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03 Sep 2017 dr. Rini Siallagan Articles 106

Prostate cancer is the most common cancer in elderly males in USA and Europe. It will become a major health concern, in developing countries like Indonesia with the proportion of elderly men in the general population is increasing. During the last decade, the 5-year relative survival percentages for prostate cancer steadily increased from 73.4% in 1999-2001 to 83.4% in 2005-2007 (EAU, 2015).


The prostate is a male gland that places in between the bladder and penis. Prostate cancer begins when cells in the prostate gland start to grow uncontrollably. The prostate size increases with age, in younger male it’s about size of a walnut and the nidus prostate will start to grow faster, after 40 years old.


Types of Prostate Cancer

Most prostate cancers are adenocarcinomas. Other very rare types of prostate cancer are sarcomas, small cell carcinomas, neuroendocrine tumors and transitional cell carcinomas. Low and moderate grade prostate cancer grow and develop slowly but high grade prostate cancer will develop and spread quickly.


The factors that determine the risk of developing clinical prostate cancer are not well known, although a few have been identified. There are three well-established risk factors for prostate cancer:

1. Increasing age- most of cases are diagnosed in men over 50 years of age.

2.  Ethnic origin – prostate cancer is more common among men of African-American and African descent than in men of Asian descent.

3. Family History- having a close relative such as brother or father who developed prostate cancer under the age 60 seems to increase the risk of you developing it.

Other probable risk factor of prostate cancer are:

1. Obesity- recent research suggest that there may be link between obesity and prostate cancer.

2. Exercise- men who regularly exercise have also been found to be at lower risk of having prostate cancer.

3. Diet- research is ongoing into the links what kind of diet to causing of prostate cancer. There is evidence that a diet high in calcium is linked to an increased risk of developing prostate cancer.

In latest research has shown that prostate cancer rates appear to be lower in men who eats food rich of containing certain nutrients likes lycopene, which are  found in cooked tomatoes and other red fruits, and selenium.  Selenium can be found in nuts, and of course we need more research to prove and know better correlation between these nutrients and lower risk of prostate cancer.

Screening and Early Detection

Early detection or opportunistic screening consists of individual case findings, which are initiated by the person being screened (patient) and/or his physician. Prostate cancer screening is one of the most controversial topics in urological literature. Many papers, discussions and debates have been produced. The reduced mortality seen recently in world wide is considered to be partly due to prostate cancer screening policy, using prostate-specific antigen test.

The primary endpoint of both types of screening has two main aspects:

1. Reduction in mortality from prostate cancer

2. A maintained quality-of-life-adjusted gain in life years.

Symptoms and signs of prostate cancer

Prostate cancer does not normally cause symptoms until the cancer has grown large enough to put pressure on the urethra. This normally results in problem associated with urination, such as:

1. Increasing frequency of urination, especially during the night

2. Difficulty in starting to pee

3. Straining or taking a long time while urinating

4. Weak flow of urine

5. Feeling that your bladder has always filled

When these symptoms appear it’s not surely it’s prostate cancer  because the other prostate diseases such as benign prostatic hyperplasia and chronic infection on the prostate will show the similar symptoms. But it’s very important to know if you have the risk of factors and suffering with those symptoms then it will be wise to consult with your urologist to be diagnosed. The treatment for prostate cancer will depend on individual circumstances and the stage of prostate cancer itself.


1. Digital rectal examination

An abnormal DRE such as nodule, fixed and hard prostate, asymmetrical lobe can be palpated and is associated with an increased risk of a higher Gleason score and should therefore be considered an indication for prostate biopsy.


2. Prostate-specific antigen

The use of PSA as a serum marker has revolutionized the diagnosis of prostate cancer. PSA is produced almost exclusively by the epithelial cells of the prostate, which is organ- but not cancer- specific. Thus, PSA may also be elevated in benign prostatic hypertrophy (BPH), prostatitis and other non-malignant conditions. Significant increasing of PSA level should guide us to perform prostate biopsy.


3. Prostate biopsy

The need for a prostate biopsy should be determined on the basis of the PSA level and/or a suspicious DRE.


4. Transrectal Ultrasonography (TRUS)

More than 70% prostate cancer will reveal as the classic picture of a hypo-echoic area in the peripheral zone of the prostate.

5. Bone scan

To find bone spreading prostate cancer.


1. Active surveillance and watchful waiting

Active surveillance aims at the proper timing of curative treatment rather than the delayed application of palliative treatment options.  It includes an active decision not to treat the patient immediately.

Watchful waiting is also known as ‘deferred treatment’ or ‘symptom-guided treatment’. This term referred to the conservative management of prostate cancer until the development of local or systemic symptoms. The patient would then be treated palliatively with transurethral resection of the prostate (TURP) and hormonal therapy or radiotherapy for the palliation of metastatic lesions.


2. Radical Prostatectomy

The surgical treatment of prostate cancer consists of radical prostatectomy that removes the entire prostate gland between the urethra and bladder, and resection of both seminal vesicles, along with sufficient surrounding tissue to obtain a negative margin. The procedure sometime is followed by bilateral pelvic lymph node dissection.


3. Adjuvant, neo-adjuvant and palliative hormonal therapy


4. Radiotherapy for localized prostate and palliative therapy


5. Chemotherapy

Editor: Gede Wirya Kusuma Duarsa, MD,MSc, Ph.D, Urologist Consultan, FICS.