Prostate Cancer

What is Prostate Cancer?

Prostate cancer, the most common cancer type in men, ranks second among cancer-related deaths. The prostate is an organ found in men, approximately the size of a walnut, located just below the bladder. Its function is to secrete fluids essential for male reproduction.

Prostate cancer is defined as the abnormal proliferation of cells forming a tumor in the prostate. These tumors can appear in just one area or in multiple locations within the prostate.

Prostate cancer is more commonly seen in men over the age of 65. Typically, it progresses without symptoms in its early stages. However, if untreated, the cancer can grow over time and press against the urinary tract, leading to urination problems, which is often how prostate cancer is initially detected.

Symptoms of Prostate Cancer

If prostate cancer remains confined to the prostate, it may not show any symptoms in some patients. However, common symptoms observed in many patients include:

• A burning sensation during urination,
• Presence of blood in semen,
• Difficulty urinating,
• Urinary incontinence,
• In advanced stages, bone metastases may occur, leading to fractures and bone pain in patients.

Signs of Prostate Cancer Spreading to Bones

Due to the silent nature of prostate cancer, progression is quite common. When prostate cancer metastasizes, it typically affects the bones first. Symptoms of prostate cancer spreading to bones include:

• Bone pain,
• Increasingly severe bone pain over time,
• Pain with movement if it has spread to long bones like the arms and legs,
• Severe pain during sleep if it has reached the spine,
• Back pain,
• Difficulty walking,
• Numbness in the legs,
• Loss of strength,
• Urinary incontinence,
• Fecal incontinence,
• Numbness in the abdominal area,
• Anemia,
• Fatigue,
• Shortness of breath,
• Dizziness,
• Fever,
• Coughing,
• Shivering,
• Susceptibility to infections,
• Abnormal bleeding.

Causes of Prostate Cancer

The primary risk factors that increase the likelihood of prostate cancer are family history and age.

Age is the most significant factor affecting prostate cancers. About 50% of men over the age of 70 and nearly all men over 90 exhibit microscopic levels of prostate cancer. Conversely, the likelihood of prostate cancer in men under 50 is significantly lower.

Another major factor in prostate cancer is family history. Approximately 15% of prostate cancer patients have a family history of the disease. Specific gene groups associated with prostate cancer have also been identified.

Lastly, smoking and obesity are also significant factors contributing to an increased risk of prostate cancer.

How is Prostate Cancer Diagnosed?

There is no early screening method for prostate cancer. In other words, a healthy man’s risk level is unknown beforehand. However, knowing the factors that contribute to prostate cancer makes regular screenings extremely important for those at risk. Men with no family history of prostate cancer should undergo regular prostate checks after the age of 50, while those with a family history should start these checks at a younger age. Screening methods include the PSA blood test and physical examination.

PSA Blood Test

PSA stands for Prostate-Specific Antigen. This particular antigen can be detected through a blood test. The PSA test is used not only to diagnose prostate cancer but also to identify conditions such as benign prostatic hyperplasia, prostatitis (prostate inflammation), and BPH (prostate enlargement).

Other factors that can cause elevated PSA levels include catheterization, sexual activity, and urinary tract surgeries. Due to the various reasons for elevated PSA levels, the PSA test alone is not a definitive diagnosis. Therefore, the PSA blood test should be supplemented with a rectal examination.

Rectal Examination

The rectal examination is a physical examination used not only to detect cancer but also to determine its location. This examination is important because the prostate is an organ that cannot be seen directly. Since the prostate is located just in front of the rectum, it can be easily examined with a finger through the rectum.

Transrectal Ultrasound

Also known as TRUS, transrectal ultrasound is a safe and convenient way to visualize the prostate using a specialized ultrasound probe. This imaging method allows for a clear assessment of the prostate’s size and aids in the evaluation of potentially cancerous nodules.

Transrectal ultrasound is especially helpful when a prostate biopsy is needed, as it enables more accurate sampling from suspicious nodules.

Insulin-Like Growth Factor

The insulin-like growth factor (IGF-1) test indirectly measures growth hormone levels produced by the body. It is a blood test that measures a small protein that plays a role in the growth of bones and tissues.

Multiparametric MRI

Multiparametric MRI is a diagnostic method that combines three different MRI scans in a single session, representing a new horizon in prostate cancer diagnostics. It provides the most detailed anatomical imaging of the prostate. Parametric MRI, the most advanced imaging method in terms of resolution, is used here. Patients classified with a PI-RADS score of 4 or 5 are diagnosed with cancer.

MR-Ultrasound Fusion Biopsy

This type of biopsy, performed with advanced technology devices and specialized computer software, is highly precise and targeted. This method helps prevent misdiagnosis.

Cases that are not detectable through traditional biopsy methods can be easily identified with this system, providing more accurate results than conventional biopsies. It is especially useful in cases where the presence of cancerous tissue cannot be confirmed. This method significantly reduces the need for repeat biopsies.

Both MRI and transrectal ultrasound methods are used in this system. The images obtained from both methods ensure the biopsy is taken from the correct location, providing a clearer early diagnosis. Additionally, the accuracy rate of this method ranges from 70% to 75%.

Stages of Prostate Cancer

Correctly identifying the stage of prostate cancer is extremely important for planning the appropriate treatment.

Stage 1

In Stage 1 prostate cancer, the cancerous tissue is limited to the prostate. At this stage, the cancer is confined to a specific part of the prostate gland, and PSA levels and Gleason scores are very low. Additionally, Stage 1 prostate cancers may not be detectable through rectal examination or imaging methods.

Stage 1 Prostate Cancer Symptoms

Since Stage 1 prostate cancer affects only the prostate, symptoms are also localized to the prostate. However, in Stage 1 patients, cancer may not be detectable through physical examination, and symptoms are generally not very pronounced. Patients at this stage typically do not experience any significant physical changes.

Stage 2

In Stage 2 prostate cancer, the tumors have spread over a larger area. At this stage, the tumor can generally extend to both lobes of the prostate. However, the cancerous tissues have not spread outside the prostate.

Additionally, in Stage 2 prostate cancers, symptoms may not be visible in imaging methods or physical examination. However, Gleason scores are usually higher.

Stage 2 Prostate Cancer Symptoms

In patients with Stage 2 prostate cancer, symptoms generally appear in the urinary tract and sexual functions. Patients diagnosed with Stage 2 prostate cancer may experience all or only a few of these symptoms, which include:

• Frequent urination
• Blood in urine
• Pain during urination
• Weak urine flow
• Urination problems
• Burning sensation during urination
• Painful ejaculation
• Blood in seminal fluid
• Erectile dysfunction

Stage 3

When prostate cancer reaches Stage 3, it generally begins to spread outside the prostate, particularly to nearby lymph nodes around the seminal vesicles.

Stage 3 Prostate Cancer Symptoms

The majority of symptoms in Stage 3 prostate cancer are related to the prostate and surrounding structures. At this stage, cancer cells are usually not present in other tissues, so symptoms remain mostly associated with urinary and sexual functions, including:

• Blood in seminal fluid
• Pain during ejaculation
• Erectile dysfunction
• Blood in urine
• Pain and burning sensation during urination
• Interrupted urine flow
• Frequent urination
• Enlargement of the prostate
• Frequent nighttime urination
• Weak urine stream
• Inflammation of the prostate gland
• Difficulty urinating

Stage 4

Stage 4 is the final stage of prostate cancer, in which the cancer metastasizes. It commonly spreads to bones and nearby or distant lymph nodes, and may also extend to organs like the liver.

Stage 4 Prostate Cancer Symptoms

In Stage 4 prostate cancer, symptoms include painful urination, decreased urine flow strength, blood in urine, bone pain, swelling in the legs, and fatigue. At this stage, cancer has spread from the prostate to lymph nodes or other parts of the body. This spread of cancer cells to lymph nodes is known as prostate cancer metastasis. Metastasized cancer cells commonly spread to the bones and liver. Due to the metastasis, symptoms may appear in other organs as well, varying depending on the affected organ.

When prostate cancer metastasizes to bone tissue, symptoms such as easy bone fractures, bone pain, and increased calcium levels in the blood may occur.

Prostate Cancer Treatment Methods

In the early stages of prostate cancer, a "watch and wait" approach is often used, as prostate cancer progresses very slowly. For most patients, prostate cancer does not cause any problems even if left untreated throughout their lives.

Non-Surgical Treatment

Several methods are used in prostate cancer treatment, each with a high success rate. However, these methods can negatively impact the daily lives of patients, prompting the development of alternative treatments. Non-surgical treatment methods are also known as focal therapy.

• Cryotherapy (Freezing),
• High-Intensity Focused Ultrasound (HIFU),
• Photodynamic Therapy,
• Radiofrequency Ablation (RITA)
• Irreversible Electroporation (Nanoknife)

In these methods, the prostate gland is not removed. Instead, the aim is to eliminate the cancer without this procedure. In the first four treatment options, cancerous tissues are targeted and destroyed, but nearby blood vessels may also be damaged, and some cancer cells in the vessels may remain. Additionally, damage to nerves and ducts can cause further complications, making irreversible electroporation the most preferred method.

Nanoknife Treatment

The most crucial aspect of Nanoknife treatment is accurately locating the cancerous tissue, which is facilitated by advanced imaging techniques.

Nanoknife treatment is performed under general anesthesia, requiring a one-day hospital stay. The procedure itself takes approximately an hour.

Radiotherapy

Radiotherapy, which has almost the same success rate as surgery in treating prostate cancer, is a method particularly used for patients whose cancerous tissues have spread beyond the prostate.

Side Effects of Radiotherapy

Radiotherapy is chosen for prostate cancer that has spread outside the prostate but has not metastasized to other areas. However, this treatment has some side effects, including difficulty urinating, diarrhea, frequent urination, and sudden urge to urinate.

In addition to early-stage side effects, there are some late-stage effects, often involving erectile dysfunction. Other possible side effects include reduced bladder capacity and narrowing of the urinary tract.

Robotic Surgery

Robotic surgery is a treatment method applied when cancerous tissue is confined to the prostate. This surgery removes the entire prostate capsule, including the vesicula seminalis located at the back of the capsule.