Introduction
Prostate cancer causing abdominal pain is the most common cancer of men above 50 in the United States. It is for men what breast cancer is for women. This is true even on a histological level, as both cancers are mostly glandular cancers (=adenocarcinomas). Both are responding to hormones, breast cancer to estrogen and prostate cancer to testosterone.
Physicians are diagnosing about 200,000 new cases of prostate cancer in the U.S. every year. The cancer grows slowly for a long period of time inside the very tough prostatic capsule. Often it switches to the other prostatic lobe (there are two lobes of the prostate gland). Next it breaks through the capsule and invades the adjacent structures. These are the seminal vesicles, the urethra, bladder, pelvic lymph glands and the pelvic bone. Prostate cancer cells can metastasize via the blood stream and enter bones such as vertebral bodies or ribs.
Prostate Cancer Symptoms
In the beginning of prostate cancer there are no symptoms. This is why every year a man needs his annual prostate examination and annual PSA blood test. Any man over 50 years should go for the PSA blood test once a year .
In case of early prostate cancer the physician would pick up a hard lump in the prostate on rectal examination and often the PSA would be positive (greater than 5). A late sign of prostate cancer is when there is a bladder outlet obstruction with urgency, frequent urination or blood in the urine. At this point the prostate capsule likely has a rupture with local invasion, which would be a stage C out of 4 stages (stage A to D). When the cancer invades into the pelvic bone there would be pain in that area. With vertebral bone metastases spontaneous compression fractures can develop, with other bone metastases pathological fractures can spontaneously occur.
Prostate Cancer Tests
In the beginning there might be no symptoms. This is where PSA screening comes in. Physicians are this discussing among themselves for a long time. Some consensus seems to be developing. The PSA test is very sensitive, but not specific (as mentioned before, BPH also often shows a positive PSA test). Therefore there are efforts to make the test more specific by measuring the proportion of free versus protein bound PSA. The physician also will likely order a transrectal ultrasound (=TRUS), which would show hypo echoic lesions where the examining finger feels hard lumps. Another blood test, the serum acid phosphatase test, is useful as it correlates well with lymph gland invasion, but it is not specific for prostate cancer alone.
Other alternative possibilities of diagnoses
Other conditions such as multiple myeloma or hemolytic anemia would, for instance, also give a positive test. However, a negative serum acid phosphatase test is reassuring that the prostate cancer has not yet metastasized. The definitive test for prostate cancer after all the other tests is a TRUS (=transrectal ultrasound) guided transrectal needle biopsy. The physician does needle biopsies in a clinic without an anesthetic. He/she samples from usually 6 separate locations throughout the prostate to increase the accuracy. The pathologist will then analyze these biopsy samples. This method is very accurate and very specific and must be done to confirm or rule out prostate cancer.
As in all cancers a tissue diagnosis is the only way how to diagnose cancer of the prostate, this is a “must”.
Prostate Cancer Treatment
In stage A or B cancer, where the prostate cancer has not extended beyond the prostate capsule, a radical selective prostatectomy can be performed, which will safe this man’s life.
Let me explain: In the past many urologists were of the opinion that there would be a “clinically irrelevant” prostate cancer entity, as it often takes very long for prostate cancer to metastasize. This is quite contrary to breast cancer where the cancer metastasizes early. The difference is that in breast cancer there is no capsule that confines the cancer, but in prostate cancer there is a very tough prostate capsule, which confines the cancer cells until late stage B prostate cancer.
Men often don’t want prostate surgery for fear of losing the ability of having sex
One of the big reasons why a man may not want to go for surgery is the fear that he may lose his ability to have sex. With the TURP procedure men are very concerned about a loss of impotence (see chapter on “enlarged prostate”). In a similar vein when the physician recommends a radical selective prostatectomy this concern comes up again.
In the past the urologist severed the nerves supplying impulses to the penis for erection with a radical prostatectomy. However, now the specialist can explain that with the help of new technology using an operating microscope this has changed. In most cases the selective radical prostatectomy preserves the nerves to the penis and therefore preserves potency after the surgical procedure.
In more advanced prostate cancer nerves have to be severed
However, the urologist can only do what is technically possible. Unfortunately there will be some cases where cancer tissue is growing around the nerve supply. In such a case, in the interest of the survival of the man’s life, the urologist has to cut through the nerves and remove the cancer.
Overall the statistics show that about 85% of stage A and B prostate cancer patients can have a successful selective radical prostatectomy and only 15% lose their potency. For stage C cancer local radiotherapy treatments or radioactive seed implants will likely slow cancer growth for a period of time, but survival rates are much worse than for patients after a selective radical prostatectomy.
More advanced prostate cancer
Occasionally the urologist might combine the two. In late stage C and D prostate cancer patients hormone therapy is aiming at removing testosterone from the system. It can often buy significant survival time, but many men complain that they suffer from testosterone hormone withdrawal.
The most effective method is a bilateral orchiectomy (=removal of both testicles). Luteinizing hormone-releasing hormone analogues achieve the same as a castration. The urologist will explain, which therapy would be the best fit for a particular patient. In late stage D patients emphasis is placed on pain relief with local radiotherapy to bone metastases and possibly some chemotherapy to slow down cancer growth.
References
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2. C Ritenbaugh Curr Oncol Rep 2000 May 2(3): 225-233.
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4. M Ohkawa et al. Br J Urol 1993 Dec 72(6):918-921.
5. Textbook of Primary Care Medicine, 3rd ed., Copyright © 2001 Mosby, Inc., pages 976-983: “Chapter 107 – Acute Abdomen and Common Surgical Abdominal Problems”.
6. Marx: Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc. , p. 185:”Abdominal pain”.
7. Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 7th ed., Copyright © 2002 Elsevier, p. 71: “Chapter 4 – Abdominal Pain, Including the Acute Abdomen”.
8. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.
9. Suzanne Somers: “Breakthrough” Eight Steps to Wellness– Life-altering Secrets from Today’s Cutting-edge Doctors”, Crown Publishers, 2008
