Prostate Cancer

The Prostate: It is a small gland in the male reproductive system, located below the bladder and in front of the rectum. Its main function is to produce part of the fluid that makes up semen (sperm).

Prostate Cancer: It occurs when cells in the prostate begin to grow uncontrollably and malignantly, forming a tumor. It is one of the most common types of cancer in men.

Evolution: Many prostate cancers grow slowly and may not cause significant problems for years. However, some can be more aggressive and spread to other parts of the body (metastasize) if left untreated.

Age: The risk increases significantly after age 50, with most cases diagnosed in men over 65.

Family History: Having a father or brother with prostate cancer doubles the risk. The risk is even higher if several family members have been affected, especially at a young age.

Ethnicity: Men of African or Afro-Caribbean descent are at higher risk and may develop the disease earlier. Men of Asian origin have a lower risk.

Diet: Some studies suggest that diets high in animal fat and dairy products, and low in fruits and vegetables, may increase the risk.

Obesity: Obesity may be associated with an increased risk of more aggressive prostate cancer.

Hereditary Genetic Alterations: Mutations in certain genes (such as BRCA1, BRCA2, HOXB13) can increase the risk, although they are responsible for a small percentage of cases.

Initial Phases: Often, prostate cancer doesn’t cause any symptoms in its early stages. That’s why screening can be important.

Urinary symptoms (may also be caused by benign conditions such as Benign Prostatic Hyperplasia – BPH):

• Difficulty starting urination.
• Weak, hesitant, or interrupted urine stream.
• The need to urinate more frequently, especially at night (nocturia).
• A feeling of urgency to urinate.
• A feeling that the bladder has not emptied completely.
• Pain or burning sensation when urinating (less common).

Symptoms in More Advanced Stages (if the cancer has grown or spread):

• Blood in the urine (hematuria) or in the semen (hematospermia).
• Sudden onset erectile dysfunction.
• Pain in the lower back, hips, or thighs (may indicate bone metastases).
• Unexplained weight loss and fatigue.

If you experience any of these symptoms, it is important to consult your doctor.

Screening (in asymptomatic men):

• The decision to undergo screening should be individualized and discussed with your doctor, considering your risk factors, general health status, and the potential benefits and risks. Generally, the discussion begins around age 50, or earlier (40-45 years) for men at high risk (family history, African ethnicity).
• PSA (Prostate-Specific Antigen): A blood test that measures PSA levels. Elevated levels may indicate prostate cancer, but can also be caused by BPH, prostatitis (inflammation of the prostate), or other factors. An elevated PSA does not automatically mean you have cancer.
• Digital Rectal Examination (DRE): The doctor inserts a gloved and lubricated finger into the rectum to palpate the prostate and detect nodules, hardening, or other abnormalities.

Diagnosis (when suspected):

• PSA and Digital Rectal Examination: Abnormal results may lead to further investigation.
• Multiparametric Magnetic Resonance Imaging of the Prostate (mpMRI): An advanced imaging test that provides detailed images of the prostate. It helps identify areas suspected of being cancerous, assess the extent of the tumor within the prostate (local staging), and guide biopsy, making it more precise.
• Prostate Biopsy: It is the only test that confirms a diagnosis of prostate cancer. Small samples of prostate tissue are collected through the perineum, guided by transrectal ultrasound, often with mpMRI image fusion) and analyzed under a microscope by a pathologist.
  • Gleason Scale (or ISUP Grade): If cancer is found, the pathologist assigns a score (Gleason Score from 6 to 10, or ISUP Grade Group from 1 to 5) that indicates the aggressiveness of the tumor. A lower Gleason score means a less aggressive and slower-growing cancer.

After diagnosis, staging is performed to determine the extent of the cancer: whether it is confined to the prostate, whether it has invaded nearby tissues, or whether it has spread to lymph nodes or other parts of the body (metastases).

In simplified terms:

• Localized Cancer: The tumor is located only within the prostate.
• Locally Advanced Cancer: The tumor has penetrated the prostate capsule and may have reached the seminal vesicles or adjacent organs (such as the bladder or rectum).
• Metastatic (or Advanced) Cancer: The cancer has spread to distant lymph nodes, bones, or other organs (lungs, liver).

Staging tests may include: prostate MRI (already mentioned), abdominal-pelvic Computed Tomography (CT) scan, bone scintigraphy, or PSMA PET (a more recent and sensitive test for detecting metastases).

For Localized or Locally Advanced Prostate Cancer (with curative intent):

• Active Surveillance:
  • For men with low-risk prostate cancer (Gleason 6, low PSA, small tumor volume) and, in some cases, favorable intermediate risk.
  • It consists of closely monitoring the cancer with regular PSA tests, digital rectal exams, MRI scans, and sometimes repeat biopsies.
  • Active treatment is only initiated if there are signs of disease progression. The goal is to avoid or delay the side effects of invasive treatments in tumors that may never cause problems.
• Surgery (Radical Prostatectomy):
  • Surgical removal of the entire prostate gland, seminal vesicles, and, in some cases, nearby pelvic lymph nodes.
  • Objective: to cure cancer by removing it completely.
  • Surgical Approaches:
    • Open Surgery: Through an incision in the lower abdomen (retropubic) or in the perineum.
    • Laparoscopic Surgery: Through small incisions, using a camera and long instruments.
    • Robotic Surgery (Robot-Assisted Radical Prostatectomy):
      • It is the most common form of radical prostatectomy in many centers, representing a significant advancement in minimally invasive surgery.It is now considered the gold standard for prostate surgery.
      • The surgeon controls robotic arms that hold thin surgical instruments, operating through small incisions.
      • Advantages of Robotic Surgery:
      • Enhanced, high-definition 3D view: It allows for a superior view of the anatomy.
      • Greater precision and dexterity: Robotic instruments have a greater range of motion than the human hand and filter out tremors.
      • Better preservation of neurovascular bundles: Crucial for erectile function.
      • More precise reconstruction from the urethra to the bladder: It contributes to a faster recovery of urinary continence.
      • Less blood loss and a reduced need for transfusions.
      • Less post-operative pain.
      • Shorter hospital stay and faster recovery.
      • Better aesthetic results (smaller scars).
• Radiotherapy:
  • It uses high-energy radiation to destroy cancer cells.
  • External Beam Radiotherapy: The radiation is administered by a machine outside the body.
  • Brachytherapy (Internal Radiation Therapy): Tiny radioactive “seeds” are implanted directly into the prostate.
  • It can be a primary curative option or used after surgery if there is a risk of recurrence. It is frequently combined with hormone therapy in higher-risk cancers.
• Other Focal Therapies (for selected cases and often in a research context):
  • Such as HIFU (High-Intensity Focused Ultrasound) or Cryotherapy, which aim to treat only the cancerous area within the prostate, preserving the rest of the gland.

For Advanced or Metastatic Prostate Cancer:

• The main goal is to control cancer growth, alleviate symptoms, and improve quality of life.
• Hormone Therapy (Androgen Deprivation Therapy – ADT):
  • This is the basis of treatment. Androgens (male hormones such as testosterone) stimulate the growth of prostate cancer cells. ADT reduces the levels of these hormones.
  • It can be administered through injections or, rarely, surgery (bilateral orchiectomy – removal of the testicles).
• New Hormonal Agents: Newer medications (such as abiraterone, enzalutamide, apalutamide, darolutamide) are very effective, even when traditional ADT stops working or in combination with it.
• Chemotherapy: Used primarily when cancer has become resistant to hormone therapy or in combination with hormone therapy in cases of high-volume/high-risk metastatic disease at diagnosis.
• Bone Therapies: Medications to strengthen bones and reduce the risk of fractures and pain when bone metastases are present (e.g., bisphosphonates, denosumab).
• Therapeutic Radionuclides: Such as Radium-223 (for bone metastases) or Lutetium-177-PSMA (a newer and more promising therapy for resistant metastatic disease).
• Immunotherapy: In some specific cases of advanced prostate cancer.
• Palliative and Supportive Care: Focused on symptom relief, psychological support, and improving quality of life at all stages of the disease.

Prostatectomia Radical: The most significant risks are urinary incontinence (involuntary loss of urine) and erectile dysfunction (difficulty in achieving or maintaining an erection). Robotic surgery, with its precision, aims to minimize these risks, but they still exist.

Radiotherapy: It can cause fatigue, urinary problems (irritation, frequency), bowel problems (diarrhea, rectal bleeding), and erectile dysfunction.

Terapia Hormonal: It can cause hot flashes, loss of libido, erectile dysfunction, fatigue, loss of muscle mass, weight gain, mood swings and, in the long term, osteoporosis.

After treatment, regular medical follow-up will be necessary.

Consultations and Examinations: Primarily PSA measurements, which become a very important marker. Imaging tests may be necessary.

Side Effects Management: Rehabilitation programs for incontinence (pelvic floor exercises), treatments for erectile dysfunction.

Psychological and Emotional Support: Essential for coping with the diagnosis and changes in quality of life.

Healthy Lifestyle: Maintaining a balanced diet, exercising, and not smoking can help with recovery and overall well-being.

There is no guaranteed way to prevent prostate cancer, but some measures can reduce the risk:

• Maintain a healthy diet, rich in fruits, vegetables, and fiber, and low in animal fats.
• Maintain a healthy weight.
• Practice physical exercise regularly.

Early detection is crucial. Discuss the need for screening with your doctor, especially if you have risk factors.

Prostate cancer is a complex disease, but with advances in diagnosis and treatment, many men live long and healthy lives after diagnosis. Information is a powerful tool.

If you have been diagnosed with prostate cancer, have an elevated PSA, or are experiencing symptoms that concern you, it is essential to seek specialized medical advice. Schedule an appointment so we can assess your individual case, discuss all available treatment options, including the advantages of robotic surgery, and define the best treatment plan for you.