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This article was originally submitted by Dr. Mashhood Hamza
The prostate is a wall-nut shaped small gland in males that produces fluid to nourish the sperms. Prostate cancer is the second leading cause of cancer-related deaths after lung cancer in men after 50 years of age in developed and developing countries.
The aetiology is unfortunately still unknown but some established non-modifiable risk factors like age on top of the list. Prostate cancer is clinically rare below the age of 50 years and the risk increases significantly above 60 years of age.
The second important etiological risk factor is race; prostate cancer has a marked ethnic and geographical variation.
The disease carries a higher risk in African-Americans than Europeans and ethnic races; in Pakistan and India shows an intermediate risk, while Chinese and Japanese shows the lowest risk.
Genetics play a pivot role in promoting carcinogenesis in their siblings; with an increase of two to three times risk in men; with a diagnosed prostate cancer in their first degree relatives.
Some genes are identified like BRCA1, BRCA2, HOXB13 and very strong family history; of breast cancer accounts for higher risk; of developing hereditary prostate carcinoma or at higher risk of developing prostate cancer in later ages. There is a strong association of male hormone testosterone and dihydrotestosterone with prostate cancer and benign prostatic disease.
Some dietary correlation in prostatic cancer versus unsaturated fats and meat consumption, but certain elements like selenium, zinc, tomatoes, Vitamin E has a protective effect.
Some of the environmental factors and occupational chemicals also promote the process of cancer
For example, men working at nuclear power plants or those; who are handling cadmium are more prone to develop prostate cancer. It is thought that lack of ultraviolet light may predispose men to develop it.
The clinical presentation of a patient with prostate cancer varies ranging from asymptomatic to severe out-flow obstruction with widespread disease. The clinical symptomatic differentiation between prostate cancer and benign prostatic disease is very difficult. Those secondary symptoms arise due to the large size of the prostate; which presents as an increase in urinary frequency all day night.
The lower urinary tract symptoms also include the incomplete evacuation of urine from the bladder, significant straining; during voiding, there is a weak stream with terminal dribbling. The midstream urine may sometimes suddenly stop and starts. Due to the feeling of incomplete evacuation, they usually go frequently with a desire to empty their bladders. Some patients present with the urge, a strong desire to pass urine.
Sometimes the patient may land in the emergency department with full occlusion of their outflow tract
As a result, this leads to acute urinary retention and the drainage of urine from the kidneys is impaired; causing pain at lower abdomen and flanks leading to renal failure, if not relieved.
Sometimes patients with prostatic symptoms had frequent visits of a neurosurgeon or a spine surgeon for backaches; sometimes it’s a bony spread or hits a spine most of the time, on my clinical judgment.
Bony spread, spinal cord compression and local symptoms; like blood in urine or blood in semen, is also noted in a variety of patients.
To evaluate patients with prostate cancer we have to take a proper history and do the physical examination; with a digital rectal examination. On digital rectal examination, there will be a hard prostate. For certain blood tests like PSA (prostatic specific antigen) a rise; in their levels, raise the suspicion of the disease but not always.
Nowadays, PSA is used as a tool in screening program; of prostate cancer, with positive family history and lower urinary tract symptoms.
The suspicion of the disease can only be confirmed by invasive investigations
For instance, Transrectal Ultrasound-guided biopsy or prostatic biopsy. The biopsy report shows how much aggressive the disease is on the basis of grading.
Once the disease is confirmed then radiological imaging is needed for further evaluation; like a local invasion or to assess any metastasis in distant organs; like lungs, liver and bone. The tools for such evaluation includes Magnetic resonance imaging of prostate (MRI), Computed tomography scan (CT-Scan) and Nuclear Bone Scans.
Prostatic carcinomas are completely curable if diagnosed earlier and are confined to prostate only. We have a lot of modalities to treat prostate cancer like; hormonal therapy, surgical options and chemoradiotherapy – depending upon the stage of the patient.