What Is the Prostate?
The prostate is a walnut-sized gland found in the male reproductive system. The normal prostate gland is quite small and weighs only about an ounce. It is somewhat firm; 30 percent of it is made up of muscular tissue, and the rest consists of glandular tissue. The prostate is located in front of the rectum just below the bladder, the organ that stores urine. It surrounds the urethra, the tube that carries urine from the bladder through the tip of the penis. In addition, the nerves responsible for erections are located on either side of the prostate. The main purpose of the prostate is to produce seminal fluid, which transports sperm during the male orgasm.

What Is Prostate Cancer?
Prostate cancer is the second most common type of cancer among American men. Cancer is a disease characterized by the uncontrolled growth and potential spread of abnormal cells. The human body is made up of billions of cells, which normally reproduce themselves by dividing so that growth occurs. Occasionally, cells abnormally grow into a mass called a tumor. Some tumors are benign (noncancerous). Others are malignant (cancerous). Prostate cancer occurs when a malignant tumor is formed in the prostate gland. If left untreated the cancer can grow and spread beyond the prostate into the surrounding tissues and lymph nodes. Moreover, the cancer can also spread to distant parts of the body such as the bones, lungs and liver. This spread is called metastasis. As a result of metastasis, many men experience aches and pains in the bones, pelvis, hips, ribs and back.

• Age. Most patients are over 65.
• Family history
• African-American men are more likely to get this type of cancer
• Diets heavy in red meat and high-fat dairy products, and low in vegetables and fruit
• Physical inactivity

• Frequent urination, particularly at night
• Difficulty starting or holding back urination
• Weak or unable to urinate
• Painful urination
• Painful ejaculation
• Difficulty have an erection
• Blood in semen or urine
• Pain in lower back, hips or upper thighs

Digital Rectal Exam: The physician feels for abnormal growth or hardness by inserting a gloved, lubricated finger into the rectum.

PSA (Prostate Specific Antigen): PSA has been employed as an indicator of early, potentially curable prostate cancer. It can identify patients with prostate cancers not detectable by digital rectal examination with the aid of a blood test.

CT Scan and MRI: These radiographic tests can often detect disease. Computed tomography scan (CT Scan) is a series of detailed pictures of areas inside the body taken from different angles; the pictures are created by a computer linked to an x-ray machine. Also called computerized tomography and computerized axial tomography (CAT) scan. Magnetic resonance imaging (MRI) is a procedure in which radio waves and a powerful magnet linked to a computer are used to create detailed pictures of areas inside the body. These pictures can show the difference between normal and diseased tissue. MRI makes better images of organs and soft tissue than other scanning techniques, such as CT or x-ray. MRI is especially useful for imaging the brain, spine, the soft tissue of joints and the inside of bones. These two tests are specifically utilized to evaluate whether the tumor has extended outside the confines of the prostate gland or into the lymph nodes that are located around the prostate.

Evaluation of Pelvic Lymph Nodes

Radionuclide Bone Scan: A test that is used to see if prostate cancer has spread to the bones. This test is used to rule out metastasis in the bony structure of the body.

Surgery is the most common treatment, particularly in early-stage prostate cancers. Part or all of the prostate may be removed. By making an incision in the abdomen (radical retropubic prostatectomy) or between the scrotum and anus (radical perineal prostatectomy) the surgeon can remove the entire prostate, including surrounding lymph nodes. Or, in a transurethral resection of the prostate (TURP), the surgeon uses electricity generated at the end of a small instrument to remove only the cancerous portion of the prostate. Loss of bladder control and impotence are frequent side effects of prostate surgery. However, GW has a long experience with nerve-sparing prostate surgery, including robotic prostatectomy. Results with preserving continence and erectile function compare favorably with other academic centers performing the operation.

If cancer has spread to nearby lymph nodes, surgery may not be a practical option.

External Beam Radiation therapy kills cancer cells with intense x-rays aimed only at the cancerous growth. With advances in technology, particular medical equipment can emit radiation from outside the patient's body, or radioactive materials can be placed internally to the targeted area. Patients may receive one or both forms of radiotherapy, depending on the size of the cancer.

Brachytherapy is the most advanced method of radioactive seed implantation. This method uses the latest advances in computer calculation of internal seed placement for maximal effect and minimal side effects. The dose of each seed is customized at the time of surgery to conform to the size of the individual prostate gland. In general, side effects of radiation therapy include extreme fatigue, though physicians recommend staying active throughout treatment. Patients may also experience painful or frequent urination, diarrhea or impotence. External beam radiation often causes hair loss and skin irritations in the area of treatment. Internal radiation, meanwhile, is less likely to affect erectile functioning but slightly more likely to cause temporary incontinence.

Hormone therapy can prevent prostate cancer cells from getting the male hormones they need to grow, even if they have spread to other parts of the body. Although it won't cure prostate cancer, hormone therapy can control it.

In Cryotherapy, the prostate is frozen rapidly to kill cancer cells. This procedure is performed by placing probes into the prostate while the patient is under anesthesia. Survival data suggests that cryotherapy for localized prostate cancer is at least equal to radiation therapy with either seed implantation or external beam.

Surveillance for a disease process is an accepted alternative. One or more criteria must be met for such a policy to be applied to a neoplasm in which morbidity or mortality can occur. In these cases, the cancer must have a low risk of morbidity and mortality, the impact of treatment upon morbidity or mortality must be of minimal effect, and the risks of treatment must outweigh the benefits.

The two general principles in selection of the ideal patient for surveillance are presence of a tumor with low biological activity and a relatively short period of time for the patient to be at risk for disease progression. Tumor characteristics thought to be associated with low biological activity and the longest disease-free survival include low tumor grade, early stage, small volume and mildly elevated PSA. Good candidates for surveillance have a relatively short life expectancy as calculated from age and coexisting medical conditions.

A patient may also choose surveillance for management of prostate cancer because of a desire to avoid or defer the side effects of other forms of therapy.

The major advantage to surveillance is the lack of morbidity associated with treatment. The disadvantage to surveillance is the risk of subsequent, possibly incurable, disease progression. Nearly one-quarter of patients diagnosed with prostate cancer die of their disease and every study of surveillance contains a cohort who died of prostate cancer. Furthermore, surveillance places the patient at risk for complications from disease progression such as pain, urinary obstruction, pathological fractures, obstruction of the ureters, and spinal cord compression. Therefore, the option of surveillance must be weighed against the potential disadvantages of withholding treatment.

In the Future
The George Washington University Hospital is at the forefront of development of new diagnostic techniques for both benign and malignant conditions of the prostate. These include the use of monoclonal antibodies for detecting cancer outside of the prostate and the use of various advances in technology to treat noncancerous prostatic enlargement. The department has an ongoing prostate research project with an exciting treatment discovery that may have a major impact on the spread of prostate cancer to other organs.