accordingly, most of the increased PSA level detected fall in the rather uncertain range of 4~10ng/ml, and may require further screening tests by a specialist. In screening for prostate cancer, the supplementary approaches of PSA/PSAD (Prostate Specific Antigen Density), annual PSA variation velocity (PSA velocity) and Age-specific PSA have been used, but their effectiveness have not been confirmed.

 

- Transrectal Ultrasonography (TRUS): TRUS is not an essential method to diagnose prostate cancer. However, if PSA level was increased without findings of hardened nodes during digital rectal examination, this could be a necessary test. This test is also conducted with prostate biopsy. The TRUS test is conducted by inserting an ultrasound probe through anus and takes about 20 minutes to finish without much pain.

 

- If there are findings suggestive of the presence prostate cancer, prostatic biopsy is done for confirmation of prostatic cancer. The biopsy is conducted through the perineum or rectum. Most of the biopsies are done while transrectal ultrasonography is being done. Before undergoing the biopsy, patients have to receive rectal enema one day before conducting the test. Patients are also advised to have a small amount of soup in the morning of the test and should take antibiotics 1 or 2 days before and after finishing the test. This is done to reduce the chance of acquiring an infection during the biopsy. Approximately 30 minutes are required for the test and anesthetics are not usually used.

 

- Tests to determine the stage of cancer: Once a patient is diagnosed with prostate cancer, he has to undergo tests such as bone scan, Magnetic Resonance Imaging (MRI), and Computed Tomography (CT) to detect the presence of metastasis in the other organs. A patient may undergo pelvic lymphadenectomy through laparoscopy to screen for metastasis into pelvic lymph nodes. It is clinically important to determine the stage of the prostate cancer before performing surgery. However, these tests could be conducted in a case by case basis according to the stage of prostate cancer and the serum PSA level.   

 

Progress, prognosis

 

Since prostate cancer have various biological morphologies, the tendency for progression is hard to predict. So far, the propagation of the tumor (Gleason’s score), serum PSA level, and clinical cancer staging are the most appropriate approaches in determining the possibility of metastasis and the prognosis of the disease. The size of tumor and multiplicity of prostate cancer cell nuclei have also been known to be helpful methods. Since prostate cancer is malignant, it can directly penetrate into surrounding tissues by breaching the perimeter of the prostate gland and it can spread through the blood and lymphatic vessels. The upper and lower portions of the prostate gland where nerves, blood vessels, and ejaculatory duct are passing through could be most susceptible structures and from there cancer can propagate into the urinary tract, the surrounding tissues of the prostate gland, and the urinary bladder and seminal vesicles. Cancer can spread into the urinary bladder and seminal vesicles due to the weakness or default in membrane overlapping with the prostate gland. Therefore, the prognosis of patients with prostate cancer is not good if the cancer is located in the areas mentioned. The presence of a tough membrane between the rectum and prostate gland protects the rectum from the direct invasion of prostatic cancer cells. Approximately 10-35% of the urinary tract is invaded by cancer cells, but this occurs at the later stages of the cancer when there is already distant metastasis or lymphatic metastasis. Surrounding the prostate gland are several lymphatic nodes. The obturator lymphatic nodes are the most frequent lymph nodes where metastasis occurs. Before performing a curative surgery, the presence of metastasis at the lymphatic nodes should be confirmed. The most common form of hematogenous metastasis occurs in bones, and can be found in 85% of patients who died from prostate cancer. The most frequently involved bones in the metastasis of prostatic cancer, listed in the order of the most common to the least common, are spine, pelvis, femur, ribs, sternum and cranial bones. Distant metastasis into the lung or liver can also occur. Metastasis into the lung occurs in 25-38% of patients who die from prostate cancer.

 

Complications

 

In patients with prostate cancer, there are a few symptoms during the earlier stages of the cancer. Bladder outlet blockage, acute urinary tract blockage, or incontinence of urination could be present but the patients may not be showing any symptoms. Prostate cancer commonly metastasizes into the bones. Bone metastases may cause neurologic dysfunctions with bone pain, lower limb paralysis due to spinal cord compression, or increased tendency for fractures.

 

Treatment

Prostate cancer, due to the unpredictable nature of its progression, needs to be treated promptly and appropriately depending on the age of the patient, the stage of the disease, and the presence of other medical problems the patient may have.

1. Radical prostatectomy: This surgical procedure is applicable in case the cancer is found in the prostate gland only, the patient is deemed to survive 10 years or more at the time of diagnosis (for the patients less than 70-75 years old), and the patient is in good general condition, healthy enough to undergo the operation. Before starting the operation, the patient normally requires undergoing examinations such as bone scan, magnetic resonance imaging (MRI) or computed tomography (CT) scan to ensure that the cancer has not spread. If necessary, a laparoscopic pelvic lymph node dissection is also done to find out whether the cancer has spread to the pelvic lymph nodes. In short, the stage of the prostate cancer is determined before operation. There are two types of radical prostatectomy depending on how the prostate is accessed; namely, retropubic prostatectomy, where the prostate gland is accessed through an incision in the abdominal wall, and perineal prostatectomy, where access is gained through an incision between the scrotum and the anus. In retropubic prostatectomy the pelvic lymph nodes along with prostate and seminal vesicles are removed, while in perineal prostatectomy the prostate gland and seminal vesicles are removed and the pelvic lymph nodes are left intact. (See Figs.1, 2)  Although each method has its own merits and faults, it is known that both of them achieve similar results. Besides the complications due to anesthesia, urinary incontinence, erectile dysfunction, urethral stricture, hemorrhage, associated tissue injury, etc. may also occur as postoperative complications. As the frequency of these complications mostly depends on the experience of the surgeon, it is recommended that patients undergo the operation at a university general hospital with vast experience in this field. Radical prostatectomy focuses on removing the cancer cells that have spread within the prostate gland. The objective is to achieve cure and this can be accomplished, in most cases, if the patient undergoes radical prostatectomy as soon as the prostate cancer is detected at an early stage. Nevertheless, pathological examination after operation sometimes shows that the stage of disease was more advanced than the assessed stage before the operation (the clinical stage of the cancer). This is not because the examination conducted before operation was wrong but because the diagnostic techniques themselves are limited. Furthermore, it may happen that the blood PSA (prostate-specific antibody) value increases after operation although the cancer is deemed to have been completely eliminated. In other words, the prostate cancer has recurred. In case of recurrence, radiotherapy or hormonal therapy is required to target the recurring prostate cancer cells.

 

2. Radiotherapy: Radiotherapy for prostate cancer can also be conducted on patients whose cancer cells have spread within prostate gland only and who is deemed to survive for 10 years or more similar to the case in radical prostatectomy. Also, it can be used in cases when surgery has been excluded as an option for effective treatment, namely when the prostate cancer cells have already spread outside the prostate gland without the presence of whole body metastases at the time of diagnosis and when prostate cancer has recurred locally after operation. Furthermore, it may be the alternative treatment of choice for patients who don’t want to undergo surgery. Typically radiotherapy for prostate cancer refers to the method of applying radiation to the affected pelvic area including prostate gland. In addition, brachytherapy can be performed. In this procedure, small plastic catheters discharging radiation are placed into the prostate gland. Figuratively, the traditional radiotherapy performs carpet bombing of the prostate gland and its surrounding tissues, while brachytherapy uses ‘Smart Bombs” in an effort to minimize the radiation exposure of surrounding tissues. Complications after radiotherapy for prostate cancer include potential injuries to the prostate gland, prostatic urethra, bladder neck, anterior rectal wall, etc. which may show a wide range of clinical symptoms. In addition, as the range of irradiation becomes wider, potential injuries to the trigonal area of the urinary bladder, urethral orifice, posterior and lateral rectal wall, and even to the bulbous and membranous urethra may occur. These injuries may result in erectile dysfunction similar to the case in radical prostatectomy. Comparing the results of these two methods in treating prostate cancer is still a matter of debate. Nevertheless, both methods seemed to be of no significant difference in the short term, while radical prostatectomy prevails in the long run. Radiotherapy is beneficial for patients that don’t require hospital treatment. Its limitations include its inability to directly stage the disease from the tissue and its inability to determine if the disease has been cured.

 

3. Hormonal therapy: Hormonal therapy in the treatment of prostate cancer is performed in case the cancer cells have spread outside the prostate gland. Therefore, hormonal therapy in prostate cancer does not focus on cure but rather aims to extend the patient’s life by restraining the progress of prostate cancer. As prostate cancer cells tend to grow faster depending on the presence of the male hormones, hormonal therapy slows down the growth of the prostate cancer cells by interrupting the inflow of male hormones. Actually, it is effective up to approx. 60-~0% when restraining the progress of prostate cancer at an early stage. However, it cannot remove entire malignant cells. The main restriction in using hormonal therapy is that within a certain period of time, the prostate cancer would return as hormone-refractory prostate cancer. The side effects of hormonal therapy differ among the categories of drugs use, but the most common complication and reaction is erectile dysfunction. Also symptoms of postmenopausal syndrome such as sweating, hot flush, hyposexuality, weight gain, lethargy, slight gynecomastia, and changes in skin and hair may also occur. Selection of the specific method of hormonal therapy should be conducted after the consideration of patient’s economic condition, effect and stability of each treatment method, and quality of life of the patient. For example, if the patient is relatively young, enough to probably maintain a healthy sex life, and if his economic condition allows it, non-steroidal anti-androgen drug stand-alone treatment can be use. Orchiectomy can be implemented when the patient is too old and is in an economically difficult situation. Sometimes treatment methods are combined depending on the situation. Since radical prostatectomy or radiotherapy cannot remove the cancer cells completely, hormonal therapy may be used before and after these treatment methods to assist in treatment.

 

A. There are a variety of hormonal therapies available including:

    • Orchiectomy: the removal of the testicles, a man's main source of testosterone.
    • LHRH analogue: LHRH (luteinizing hormone-releasing hormone) is the hormone that is secreted from hypothalamus. Administration of analogue that is made when transforming the composition of LHRH can reduce blood testosterone levels   
    • Estrogen drug: Estrogen is the female hormone that has been used before the appearance of LHRH analogue. This also reduces blood testosterone levels
    • Anti-androgen drug: It is divided into steroid and non-steroid drug, which inhibits dihydrotestosterone (DHT), the most active male hormone.
    • Combined androgen blockade (CAB): This is the therapy of simultaneously interfering with androgens produced in the testes and adrenal gland.

B. Patients suitable for Hormonal Therapy: In case the cancer cells are limited locally and exist within prostate gland only, surgery or radiotherapy applies, but when the cancer has spread outside the prostate gland, the treatment varies. First of all, it is necessary to exactly understand the stage of the prostate cancer, (Staging of prostate cancer is explained enough in chapters 4 through 5). A patient is suitable for hormonal therapy when his cancer cells have spread outside prostate gland. When prostate cancer has spread to the adjacent organs such as seminal vesicle, bladder or rectum (progressed locally) it falls under the stage of T4, C or D. When the cancer has spread to the lymph nodes within the pelvis it is designated as D1+ or N+. When whole body metastases to bones are present, the stage of cancer is described as D2 or M+. In case the cancer has spread locally, radiotherapy or hormone-radiotherapy combined treatment is available. Question on which method is better is still a matter of debate, but hormonal therapy is optimal once whole body metastases were identified. However, you need to keep in mind that hormonal therapy is not a cure for prostate cancer but is only a means of prolonging the progress of cancer and subsequently the life of the patient.

 

C. Why hormonal therapy: In the 1940’s Huggins and Hodges verified that the male hormone (Androgen-male hormone is produced from testicles) plays a critical role in the growth of prostate cancer by observing that the removal of the testicles in metastatic patients causes degeneration of the prostate cancer cells. Since then, it became the fundamental rule to treat advanced prostate cancer initially with endocrinotherapy with androgen blockade, from which 70-80% of the patients treated showed improvement of symptoms or relief of cancer pain.  As hormonal therapy is applied to the whole body, its side effects appear on the whole body. Furthermore it doesn’t cure the localized prostate cancer. For these reasons, we don’t recommend it as the treatment for localized prostate cancer.

 

D. Orchiectomy: Is the method of removing the testicles that produce male hormone required for the growth of prostate cancer, it is also called surgical castration. Both testicles are removed with spermatic cord left after the scrotum is cut open. In this case, you can have an artificial testicle put into your scrotum to make it look the same as before.

 

a. Advantages of orchiectomy

      • Simple and inexpensive compared to the other treatment methods.
      • Patients don’t require hospital treatment.
      • Effectively reduces the level of male hormones in the body.
      • Reduces the level of male hormones irreversibly to the same level when treated with castration within a couple hours after operation.
      • A certain appearance of scrotum remains, but an artificial testicle can be put into scrotum if required.

b. Disadvantages of orchiectomy

      • In most cases of men, it results in a decreased sexual desire.
      • It may cause erectile dysfunction.
      • Male hormones (approx. 5-10%) partly produced by the adrenal glands are not interrupted.
      • Patients may have hot flush similar to the symptom of menopausal women
      • It may cause enlarged breasts in men (female-appearing breasts). Half of the patients who undergo the operation may have nipple tenderness or hyperesthesia.
      • It is irreversible, namely once removed the testicle cannot be restored.
      • Patients may gain weight.
      • Patients may have psychological deprivation feeling that the symbol of maleness is removed.

E. LHRH analog. LHRH stimulates the secretion of luteinizing hormone (LH) which in turn stimulates the secretion of male hormones in the testicles. LHRH analog is structurally similar to the original LHRH that is secreted from the brain. Administration of this analogue increases the creation of LH in the initial stage, but its creation is stamped out after all, which eventually stops the creation of male hormones in the end. This is normally injected under the abdominal skin once a month and should be administered continuously unless the patient undergoes orchiectomy. Recently an extremely potent drug has been developed and sold in the market, which is effective for 3 months once administered. At the early stage of its administration, the level of male hormones increases for 7-10 days and the patient can experience the so-called “Flare Phenomenon” in which the cancer symptoms temporarily get worse. In order to avoid such phenomenon, the patient may have anti-androgen drug administered concurrently during the initial stage. There appears to be the same effect as orchiectomy with the degree of male hormones at the same level when treated with castration on day 7 ~ 10 after its administration. For this reason, this method is called "Medical Castration"

 

a. Advantages of LHRH analog

      • Reduces the level of male hormones in the blood at the same level as when treated with castration but without removing the testicles through surgery. 
      • Effective in enhancing the life quality similar to the surgical operation.
      • There is a room for the patient to undergo the testicle-removing operation at later stage.

b. Disadvantages of LHRH analog

      • In most cases of men, it results in decreased sexual desire.
      • It may cause erectile dysfunction.
      • The patient may have to take an anti-androgen drug concurrently in the initial stage in order to avoid flare phenomenon.
      • It may cause hot flush similar to the symptom of menopausal women.
      • It may cause enlarged breasts in men (female-appearing breasts) and nipple tenderness.
      • Patients may gain weight.
      • Periodically, patients need to go to the hospital to receive shots.
      • The size of the testicles can be reduced.
      • Expensive cost of drugs.

F. Estrogen Drug. Before the appearance of LHRH analog, the female hormone, estrogen, was mainly used for the treatment of metastatic prostate cancer as a substitute for testicle removal. DES is its representative drug which restrains the production of male hormones and requires approx. 2 weeks to reduce the level of male hormones in the blood down to the level when treated with castration. Nevertheless, the frequency of its usage has gradually decreased since the possible occurrence of cardiovascular complications was reported.

 

a. Advantages of Estrogen Drug

      • Effective as much as orchiectomy or LHRH analog.
      • Oral administration in tablet form, not necessary for the patient to go to hospital periodically
      • Inexpensive cost

b. Disadvantages of Estrogen Drug

      • Requires approx. 2 weeks to reduce the degree of male hormones in the blood.
      • It may cause cardiovascular complications. Therefore it is not suitable for Parkinson's disease or Venous Thrombosis patients.
      • In most cases of men, it results in the decreased sexual desire.
      • It may cause erectile dysfunction.
      • It may cause enlarged breasts in men (female-appearing breasts).
      • Patients may have foot or ankle swelling which require diuretic treatment.
      • Drug requires constant administration.

G. Anti-androgen Drug. Anti-androgen drug in various forms restrains the production of the male hormone or its reaction. Anti-androgen drug is mostly used in the combined androgen blockade that will be mentioned later. The characteristics of each anti-androgen drug are as follows:

      • Eulexin (flutamide). It was developed by Schering-Plough Corp. Administration is oral and taken three times a day. When individually administered, it doesn’t reduce the male hormones in the blood. So no complications such as decreased sexual desire or erectile dysfunction follow. Nevertheless, 15-25% of the patients may suffer from diarrhea while 2% of them may have slight toxic liver disease. It may cause female-appearing breasts and nipple tenderness too. In some cases, the cancer becomes serious or the serum PSA level increases from the patients who have had this drug for a long time, which is presumably caused by the cancer metastasis. Sometimes discontinuance of the oral medication at this stage may improve the state of illness, which is called 'Anti-androgen withdrawal syndrome'.
      • Casodex (bicalutamide). As the drug developed by Zeneca Pharmaceuticals, it doesn’t reduce the male hormones in the blood similar to Eulexin. Therefore it never causes decreased sexual desire, erectile dysfunction, or diarrhea. In addition, its once-a-day dosage is very convenient for patients. Nevertheless, it may cause female-appearing breasts), nipple tenderness, and 'Anti-androgen withdrawal syndrome' similar to Eulexin.
      • Nilandron (nilutamide). As the drug developed by Hoechst Marion Roussel, recently it has been officially approved by FDA U.S.A. The efficacy of the drug is similar to that of the two drugs above, but it may cause interstitial pneumonia and night blindness, so it is rarely used in Korea.
      • Cyproterone acetate. All anti-androgen drugs previously described are non-steroidal drugs. This drug is a steroidal anti-androgen compound. It reduces male hormones in the blood but is rarely used because this drug may cause decreased sexual desire or erectile dysfunction.
      • Ketoconazole. This drug is an anti-fungal agent but also inhibits the enzyme that stimulates the production of male hormones. It acts very fast, which is effective in alleviating the symptoms of prostate cancer that suppresses bone marrow in a short time. It inhibits the male hormones produced by the testicles as well as those produced by the adrenal glands. Nevertheless, it is used in exceptional cases only because of its side effects such as gastro-intestinal disorders, hepatotoxicity, female-appearing breasts, and hypocalcaemia.

H. Combined Androgen Blockade (CAB). Male hormones are produced by testicles, but partly produced by the adrenal glands. Thus, the method in which even hormones produced by adrenal gland are interrupted for more effective interruption of male hormones is called concurrent androgen interruption. This method uses either surgical (orchiectomy) or medical (LHRH analog) castration plus an anti-androgen drug. However, it is still a matter of debate whether such combined androgen blockade is more effective than monotherapy. It is known to be effective in metastatic prostate cancer in early stages.

    • Problem of Hormonal Therapy. As mentioned, the objective of hormonal therapy is not to cure the cancer but to extend the progress of cancer and the life of patient. Normally, for patients who have undergone long term hormone therapy, prostate cancer tends to be changed into hormone resistance syndrome. In this case, it can be treated with secondary hormone therapy, cancer chemotherapy, etc. These are not the perfect solutions though, and are still being studied by urologists. Furthermore, there is no accepted 'right' time to start hormone treatment, but normally it is determined depending on the age of patient, erection problem, life quality, etc.

4. Watchful Waiting. Watchful waiting can be selectively adopted for some of the prostate cancer patients. It is not just waiting and doing nothing without any examination.  Patients have to regularly undergo digital rectal examination, serum PSA measurement, and prostate ultrasound imaging if necessary. Watchful waiting can be adopted in case of followings.

    • The patients who are deemed to survive less than 10 years due to old age or affected by any other disease
    • Aged at 70 or more and differentiation of cancer cell is at high grade (in case Gleason's score is 2)
    • In case the size of cancer is small
    • In case prostate cancer has spread within prostate gland, but the treatment method is not decided yet
    • In case prostate cancer is found, but no symptom is shown

Watchful Waiting in the management of prostate cancer, is advantageous because complications of therapy are avoided, cost is inexpensive, and allows affordable time for patient and his family.  It can also be critical because the cancer may be getting worse. 
 

Consult a doctor in the following cases

    • Male who is 40 years old or older, with family history of prostate cancer
    • Patients with abnormally high PSA (4ng/ml or higher) or with abnormal digital rectal examination.
    • Patients with bladder outlet obstruction experiencing symptoms such as dysuria and intermittency, acute urinary retention, hematuria and urinary incontinence
    • Patients or aging male with unidentified bone pain, neurological symptoms or pathologic fractures

Prostate cancer that normally doesn’t show any symptom at its early stage cannot be detected easily from the subjective symptoms of the patient himself. The cancer has already spread when patients start having symptoms such as bone pain, etc. Accordingly it is very important for the patient to consult with the doctor and undergo proper treatment when prostate cancer has spread within prostate gland. For this reason, the screening test using the serum PSA level is frequently implemented. Nevertheless, it still remains a matter of debate whether such selective examination can detect clinically significant prostate cancer at an early stage and reduce the prostate cancer death rate. Most urologists recommend that patients at 50 years old or more (especially who is deemed to survive less than 10 years) should undergo tests such as serum PSA level measurement and digital rectal examination. In fact, the typical comprehensive physical check includes this serum PSA level measurement. In case it shows an abnormal result (PSA level over 4ng/ml), the patient has to consult with the urologist.

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