Anne Katz - Prostate Cancer and the Man You Love: Supporting and Caring for Your Loved One

Anne Katz, PhD, RN, FAAN, works as a clinical nurse specialist and certified sexuality counselor at the Manitoba Prostate Centre in Winnipeg, Canada. She supports men with prostate cancer and their partners through prostate cancer, from diagnosis and into survivorship. This book is her fifteenth publication and a complete revision of the first edition of Prostate Cancer and The Man You Love (2012).

This chapter explains the basics of prostate cancer to prepare you for reading the rest of this book. It contains an accessible description of the development of prostate cancer, screening for the disease, and how the pathology results and imaging studies guide the stage and grade of the cancer that in turn dictates treatment options. The various treatment options are described as well as the impact of each treatments side effects on the couple.

Prostate cancer is a very common cancer in men, second only to skin cancer. It is most often diagnosed in men over the age of fifty years, and men of African American and Caribbean African ancestry are at high risk of developing this cancer. There may be a link to a family history of prostate cancer but most men will develop this cancer, regardless of family history. There are some identified genetic risk factors; men who carry the BRCA1 and BRCA2 genes as well as those with Lynch syndrome are at higher risk of developing prostate cancer. Other risk factors with less evidence include being exposed to Agent Orange or chemical agents associated with firefighting. Being an older man remains the greatest risk factor, and this cannot be modified or prevented!

The prostate gland lies below the bladder and surrounds the top part of the urethra (the tube that drains urine from the bladder). The prostate produces a fluid (seminal fluid) that nourishes sperm; during orgasm the prostate contracts and propels the semen out of the penis through the urethra. The prostate gland is about the size of a walnut and often increases in size as the man ages. This causes the man to need to urinate more frequently as well as incomplete emptying of the bladder. Prostate cancer, however, is not commonly accompanied by any symptoms at all, and men are often shocked when they are diagnosed because they had no warning that something was wrong.

The PSA (prostate-specific antigen) test is a blood test that is used to screen for the presence of the PSA protein that can be a warning sign of prostate cancer. Both the prostate and prostate cancer cells produce this protein. The PSA test is plagued by low accuracy with both false positive and false negative results. A false positive result will cause anxiety in the patient as he waits for another test, a biopsy, that will show if he has prostate cancer or not. A false negative result may mean that a diagnosis is missed. There are cutoffs based on age for the PSA: for a man in his forties, the PSA should be between 0 and 2.5 ng/ml; for a man in his fifties, it can be as high as 3.5 ng/ml; for a man in his sixties, the normal range is between 0 and 4.5 ng/ml; and for a man in his seventies, it can range between 0 and 6.5 ng/ml. If the amount of the protein in the blood is raised, the man should have a biopsy of the prostate, a diagnostic test, that shows whether there is cancer in the prostate gland.

A biopsy is required to diagnose prostate cancer. In this procedure, twelve or more samples of tissue are taken from the prostate. The biopsy has traditionally been performed using ultrasound to ensure that the samples are taken from specific areas in the prostate. During the biopsy, a probe is inserted into the rectum and tissue samples are taken from the prostate using long needles. Local anesthetic is injected into the area surrounding the prostate to minimize pain, but men often report that the procedure is still painful. The pain may be worse if the man is anxious (Chestnut 2020); this likely affects most men who have this procedure. A biopsy is not without risk. Because the biopsy needles go through the wall of the rectum, infections are possible. This is why men are prescribed antibiotics for the procedure; but even with this, a small percentage of men may develop an infection and may need to be hospitalized for treatment.

The ultrasound does not clearly show the location of cancer cells, so, more recently, using multiparametric magnetic resonance (MRI) imaging to guide the biopsy allows for more accurate targeting of any lesions in the prostate (Goldberg et al. 2020). This improves the identification of higher-grade prostate cancer and provides more information to guide treatment. An MRI does not use radiation but, instead, uses radio waves to produce a series of images that are then studied by the radiologist, and a report is sent to the provider who requested the MRI. The radiolo-gist uses the Prostate Imaging Reporting and Data System (PI-RADS) to score the MRI. The PI-RAD score goes from 1 (most likely not cancer) to 5 (very suspicious for cancer).

The Gleason score is a measure of the aggressiveness of prostate cancer found from the biopsy. A pathologist looks at the tissues from the biopsy and assigns a grade between 3 and 5 to the area of the sample that has the most cancer cells. Cancer cells look different from normal cells, and the degree of abnormality is described as patterns 3, 4 or 5. Then, the pathologist looks at the area that has the second highest volume of cancer cells and, once again, assigns a number between 3 and 5 to those cells. The two numbers are then added (for example, 3 + 4 = 7) and this number is known as the Gleason score. Gleason scores (the sum of the two numbers) range from 6/10 to 10/10. This number reflects the aggressiveness of the cancer, with 10/10 being the worst.

A newer system of grading has been developed (Kryvenko and Epstein 2016) and is approved by both the International Society of Urological Pathology and the World Health Organization (Chen et al. 2018). The grading comprises five groups representing Gleason scores between 6 and 10 and is suggested to be clearer to both physicians and men with prostate cancer.

Table 1.1

The biopsy report usually contains what percentage of cancer cells is contained in each sample. Consideration of how many samples contain cancer (e.g., 3/12) and how much volume there is in each sample (e.g., 10 percent or 1 mm) is used to help the physician recommend a certain treatment.

The use of biomarkers is an area of interest for screening, diagnosis, and treatment decision-making in prostate cancer. There are many tests to identify biomarkers available as well as even more in development. Most use either urine, blood, or tissue samples. However, there are still questions about the validity of these testshow they compare to each other as well as their costs and, thus, affordability. Two of these tests, Prolaris and Oncotype DX, provide information about which men with positive biopsies need to be treated and which can be monitored (Kohaar, Petrovics, and Srivastava 2019).

It is important to remember that the existence of a test does not guarantee it will provide useful information.