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It has been 5 years since the publication of this Clinical Practice Guideline and it is subject to updating. From an anatamopathological point of view, localised prostate cancer is the verified presence of prostate adenocarcinoma without extension to the prostate capsule (pT1-pT2), without lymphatic invasion (N0) and without metastasis (M0). The patient with clinically localised prostate cancer is consistent with the stage cT1-cT2, N0-Nx, M0-Mx.
The clinical TNM stage is insufficient to establish the most appropriate treatment for patients with localised prostate cancer, as it does not reflect the prognostic situation in full. There are several prognostic factors used in routine clinical practice, since there is evidence from observational studies that they are risk factors which are independent of mortality in patients with localised prostate cancer. Univariate and multivariate analysis of prognostic factors for prostate cancer identify the Gleason grade as one of the most significant prognostic markers, with the worst results for survival, tumour extension and disease-free period the more undifferentiated the tumour33-47. If the Gleason grade is evaluated along with the clinical stage even more accurate prognoses can be made38. Prostate cancer causes the release of a number of substances in the blood, including prostate specific antigen (PSA).
A post-treatment increase also indicates a deterioration in survival results54 and always precedes the clinical recurrence of cancer44. Values of free PSA and PSA-ACT are also independent prognostic survival factors in patients with prostate cancer41. The prostate is divided into three parts: the peripheral zone, the transition zone and the central zone33(see Figure 1). A high proportion (67%) of prostate cancers have multiple locations, which can have different histological degrees (heterogeneity)37,60. Multifocality is associated with higher rates of recurrence, and with a more advanced degree and stage60.
Extracapsular extension is an indicator of poor prognosis, with higher rates of PSA relapse and progression of the disease35,61,62. Some authors believe that the prognostic significance of extracapsular extension is due to its association with other variables, such as tumour size or infiltration of the seminal vesicules34,35,64,65, but others found worse outcomes in patients with capsular penetration, regardless of the possible associated locoregional variables61,62. Invasion of the seminal vesicles is a poor prognosis factor associated with higher rates of progression of the disease and PSA relapse40,62,64. Several authors argue that this increased risk of adverse outcomes is due to its association with other poor prognosis markers, such as the Gleason grade, extra-capsular extension, tumour volume, positive surgical margins or pre-operation PSA levels53, 62,64. In addition, Debra et al believe that the meaning of the prognosis in the invasion of seminal vesicles is not constant, and depends on the vesicle zone affected: if the invasion is in the distal portion, the prognosis is worse than when it occurs in the proximal zone66. Some studies have found that positive surgical margins are a predictor of increased risk of disease progression or PSA relapse36,40,43,62.
Although for some authors this effect of positive surgical margins is due to its association with other variables that worsen the prognosis, such as seminal vesicle invasion, extracapsular extension, preoperative PSA, Gleason grade or tumour volume36,62, others have found prognostic significance independently40,43,62. A greater tumour volume in the prostatectomy sample is associated with increased risk of progression of the disease and PSA relapse35,36,62. The growth of a tumour of a certain size requires angiogenesis, and when it starts to form new vessels, the risk of metastasis is also increase33. Other authors have found no association between microvascular density of the tumour and the prognosis of patients with prostate cancer76. Several studies have been used histological nuclear morphometry (analysis of the shape and size of cell nuclei) to make predictions on the prognoses in prostate cancer33. There are two forms of IGF (insulin-like growth factors, formerly called somatomedins): IGF-I and IGF-II. The imbalance in IGF production of the proteins it binds to is linked with different pathological conditions. Mutation of the gene suppressor p53 gene may cause disproportionate cell growth and has been associated with many malignant tumours33.
The protein p27 can inhibit the cell cycle and it may have some effect on tumour suppression. Yang et al found that low or undetectable levels of p27 expression are an adverse prognostic factor in patients with clinically localised prostate cancer treated with prostatectomy, especially in the pathological stages pT2-pT3b102. Several authors have found that patients with prostate cancer with DNA diploid have better prognosis results (longer survival and disease-free periods, less advanced Gleason stage, lower risk of metastasis, better response to treatment) than those with non-diploid tumours. The increase in the proportion of cells in the S phase of the cell cycle is associated with shorter survival and disease-free periods in clinically localised prostate cancer116,117. Some gene expression profiles are associated with poorer survival outcomes or treatment response in breast cancer118,119, and studies are being performed to find out whether the same is true for prostate cancer33. It has been suggested that the existence of alterations in the expression of the androgen receptors is a risk factor for less biochemical progression-free and overall survival in patients with advanced prostate cancer (locally advanced or disseminated)25-30. For patients with clinically localised prostate cancer, what is the safety and efficacy of different treatment options? Other treatments, usually considered experimental4,17, are cryotherapy or HIFU (high intensity focused ultrasound). The watchful waiting attitude is the conscious decision not to provide any kind of treatment until the progression of the disease or presence of symptoms is apparent. The randomised clinical trial of Bill-Axelson et al121compared the efficacy of radical prostatectomy with watchful waiting in patients with localised prostate cancer.
The clinical trial of Steineck et al122 compared the quality of life for radical prostatectomy v watchful waiting in patients with localised prostate cancer. The aim of active surveillance is to avoid unnecessary treatment for patients with very slow tumour progression (with a low probability of having clinical progression during their lifetime), and treating only those cancers that show early signs of progression, where treatment with intent to cure could benefit the patients. These patients received treatment with intent to cure when the PSA doubling time was less than 2-3 years, when a Gleason ≥ 7 appeared in a prostate biopsy or when the patient requested it.
The systematic revision of Martin et al123compared active surveillance protocols for patients with localised prostate cancer, including 5 series of cases. Repeated yearly biopsies, after 4 years and 7 years, with at least 10 cylinders in each biopsy. Estimation of the PSA speed with linear regression, using at least 5 PSA determinations extending over at least a year. The studies that have been performed so far analysing radiotherapy as a treatment for prostate cancer have a follow-up period less than the surgery series. In the systematic review of Nilsson et al126 on the effects of radiotherapy for prostate cancer, the effects of radiotherapy alone are compared with radiotherapy associated with an intervention. In the systematic review of the Medical Services Advisory Committee (MSAC) in the Australian Ministry of Health127, which includes systematic revisions, retrospective cohort studies and a series of cases, brachytherapy was evaluated with permanent I-125 implants in patients with localised prostate cancer at low risk. In the systematic revision of Nilsson et al126 the use of high dose rate brachytherapy (HDR) in patients with prostate cancer was also studied. The systematic revision of the MSAC127 also compares the toxicity of brachytherapy vs external beam radiation vs radical prostatectomy. The study by Potosky et al129 is a retrospective cohort study comparing the adverse effects of RP vs ERT, with 5 years of follow-up. In the SINTEF systematic review128, which analyses brachytherapy in patients with localised prostate cancer, a case-control study comparing BT vs ERT was investigated. The study by Robinson et al130 is a systematic review comparing rates of erectile dysfunction after RP with preservation of neurovascular bundles (PNB) with other treatments.
In the systematic review of Morris et al131, which includes randomised and non-randomised trials, conformal radiotherapy is compared with conventional for the treatment of localised prostate cancer. In the trial by Koper et al133, which applied a dose of 66 Gy in both groups, a gastrointestinal toxicity of grade 2 was observed in 32% for conventional radiotherapy and 19% for conformal radiotherapy, characterised by anal toxicity and proctitis (p = 0.02).
The randomised study by Storey et al134, which compares conventional and conformal radiotherapy with escalating doses, identified no statistically significant differences in acute rectal or bladder toxicity (p = 0.6). In addition, the Morris review identified 15 non-randomised articles for which no statistically significant differences were found in toxicity when comparing the equivalent dose application of conformal radiotherapy with conventional radiotherapy.
In another clinical trial by Dearnaley et al from 2007135, improved results were seen for intestinal toxicity (adverse effect frequencies of 8% and 5%, but without statistically significant differences) for the conformal radiotherapy group with escalating doses. The systematic review of the Galicia Health Technologies Evaluation Agency, evaluation-t136 analysed the safety and efficacy of treatment with intensity modulated radiation therapy (IMRT).
The systematic review of Hummel et al139 attempts to assess the clinical efficacy of new and emerging technologies for localised prostate cancer.
Another systematic review of the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom140 evaluates the safety and efficacy of HIFU for the treatment of prostate cancer. The systematic revision of Shelley et al141 compared the efficacy and adverse effects of cryotherapy with those of other primary treatments (radical prostatectomy, radiation therapy and observation) for the management of patients with T1-T3 prostate cancer. In other words, different, well-performed systematic reviews139-141 have not been able to identify high-quality scientific literature that would support HIFU or cryotherapy as first-line treatment in patients with localised prostate cancer, which leads to the conclusion that there is insufficient evidence in this regard.
For the management of patients with clinically localised prostate cancer, radical prostatectomy (RP) is more effective than watchful waiting121. For the management of patients with clinically localised prostate cancer, watchful waiting does not improve the quality of life in a clinically significant manner when compared with RP, except in the sexual area122. In patients with clinically localised prostate cancer who received active surveillance, with an average follow up of 5.3 years, 15% of patients experienced early PSA relapse, 3% clinical progression, 4% histological progression and 12% sought radical treatment. There are no statistically significant differences found when comparing the efficacy of external beam radiation (ERT), RP and brachytherapy (BT) for clinically localised prostate cancer risk at low or intermediate risk126-128.
The Association of BT with ERT may have better biochemical progression-free survival results (BPFS) at 5 years than exclusive application of ERT in patients with clinically localised prostate cancer128.
The minimum total dose obtained with high dose rate (HDR) BT is much higher than that achieved with 3D-CRT, with an acceptable toxicity, inducing local healing in the majority of patients with clinically localised prostate cancer, including those at high risk126. In patients with clinically localised prostate cancer, those treated with BT have a greater risk of urethral obstruction, while those treated with RP are more likely to suffer urinary incontinence. Patients with clinically localised prostate cancer treated with BT or ERT have similar rectal toxicity which is higher than that for patients undergoing RP. In patients with clinically localised prostate cancer, BT may have an equal or better toxicity profile in the area of sexual function than RP and ERT127, 128. When comparing the efficacy of conformal and conventional radiotherapy, no statistically significant differences can be found for similar doses in clinically localised prostate cancer131. In patients with clinically localised prostate cancer, rectal toxicity with conformal radiotherapy (RT) is equal to or less than conventional RT132- 135. For the management of patients with clinically localised prostate cancer, there is no difference in the efficacy of IMRT (intensity modulation radiotherapy) and 3-dimensional conformal RT. There is no evidence to support high-intensity focused ultrasound (HIFU) or cryotherapy as first-line treatment in patients with clinically localised prostate cancer139, 141. In patients with clinically localised prostate cancer with a life expectancy exceeding 10 years, radical prostatectomy or external beam radiotherapy is recommended.
In patients with clinically localised prostate cancer treated with external beam radiotherapy, it must be 3-dimensional conformal, as this allows the administration of higher doses of radiation with greater safety.
In patients with clinically localised prostate cancer treated with external beam radiation, brachytherapy may be associated to allow escalating dosages to be achieved.
In patients with clinically localised prostate cancer with a life expectancy below 10 years, watchful waiting may be an alternative. PSA determinations and rectal examination every three months during the first 2 years, then later, every six months. Primary cryotherapy and high intensity focused ultrasound techniques are experimental in prostate cancer patients at a clinically localised stage. Randomised trials should be started comparing cryotherapy and high intensity focused ultrasound with standard treatments in patients with clinically localised prostate cancer.
In patients with clinically localised prostate cancer for which surgery is indicated, what is the safety and efficacy of different types of laparoscopic radical surgery (transperitoneal or extraperitoneal, robot-assisted or not) in comparison with open radical prostatectomy? In a patient with clinically localised prostate cancer for which radical surgery with intent to cure is indicated, does lymphadenectomy increases cure rates for the disease? In patients with clinically localised prostate cancer for which radical prostatectomy is indicated, what percentage of positive surgical margins are obtained when keeping or not keeping neurovascular bundles (uni- or bilaterally)? Radical prostatectomy can be done with a retropubic or perineal incision with or without a laparoscopic technique.
For the incorporation of a minimally invasive method, the oncological and functional results obtained with the new technique must be at least equivalent to the test reference142. The evaluation of the rate of positive surgical margins is essential for proper evaluation for different surgical procedures from the oncological point of view147. Finding positive surgical margins in prostatectomised patients is associated with higher rates of PSA relapse, local and systemic progression148. The Guazzoni et al study147 is a randomised clinical trial of 120 patients with clinically localised prostate cancer subject to open (ORP) or laparoscopic radical prostatectomy (LRP)g carried out by the same surgeon with extensive experience in both techniques. A systematic review by the United Kingdom National Institute for Health and Clinical Excellence143 evaluated the safety and efficacy of LRP, in comparison with ORP, for localised prostate cancer.
A systematic review of Tooher et al143 compares LRP (transperitoneal, extraperitoneal or robot-assisted) and ORP. Besides relying on clinical criteria, whether LRP is used or not depends on the resources available in the hospital. The elimination of microscopic lymph node metastases, which could theoretically increase patient survival and disease-free periods. The most accurate identification of patients with positive lymph nodes, which would allow a better staging for the cancer, and thus the application of a more appropriate treatment for the patient.
Extended pelvic lymphadenectomyh includes a larger number of lymph nodes than the limited or standardi treatment. The study by Allaf et al150 is a retrospective cohort study involving 4,000 patients with clinically localised prostate cancer, comparing extended lymphadenectomy (n = 2,135) v limited (n = 1,865), with each technique applied by a different surgeon.
The 2003 study from Bader et al151 is a cohort study involving 367 men with clinically localised prostate cancer subjected to prostatectomy, with a comparison of results with and without LN. The study by Clark et al152 is a clinical trial that compares extended and limited lymphadenectomy in 123 patients with clinically localised prostate cancer. If the aim is to increase cure rates, it seems that extended lymphadenectomy is not indicated for patients with localised prostate cancer, except in clinical studies. The preservation of the neurovascular bundles surrounding the prostate after performing radical surgery is intended to functionally improve the patient, especially in the sexual sphere but also with regard to urinary incontinence148,154,159. The study by Sofer et al148 is a retrospective cohort study evaluating the effect of radical prostatectomy (RP) with the preservation of neurovascular bundles (PNB) vs RP without PNB (the surgeon applies PNB when he feels that it is technically feasible, which can skew the results, because patients with PNB may be less at risk).
The study by Robinson et al130 is a systematic review comparing the rates of erectile dysfunction after RP with PNB vs other treatments. The study of Kundu et al154 includes 1,834 patients who underwent retropubic RP with or without PNB, whether uni- or bilaterally.
The study of Wille et al155 is a small sample size retrospective cohort study which analyses post-RP urinary continence results according to a number of variables. In conclusion, the various studies suggest that there is no difference between preserving the bundles or not with respect to the margins and incontinence, but there is a difference with regard to sexual potency, in studies with a minimum follow-up of 1 year.
Prostatectomy patients are getting younger, so the maintenance of erectile function (in addition to urinary incontinence) is an important aspect to consider when deciding on treatment. There are no differences in the rates of positive surgical margins between both groups (laparoscopic vs open prostatectomy) in patients with clinically localised prostate cancer147. There are better results for LRP (compared with ORP) in reducing blood loss, early withdrawal of the catheter, postoperative pain on the first day, length of hospital stay and preoperative complication rate in patients with clinically localised prostate cancer146,147. No significant differences were found for urinary continence when comparing different types of LRP and ORP in patients with clinically localised prostate cancer143,149. With regard to impotence, there is a tendency to get better results with LRP in patients with clinically localised prostate cancer, although there are no significant differences between the two techniques (small sample size)143. In patients with clinically localised prostate cancer, comparing extended vs limited lymphadenectomy, no differences were found in biochemical progression free survival after 5 years150. No differences were found when comparing extended vs limited for biochemical progression-free survival in patients with positive lymph nodes and clinically localised prostate cancer, although there was a tendency for better survival in patients who underwent the extended dissection (p = 0.07) 150.
In patients with clinically localised prostate cancer, extended lymphadenectomy allows more patients with lymph node affectation and more positive lymph nodes to be detected than the limited150.
In patients with clinically localised prostate cancer, there were no differences in unilateral surgical complications when comparing extended vs limited lymphadenectomy152. In patients with clinically localised prostate cancer subjected to radical prostatectomy, the preservation or not of neurovascular bundles has no significant effect on biochemical progression at 3 years nor on the percentage of positive microscopic surgical margins148.
For patients with clinically localised prostate cancer who had a prostatectomy, there was a tendency to maintain erectile function when neurovascular bundles were preserved130. In patients with clinically localised prostate cancer who underwent radical prostatectomy, there were no statistically significant differences in urinary continence results if the neurovascular bundles were preserved or not154,155. In clinically localised prostate cancer with radical prostatectomy indicated, either laparoscopic or open surgery can be employed.
In patients with clinically localised prostate cancer risk at intermediate or high risk treated with radical prostatectomy, a lymphadenectomy must be performed. In patients with clinically localised prostate cancer with radical prostatectomy indicated, it is recommended to preserve the neurovascular bundles when intraoperative findings permit. According to the previous risk of the patient, previous studies suggest that changes in the dose, volume and fractionation of radiotherapy received by men with localised and locally advanced prostate cancer can have an impact on survival and disease control, and can also affect the toxicity of the treatment126,156. The Khuntia et al study157 is a prospective cohort study, which includes T1-T3 patients treated with external radiotherapy (RT). In a randomised clinical trial by Peeters et al137 with T1b-T4 patients, it was found that there were no statistically significant differences for BPFS after 5 years when comparing 68 Gy vs 78 Gy in the low risk group.
In another clinical trial by Pollack et al159 70 Gy was compared to 78 Gy in patients with T1-T3 prostate cancer, where the minipelvis and prostate with vesicles were radiated. The article by Hanks et al160 is a prospective dose escalation cohort study, which analyses patients with localised prostate cancer treated with external RT (median 9 years of follow-up).
The Peeters et al trial137, which analysed patients T1b-T4 and the intermediate risk group, found that there are statistically significant better results for the BPFS at 5 years in the higher dose when comparing 68 Gy vs 78 Gy. In the test Peeters et al study137, in the high-risk group for BPFS at 5 years, there is a tendency to find better results for the higher dose when comparing 68 Gy vs 78 Gy. In another Peeters article138, the same patients as in the previous study137 are included, but toxicity results are offered instead of efficacy results. In patients with localised and locally advanced prostate cancer at low risk, no evidence has been found that irradiation of the pelvis improves results.
The 2003 study by Roach et al163 is a random clinical trial comparing RT with PV + neoadjuvant hormone therapy (HT) vs RT with PV + adjuvant HT vs RT with POV + neoadjuvant HT vs RT with POV + adjuvant HT in patients with prostate cancer (67% were pT2c-pT4).
The prostate is a walnut-shaped gland located below the bladder and in front of the rectum. The glandular cells produce a milky fluid, and during sex the smooth muscles contract and squeeze this fluid into the urethra. The prostate gland also contains an enzyme, called 5 alpha-reductase, that converts testosterone to dihydrotestosterone, another male hormone that has a major impact on the prostate. Scientists are researching other genetic variations that may increase prostate cancer risk. A gene is a short segment of DNA which is interpreted by the body as a plan or template for building a specific protein. Male hormones (androgens), particularly testosterone, may play a role in the development or aggressiveness of prostate cancer. Researchers are studying whether prostatitis (inflammation of the prostate gland) may be associated with increased prostate cancer risk.
Because a Western lifestyle is associated with prostate cancer, so dietary factors have been intensively studied.
Click the icon to see an image of the sources of vitamin D.Click the icon to see an image of the sources of vitamin E. Finasteride (Proscar, generic) and dutasteride (Avodart) are drugs used to treat benign prostatic hyperplasia (BPH).
Finasteride and dutasteride may cause reduced sexual drive and problems with erection during the first 1 - 2 years of use.
A survival rate indicates the percentage of patients who live a specific number of years after the cancer is diagnosed. Treatment of prostate cancer varies depending on the stage of the cancer and may include surgical removal, radiation, chemotherapy, hormonal manipulation or a combination of these treatments.
Because so many prostate tumors are low-grade and slow growing, survival rates are excellent when prostate cancer is detected in its early stages. If the disease is at the locally-advanced stage, in which it has spread beyond the prostate but only to nearby regions, it is more difficult to cure, but survival rates can be prolonged for years in many men. If prostate cancer has spread to distant organs (metastasized), average survival time is 1 - 3 years, but some of these patients may live much longer.
If cancer recurs after initial treatment for early-stage tumors, it is still potentially curable if it is contained within the prostate, although in most cases the cancer has spread. Urine flows from the kidney through the ureters into the urinary bladder where it is temporarily stored. Significant pain in one or more bones may indicate the occurrence of metastases (spread of disease). BPH is a urinary condition that can develop into an enlarged prostate, which puts pressure on the urethra and causes urinary problems. Benign prostatic hypertrophy (BPH) is a non-cancerous enlargement of the prostate gland, commonly found in men over the age of 50. Men ages 50 - 75 should be offered annual screening with the PSA test and digital rectal exam.

Men with a family history of prostate cancer and all African-American men should consider annual screening at about age 40 - 45. PSA screening may result in the detection of some possible cancers that would never have bothered the patient and would never have posed a threat to his life. An ultrasound procedure called transrectal ultrasonography (TRUS) may be used to help the doctor see where to take the needle biopsy. Computed tomography (CT) or magnetic resonance imaging (MRI) scans can further pinpoint the location of cancer that has spread beyond the prostate. N followed by 0 through 3 refers to whether the cancer has reached the regional lymph nodes, which are located next to the prostate in the pelvic region. Tumors are assigned scores according to a scale known as the Gleason system, which measure how well or how poorly organized the cancer cells are under the microscope.
Score 7 - 10: Moderately poorly to poorly differentiated, with 15-year survival rates of 15 - 40%.
Patients should be aware that doctors may be biased to prefer a specific treatment depending on their specialty, with urologists tending to recommend surgery and radiation oncologists recommending radiation therapy.
Stage III, locally advanced cancer, means that the cancer has spread into the seminal vesicles (glands at the base of the bladder, which are connected to the prostate gland and help produce semen).
Recent guidelines recommend that patients with localized cancer should be classified as low, intermediate, or high risk.
Compared with active surveillance, radical prostatectomy may lower the risk of cancer recurrence and death, at least in men younger than age 65 at the time of diagnosis. For men at intermediate and high risk, adding androgen deprivation (hormonal) therapy to external beam radiation may improve survival but increase adverse side effects.
Initial (first-line) androgen deprivation therapy is seldom recommended for localized prostate cancer except for the relief of symptoms in patients with poor prognoses.
Patients with localized prostate cancer should have the opportunity to enroll in clinical trials investigating new types of therapy. If prostate cancer has been eliminated after initial treatment, PSA levels should drop after surgery. It is common for PSA levels to temporarily rise following radiation seed implantation without signaling cancer recurrence.
Treatment options for recurrent cancer depend on various factors, including prior treatment, site of recurrence, coexistent illnesses, and individual patient considerations. Patients whose cancer recurs locally after prostatectomy: Radiation therapy, androgen deprivation therapy. Patients whose cancer recurs locally after radiation therapy: Androgen deprivation therapy, prostatectomy (very select patients). Prostate cancer treatments can cause distressing side effects by impairing sexual function (erectile dysfunction), urination (incontinence or difficulty urinating), bowel function (incontinence), and energy levels (fatigue).
Side effects vary among patients and it is difficult to predict how an individual patient will respond. External beam radiation therapy provides the best initial results for recovery of sexual function. Nerve-sparing prostatectomy generally produces better sexual function than conventional radical prostatectomy. External beam radiation therapy produces better urinary control and sexual function than brachytherapy, but brachytherapy has better results for these side effects than radical prostatectomy. Radiotherapy (both brachytherapy and external beam radiation) generally causes more bowel problems than surgery, although this side effect usually improves after 1 year. Some doctors think that because prostate cancer grows so slowly, it is likely that older men will die from causes unrelated to the cancer.
Radical prostatectomy is the surgical removal of the entire prostate gland along with the seminal vesicles (the vessels that carry semen) and surrounding tissue.
Retropubically (through the abdomen and under the pubic bone, exposing the entire surface of the prostate). Nerve-sparing techniques can improve quality of life, by decreasing the occurrence of incontinence and erectile dysfunction. Patients remain hospitalized for about 3 days after an open procedure or 2 days after less invasive procedure.
The main complications from radical prostatectomy are urinary incontinence and erectile dysfunction. Erectile dysfunction after radical prostatectomy is caused by nerves that were damaged or removed during the surgery. With the use of effective nerve-sparing techniques, men who were sexually active before surgery and are involved in an ongoing relationship seem to have a better chance of returned sexual function.
Radiation therapy used to be reserved for older men (over age 70) with locally advanced prostate cancer who had a life expectancy of 15 years or less.
In external beam radiation therapy, a doctor focuses a beam of radiation directly on the tumor for 35 3-minute treatments given 5 times a week over 7 weeks. Patients considering external beam radiation should be aware that higher radiation doses may reduce the risk for cancer recurrence and improve survival outcome. Brachytherapy is mainly used for men who have early stage prostate cancer that is relatively slow growing. Many patients experience a need for frequent urination shortly after radiation therapy, and urgency persists longterm for about some patients. Unlike surgery, erectile dysfunction does not usually occur immediately following radiation therapy. Cryosurgery is an alternative to standard prostatectomy for men with localized prostate cancer who do not want or who are not appropriate candidates for radical prostatectomy. Cryosurgery is typically a 2-hour outpatient procedure, although some patients may need to stay in the hospital overnight. Nearly all patients experience erectile dysfunction after cryosurgery, and urinary incontinence is also common.
This therapy is still considered experimental by some doctors, and there are no long-term data to compare its effectiveness with standard prostatectomy.
Male hormones (called androgens), particularly testosterone and dihydrotestosterone, determine male secondary sex characteristics and stimulate prostate cell growth. Androgen deprivation therapy (also called androgen suppression therapy or hormone therapy) uses drugs or surgery to suppress or block male hormones, particularly testosterone and dihydrotestosterone, that stimulate the growth of prostate cells. Androgen deprivation therapy is used for advanced and metastatic cancer and may be used if treatment for localized prostate cancer has failed and cancer recurs (as indicated by rising PSA levels). ASCO recommends either removal of both testicles (bilateral orchiectomy) or injections with luteinizing hormone-releasing hormone (LHRH) as initial androgen deprivation treatments.
When prescribing hormone therapy drugs, some doctors recommend periodically stopping and restarting treatment (intermittent therapy). The primary drugs used for suppressing androgens are called luteinizing hormone-releasing hormones (LHRH) agonists. Treatment with LHRH agonists produces a testosterone surge in the first week, which may actually intensify symptoms. The main anti-androgen drugs include flutamide (Eulexin, Drogenil), nilutamide (Nilandron), and bicalutamide (Casodex). In 2008, the FDA approved degarelix as a hormonal drug treatment for advanced prostate cancer.
Men often experience fatigue, loss of energy, and emotional distress from androgen suppression treatment.
In addition, there is growing evidence that androgen deprivation therapy increases the risks for heart attack, stroke, and diabetes. Prostate cancer that does not respond to hormonal treatment is called hormone-resistant, or hormone-refractory, cancer. Chemotherapy drugs for prostate cancer include docetaxel (Taxotere), mitoxantrone (Novantrone), estramustine (Emcyt), and various platinum-based drugs, such as carboplatin. Docetaxel-based drug regimens are emerging as the main chemotherapy treatment for hormone-refractory prostate cancer.
Wilt TJ, MacDonald R, Hagerty K, Schellhammer P, Kramer BS.Five-alpha-reductase inhibitors for prostate cancer prevention. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.
The recommendations included should be considered with caution taking into account that it is pending evaluate its validity. A minority of clinically relevant cases remain confined to the prostate for many years, while others rapidly transform into a life-threatening disease33. Patients diagnosed with clinically localised prostate cancer should be categorised into risk or prognosis subgroups on the basis of known risk factors, primarily PSA and Gleason. The most used are the Gleason grade and PSA pre-treatment, but others have also been proposed whose importance is much discussed, including extension of the tumour beyond the prostate capsule, the invasion of the seminal vesicles, the tumour volume, etc33. The use of combined Gleason indices (relative proportion of samples with a high degree of cancer) provide more accurate prognostic information48.
However, it has been found that when the tumour is of a high degree, the prognosis is poor even when there is organ-confinement39.
When it is attempted with a fine needle biopsy sample, a high error rate is found, often higher then 50%49,50. There are three forms of circulating PSA: free PSA, PSA covalently linked to alpha-1 antichymotrypsin (PSA-ACT) and PSA combined with alpha-2 macroglobulin (PSA-MG). Irrespective of other factors, a high value during diagnosis means worse survival results, more likelihood of PSA relapse and an increased risk of death41,42,45,53-55.
Therefore, total PSA has become the most relevant information for monitoring patients with prostate cancer.
Several studies have found that the tumours of the transition zone data have a better prognosis (malignancy, extension of the tumour, biochemical recurrence-free survival) than those in the peripheral zone34,56-59. This unfavourable relationship increases when there is an increased level of invasion and penetration of the capsule by the tumour61,63. However, several studies have found that this adverse effect is due to its association with several prognostic factors35,36,40,67, including the existence of capsular penetration, positive surgical margins, seminal vesicle invasion or an advanced Gleason grade34-36,62,67. In one study of men treated with radical radiotherapy68, it was found that the rate of distant metastasis after 5 years was significantly higher in patients older than 65 years.
One study found no differences between different age groups in a cohort of 6,890 patients71. Some authors maintain that the increase in microvascular density is a poor prognosis factor in clinically localised prostate cancer, with a higher risk of progression of the disease or PSA relapse62,73-75.
Some authors77,78 have stated that the amount of the elliptically shaped nuclei is a very important prognostic factor. The low immunohistochemical expression of E-cadherin in patients with prostate cancer represents a poor prognosis factor, leading to lower survival, a more advanced disease or a higher risk of recurrence85-89. The increase in IGF-II or IGFBP5 is associated with the pathological stage, the appearance of lymph node metastases, malignant tissue and levels of PSA, in contrast to the increase in IGF-I and IGFBP3. The appearance of mutations in p53 is a poor prognosis factor associated with lower biochemical progression-free survival, increased risk of clinical progression or the appearance of metastasis, resistance to radiotherapy itself or lower overall survival53-101. Low levels of p27 expression have been associated with worse prognoses in several tumours33. Its overexpression in patients with prostate cancer, paradoxically, indicates an increased risk of poorer clinical outcomes103. The increase in the Ki-67 index (the fraction of positive nuclei with Ki-67 in immunohistochemistry) is associated with earlier progression and greater risk of prostate cancer recurrence113-115.
Their function is to mediate the biological effects of male sex hormones in target cells, by activating the transcription of androgen-dependent genes. This consists of not doing anything until the aggressiveness of the tumour increases; at which point treatment with intent to cure is started.
In the latter situation, hormonal or palliative treatment could be started, but any radical treatment option is excluded. In this management option, patients are monitored and offered a radical treatment when progression of the disease is apparent17,120. They agreed only in the PSA determination and digital rectal examination in active surveillance, with initial checks after each quarter, then every 6 months. It also proposed offering active surveillance to other low risk patients and considered it as an alternative for patients at intermediate risk. The review concluded that the available evidence did not demonstrate any differences in survival or disease progression in these patients compared with ERT v RP v BT.
No differences were found in progression-free biochemical survival (PFBS) after 5 years, although the groups were not entirely comparable in terms of age and clinical stage. This consists of the application of brachytherapy at a high dose rate with Ir-192 in combination with ERT to provide a boost in the prostate. Higher rates of urinary obstruction were found in patients treated with BT, but no differences with regard to sexual function or proctitis were found.
The results are derived from non-randomised studies of low sample size which may be biased, because they allowed neoadjuvant hormonal therapy (which can block testosterone for up to one year after finishing treatment).
In terms of efficacy, the conclusion was that, at similar doses, there were no statistically significant differences for local control of the disease, disease-free survival, biochemical progression-free survival or overall survival. This is a (more advanced) 3-dimensional conformal radiotherapy technique, evaluated on patients with localised and locally advanced (T1-T3) prostate cancer. Its use can be beneficial for patients with localised prostate cancer of intermediate or high risk.
With regard to cryotherapy (cryoablation of the prostate) and HIFU (high intensity focused ultrasound), analysed using non-comparative studies, it concludes that there is no evidence to support their use as a first line of treatment. The localised prostate cancer studies were case series with short follow-up periods (less than 2 years). IMRT provides better results in the sexual sphere (p = 0.003), and allows higher doses to be given with less rectal toxicity136. And what results are obtained with regard to urinary incontinence and erectile dysfunction?
Radical prostatectomy with a laparoscope eliminates the need for large incisions in the body. No statistically significant differences in the results for biochemical progression-free survival at 5 years were found. In this study, the same patient received an extended LN on one side and a limited LN on the other side. In patients at intermediate or high risk, it could be used only to improve the staging of the patient.
The results were obtained from non-randomised studies, with low sample size, and may be biased because they allow neoadjuvant hormonal therapy (which can block testosterone for up to a year after finishing the treatment).
One cannot rule out that there were no differences, however, because the study had insufficient statistical power to analyse the subgroups and because some patients received a lesser dose than was planned initially. Some authors161,162 deal only with the prostate (POV, with a maximum volume of 10 x 10 cm), partial pelvis or minipelvis (MPV, which includes the prostate, seminal vesicles and periprostatic lymph nodes and obturators, with a typical size of 10 x 14 cm), and total pelvis (TPV, which includes the prostate, seminal vesicles and external iliac lymph nodes). Risk FactorsThe major risk factors for prostate cancer are age, family history, and ethnicity.
They are also more likely to develop prostate cancer at a younger age and to have more aggressive forms of the disease. Other types of hormones, such as the growth hormone insulin-like growth factor-1 (IGF-1), may also be associated with some types of prostate cancer. In particular, high consumption of red meat and high-fat dairy products has been linked to increased risk for prostate cancer.
However, it is not clear whether this is due to the nutrients contained in these foods, or the fact that these foods are low in fat.
Major clinical studies have found that vitamin and mineral supplements (vitamin E, vitamin C, vitamin D, and selenium) do not prevent prostate cancer.
They block an enzyme that converts testosterone to dehydroepiandrosterone (DHEA), the form of the male hormone that stimulates the prostate. It was based on results of a large 7-year clinical trial that showed that finasteride reduced the overall relative risk of developing prostate cancer by about 25%. For prostate cancer, the 10-year survival rate is about 93% and the 15-year survival rate is about 77%.
As the bladder becomes distended with urine, nerve impulses from the bladder signal the brain that it is full, giving the individual the urge to void. This chronic pain occurs most often in the spine and sometimes flares in the pelvis, the lower back, the hips, or the bones of the upper legs. BPH is not a cancerous or precancerous condition, but its symptoms can mimic late-stage prostate cancer. DiagnosisThere is great uncertainty and controversy over whether the benefits of regular screening for prostate cancer outweigh the risks for most men. Before deciding to be tested, men need to discuss the pros and cons of screening with their doctors. However, the United States Preventive Services Task Force notes that there is insufficient evidence to determine whether routine prostate cancer screening has benefits.
Because of shortened lifespan, responding to abnormal PSA results in this age group may lead to overly aggressive treatment.
Prostate cancer forms in the prostate gland, and can sometimes be felt on digital rectal examination.
Prostate specific antigen (PSA) is a protein produced in the prostate gland that keeps semen in liquid form. Only a biopsy, in which a tiny sample of prostate tissue is surgically removed, can actually confirm a diagnosis of prostate cancer.
Ultrasound is not effective as a diagnostic tool by itself because it cannot differentiate very well between benign inflammations and cancer. To perform a bone scan, doctors inject low doses of a radioactive substance into the patient's vein, which accumulates in bones that have been damaged by cancer. Staging and GradingA pathologist will read the biopsy report and assign a grade to the tumor cells.
Cancers are staged according to whether they are still localized (still within the prostate gland) or have spread beyond the original site. Cancer cells are incidentally found in 5% or less of tissue samples from prostate surgery unrelated to cancer. To determine a prognosis, two numbers are assigned, representing the dominant grade and then the minor grade. TreatmentTreatment choices are generally based on the patient's age, the stage and grade of the cancer, overall health status, and the patient's personal preferences for the risks and benefits of each therapy. To date, neither treatment nor active surveillance has emerged with a definitive survival advantage for localized prostate cancer. Doctors determine the risk category by using criteria such as PSA tests, tumor aggressiveness, and the clinical stage of the tumor. Adding hormonal therapy to radical prostatectomy does not improve survival or cancer recurrence rates. Rising PSA levels do not necessarily mean that the cancer has spread or even that clinical cancer will recur during a man's lifetime. A man must weigh his own emotional responses to the possibility of these side effects versus the possible stress of active surveillance. Active Surveillance (Watchful Waiting)Watchful waiting involves lifestyle change and careful monitoring for cancer progression. More aggressive therapies (surgery and radiation) are usually recommended for men in their 50s and younger. There is therefore little potential benefit from surgery or radiation, with both posing a risk for erectile dysfunction and incontinence.
The perineal approach causes less bleeding and has a shorter recovery time, but it makes it more difficult to preserve nerves and remove lymph nodes. Less invasive surgical techniques using laparoscopy have been developed for radical prostatectomy. In cases where the tumor lies too closely to the nerve, nerve-sparing techniques may not be possible.
Other complications include the usual risks of any surgery, such as blood clots, heart problems, infection, and bleeding. When the urinary catheter is first removed following surgery, nearly all patients lack control of urinary function and will leak urine for at least a few days and sometimes for months. Radiation TherapyRadiation therapy may be used as an initial treatment for localized prostate cancer. 3-D conformal techniques use computers and a three-dimensional image of the prostate to target the tumor precisely, using high-dose radiation beams.
It is also used in combination with external beam radiation to treat intermediate-risk localized prostate cancer. One area of controversy is whether to use adjuvant radiation after surgery on patients whose PSA levels are very low or undetectable but who have other test results that indicate the cancer is likely to spread.
Some studies suggest that salvage radiation could be more beneficial than previously thought, even for men with aggressive prostate cancer.
Cryosurgery may also be used as a salvage procedure for patients who have undergone radiation therapy and have had cancer recurrence detected early.

Other complications of cryosurgery include urinary retention, swelling, and fistula formation. When prostate cells, both healthy and cancerous, are deprived of androgens, they no longer proliferate and eventually die. Androgen deprivation therapy is not a cure for prostate cancer, but it can help control symptoms and disease progression. In 2007, the American Society of Clinical Oncology (ASCO) published clinical guidelines for androgen deprivation therapy in patients with recurrent, progressive, or advanced prostate cancer. It is the single most effective method of reducing androgen hormones, but because it is permanent it is not suitable for intermittent or temporary androgen deprivation.
Patients do not experience a reversal of sex characteristics and the voice does not change. LHRH drugs block the pituitary gland from producing hormones that stimulate testosterone production. They are generally used in combination with LHRH agonists or orchiectomy to completely block androgen hormones. They include estrogen therapy and ketoconazole (Nizoral), an anti-fungal drug that blocks testosterone production.
Degarelix belongs to a class of drugs called gonadotropin releasing hormone (GnRH) receptor inhibitors.
Hormonal drugs combined with radiation therapy may improve survival rates in moderate- or high-risk groups. Some studies suggest benefits from using hormone therapy before surgery (neoadjuvant therapy) to reduce the tumor size, but this approach does not appear to increase survival. Hormonal therapy may significantly impair quality of life, particularly in men who had no symptoms beforehand and whose cancer has not metastasized. A number of medications, especially bisphosphonates, are available to help prevent or reduce bone loss.
These drugs are often combined with other cancer drugs (such as 5-fluorouacil) or corticosteroids (such as prednisone). In 2004, the FDA approved docetaxel injection in combination with prednisone for treatment of patients with hormone-resistant prostate cancer. Androgen suppression and radiation vs radiation alone for prostate cancer: a randomized trial. Vitamins E and C in the prevention of prostate and total cancer in men: the Physicians' Health Study II randomized controlled trial. Diabetes and cardiovascular disease during androgen deprivation therapy for prostate cancer. Multivitamin use and risk of prostate cancer in the National Institutes of Health-AARP Diet and Health Study. Effect of selenium and vitamin E on risk of prostate cancer and other cancers: the Selenium and Vitamin E Cancer Prevention Trial (SELECT).
Quality of life after surgery, external beam irradiation, or brachytherapy for early-stage prostate cancer. Initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer: 2006 update of an American Society of Clinical Oncology practice guideline. Survival following primary androgen deprivation therapy among men with localized prostate cancer. Cancer screening in the United States, 2009: a review of current American Cancer Society guidelines and issues in cancer screening. Diet and dietary supplement intervention trials for the prevention of prostate cancer recurrence: a review of the randomized controlled trial evidence.
Systematic review: comparative effectiveness and harms of treatments for clinically localized prostate cancer. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. In another publication69, the time of PSA relapse after radical prostatectomy was significantly higher for those less than 70 years of age. In addition, Austin et al suggested that race is an important modifier on the effect of age on prognosis. Others have analysed the size of nuclei79-84 and other morphometric factors79-81 to make prognostic predictions about localised prostate cancer. The greater expression of another type of p21 (Ras p21), is associated with lower survival after 5 years104. The gene for these receptors is in the X chromosome and contains a series of repeated CAG nucleotide triplets. This attitude is often adopted with men of an advanced age or with significant comorbidities, with a low probability that the cancer will progress in any meaningful way during their expected lifetime17. It is believed that the only clinically significant differences for quality of life between the two treatment s are those relating to the sexual sphere, where there are better results for watchful waiting.
They also looked at 3 other studies (one cohort study of 2,222 patients, a case-control study and a series of cases) comparing BT with ERT, and in those where there were no differences found in PFBS at 5 and 7 years, although the groups were not entirely comparable in the case studies and controls, and the follow-up time was very short for the series of cases. Three retrospective localised prostate cancer studies of poor quality were found which compare IMRT and 3D-CRT. The combination of BT + ERT may decrease the rate of rectal complications with respect to treatment with BT127-129. It allows lymphadenectomy and conservation of neurovascular bundles, as well as the use of robotic arms to facilitate the operation. No statistically significant differences were found between LRP (transperitoneal - TLRP, extraperitoneal - ELRP or robot-assisted: RALRP) and ORP for either biochemical progresion free-survival or urinary incontinence with a follow-up of less than 3 years. The learning curve for laparoscopic radical prostatectomy is much longer than for the open, but the robot type is much less than conventional laparoscopic methods149. This study offered no information on other relevant clinical or anatamopathological data (pre-operative PSA, Gleason score, clinical stage). After 6 years no significant difference was found in PSA relapse-free survival between patients with or without LN. No differences were found when comparing extended vs limited for biochemical recurrence-free survival in patients with positive lymph nodes, although there was a trend for improved survival results in patients who underwent extended dissection (p = 0.07). 43% of the patients had a pathological stage pT3 (infra staging), this group had a greater chance of having positive lymph nodes than those who were in stages pT1-T2 (39% v 13%). No statistically significant differences were found between both groups with respect to unilateral surgical complications. The percentage of positive surgical margins was 24% in patients with PNB and 31% in those without PNB (no statistically significant differences were found). No statistically significant differences were found (p = 0.3) in the recovery of urinary continence when comparing RP and PNB v RP without PNB (minimum follow-up of 18 months).
It concludes that PNB (both uni- and bilateral) does not affect urinary continence results (no statistically significant difference between the performance or not of PNB in RP). Moreover, by increasing the median dose from 70 Gy to 78 Gy, the greatest improvement was found in the intermediate and high risk group. In this study, different volumes and dose limits (VD) are compared and different institutions are involved.
The choice of volume to be used in the study depended on the centre treating the patient: TPV in two centres, PSSV in another centre. As with any cancer, if it is advanced or left untreated in early stages, it may eventually spread through the blood and lymph fluid to other organs. The central area of the prostate that wraps around the urethra is called the transition zone. It grows only slightly until puberty, when it begins to enlarge rapidly, attaining normal adult size and shape, about that of a walnut, when a man reaches his early 20s. Having one family member with prostate cancer doubles a man's own risk, and having three family members increases risk by 11-fold. Nutritious foods that are part of a healthy diet are the best sources for vitamins and minerals. However, in this study, a few more men who took finasteride developed a high-grade aggressive form of prostate cancer than the men who did not take finasteride. By voluntarily relaxing the sphincter muscle around the urethra, the bladder can be emptied of urine.
Symptoms include urgency, frequency, and pain in urination, sometimes accompanied by fever or blood in the urine. If a man chooses to be tested, or would like the doctor to make the decision, he should be screened yearly with a PSA test and digital rectal exam.
The doctor inserts a gloved and lubricated finger into the patient's rectum and feels the prostate for bumps or other abnormalities.
As a result, the American Cancer Society does not recommend routine PSA testing, although individual men may choose to be tested. A biopsy is usually performed to confirm or rule out cancer based on a combination of PSA test levels, findings on the DRE, family history, and patient’s age and ethnicity.
The PSAV may help determine when treatment should begin and which treatment should be used. The Gleason system classifies and scores the cancers cells based on their microscopic appearance.
Delaying treatment, while having the cancer monitored for signs of progression, is also an acceptable option.
Studies indicate that compared to watchful waiting, radical prostatectomy may lower the risk of cancer recurrence and death, particularly for younger men with aggressive tumors.
However, several recent studies have suggested that treatment provides a survival advantage over watchful waiting for some men with early-stage prostate cancer.
A sudden rise or persistently elevated PSA levels after treatment are often indications that prostate cancer persists.
These techniques use smaller incisions and allow faster recovery, but they require special surgical training. A temporary catheter used to pass urine is kept in place when the patient is sent home and is usually removed about 3 weeks after the open operation or 1 week after their robotic procedure.
Use of these drugs three times a week accompanied by sexual stimulation is now commonly recommended. It may also be used as treatment for cancer that has not been fully removed or has recurred after surgery. Poorer candidates for brachytherapy include men who have had transurethral resection of the prostate (TURP) and patients with advanced cancer, high-grade tumors, or very enlarged prostate glands. Patients with adverse findings and low PSA have to weigh the potential complications of radiation therapy against the odds of recurrence without it. The goal of cryosurgery is destruction of the entire prostate gland and possibly surrounding tissue.
Incontinence and fistulas tend to occur more when cryosurgery is used as a salvage procedure than when it is used as a primary procedure. The guidelines recommend that hormone therapy should, in general, be delayed until patients begin to experience symptoms from their cancer. More research needs to be conducted to determine the effectiveness of intermittent therapy.
Orchiectomy plus radical prostatectomy may delay progression in patients with cancers that have spread only to the pelvic lymph nodes. It works by suppressing testosterone and thereby slowing the growth and progression of prostate cancer.
Patients who received this drug combination survived on average 2.5 months longer than patients who received mitoxantrone and prednisone.
Comparative effectiveness of therapies for clinically localized prostate cancer: executive summary no. It is associated with other unfavourable circumstances, such as extracapsular extension, seminal vesicle invasion, increased tumour or positive surgical margins. And in a third study70, the rate of PSA relapse after radical prostatectomy was significantly higher in the over-70 age group, compared to rates found with those under 51 and with those in the 51-70 age group. In their study, with black men, younger patients had more advanced tumours at diagnosis and poorer outcomes for survival, while the study showed the opposite for white men72.
The length of these repetitions varies among individuals and is associated with the transcriptional activity of the androgen receptors33.
In other words, surgery is a statistically significant more effective treatment than watchful waiting.
When comparing BT + ERT v ERT, a case-control study found a greater PFBS after 5 years for the combined treatment (67% v 44%), although in this study the follow-up was incomplete and the average age of the control group was 5 years older. The review concluded that the total minimum dose obtained with this technique is far superior to those achieved with 3D-CRT, with an acceptable toxicity, and it induces local healing in most patients, even those at high risk. The authors of this revision concluded that, although it needs more evidence on the safety and efficacy of BT as a treatment for prostate cancer, its use can be recommended for patients with localised prostate cancer at low-risk, with a glandular volume less than 40 cm3 and availability of treatment (it is not possible to implement it in all Spanish public establishments).
It considers cryotherapy to be an experimental procedure, and therefore not a first choice treatment. The existence of positive lymph nodes is statistically significantly associated with increased risk of progression, decreased cancer-specific survival (74% at 5 years) and a greater probability of relapse.
Positive lymph nodes were found in only 8 patients, making it impossible to find any statistically significant differences between each group. In other words, in patients with T1 and T3 prostate cancer and intermediate and high risk, the best BPFS results at 5 years were in the ≥ 72 Gy group (median 78 Gy). The gland generally remains stable until men reach their mid-40s, when, in most men, the prostate begins to enlarge again through a process of cell multiplication.
Fortunately, the cancer is usually very slow growing and older men with the cancer typically die of something else. Prostate cancer is more common in North America and northern Europe, and less common in Africa, Latin America, and Asia. Lycopene, which is found in tomatoes, has been a target of research interest, but the evidence for its protective benefit is still inconclusive.
A high intake of calcium has been linked to an increased risk of prostate cancer in some studies. More recent studies have suggested that 5-ARI drugs may not increase the risk of developing aggressive cancer. Research indicates that men who are diagnosed with low-grade prostate cancers have a minimal risk of dying from prostate cancer up to 20 years after diagnosis. Doctors cannot yet determine which early-stage tumors pose a risk of being aggressive and need treatment, and which tumors should be left alone. Measuring PSA levels increases the chance for detecting the presence of cancer when it is microscopic.
If a biopsy gives a negative result but the doctor still suspects cancer, repeat biopsies may be performed. Based on the grade, PSA test, digital rectal exam, and possibly imaging tests, the doctor stages the cancer. For example, a tumor with a dominant grade of 3 and a minor grade of 4 are given a Gleason score of 7. If test results indicate cancer progression, doctor and patient consider treatment options (surgery, radiation, or drugs). The general recommendation is that aggressive therapy is suitable for those who have a life expectancy of more than 10 years and who have localized but mid- to high-grade tumors.
Laparoscopic surgery may also be done using a robotic system, which involves the surgeon directing a robotic arm through a computer monitor. In general, younger patients with early-stage cancers recover fastest and experience the fewest side effects. A percentage of men will continue to have small amounts of leakage with heavier exertion or possibly sexual activity.
Other treatments for erectile dysfunction (alprostadil injections, vaccum devices, penile implants) may also be options.
In advanced cancer, radiation therapy is used to shrink the size of the tumor and relieve symptoms. Steel probes are inserted through the skin between the anus and the rectum and into the prostate. However, when therapy is deferred, patients should regularly visit their doctors every 3 - 6 months for careful monitoring of their condition. Hormonal drugs before radiation (neoadjuvant therapy) may be helpful in shrinking enlarged glands so that brachytherapy (radiation implants) can be used. Side effects can be serious and may include gastrointestinal problems (nausea, vomiting, or diarrhea), fatigue, low blood cell counts, and increased risk for blood clots. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. The authors concluded that BT compared with ERT or RP seems to provide comparable results, although the evidence is scant. As for safety, better (and statistically significant) results were found for IMRT on the quality of life related to the sexual sphere (p = 0003).
For patients at low risk, IMRT slows the process without adding any benefits to 3-dimensional conformal radiotherapy. And, although not significant (due to low sample size), there are differences with regard to sexual impotence, with a tendency to get better results for LRP in different studies. No statistically significant differences were found when comparing the BF of patients with PNB v patients without PNB after 3 years of surgery (not even when stratifying according to preliminary risk), nor when comparing unilateral PNB v bilateral PNB v patients without PNB.
Other authors164 irradiate a volume which includes the prostate and seminal vesicles (PSSV field). In other words, for patients with clinically localised prostate cancer and a high risk of metastasis (greater than 15% risk), when comparing pelvic irradiation with prostate and seminal vesicles, no statistically significant differences for clinical control and cancer-specific survival with a follow-up period of up to 15 years were found. As many as 90% of all prostate cancers remain dormant and clinically unimportant for decades. However, men diagnosed with more severe forms of prostate cancer have a higher risk of dying within 10 years. The concern is that routine screening for early detection of tumors may lead to invasive and unnecessary treatment. Recent research suggests that men with early-stage prostate cancer who have a slow PSAV are more likely to live longer than men with rapidly rising PSA levels.
The following scores are often used to suggest how well or poorly the tumor is differentiated. The tumor grade may be the best guide for determining the risks in choosing watchful waiting.
SurgeryIn men whose cancer is confined to the prostate, surgical resection (radical prostatectomy) offers the potential for cure. Not every hospital can do robotic-assisted laparoscopic prostatectomy and these procedures are difficult to perform. Even with experienced doctors, the distribution of radioactive seeds may be uneven, increasing the risk for insufficient doses.
It usually goes away eventually, but a few patients have diarrhea flare-ups for years afterwards. Liquid nitrogen is pumped through the probes to freeze all prostate cells, both healthy and cancerous.
In other words, for patients with localised prostate cancer who have undergone a prostatectomy, the probability of erectile function is greater if the neurovascular bundles are preserved. In other words, a dose of 78 Gy maintains anal bleeding and losses below 10% in patients with T1-T4 prostate cancer. For example, Asians who live in the United States have a higher rate of prostate cancer than those who live in Asia. Each year, nearly 200,000 men in the United States are diagnosed with prostate cancer, and about 27,000 die from the disease. Patients should report symptoms such as weight loss, pain, urinary problems, fatigue, or impotence to their doctors.
Cure rates from initial surgery in men with localized cancer are about 90%, depending on tumor stage, tumor grade, PSA levels, and overall health of the patient. In addition, in some cases the seeds can migrate through the bloodstream to other parts of the body. Any duplication or distribution of the information contained herein is strictly prohibited. The results of this study in light of the clinical or pathological patient data were not analysed.
PSA levels can be increased by various factors other than prostate cancer, including benign prostatic hyperplasia, prostatitis, advanced age, and ejaculation within 48 hours of the test. Most patients can consider themselves disease-free if their PSA levels remain undetectable 10 years after surgery.

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