I have prostate cancer. What now?
The news of being told that you have cancer is devastating. When people hear this word they are suddenly staring mortality in the face. With prostate cancer in general there is no need to panic. The disease is usually slow growing unlike say a leukaemia or a pancreatic cancer and there is time to think about your possible treatment options.
The very first two issues to be confronted from the clinicians point of view is firstly to determine what stage the disease has reached within the prostate gland and secondly to establish if the disease is localised or has spread outside the gland. (This is called metastasis of cancer). For more information on staging and local or metastatic disease see Facts on prostate cancer.
Your urologist will first look at the data in front of him with regards to your clinical symptoms; his physical examination; the biopsy data; and the level of your PSA. From this information the urologist can glean some idea of your current staging and what possible treatment options can be offered to you. Many statistical tables have been developed by urologists based on tens of thousands of previous patients that give probabilities on the status of your disease. Variables used include Gleason score, prostate size, tumour extent in the gland, perineural invasion, clinical feel of the gland and the PSA level. For more information on these terms visit the page on Facts on prostate cancer. The staging of the disease determines how aggressive your cancer is at present and what are the chances that the disease has spread already to other areas of your body. The urologist will grade prostate cancer into low, intermediate and high risk for metastatic spread. When one has an advanced cancer within the prostate gland even if no metastatic disease is found on testing, the chances are very high that there is already distant spread but too small yet to be detected by current methods.
If the above results suggest that the disease is organ confined then this is very good news for you the patient. The urologist will then in all likelihood request additional tests to confirm or refute this initial impression. Usually these tests will consist of a bone scan; chest x-ray; abdominal sonar and or a CT scan; and some routine blood tests.
Bone scan: The most common organ that the prostate cancer goes to is the skeleton. Prostate cancer cells have an affinity for the environment afforded by the bones. The bone scan is a nuclear medicine test. A very low dose of a radioactive tracer is injected into a vein. The radioactive tracer does not cause you harm or make you radio-active to other people. This tracer will seek out the bones of your body and temporarily bind to the bone cells and make the bones visible to an instrument known as a gamma camera. This camera can be looked upon as a sophisticated Geiger counter. The scan of your bones is done about two hours after the injection of the radioactive material so you should schedule other business whilst you are waiting to lie under the camera.
Prostate cancer cells are greedy for the tracer and so absorb more and thus deposits of tumour in the bones will show up on the films as hot spots. If any hot spots are seen then x-rays of those particular sites are taken to look for the classical signs of a bone metastasis. It is important to remember that other conditions such as injury and inflammation can also appear as hot spots.
Abdominal sonar: This is a non invasive scan where a soft probe coated with jelly is rubbed over your abdomen. Everyone has seen TV gynaecologists looking at babies in pregnant mothers using one of these instruments. The machine allows a radiologist to look at your internal organs such as the liver. Prostate cancers can spread to the liver and lesions that look like balls can be visualised within the liver tissue. If the lymph glands within the pelvis are involved with tumour they can also be seen on sonar if they have become enlarged by the tumour.
CT scan: Some urologists like to obtain a CT scan of the abdomen and pelvis because they feel that it provides additional information on possible disease dissemination. Not everyone is in agreement that a CT scan is necessary. It is an expensive test and it can confuse the picture so it is not routinely done.
A CT scan is not painful except for the insertion of a drip to give you a substance called contrast. Contrast helps to distinguish internal structures on the CT scan pictures. The contrast when injected can give you a warm feeling up your arm into your neck. If you have an allergy to iodine or shellfish it is important to inform the radiologist as he will then reconsider giving you the contrast.
The radiologist when studying the scan will pay particular attention to the capsule around the prostate gland to look for tumour penetration. He will also look for enlarged pelvic modes alongside and above the prostate gland. The other abdominal organs will also be assessed for any possible metastatic lesions.
Chest x-ray: A plain x-ray of the chest is taken to look for what doctors call cannon balls in the lungs. A cannon ball is a circular opacity within the lungs caused by a tumour deposit. The x-ray will also be assessed for other diseases of ageing such as emphysema and heart failure which again can have a bearing on the type of treatment you could safely withstand.
Calcium; phosphate and alkaline phosphatase: These tests indicate how rapidly bone is metabolising. When abnormal they can indicate that there is a malignant process within the bones.
Liver function tests: A battery of tests collectively known as liver functions can reveal abnormalities. When the liver is invaded by tumour, enzymes manufactured by the liver in particular AST, ALT, LDH and alkaline phosphatase become abnormally high.
Renal function tests: Sometimes kidney function is affected by a prostate gland that has obstructed the bladder. A blocked bladder causes a back pressure on the kidneys. This can cause chronic renal failure. Either the prostate tumour or an enlarged prostate gland can cause obstruction to the bladder. The presence of renal failure will influence what forms of therapy you could undergo.
When all the requested tests have been conducted and reported on, the urologist will call you back to his office to discuss the results and what they mean.
Firstly the urologist will let you know if you have localised or metastatic disease. This is very important as this will determine what treatment you can have and to a certain extent your life expectancy. See Treatment for local disease and Treatment for metastatic disease At this point it is important to mention that the tests urologists can obtain are not infallible. Up to twenty percent of patients determined to have localised disease actually already have metastatic disease somewhere in their bodies. This factor becomes evident during long term follow up after your prostate cancer treatment for local disease is completed.
Secondly your overall state of health will be discussed. Prostate cancer in general occurs in ageing men who have a higher risk of concurrent disease. If it becomes evident that you have significant additional medical problems then this will have an impact on your possible treatment options. For example men in a poor state of health or who have a low chance of living another ten years are unlikely to be offered radical surgery.
At this meeting it is important to ask your urologist as many questions as you deem relevant to your condition. You do have a right to know. You should also spend time mulling over all the information you have been given about your disease status.
Thirdly the urological surgeon will go over the treatment options he or she believes are suitable for your condition. It will be suggested what treatment option you should accept but you are not obliged to follow the advice given. You are the person with the disease not the urologist. You must choose the treatment with which you feel the most comfortable. Of course many people are happy to follow the advice of an urologist and leave all decision making to the medical people. Everyone is different. Take the route that gives you the best feeling of satisfaction.