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{{DiseaseDisorder infobox |
__NOTOC__
  Name          = Prostate cancer |
'''For patient information click [[Prostate cancer (patient information)|here]].'''
  ICD10          = {{ICD10|C|61||c|60}} |
{{Prostate cancer}}
  ICD9          = {{ICD9|185}} |
{{SCC}}; {{MJM}}; {{AE}} {{SC}} {{sali}} {{KKV}}
  Image          = Prostatelead.jpg |
  Caption        = |
  ICDO          = |
  OMIM          = 176807 |
  DiseasesDB    = 10780 |
  MedlinePlus    = 000380 |
  eMedicineSubj  = radio |
  eMedicineTopic = 574 |
  MeshID        = D011471 |
}}
{{Search infobox}}
{{SCC}}


{{Editor Join}}
{{SK}} Prostate adenocarcinoma, neoplasm of prostate, tumor of prostate, tumor of prostate, malignant tumor of the prostate, cancer of the prostate, malignant prostatic tumor, malignant prostatic tumour, malignant tumor of prostate


==Overview==
==[[Prostate cancer overview|Overview]]==


'''Prostate cancer''' is a [[disease]] in which [[cancer]] develops in the [[prostate]], a gland in the [[male]] [[reproductive system]]. It occurs when [[cell (biology)|cell]]s of the prostate [[Mutation|mutate]] and begin to multiply out of control. These cells may spread ([[Metastasis|metastasize]]) from the prostate to other parts of the body, especially the [[bone]]s and [[lymph node]]s. Prostate cancer may cause pain, difficulty in [[urination|urinating]], problems during sexual intercourse, [[erectile dysfunction]] and other [[symptoms]].
==[[Prostate cancer historical perspective|Historical Perspective]]==


Rates of prostate cancer vary widely across the world. Although the rates vary widely between countries, it is least common in South and East Asia, more common in Europe, and most common in the United States.<ref>{{cite web | url = http://web.archive.org/web/20060205235509/http://www.jncicancerspectrum.oxfordjournals.org/cgi/statContent/cspectfstat;99 | title = IARC Worldwide Cancer Incidence Statistics—Prostate | publisher = Oxford University Press | work = JNCI Cancer Spectrum | date = December 19, 2001}} Retrieved on 2007-04-05 through the Internet Archive</ref> Prostate cancer develops most frequently in men over fifty. This cancer can occur only in men, as the prostate is exclusively of the male reproductive tract. It is one of the most common types of cancer in men. However, many men who develop prostate cancer never have symptoms, undergo no therapy, and eventually die of other causes. That is because malignant [[neoplasm]]s of the prostate are, in most cases, slow-growing, and because most of those affected are over 60. Hence they often die of causes unrelated to the prostate cancer, such as heart/circulatory disease, pneumonia, other unconnected cancers or old age. Many factors, including [[genetics]] and [[Diet (nutrition)|diet]], have been implicated in the development of prostate cancer.
==[[Prostate cancer classification|Classification]]==
Prostate cancer is most often discovered by PSA ([[prostate specific antigen]]) screening and less commonly by [[physical examination]] or by symptoms.  There is some current concern about the accuracy of the PSA test and its usefulness. Suspected prostate cancer is typically confirmed by taking a [[biopsy]] of the prostate and examining it under a [[microscope]]. Further tests, such as [[CT scan]]s and [[bone scan]]s, may be performed to determine whether prostate cancer has spread.


Treatment options for prostate cancer with intent to cure are primarily [[surgery]] and [[radiation therapy]]. Other treatments such as [[hormonal therapy]], [[chemotherapy]], [[proton therapy]], cryosurgery, high intensity focused ultrasound (HIFU) also exist depending on the clinical scenario and desired outcome. [[Abiraterone|Abiraterone Acetate]] is showing promise in reducing Tumor Size and [[Prostate specific antigen|PSA]] levels in Aggressive end-stage prostate cancers.<ref>{{ cite news | author = Richard Warry |  title =  Drug for deadly prostate cancer  |  url = http://news.bbc.co.uk/2/hi/health/7517414.stm | publisher = BBC date = July 22, 2008  | accessdate = 2008-07-23 }}</ref> The age and underlying health of the man as well as the extent of spread, appearance under the microscope and response of the cancer to initial treatment are important in determining the outcome of the disease. The decision whether or not to treat localized prostate cancer (a tumor that is contained within the prostate) with curative intent is a [[patient trade-off]] between the expected beneficial and harmful effects in terms of patient survival and quality of life.
==[[Prostate cancer pathophysiology|Pathophysiology]]==


==Prostate==
==[[Prostate cancer causes|Causes]]==
{{main|Prostate}}
The [[prostate]] is a part of the male [[reproductive system|reproductive]] [[organ (anatomy)|organ]] which helps make and store [[seminal fluid]]. In adult men a typical prostate is about three centimeters long and weighs about twenty grams.<ref>{{cite book| last=Aumüller| first=G.| title=Prostate Gland and Seminal Vesicles| publisher=Springer-Verlag| location=Berlin-Heidecool.lberg| year=1979}}</ref> It is located in the [[pelvis]], under the [[urinary bladder]] and in front of the [[rectum]]. The prostate surrounds part of the [[urethra]], the tube that carries [[urine]] from the bladder during [[urination]] and semen during [[ejaculation]].<ref>{{cite book| last=Moore| first=K.| coauthors=Dalley, A.| title=Clinically Oriented Anatomy| publisher=Lippincott Williams & Wilkins| location=Baltimore, Maryland| year=1999}}</ref> Because of its location, prostate diseases often affect urination, ejaculation, and rarely [[defecation]]. The prostate contains many small [[gland]]s which make about twenty percent of the fluid constituting semen.<ref>{{cite book| last=Steive| first=H.| chapter=Männliche Genitalorgane| title=Handbuch der mikroskopischen Anatomie des Menschen. Vol. VII Part 2| pages=1–399| location=Berlin| publisher=Springer| year=1930}}</ref> In prostate cancer the cells of these prostate glands [[mutation|mutate]] into cancer cells. The prostate glands require male [[hormone]]s, known as [[androgen]]s, to work properly. Androgens include [[testosterone]], which is made in the [[testes]]; [[dehydroepiandrosterone]], made in the [[adrenal gland]]s; and [[dihydrotestosterone]], which is converted from testosterone within the prostate itself. Androgens are also responsible for [[secondary sex characteristic]]s such as facial hair and increased muscle mass.


==Symptoms==
==[[Prostate cancer differential diagnosis|Differentiating Prostate Cancer from other Cancers]]==


Early prostate cancer usually causes no symptoms. Often it is diagnosed during the workup for an elevated [[prostate specific antigen|PSA]] noticed during a routine checkup. Sometimes, however, prostate cancer does cause symptoms, often similar to those of diseases such as [[benign prostatic hypertrophy]]. These include [[urinary frequency|frequent urination]], [[nocturia|increased urination at night]], difficulty starting and maintaining a steady stream of urine, [[hematuria|blood in the urine]], and [[dysuria|painful urination]]. Prostate cancer is associated with urinary dysfunction as the prostate gland surrounds the prostatic urethra. Changes within the gland therefore directly affect urinary function. Because the [[vas deferens]] deposits seminal fluid into the prostatic urethra, and secretions from the prostate gland itself are included in semen content, prostate cancer may also cause problems with sexual function and performance, such as difficulty achieving [[erection]] or painful [[ejaculation]].<ref>{{cite journal| last=Miller| first=DC| coauthors=Hafez, KS, Stewart, A, et al| title=Prostate carcinoma presentation, diagnosis, and staging: an update from the National Cancer Data Base| journal=Cancer| year=2003| volume=98| pages=1169| pmid=12973840| doi=10.1002/cncr.11635}}</ref>.
==[[Prostate cancer epidemiology and demographics|Epidemiology and Demographics]]==


Advanced prostate cancer can spread to other parts of the body and this may cause additional symptoms. The most common symptom is [[bone pain]], often in the [[vertebrae]] (bones of the spine), [[pelvis]] or [[rib]]s. Spread of cancer into other bones such as the [[femur]] is usually to the proximal part of the bone. Prostate cancer in the [[vertebral column|spine]] can also compress the [[spinal cord]], causing leg weakness and [[urinary incontinence|urinary]] and [[fecal incontinence]].<ref>{{cite journal| last=van der Cruijsen-Koeter| first=IW| coauthors=Vis AN, Roobol MJ, Wildhagen MF, de Koning HJ, van der Kwast TH, Schroder FH| title=Comparison of screen detected and clinically diagnosed prostate cancer in the European randomized study of screening for prostate cancer, section rotterdam| journal=Urol| year=2005| month=July| volume=174| issue=1| pages=121–5| pmid=15947595| doi=10.1097/01.ju.0000162061.40533.0f}}</ref>
==[[Prostate cancer risk factors|Risk Factors]]==


==Pathophysiology==
==[[Prostate cancer screening|Screening]]==
[[Image:Normal cancer cell division from NIH-2.png|thumb|left|When normal cells are damaged beyond repair, they are eliminated by [[apoptosis]]. Cancer cells avoid apoptosis and continue to multiply in an unregulated manner.]]


Prostate cancer is classified as an [[adenocarcinoma]], or glandular cancer, that begins when normal semen-secreting prostate gland cells [[mutation|mutate]] into cancer cells. The region of prostate gland where the adenocarcinoma is most common is the peripheral zone.
==[[Prostate cancer natural history|Natural History, Complications and Prognosis]]==
 
Initially, small clumps of cancer cells remain confined to otherwise normal prostate glands, a condition known as [[carcinoma in situ]] or [[prostatic intraepithelial neoplasia]] (PIN).
 
Although there is no proof that PIN is a cancer precursor, it is closely associated with cancer. Over time these cancer cells begin to multiply and spread to the surrounding prostate tissue (the [[stroma]]) forming a [[tumor]].
 
Eventually, the tumor may grow large enough to invade nearby organs such as the [[seminal vesicles]] or the [[rectum]], or the tumor cells may develop the ability to travel in the [[blood]]stream and [[lymphatic system]].
 
Prostate cancer is considered a [[malignant]] tumor because it is a mass of cells which can invade other parts of the body. This invasion of other organs is called [[metastasis]]. Prostate cancer most commonly metastasizes to the [[bone]]s, [[lymph node]]s, rectum, and bladder.
 
==Etiology==
 
The specific causes of prostate cancer remain unknown.<ref>{{cite journal| first=Ann W.| last=Hsing| coauthors=Anand P. Chokkalingam| title=Prostate cancer epidemiology| journal=Frontiers in Bioscience| volume=11| pages=1388–1413| month=May 1| year=2006| url=http://www.bioscience.org/2006/v11/af/1891/fulltext.htm| doi=10.2741/1891}}</ref>  A man's risk of developing prostate cancer is related to his [[aging|age]], [[genetics]], [[Race (classification of human beings)|race]], [[diet (nutrition)|diet]], [[lifestyle]], [[medication]]s, and other factors. The primary risk factor is age. Prostate cancer is uncommon in men less than 45, but becomes more common with advancing age. The average age at the time of diagnosis is 70.<ref>{{cite journal| last=Hankey| first=BF| coauthors=Feuer EJ, Clegg LX, Hayes RB, Legler JM, Prorok PC, Ries LA, Merrill RM, Kaplan RS| title=Cancer surveillance series: interpreting trends in prostate cancer—part I: Evidence of the effects of screening in recent prostate cancer incidence, mortality, and survival rates| journal=J Natl Cancer Inst| year=1999| month=June 16| volume=91| issue=12| pages=1017–24| pmid=10379964| doi=10.1093/jnci/91.12.1017}}</ref> However, many men never know they have prostate cancer. Autopsy studies of Chinese, German, Israeli, Jamaican, Swedish, and Ugandan men who died of other causes have found prostate cancer in thirty percent of men in their 50s, and in eighty percent of men in their 70s.<ref>{{cite journal| last=Breslow| first=N| coauthors=Chan CW, Dhom G, Drury RA, Franks LM, Gellei B, Lee YS, Lundberg S, Sparke B, Sternby NH, Tulinius H.| title=Latent carcinoma of prostate at autopsy in seven areas. The International Agency for Research on Cancer, Lyons, France| journal=Int J Cancer| year=1977| month=November 15| volume=20| issue=5| pages=680–8| pmid=924691| doi=10.1002/ijc.2910200506}}</ref> In the year 2005 in the United States, there were an estimated 230,000 new cases of prostate cancer and 30,000 deaths due to prostate cancer.<ref>{{cite journal| last=Jemal A| coauthors=Murray T, Ward E, Samuels A, Tiwari RC, Ghafoor A, Feuer EJ, Thun MJ| title=Cancer statistics, 2005| journal=CA Cancer J Clin| year=2005| month=Jan-Feb| volume=55| issue=1| pages=10–30| pmid=15661684}} Erratum in: CA Cancer J Clin. 2005 Jul-Aug;55(4):259</ref>
 
A man's genetic background contributes to his risk of developing prostate cancer. This is suggested by an increased [[incidence (epidemiology)|incidence]] of prostate cancer found in certain racial groups, in identical [[twin]]s of men with prostate cancer, and in men with certain [[gene]]s. In the United States, prostate cancer more commonly affects black men than white or Hispanic men, and is also more deadly in black men.<ref>{{cite journal| last=Hoffman| first=RM| coauthors=Gilliland FD; Eley JW; Harlan LC; Stephenson RA; Stanford JL; Albertson PC; Hamilton AS; Hunt WC; Potosky AL| title=Racial and ethnic differences in advanced-stage prostate cancer: the Prostate Cancer Outcomes Study| journal=J Natl Cancer Inst| year=2001| month=March 7| volume=93| issue=5| pages=388–95| pmid=11238701| doi=10.1093/jnci/93.5.388}}</ref> Men who have a brother or father with prostate cancer have twice the usual risk of developing prostate cancer.<ref>{{cite journal| last=Steinberg| first=GD| coauthors=Carter BS; Beaty TH; Childs B; Walsh PC| title=Family history and the risk of prostate cancer| journal=Prostate| year=1990| volume=17| issue=4| pages=337–47| pmid=2251225| doi=10.1002/pros.2990170409}}</ref> [[Twin study|Studies of twins]] in Scandinavia suggest that forty percent of prostate cancer risk can be explained by [[heritability|inherited factors]].<ref>{{cite journal| last=Lichtenstein| first=P| coauthors=Holm NV; Verkasalo PK; Iliadou A; Kaprio J; Koskenvuo M; Pukkala E; Skytthe A; Hemminki K| title=Environmental and heritable factors in the causation of cancer—analyses of cohorts of twins from Sweden, Denmark, and Finland| journal=N Engl J Med| year=2000| month=July 13| volume=343| issue=2| pages=78–85| pmid=10891514| doi=10.1056/NEJM200007133430201}}</ref> However, no single gene is responsible for prostate cancer; many different genes have been implicated. Two genes (''[[BRCA1]]'' and ''[[BRCA2]]'') that are important risk factors for [[ovarian cancer]] and [[breast cancer]] in women have also been implicated in prostate cancer.<ref>{{cite journal| last=Struewing| first=JP| coauthors=Hartge P; Wacholder S; Baker SM; Berlin M; McAdams M; Timmerman MM; Brody LC; Tucker MA| title=The risk of cancer associated with specific mutations of BRCA1 and BRCA2 among Ashkenazi Jews| journal=N Engl J Med| year=1997| month=May 15| volume=336| issue=20| pages=1401–8| pmid=9145676| doi=10.1056/NEJM199705153362001}}</ref>
 
Dietary amounts of certain [[food]]s, [[vitamin]]s, and [[dietary mineral|minerals]] can contribute to prostate cancer risk. Men with higher serum levels of the short-chain [[Omega-6 fatty acid|ω-6 fatty acid]] [[linoleic acid]] have higher rates of prostate cancer. However, the same series of studies showed that men with elevated levels of long-chain ω-3 ([[eicosapentaenoic acid|EPA]] and [[docosahexaenoic acid|DHA]]) had lowered incidence.<ref>{{cite web|author=Gann, PH and Giovannucci|title=Prostate Cancer and Nutrition|year=2005|accessmonthday=February 20 |accessyear=2006 |url= http://www.prostatecancerfoundation.org/atf/cf/%7B705B3273-F2EF-4EF6-A653-E15C5D8BB6B1%7D/Nutrition_Guide.pdf|format=PDF}} in .pdf format.</ref> A long-term study reports that "blood levels of trans fatty acids, in particular [[trans fats]] resulting from the hydrogenation of vegetable oils, are associated with an increased prostate cancer risk."<ref>Chavarro et al., "A prospective study of blood trans fatty acid levels and risk of prostate cancer," Proc. Amer. Assoc. Cancer Res., Volume 47, 2006 [http://www.aacrmeetingabstracts.org/cgi/content/abstract/2006/1/943]. See also [http://www.cancersupportivecare.com/nutritionprostate.pdf Ledesma 2004 Nutrition & prostate cancer].</ref> Other dietary factors that may increase prostate cancer risk include low intake of [[vitamin E]] (Vitamin E is found in green, leafy vegetables), [[omega-3 fatty acid]]s (found in fatty fishes like salmon), and the mineral [[selenium]]. A study in 2007 cast doubt on the effectiveness of lycopene (found in tomatoes) in reducing the risk of prostate cancer.<ref name="pmid17507623">{{cite journal | author = Peters U, Leitzmann MF, Chatterjee N, Wang Y, Albanes D, Gelmann EP, Friesen MD, Riboli E, Hayes RB | title = Serum lycopene, other carotenoids, and prostate cancer risk: a nested case-control study in the prostate, lung, colorectal, and ovarian cancer screening trial | journal = Cancer Epidemiol. Biomarkers Prev. | volume = 16 | issue = 5 | pages = 962–8 | year = 2007 | pmid = 17507623 | doi = 10.1158/1055-9965.EPI-06-0861 | url = http://cebp.aacrjournals.org/cgi/pmidlookup?view=long&pmid=17507623| accessdate = 2007-12-17}}</ref> Lower [[blood]] levels of [[vitamin D]] also may increase the risk of developing prostate cancer. This may be linked to lower exposure to [[ultraviolet radiation|ultraviolet (UV) light]], since UV light exposure can increase vitamin D in the body.<ref>{{cite journal| last=Schulman| first=CC| coauthors=Ekane S; Zlotta AR| title=Nutrition and prostate cancer: evidence or suspicion?| journal=Urology| year=2001| month=September| volume=58| issue=3| pages=318–34| pmid=11549473| doi=10.1016/S0090-4295(01)01262-6}}</ref>
 
There are also some links between prostate cancer and medications, medical procedures, and medical conditions. Daily use of [[non-steroidal anti-inflammatory drugs|anti-inflammatory medicines]] such as [[aspirin]], [[ibuprofen]], or [[naproxen sodium|naproxen]] may decrease prostate cancer risk.<ref>{{cite journal| last=Jacobs| first=EJ| coauthors=Rodriguez C, Mondul AM, Connell CJ, Henley SJ, Calle EE, Thun MJ| title=A large cohort study of aspirin and other nonsteroidal anti-inflammatory drugs and prostate cancer incidence| journal=J Natl Cancer Inst| year=2005| month=July 6| volume=97| issue=13| pages=975–80| pmid=15998950}}</ref> Use of the [[hypolipidaemic agent|cholesterol-lowering drugs]] known as the [[statin]]s may also decrease prostate cancer risk.<ref>{{cite journal| last=Shannon| first=J| coauthors=Tewoderos S, Garzotto M, Beer TM, Derenick R, Palma A, Farris PE| title=Statins and prostate cancer risk: a case-control study| journal=Am J Epidemiol| year=2005| month=August 15| volume=162| issue=4| pages=318–25| pmid=16014776| doi=10.1093/aje/kwi203}}  Epub 2005 July 13</ref>  More frequent ejaculation also may decrease a man's risk of prostate cancer. One study showed that men who ejaculated five times a week in their 20s had a decreased rate of prostate cancer, though others have shown no benefit.<ref name="pmid12887469">{{cite journal | author = Giles GG, Severi G, English DR, McCredie MR, Borland R, Boyle P, Hopper JL | title = Sexual factors and prostate cancer | journal = BJU Int. | volume = 92 | issue = 3 | pages = 211–6 | year = 2003 | month = August | pmid = 12887469 | doi = 10.1046/j.1464-410X.2003.04319.x }}</ref><ref>{{cite journal| last= Leitzmann | first= Michael F. | title= Ejaculation Frequency and Subsequent Risk of Prostate Cancer | journal= JAMA | year= 2004 | month= April 7 | volume= 291 | issue= 13 | pages= 1578–86|id= 2004;291:1578-1586 | doi= 10.1001/jama.291.13.1578 | pmid= 15069045| unused_data= |Elizabeth A. Platz, ScD; Meir J. Stampfer, MD; Walter C. Willett, MD; Edward Giovannucci, MD}}[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=15069045&query_hl=2&itool=pubmed_docsum| PMID: 15069045]</ref> [[Infection]] or [[inflammation]] of the prostate ([[prostatitis]]) may increase the chance for prostate cancer. In particular, infection with the [[sexually transmitted infection]]s [[Chlamydia infection|chlamydia]], [[gonorrhea]], or [[syphilis]] seems to increase risk.<ref>{{cite journal| last=Dennis| first=LK| coauthors=Lynch CF; Torner JC| title=Epidemiologic association between prostatitis and prostate cancer| journal=Urology| year=2002| month=July| volume=60| issue=1| pages=78–83| pmid=12100928| doi=10.1016/S0090-4295(02)01637-0}}</ref>
Finally, [[obesity]]<ref>{{cite journal| last=Calle| first= EE| coauthors=Rodriguez C, Walker-Thurmond K, Thun MJ| title=Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults| journal=N Engl J Med| year=2003 | month=April 24| volume=348| issue=17| pages=1625–38| pmid=12711737| doi=10.1056/NEJMoa021423}}</ref>
and elevated blood levels of [[testosterone]]<ref>{{cite journal| last=Gann| first= PH| coauthors=Hennekens CH, Ma J, Longcope C, Stampfer MJ| title=Prospective study of sex hormone levels and risk of prostate cancer| journal=J Natl Cancer Inst| year=1996| month=August 21| volume=88| issue=16| pages=1118–26| pmid=8757191| doi=10.1093/jnci/88.16.1118}}</ref>
may increase the risk for prostate cancer.
 
Research released in May 2007, found that US war veterans who had been exposed to Agent Orange had a 48% increased risk of prostate cancer recurrence following surgery.<ref name="aorange"> {{cite web|url=https://my.mcg.edu/portal/page/portal/News/archive/2007/Veterans%20exposed%20to%20Agent%20%20Orange%20have%20higher%20rates%20of%20prost |title=Veterans exposed to Agent Orange have higher rates of prostate cancer recurrence |date=May 20, 2007 |work=Medical College of Georgia News }}</ref>
 
Prostate cancer risk can be decreased by modifying known risk factors for prostate cancer, such as decreasing intake of animal fat.<ref>{{cite journal | author= | title=Position of the American Dietetic Association and Dietitians of Canada: Vegetarian diets | journal=J Am Diet Assoc | year=2003 | pages=748–65 | volume=103 | issue=6  | pmid=12778049| doi=10.1053/jada.2003.50142}}</ref>
 
One research study, by the [[The Cancer Council Australia|Cancer Council Victoria]], has shown that men who report that they regularly ("more than five times per week") [[masturbation|masturbate]] have up to one third fewer occurrences of prostate cancer.<ref name="BBC_NEWS_Masturbation">{{cite web | url = http://news.bbc.co.uk/1/hi/health/3072021.stm | title =  Masturbation 'cuts cancer risk' | author = | authorlink = | coauthors = | date = 2003-07-16 | format = | work = Health | publisher = BBC NEWS | pages = | language = | archiveurl = | archivedate = | quote = | accessdate = 2008-04-24 }}</ref><ref name="pmid12887469"/> The researchers [[hypothesis|hypothesize]] that this could be because regular ejaculation reduces the buildup of [[cancer|carcinogenic]] deposits such as 3-[[methylcholanthrene]], produced from the breakdown of cholesterol, which could damage the cells lining the prostate. The researchers also speculated that frequent ejaculation may cause the prostate to mature fully, making it less susceptible to carcinogens. It is also possible that there is another factor (such as hormone levels) that is a [[Correlation does not imply causation|common cause]] of both a reduced susceptibility to prostate cancer and a tendency toward frequent masturbation.
 
There is also some evidence that frequent sexual intercourse is associated with reduced risk of prostate cancer, although contrarily the risks associated with STDs have been shown to increase the risk of prostate cancer.<ref name="BBC_NEWS_Masturbation"/><ref name="pmid12887469"/> Once the lining of the prostate is affected with cancer, the only known treatments are surgery and radiation therapy. Both may limit the ability to have erections afterward.
 
==Prevention==
 
===Vitamins and medication===
 
Evidence from epidemiological studies supports protective roles in reducing prostate cancer for dietary [[selenium]], [[vitamin E]], [[lycopene]], and [[soy]] foods.  High plasma levels of [[Vitamin D]] may also have a protective effect.<ref>{{cite journal |author=Wigle DT, Turner MC, Gomes J, Parent ME |title=Role of hormonal and other factors in human prostate cancer |journal=J Toxicol Environ Health B Crit Rev |volume=11 |issue=3-4 |pages=242–59 |year=2008 |month=March |pmid=18368555 |doi=10.1080/10937400701873548 |url=}}</ref> Estrogens from fermented [[soybeans]] and other plant sources (called [[phytoestrogen]]s) may also help prevent prostate cancer.<ref>{{cite journal| last=Strom| first= SS| coauthors=Yamamura Y, Duphorne CM, Spitz MR, Babaian RJ, Pillow PC, Hursting SD| title=Phytoestrogen intake and prostate cancer: a case-control study using a new database| journal=Nutr Cancer| year=1999| volume=33| issue=1| pages=20–5| pmid=10227039}} Erratum in: Nutr Cancer 2000;36(2):243.</ref> The [[selective estrogen receptor modulator]] drug [[toremifene]] has shown promise in early trials.<ref>{{cite journal| last=Steiner| first=MS| coauthors=Pound, CR, Gingrich, JR, et al.| title=Acapodene (GTx-006) reduces high-grade prostatic intraepithelial neoplasia in phase II clinical trial (abstract)| journal=Proc Am Soc Clin Oncol| year=2002| volume=21| pages=180a}}</ref><ref>{{cite journal| last=Price| first= D| coauthors=Stein, B, Goluboff, E, et al.| title=Double-blind, placebo-controlled trial of toremifene for the prevention of prostate cancer in men with high-grade prostatic intrapeithelial neoplasia (abstract)| journal=J Clin Oncol| year=2005| volume=23| pages=106s}}</ref> Two medications which block the conversion of [[testosterone]] to [[dihydrotestosterone]], [[finasteride]]<ref>{{cite journal| last=Thompson| first=IM| coauthors=Goodman PJ, Tangen CM, Lucia MS, Miller GJ, Ford LG, Lieber MM, Cespedes RD, Atkins JN, Lippman SM, Carlin SM, Ryan A, Szczepanek CM, Crowley JJ, Coltman CA Jr.| title=The influence of finasteride on the development of prostate cancer| journal=N Engl J Med| year=2003| month=July 17| volume=349| issue=3| pages=215–24| pmid=12824459| doi=10.1056/NEJMoa030660}}</ref>
and [[dutasteride]],<ref>{{cite journal| last=Andriole| first=GL| coauthors=Roehrborn C, Schulman C, Slawin KM, Somerville M, Rittmaster RS| title=Effect of dutasteride on the detection of prostate cancer in men with benign prostatic hyperplasia| journal=Urology| year=2004| month=September| volume=64| issue=3| pages=537–41; discussion 542–3| pmid=15351586| doi=10.1016/j.urology.2004.04.084}}</ref> have also shown some promise. The use of these medications for primary prevention is still in the testing phase, and they are not widely used for this purpose. The initial problem with these medications is that they may preferentially block the development of lower-grade prostate tumors, leading to a relatively greater chance of higher grade cancers, and negating any overall survival improvement.  More recent research found that [[finasteride]] did not increase the percentage of higher grade cancers. 
 
A 2008 study update found that finasteride reduces the incidence of prostate cancer by 30%. In the original study it turns that that the smaller prostate caused by finasteride means that a doctor is more likely to hit upon cancer nests and more likely to find aggressive-looking cells.  Most of the men in the study who had cancer — aggressive or not — chose to be treated and many had their prostates removed. A pathologist then carefully examined every one of those 500 prostates and compared the kinds of cancers found at surgery to those initially diagnosed at biopsy. Finasteride did not increase the risk of High-Grade prostate cancer.<ref>{{ cite news | author = Gine Kolata |  title = New Take on a Prostate Drug, and a New Debate  |  url = http://www.nytimes.com/2008/06/15/health/15prostate.html?ei=5087&em=&en=813eaa4e10f57756&ex=1213675200&adxnnl=1&adxnnlx=1213503418-GD4DbGjYsDxqV/xuGWnE1A | publisher = [[NY Times]] date = June 15, 2008  | accessdate = 2008-06-15 }}</ref><ref>{{cite journal  |author=Potosky A, Miller B, Albertsen P, Kramer B |title=Finasteride Does Not Increase the Risk of High-Grade Prostate Cancer: A Bias-Adjusted Modeling Approach |  url  =  http://cancerpreventionresearch.aacrjournals.org/cgi/rapidpdf/1940-6207.CAPR-08-0092v1 |journal= Cancer Prevention Research |volume= Published Online First on May 18, 2008 as 10.1158/1940-6207.CAPR-08-0092  |year=2008 |doi=10.1158/1940-6207.CAPR-08-0092  |pages=174 }}</ref>
 
[[Green tea]] may be protective (due to its [[polyphenol]] content),<ref>{{cite journal |author=Lee AH, Fraser ML, Meng X, Binns CW |title=Protective effects of green tea against prostate cancer |journal=Expert Rev Anticancer Ther |volume=6 |issue=4 |pages=507–13 |year=2006 |month=April |pmid=16613539 |doi=10.1586/14737140.6.4.507 |url=}}</ref> although the most comprehensive clinical study indicates that it has no protective effect.<ref>{{cite journal |author=Kikuchi N, Ohmori K, Shimazu T, ''et al'' |title=No association between green tea and prostate cancer risk in Japanese men: the Ohsaki Cohort Study |journal=Br. J. Cancer |volume=95 |issue=3 |pages=371–3 |year=2006 |month=August |pmid=16804523 |doi=10.1038/sj.bjc.6603230 |url=}}</ref> 
A 2006 study of green tea derivatives demonstrated promising prostate cancer prevention in patients at high risk for the disease.<ref>{{cite journal |author=Bettuzzi S, Brausi M, Rizzi F, Castagnetti G, Peracchia G, Corti A |title=Chemoprevention of human prostate cancer by oral administration of green tea catechins in volunteers with high-grade prostate intraepithelial neoplasia: a preliminary report from a one-year proof-of-principle study |journal=Cancer Res |volume=66 |issue=2 |pages=1234–40 |year=2006 |pmid=16424063 | doi = 10.1158/0008-5472.CAN-05-1145}}</ref> Recent research published in the Journal of the [[National Cancer Institute]] suggests that taking [[multivitamins]] more than seven times a week can increase the risks of contracting the disease.<ref name="BBC_NEWS_Multivitamin">{{cite web | url = http://news.bbc.co.uk/1/hi/health/6657795.stm| title = Multivitamin prostate warning | author = | authorlink = | coauthors = | date = 2007-05-16 | format = | work = Health | publisher = BBC NEWS | pages = | language = | archiveurl = | archivedate = | quote = | accessdate = 2008-04-23}}</ref><ref name="pmid17505071">{{cite journal | author = Lawson KA, Wright ME, Subar A, Mouw T, Hollenbeck A, Schatzkin A, Leitzmann MF | title = Multivitamin use and risk of prostate cancer in the National Institutes of Health-AARP Diet and Health Study | journal = J. Natl. Cancer Inst. | volume = 99 | issue = 10 | pages = 754–64 | year = 2007 | month = May | pmid = 17505071 | doi = 10.1093/jnci/djk177 | url =  }}</ref> This research was unable to highlight the exact vitamins responsible for this increase (almost double), although they suggest that vitamin A, vitamin E and beta-carotene may lie at its heart. It is advised that those taking multivitamins never exceed the stated daily dose on the label. Scientists recommend a healthy, well balanced diet rich in fiber, and to reduce intake of meat.
 
A 2007 study published in the Journal of the National Cancer Institute found that men eating [[cauliflower]], [[broccoli]], or one of the other [[cruciferous vegetables]], more than once a week were 40% less likely to develop prostate cancer than men who rarely ate those vegetables.<ref name="CBS_News_Broccoli">{{cite web | url = http://www.cbsnews.com/stories/2007/07/24/health/webmd/main3094509.shtml | title = Broccoli May Help Cut Prostate Cancer, Broccoli, Cauliflower May Make Aggressive Prostate Cancer Less Likely  | author = | authorlink = | coauthors = | date = 2007-07-24 | format = | work = | publisher = CBS News | pages = | language = | archiveurl = | archivedate = | quote = | accessdate = 2008-04-23}}</ref><ref name="pmid17652276">{{cite journal | author = Kirsh VA, Peters U, Mayne ST, Subar AF, Chatterjee N, Johnson CC, Hayes RB | title = Prospective study of fruit and vegetable intake and risk of prostate cancer | journal = J. Natl. Cancer Inst. | volume = 99 | issue = 15 | pages = 1200–9 | year = 2007 | month = August | pmid = 17652276 | doi = 10.1093/jnci/djm065 | url =  }}</ref> The [[phytochemical]]s [[indole-3-carbinol]] and [[diindolylmethane]], found in cruciferous vegetables, has [[antiandrogen]]ic and immune modulating properties.<ref>{{cite journal
|author=Sarkar FH, Li Y
|title=Indole-3-carbinol and prostate cancer
|journal=J. Nutr.
|volume=134
|issue=12 Suppl
|pages=3493S–3498S
|year=2004
|month=December
|pmid=15570059
|doi=
|url=
}}</ref><ref>{{cite journal
|author=Hsu JC, Zhang J, Dev A, Wing A, Bjeldanes LF, Firestone GL
|title=Indole-3-carbinol inhibition of androgen receptor expression and downregulation of androgen responsiveness in human prostate cancer cells
|journal=Carcinogenesis
|volume=26
|issue=11
|pages=1896–904
|year=2005
|month=November
|pmid=15958518
|doi=10.1093/carcin/bgi155
|url=http://carcin.oxfordjournals.org/cgi/content/full/26/11/1896
|accessdate=2008-09-12
}}</ref>
 
===Ejaculation frequency===
 
In 2003, an Australian research team led by Graham Giles of The Cancer Council Australia concluded that frequent [[masturbation]] by males appears to help prevent the development of prostate cancer.<ref>[http://www.blackwell-synergy.com/links/doi/10.1046%2Fj.1464-410X.2003.04319.x]Giles, et al., Sexual factors and prostate cancer, BJU International, Volume 92 Issue 3, Ausust 2003, pp. 211-216</ref><ref name="BBC_NEWS_Masturbation"/> Australian research concluded that the more men ejaculate between the ages of 20 and 50, the less likely they are to develop prostate cancer. The protective effect is greatest while men are in their twenties: those who had ejaculated more than five times per week in their twenties, for instance, were one-third less likely to develop aggressive prostate cancer later in life. The results contradict those of previous studies, which have suggested that having had many sexual partners, or a high frequency of sexual activity, increases the risk of prostate cancer by up to 40 percent. The key difference is that these earlier studies defined sexual activity as sexual intercourse, whereas this study focused on the number of ejaculations, whether or not intercourse was involved.<ref name="New_Scientist">{{cite web | url = http://www.newscientist.com/article/dn3942-masturbating-may-protect-against-prostate-cancer.html | title = Masturbating may protect against prostate cancer | author = Douglas Fox | authorlink = | coauthors = | date = 2003-07-16 | format = | work = | publisher = New Scientist | pages = | language = | archiveurl = | archivedate = | quote = | accessdate = 2008-04-23}}</ref> Another study completed in 2004 reported that "Most categories of ejaculation frequency were unrelated to risk of prostate cancer. However, high ejaculation frequency was related to decreased risk of total prostate cancer." The report abstract concluded, "Our results suggest that ejaculation frequency is not related to increased risk of prostate cancer." <ref>{{cite journal |author=Leitzmann MF, Platz EA, Stampfer MJ, Willett WC, Giovannucci E |title=Ejaculation frequency and subsequent risk of prostate cancer |journal=JAMA |volume=291 |issue=13 |pages=1578–86 |year=2004 |month=April |pmid=15069045 |doi=10.1001/jama.291.13.1578 |url=}}</ref>
 
===More fish oil, less vegetable oil===
 
A high consumption of [[omega-6]] [[polyunsaturated fatty acids]] (PUFAs), which are found in most types of [[vegetable oil]] (e.g. [[corn oil]] - the most consumed oil in USA, [[soybean oil]], [[sunflower oil]], etc.), increased prostate tumor growth, speeded up histopathological progression, and decreased survival, while the [[omega-3]] [[fatty acids]] (e.g. in [[fish oil]]) had the opposite, beneficial effect<ref>{{cite journal |author=Yong Q. Chen, at al |title=Modulation of prostate cancer genetic risk by omega-3 and omega-6 fatty acids |journal=The Journal of Clinical Investigation |volume=117  |issue=7 |year=2007 |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1890998 |accessdate=2008-11-30 |doi=10.1172/JCI31494 |pmid=1890998 |unused_data=|pages: 1866-1875}}</ref>.
 
===Myristic and palmitic saturated fatty acids===
Some researches have indicated that some specific saturated fatty acids ([[myristic acid]]<ref name="pmid14693732">{{cite journal | author = Männistö S, Pietinen P, Virtanen MJ, Salminen I, Albanes D, Giovannucci E, Virtamo J | title = Fatty acids and risk of prostate cancer in a nested case-control study in male smokers | journal = Cancer Epidemiol. Biomarkers Prev. | volume = 12 | issue = 12 | pages = 1422–8 | year = 2003 | month = December | pmid = 14693732 | doi = | url = http://cebp.aacrjournals.org/cgi/reprint/12/12/1422.pdf | issn = }}</ref><ref name="palmiticmyristic"/><ref name="saturated"/> and [[palmitic acid]]<ref name="palmiticmyristic">{{cite journal | author = Kurahashi N, Inoue M, Iwasaki M, Sasazuki S, Tsugane AS | title = Dairy product, saturated fatty acid, and calcium intake and prostate cancer in a prospective cohort of Japanese men | journal = Cancer Epidemiol. Biomarkers Prev. | volume = 17 | issue = 4 | pages = 930–7 | year = 2008 | month = April | pmid = 18398033 | doi = 10.1158/1055-9965.EPI-07-2681 | url = | issn = }}</ref><ref name="saturated">{{cite journal | author = Crowe FL, Allen NE, Appleby PN, Overvad K, Aardestrup IV, Johnsen NF, Tjønneland A, Linseisen J, Kaaks R, Boeing H, Kröger J, Trichopoulou A, Zavitsanou A, Trichopoulos D, Sacerdote C, Palli D, Tumino R, Agnoli C, Kiemeney LA, Bueno-de-Mesquita HB, Chirlaque MD, Ardanaz E, Larrañaga N, Quirós JR, Sánchez MJ, González CA, Stattin P, Hallmans G, Bingham S, Khaw KT, Rinaldi S, Slimani N, Jenab M, Riboli E, Key TJ | title = Fatty acid composition of plasma phospholipids and risk of prostate cancer in a case-control analysis nested within the European Prospective Investigation into Cancer and Nutrition | journal = Am. J. Clin. Nutr. | volume = 88 | issue = 5 | pages = 1353–63 | year = 2008 | month = November | pmid = 18996872 | doi = | url = http://www.ajcn.org/cgi/content/abstract/88/5/1353 | issn = }}</ref> are associated with increased risk of prostate cancer in a dose-dependent manner. Another study further investigated these and other saturated fatty acids.<ref name="saturated"/> However it's still uncertain if this association is a cause or consequence of the disease.
 
==Screening==
{{main|Prostate cancer screening}}
 
Prostate cancer [[screening (medicine)|screening]] is an attempt to find unsuspected cancers. Screening tests may lead to more specific follow-up tests such as a [[biopsy]], where small cores of the prostate are removed for closer study. Prostate cancer screening options include the [[Rectal examination|digital rectal exam]] and the [[prostate specific antigen]] (PSA) blood test. Screening for prostate cancer is controversial because it is not clear if the benefits of screening outweigh the risks of follow-up diagnostic tests and cancer treatments.
 
Prostate cancer is usually a slow-growing cancer, very common among older men. In fact, most prostate cancers never grow to the point where they cause symptoms, and most men with prostate cancer die of other causes before prostate cancer has an impact on their lives. The PSA screening test may detect these small cancers that would never become life threatening. Doing the PSA test in these men may lead to [[overdiagnosis]], including additional testing and treatment. Follow-up tests, such as [[prostate biopsy]], may cause pain, bleeding and infection. Prostate cancer treatments may cause urinary [[Urinary incontinence|incontinence]] and [[erectile dysfunction]]. Therefore, it is essential that the risks and benefits of diagnostic procedures and treatment be carefully considered before PSA screening.
 
Several medical societies have not found sufficient evidence to support routine screening for prostate cancer - but the American Urological Association supports annual screening and digital examination for men over 50 years old - and starting earlier for 'men at high risk (those with a family history of prostate cancer or African American men)'. <ref>[http://www.auanet.org/content/guidelines-and-quality-care/policy-statements/e/early-detection-of-prostate-cancer.cfm ''Early Detection of Prostate Cancer'', American Urological Association, Washington, D.C., revised: October 2008].Accessed: 12-01-2008 </ref>
* In 2002, the [[US Preventive Services Task Force|U.S. Preventive Services Task Force]] (USPSTF) concluded that the evidence was insufficient to recommend for or against routine screening for prostate cancer using PSA testing or digital rectal examination (DRE).<!--
  --><ref name="USPSTF 2002">{{cite web |author=US Preventive Services Task Force |month=December |year=2002 |title=Screening for Prostate Cancer |publisher=Agency for Healthcare Research and Quality |url=http://www.ahrq.gov/clinic/uspstf/uspsprca.htm}}
    {{cite journal |author=[[US Preventive Services Task Force|USPSTF]] |month=December 3, |year=2002 |title=Screening for prostate cancer: recommendation and rationale |journal=[[Annals of Internal Medicine|Ann Intern Med]] |volume=137 |issue=11 |pages=915–6 |pmid=12458992 |url=http://www.annals.org/cgi/reprint/137/11/915.pdf|format=PDF}}<br>
    {{cite journal |author=Harris R, Lohr KN |month=December 3, |year=2002 |title=Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force |journal=[[Annals of Internal Medicine|Ann Intern Med]] |volume=137 |issue=11 |pages=917–29 |pmid=12458993 |url=http://www.annals.org/cgi/reprint/137/11/917.pdf|format=PDF}}</ref> The previous 1995 USPSTF recommendation was against routine screening.
* In 1997, [[American Cancer Society]] (ACS) guidelines began recommending that beginning at age 50 (age 45 for African-American men and men with a family history of prostate cancer, and since 2001, age 40 for men with a very strong family history of prostate cancer), PSA testing and DRE be ''offered'' annually to men who have a life-expectancy of 10 or more years (average life expectancy is 10 years or more for U.S. men under age 76)<!--
  --><ref name="US life table 2003">{{cite journal |author=Arias E |month=April 19, |year=2006 |title=United States Life Tables, 2003 |journal=Natl Vital Stat Rep |volume=54 |issue=14 |pages=1–40 |pmid=16681183 |url=http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_14.pdf|format=PDF}}</ref> along with information on the risks and benefits of screening.<!--
  --><ref name="ACS guidelines">{{cite journal |author=von Eschenbach A, Ho R, Murphy GP, Cunningham M, Lins N |month=September-October |year=1997 |title=American Cancer Society guideline for the early detection of prostate cancer: update 1997 |journal=CA Cancer J Clin |volume=47 |issue=5 |pages=261–4 |pmid=9314820 |url=http://caonline.amcancersoc.org/cgi/reprint/47/5/261.pdf |format=PDF|doi=10.3322/canjclin.47.5.261}}
    {{cite web |author=[[American Cancer Society|ACS]] |month=March 28, |year=2007 |title=Prostate Cancer: Early Detection |url=http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp |accessdate=2007-11-19}}<br>
    {{cite journal |author=Smith RA, Cokkinides V, Eyre HJ |month=March-April |year=2007 |title=Cancer screening in the United States, 2007: a review of current guidelines, practices, and prospects |journal=CA Cancer J Clin |volume=57 |issue=2 |pages=90–104 |pmid=17392386 |url=http://caonline.amcancersoc.org/cgi/reprint/57/2/90.pdf|format=PDF}}<br>
    {{cite journal |author=Smith RA, Cokkinides V, Eyre HJ |month=January-February |year=2006 |title=American Cancer Society guidelines for the early detection of cancer, 2006 |journal=CA Cancer J Clin |volume=56 |issue=1 |pages=11–25 |pmid=16449183 |url=http://caonline.amcancersoc.org/cgi/reprint/57/2/90.pdf|format=PDF}}</ref> The previous ACS recommendations since 1980 had been for routine screening for prostate cancer with DRE annually beginning at age 40, and since 1992 had been for routine screening with DRE and PSA testing annually beginning at age 50.<!--
  --><ref name="ACS history">{{cite web |author=[[American Cancer Society|ACS]] |month=March 29, |year=2007 |title=Chronological History of ACS Recommendations on Early Detection of Cancer |url=http://www.cancer.org/docroot/PED/content/PED_2_3X_Chronological_History_of_ACS_Recommendations_on_Early_Detection_of_Cancer.asp}}</ref>
* The 2007 [[National Comprehensive Cancer Network]] (NCCN) guideline recommends ''offering'' a baseline PSA test and DRE at ages 40 and 45 and annual PSA testing and DRE beginning at age 50 (with annual PSA testing and DRE beginning at age 40 for African-American men, men with a family history of prostate cancer, and men with a PSA ≥ 0.6 ng/mL at age 40 or PSA > 0.6 ng/mL at age 45) through age 80, along with information on the risks and benefits of screening. Biopsy is recommended if DRE is positive or PSA ≥ 4 ng/mL, and biopsy considered if PSA > 2.5 ng/mL or PSA velocity ≥ 0.35 ng/mL/year when PSA ≤ 2.5 ng/mL.<!--
  --><ref name="NCCN 2007">{{cite web |author=[[National Comprehensive Cancer Network|NCCN]] |month=May 10, |year=2007 |title=Prostate Cancer Early Detection V.2.2007 |work=NCCN Clinical Practice Guidelines in Oncology |url=http://www.nccn.org/professionals/physician_gls/PDF/prostate_detection.pdf|format=PDF}}</ref>
* Some U.S. radiation oncologists and medical oncologists who specialize in treating prostate cancer recommend obtaining a baseline PSA in all men at age 35<!--
  --><ref name="D'Amico 2004">{{cite web |author= |month=July |year=2004 |title=Study suggests value of regular PSA tests for tracking prostate cancer |publisher=[[Dana-Farber Cancer Institute]] |url=http://www.hms.harvard.edu/news/pressreleases/df/0704prostate_test.html}}
    {{cite journal |author=Kladko B |month=August 15, |year=2005 |title=Prostate cancer test gets another look |journal=The Boston Globe |url=http://www.boston.com/yourlife/health/men/articles/2005/08/15/prostate_cancer_test_gets_another_look/?page=full}}</ref> or beginning annual PSA testing in high risk men at age 35.<!--
  --><ref name="Strum 2005">{{cite journal |author=Strum SB, Pogliano D |month=May |year=2005 |title=What every doctor who treats male patients should know |journal=PCRI Insights |volume=8 |issue=2 |pages=4–5 |url=http://www.prostate-cancer.org/resource/pdf/Is8-2.pdf|format=PDF}}</ref>
* The American Urological Association Patient Guide to Prostate Cancer.<!--
  --><ref name="AUA Patient Guide 2008">{{cite web |author=American Urological Association (AUA) |year=2008 |title=Prostate Cancer Patient Guide |work=AUA Patient Guidelines |url=http://www.auanet.org/guidelines/patient_guides/pc08.pdf|format=PDF}}</ref>
 
Since there is no general agreement that the benefits of PSA screening outweigh the harms, the consensus is that clinicians use a process of shared decision-making that includes discussing with patients the risks of prostate cancer, the potential benefits and harms of screening, and involving the patients in the decision.<!--
--><ref name="Ross 2004">{{cite journal |author=Ross LE, Coates RJ, Breen N, Uhler RJ, Potosky AL, Blackman D |year=2004 |title=Prostate-specific antigen test use reported in the 2000 National Health Interview Survey |journal=Prev Med |volume=38 |issue=6 |pages=732–44 |pmid=15193893 | doi = 10.1016/j.ypmed.2004.01.005}}</ref>
 
However, because PSA screening is widespread in the United States, following the recommendations of major scientific and medical organizations to use shared decision-making is legally perilous in some U.S. states.<!--
--><ref name="Lewis 2007">{{cite journal |author=Lewis MH, Gohagan JK, Merenstein DJ |year=2007 |title=The locality rule and the physician's dilemma: local medical practices vs the national standard of care |journal=[[Journal of the American Medical Association|JAMA]] |volume=297 |issue=23 |pages=2633–7 |pmid=17579232 |doi=10.1001/jama.297.23.2633}}</ref>
In 2003, a Virginia jury found a [[general practitioner#United States|family practice]] [[residency (medicine)|residency program]] guilty of [[medical malpractice|malpractice]] and liable for $1 million for following national [[medical guideline|guideline]]s and using shared decision-making, thereby allowing a patient (subsequently found to have a high PSA and incurable advanced prostate cancer) to decline a screening PSA test, instead of routinely ordering without discussion PSA tests in all men ≥ 50 years of age as four local physicians testified was their practice, and was accepted by the jury as the local [[standard of care]].<!--
--><ref name="Mernstein 2004">{{cite journal |author=Merenstein D |year=2004 |title=Winners and losers |journal=[[Journal of the American Medical Association|JAMA]] |volume=291 |issue=1 |pages=15–6 |pmid=14709561 |doi=10.1001/jama.291.1.15}}</ref>
An estimated 20 million PSA tests are done per year in North America and possibly 20 million more outside of North America.<!--
--><ref name="De Angelis 2007">{{cite journal |author=De Angelis G, Rittenhouse HG, Mikolajczyk SD, Blair Shamel L, Semjonow A |year=2007 |title=Twenty years of PSA: from prostate antigen to tumor marker |journal=Rev Urol |volume=9 |issue=3 |pages=113–23 |pmid=17934568 |url=http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2002501&blobtype=pdf}}</ref>
* In 2000, 34.1% of all U.S. men age ≥ 50 had a ''screening'' PSA test within the past year and 56.8% reported ever having a PSA test.<!--
--><ref name="Ross 2004"/>
* In 2000, 33.6% of all U.S. men age 50–64 and 51.3% of men age ≥ 65 had a PSA test within the past year.<!--
--><ref name="Swan 2003">{{cite journal |author=Swan J, Breen N, Coates RJ, Rimer BK, Lee NC |year=2003 |title=Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey |journal=Cancer |volume=97 |issue=6 |pages=1528–40 |pmid=12627518 |url=http://www3.interscience.wiley.com/cgi-bin/fulltext/103521394/PDFSTART |doi=10.1002/cncr.11208}}</ref>
* In 2005, 33.5% of all U.S. men age 50–64 had a PSA test in the past year.
** 37.5% of men with private [[health insurance#Health insurance in the United States|health insurance]], 20.8% of men with Medicaid insurance, 14.0% of currently [[Health care in the United States#Inequities|uninsured]] men, and 11.5% of men uninsured for > 12 months.<!--
--><ref name="Ward 2008">{{cite journal |author=Ward E, Halpern M, Schrag N, Cokkinides V, DeSantis C, Bandi P, Siegel R, Stewart A, Jemal A |month=Jan-Feb |year=2008 |title=Association of insurance with cancer care utilization and outcomes |journal=CA Cancer J Clin |volume=58 |issue=1 |pages=9–31 |url=http://caonline.amcancersoc.org/cgi/reprint/58/1/9.pdf |format=PDF|pmid=18096863 |doi=10.3322/CA.2007.0011}}</ref>
* In 2000–2001, 34.1% of all Canadian men age ≥ 50 had a ''screening'' PSA test within the past year and 47.5% reported ever having a ''screening'' PSA test.<!--
--><ref name="Beaulac 2006">{{cite journal |author=Beaulac JA, Fry RN, Onysko J |year=2006 |title=Lifetime and recent prostate specific antigen (PSA) screening of men for prostate cancer in Canada |journal=Can J Public Health |volume=97 |issue=3 |pages=171–6 |pmid=16827400}}</ref>
* Canadian men in Ontario were most likely to have had a PSA test within the past year and men in Alberta were least likely to have had a PSA test with the past year or ever.<!--
--><ref name="Gibbons 2003">{{cite journal  |author=Gibbons L, Waters C |month=May |year=2003 |title=Prostate cancer--testing, incidence, surgery and mortality |journal=Health Rep |volume=14 |issue=3 |pages=9–20 |pmid=12816012 |url=http://www.statcan.ca/english/studies/82-003/archive/2003/14-3-a.pdf|format=PDF}}</ref>
 
===Digital rectal examination===
 
[[Rectal examination|Digital rectal examination]] (DRE) is a procedure where the examiner inserts a gloved, lubricated finger into the rectum to check the size, shape, and texture of the prostate. Areas which are irregular, hard or lumpy need further evaluation, since they may contain cancer. Although the DRE only evaluates the back of the prostate, 85% of prostate cancers arise in this part of the prostate. Prostate cancer which can be felt on DRE is generally more advanced.<ref>{{cite journal| last=Chodak| first=GW| coauthors=Keller P, Schoenberg HW| title=Assessment of screening for prostate cancer using the digital rectal examination| journal=J Urol| year=1989| month=May| volume=141| issue=5| pages=1136–8| pmid=2709500}}</ref> The use of DRE has never been shown to prevent prostate cancer deaths when used as the only screening test.<ref>{{cite journal| last=Krahn| first=MD| coauthors=Mahoney JE, Eckman MH, Trachtenberg J, Pauker SG, Detsky AS| title=Screening for prostate cancer.. A decision analytic view| journal=JAMA| year=1994| month=September 14| volume=272| issue=10| pages=773–80| pmid=7521400| doi=10.1001/jama.272.10.773}}</ref>
 
===Prostate specific antigen===
{{main|Prostate specific antigen}}
The PSA test measures the blood level of [[prostate-specific antigen]], an [[enzyme]] produced by the prostate. Specifically, PSA is a [[serine protease]] similar to [[kallikrein]]. Its normal function is to liquify gelatinous semen after ejaculation, allowing [[Spermatozoon|spermatozoa]] to more easily navigate through the uterine [[cervix]].
 
The risk of prostate cancer increases with increasing PSA levels.<!--
  --><ref name="Catalona 2007">{{cite web |author=Catalona WJ |month=August 16, |year=2007 |title=How I manage a patient with a newly elevated PSA |work=2007 [[Centers for Disease Control and Prevention|CDC]] Cancer Conference |url=http://www.cdccancerconference.net/Presentations/ET2.0/ET2.0_Catalona.pdf|format=PDF}}</ref> 4 ng/mL was chosen arbitrarily as a decision level for biopsies in the clinical trial upon which the [[Food and Drug Administration|FDA]] in 1994 based adding prostate cancer detection in men age 50 and over as an approved indication for the first commercially available PSA test.<!--
  --><ref name="Kolota 2004">{{cite journal |author=Kolota G |month=May 30, |year=2004 |title=It was medical gospel, but it wasn't true |journal=The New York Times |pages=4.7 |url=http://query.nytimes.com/gst/fullpage.html?res=9F05E5DD1E3EF933A05756C0A9629C8B63&sec=&spon=&pagewanted=all}}<br>
    {{cite journal |author=Thompson IM, Pauler DK, Goodman PJ, Tangen CM, Lucia MS, Parnes HL, Minasian LM, Ford LG, Lippman SM, Crawford ED, Crowley JJ, Coltman CA Jr |month= May 27, |year=2004 |title=Prevalence of prostate cancer among men with a prostate-specific antigen level < or =4.0 ng per milliliter |journal=N Engl J Med |volume=350 |issue=22 |pages=2239–46 |pmid=15163773}}<br>
    {{cite journal |author=Carter HB |month= May 27, |year=2004 |title=Prostate cancers in men with low PSA levels--must we find them? |journal=N Engl J Med |volume=350 |issue=22 |pages=2292–4 |pmid=15163780 |doi=10.1056/NEJMe048003}}<br>
    {{cite journal |author=Catalona WJ, Richie JP, Ahmann FR, Hudson MA, Scardino PT, Flanigan RC, deKernion JB, Ratliff TL, Kavoussi LR, Dalkin BL, et al. |month= May |year=1994 |title=Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicenter clinical trial of 6,630 men |journal=J Urol |volume=151 |issue=5 |pages=1283–90 |pmid=7512659}}<br>
    {{cite web |author=[[Food and Drug Administration|FDA]] |month=August 29, |year=1994 |title=FDA approves test for prostate cancer |url=http://www.fda.gov/bbs/topics/ANSWERS/ANS00598.html}}</ref>
4 ng/mL was used as the biopsy decision level in the [[Prostate cancer screening#Randomized controlled trials|PLCO]] trial, 3 ng/mL was used in the [[Prostate cancer screening#Randomized controlled trials|ERSPC]] and [[Prostate cancer screening#Randomized controlled trials|ProtecT]] trials, and 2.5 ng/mL is used in the 2007 NCCN guideline.
 
PSA levels can change for many reasons other than cancer. Two common causes of high PSA levels are enlargement of the prostate ([[benign prostatic hypertrophy]] (BPH)) and infection in the prostate ([[prostatitis]]). It can also be raised for 24 hours after ejaculation and several days after catheterization. PSA levels are lowered in men who use medications used to treat BPH or [[baldness]]. These medications, [[finasteride]] (marketed as Proscar or Propecia) and [[dutasteride]] (marketed as Avodart), may decrease the PSA levels by 50% or more.
 
Several other ways of evaluating the PSA have been developed to avoid the shortcomings of simple PSA screening. The use of age-specific reference ranges improves the sensitivity and specificity of the test. The rate of rise of the PSA over time, called the PSA velocity, has been used to evaluate men with PSA levels between 4 and 10 ng/ml, but it has not proven to be an effective screening test.<ref>{{cite journal| last=Roobol| first=MJ| coauthors=Kranse R, de Koning HJ, Schroder FH| title=Prostate-specific antigen velocity at low prostate-specific antigen levels as screening tool for prostate cancer: results of second screening round of ERSPC (ROTTERDAM)| journal=Urology| year=2004| month=February| volume=63| issue=2| pages=309–13; discussion 313–5| pmid=14972478| doi=10.1016/j.urology.2003.09.083}}</ref> Comparing the PSA level with the size of the prostate, as measured by [[Medical ultrasonography|ultrasound]] or [[magnetic resonance imaging]], has also been studied. This comparison, called PSA density, is both costly and has not proven to be an effective screening test.<ref>{{cite journal| last=Catalona| first=WJ| coauthors=Richie JP, deKernion JB, Ahmann FR, Ratliff TL, Dalkin BL, Kavoussi LR, MacFarlane MT, Southwick PC| title=Comparison of prostate specific antigen concentration versus prostate specific antigen density in the early detection of prostate cancer: receiver operating characteristic curves| journal=J Urol| year=1994| month=December| volume=152| issue=6 Pt 1| pages=2031–6| pmid=7525994}}</ref> PSA in the blood may either be free or bound to other [[protein]]s. Measuring the amount of PSA which is free or bound may provide additional screening information, but questions regarding the usefulness of these measurements limit their widespread use.<ref>{{cite journal| last=Hoffman| first=RM| coauthors=Clanon DL, Littenberg B, Frank JJ, Peirce JC| title=Using the free-to-total prostate-specific antigen ratio to detect prostate cancer in men with nonspecific elevations of prostate-specific antigen levels| journal=J Gen Intern Med| year=2000| month=October| volume=15| issue=10| pages=739–48| pmid=11089718| doi=10.1046/j.1525-1497.2000.90907.x}}</ref><ref>{{cite journal| last=Partin| first=AW| coauthors=Brawer MK; Bartsch G; Horninger W; Taneja SS; Lepor H; Babaian R; Childs SJ; Stamey T; Fritsche HA; Sokoll L; Chan DW; Thiel RP; Cheli CD| title=Complexed prostate specific antigen improves specificity for prostate cancer detection: results of a prospective multicenter clinical trial| journal=J Urol| year=2003| month=November| volume=170| issue=5| pages=1787–91| pmid=14532777| doi=10.1097/01.ju.0000092695.55705.dd}}</ref>


==Diagnosis==
==Diagnosis==
[[Image:Prostatehistopath.jpg|thumb|right|500px|'''Normal prostate (A) and prostate cancer (B).''' In prostate cancer, the regular glands of the normal prostate are replaced by irregular glands and clumps of cells, as seen in these pictures taken through a microscope.]]
When a man has symptoms of prostate cancer, or a screening test indicates an increased risk for cancer, more invasive evaluation is offered.
The only test which can fully confirm the diagnosis of prostate cancer is a [[biopsy]], the removal of small pieces of the prostate for microscopic examination. However, prior to a biopsy, several other tools may be used to gather more information about the prostate and the urinary tract. [[Cystoscopy]] shows the urinary tract from inside the bladder, using a thin, flexible camera tube inserted down the [[urethra]]. [[Transrectal ultrasonography]] creates a picture of the prostate using sound waves from a probe in the rectum.
===Biopsy===
{{main|Prostate biopsy}}
If cancer is suspected, a biopsy is offered. During a biopsy a [[urology|urologist]] or [[radiology|radiologist]] obtains tissue samples from the prostate via the rectum. A biopsy gun inserts and removes special hollow-core needles (usually three to six on each side of the prostate) in less than a second. Prostate biopsies are routinely done on an outpatient basis and rarely require hospitalization. Fifty-five percent of men report discomfort during prostate biopsy.<ref>{{cite journal| last=Essink-Bot| first=ML| coauthors=de Koning HJ, Nijs HG, Kirkels WJ, van der Maas PJ, Schroder FH| title=Short-term effects of population-based screening for prostate cancer on health-related quality of life| journal=J Natl Cancer Inst| year=1998| month=June 17| volume=90| issue=12| pages=925–31| pmid=9637143| doi=10.1093/jnci/90.12.925}}</ref>
====Gleason score====
{{main|Gleason score}}
The tissue samples are then examined under a microscope to determine whether cancer cells are present, and to evaluate the microscopic features (or [[Gleason score]]) of any cancer found.
====Tumor markers====
{{main|Tumor markers}}
Tissue samples can be stained for the presence of PSA and other tumor markers in order to determine the origin of maligant cells that have metastasized.<ref name="pmid17667550">{{cite journal |author=Chuang AY, Demarzo AM, Veltri RW, Sharma RB, Bieberich CJ, Epstein JI |title=Immunohistochemical Differentiation of High-grade Prostate Carcinoma From Urothelial Carcinoma |journal= The American Journal of Surgical Pathology|volume=31 |issue=8 |pages=1246–1255 |year=2007 |pmid=17667550 |doi=10.1097/PAS.0b013e31802f5d33}}</ref>
===New tests being investigated===
Currently, an active area of research involves non-invasive methods of prostate tumor detection. Adenoviruses modified to transfect tumor cells with harmless yet distinct genes (such as luciferase) have proven capable of early detection. So far, though, this area of research has only been tested in animal and [[LNCaP]] models.<ref>Iyer M, Salazar FB, Lewis X, Zhang L, Wu L, Carey M and Gambhir SS. Non-invasive imaging of a transgenic mouse model using a prostate-specific two-step transcriptional amplification strategy. Transg Res.2005; 14(1): 47–55</ref>
====PCA3====
Another potential non-invasive method of early prostate tumor detection is through a molecular test that detects the presence of cell-associated [[PCA3]] mRNA in urine. [[PCA3]] mRNA is expressed almost exclusively by prostate cells and has been shown to be highly over-expressed in prostate cancer cells. [[PCA3]] is not a replacement for PSA but an additional tool to help decide if, in men suspected of having prostate cancer, a biopsy is really needed. The higher the expression of [[PCA3]] in urine, the greater the likelihood of a positive biopsy, i.e. the presence of cancer cells in the prostate. Company [http://www.diagnocure.com/en/products-projects/prostate-cancer/prostate-cancer.php Diagnocure] has an exclusive worldwide license for all diagnostic and therapeutic applications related to [[PCA3]]
====Early prostate cancer====
It was reported in April 2007 that a new blood test for [[early prostate cancer antigen-2]] (EPCA-2) is being researched that may alert men if they have prostate cancer and how aggressive it will be.<ref>[http://www.msnbc.msn.com/id/18328032/site/newsweek/ A Prostate Cancer Revolution]. Newsweek, April 26, 2007.</ref><ref name="pmid17437801">{{cite journal |author=Hansel DE, DeMarzo AM, Platz EA, ''et al'' |title=Early prostate cancer antigen expression in predicting presence of prostate cancer in men with histologically negative biopsies |journal=J. Urol. |volume=177 |issue=5 |pages=1736–40 |year=2007 |pmid=17437801 |doi=10.1016/j.juro.2007.01.013}}</ref>
===Prostasomes===
Epithelial cells of the prostate secrete [[prostasomes]] as well as [[Prostate specific antigen|PSA]]. Prostasomes are membrane –surrounded, prostate-derived organelles that appear extracellularly and one of their physiological functions is to protect the sperm from attacks by the female immune system. Cancerous prostate cells continue to synthesize and secrete prostasomes and may be shielded against immunological attacks by these prostasomes. Research of several aspects of prostasomal involvement in prostate cancer has been performed.<ref>Ronquist G, Carlsson L, Larsson A, Nilsson BO: "Prostasomes: Proceedings from a symposium held at the Wenner-Gren Centre, Stockholm, June 2001" pp. 1-9. Portland Press , London
</ref>
====Prostate mapping====


Prostate Mapping is a new diagnostic process developed by urology and radiology consultants in the UK. This is a method of diagnosis which may be accurate in determining the precise location and aggressiveness of cancer. It uses a combination of multi-sequence MRI imaging techniques and a template guided biopsy system and involves taking multiple biopsies through the skin that lies in front of the back passage rather than through the back passage. The procedure is carried out under general anaesthetic.
[[Prostate cancer history and symptoms| History and Symptoms]] | [[Prostate cancer physical examination | Physical Examination]] | [[Prostate cancer staging | Staging]] | [[Prostate cancer laboratory studies | Laboratory Findings]] | [[Prostate cancer x ray|X Ray]] | [[Prostate cancer CT|CT]] | [[Prostate cancer MRI|MRI]] | [[Prostate cancer ultrasound| Ultrasound]] | [[Prostate cancer other imaging findings|Other Imaging Findings]] | [[Prostate cancer other diagnostic studies|Other Diagnostic Studies]] | [[Prostate cancer biopsy|Biopsy]]
 
==Staging==
{{main|Prostate cancer staging}}
An important part of evaluating prostate cancer is determining the [[cancer staging|stage]], or how far the cancer has spread. Knowing the stage helps define [[prognosis]] and is useful when selecting therapies. The most common system is the four-stage [[TNM]] system (abbreviated from Tumor/Nodes/Metastases). Its components include the size of the tumor, the number of involved [[lymph node]]s, and the presence of any other [[metastasis|metastases]].
 
The most important distinction made by any staging system is whether or not the cancer is still confined to the prostate. In the TNM system, clinical T1 and T2 cancers are found only in the prostate, while T3 and T4 cancers have spread elsewhere. Several tests can be used to look for evidence of spread. These include [[computed tomography]] to evaluate spread within the pelvis, [[bone scan]]s to look for spread to the bones, and [[endorectal coil magnetic resonance imaging]] to closely evaluate the prostatic capsule and the [[seminal vesicles]]. Bone scans should reveal osteoblastic appearance due to ''increased'' bone density in the areas of bone metastasis - opposite to what is found in many other cancers that metastasize.
 
[[Computed tomography]] (CT) and [[magnetic resonance imaging]] (MRI) currently do not add any significant information in the assessment of possible lymph node metastases in patients with prostate cancer according to a meta-analysis.<ref name="pmid17936849">{{cite journal |author=Smith JA, Chan RC, Chang SS, ''et al'' |title=A comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy |journal=J. Urol. |volume=178 |issue=6 |pages=2385–9; discussion 2389–90 |year=2007 |pmid=17936849 |doi=10.1016/j.juro.2007.08.008 |url=http://linkinghub.elsevier.com/retrieve/pii/S0022-5347(07)01979-9}}</ref> The [[sensitivity (tests)|sensitivity]] of CT was 42% and [[specificity (tests)|specificity]] of CT was 82%. The [[sensitivity (tests)|sensitivity]] of MRI was 39% and the [[specificity (tests)|specificity]] of MRI was 82%. For patients at similar risk to those in this study (17% had positive pelvic lymph nodes in the CT studies and 30% had positive pelvic lymph nodes in the MRI studies), this leads to a [[positive predictive value]] (PPV) of 32.3% with CT, 48.1% with MRI, and [[negative predictive value]] (NPV) of 87.3% with CT, 75.8% with MRI.
 
After a prostate biopsy, a [[pathology|pathologist]] looks at the samples under a microscope. If cancer is present, the pathologist reports the [[Grading (tumors)|grade]] of the tumor. The grade tells how much the tumor tissue differs from normal prostate tissue and suggests how fast the tumor is likely to grow. The Gleason system is used to grade prostate tumors from 2 to 10, where a [[Gleason score]] of 10 indicates the most abnormalities. The pathologist assigns a number from 1 to 5 for the most common pattern observed under the microscope, then does the same for the second most common pattern. The sum of these two numbers is the Gleason score. The [[Whitmore-Jewett stage]] is another method sometimes used. Proper grading of the tumor is critical, since the grade of the tumor is one of the major factors used to determine the treatment recommendation.
 
==Risk assessment==
 
Many prostate cancers are not destined to be lethal, and most men will ultimately die from causes other than of the disease. Decisions about treatment type and timing may therefore be informed by an estimation of the '''risk''' that the tumor will ultimately recur after treatment and/or progress to metastases and mortality. Several tools are available to help predict outcomes such as pathologic stage and recurrence after surgery or radiation therapy. Most combine stage, grade, and PSA level, and some also add the number or percent of biopsy cores positive, age, and/or other information.
 
The D’Amico classification stratifies men to low, intermediate, or high risk based on stage, grade, and PSA. It is used widely in clinical practice and research settings. The major downside to the 3-level system is that it does not account for multiple adverse parameters (e.g., high Gleason score ''and'' high PSA) in stratifying patients.
 
The Partin tables predict pathologic outcomes (margin status, extraprostatic extension, and seminal vesicle invasion) based on the same 3 variables, and are published as lookup tables.
 
The Kattan nomograms predict recurrence after surgery and/or radiation therapy, based on data available either at time of diagnosis or after surgery. The nomograms can be calculated using paper graphs, or using software available on a website or for handheld computers. The Kattan score represents the likelihood of remaining free of disease at a given time interval following treatment.
 
The [http://urology.ucsf.edu UCSF] Cancer of the Prostate Risk Assessment (CAPRA) score predicts both pathologic status and recurrence after surgery. It offers comparable accuracy as the Kattan preoperative nomogram, and can be calculated without paper tables or a calculator. Points are assigned based on PSA, Grade, stage, age, and percent of cores positive; the sum yields a 0–10 score, with every 2 points representing roughly a doubling of risk of recurrence. The CAPRA score was derived from community-based data in the [http://www.capsure.net CaPSURE] database. It has been validated among over 10,000 prostatectomy patients, including patients from CaPSURE;  the SEARCH registry, representing data from several Veterans Administration and active military medical centers; a multi-institutional cohort in Germany; and the prostatectomy cohort at Johns Hopkins University.


==Treatment==
==Treatment==


Treatment for prostate cancer may involve [[watchful waiting]], [[surgery]], [[radiation therapy]] including [[brachytherapy]] ([[prostate brachytherapy]]) and external beam radiation, [[High Intensity Focused Ultrasound (HIFU)]], [[chemotherapy]], [[cryosurgery]], hormonal therapy, or some combination. Which option is best depends on the stage of the disease, the Gleason score, and the PSA level. Other important factors are the man's age, his general health, and his feelings about potential treatments and their possible side effects. Because all treatments can have significant [[Adverse effect (medicine)|side effect]]s, such as erectile dysfunction and urinary incontinence, treatment discussions often focus on balancing the goals of therapy with the risks of lifestyle alterations.
[[Prostate cancer medical therapy|Medical Therapy]] | [[Prostate cancer surgery|Surgery]] | [[Prostate cancer primary prevention|Primary Prevention]] | [[Prostate cancer secondary prevention|Secondary Prevention]] | [[Prostate cancer cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Prostate cancer future or investigational therapies|Future or Investigational Therapies]] | [[Prostate cancer alternative therapy|Alternative Therapy]]
 
The selection of treatment options may be a complex decision involving many factors. For example, radical prostatectomy after primary radiation failure is a very technically challenging surgery and may not be an option.<ref name="pmid16314889">{{cite journal | author = Mouraviev V, Evans B, Polascik TJ | title = Salvage prostate cryoablation after primary interstitial brachytherapy failure: a feasible approach | journal = Prostate Cancer Prostatic Dis. | volume = 9 | issue = 1 | pages = 99–101 | year = 2006 | pmid = 16314889 | doi = 10.1038/sj.pcan.4500853 | url =  }}</ref> This may enter into the treatment decision.
 
If the cancer has spread beyond the prostate, treatment options significantly change, so most doctors who treat prostate cancer use a variety of [[nomogram]]s to predict the probability of spread. Treatment by watchful waiting, HIFU, radiation therapy, cryosurgery, and surgery are generally offered to men whose cancer remains within the prostate. Hormonal therapy and chemotherapy are often reserved for disease which has spread beyond the prostate. However, there are exceptions: radiation therapy may be used for some advanced tumors, and hormonal therapy is used for some early stage tumors. [[Cryotherapy]], hormonal therapy, and chemotherapy may also be offered if initial treatment fails and the cancer progresses.


===Active Surveillance===
==Case Studies==
[[Prostate cancer case study one|Case #1]]


Active Surveillance refers to observation and regular monitoring without invasive treatment. Active surveillance is often used when an early stage, slow-growing prostate cancer is found in an older man. Conversely [[watchful waiting]] may also be suggested when the risks of surgery, radiation therapy, or hormonal therapy outweigh the possible benefits. Other treatments can be started if symptoms develop, or if there are signs that the cancer growth is accelerating (e.g., rapidly rising PSA, increase in Gleason score on repeat biopsy, etc.). Most men who choose active surveillance for early stage tumors eventually have signs of tumor progression, and they may need to begin treatment within three years.<ref>{{cite journal| last=Wu| first=H| coauthors=Sun L, Moul JW, Wu HY, McLeod DG, Amling C, Lance R, Kusuda L, Donahue T, Foley J, Chung A, Sexton W, Soderdahl D| title=Watchful waiting and factors predictive of secondary treatment of localized prostate cancer| journal=J Urol| year=2004| month=March| volume=171| issue=3| pages=1111–6| pmid=14767282| doi=10.1097/01.ju.0000113300.74132.8b}}</ref>  Although men who choose active surveillance avoid the risks of surgery and radiation, the risk of metastasis (spread of the cancer) may be increased.
==Related Chapters==
 
* [[Atypical small acinar proliferation]]
For younger men, a trial of active surveillance may not mean avoiding treatment altogether, but may reasonably allow a delay of a few years or more, during which time the quality of life impact of active treatment can be avoided. Published data to date suggest that carefully selected men will not miss a window for cure with this approach. Additional health problems that develop with advancing age during the observation period can also make it harder to undergo surgery and radiation therapy.
* [[Testosterone]]
 
* [[Gleason score]]
===Natural Therapy===
 
As an alternative to active surveillance or invasive treatments, which does nothing to change the course of disease, a growing number of clinicians and researchers are looking at non-invasive ways to help men with apparently localized prostate cancer. Perhaps most convincing among this group are Dean Ornish, MD and colleagues, previously made famous for showing that aggressive lifestyle changes can reverse atherosclerosis, and now showing that PSA can be lowered in men with apparent localized prostate cancer using a vegan diet (fish allowed), regular exercise, and stress reduction.<ref>{{cite journal | last=Ornish| first=D| coauthors=Weidner G, Fair WR, et al.| title=Intensive lifestyle changes may affect the progression of prostate cancer| journal=J Urol| year=2005| volume=174| issue=3| pages=1065–70| pmid=16094059}}</ref> These results have so far proven durable after two-years' treatment.<ref>{{cite journal| last=Frattaroli| first=J| coauthors=Weidner G, Kemp C, et al.| title=Clinical events in Prostate CAncer Lifestyle Trial: Results from two years of follow-up| journal=Urology| year=2008| month=July| pmid= 18602144| volume=epub ahead of print}}</ref>
 
Many other single agents have been shown to reduce PSA, slow PSA doubling times, or have similar effects on secondary markers in men with localized cancer in short term trials, such as the Wonderful variety of pomegranate juice 8 oz daily or genistein, an isoflavone found in various legumes, 60 mg per day.<ref>{{cite journal| last=Pantuck| first=AJ| coauthors=Leppert JT, Zomorodian N, et al.| title=Phase II study of pomegranate juice for men with rising prostate-specific antigen following surgery or radiation for prostate cancer| journal=Clin Cancer Res| year=2006| volume=12| issue=13| pages=4018–26| pmid=16818701}}</ref><ref>{{cite journal| last=Kumar| first=NB| coauthors=Cantor A, Allen K, et al.| title=The specific role of isoflavones in reducing prostate cancer risk| journal=Prostate| year=2004| volume=59| issue=2| pages=141–7| pmid= 15042614}}</ref> The potential of using multiple such agents in concert, let alone combining them with lifestyle changes, has not yet been studied but the potential is great. This is particularly true because most of these natural approaches have very low adverse effect rates, and in fact tend to help other risk factors and disease conditions such as atherosclerosis, diabetes, and risk for other cancers at the same time they are helping slow down prostate cancer. A more thorough review of natural approaches to prostate cancer has been published.<ref>{{cite journal| last=Yarnell| first=E| title=A naturopathic approach to prostate cancer. Part 2: Guidelines for treatment and prevention| journal=Altern Complemen Ther| year=1999| volume=5| issue=6| pages=360–8}}</ref>
 
===Surgery===
 
Surgical removal of the prostate, or [[prostatectomy]], is a common treatment either for early stage prostate cancer, or for cancer which has failed to respond to radiation therapy. The most common type is [[radical retropubic prostatectomy]], when the surgeon removes the prostate through an abdominal incision. Another type is [[radical perineal prostatectomy]], when the surgeon removes the prostate through an incision in the [[perineum]], the skin between the [[scrotum]] and [[anus]]. Radical prostatectomy can also be performed laparoscopically, through a series of small (1cm) incisions in the abdomen, with or without the assistance of a surgical robot.
 
[[Radical prostatectomy]] is effective for tumors which have not spread beyond the prostate;<ref name="pmid15888698">{{cite journal |author=Bill-Axelson A, Holmberg L, Ruutu M, ''et al'' |title=Radical prostatectomy versus watchful waiting in early prostate cancer |journal=N. Engl. J. Med. |volume=352 |issue=19 |pages=1977–84 |year=2005 |pmid=15888698 |doi=10.1056/NEJMoa043739}}</ref> cure rates depend on risk factors such as PSA level and Gleason grade. However, it may cause [[nerve]] damage that significantly alters the quality of life of the prostate cancer survivor.
 
Radical prostatectomy has traditionally been used alone when the cancer is small. In the event of positive margins or locally advanced disease found on pathology, adjuvant radiation therapy may offer improved survival. Surgery may also be offered when a cancer is not responding to radiation therapy. However, because radiation therapy causes tissue changes, prostatectomy after radiation has a higher risk of complications.
 
Laparoscopic radical prostatectomy, LRP, is a new way to approach the prostate surgically with intent to cure. Contrasted with the open surgical form of prostate cancer surgery, laparoscopic radical prostatectomy does not require a large incision. Relying on modern technology, such as miniaturization, fiber optics, and the like, laparoscopic radical prostatectomy is a minimally invasive prostate cancer treatment. 
 
In the hands of an experienced surgeon, robotic assisted laparoscopic prostatectomy (RALP) may reduce positive surgical margins when compared to [[radical retropubic prostatectomy]] (RRP) among patients with [[prostate cancer]] according to a retrospective study.<ref name="pmid17936849">{{cite journal |author=Smith JA, Chan RC, Chang SS, ''et al'' |title=A comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy |journal=J. Urol. |volume=178 |issue=6 |pages=2385–9; discussion 2389–90 |year=2007 |pmid=17936849 |doi=10.1016/j.juro.2007.08.008 |url=http://linkinghub.elsevier.com/retrieve/pii/S0022-5347(07)01979-9}}</ref> The [[relative risk reduction]] was 57.7%. For patients at similar risk to those in this study (35.5% of patients had positive surgical margins following RRP), this leads to an [[absolute risk reduction]] of 20.5%. 4.9 patients must be treated for one to benefit ([[number needed to treat]] = 4.9). The relative merits of RALP and benefits over open radical prostatectomy are an area of intense research currently in urology and no definitive data, that has been widely accepted by the broader urological community, exists to say it is superior to a open radical retropubic prostatectomy.
 
[[Transurethral resection of the prostate]], commonly called a "TURP," is a surgical procedure performed when the tube from the bladder to the penis ([[urethra]]) is blocked by prostate enlargement. TURP is generally for benign disease and is not meant as definitive treatment for prostate cancer. During a TURP, a small instrument ([[cystoscope]]) is placed into the penis and the blocking prostate is cut away.
 
In metastatic disease, where cancer has spread beyond the prostate, removal of the [[testicle]]s (called [[orchiectomy]]) may be done to decrease testosterone levels and control cancer growth. (See hormonal therapy, below).
 
The most common serious complications of surgery are loss of [[urinary incontinence|urinary control]] and [[impotence]]. Reported rates of both complications vary widely depending on how they are assessed, by whom, and how long after surgery, as well as the setting (e.g., academic series vs. community-based or population-based data). Although penile sensation and the ability to achieve [[orgasm]] usually remain intact, erection and ejaculation are often impaired. Medications such as [[sildenafil]] (Viagra), [[tadalafil]] (Cialis), or [[vardenafil]] (Levitra) may restore some degree of potency. For most men with organ-confined disease, a more limited "nerve-sparing" technique may help reduce urinary incontinence and impotence.<ref>{{cite journal| last=Gerber| first=GS| coauthors=Thisted RA, Scardino PT, Frohmuller HG, Schroeder FH, Paulson DF, Middleton AW Jr, Rukstalis DB, Smith JA Jr, Schellhammer PF, Ohori M, Chodak GW| title=Results of radical prostatectomy in men with clinically localized prostate cancer| journal=JAMA| year=1996| month=August 28| volume=276| issue=8| pages=615–9| pmid=8773633| doi=10.1001/jama.276.8.615}}</ref>
 
===Radiation therapy===
[[Image:brachytherapy.jpg|thumb|left|250px|'''[[Brachytherapy]]''' for prostate cancer is administered using "seeds," small radioactive rods implanted directly into the tumor.]][[Radiation therapy]], also known as radiotherapy, is often used to treat all stages of prostate cancer, or when surgery fails.  Radiotherapy uses [[ionizing radiation]] to kill prostate cancer cells. When absorbed in tissue, [[Ionizing radiation]] such as Gamma and x-rays damage the [[DNA]] in cells, which increases the probability of apoptosis (cell death). Two different kinds of radiation therapy are used in prostate cancer treatment: [[external beam radiotherapy|external beam radiation therapy]] and [[brachytherapy]] (specifically [[prostate brachytherapy]]).
 
External beam radiation therapy uses a [[linear accelerator]] to produce high-energy x-rays which are directed in a beam towards the prostate. A technique called Intensity Modulated Radiation Therapy ([[IMRT]]) may be used to adjust the radiation beam to conform with the shape of the tumor, allowing higher doses to be given to the prostate and seminal vesicles with less damage to the bladder and rectum. External beam radiation therapy is generally given over several weeks, with daily visits to a radiation therapy center. New types of radiation therapy may have fewer side effects than traditional treatment. One of these is [[Tomotherapy]].
 
[[Image:linacprostate.jpg|thumb|right|150px|[[External beam radiotherapy|External beam radiation therapy]] for prostate cancer is delivered by a linear accelerator, such as this one.]]
Permanent implant brachytherapy is a popular treatment choice for patients with low to intermediate risk features, can be performed on an outpatient basis, and is associated with good 10-year outcomes with relatively low morbidity<ref>{{cite journal| last=Nag| first=S| coauthors=Beyer D, Friedland J, Grimm P, Nath R| title=American Brachytherapy Society Recommendations for Transperineal Permanent Brachytherapy of Prostate Cancer | journal=Int. J. Rad. Onc. Biol. Phys. | year=1999| month=?| volume=44| issue=4| pages=789–799| id=?}} Review.</ref>  It involves the placement of about 100 small "seeds" containing radioactive material (such as [[iodine-125]] or [[palladium-103]]) with a needle through the skin of the [[perineum]] directly into the tumor while under spinal or general anesthetic. These seeds emit [[Superficial X-ray|lower-energy X-rays]] which are only able to travel a short distance. Although the seeds eventually become inert, they remain in the prostate permanently. The risk of exposure to others from men with implanted seeds is generally accepted to be insignificant.<ref>{{cite journal| last=Perez| first=CA| coauthors=Hanks GE, Leibel SA, Zietman AL, Fuks Z, Lee WR| title=Localized carcinoma of the prostate (stages T1B, T1C, T2, and T3). Review of management with external beam radiation therapy| journal=Cancer| year=1993| month=December 1| volume=72| issue=11| pages=3156–73| pmid=7694785| doi=10.1002/1097-0142(19931201)72:11<3156::AID-CNCR2820721106>3.0.CO;2-G}} Review.</ref> 
 
Radiation therapy is commonly used in prostate cancer treatment. It may be used instead of surgery or after surgery in early stage prostate cancer. In advanced stages of prostate cancer radiation is used to treat painful bone metastases. Radiation treatments also can be combined with hormonal therapy for intermediate risk disease, when radiation therapy alone is less likely to cure the cancer. Some radiation oncologists combine external beam radiation and brachytherapy for intermediate to high risk situations. One study found that the combination of six months of androgen suppressive therapy combined with external beam radiation had improved survival compared to radiation alone in patients with localized prostate cancer.<ref>{{cite journal | author=D'Amico AV, Manola J, Loffredo M, Renshaw AA, DellaCroce A, Kantoff PW | title=6-month androgen suppression plus radiation therapy vs radiation therapy alone for patients with clinically localized prostate cancer: a randomized controlled trial | journal=JAMA | year=2004 | pages=821–7 | volume=292 | issue=7  | pmid=15315996 | doi = 10.1001/jama.292.7.821}}</ref> Others use a "triple modality" combination of external beam radiation therapy, brachytherapy, and hormonal therapy.
 
Radiation therapy uses high-energy rays or particles to kill cancer cells.<ref>[http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Radiation_Therapy_36.asp?rnav=cri  American Cancer Society: Radiation Treatment]</ref>
When delivered in the correct dosage, radiation can reduce the risk of recurrence. 
 
Less common applications for radiotherapy are when cancer is compressing the spinal cord, or sometimes after surgery, such as when cancer is found in the seminal vesicles, in the lymph nodes, outside the prostate capsule, or at the margins of the biopsy.
 
Radiation therapy is often offered to men whose medical problems make surgery more risky. Radiation therapy appears to cure small tumors that are confined to the prostate just about as well as surgery. However, some issues remain unresolved, such as whether radiation should be given to the rest of the pelvis, how much the [[absorbed dose]] should be, and whether hormonal therapy should be given at the same time.
 
Side effects of radiation therapy might occur after a few weeks into treatment. Both types of radiation therapy may cause [[diarrhea]] and mild [[Gastrointestinal bleeding|rectal bleeding]] due to [[radiation proctitis]], as well as urinary incontinence and impotence. Symptoms tend to improve over time.  Rates for impotence when comparing radiation to nerve-sparing surgery are similar.  Radiation has lower rates of incontinence but higher rates of occasional mild rectal bleeding.<ref>{{cite journal| last=Lawton| first=CA| coauthors=Won M, Pilepich MV, Asbell SO, Shipley WU, Hanks GE, Cox JD, Perez CA, Sause WT, Doggett SR, et al| title=Long-term treatment sequelae following external beam irradiation for adenocarcinoma of the prostate: analysis of RTOG studies 7506 and 7706| journal=Int J Radiat Oncol Biol Phys| year=1991| month=September| volume=21| issue=4| pages=935–9| pmid=1917622}}</ref> Men who have undergone external beam radiation therapy may have a slightly higher risk of later developing [[colon cancer]] and [[bladder cancer]].<ref>{{cite journal| last=Brenner| first=DJ| coauthors=Curtis RE, Hall EJ, Ron E| title=Second malignancies in prostate carcinoma patients after radiotherapy compared with surgery| journal=Cancer| year=2000| month=January 15| volume=88| issue=2| pages=398–406| pmid=10640974| doi=10.1002/(SICI)1097-0142(20000115)88:2<398::AID-CNCR22>3.0.CO;2-V}}</ref>
 
===Cryosurgery===
 
[[Cryosurgery]] is another method of treating prostate cancer in which the prostate gland is exposed to freezing temperatures.<ref>PreventProstateCancer.info: A Brief Overview of Prostate Cancer [http://www.preventprostatecancer.info/Articles/files/5e098219e5c93597247a2f997a4c677f-1.html]</ref> It is less invasive than radical prostatectomy, and [[general anesthesia]] is less commonly used. Under ultrasound guidance, a method invented by Dr. Gary Onik,<ref>{{cite web | title=Cryosurgical system for destroying tumors by freezing | url=http://www.patentstorm.us/patents/5334181.html | accessdate= 1994-08-02}}</ref> metal rods are inserted through the skin of the [[perineum]] into the prostate. Highly purified Argon gas is used to cool the rods, freezing the surrounding tissue at −186 °[[Celsius|C]] (−302 °[[Fahrenheit|F]]). As the water within the prostate cells freeze, the cells die. The [[urethra]] is protected from freezing by a [[Foley catheter|catheter]] filled with warm liquid. Cryosurgery generally causes fewer problems with urinary control than other treatments, but impotence occurs up to ninety percent of the time. When used as the initial treatment for prostate cancer and in the hands of an experienced cryosurgeon, cryosurgery has a 10 year biochemical disease free rate superior to all other treatments including radical prostatectomy and any form of radiation.<ref>{{cite journal| last=Bahn| first=DK| coauthors=Lee F, Badalament R, Kumar A, Greski J, Chernick M| title=Targeted cryoablation of the prostate: 7-year outcomes in the primary treatment of prostate cancer| journal=Urology| year=2002| month=August| volume=60| issue=2 Suppl 1| pages=3–11| pmid=12206842| doi=10.1016/S0090-4295(02)01678-3}}</ref> Cryosurgery has also been demonstrated to be superior to radical prostatectomy for recurrent cancer following radiation therapy.
 
===Hormonal therapy===
[[Image:prostatehormone.jpg|right|thumb|200px|'''Hormonal therapy in prostate cancer.''' Diagram shows the different organs (''purple text''), hormones (''black text and arrows''), and treatments (''red text and arrows'') important in hormonal therapy.]] 
[[Hormonal therapy (oncology)|Hormonal therapy]] uses medications or surgery to block prostate cancer cells from getting [[dihydrotestosterone]] (DHT), a hormone produced in the prostate and required for the growth and spread of most prostate cancer cells. Blocking DHT often causes prostate cancer to stop growing and even shrink. However, hormonal therapy rarely cures prostate cancer because cancers which initially respond to hormonal therapy typically become resistant after one to two years. Hormonal therapy is therefore usually used when cancer has spread from the prostate. It may also be given to certain men undergoing radiation therapy or surgery to help prevent return of their cancer.<ref>{{cite journal| last=Robson| first=M| coauthors=Dawson N| title=How is androgen-dependent metastatic prostate cancer best treated?| journal=Hematol Oncol Clin North Am| year=1996| month=June| volume=10| issue=3| pages=727–47| pmid=8773508| doi=10.1016/S0889-8588(05)70364-6}} Review.</ref>
 
Hormonal therapy for prostate cancer targets the pathways the body uses to produce DHT. A [[feedback loop]] involving the testicles, the hypothalamus, and the pituitary, adrenal, and prostate glands controls the blood levels of DHT. First, low blood levels of DHT stimulate the [[hypothalamus]] to produce [[gonadotropin releasing hormone]] (GnRH). GnRH then stimulates the [[pituitary gland]] to produce [[luteinizing hormone]] (LH), and LH stimulates the [[testicles]] to produce testosterone. Finally, testosterone from the testicles and dehydroepiandrosterone from the [[adrenal gland]]s stimulate the prostate to produce more DHT. Hormonal therapy can decrease levels of DHT by interrupting this pathway at any point.
There are several forms of hormonal therapy:
 
*[[Castration|Orchiectomy]] is surgery to remove the testicles. Because the testicles make most of the body's testosterone, after orchiectomy testosterone levels drop. Now the prostate not only lacks the testosterone stimulus to produce DHT, but also it does not have enough testosterone to transform into DHT.
*[[Antiandrogens]] are medications such as [[flutamide]], [[bicalutamide]], [[nilutamide]], and [[cyproterone acetate]] which directly block the actions of testosterone and DHT within prostate cancer cells.
*Medications which block the production of adrenal androgens such as DHEA include [[ketoconazole]] and [[aminoglutethimide]]. Because the adrenal glands only make about 5% of the body's androgens, these medications are generally used only in combination with other methods that can block the 95% of androgens made by the testicles. These combined methods are called total androgen blockade (TAB). TAB can also be achieved using antiandrogens.
*GnRH action can be interrupted in one of two ways. [[Gonadotropin-releasing hormone analog|GnRH antagonists]] suppress the production of LH directly, while [[Gonadotropin-releasing hormone analog|GnRH agonists]] suppress LH through the process of [[downregulation]] after an initial stimulation effect. [[Abarelix]] is an example of a GnRH antagonist, while the GnRH agonists include [[leuprolide]], [[goserelin]], [[triptorelin]], and [[buserelin]]. Initially, GnRH agonists ''increase'' the production of LH. However, because the constant supply of the medication does not match the body's natural production rhythm, production of both LH and GnRH decreases after a few weeks.<ref>{{cite journal| last=Loblaw| first=DA| coauthors=Mendelson DS, Talcott JA, Virgo KS, Somerfield MR, Ben-Josef E, Middleton R, Porterfield H, Sharp SA, Smith TJ, Taplin ME, Vogelzang NJ, Wade JL Jr, Bennett CL, Scher HI; American Society of Clinical Oncology| title=American Society of Clinical Oncology recommendations for the initial hormonal management of androgen-sensitive metastatic, recurrent, or progressive prostate cancer| journal=J Clin Oncol| year=2004| month=July 15| volume=22| issue=14| pages=2927–41| pmid=15184404| doi=10.1200/JCO.2004.04.579}} Erratum in: J Clin Oncol. 2004 November 1;22(21):4435.</ref>
*A very recent Trial I study (N=21) found that [[Abiraterone|Abiraterone Acetate]] caused dramatic reduction in [[PSA]] levels and [[Tumor]] sizes in aggressive end-stage prostate cancer for 70% of patients.  This is prostate cancer that resists all other treatments (e.g., castration, other hormones, etc.).  Officially the impacts on life-span are not yet known because subjects have not been taking the drug very long.  Larger Trial III Clinical Studies are in the works.  If successful an approved treatment is hoped for around 2011.<ref>{{cite journal| last=de Bono| first=Johann| coauthors= Gerhardt Attard, Alison H.M. Reid, Timothy A. Yap, Florence Raynaud, Mitch Dowsett, Sarah Settatree, Mary Barrett, Christopher Parker, Vanessa Martins, Elizabeth Folkerd, Jeremy Clark, Colin S. Cooper, Stan B. Kaye, David Dearnaley, Gloria Lee | title= Phase I Clinical Trial of a Selective Inhibitor of CYP17, Abiraterone Acetate, Confirms That Castration-Resistant Prostate Cancer Commonly Remains Hormone Driven| url = http://jco.ascopubs.org/cgi/content/abstract/JCO.2007.15.9749v1 | journal=J Clin Oncol| year=2004| month=July 21| volume= | issue= | pages= online| pmid=15184404| doi=10.1200/JCO.2007.15.9749| nopp=true}} Erratum in: J Clin Oncol. Early Release, published ahead of print July 21, 2008</ref><ref>{{ cite news | author = Richard Warry |  title =  Drug for deadly prostate cancer  |  url = http://news.bbc.co.uk/2/hi/health/7517414.stm | publisher = [[BBC]] | date = July 22, 2008  | accessdate = 2008-07-23 }}</ref>
 
The most successful hormonal treatments are orchiectomy and GnRH agonists. Despite their higher cost, GnRH agonists are often chosen over orchiectomy for cosmetic and emotional reasons. Eventually, total androgen blockade may prove to be better than orchiectomy or GnRH agonists used alone.
 
Each treatment has disadvantages which limit its use in certain circumstances. Although orchiectomy is a low-risk surgery, the psychological impact of removing the testicles can be significant. The loss of testosterone also causes [[Hot flush|hot flashes]], weight gain, loss of [[libido]], enlargement of the [[breast]]s ([[gynecomastia]]), impotence and [[osteoporosis]]. GnRH agonists eventually cause the same side effects as orchiectomy but may cause worse symptoms at the beginning of treatment. When GnRH agonists are first used, testosterone surges can lead to increased bone pain from metastatic cancer, so antiandrogens or abarelix are often added to blunt these side effects. Estrogens are not commonly used because they increase the risk for [[cardiovascular disease]] and [[thrombosis|blood clots]]. The antiandrogens do not generally cause impotence and usually cause less loss of bone and muscle mass. Ketoconazole can cause [[Hepatotoxicity|liver damage]] with prolonged use, and aminoglutethimide can cause skin [[rash]]es.
 
=== Palliative care ===
[[Palliative care]] for advanced stage prostate cancer focuses on extending life and relieving the symptoms of metastatic disease. As noted above [[Abiraterone|Abiraterone Acetate]] is showing some promise in treating advance stage prostate cancer.  It causes a dramatic reduction in [[Prostate specific antigen|PSA]] levels and [[Tumor]] sizes in aggressive advanced-stage prostate cancer for 70% of patients.  [[Chemotherapy]] may be offered to slow disease progression and postpone symptoms. The most commonly used regimen combines the chemotherapeutic drug [[docetaxel]] with a [[corticosteroid]] such as [[prednisone]].<ref>{{cite journal| last=Tannock| first=IF| coauthors=de Wit R, Berry WR, Horti J, Pluzanska A, Chi KN, Oudard S, Theodore C, James ND, Turesson I, Rosenthal MA, Eisenberger MA; TAX 327 Investigators| title=Docetaxel plus prednisone or mitoxantrone plus prednisone for advanced prostate cancer| journal=N Engl J Med| year=2004| month=October 7| volume=351| issue=15| pages=1502–12| pmid=1547021| doi=10.1056/NEJMoa040720}}</ref> [[Bisphosphonates]] such as [[zoledronic acid]] have been shown to delay skeletal complications such as [[fracture]]s or the need for radiation therapy in patients with hormone-refractory metastatic prostate cancer.<ref>{{cite journal | author=Saad F, Gleason DM, Murray R, Tchekmedyian S, Venner P, Lacombe L, Chin JL, Vinholes JJ, Goas JA, Chen B | title=A randomized, placebo-controlled trial of zoledronic acid in patients with hormone-refractory metastatic prostate carcinoma | journal=J Natl Cancer Inst | year=2002 | pages=1458–68 | volume=94 | issue=19  | pmid=12359855}}</ref> 
 
[[Bone pain]] due to metastatic disease is treated with [[opioid]] [[Analgesic|pain relievers]] such as [[morphine]] and [[oxycodone]]. External beam radiation therapy directed at bone metastases may provide [[pain]] relief. Injections of certain [[radioisotope]]s, such as [[strontium-89]], [[phosphorus-32]], or [[samarium-153-ethylene diamine tetramethylene phosphonate|samarium-153]], also target bone metastases and may help relieve pain.
 
===High Intensity Focused Ultrasound (HIFU)===
 
[[HIFU]] for prostate cancer utilizes [[high intensity focused ultrasound]] (HIFU) to ablate/destroy the tissue of the prostate. During the HIFU procedure, sound waves are used to heat the prostate tissue thus destroying the cancerous cells. Essentially, ultrasonic waves are precisely focused on specific areas of the prostate to eliminate the prostate cancer with minimal risks of affecting other tissue or organs. Temperatures at the focal point of the sound waves can exceed 100 °[[Celsius|C]] (212 °[[Fahrenheit|F]]).<ref name="Thomas-A">Thomas A. Gardner and Michael A Koch, Indiana University Medical Center, Indianapolis. Prostate Cancer Therapy with High-Intensity Focused Ultrasound-Comprehensive Review. Clinical Genitourinary Cancer Vol 4. No.3, 2005.</ref> In lay terms, the HIFU technology is similar to using a magnifying glass to burn a piece of paper by focusing sunlight at a small precise point on the sheet. The ability to focus the ultrasonic waves leads to a relatively low occurrence of both [[incontinence]] and [[impotence]]. (0.6% and 0-20%, respectively)<ref name="Toyoaki-Uchida">Toyoaki Uchida, et al. Five years experience of transrectal high-intensity focused ultrasound using the Sonablate device in the treatment of localized prostate cancer. Dept of Urology University of Tokai Hachioji Hospital. International Journal of Urology</ref> According to international studies, when compared to other procedures, HIFU has a high success rate with a reduced risk of side effects. Studies using the Sonablate 500 HIFU machine have shown that 94% of patients with a pretreatment PSA ([[Prostate Specific Antigen]]) of less than 10 ng/mL were cancer-free after three years.<ref name="Toyoaki-Uchida"/>  However, many studies of HIFU were performed by manufacturers of HIFU devices, or members of manufacturers' advisory panels.<ref>Tom Pickles, Larry Goldenberg, Gary Steinhoff. High Intensity Focused Ultrasound for Prostate Cancer. British Columbia Cancer Agency http://www.bccancer.bc.ca/NR/rdonlyres/08EA1C8E-4345-4C7E-A83A-1F84853A1C27/8101/HIFUreport2005Feb10revised1.pdf</ref>
 
HIFU was first used in the 1940s and 1950s in efforts to destroy tumors in the central nervous system. Since then, HIFU has been shown to be effective at destroying malignant tissue in the brain, prostate, spleen, liver, kidney, breast, and bone.<ref name="Thomas-A"/> Today, the HIF procedure for prostate cancer is performed using a transrectal probe. This procedure has been performed for over ten years and is currently approved for use in Japan, Europe, Canada, and parts of Central and South America.
 
Although not yet approved for use in the Unites States, many patients have received the HIFU procedure at facilities in Canada, and Central and South America.
Currently, therapy is available using the Sonablate 500 or the Ablatherm. The Sonablate 500 is designed by Focus Surgery of Indianapolis, Indiana and is used in international HIFU centers around the world.
 
==Prognosis==
 
Prostate cancer rates are higher and prognosis poorer in developed countries than the rest of the world. Many of the risk factors for prostate cancer are more prevalent in the developed world, including longer life expectancy and diets high in red meat and dairy products (although it must be noted, that people who consume larger amounts of meat and dairy, also tend to consume fewer portions of fruits and vegetables. It's not currently known whether or not both of this factors, or just one of them, contributes to the occurrence of prostate cancer).<ref>[http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_What_are_the_risk_factors_for_prostate_cancer_36.asp ACS :: What Are The Risk Factors for Prostate Cancer?<!-- Bot generated title -->]</ref> Also, where there is more access to screening programs, there is a higher detection rate. Prostate cancer is the ninth most common cancer in the world, but is the number one non-skin cancer in United States men. Prostate cancer affected eighteen percent of American men and caused death in three percent in 2005.<ref>{{cite journal| last=Jemal| first=A| coauthors=Murray T; Ward E; Samuels A; Tiwari RC; Ghafoor A; Feuer EJ; Thun MJ| title=Cancer statistics, 2005| journal=CA Cancer J Clin| year=2005| month=Jan-Feb| volume=55| issue=1| pages=10–30| pmid=15661684}} Erratum in: CA Cancer J Clin. 2005 Jul-Aug;55(4):259.</ref> In Japan, death from prostate cancer was one-fifth to one-half the rates in the United States and Europe in the 1990s.<ref>{{cite journal| last=Wakai| first=K| title=Descriptive epidemiology of prostate cancer in Japan and Western countries| journal=Nippon Rinsho| year=2005| month=February| volume=63| issue=2| pages=207–12| pmid=15714967}} Review. {{Ja icon}}</ref> In India in the 1990s, half of the people with prostate cancer confined to the prostate died within ten years.<ref>{{cite journal| last=Yeole| first=BB| coauthors=Sunny L| title=Population based survival from prostate cancer in Mumbai (Bombay), India| journal=Indian J Cancer| year=2001| month=Jun-Dec| volume=38| issue=2–4| pages=126–32| pmid=1259345}}</ref> African-American men have 50–60 times more prostate cancer and prostate cancer deaths than men in Shanghai, China.<ref>{{cite journal| last=Hsing| first= AW| coauthors=Tsao L, Devesa SS| title=International trends and patterns of prostate cancer incidence and mortality| journal=Int J Cancer| year=2000| month=January 1| volume=85| issue=1| pages=60–7| pmid=10585584| doi=10.1002/(SICI)1097-0215(20000101)85:1<60::AID-IJC11>3.0.CO;2-B}}</ref> In Nigeria, two percent of men develop prostate cancer and 64% of them are dead after two years.<ref>{{cite journal| last=Osegbe| first=DN| title=Prostate cancer in Nigerians: facts and nonfacts| journal=J Urol| year=1997| month=April| volume=157| issue=4| pages=1340–3| pmid=9120935| doi=10.1016/S0022-5347(01)64966-8}}</ref>
 
In patients who undergo treatment, the most important clinical prognostic indicators of disease outcome are stage, pre-therapy PSA level and Gleason score. In general, the higher the grade and the stage, the poorer the prognosis. [[Nomogram]]s can be used to calculate the estimated risk of the individual patient. The predictions are based on the experience of large groups of patients suffering from cancers at various stages.<ref>{{cite journal | author=Di Blasio CJ, Rhee AC, Cho D, Scardino PT, Kattan MW | title=Predicting clinical end points: treatment nomograms in prostate cancer | journal=Semin Oncol | year=2003 | pages=567–86 | volume=30 | issue=5  | pmid=14571407 | doi=10.1016/S0093-7754(03)00351-8}}</ref>
 
==Progression==
 
In 1941, Charles Huggins reported that [[androgen]] ablation therapy causes regression of primary and metastatic androgen-dependent prostate cancer.<ref>Huggins C, Steven RE and Hodges CV, Studies on prostatic cancer. Arch. Sug. 43:209–223, 1941.</ref> [[Androgen]] ablation therapy causes remission in 80-90% of patients undergoing therapy, resulting in a median progression-free survival of 12 to 33 months.  After remission an androgen-independent phenotype typically emerges, where the median overall survival is 23–37 months from the time of initiation of [[androgen]] ablation therapy.<ref>Hellerstedt BA and Pienta KJ, The current state of hormonal therapy for prostate cancer, CA Cancer J. Clin. 52: 154–179, 2002.PMID 12018929</ref> The actual mechanism contributes to the progression of prostate cancer is not clear and may vary between individual patient. A few possible mechanisms have been proposed.<ref>Feldman BJ, Feldman D. The development of androgen-independent prostate cancer. Nat Rev Cancer. 2001 Oct;1(1):34–45. PMID 11900250</ref> Scientists have established a few prostate cancer cell lines to investigate the mechanism involved in the progression of prostate cancer. LNCaP, PC-3, and DU-145 are commonly used prostate cancer cell lines. The LNCaP cancer cell line was established from a human lymph node metastatic lesion of prostatic adenocarcinoma. PC-3 and DU-145 cells were established from human prostatic adenocarcinoma metastatic to bone and to brain, respectively. LNCaP cells express [[androgen receptor]] (AR), however, PC-3 and DU-145 cells express very little or no AR. AR, an androgen-activated [[transcription factor]], belongs to the steroid [[nuclear receptor]] family. Development of the prostate is dependent on androgen signaling mediated through AR, and AR is also important during the development of prostate cancer. The proliferation of LNCaP cells is [[androgen]]-dependent but the proliferation of PC-3 and DU-145 cells is [[androgen]]-insensitive.Elevation of AR expression is often observed in advanced prostate [[tumor]]s in patients.<ref>Linja MJ, Savinainen KJ, Saramaki OR, Tammela TL, Vessella RL, Visakorpi T. Amplification and overexpression of androgen receptor gene in hormone-refractory prostate cancer. Cancer Res. 2001 May 1;61(9):3550–5. PMID 11325816</ref><ref>Ford OH 3rd, Gregory CW, Kim D, Smitherman AB, Mohler JL. Androgen receptor gene amplification and protein expression in recurrent prostate cancer. J Urol. 2003 Nov;170(5):1817–21.PMID 14532783</ref> Some androgen-independent LNCaP sublines have been developed from the ATCC androgen-dependent LNCaP cells after androgen deprivation for study of prostate cancer progression. These [[androgen]]-independent LNCaP cells have elevated [[AR]] expression and express [[prostate specific antigen]] upon [[androgen]] treatment. [[Androgen]]s paradoxically inhibit the proliferation of these [[androgen]]-independent prostate [[cancer]] cells.<ref>Kokontis J, Takakura K, Hay N, Liao S. Increased androgen receptor activity and altered c-myc expression in prostate cancer cells after long-term androgen deprivation. Cancer Res. 1994 March 15;54(6):1566–73. PMID 7511045</ref><ref>Umekita Y, Hiipakka RA, Kokontis JM, Liao S. Human prostate tumor growth in athymic mice: inhibition by androgens and stimulation by finasteride. Proc Natl Acad Sci U S A. 1996 October 15;93(21):11802-7. PMID 8876218</ref><ref>Kokontis JM, Hsu S, Chuu CP, Dang M, Fukuchi J, Hiipakka RA, Liao S. Role of androgen receptor in the progression of human prostate tumor cells to androgen independence and insensitivity. Prostate. 2005 December 1;65(4):287-98. PMID 16015608</ref> [[Androgen]] at a concentration of 10-fold higher than the physiological concentration has also been shown to cause growth suppression and reversion of androgen-independent prostate cancer xenografts or androgen-independent prostate tumors derived [[in vivo]] model to an [[androgen]]-stimulated phenotype in athymic mice.<ref>Chuu CP, Hiipakka RA, Fukuchi J, Kokontis JM, Liao S. Androgen causes growth suppression and reversion of androgen-independent prostate cancer xenografts to an androgen-stimulated phenotype in athymic mice. Cancer Res. 2005 March 15;65(6):2082–4. PMID 15781616 </ref><ref>Chuu CP, Hiipakka RA, Kokontis JM, Fukuchi J, Chen RY, Liao S. Inhibition of tumor growth and progression of LNCaP prostate cancer cells in athymic mice by androgen and liver X receptor agonist. Cancer Res. 2006 July 1;66(13):6482–6. PMID 16818617</ref> These observation suggest the possibility to use androgen to treat the development of relapsed androgen-independent prostate tumors in patients. Oral infusion of [[green tea]] [[polyphenols]], a potential alternative therapy for prostate cancer by natural compounds, has been shown to inhibit the development, progression, and [[metastasis]] as well in autochthonous transgenic adenocarcinoma of the mouse prostate (TRAMP) model, which spontaneously develops prostate cancer.<ref>Gupta S, Hastak K, Ahmad N, Lewin JS, Mukhtar H. Inhibition of prostate carcinogenesis in TRAMP mice by oral infusion of green tea polyphenols. Proc Natl Acad Sci U S A. 2001 August 28;98(18):10350-5. PMID 11504910</ref>
 
==Epidemiology==
 
Rates of prostate cancer vary widely across the world. Although the rates vary widely between countries, it is least common in South and East Asia, more common in Europe, and most common in the United States.<ref>{{cite web | url = http://web.archive.org/web/20060205235509/http://www.jncicancerspectrum.oxfordjournals.org/cgi/statContent/cspectfstat;99 | title = IARC Worldwide Cancer Incidence Statistics—Prostate | publisher = Oxford University Press | work = JNCI Cancer Spectrum | date = December 19, 2001}} Retrieved on 2007-04-05 through the Internet Archive</ref> According to the [[American Cancer Society]], prostate cancer is least common among Asian men and most common among black men, with figures for white men in-between.<ref> [http://www.cancer.org/docroot/CRI/content/CRI_2_2_2X_What_causes_prostate_cancer_36.asp?sitearea= Overview: Prostate Cancer&mdash;What Causes Prostate Cancer?] American Cancer Society (2006-05-02). Retrieved on 2007-04-05</ref><ref> [http://www.hsc.stonybrook.edu/som/urology/urology_cp_prostatecancer.cfm Prostate Cancer FAQs.] State University of New York School of Medicine Department of Urology (2006-08-31). Retrieved on 2007-04-05</ref> However, these high rates may be affected by increasing rates of detection.<ref>{{cite journal |author=Potosky A, Miller B, Albertsen P, Kramer B |title=The role of increasing detection in the rising incidence of prostate cancer |journal=[[Journal of the American Medical Association|JAMA]] |volume=273 |issue=7 |pages=548&ndash;52 |year=1995 |pmid=7530782 |doi=10.1001/jama.273.7.548}}</ref> 
 
Prostate cancer develops most frequently in men over fifty. This cancer can occur only in men, as the prostate is exclusively of the male reproductive tract. It is the most common type of cancer in men in the United States, where it is responsible for more male deaths than any other cancer, except [[lung cancer]]. In the United Kingdom it is also the second most common cause of cancer death after lung cancer, where around 35,000 cases are diagnosed every year and of which around 10,000 die of it. However, many men who develop prostate cancer never have symptoms, undergo no therapy, and eventually die of other causes. That is because malignant [[neoplasm]]s of the prostate are, in most cases, slow-growing, and because most of those affected are over 60. Hence they often die of causes unrelated to the prostate cancer, such as heart/circulatory disease, pneumonia, other unconnected cancers or old age. Many factors, including [[genetics]] and [[Diet (nutrition)|diet]], have been implicated in the development of prostate cancer.  The Prostate Cancer Prevention Trial found that [[finasteride]] reduces the incidence of prostate cancer rate by 30%.  There had been a controversy about this also increasing the risk of more aggressive cancers, but more recent research showed this was not the case.<ref>{{ cite news | author = Gine Kolata |  title = New Take on a Prostate Drug, and a New Debate  |  url = http://www.nytimes.com/2008/06/15/health/15prostate.html?ei=5087&em=&en=813eaa4e10f57756&ex=1213675200&adxnnl=1&adxnnlx=1213503418-GD4DbGjYsDxqV/xuGWnE1A | publisher = NY Times | date = June 15, 2008  | accessdate = 2008-06-15 }}</ref><ref>{{cite journal  |author=Potosky A, Miller B, Albertsen P, Kramer B |title=Finasteride Does Not Increase the Risk of High-Grade Prostate Cancer: A Bias-Adjusted Modeling Approach |  url  =  http://cancerpreventionresearch.aacrjournals.org/cgi/rapidpdf/1940-6207.CAPR-08-0092v1 |journal= Cancer Prevention Research |volume= Published Online First on May 18, 2008 as 10.1158/1940-6207.CAPR-08-0092  |year=2008 |doi=10.1158/1940-6207.CAPR-08-0092  |pages=174 }}</ref>
 
== History ==
 
[[Image:Schally portrait.jpg|right|thumb|150px|'''Andrzej W. Schally''' was awarded the 1977 Nobel Prize in Medicine for his research relating to prostate cancer.]]
Although the prostate was first described by Venetian anatomist [[Niccolò Massa]] in 1536, and illustrated by Flemish anatomist [[Vesalius|Andreas Vesalius]] in 1538, prostate cancer was not identified until 1853.<ref>Adams, J. ''The case of scirrhous of the prostate gland with corresponding affliction of the lymphatic glands in the lumbar region and in the pelvis.'' Lancet 1, 393 (1853).</ref> Prostate cancer was initially considered a rare disease, probably because of shorter [[life expectancy|life expectancies]] and poorer detection methods in the 19th century. The first treatments of prostate cancer were surgeries to relieve urinary obstruction.<ref>Lytton, B. ''Prostate cancer: a brief history and the discovery of hormonal ablation treatment.'' J. Urol. 165, 1859–1862</ref> Removal of the entire gland (radical perineal [[prostatectomy]]) was first performed in 1904 by Hugh H. Young at [[Johns Hopkins Hospital]].<ref>Young, H. H. ''Four cases of radical prostatectomy.'' Johns Hopkins Bull. 16, 315 (1905).</ref> Surgical removal of the testes ([[orchiectomy]]) to treat prostate cancer was first performed in the 1890s, but with limited success. [[Transurethral resection of the prostate]] (TURP) replaced radical prostatectomy for symptomatic relief of obstruction in the middle of the 20th century because it could better preserve penile erectile function. Radical retropubic prostatectomy was developed in 1983 by Patrick Walsh.<ref>Walsh, P. C., Lepor, H. & Eggleston, J. C. ''Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations.'' Prostate 4, 473-485 (1983). PMID 6889192</ref> This surgical approach allowed for removal of the prostate and lymph nodes with maintenance of penile function.
 
In 1941 Charles B. Huggins published studies in which he used [[estrogen]] to oppose testosterone production in men with metastatic prostate cancer. This discovery of "chemical [[castration]]" won Huggins the 1966 [[Nobel Prize in Physiology or Medicine]].<ref>Huggins, C. B. & Hodges, C. V. ''Studies on prostate cancer: 1. The effects of castration, of estrogen and androgen injection on serum phosphatases in metastatic carcinoma of the prostate.'' Cancer Res. 1, 203 (1941).</ref> The role of the hormone [[GnRH]] in reproduction was determined by Andrzej W. Schally and [[Roger Guillemin]], who both won the 1977 Nobel Prize in Physiology or Medicine for this work.
 
Receptor agonists, such as [[leuprolide]] and [[goserelin]], were subsequently developed and used to treat prostate cancer.<ref>Schally, A. V., Kastin, A. J. & Arimura, A. ''Hypothalamic FSH and LH-regulating hormone. Structure, physiology and clinical studies.'' Fertil. Steril. 22, 703–721 (1971).</ref><ref>Tolis G, Ackman D, Stellos A, Mehta A, Labrie F, Fazekas AT, Comaru-Schally AM, Schally AV. ''Tumor growth inhibition in patients with prostatic carcinoma treated with luteinizing hormone-releasing hormone agonists.'' Proc Natl Acad Sci U S A. 1982 Mar;79(5):1658–62 PMID 6461861</ref> 
 
[[Radiation therapy]] for prostate cancer was first developed in the early 20th century and initially consisted of intraprostatic [[radium]] implants. External beam radiation became more popular as stronger radiation sources became available in the middle of the 20th century. Brachytherapy with implanted seeds was first described in 1983.<ref>Denmeade SR, Isaacs JT. ''A History of Prostate Cancer Treatment.'' Nature Reviews Cancer 2, 389–396 (2002). PMID 12044015</ref> Systemic chemotherapy for prostate cancer was first studied in the 1970s. The initial regimen of [[cyclophosphamide]] and [[5-fluorouracil]] was quickly joined by multiple regimens using a host of other systemic chemotherapy drugs.<ref>Scott, W. W. et al. ''Chemotherapy of advanced prostatic carcinoma with cyclophosphamide or 5-fluorouracil: results of first national randomized study.'' J. Urol. 114, 909–911 (1975). PMID 1104900</ref>
 
==Histopathological Findings in Prostatic Adenocarcinoma==
 
=== Prostate: Adenocarcinoma===
 
<youtube v=1SZPLS1dxTo/>
 
== Prostate: Adenocarcinoma (Gleason grading system)==
 
=== Prostate: Adenocarcinoma (Gleason grade 1)===
 
<youtube v=F7V0Zl7a2FY/>
 
=== Prostate : Adenocarcinoma (Gleason grade 2)===
 
<youtube v=YSOLiSklIXw/>
 
=== Prostate : Adenocarcinoma (Gleason grade 3)===
 
<youtube v=TG8vR_pE7yA/>
 
=== Prostate: Adenocarcinoma (Gleason grade 4)===
 
<youtube v=R2Cl4HScdGc/>
 
=== Prostate: Adenocarcinoma (Gleason grade 5)===
 
<youtube v=F7V0Zl7a2FY/>
 
== See also ==
*[[Atypical small acinar proliferation]]
*[[Testosterone]]
 
==References==
{{reflist|3}}
 
==External links==
*[http://www.youtube.com/watch?v=gqEOYBNnqb4 Prostate Cancer & Endothelin: PMAP The Proteolysis Map - animation]
*{{dmoz|Health/Conditions_and_Diseases/Cancer/Genitourinary/Prostate/}}


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{{Urogenital neoplasia}}
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[[Category:Disease]]
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Steven C. Campbell, M.D., Ph.D.; Michael Maddaleni, B.S.; Associate Editor(s)-in-Chief: Shanshan Cen, M.D. [1] Syed Musadiq Ali M.B.B.S.[2] Kavya Keerthi Vadlamudi, M.B.B.S.[3]

Synonyms and keywords: Prostate adenocarcinoma, neoplasm of prostate, tumor of prostate, tumor of prostate, malignant tumor of the prostate, cancer of the prostate, malignant prostatic tumor, malignant prostatic tumour, malignant tumor of prostate

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