Module 1, Chapter 4: Types of Cancer and their Surgical Procedures

Excerpt - Prostate Cancer pp 41-44

This excerpt is part of the 4 Modules included in the Self-Study course for the Cancer Exercise Specialist® Advanced Qualification (recognized worldwide). Students take 30-180 days to study the materials (500+ pages of textbook materials in 4 Modules, covering 26 types of cancer and pediatrics) and then take the 125 question final exam. With a passing grade of 80% you'll receive a certificate for the Cancer Exercised Specialist® Advanced Qualification (recognized worldwide), and receive a professional listing in our global Cancer Exercise Specialist directory. Review the Self-Study course here: https://ceti.teachable.com/p/14th-edition-cancer-exercise-specialist-advanced-qualification

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Module 1 Excerpt - Prostate Cancer pp 41-44

Prostate cancer is the second most commonly occurring cancer in men and the fourth most commonly occurring cancer overall. There were 1,414,259 new cases and 375,304 deaths worldwide in 2020. Most men over the age of 50 will have some experience with prostate disease - with either an enlarged prostate or cancer. African American men have the highest prostate cancer incidence in the world (about 60% higher than in non-Hispanic whites. They are also more likely to have advanced disease at the time of diagnosis and are more likely to die of prostate cancer.

Prostate cancer death rates have been decreasing since the early 1990s in men of all races/ethnicities, though they remain more than twice as high in Blacks than in any other group. To fully understand the role of genetics and environment in the prostate cancer disparity experienced by African American men, the rates of prostate cancer among African American men and one of their ancestral populations in west Africa have been studied. Data sources were from the World Health Organization (WHO) and reported hospital records in the literature. Based on the WHO's worldwide cancer data, west African men have much lower prostate cancer incidence and mortality compared to African American men.

For example, compared to Nigerian men, African American men are >10 times likely to develop prostate cancer and 3.5 times likely to die from the disease. However, contrary to the global ranking by WHO, there is documented evidence in the literature indicating that prostate cancer in at least one west African country is similar to rates found in the United States and in Caribbean Islands. Another important risk factor is a positive family history.

If a man has a father or brother with the disease, his risk for developing it is twice that of a man with no family history.

Cancer of the prostate is referred to as an indolent cancer, one that grows extremely slowly, sometimes taking as long as two to four years to double in size. Because the median age for diagnosis is 72, many men will elect to forgo aggressive treatment and opt for "watchful waiting" instead. When a man enters his fifties, or thereabouts, the testicles begin to suddenly secrete testosterone, the male sex hormone. This causes the prostate to grow, increasing in size by half nearly every ten years. More than 50% of men between the ages of 60-70 suffer from a non-cancerous condition called benign prostatic hyperplasia. As the prostate enlarges, it compresses the urethra and the channel for the urine to pass through. Men typically feel an urgency to go to the bathroom but are unable to void.

The obstruction can make urination very painful. Should a cell in the prostate turn into cancer, the testosterone will spur the tumors growth like gasoline fueling a fire. Two options for stopping the supply of testosterone exist; surgically removing the testicles or by administering hormones that either halt testosterone production or block its effect.

With early prostate cancer, there are usually no signs or symptoms, however with more advanced prostate cancer, men may experience a weak or interrupted flow of urine, need to urinate frequently (especially at night), blood in the urine, inability to urinate, or difficulty starting to urinate, urine flow that is not easily stopped, painful or burning urination with radiating pain in the back, pelvis, or hips that doesn't go away, and shortness of breath, feeling very tired, fast heartbeat, dizziness, and pale skin cause by anemia. These symptoms may indicate other prostate problems however, they should not be ignored, and the patient should be seen by a doctor to determine whether it is a cancerous or non-cancerous enlargement. Regular digital exams are recommended to detect early prostate cancer because it often does not cause any symptoms.

For men that are diagnosed with low-risk prostate cancer, treatment may not be necessary immediately. Some men will never need treatment. Many doctors sometimes recommend active surveillance in which regular follow-up blood tests, rectal exams and biopsies may be performed to monitor progression of your cancer. If tests show that the cancer is progressing, the patient may then opt for a prostate cancer treatment such as surgery or radiation.

Active surveillance is typically only an option for cancer that is asymptomatic, is expected to grow very slowly and is contained in a small area of the prostate. Another time it may be recommended is when the patient has another serious health condition or is of an advanced age that makes cancer treatment more difficult. The downside is that active surveillance carries the obvious risk that the cancer may metastasize between checkups, reducing the likelihood of a cure.

Gleason Score - is the most common scale that is used to evaluate the grade of prostate cancer cells is called a Gleason score. Gleason scoring combines two numbers and can range from 2 (nonaggressive cancer) to 10 (very aggressive cancer).

Most Gleason scores used to assess prostate biopsy samples range from 6 to 10, with lower numbers seldom being used. A score of 6 indicates a low-grade prostate cancer. A score of 7 indicates a medium-grade prostate cancer. Scores from 8 to 10 indicate high-grade cancers.

Minimally Invasive Surgery - is defined as a surgical procedure performed through small incisions, usually made in the abdominal wall, the result of which is the least possible damage to organs and surrounding tissue. The general advantages of minimally invasive surgery for clients are minimal blood loss, quicker recovery, and a better cosmetic result. The main goals of laparoscopic radical prostatectomy are to cure the patient and preserve his quality of life both in the short term, easier recovery after the operation, and in the long term - preservation of continence and potency. The surgeon begins the laparoscopic radical prostatectomy by making one incision (one centimeter, or less than half an inch, in length) around the navel to insert a thin, lighted tube with a telescopic camera on its tip (called a laparoscope) into the body. The camera projects an extremely clear, highly magnified visualization of the surgical area onto a screen in the operating room, by which the surgical team operates.

A harmless gas is introduced into the abdomen to create a space large enough to perform the surgery. The operation is performed with specialized surgical instruments inserted through four tiny incisions in the pelvic area, and the prostate (and, if necessary, lymph nodes and surrounding tissue) is removed.

Although it is not always possible due to the size and location of the cancer, one of the primary goals of radical prostatectomy is to be "nerve-sparing." This means that the surgeon preserves the web of tiny nerves that control erection and keeps them intact.

This extremely delicate and precise technique is made possible with the laparoscopic approach because of the quality of the visualization of the surgical field, due to the magnification of the surgical area and reduced bleeding.

Advantages of a Minimally Invasive Approach: 

• Incisions are usually made in the abdominal wall (least damage to organs and surrounding tissue)
• Less blood loss during surgery
• Less pain following the operation
• Shorter recovery period
• Faster hospital discharge (65 percent of clients are discharged the day after surgery, and 30 percent two days after surgery)
• Quicker return to normal activities and work (usually within three weeks)
• Better cosmetic result - 4 or 5 tiny incisions versus an 8 inch or larger incision from open surgery
• In 90 percent of clients, the Foley catheter (a thin tube inserted into the bladder to drain urine) can be removed within one week. With open surgery, the catheter usually stays in for 2 or 3 weeks following the procedure.

Radical Prostatectomy - surgical removal of the prostate, the surrounding tissue, and seminal vessels (holds the liquid that mixes with sperm to form semen). The incision is made either through the lower abdomen (retropubic prostatectomy), or in a perineal prostatectomy, through the perineum, the area between the scrotum and the anus. The perineal approach is used less often because it's more likely to lead to erection problems and because the nearby lymph nodes can't be removed. Should a tumor extend through the prostates' fibrous capsule to infiltrate neighboring lymph nodes or scatter to distant sites, prostatectomy is no longer a viable option.

An advantage to the retropubic approach is that it enables the surgeon to biopsy the nodes in the pelvic area. If no evidence of nodal involvement is found, the prostate is removed right then and there. The patient will probably stay in the hospital for a few days after the surgery, and their activities will be limited for several weeks. Many men with localized prostate cancer will choose radiation therapy as their initial treatment.

Following treatment, if they have an elevated PSA and a positive prostate biopsy, the cancer may not have been completely eliminated, or may have returned. A radical prostatectomy that is performed following radiation treatment is known as a salvage radical prostatectomy. This procedure has been shown to eliminate prostate cancer for ten years or more.

Most men will remain in the hospital for 2-3 days and it takes roughly three months for full recovery (slightly less if done laparoscopically). Depending on a man's age and general condition of health, it may be enough the first week for them to walk 6 or 8 times for 5-10 minutes inside of their home. They can gradually increase time and distance as their stamina improves. For two weeks following surgery they will have a catheter; when walking they will need to use the leg bag and fasten it comfortably under loose fitting pants. Patients can start doing pelvic floor muscle exercises again as soon as their catheter has been removed (usually one to three weeks after surgery). Patients should not participate in strenuous activity or heavy lifting for at least one month after surgery and should not ride a bicycle for at least 12 weeks after surgery.

Potential side effects of radical prostatectomy: 

• 65-90% impotence rate
• Shortening of the penis by 1-2 cm.
• Bladder spasms
• Heart attack
• Stroke
• Blood clots in the legs
• 1 in 20 men are left without urinary control
• Virtually all clients can expect to be incontinent for 3-4 months after surgery
• Infertility
• Inguinal hernia
• 1 in 5 men must contend with long-term stress incontinence

Pelvic lymph node dissection (pelvic lymphadenectomy) - surgical biopsy of the lymph nodes in the pelvic area performed through the retropubic approach.

Potential side effects of pelvic lymph node dissection: 

• Lower extremity lymphedema
• Infection
• Nerve damage
• Seroma

Transurethral resection of the prostate (TURP) - surgical removal of the prostatic tissue to relieve symptoms. The surgeon passes a flexible cytoscope through the urethra and into the prostate. An electrified wire loop is inserted through the scope and used to cut away the tumor or nonmalignant tissue that is obstructing the flow of urine. This procedure would typically be used for a patient who was diagnosed late in the course of the disease and didn't respond to traditional medical therapy, or who chose watchful waiting and then had progressive local disease that caused bladder outlet obstruction. It is a palliative treatment for relieving pain and restoring normal urine flow. The operation usually takes about an hour.

After surgery, a catheter is inserted through the penis into the bladder. It remains in place for 1 to 3 days to help urine drain while the prostate heals. 

The patient can usually leave the hospital after 1 to 2 days and return to work in 1 to 2 weeks. Patients can start doing pelvic floor muscle exercises again as soon as their catheter has been removed (usually one to three weeks after surgery).

Potential side effects of TURP:

• Recurring urinary tract infections
• 1 in 10 men will experience partial impotence or incontinence
• 9 in 10 men will experience retrograde ejaculation (semen discharges into the bladder instead of through the urethra and out the penis)
• Difficulty urinating - may last several months
• Bloody urine after surgery
• TURP Syndrome (blindness, fixed pupils, confusion, convulsions, coma, acute renal failure, and reflex bradycardia from fluid absorption)
• Low sodium in blood

Bi-lateral orchiectomy - is the surgical removal of the testicles, through a small incision in front of the scrotum. This is considered the most effective method of hormonal ablation therapy. 

Although patients can go home a few hours after the procedure, it may take two weeks - two months for full recovery. Patients should not lift anything over ten pounds for the first two weeks.

Potential side effects of bi-lateral orchiectomy: 

• Fatigue
• Weight gain
• Potential impotence
• Breast tenderness or growth
• Hot flashes or flushing
• Decreased sexual desire
• Osteoporosis and reduction of muscle tone over prolonged periods
• Lower extremity lymphedema

"Hormone-refractory" prostate cancer or HRPC (also known as "androgen-independent" prostate cancer or AIPC) is prostate cancer that is no longer responding to hormonal therapy. Standard therapy for the management of HRPC has become the combination

of Taxotere® (Docetaxel) and prednisone given daily for 3 weeks for 8 cycles of therapy.