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The Prostate Gland

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Tests involved with prostate cancer treatment:

Prostate Cancer Discussion on:Factors Determining Treatment

Radical Retropubic Prostatectomy

Trans Rectal Ultrasound (TRUS) Guided biopsies

Trans Urethral Resection of the Prostate (TURP)


Prostate Cancer Discussion on:

Factors Determining Treatment

Probably the three most important factors that influence treatment are the Clinical Stage
and the Gleason Score and your PSA blood test level at the time of diagnosis.

The Clinical Stage refers to how advanced Doctors think the cancer is in terms of whether
it has remained localised to the prostate or as to whether it has spread; a staging system
known as the TNM staging system is used.  The T, N and M stand for Tumour, Nodes and Metastases respectively.

The T stage is the most relevant when it comes to considering radical treatment.

If the N stage or M stage is positive it indicates that the cancer is unlikely to be curable and
has already spread to the lymph glands (nodes) or elsewhere in the body (metastases).

The most common stage considered for localised treatment is Stage T1c which means that the prostate felt normal when examined through the back passage and the only thing that alerted Doctor to the possibility of cancer being present was the abnormal PSA level. 

Stage T1a and T1b tumours are ones detected unexpectedly following prostate surgery for
other reasons.   Stage T2 tumours mean that the prostate felt abnormal at the time of examination of the prostate through the back passage.  

Stage T3 and T4 tumours are tumours that have begun to invade the tissues immediately
beyond the prostate and are much less likely to be curable.

The Gleason Score (or Sum) is something that the pathologist tells about the cancer in
terms of its aggressiveness on the basis of careful inspection under the microscope.
The Gleason Score is actually made up of 2 numbers known as Gleason Grades.
When a pathologist looks at the prostate cancer under the microscope, a number grade
from 1 to 5 is assigned to the areas most representative of the cancer present (the
primary Gleason Grade).  A second number grade from 1 to 5 is given to the second
most representative area within the cancer (The secondary Gleason Grade).These two
numbers are added together to give the Gleason Score, the maximum Gleason Score is
10 and the minimum Gleason score is 2.  The higher the score, the more aggressive the
tumour is likely to be and this will impact on the likely success of treatment.

Other factors such as the PSA blood test result may help give a fairly good indication of
the staging of the cancer although it in itself is not entirely accurate.   It is certainly useful
in assisting with pre-treatment investigations.  Ideally we would like to see the PSA levels
less than 10 ng/mL although slightly higher levels can, in selected cases, still be suitable
for treatment with curative intent.  Levels in their hundreds or even thousands, indicate
advanced disease.

To some extent, additional information on the pathology report such as the presence of
perineural invasion (cancer cells following nerve fibres) and the actual number of biopsies
might be of significance and your doctor will discuss this with you if relevant to your case.

How do we know if the cancer has spread or not?

Large number of patients in a number of studies have shown that if your PSA level is less
than 10, the chances of having abnormalities to suggest spread of cancer on Bone Scans
or CT Scans of the abdomen are remote unless your Gleason Score is unfavourably high
(eg 8 to 10) for this reason, it is unnecessary for most men being selected for treatment
with curative intent to have the requirement to undergo additional tests.

The same more or less applies for likelihood of lymph node spread.  In the past, Urologists
used to routinely remove the lymph glands near the prostate and as a result, they are now
better able to predict as to who is more likely to have signs of microscopic spread into the
lymph glands.  The removal of lymph glands does carry greater risk to prostate cancer
surgery and the ability to select out these men better has obvious benefits.

What are the treatment options available?

The treatment of localised prostate cancer falls loosely into three main categories; these
are watchful waiting, surgery and radiotherapy.

The majority of men who are diagnosed with prostate cancer will die with their disease
rather than from their prostate cancer.  Prostate cancer is not a uniform disease amongst
all men and varies in its aggressiveness considerably depending on each individual.

Watchful waiting

refers to non-treatment of the cancer and simply monitoring with regular PSA blood testing.
This form of treatment is certainly appropriate in selected men, particularly elderly men and
those with significant competing causes for death.

Types of Surgery

Radical Retropubic Prostatectomy
Radical Perineal Prostatectomy
Laparoscopic Radical Prostatectomy

With surgery, the mainstay of treatment has been in the form of a Radical Retropubic Prostatectomy when people are talking about surgery for prostate cancer, they in
almost all instances referring to this type of surgery.  With this type of surgery, the prostate
is removed in its entirety and the bladder joined to the urethra.  The details are outlined in a separate Radical Retropubic Prostatectomy section.

Other forms of surgery include Radical Perineal Prostatectomy this involves the cut
being made between the back passage and the back of the scrotum. This form of surgery
has never really achieved widespread popularity amongst surgeons due various technical
factors however, in the hands of surgeons with a special interest in this form of surgery,
it is a valid alternative to the conventional form of surgery.

A newer form of surgery is being offered but at this point in time it must be regarded as
being investigational this is a keyhole type of surgery called Laparoscopic Radical Prostatectomy.   A series of telescopic instruments are used to carry out what would
normally be done through an open cut.  The advantages of the new technique are the
faster recovery and there is some theoretical evidence that potency may be easier to
preserve with this technique it must be emphasized that there is no published data
that indicates any superiority in the success of laparoscopic surgery over conventional
nerve sparing open surgery (for potency preservation).

Types of Radiotherapy

Conventional External Beam Radiotherapy
with or without dose escalation

Seed brachytherapy

Wire brachytherapy

It is no longer as simple to say that one is going to have radiotherapy to treat their
prostate cancer although when most people are talking about radiotherapy, they are
talking about external beam radiotherapy.  The results of conventional radiotherapy are
not greatly different to surgery but there is trade off with the types of side effects that can
arise.  These side effects are largely on the basis that normal tissue surrounding the prostate
is affected to varying degrees by the radiation treatment intended for the cancer.
Radiotherapy will also affect the ability of tissue to heal and subsequent treatment with
surgery is largely not feasible. Brachytherapy refers to inserting the radioactive material physically into the prostate.It is performed under ultrasound guidance and either seeds or
wires containing radioactive material is inserted through puncture holes in the perineum
(which is that space between the back passage and the back of the scrotum).

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