Prostate Cancer

Prostate cancer is the most common malignancy affecting men, with 21% of new cancers annually in the male population being prostate cancer. However, the ratio of 8:1 in terms of incidence to deaths shows that, although the disease is fatal for some men, the majority die from other causes. Additionally, forensic data indicate that nearly 70% of men over 80 years old had prostate cancer that they were unaware of.

Based on the above, therapeutic decisions for a patient with newly diagnosed prostate cancer take into account the likelihood of metastasis development and death. Therefore, there are patients who will not require any therapeutic intervention for many years, while others will need to start treatment immediately. It should be emphasized that the best decision for therapeutic approaches may require the close collaboration of many specialists involved, even in the early stages of the disease.

Figure: The hypothalamic-pituitary axis stimulates hormonally both the testes (LH, FSH) and the adrenal glands (ACTH). This stimulation leads to the production of testosterone by the testes and androgens by the adrenal glands. These substances exert their effect on prostate cancer cells through the androgen receptor present in these cells. The binding of androgens to the receptor ensures the viability and growth of the tumor. The pharmacological intervention aims to block this binding. LHRH agonists inhibit the hypothalamic-pituitary axis and therefore prevent positive hormonal signals from reaching the testes. Thus, testosterone production is fully suppressed, and prostate cancer cells are deprived of their essential growth factor.

Early Diagnosis – Preventive Screening

Preventive screening for the early diagnosis of prostate cancer primarily includes the digital rectal examination of the prostate and the PSA test. It should be emphasized that PSA is not a perfect marker for diagnosing prostate cancer. The detection of an abnormal PSA value, especially when not combined with a digital rectal examination by a urologist, should not be considered sufficient to establish a diagnosis of malignancy. The definitive diagnosis can only be made through a prostate biopsy.

Locally Confined Disease

Locally confined disease refers to the condition in which prostate cancer is limited to the prostate gland only. In this case, surgical removal is the most obvious treatment option. However, even at this stage, close monitoring and radiotherapy may provide alternative approaches. In all cases, the goal is to cure the patient. The factors that influence the treatment decision include the patient's age, the presence of other serious illnesses, the tumor's differentiation (Gleason score), the clinical stage of the disease (which is determined by the urologist through digital rectal examination), and the PSA level. The decision for the best treatment is largely individualized and should be made after a discussion between the patient and the treating physician, who is usually the urologist who made the diagnosis.

Local Recurrence

Typically, patients present after initial treatment (prostatectomy, radiotherapy) with gradually increasing PSA levels. In this case, local recurrence is highly likely. The most common options are radiotherapy and hormone therapy.

Systemic Recurrence

At this stage, the patient presents with metastases and involvement of the disease in other organs outside the prostate. The most common site for metastases is the bones. The primary treatment for metastatic prostate cancer is pharmacological castration, which essentially means the elimination of the patient's testosterone production, as prostate cancer is a hormonally driven disease. This is achieved with hormonal medications. Testosterone is an androgen produced by the testes, and together with the adrenal androgens, it normally contributes to prostate growth (Image). However, when prostate cancer develops, androgen action promotes the growth of the malignancy. Therefore, a key goal of treatment is to block androgen activity in the cancerous prostate cells.

It should be emphasized that, despite the presence of metastases, there are now many treatment options available, resulting in survival for many years, with excellent quality of life being the norm for most patients. Treatment options include systemic chemotherapy, newer anti-androgens, and radium therapy. Radiotherapy can also be used to address specific symptoms (e.g., pain from bone metastases).