Mount Sinai - Prostate Cancer

Signs and Symptoms

As with many malignancies, by the time a patient has symptoms associated with his cancer, it is frequently too late to intervene with curative therapies. The signs and symptoms of prostate cancer are then related to locally extensive disease, manifest by difficulty urinating, getting up frequently at nighttime, daytime frequency, urgency, or the need to hurry at the first sign that one needs to urinate. Such symptoms can be associated with prostate cancer, though more commonly these are associated with BPH. In some instances, these symptoms may be associated with gross hematuria, meaning blood that may be seen in the urine by the naked eye.

Unfortunately, some men are first diagnosed with prostate cancer due to signs and symptoms of metastatic disease. Prostate cancer most commonly spreads to the bone, especially the lower spine, leading to symptoms of back pain. When erosion of the spine is such that the spinal column weakens, patients can have neurological signs and symptoms in their legs such as weakness and difficulty walking.

The widespread use of prostate specific antigen (PSA) now allows us to diagnose more men with prostate cancer at earlier stages of their disease. PSA is an enzyme that is produced in the prostate. Its main function is to aid in liquifying the ejaculate. It is found at very high levels in semen. Some PSA leaks into the bloodstream, so it can therefore be measured by a blood test.

While an elevation in the PSA is specific for a disease within the prostate, it is not specific for prostate cancer, as elevations can also be associated with BPH or infections of the prostate. However, statistically speaking, men with a PSA between 4ng/ml and 10ng/ml have approximately a 25% chance of having prostate cancer, while men who have a PSA of greater than 10ng/ml have approximately a 50% chance of having prostate cancer. The goal of the Prostate Health and Research Center, through outreach and education, is to have men, especially those at higher risk (i.e. African-American or men with strong family history of the disease), screened with yearly PSA and rectal exams so that a diagnosis will be ascertained earlier, at which time available curative therapies are much more likely to be efficacious.

A second PSA blood test has been developed called free PSA. Most of the PSA that is measured in the blood stream is bound to proteins so that only a small fraction of the PSA is free-floating, termed "free PSA." Urologists use the % free PSA, which is derived by dividing the free PSA by the total PSA value. Men with prostate cancer have much lower levels of % free PSA than those who do not have prostate cancer.

Through careful analysis, two important cut points of the percent free PSA have been reached. For men with a PSA between 4-10, a free PSA of < 10% indicates a 50% likelihood of cancer. When the % free PSA is greater than 26%, the likelihood that the patient has prostate cancer is usually less than 10%. These cutoffs are most useful in a patient who has undergone a prostate needle biopsy that did not show cancer as the patient and his physician are trying to decide on further study.

Symptoms

The signs and symptoms of prostate cancer are then related to locally extensive disease, manifest by difficulty urinating, getting up frequently at nighttime, daytime frequency, urgency, or the need to hurry at the first sign that one needs to urinate. However, these symptoms can also be associated with benign enlargements of the prostate (BPH) and should not be confused with BPH. In some instances, these symptoms may be accompanied with gross hematuria, meaning blood in the urine that may be seen by the naked eye.

Diagnosis

Through improved diagnostic capabilities and enhanced public awareness, more men now seek medical attention or advice for the various diseases associated with the prostate. In parallel, medicine through science and technology has improved and expanded methods of treatment.

In men without symptoms, prostate cancer can be diagnosed on the basis of an abnormal digital rectal examination or on the basis of an abnormal blood test for prostate specific antigen (PSA).

A transrectal ultrasound guided needle biopsy is generally recommended when the PSA is elevated or an abnormality is detected on a digital rectal exam. Many patients ask why they need a biopsy if their PSA is normal but the digital rectal exam is abnormal. In fact approximately 20 percent of the men diagnosed with prostate cancer in the United States have a normal PSA but on biopsy for an abnormality on rectal exam are found to have a clinically relevant prostate cancer.

Biopsy

The prostate needle biopsy is performed in the physician’s office with minimal preparation, using a local anesthetic to ease the discomfort of the procedure. This is achieved by injecting small amounts of local anesthetic, with a very small needle, where the prostate joins the base of the bladder. Depending on the size of the prostate, anywhere from six to 12 core biopsies are taken. The most common problems a patient may face after a biopsy include bleeding in the urine and the stool, or semen. This is usually transient. Some patients can develop an infectious complication, though this is less than 1/100 patients.

The advantage of the prostate needle biopsy diagnosis is that it can usually distinguish between BPH and prostate cancer. However, some men are discovered to have a lesion called PIN, which stands for Prostatic Intraepithelial Neoplasia. The exact nature of this lesion is unclear. Many feel that this is a precursor of overt cancer of the prostate but this has yet to be proven. We do know that patients with PIN have an approximately 40 - 50 percent likelihood of developing prostate cancer within five years. We carefully follow these patients with serial PSAs and biopsies where indicated, either through patient preference, change in rectal exam or an increase in PSA. This lesion is an attractive candidate for intervention by complementary or alternative therapies in our Hospital.

Prostate Cancer

Signs and Symptoms

Symptoms

Diagnosis

Biopsy

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