Malignant prostate cancers

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The prostate is a fibromuscular and glandular organ that is found only in men. It is just below the bladder, in front of the rectum. About the size of a walnut in normal condition, the size the prostate can change, and as years go by or due to certain pathologies, it may swell to the point of causing problems, especially urinary disorders. The prostate produces part of the seminal fluid expelled during ejaculation and provides essential components for sperm survival and quality. That is why, some alterations in the organ structure and state may affect male fertility.

Prostate cancer develops from the cells that are present inside the prostate itself, which begin to grow uncontrollably.
It is one of the most common cancers in the male population and accounts for around 20% of all cancers diagnosed in men. Considering the latest statistics, around one every 8 men in our country is likely to get sick. However, the risk of the malignancy having a fatal outcome is low, especially if action is taken in time.

Types of prostate cancer:

• Adenocarcinoma: it is the most frequent one (malignant tumour that develops from glandular tissue)
• Sarcomas (malignant tumours of the connective tissue)
• Small cell carcinomas (the rarest and most aggressive histotype, which originates from neuroendocrine cells, and therefore, is related to the nervous system and glands)
• Transitional cell carcinomas (rare histotype that develops at the level of the cells that form the inner lining of the bladder wall)

Causes of malignant prostate cancer

The main risk factors for the onset of prostate cancer are:

• Age: the likelihood of having prostate cancer rises significantly after age 50, and about two out of three cancers are diagnosed in men older than 65 years old.
• Family history: have a blood relative with prostate cancer doubles a man's risk of having it compared to men who do not have any case in the family.
• The presence of mutations in some genes (such as BRCA1 and BRCA2, or the HPC1 gene).
• The presence of high levels of hormones such as testosterone, which promotes the growth of prostate cells, and IGF1.
• Lifestyle: a diet high in saturated fat, obesity, lack of exercise.

Symptoms of malignant prostate cancer

In its early stages, prostate cancer is asymptomatic, so much so that around 30% of cases are discovered when the disease has already spread beyond the gland.

When the tumour mass grows, it gives rise to urinary symptoms: 

• Trouble urinating (especially starting)
• Need to urinate more often
• Pain when urinating
• Feeling of not being able to urinate completely
• Blood in the urine or semen

It is worth noticing that slight symptoms may be, in any case, an expression of the bad condition of the urinary system, and that this may get worse over time. After the age of 50, a urological examination every 12 months for preventive purposes is necessary.

Adequate prevention helps to detect any pathologies at an early stage and thus, to treat them more effectively.

Diagnosis of malignant prostate cancer

In most cases, the diagnosis of prostate cancer relies on screening tests (periodic check-ups aimed at detecting a disease before it is manifested through symptoms).
As mentioned above, these check-ups are often part of a routine medical visit, mainly for men who are over 40 years old. The doctor may also recommend specialist examinations due to symptoms that are signs of a prostate disorder. These examinations include:

• Rectal exam: about 70% of cancers develop near the outside of the prostate and, in some cases, they can already be detected through this exam.
• PSA (Prostate-Specific Antigen) blood test: consists in taking a blood sample to check the blood level of PSA, a substance produced by the prostate gland which helps to fluidify the seminal fluid. High or rising levels of PSA could indicate prostate cancer.
• Biopsy: the doctor may decide to prescribe a multiple transrectal ultrasound-guided prostate biopsy, under local anaesthesia. This is the only test that can detect the presence of tumour cells with certainty. The biopsy consists in taking and then analysing small tissue samples from different areas of the prostate. 

If the tests detect the presence of a tumour, the stage can be defined by means of:

• Multiparametric magnetic resonance imaging
• Pelvis/abdomen CT scanning with contrast agents
• Bone scintigraphy

     
Depending on the stage, the degree of the tumour and the level of PSA, 'classes of risk' are assigned, which indicate the risk of disease progression (i.e. recurrence). The doctor then recommends the patient the most suitable therapy or therapies.

In general, 3 classes of risk are traditionally considered:

1. Low risk
2. Intermediate risk
3. High risk

At the CNAO Foundation we treat 'high' risk prostate cancer.

Treatment of malignant prostate cancer

At CNAO, hadrontherapy to treat 'high' risk prostate cancer is the subject of a clinical trial to evaluate the effectiveness and safety of a 'boost' overdose with carbon ions on the prostate combined with a treatment with photons on lymph nodes and areas at risk of the spread of the disease.

Compared to photons, carbon ions have both physical and biological advantages:

• physical because they are able to adjust the dose very well to the prostate target saving the toxic and functional effects on the nearby healthy organs (in particular rectum, bladder and bulb of penis)
• biological because they can beat the radio-resistance that the most aggressive forms of these tumours show.

There are two treatment schemes that are currently active at CNAO to treat high risk prostate cancer: 

• a routine healing treatment, which includes 16 sections from Monday to Thursday for four weeks;
• a boost (overdose) of carbon ions to which a traditional radiotherapy treatment with photons is subsequently added

The data collected so far at our Centre shows very low toxicity and excellent tolerability to the treatment.

All high-risk prostate cancers also include a hormone therapy; the reference for this type of treatment is not the radiotherapist, but rather the urologist or the oncologist.