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Patient Awareness  

Courtesy :Dr. Sujata Patwardhan , Dr. Ankush Gupta

Topics


Testicular Cancer

The main early symptom of testicular cancer is a painless lump that develops in one testis. Treatment involves surgery to remove the affected testis. Chemotherapy and/or radiotherapy may also be advised if the cancer has spread from the testis. Treatment often works well, even for testicular cancer that has spread. More than 9 in 10 men who are diagnosed with testicular cancer can be cured.

What are the testes?

Description: Male Reproductive Organs (154.gif)
Description: Cross-section diagram of a testis (146.gif)

The testes hang down behind the penis and make sperm. It is normal for one testes to be slightly bigger than the other, and for one to hang slightly lower than the other. The testes themselves feel like smooth, soft balls inside the baggy scrotum. At the top and to the back of each testis is the epididymis (this stores the sperm). This feels like a soft swelling attached to the testis, and can be quite tender if you press it firmly.

Leading from the epididymis is the vas deferens. You can feel each vas deferens at each side at the back and top of the scrotum. They feel like soft, narrow tubes which pass up and into the groin. (The vas deferens carries the sperm to the penis.) Some people confuse the normal epididymis or vas deferens with an abnormal lump.
What is cancer?
Cancer is a disease of the cells in the body. The body is made up from millions of tiny cells. There are many different types of cell in the body, and there are many different types of cancer which arise from different types of cell. What all types of cancer have in common is that the cancer cells are abnormal and multiply 'out of control'.

A malignant tumour is a 'lump' or 'growth' of tissue made up from cancer cells which continue to multiply. Malignant tumours invade into nearby tissues and organs which can cause damage. Malignant tumours may also spread to other parts of the body. This happens if some cells break off from the first (primary) tumour and are carried in the bloodstream or lymph channels to other parts of the body. These small groups of cells may then multiply to form 'secondary' tumours (metastases) in one or more parts of the body. These secondary tumours may then grow, invade and damage nearby tissues, and spread again.

Some cancers are more serious than others, some are more easily treated than others (particularly if diagnosed at an early stage), some have a better outlook (prognosis) than others.

So, cancer is not just one condition. In each case it is important to know exactly what type of cancer has developed, how large it has become, and whether it has spread. This will enable you to get reliable information on treatment options and outlook.
What is testicular cancer?
Testicular cancer is a 'germ cell cancer' as the cells which become cancerous are those involved with making sperm. Around half of all cases occur in men under 35 years but testicular cancer rarely occurs before puberty.  Testicular cancers are divided into two main types (depending on the exact type of cell causing the cancer):

  • Seminomas which occur in about half of cases. They most commonly occur in men between 25 and 55 years.
  • Non-seminomas. These make up the rest and are mainly teratomas, but include some other rare types. Teratomas usually affect men aged between 15 and 35 years.

In general, all types of testicular cancer cause similar symptoms and are treated much the same.
What causes testicular cancer?
Risk factors that increase the chance testicular cancer may develop include:

  • Geography. The highest rate of testicular cancer occurs in white men in northern Europe. So, some genetic or environmental factor may be involved.
  • Family history. Brothers of affected men have an increased risk.
  • Undescended testes. The testes develop in the abdomen and usually descend into the scrotum before birth. Some babies are born with one or both testes which have not come down into the scrotum. This can be fixed by a small operation. There is a large increased risk in men who have not had their 'undescended testis' surgically fixed. There is still some increased risk in men who had an undescended testis fixed when they were a baby.
  • Infertility. Infertile men with an abnormal sperm count have an increased risk.
  • HIV/AIDS. Men who have HIV or AIDS have an increased risk.

Vasectomy does not increase the risk of testicular cancer. (Several years ago there was a 'scare' linking vasectomy with testicular cancer. Studies have ruled out this link.)
What are the symptoms of testicular cancer?
Lump on a testis
In most cases, the first symptom noticed is a lump that develops on one testis. The lump is usually painless. (Note: most swellings and lumps in the scrotum are not due to cancer. There are various other causes. However, you should always tell a doctor if you discover a swelling or lump in one of your testes. It needs checking out as soon as possible.)
Other symptoms
Sometimes there is general swelling or discomfort in one of the testes. If the cancer is not treated and spreads to other parts of the body then various other symptoms can develop. These may include breast tenderness, back pain or shortness of breath.
How is testicular cancer diagnosed and assessed?
To confirm the diagnosis
Your doctor will examine your testes and refer you to a specialist if he or she suspects that the lump is a tumour. A specialist will examine you again and may advise:

  • An ultrasound scan. This is a simple painless test which uses sound waves to scan the testes. This test can tell if the lump is a solid mass (likely to be a tumour) or a benign cyst (a fluid filled lump which is common in the testes).
  • Blood tests. Testicular cancers often make chemicals which can be detected in a blood sample. The presence of one or more of these chemicals can help to confirm a testicular cancer. They are a 'marker' of testicular cancer. However, you can still have a testicular cancer without being able to detect 'marker' chemicals in the blood. So, a negative result does not rule out cancer.

On the basis of of the examination, and the above tests, a specialist can be confident whether you have cancer or some other cause for the swelling. If cancer is diagnosed then the usual advice is to have an operation to remove the affected testis. The testis which is removed is examined under the microscope to confirm cancer.

Note: if you have one testis removed, it should not affect your sex life. You should still have normal erections, make sperm and hormones from the other testis and so can still father children. However, if you have chemotherapy or radiotherapy (see below) it may affect your fertility. But, many men find that their fertility returns to normal a year after they have received their chemotherapy or radiotherapy treatment.
Assessing the extent and spread
If you are confirmed to have testicular cancer then further tests are usually advised to assess if the cancer has spread. This assessment is called 'staging' of the cancer which aims to find out:

  • Whether the cancer has spread to nearby lymph nodes and lymph nodes in the abdomen.
  • Whether the cancer has spread to other areas of the body (metastasised).

By finding out the stage of the cancer it helps doctors to advise on the best treatment options. It also gives a reasonable indication of outlook (prognosis).

Tests which may be advised to 'stage' the cancer include a CT scan, an MRI scan, chest X-ray or other tests.

Another useful test is the 'marker' blood test described above. If you had a positive test before an operation to remove the cancerous testis, then the test may be repeated after the operation. If the test becomes negative it means that the cancer was probably confined to the testis. If it remains positive then it means that some cancer cells have spread to somewhere else in your body.

The tumour markers commonly tested for are alpha-fetoprotein (AFP), beta human chorionic gonadotrophin (β HCG), lactic dehydrogenase (LDH) and placental alkaline phosphatase (PALP).
What is the treatment for testicular cancer?
Treatment options which may be considered include surgery, chemotherapy and radiotherapy. The treatment advised for each case depends on various factors such as the stage of the cancer, the type of cancer (seminoma or non-seminoma), and your general health.
Surgery
Surgery to remove the affected testis is normally advised in all cases. This alone may be curative if the cancer is in an early stage and has not spread. (Radiotherapy may also be advised for seminomas even at an early stage.)

Further surgery may also be needed for some men after radiotherapy or chemotherapy, to remove any cancer cells present in the lymph nodes of the abdomen or chest.
Chemotherapy
Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells, or stop them from multiplying.

Chemotherapy is often given after surgery, even if the cancer has not spread.
Radiotherapy
Radiotherapy is a treatment which uses high energy beams of radiation which are focused on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying.

Radiotherapy is sometimes given to men with seminoma to prevent the cancer coming back after surgery or to treat any cancer cells that have spread to the lymph nodes at the back of the abdomen.

When chemotherapy or radiotherapy are used in addition to surgery it is known as 'adjuvant chemotherapy' or 'adjuvant radiotherapy'.
Follow up after treatment
You will normally be followed up for several years following successful treatment to check that the cancer has not come back. This may include regular blood tests which check for marker chemicals (see above). You may also have regular chest X-rays or other scans or tests to check that you are free of any recurrence.
What is the prognosis (outlook)?
The outlook is usually very good. Treatment for testicular cancer is usually very successful. During the last 40 years, testicular cancer has become a curable cancer in over 95% of cases.

  • If your testicular cancer is diagnosed and treated at an early stage, you can expect to be cured. Most testicular cancers are diagnosed at an early stage.
  • Even if the cancer has spread to other parts of the body, there is still a good chance of a cure. For testicular cancer that has spread to other parts of the body the chance of being cured is much higher than for many other types of cancers which have spread. This is because the cancerous cells of testicular cancer often respond well to chemotherapy.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information on outlook above is very general. You should ask the specialist who knows your case about your particular outlook.
Detecting testicular cancer early
Young men and teenage boys should get to know how their testes normally feel. Report any changes or lumps to your doctor.


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Bladder Cancer


The common early symptom of bladder cancer is blood in the urine. In most cases, the cancer is confined to the inside lining of the bladder. Treatment of these 'superficial' bladder cancers is relatively easy and often curative. If the cancer has spread into or through the muscle layer of the bladder wall then treatment is less likely to be curative, but can often slow the progress of the cancer.

What is the bladder?

Description: urinary tract (074.gif)
The bladder is part of the urinary tract. It is at the bottom of the abdomen. It fills with urine and we pass urine out from time to time through a tube called the urethra. The urethra passes through the prostate gland and penis in men. The urethra is shorter in women and opens just above the vagina.

Urine is made in the kidneys and contains water and waste materials. A tube called a ureter comes from each kidney and drains the urine into the bladder.

The cells that line the inside of the bladder are called transitional cells or urothelial cells. There is a thin layer of cells beneath the lining called the lamina propria.

The outer part of the bladder wall contains a thick layer of muscle tissue which contracts from time to time to push out the urine.
What is cancer?
Cancer is a disease of the cells in the body. The body is made up from millions of tiny cells. There are many different types of cell in the body, and there are many different types of cancer which arise from different types of cell. What all types of cancer have in common is that the cancer cells are abnormal and multiply 'out of control'.

A malignant tumour is a 'lump' or 'growth' of tissue made up from cancer cells which continue to multiply. Malignant tumours can invade into nearby tissues and organs which can cause damage.

Malignant tumours may also spread to other parts of the body. This happens if some cells break off from the first (primary) tumour and are carried in the bloodstream or lymph channels to other parts of the body. These small groups of cells may then multiply to form 'secondary' tumours (metastases) in one or more parts of the body. These secondary tumours may then grow, invade and damage nearby tissues, and spread again.

Some cancers are more serious than others, some are more easily treated than others (particularly if diagnosed at an early stage), some have a better outlook (prognosis) than others.

So, cancer is not just one condition. In each case it is important to know exactly what type of cancer has developed, how large it has become, and whether it has spread. This will enable you to get reliable information on treatment options and outlook.
What is bladder cancer and how common is it?
Bladder cancer is a common cancer.  The bladder cancer develops from the transitional cells which line the inside of the bladder. This type of cancer is called 'transitional cell bladder cancer.

Transitional cell bladder cancer is divided into two groups:

  • Superficial tumours. These occur in about 4 in 5 cases. These tumours are confined to the inner lining, or just below the inside lining, of the bladder. Sometimes the cells which form this type of cancer multiply to form little growths which stick out like 'warts' from the inside lining of the bladder.
  • Muscle invasive tumours. These occur in about 1 in 5 cases. These tumours have spread to the muscle layer of the bladder, or right through the wall of the bladder.

The treatment and outlook for each of these two groups are very different. Superficial tumours rarely spread and can usually be cured. However, if left untreated, in some cases they can develop into muscle invasive tumours. Muscle invasive tumours have a high chance of spreading to other parts of the body (metastasise), and treatment has less chance of being curative.
What causes bladder cancer?
A cancerous tumour starts from one abnormal cell. The exact reason why a cell becomes cancerous is unclear. It is thought that something damages or alters certain genes in the cell. This makes the cell abnormal and multiply 'out of control'.

In many cases, the reason why a bladder cancer develops is not known. However, there are factors which are known to alter the risk of bladder cancer developing. These include:

  • Increasing age. Most bladder cancers occur in people over the age of 50. It is rare in people younger than 40.
  • Smoking. Bladder cancer is four times more common in smokers than non-smokers. Some of the chemicals from tobacco get into the body and are passed out in urine. These chemicals in the urine are carcinogenic (damaging) to the bladder cells. It is estimated that about one third of bladder cancers are related to smoking.
  • Other chemicals. Certain work-place and environmental chemicals have been linked to bladder cancer, for example substances used in the rubber and dye industries.  However, bladder cancer may develop as late as 10-25 years after exposure to certain chemicals. This means that some cases are still being diagnosed in people who worked with these chemicals years ago.
  • Gender. Bladder cancer is about three times more common in men than women.
  • Ethnic background. Bladder cancer is more common in white people than in black people.
  • Food and drink. People who eat plenty of fruit and vegetables have a lower risk of developing bladder cancer than those who do not. Also, people who drink a lot of coffee have a slightly increased risk.
  • Previous radiotherapy or chemotherapy increases the risk.
  • Schistosomiasis. This bladder infection, which is caused by a parasite in certain hot countries, increases the risk.
  • Repeated bouts of other types of bladder infection may also slightly increase the risk

What are the symptoms of bladder cancer?
Blood in urine
In most cases, the first symptom is to pass blood in the urine (haematuria). Haematuria caused by an early bladder tumour is usually painless. You should always see your doctor if you pass blood in your urine. The blood in the urine may 'come and go' as the tumour bleeds from time to time.
Other symptoms
Some tumours may cause irritation of the bladder and cause symptoms similar to a urine infection. For example, passing urine frequently or pain on passing urine. If the cancer is a muscle invasive type, and grows through the wall of the bladder, then other symptoms may develop over time. For example, pain in the lower abdomen.

If the cancer spreads to other parts of the body, various other symptoms can develop.
How is bladder cancer diagnosed and assessed?
To confirm the diagnosis
Urine microscopy - a sample of urine can be sent to the laboratory to look for cancerous cells under the microscope. This test may detect cancer cells. However, if no cancer cells are seen it does not rule out bladder cancer. Further tests are performed to confirm or rule out the diagnosis if symptoms suggest bladder cancer.

Cystoscopy - this test is commonly done to confirm a bladder tumour. A cystoscopy is where a doctor  looks into the bladder with a special thin telescope called a cystoscope. The cystoscope is passed into the bladder via the urethra. A cystoscopy which is done to just look into the bladder is normally done under local anaesthetic. If a procedure is done via a cystoscope such as removing a tumour then a general anaesthetic is usually used.

During cystoscopy a urologist can:

  • See any areas on the lining of the bladder which look abnormal.
  • Take biopsies of suspicious areas. A biopsy is when a small sample of tissue is removed from a part of the body. The sample is then examined under the microscope to look for abnormal cells.
  • Remove a superficial tumour with instruments which can be passed down a side channel of the cystoscope.



Special urine tests - urine tests have been developed which can detect bladder cancer. For example, urine tests called the BTA test, the NMP22 test and the MCM5 test. These tests detect chemicals and proteins in urine that are made by bladder cancer cells. However, these tests are still not sensitive enough to diagnose all bladder cancers so are not routinely used.

Ultrasound scan - this is a safe and painless test which uses sound waves to create images of organs and structures inside your body. It may be used to diagnose a bladder cancer.

CT scan - another test called CT urogram is a special type of CT scan that obtains pictures of your urinary tract. This is sometimes done to look for a bladder tumour.
Assessing the extent and spread
If initial tests confirm that the cancer is a superficial tumour then no further tests may be necessary. Superficial bladder tumours have a low risk of spread to other parts of the body.

However, if you have a muscle invasive tumour, then further tests may be advised to assess if the cancer has spread. For example, a CT scan, an MRI scan, or other tests  This assessment is called 'staging' of the cancer. The aim of staging is to find out:

  • How much the tumour in the bladder has grown, and whether it has grown to the edge, or through the outer part of the bladder wall.
  • Whether the cancer has spread to local lymph nodes.
  • Whether the cancer has spread to other areas of the body (metastasized).

By finding out the stage of the cancer it helps doctors to advise on the best treatment options. It also gives a reasonable indication of outlook (prognosis). See separate leaflet called 'Cancer - Staging and Grading Cancer' for more detail.
What is the treatment for superficial bladder tumours?
Removal of the tumour
Most superficial bladder tumours are removed by a specialist with the aid of a cystoscope (described earlier). This is called 'transurethral resection - TUR' as the tumour is removed (resected) via a cystoscope which is passed up the urethra. It does not involve an operation to cut into the bladder. Thin instruments can be passed down a side-channel of the cystoscope to remove the tumour.
Immediate chemotherapy
Following a TUR, it is usual to have one dose of 'intravesical chemotherapy' (chemotherapy in the bladder). This is usually done within 24 hours of having a TUR. It involves inserting a liquid into the bladder via a catheter which then remains for a few hours. The liquid contains a chemotherapy drug. Chemotherapy drugs kill cancer cells, or stop them from multiplying. The aim is to kill any cancer cells that have been left behind following the TUR. Studies have shown that one dose of 'intravesical chemotherapy' reduces the chance of the tumour recurring in the future.
Further chemotherapy / immunotherapy
The tumour that is removed during a TUR is examined under the microscope. This enables the exact stage and type of the tumour to be determined. Depending on the stage and type of the cancer, further 'intravesical chemotherapy' may be advised. This is done by using a catheter (as described above) and may be done every 1-4 weeks for several months. The aim is to be as certain as possible that all cancer cells are killed, which reduces the chance of recurrence of the tumour.

The most commonly used drug for further chemotherapy is called BCG. This is actually a vaccine which is used to prevent TB. It is not clear how it works for bladder cancer. It may stimulate the immune system in some way to clear any abnormal cells in the bladder lining. So, strictly speaking, treatment with BCG is 'immunotherapy'. Other chemotherapy drugs are sometimes used instead of BCG.
Repeat checks
After a superficial tumour is removed, you will need a cystoscopy every so often. A recurrence of a tumour occurs in some cases, and routine 'check cystoscopies' will detect these at an early stage. If one recurs, it can be treated again. The time interval between check cystoscopies is every 3-4 months at first but may become longer if the bladder remains free of tumour at each check. You may need a check cystoscopy every now and then for several years to make sure the tumour has not returned.

As mentioned above, urine tests have been developed to diagnose bladder cancer. If trials are successful, a urine test may become the way to check if a tumour has recurred rather than a cystoscopy.
What are the treatment options for muscle invasive tumours?
Treatment options that may be considered include surgery, chemotherapy and radiotherapy. The treatment advised for each case depends on various factors such as the stage of the cancer (how large the cancer is and if it has spread), and your general health.

You should have a full discussion with a specialist who knows your case. He or she will be able to give the pros and cons, the likely success rate, the possible side-effects, and other details about the various possible treatment options for your type of cancer.

You should also discuss with your specialist the aims of treatment. For example:

  • Treatment may aim to cure the cancer. Some bladder muscle invasive cancers can be cured, particularly if they are treated in the early stages of the disease. (Doctors tend to use the word 'remission' rather than the word 'cured'. Remission means there is no sign of the cancer following treatment. If you are 'in remission', you may be cured. However, in some cases a cancer returns months or years later. This is why doctors are sometimes reluctant to use the word cured.)
  • Treatment may aim to control the cancer. If a cure is not realistic, with treatment it is often possible to limit the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for some time.
  • Treatment may aim to ease symptoms. If a cure is not possible, treatments may be used to reduce the size of a cancer which may ease symptoms such as pain. If a cancer is advanced then you may require treatments such as painkillers or other treatments to help keep you free of pain or other symptoms.

Surgery
An operation to remove the bladder is the most common treatment. This is a major operation. Before surgery you need a full discussion with a surgeon to understand the implications of the operation planned. For example, you will need an alternative way of passing urine if you have your bladder removed. One way for this is by a 'urostomy'. This is where a surgeon uses a technique to arrange a system for urine to drain into a bag which you wear on the outside of your abdomen. An alternative operation may be possible where the surgeon creates an artificial type of bladder from a part of the gut.

Even if the cancer is advanced and a cure is not possible, some surgical techniques may still have a place to ease symptoms. For example, if the passage of urine is blocked by a tumour then placing a catheter or other techniques may be appropriate.
Radiotherapy
Radiotherapy is sometimes used instead of surgery. Radiotherapy is a treatment which uses high energy beams of radiation which are focused on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying.
Chemotherapy
Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells, or stop them from multiplying. Prior to surgery or radiotherapy, a course of chemotherapy may be advised. This is called 'neoadjuvant chemotherapy'. Chemotherapy used before surgery may improve the outlook (prognosis). In some cases a course of chemotherapy is given following surgery.
What is the prognosis (outlook)?

  • Superficial bladder tumours. There is a good chance of a cure with treatment. Also, routine checks every few months following treatment will often detect recurrences early, and treatment can be repeated as necessary.
  • Muscle invasive bladder tumours. A cure is less likely than with a superficial tumour. As a rule, the earlier the stage of the tumour, the better the chance of a cure with the treatments listed above. However, even if it is not cured, treatment can often slow down the progression of the cancer.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information above about outlook is very general. The specialist who knows your case can give more accurate information about your particular outlook, and how well your type and stage of cancer is likely to respond to treatment.


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Kidney Cancer


Most cases of kidney cancer develop in people over the age of 60. The most common early symptom is blood in the urine. If kidney cancer is diagnosed at an early stage, there is a good chance of a cure. In general, the more advanced the cancer (the more it has grown and spread), the less chance that treatment will be curative. However, treatment can often slow the progress of the cancer.

What are the kidneys?

Description: Cross-section diagram of the urinary tract (160.gif)
Kidneys are organs which remove wastes from the body by filtering blood and producing urine. The kidney comprises of several microscopic filtering units called the nephrons which are actively involved in urine production. It is normal to have two kidneys however we can live perfectly well with just one healthy kidney.
What is cancer?
Cancer is a disease of the cells in the body. The body is made up from millions of tiny cells. There are many different types of cell in the body, and there are many different types of cancer which arise from different types of cell. What all types of cancer have in common is that the cancer cells are abnormal and multiply 'out of control'. A malignant tumour is a 'lump' or 'growth' of tissue made up from cancer cells which continue to multiply. Malignant tumours invade into nearby tissues and organs which can cause damage.

Malignant tumours may also spread to other parts of the body. This happens if some cells break off from the first (primary) tumour and are carried in the bloodstream or lymph channels to other parts of the body. These small groups of cells may then multiply to form 'secondary' tumours (metastases) in one or more parts of the body. These secondary tumours may then grow, invade and damage nearby tissues, and spread again.

Some cancers are more serious than others, some are more easily treated than others, some have a better outlook (prognosis) than others.

So, cancer is not just one condition. In each case it is important to know exactly what type of cancer has developed, how large it has become, and whether it has spread. This will enable you to get reliable information on treatment options and outlook.
What is kidney cancer?
There are several types of kidney cancer, but most cases are 'renal cell cancer'. This is sometimes called 'renal adenocarcinoma' or 'renal cell carcinoma' or 'hypernephroma'.
Renal cell cancer
This type of cancer develops from a cell in a kidney tubule which becomes cancerous. The cancer grows and forms into a tumour within the kidney. As the tumour grows:

  • The affected kidney tends to become larger. In time the tumour may grow through the wall of the kidney and invade nearby tissues and organs such as the muscles around the spine, the liver, the nearby large blood vessels, etc.
  • Some cells may break off into the lymph channels or bloodstream. The cancer may then spread to nearby lymph nodes or spread to other areas of the body (metastasise).

Renal cell cancers can be divided into several 'sub-types' by looking at certain features of the cells under a microscope. For example, most are 'clear cell' renal cell cancers, but some other types occur such as 'sarcomatoid', or 'granular' renal cell cancers. Knowing the sub-type of the cancer can be important as some respond to treatment better than others.
Other types of kidney cancer
Some rare types of cancer arise from other types of cell within the kidney. For example:

  • Transitional cell (urothelial) cancers are cancers which arise from transitional cells. These are cells which line the renal pelvis, ureters and bladder. Transitional cell cancer is common in the bladder, but in some cases it develops in the renal pelvis.
  • Wilms Tumour and Clear Cell Sarcoma of the kidney are types of kidney cancer which develop only in children.

 
What causes kidney cancer (renal cell cancer)?
Most people develop kidney cancer for no apparent reason. However, certain risk factors increase the chance that kidney cancer may develop. These include:

  • Age. Most cases develop in people over the age of 60. It is uncommon in people under 50. It is also more common in men.
  • Smoking. About a third of kidney cancers are thought to be caused by smoking. Some of the chemicals from tobacco get into the body and are passed out in urine. These chemicals in the urine can be carcinogenic (damaging) to kidney tubule cells.
  • Other chemical carcinogens. Some workplace chemicals have been linked to an increased risk of kidney cancer. For example, asbestos, cadmium and some organic solvents.
  • Obesity. Obesity is an established risk factor for kidney cancer. About a quarter of kidney cancer cases are due to being overweight.
  • Kidney dialysis. People on long term dialysis have an increased risk.
  • Hypertension. There is a greater risk in people who have high blood pressure.
  • Genetic factors may play a role in some cases. (A 'faulty gene' which runs in some families may sometimes trigger kidney cancer. Also, people with some rare genetic disorders have a higher risk of developing kidney cancer. For example, von Hippel-Lindau syndrome, Birt-Hogg-Dube syndrome and tuberous sclerosus.)

What are the symptoms of kidney cancer?
Many people with kidney cancer have no symptoms at first, especially when the cancer is small. As the cancer develops, the following may occur.
Blood in urine
In many cases, the first symptom is to pass blood in the urine ('haematuria') which is usually painless. The blood in the urine may 'come and go' as the tumour bleeds from time to time. (There are many causes of blood in the urine apart from cancer such as bladder or kidney infections, inflammation of the kidney, kidney stones, etc. You should always report this symptom to your doctor, even if it goes, to clarify the cause of the bleeding.)
Other symptoms
Various other symptoms may occur, typically as the tumor becomes larger, and include:

  • Pain or discomfort in the side or back of the abdomen ('loin pain').
  • Fever (high temperatures) and sweats.
  • A swelling in the area over a kidney.
  • Anaemia, which can cause tiredness. You may also look pale.
  • Some renal cell tumours produce abnormal amounts of certain hormones. This can lead to problems such as:
    • A high blood calcium level which can cause various symptoms such as increased thirst, feeling sick, tiredness, and constipation.
    • Too many red blood cells being made (polycythaemia).
    • High blood pressure.

As the cancer becomes larger you may feel generally unwell and lose weight. If the cancer spreads to other parts of the body, various other symptoms can develop.
How is kidney cancer diagnosed and assessed?
A doctor may suspect that you have kidney cancer from the symptoms and signs listed above, and then arrange tests to confirm the diagnosis. However, in developed countries, about half of kidney cancers are diagnosed before any symptoms develop. They are usually seen 'by chance' when a scan or other investigation is done for another reason.
Tests to confirm the diagnosis
An ultrasound scan of the kidney can usually detect a kidney cancer. This is often one of the first tests done if your doctor suspects that you may have kidney cancer. An ultrasound scan is a safe and painless test which uses sound waves to create images of organs and structures inside your body.  A more sophisticated scan called a CT scan may be used if there is doubt about the diagnosis.
Assessing the extent and spread
If you are found to have a kidney cancer, then other tests are likely to be advised. These may include one or more of: a CT or MRI scan of the abdomen and chest, a chest X-ray, blood tests, and sometimes other tests.  This assessment is called 'staging' of the cancer.

The aim of staging is to find out:

  • How much the tumour in the kidney has grown, and whether it has grown to the edge, or through the outer part of the kidney.
  • Whether the cancer has spread to local lymph glands (nodes).
  • Whether the cancer has spread to other areas of the body (metastasised).

Finding out the stage of the cancer helps doctors to advise on the best treatment options. It also gives a reasonable indication of outlook (prognosis).
What are the treatments for kidney cancer (renal cell cancer)?
Treatment options which may be considered include surgery, radiotherapy, arterial embolisation and immunotherapy. (In general, chemotherapy does not work as well for renal cell cancer as for some other types of cancer. Therefore, it is not often used as a treatment.) The treatment advised for each case depends on various factors such as the stage of the cancer (how large the cancer is and whether it has spread), the exact sub-type or 'grade' of the cancer, and your general health.

You should have a full discussion with a specialist who knows your case. They will be able to give the pros and cons, likely success rate, possible side-effects, and other details about the various possible treatment options for your type of cancer.

You should also discuss with your specialist the aims of treatment. For example:

  • In some cases, the treatment aims to cure the cancer. Some kidney cancers can be cured, particularly if they are treated in the early stages of the disease. (Doctors tend to use the word 'remission' rather than the word 'cured'. Remission means there is no evidence of cancer following treatment. If you are 'in remission', you may be cured. However, in some cases a cancer returns months or years later. This is why doctors are sometimes reluctant to use the word cured.)
  • In some cases, the treatment aims to control the cancer. If a cure is not realistic, with treatment it is often possible to limit the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for some time.
  • In some cases, treatment aims to ease symptoms. For example, if a cancer is advanced then you may require treatments such as painkillers or other treatments to help keep you free of pain or other symptoms. Some treatments may be used to reduce the size of a cancer which may ease symptoms such as pain.

Surgery
An operation to remove all (or sometimes part) of the affected kidney is the most common treatment. This is usually done as an open operation but it can also be done as a keyhole operation for some cases. If the cancer is at an early stage and not spread then surgery alone may be curative. If the cancer has spread to other parts of the body, surgery to remove the affected kidney may still be advised, often in addition to other treatments.

In some cases, surgery is done to remove a secondary kidney tumour which has spread to another part of the body. For example, some secondary tumours which develop in the liver or lung can be removed.
Radiotherapy
Radiotherapy is a treatment which uses high energy beams of radiation which are focused on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying.  Radiotherapy may be advised in addition to surgery which aims to kill any cancerous cells which may have been left behind following an operation.

Radiotherapy may be used to treat the primary cancer instead of surgery if your general health is poor. It is also commonly used to treat kidney cancer which has spread to other sites such as secondary tumours which develop in a bone or the brain.
Arterial embolisation
This may be used instead of surgery (for example, if you are not well enough for surgery). The aim of this treatment is to block off the blood vessel (artery) which is supplying a kidney tumour with blood. To do this a catheter is inserted into a blood vessel in the groin. (A catheter is a long thin, flexible, hollow tube.) Using X-Ray pictures for guidance, the catheter is pushed up into the blood vessel in the affected kidney. When it is in the correct place a substance is injected down the catheter into the blood vessel to block the blood vessel. The tumour is then deprived of its blood supply and so dies.
Immunotherapy (sometimes called biological therapy)
This treatment uses drugs to stimulate the immune system to attack cancerous cells. Two drugs are commonly used to treat kidney cancer - interferon and aldesleukin (sometimes called interleukin 2).

Other immune therapies such as using 'vaccines' to stimulate your immune system to fight cancer cells and using monoclonal antibodies to attack cancer cells are being investigated as possible new treatments for kidney cancer.

There have recently been new targeted treatments introduced which are sunitinib and sorafenib. They are types of drugs called multikinase inhibitors which interfere with the growth of cancer cells. They also work by slowing the growth of new blood vessels within the tumour. They can shrink the cancer or slow its growth.
What is the prognosis (outlook)?
The outlook is best in those who are diagnosed when the cancer is confined within a kidney, has not spread, and who are otherwise in general good health. Surgical removal of an affected kidney in this situation gives a good chance of cure. However, many people with kidney cancer are diagnosed when the cancer has already spread. In this situation a cure is less likely. However, treatment can often slow down the progression of the cancer.

The response to treatment can also vary from case to case. This may be partly related to the exact sub-type or grade of the cancer. Some kidney cancers, even some which are advanced and have spread, respond much better to immunotherapy than others.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information on outlook above is very general. The specialist who knows your case can give more accurate information about your particular outlook, and how well your type and stage of cancer is likely to respond to treatment.


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Penile Cancer (Cancer of the Penis)


. Most cases develop in men over the age of 50. The cause is not clear. There is a good chance of a cure if it is diagnosed and treated in an early stage (as many cases are). In general, the more advanced the cancer (the more it has grown and spread), the less chance that treatment will be curative.

What is cancer?
Cancer is a disease of the cells in the body. The body is made up from millions of tiny cells. There are many different types of cell in the body, and there are many different types of cancer which arise from different types of cell. What all types of cancer have in common is that the cancer cells are abnormal and multiply 'out of control'.

A malignant tumour is a 'lump' or 'growth' of tissue made up from cancer cells which continue to multiply. Malignant tumours invade into nearby tissues and organs which can cause damage.

Malignant tumours may also spread to other parts of the body. This happens if some cells break off from the first (primary) tumour and are carried in the bloodstream or lymph channels to other parts of the body. These small groups of cells may then multiply to form 'secondary' tumours (metastases) in one or more parts of the body. These secondary tumours may then grow, invade and damage nearby tissues and can spread again.

Some cancers are more serious than others, some are more easily treated than others (particularly if diagnosed at an early stage), some have a better outlook (prognosis) than others.

So, cancer is not just one condition. In each case it is important to know exactly what type of cancer has developed, how large it has become and whether it has spread. This will enable you to get reliable information on treatment options and outlook
What is penile cancer and what causes it?
Penile cancer is a cancer that develops on the penis. A cancerous tumour starts from one abnormal cell. The exact reason why a cell becomes cancerous is unclear. It is thought that something damages or alters certain genes in the cell. This makes the cell abnormal and multiply 'out of control'.

In most cases, the reason why penile cancer develops is not known. However, there are factors which are known to alter the risk of penile cancer developing. These include:

  • Age. Penile cancer is more common in men over the age of 50.
  • Many cases of penile cancer are associated with an infection with certain types of human papillomavirus (see below).
  • Some skin conditions of the foreskin are can increase the risk of having penile cancer in the future. These include a condition called erythroplasia of Queyrat and balanitis xerotica obliterans. These are both rare conditions.
  • Phimosis in adults and poor hygiene around the foreskin can increase the risk of penile cancer. Phimosis is when the foreskin remains unusually tight and cannot be drawn back from the head of the penis.
  • Having a circumcision as a baby or child seems to protect against penile cancer.

Human papilloma virus (HPV) and penile cancer
There are many strains of HPV. Two types, HPV 16 and 18, are involved in the development of many cases of penile cancer. (Note: some other strains of HPV cause common warts and verrucas. These strains of HPV are not associated with penile cancer.)

The strains of HPV associated with penile cancer are nearly always passed on by having sex with an infected person. An infection with one of these strains of HPV does not usually cause symptoms. So, you cannot tell if you or the person you have sex with are infected with one of these strains of HPV.

In some men, the strains of HPV that are associated with penile cancer seem to affect the cells of the penis. This makes them more likely to become abnormal which may later (usually many years later) turn into cancerous cells. Note: within two years, 9 out of 10 infections with HPV will clear completely from the body. This means that most men who are infected with these strains of HPV will never develop cancer.

What are the symptoms of penile cancer?
Almost all penile cancers first develop on the glans (head) of the penis or on the underside skin of the foreskin (if you are not circumcised). It is rare to develop penile cancer on the main shaft of the penis. Therefore, you may only notice an early cancer if you pull back your foreskin.

Typically, the first symptom is a change in colour of the skin of the affected part of the glans or foreskin of the penis. The affected skin can also become thickened or appear like a small red rash. The affected area of skin may then gradually develop into a small flat growth (often bluish-brown in colour) or a growth or sore which may bleed. It does not usually cause pain. In some cases the early cancer develops as small crusty bumps.

Left untreated, the cancer typically grows to involve the entire surface of the glans and/or foreskin. It then eventually spreads further to deeper parts of the penis and to other areas of the body to cause various other symptoms.
How is penile cancer diagnosed and assessed?
Anyone who has an abnormal growth or sore on their penis will have a thorough examination by their doctor. This will usually include feeling for any enlarged lymph glands in the groin. You will then be referred to see a specialist in the hospital.

It is likely that further tests in the hospital will be arranged. These may include:

  • A biopsy. This is where a small piece of tissue is taken from the cancer and sent to the laboratory. Sometimes biopsies are also taken from the lymph glands in the groin. Results of a biopsy can take two weeks.
  • An MRI of the penis may be performed to assess the size of the cancer.
  • A CT scan of the chest, abdomen and pelvis may be performed. These scans can provide detail on the structure of the internal organs.

Stages of penile cancer range from stage 1 (where the cancer is confined to the skin of the penis) to stage 4 (where there is spread to lymph nodes deep in the pelvis or to other parts of the body).
Grading of the cancer cells
If a biopsy of the cancer is taken then the cells can assessed. By looking at certain features of the cells under the microscope the cancer can be 'graded'.

  • Grade 1 (low grade) - the cells look reasonably similar to normal cells. The cancer cells are said to be 'well differentiated'. The cancer cells tend to grow and multiply quite slowly and are not so 'aggressive'.
  • Grade 2 - is a middle grade.
  • Grade 3 - the cells look very abnormal and are said to be 'poorly differentiated'. The cancer cells tend to grow and multiply quite quickly and are more 'aggressive'.

Finding out the stage and grade of the cancer helps doctors to advise on the best treatment options. It also gives a reasonable indication of prognosis
What are the treatment options for penile cancer?
Treatment options may include surgery, chemotherapy and radiotherapy. The treatment advised for each case depends on various factors such as the stage and grade of the cancer, and your general health. A specialist will be able to give the pros and cons, likely success rate, possible side-effects and other details about the various possible treatment options for your type and stage of cancer.

You should also discuss with your specialist the aims of treatment. For example:

  • In some cases, treatment aims to cure the cancer. (Doctors tend to use the word 'remission' rather than the word 'cured'. Remission means there is no sign of cancer following treatment. If you are 'in remission', you may be cured. However, in some cases a cancer returns months or years later. This is why doctors are sometimes reluctant to use the word cured.)
  • In some cases, treatment aims to control the cancer. If a cure is not realistic, with treatment it is often possible to limit the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for some time.
  • In some cases, treatment aims to ease symptoms. For example, if a cancer is advanced then you may require treatments such as painkillers or other treatments to help keep you free of pain or other symptoms. Some treatments may be used to reduce the size of a cancer which may ease symptoms such as pain.

Surgery
An operation is advised in most cases. The type of operation depends upon the size of the cancer and its position on the penis. If the cancer is small and only on the skin of the penis then the cancer and a small amount of normal tissue can be removed. However, if the cancer is larger then either part of the penis (partial penectomy) or even the entire penis (total penectomy) is removed. The removed cancer is sent for biopsy to see if all of it has been taken out. In case the biopsy shows evidence of tumor being left behind (positive margins) then a repeat operation may be required.

Reconstructive surgery is an option for many men but this is only performed once complete removal of the cancer is confirmed on biopsy. Your surgeon will be able to discuss the different types of reconstructive surgery with you in more detail. The lymph glands in the groin are often also removed during the operation or later on at repeat surgery.
Chemotherapy
Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells or stop them from multiplying.  Chemotherapy may be given after having an operation. This aims to kill any cancer cells that have been left behind following the operation.

Sometimes chemotherapy is given before surgery to reduce the size of the cancer. This may make surgery easier and more likely to be successful.
Radiotherapy
Radiotherapy is a treatment that uses high energy beams of radiation which are focused on cancerous tissue. This kills cancer cells or stops cancer cells from multiplying.  Radiotherapy is sometimes used for smaller cancers in people who do not need an operation. This is less common though.
Other treatments
If the cancer is at an early stage and is only on the glans (the head of the penis), sometimes doctors prescribe a cytotoxic (cell-killing) cream that can be used on the cancer.
What is the prognosis (outlook)?
There is a good chance of a cure if penile cancer is diagnosed and treated when it is at an early stage (confined to the penis and has not spread to the lymph glands). Most treatments for penile cancer will not affect your ability to have sex, even if you need an operation. In general, the later the stage and the higher the grade of the cancer, the poorer the outlook. Even if a cure is not possible, treatment can often slow down the progression of the cancer.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information about outlook given above is very general. The specialist who knows your case can give more accurate information about your particular outlook, and how well your stage and grade of cancer is likely to respond to treatment.


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Prostate Cancer


Most cases of prostate cancer develop in older men. In many cases the cancer is slow-growing, does not reduce life expectancy, and may not need treatment. In some cases it is more aggressive, spreads to other parts of the body, and may benefit from treatment. In general, the more advanced the cancer (the more it has grown and spread), the less chance that treatment will be curative. However, treatment can often slow the progress of the cancer.

What is the prostate gland?

Description: Cross-section diagram of the prostate and nearby organs (050.gif)
The prostate gland (just called prostate from now on) is only found in men. It lies just beneath the bladder. It is normally about the size of a chestnut.

The urethra (the tube which passes urine from the bladder) runs through the middle of the prostate. The prostate's main function is to produce fluid which protects and enriches sperm.

The prostate often gets bigger (enlarges) gradually after the age of about 50. By the age of 70, about 8 in 10 men have an enlarged prostate. It is common for older men to have urinary symptoms caused by a benign (non-cancerous) enlargement of the prostate. Some men also develop prostate cancer.
What is cancer?
Cancer is a disease of the cells in the body. The body is made up from millions of tiny cells. There are many different types of cell in the body, and there are many different types of cancer which arise from different types of cell. What all types of cancer have in common is that the cancer cells are abnormal and multiply out of control.

A malignant tumour is a lump or growth of tissue made up from cancer cells which continue to multiply. Malignant tumours invade into nearby tissues and organs which can cause damage.

Malignant tumours may also spread to other parts of the body. This happens if some cells break off from the first (primary) tumour and are carried in the bloodstream or lymph channels to other parts of the body. These small groups of cells may then multiply to form secondary tumours (metastases) in one or more parts of the body. These secondary tumours may then grow, invade and damage nearby tissues, and spread again.

Some cancers are more serious than others, some are more easily treated than others (particularly if diagnosed at an early stage), and some have a better outlook (prognosis) than others.

So, cancer is not just one condition. In each case it is important to know exactly what type of cancer has developed, how large it has become, and whether it has spread. This will enable you to get reliable information on treatment options and outlook.
What is prostate cancer?
Prostate cancer is a cancer which develops from cells in the prostate gland. Most cases develop in men over the age of 65.

Prostate cancer is different to most other cancers because small areas of cancer within the prostate are actually very common, especially in older men. These may not grow or cause any problems for many years (if at all).
What causes prostate cancer?
A cancerous tumour starts from one abnormal cell. The exact reason why a cell becomes cancerous is unclear. It is thought that something damages or alters certain genes in the cell. This makes the cell abnormal and multiply out of control.

Although the exact cause is unclear, certain risk factors increase the chance that prostate cancer may develop. These include:

  • Ageing. Most cases occur in older men.
  • Family history and genetic factors. If your father or brother had prostate cancer at a relatively early age (before they were 60) then you have an increased risk. Also, if the type of breast cancer which is linked to a faulty gene runs in your female relatives, then you are at increased risk of prostate cancer. These factors point towards a faulty gene which may occur in some men.
  • Ethnic group. Prostate cancer is more common in African-Caribbean men and less common in Asian men.
  • Diet is possibly a risk factor. As with other cancers, a diet high in fats and low in fruit and vegetables may increase the risk.
  • Exposure to the metal cadmium may be a risk.

What are the symptoms of prostate cancer?
Prostate cancer is often slow-growing. There may be no symptoms at first, even for years. As the tumour grows, it may press on and irritate the urethra, or cause a partial blockage to the flow of urine. Symptoms may then develop and can include one or more of the following:

  • Poor stream. The flow of urine is weaker, and it takes longer to empty your bladder.
  • Hesitancy. You may have to wait at the toilet for a while before urine starts to flow.
  • Dribbling. A bit more urine may trickle out and stain your underpants soon after you finish at the toilet.
  • Frequency. You may pass urine more often than normal.
  • Urgency. You may have to get to the toilet quickly.
  • Poor emptying. You may have a feeling of not quite emptying your bladder.

Note: all the above symptoms are common in older men. Most men who develop the above symptoms do not have prostate cancer but have a benign (non-cancerous) enlargement of the prostate. However, it is best to get any new symptoms checked out by a doctor.

Other symptoms such as pain at the base of the penis or passing blood occasionally occur. (These do not occur with benign prostate enlargement.)

If the cancer spreads to other parts of the body, various other symptoms can develop. The most common site for the cancer to spread is to one or more bones, especially the pelvis, lower spine and hips. Affected bones can become painful and tender. Sometimes the first symptoms to develop are from secondary tumours in bones.
Screening for prostate cancer
Screening for prostate cancer is controversial. A routine blood test which shows a high PSA may indicate that you have prostate cancer.
PSA is a chemical which is made by both normal and cancerous prostate cells. Basically, the higher the level of PSA, the more likely that you have cancer of the prostate. However, a mild to moderately raised PSA can occur in conditions other than prostate cancer. (If you have confirmed prostate cancer, the PSA blood test is also used to monitor treatment. If treatment is working and cancer cells are killed then the level of PSA falls.) Also, many prostate cancers are slow-growing and do not cause problems, particularly in older men. Some experts believe that if all men were screened then there may be many men found with a raised PSA level. Many men may then be investigated and treated unnecessarily with all the possible risks and side-effects of the investigations and treatment. Put simply, some people believe that screening for all men may do more harm than good.

However, you can decide for yourself if you would like a PSA test. It is best to discuss the pros and cons of the test with your GP. After counselling, if you decide that you would like the test, many GPs will do the test on request.

How is prostate cancer diagnosed?
Initial assessment
If a doctor suspects that you may have prostate cancer, he or she will usually:

  • Examine the prostate gland. They do this by inserting a gloved finger through the anus into the rectum to feel the back of the prostate gland. An enlarged-feeling gland, particularly if it is not smooth to feel, may indicate prostate cancer. However, a normal-feeling prostate does not rule out prostate cancer.
  • Do a blood test to measure the level of prostate specific antigen (PSA).
  • A PCA3 test may be offered. This is a new urine test which provides a more effective means of detecting prostate cancer than the PSA test. PCA3 is a chemical made particularly by prostate cancer cells. Up to 100 times more PCA3 is present in prostate cancer cells than non-cancerous cells. A certain level of PCA3 in the urine is a good indication that prostate cancer is present. This test is combined with a rectal examination. A normal feeling prostate combined with a negative PCA3 test can be reassuring and may help avoid the need for prostate biopsies.

Biopsy - to confirm the diagnosis
A biopsy is when a small sample of tissue is removed from a part of the body. The sample is then examined under the microscope to look for abnormal cells. A biopsy can usually confirm the presence of prostate cancer.

A biopsy is not always necessary to confirm a diagnosis of prostate cancer. Your doctor will be able to discuss the reasons for you to have a biopsy, if appropriate, with you in more detail.

A small biopsy of the prostate is taken by using a fine needle. This is usually done with the aid of a special ultrasound scanner. The probe of the scanner is about the size and shape of a finger. It is passed through the anus into the rectum to lie behind the prostate. This finds the exact position of the prostate. The doctor then pushes a fine needle into the back of the prostate from within the rectum to obtain the biopsy. Several samples are usually taken from different parts of the prostate.

To biopsy the prostate can be uncomfortable. Therefore, local anaesthetic is used to reduce the pain as much as possible.
Assessing the severity and spread of prostate cancer
The severity of the disease is mainly based on three factors - the grade of the cancer cells, the stage of the cancer, and the blood PSA level.
Grade of the cancer
Biopsy samples are looked at under the microscope to assess the cancer cells. By looking at certain features of the cells the cancer can be graded. The common grading system used is called the Gleason Score.

A Gleason score of between 2 and 6 is a low-grade prostate cancer. It is likely to grow very slowly. A Gleason score of 7 is an intermediate grade that will grow at a moderate rate. A Gleason score of 8 to10 is a high-grade cancer that is likely to grow more quickly.
Staging
If you are confirmed to have prostate cancer, further tests may be advised to assess if it has spread. These tests are not advised in all cases. It depends on factors such as your age and the grade of the tumour cells. Tests which may be done include a bone scan, a CT scan, an MRI scan, an abdominal ultrasound scan or other tests.  This assessment is called staging of the cancer. The aim of staging is to find out:

  • How much the tumour has grown, and whether it has grown through the wall of the prostate and into nearby structures such as the bladder wall.
  • Whether the cancer has spread to local lymph nodes.
  • Whether the cancer has spread to other areas of the body (metastasised)

What are the treatment options for prostate cancer?
The treatment of prostate cancer is complicated. It varies tremendously between different cases. In addition, different men may choose to have different treatments compared to others with a similar type of prostate cancer.

Treatment options which may be considered include: surgery, radiotherapy, hormone treatment and, less commonly, chemotherapy. Often a combination of two or more of these treatments is used. The treatments used depend on:

  • The cancer itself - its size and stage (whether it has spread), the grade of the cancer cells, the PSA level, AND
  • The man with the cancer - your age, your general health and also personal preferences for treatment.

For example, certain types of prostate cancer are confined to the prostate, are slow-growing and are unlikely to affect your life expectancy. Some types are more aggressive, more likely to spread and may cause serious illness and lead to death unless treated. The risks and possible side-effects of treatment are another consideration.

The treatment options are usually different for early prostate cancer that is confined to the prostate gland, local advanced prostate cancer, and late or advanced prostate cancer.

You should have a full discussion with a specialist who knows your case. They will be able to give the pros and cons, likely success rate, possible side-effects, and other details about the various possible treatment options for your type of cancer.

You should also discuss with your specialist the aims of treatment. For example:

  • Treatment may aim to cure the cancer. In particular, the earlier the stage of the cancer, the better the chance of a cure. (Doctors tend to use the word remission rather than the word cured. Remission means there is no evidence of cancer following treatment. If you are in remission, you may be cured. However, in some cases a cancer returns months or years later. This is why doctors are sometimes reluctant to use the word cured.)
  • Treatment may aim to control the cancer. If a cure is not realistic, with treatment it is often possible to limit the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for some time.
  • Treatment may aim to ease symptoms. Even if a cure is not possible, treatments may be used to reduce the size of a cancer, which may ease symptoms such as pain. If a cancer is advanced then you may require treatments such as nutritional supplements, painkillers, or other techniques to help keep you free of pain or other symptoms.

The following is an overview of treatment options which you may have after discussion with your doctor.
Treatment options for early prostate cancer
Active surveillance
Many prostate cancers are diagnosed at an early stage by PSA testing. Prostate cancer is often very slow-growing and for many men with prostate cancer, the disease may never progress or cause any symptoms. In other words, many men with prostate cancer will never need any treatment. Treatments for prostate cancer can cause side-effects, which can affect your lifestyle. By monitoring the cancer with active surveillance, you can avoid or delay the side-effects of treatment.

Active surveillance aims to find those cancers that are likely to grow and cause symptoms if they are not treated. These cancers can then be treated at an early stage.

Active surveillance may be suitable if you have low to medium risk prostate cancer. It will involve regular check-ups with PSA tests, rectal examination of the prostate and possibly repeat prostate biopsies.
Surgery
Removing the prostate (radical prostatectomy) can be curative if the cancer is in an early stage (confined to the prostate and not spread). It is a major operation and so tends to be advised more often for younger men whose general health is good, especially if the cancer grade means the cancer is likely to spread in the future. Side-effects such as impotence and/or incontinence of urine may occur following a prostatectomy.
Radiotherapy
Radiotherapy is a treatment which uses high energy beams of radiation which are focused on cancerous tissue. This kills cancer cells, or stops cancer cells from multiplying.

Radical radiotherapy may be used as an alternative to surgery. Two types of radiotherapy are used for prostate cancer - external and internal. Again, the type chosen depends on various factors such as the size, grade and stage of cancer.

Radiotherapy is often more suitable for men who are not fit enough or choose not to have an operation.

  • External radiotherapy. This is where radiation is targeted on the prostate cancer from a machine. (This is common type of radiotherapy used for many types of cancer.)
  • Internal radiotherapy (brachytherapy). This treatment involves inserting a small radioactive implant into the cancerous tumour, or next to the tumour. Sometimes radioactive seeds are placed into the prostate gland. The seeds are left in place permanently but lose their radioactivity over time. Sometimes a larger radioactive implant is inserted into the prostate for a short time and then removed. External radiotherapy may be also given with this type of brachytherapy.

Treatment options for locally advanced prostate cancer
When the cancer has spread into the capsule of the prostate or into the surrounding tissues near to the prostate then it is called locally advanced prostate cancer.

You may be offered hormone treatment with radiotherapy. The radiotherapy given is usually similar to that given for men with early prostate cancer although the radiotherapy may include the surrounding structures in addition to the prostate. Some men just receive hormone treatment. As the choice of treatment depends on many factors, your doctor will discuss the treatment with you in more detail.
Hormone treatment
Prostate cancer cells need the male hormone called testosterone to grow and multiply well. Testosterone is made in the testes and circulates in the bloodstream. Hormone treatments aim to stop you from making testosterone or to block the effect of testosterone on prostate cancer cells. Hormone treatments do not cure prostate cancer but may greatly slow down the growth of the cancer for a number of years.

Two groups of drugs are available:

  • Drugs which work on the pituitary gland. For example: goserelin and leuprorelin. (Your pituitary gland makes a hormone which circulates in the bloodstream to stimulate the testes to make testosterone. These drugs stop your pituitary from making this stimulating hormone.) These drugs are given by an injection.
  • Drugs which block the action of testosterone (anti-androgen drugs). For example: bicalutamide, flutamide and cyproterone acetate. These drugs are tablets.

Another type of hormone treatment which may be offered is surgical removal of the testes (orchidectomy). Without testes you no longer make testosterone.

Hormone treatments can cause side-effects such as erectile dysfunction (impotence), hot flushes, sweating and other problems.
Treatment options for late or advanced prostate cancer
Late or advanced prostate cancer is when the cancer has spread to other parts of the body. Hormone treatments are usually given as the cancer cells in other parts of the body still need testosterone to grow and multiply.

You may decide not to start hormone treatment until you develop symptoms. Your doctor will be able to discuss the timings of treatments with you in more detail.
Chemotherapy
Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells, or stop them from multiplying. Chemotherapy is not commonly used for the treatment of prostate cancer. It may be used for more advanced cancers.
Radiotherapy
Even if the cancer is advanced and a cure is not possible, radiotherapy may have a place to ease symptoms. For example, radiotherapy may be used to shrink secondary tumours which have spread to bones and are causing pain.
Watchful waiting
In some cases it may be best not to have any active treatment but to see how the cancer develops. This is called watchful waiting. Various factors are taken into account such as the stage of the cancer, your age, general health, the impact and potential side-effects if treatment were to be used. Watchful waiting may be more appropriate for men where the cancer is not causing much in the way of symptoms, is slow-growing, especially in older men. With a watchful waiting approach you will still have regular check ups and the decision about treatment can be reviewed at any time.
Newer treatments
Cryotherapy (also known as cryosurgery) is an alternative treatment for men with early prostate cancer.  It involves placing a number of metal probes through the skin and into the affected area of the prostate gland. The probes contain liquid nitrogen, which freezes and destroys the cancer cells.

High intensity focused ultrasound (HIFU) treatment may be offered to some men, again with early prostate cancer. HIFU involves inserting a probe into the rectum. It is then pushed through the wall of the bowel into the prostate gland. The probe produces a high-energy beam of ultrasound which then heats and destroys the cancer. The probe is surrounded by a cooling balloon to protect the normal prostate tissue from damage.
What is the prognosis (outlook)?
The outlook for prostate cancer is very variable. Some prostate cancers are slow-growing and do not affect life expectancy. On the other hand some are already spread to other parts of the body when they are diagnosed. The response to treatment is also variable.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information on outlook above is very general. The specialist who knows your case can give more accurate information about your particular outlook, and how well your type and stage of cancer is likely to respond to treatment.


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