- Prostate cancer is one of the most common cancers to affect American men. High-risk prostate cancer is an aggressive type of cancer that makes up around 15% of all prostate cancer cases.
- Symptoms of this disease include sexual and urinary problems.
- Physical exams, lab tests, and imaging tests, like multiparametric MRI, are often used to screen, grade, and stage prostate cancer.
- Treatment options for high-risk prostate cancer include surgery, radiation therapy, and medication.
Prostate cancer is among the most common cancers affecting American men. According to the American Cancer Society, 1 in 8 men may be diagnosed with this cancer during their lifetime, and 1 in 41 is likely to die of prostate cancer.
While prostate cancer may be a serious disease, a majority of men diagnosed with it do not die from it. Early detection of prostate cancer, while the cancer is still confined to the prostate gland, has the best chance for a successful outcome.
What is high-risk prostate cancer?
Let’s start with the prostate. The prostate is a small, walnut-shaped gland situated just below the urinary bladder in men. It helps to produce seminal fluid.
The majority of prostate cancers are adenocarcinomas – a cancer developing from the glandular cells (cells that produce glandular secretion; in this case some seminal fluid). Most prostate cancers grow very slowly and do not grow beyond the gland.
Advanced prostate cancers are aggressive – they grow and spread rapidly. These may cause death if not detected and treated early.
Prostate cancer staging.
Clinical staging of prostate cancer is based on the following parameters:
- A digital rectal examination (DRE) by an experienced healthcare practitioner
- A pre-treatment serum prostate-specific antigen, or PSA level
- A Gleason Score
- And the extent of cancer spread as assessed by examining various biopsy cores.
This helps the grading of men with localized disease into various clinical risk categories according to the primary tumor.
PSA, or prostate specific antigen, is a protein produced by the prostate gland. This protein is also detected in serum. When there are issues with the prostate gland (like cancer), the amount of this protein is elevated.
The Gleason Score, named after Dr. Donald Gleason, who developed this system, is based on a scale of 1 to 5, depending on the distinct changes cancerous cells go through. When a pathologist is viewing a biopsy sample, they will assign a Gleason grade to the most predominant type of cancer cells, and the other to the second most predominant type. The addition of these two numbers gives the final Gleason Score (which ranges from 6 to 10)
Most healthcare professionals in the U.S. use the risk stratification system from the National Comprehensive Cancer Network (NCCN) risk stratification system. This system helps inform many American medical associations’ guidelines about treating clinically localized prostate cancer. For example, it’s been used by the American Urological Association, along with the American Society for Radiation Oncology, Society of Urologic Oncology, and the American Society of Clinical Oncology.
The NCCN system categorizes high-risk prostate cancer as:
- A PSA above 20 ng/mL or an ISUP grade of 4/5 (Gleason score >7) or cT2c, or
- Any PSA, any ISUP grade, cT3-4 or cN+ (locally advanced)
To clarify from above, ISUP Grading is a simple assessment system used by the International Society of Urological Pathology. It scores cancer aggressiveness from 1(low risk group) to 5 (high risk group).
The D’Amico Risk Classification for Prostate Cancer is another assessment system worth mentioning.
Many European guidelines, unlike the NCCN system, don’t define what qualifies as very low-risk or very high-risk disease. The descriptions of other risk categories only somewhat differentiate.
Signs and symptoms of prostate cancer.
When the cancer is in its early stages, it is usually symptomless. In the later, more advanced, clinical stages, some symptoms can be observed, like:
- Problems with urination (weak or slow stream, frequent urge to urinate, especially during the night)
- Erectile dysfunction
- Blood in semen or urine
- Bladder or bowel incontinence
- Weakness in legs and/or feet
- Pain in areas where cancer has spread to the bones (hips, back, chest)
These symptoms are not exclusive to prostate cancer and may be due to other underlying medical conditions. For example, urinary incontinence may also be due to benign hyperplasia (non-cancerous enlargement) of the prostate. Always consult your medical practitioner if you experience any of these symptoms.
Diagnosing high-risk prostate cancer.
Because prostate cancer usually affects older men (50 years and above), medical practitioners may order a PSA test during a routine blood test. They should also try to understand your medical history and ask you questions regarding any symptoms you might be experiencing, especially urinary or sexual issues.
Screening tests for prostate cancer.
If the test returns elevated PSA levels, further examination may be done.
Digital Rectal Exam (DRE).
In this test, the medical practitioner will insert a lubricated, gloved finger into your rectum and feel the size of your prostate gland.
Advanced PSA tests.
Advanced tests like Prostate Health Index (PHI) and the 4Kscore test combine the results of different PSA tests to arrive at an overall score that is a better indicator of whether a man has prostate cancer.
Imaging tests like the multiparametric MRI or transrectal ultrasound (TRUS) are usually used to screen for prostate cancer. The American Joint Committee on Cancer Staging recommends the use of multiparametric MRIs for staging of prostate cancer.
An MRI scan can also help to visualize the presence of cancer outside the gland and whether the adjoining seminal vesicles have been invaded or the pelvic node is involved.
While challenges may arise in result interpretation due to magnet strength and other factors like variability caused due to the expertise of the reader, Ezra addresses these challenges by using state-of-the-art MRI equipment with 3T magnet strength.
We also address the problems of reader variability by having your MRI scans reviewed by board certified and experienced radiologists.
If the above test results suggest that you may have prostate cancer, your medical practitioner will most likely order a biopsy. A core needle biopsy will be performed by a urologist to remove small cylinders of prostate tissue. The biopsy samples will then be viewed to determine if the cells are cancerous and also to calculate the Gleason Score. However, biopsies carry risks. It may be best to do a Prostate MRI first.
Treatment options for high-risk prostate cancer.
Currently, different treatment modalities are used, usually in combination, to provide optimal treatment and the best possible prognosis. For patients with localized high-risk prostate cancer, the treatment options include RT, or radical prostatectomy along with pelvic lymph node dissection and androgen deprivation therapy. Usually, the multimodal approach is guided by the individual’s case and the input of a team of medical experts.
The surgical removal of the prostate gland follows the first principle of treatment of high-risk localized (in which the cancer is within the prostate gland or localized within the surrounding area) prostate cancer, which is to treat the primary tumor.
In radical prostatectomy, the entire prostate gland and the seminal vesicles (in some cases, also the pelvic lymph nodes) are removed.
The major side effect of surgery may be loss of sexual function. Urinary incontinence may also be another side effect of surgery.
The male hormone (androgen) testosterone enhances prostate cancer growth. Hormone therapy tries to reduce the levels of androgen to control cancer growth. This is also called androgen deprivation therapy (ADT) or androgen suppression therapy.
External beam radiation therapy (EBRT) is a well-established treatment modality for prostate cancer. In this therapy, a machine focuses a beam of X-rays on the area where the cancer is located.
Another type of radiation therapy, called brachytherapy, uses radioactive material that is inserted into the prostate where it keeps giving off radiation. These radioactive “seeds” may be low-dose or high-dose and may be left inside the prostate permanently or for short-term, respectively. When treating high-risk prostate cancer, brachytherapy must be used alongside other methods.
Radiation therapy causes some side effects during treatment. They include problems with urinary function (frequent urge), bowel function (including diarrhea), sexual functions, rectal bleeding, and tiredness.
Survival rate of high-risk prostate cancer.
Cancer survival rates are not absolute numbers but are derived from previous outcomes of a large population.
The 5-year survival rate of prostate cancer is the highest of all cancers and is usually close to 100%, if the cancer is localized (it is confined within the prostate gland or in the immediate surroundings). This means that almost all prostate cancer patients will live for at least 5 years from the day they were first diagnosed.
For high-risk patients, however, the survival rates depend upon the treatment modalities used. In a study that observed the patterns of biochemical recurrence (BCR) of cancer in patients who had undergone radical prostatectomy alone, for instance, the 5-year BCR-free survival rate was slightly over 55%.
To better understand your prognosis, talk to your team of medical experts.
Effect of high-risk prostate cancer on the quality of life.
Any kind of cancer negatively affects the quality of life. Apart from the disease itself, which may harm the body in multiple ways, the current treatment modalities also have side effects that reduce the quality of life.
In high-risk prostate cancer patients, symptoms may impact one’s sex life. Due to incontinence, people with this disease may also feel uncomfortable in social situations. However, treatment procedures, like radiation therapy, also have a negative impact on the social, emotional and financial aspects of a patient’s life.
While planning treatment strategies for any patient, for any kind of cancer, the medical team has to consider the risk-benefit ratio, which is different for different patients.
Early detection: Key to better clinical outcomes.
Early detection of any type of cancer is often related to a better prognosis.
The Ezra Full Body.
The Ezra Full Body is an MRI-based scan service that screens for potential cancers in the head, neck, abdomen, and pelvis. It is priced at $1,950 or $180 a month, and includes screening of the following organs:
- Adrenal glands
The Ezra Full Body Plus.
The Ezra Full Body Plus is our most advanced service that scans up to 14 organs and is priced at $2,350 or $220 a month. It also includes a 5-minute low-dose chest CT for those who medically qualify, coronary calcium scoring of the heart, and a Prostate MRI with IV contrast to screen for prostate cancer.
Unfortunately, men usually have to first get a prostate biopsy before their health insurance will cover a prostate MRI with IV contrast. This is counter-intuitive because performing a non-invasive, less risky procedure (like an MRI) to visualize a medical problem first is always a better option than an invasive one. Also, a prostate biopsy has notable risks like infection and bleeding.