Prostate cancers

The first test to diagnose prostate cancer is rectal exploration, which is performed directly by the urologist.

The doctor, after putting on a lubricated glove, inserts a finger through the anus to palpate the posterior wall of the prostate, assess its size and consistency, and to detect any suspicious nodules.

This examination, which can be uncomfortable but is usually not painful, is important because about 70% of tumors develop right near the outside of the prostate and, in about 20% of cases, are detected by rectal exploration.

The PSA, Prostate-Specific Antigen, is a protein produced by the prostate that serves to thin seminal fluid and is always present in small amounts in the blood. His level however tends to increase with advancing age and/or if there are prostate problems: prostatitis (inflammation), hyperplasia (increased volume) and tumor. A simple blood draw is all that is needed to measure its level; a normal PSA level is between 0 and 4 ng/ml.

However, this measure is not very significant because in 30% of cases the PSA may be in the normal range despite the presence of prostate cancer. Therefore, it is also useful to measure the change in PSA level over time: in fact, the faster this level rises, the more likely it is to indicate the presence of cancer, prostatitis, or prostate hyperplasia.

Interpretation of the examination result will also always take into consideration the patient’s age and medical history.

This diagnostic examination, which is based on the use of electromagnetic waves, makes it possible to detect in the prostate the presence of suspicious areas. It is defined as multi-parametric precisely because it allows the following Evaluate the prostate through several parameters, very thoroughly. Indeed, it can identify lesions as small as 1 centimeter in size and helps distinguish malignant from benign ones.

If a tumor is identified, this examination allows the extent of the tumor to be assessed and to guide the choice of any subsequent treatment.

It is performed at the Division of Radiodiagnostics.

If, following the initial examinations, the urologist suspects the presence of a tumor-for example, if he or she has detected a lump by rectal exploration, if the PSA dosage is higher than normal, and if imaging examinations have shown suspicious areas-a biopsy should be performed, which consists of taking a few samples of cells from the prostate.

The biopsy is performed with the guidance of theultrasonography (thus involving the insertion of the ultrasound probe into the rectum). Tissue samples (usually between 4 and 18) are taken through a needle that is inserted into the prostate through the rectum (transrectal needle biopsy) or through the area between the testes and the anus (transperineal needle biopsy).

Today, new systems make it possible to perform targeted prostate biopsies at the level of suspicious areas on imaging examinations, thus increasing the diagnostic capability of prostate biopsy: this is the so-called “fusion biopsy“.

Biopsy is usually performed on an outpatient basis under local anesthesia. It can be bothersome and cause bleeding, which, in most cases, is mild and is manifested by traces of blood in urine and semen in the days following the examination.

Prostate tissue samples taken by biopsy are sent to the Pathology Anatomy Laboratory where they undergo histological examination under a microscope. If the anatomic pathologist detects tumor cells, he or she will make sure Whether it is a malignant tumor; in this case, the degree of malignancy (or aggressiveness) of the disease.

The degree of tumor aggressiveness defines how much the cancer cells differentiate from healthy cells. It is denoted by the so-called “Gleason” degree, which is presented as the sum of two numbers:

• tumors of grade 6 (3+3) are the least aggressive
• tumors of grade 7 (3+4 and 4+3) have an’intermediate aggressiveness
• tumors between grade 8 (4+4) to grade 10 (5+5) are very aggressive.

In the case of an average or very aggressive tumor, it is necessary to perform other examinations to check whether the disease has spread to the lymph nodes or other organs and thus to determine the extent (or stage) of the tumor.

The examinations normally indicated in these cases are the CT SCAN, the Bone scintigraphy and the PET SCAN. Based on the outcome of one or more of these examinations, the stage of the tumor which is expressed by TNM parameters, where T indicates tumor size, N the status of lymph nodes (whether nicked or not), and M the presence of metastases.

Correlating these three parameters with Gleason grade and PSA level determines the tumor risk grade: low, intermediate or high.

The CT scan of the abdomen-pelvis tract is an examination that makes use of ionizing radiation (X-rays) to create highly detailed three-dimensional images of areas inside the body. A contrast agent is injected to help visualize the images produced by the instrument.

It is performed at the Division of Radiodiagnostics.

Bone scintigraphy is performed to check for thepossible presence of bone metastases. Through the som administration of a radiopharmaceutical which goes into healthy tissues, scintigraphy allows for an in-depth study of bone because it allows for an analysis of the transformation process and how bone regenerates.

PET scan is a test that indicates the presence and activity of the tumor by highlighting the abnormal metabolism of the cells. In the case of prostate cancer, a radiopharmaceutical is injected (choline or PSMA), which is highly concentrated in tumor cells wherever they are located. From here the radiopharmaceutical emits signals that are transformed into images.

PET scanning is performed at the Division of Nuclear Medicine.

When the tumor is located within the prostate, surgery to remove the prostate (prostatectomy) is necessary.

At the Candiolo Institute, robotic surgery is used for this type of procedure: the surgeon, from a computerized workstation, maneuvers the arms of a robot that terminate with miniaturized surgical instruments-with which he makes incisions of a few millimeters-and a 3-D camera. The robot provides the surgeon with high-definition images to facilitate him or her during the procedure, which, because it lacks the physiological tremor of the hand, allows very precise movements to be performed.

This is an extremely minimally invasive method that has many advantages for the patient over traditional (open) surgery: the duration of surgery is shorter, the surgical act is more accurate and effective in preserving, when possible, the nerves that control urinary continence and erection, bleeding and infection risks are decreased, and scarring is reduced. All this also implies a shorter hospital stay and faster recovery time.

In patients with more aggressive tumors, the surgeon also removes lymph nodes (lymphadenectomy) that might be affected by the disease.

After removing the prostate, the surgeon restores the continuity of the urinary tract by connecting the bladder to the urethra with a few stitches. To allow the reconstructed tissues to heal, a catheter is inserted that drains urine into an external bag and is usually removed before the patient is discharged.

When it is not possible to surgically remove the prostate because the patient suffers from other diseases or is at a very advanced age, or when the disease recurs at a low grade or alternatively in the case of post-radiotherapy recurrence, a minimally invasive surgery technique can be used:

• • the High Intensity Focused Ultrasound ( HIFU) technique , which uses high-intensity focused ultrasound guided through a robotic system to destroy the tumor while preserving surrounding tissues and sexual and urinary functions;

• • cryotherapy, a technique that uses cold to selectively target the tumor; it involves inserting needles into the prostate that, by generating temperatures below 0°C, cause cancer cells to die.

Radiation therapy is a localized, noninvasive therapy that, through the use of high-energy radiation (ionizing radiation), is able to damage and lead to necrosis of localized neoplastic cells at the level of the treatment area,

Radiation therapy is commonly given on an outpatient basis, on a daily basis, or in selected cases on alternate days, Saturdays, Sundays and holidays excluded. The duration of each treatment generally varies between ten to twenty minutes and the number of sessions depends on several factors, both related to radiotherapy techniques and the stage of disease, and generally ranges from one to four to six weeks. Such treatment does not make one radioactive, and allows one to be in contact with other people without danger during the entire period.

The indications for radiation therapy in prostate cancer are many, and vary according to risk class and disease presentation.

Radiation therapy may then be proposed:

• • in the newly diagnosed prostate cancer patient as an alternative to surgery (exclusive radiotherapy), ensuring the same therapeutic efficacy. In the case of localized disease, radiotherapy with sterotaxic technique (a high-complexity technique involving the delivery of high doses per fraction with extreme precision in a small number of sessions) of five or seven sessions on alternate days combined or not with hormone therapy may be used. Alternatively, in cases of higher-risk disease, conventional treatment (moderate hypofractionation) of 26 sessions combined or not with hormone therapy may be proposed;

• • in the prostatectomy operated patient, immediately after surgery, if risk factors for local recurrence are present (postoperative radiotherapy), or in case of subsequent PSA increase (salvage radiotherapy);

• • may be proposed case of occurrence of lymph node or bone metastasis or disease-related symptoms.

In the treatment of prostate cancer, hormone therapy-also called hormone or endocrine therapy-is aimed at preventing the production or blocking the action of testosterone, the male hormone produced by the testes that affects cancer growth because it stimulates its cell multiplication.

Hormone therapy can be used:

• • before surgery and/or radiotherapy to reduce prostate volume;

• • after surgery and radiotherapy, to reduce the risk of recurrence, or in combination with radiotherapy in intermediate-high risk tumors;

• • For the treatment of advanced or metastatic cancers.

There are two main categories of anti-hormonal drugs for prostate cancer:

• GnRH analog drugs, which block testosterone production and are administered by intramuscular or subcutaneous injection at intervals of 1 to 3 months;
• antiandrogen drugs, which bind to proteins on the surface of cancer cells, preventing testosterone from entering; they are given in tablets to be taken daily, often also in combination with GnRH analogs.

Hormone therapy, which can be given at home, can keep the tumor under control for several years. Its effectiveness should be monitored with periodic PSA checks.

Recently, second-generation hormonal drugs that improve tumor control have been introduced.

Chemotherapy hinders the growth and reproduction of cells and causes the death of cells that multiply faster than normal, a typical feature of cancer cells.

In the treatment of prostate cancer, chemotherapy is usually used in patients with advanced cancer who do not respond to hormone therapy, to alleviate the symptoms of the disease.

Chemotherapy is given in cycles, intravenously, on a day-hospital basis; each cycle lasts for a few days and is followed by a few weeks of rest. The number of cycles depends on the type of tumor and the response to the drugs, which can vary greatly from patient to patient. The most widely used drug is Docetaxel.

All cancer treatments involve side effects that impact quality of life more or less severely. At the Prostate Cancer Unit of the Candiolo Institute, the patient, before starting treatment, is informed of the possible side effects that each treatment option entails and the possible solutions. The physicians and nurses in the multidisciplinary team are available to provide the patient with all the support he or she needs to manage the various side effects he or she will face in the course of treatment.

The most important side effects caused by prostate cancer therapies are erectile dysfunction andurinary incontinence.

To resolve erectile dysfunction, it is possible to embark on a course of rehabilitation that includes taking specific medications and support from a psychologist.

To overcome urinary incontinence, specific exercises for pelvic floor rehabilitation can be learned with the help of a physical therapist.

Prostate cancer can also have a major impact on the psychological sphere: in fact, the disease often arises at a sensitive time in a person’s life, which coincides with the end of work, and can also cause disorders, such as urinary incontinence and sexual dysfunction, which can impair self-esteem and relationships.

Therefore, at the Prostate Cancer Unit of the Candiolo Institute, every patient in need is offered qualified psychological support to help him or her cope positively with the diagnosis, treatment, and side effects of therapies, and to redefine his or her social and work role.

You can also participate in psychological support groups to compare yourself with others who have gone through or are going through the same experience.

To ensure timely and direct support and receive timely answers to concerns and questions, a dedicated support service is in place at the Candiolo Institute for all patients.

From Monday to Friday, from 8 a.m. to 5 p.m., you can contact the secretariat of the oncology day hospital at 011.993.3775, reporting the need for urgent consultation.

The patient will be quickly put in touch with his or her medical specialist, to receive clear answers and immediate support.

The cancer patient is a person with complex needs that requires multidisciplinary support not only for the cancer disease, but also for all related issues.

At the Candiolo Institute, patients who need or require it have access to specialists in different areas to receive nutritional support, physical therapy, pain therapy and management of other associated conditions.

Only 5-10% of prostate cancers are due to a hereditary mutation of certain genes-such as the HPC1 gene or the BRCA1 and BRCA2 genes-that are passed from parents to offspring.

Healthy people carrying these mutations, in addition to being more likely to get sick, may develop prostate cancer at a younger age, before age 50, and in a more aggressive form. Therefore, patients who have already developed particularly aggressive prostate cancer and have another family member who has had this cancer before age 60 should seek genetic counseling.

The Prostate Cancer Unit at the Candiolo Institute has an outpatient genetic counseling clinic where a geneticist, an expert in hereditary-familial cancers, offers cancer risk assessment counseling and genetic testing to patients in need, as well as a diagnostic surveillance program for healthy people at high genetic risk.

The Social Service Department of the Candiolo Institute conducts information and orientation interviews to patients and their families on how to access services in the area and how to obtain welfare and social security benefits provided by law (disability, benefits for aids and prostheses, work leave, etc.).

The service operates on Wednesdays and Fridays from 9 a.m. to 1 p.m. (phone: 011 9933059).

With the conclusion of the course of treatment, the follow-up period begins during which, through a series of examinations and visits, the side effects of the therapies performed and their effectiveness are monitored and the patient’s recovery is assessed. Follow-up visits are especially important to intercept any recurrences early, so that appropriate therapy can be intervened. They are also a valuable opportunity for dialogue with one’s medical specialist.

It is the same oncologist in the Prostate Cancer Unit who schedules follow-up visits, in which the patient’s health condition is assessed, rectal exploration may be performed, and required test reports are reviewed.

The prostate cancer follow-up program includes examination of the PSA assay, and, in case of suspicious values, possible follow-up MRI and/or PET (Positron Emission Tomography) scan.

Due to the high number of cases treated each year, the Candiolo Institute is a national reference for taking care of esophageal cancer. Our experience enables us to deal with even the most complex situations, always with a personalized approach built on the clinical and personal profile of each patient.

Establishing the treatment plan always starts with an accurate and timely diagnosis. Patients have access to state-of-the-art imaging technologies that allow accurate assessment of the extent of the disease.

In addition, the Institute offers advanced and sophisticated laboratory investigations, including molecular and genomic analyses, which are critical for identifying biological features of cancer and guiding therapeutic decisions.

When indicated, surgery is performed with minimally invasive techniques (laparoscopic or thoracoscopic), which reduce operative trauma, promote faster recovery, and improve postoperative quality of life. Every treatment choice is defined within the GIC, ensuring a consistent and integrated approach.

As an IRCCS, the Candiolo Institute combines clinical practice with a strong vocation for scientific research. Patients can be evaluated for inclusion in active clinical trials, which represent a real chance to access innovative therapies not yet available in standard practice. Collaboration between care and research is a distinctive value that translates into concrete opportunities for the patient.

The Interdisciplinary Care Group takes care of the person at every stage: from diagnosis to treatment to follow-up, with attention to nutritional support, psychological health, and reintegration into daily life. The organization of checkups, visits and treatment is designed to ensure continuity and serenity, always valuing the human dimension of care.