Prostate cancer is the uncontrollable growth of prostate gland’s cells. The prostate gland is found only in males and it is responsible for producing some of the fluid that is part of semen.

The exact cause of prostate cancer is still unknown, but basically, prostate cancer results from DNA abnormalities affecting normal prostate cells. DNA abnormalities can either be inherited from a parent or can be acquired during a person’s lifetime.

 Factors that can increase the risk of prostate cancer include being old, family history of prostate or breast cancer, certain ethnic groups, obesity, and other risk factors that may include lack of exercise, smoking, radiation exposure, inflammation of the prostate, and sexually transmitted diseases.

When prostate cancer occurs, the cells of prostate gland mutate into cancer cells. Prostate cancer growth and progression are dependent upon androgen receptor (AR) signaling.

Early prostate cancer causes no noticeable symptoms. When problems are noticed, they appear as problems concerning urinating. Mainly, prostate cancer’s symptoms may include pain during ejaculation, the feeling that the bladder cannot be fully emptied, pain or a burning sensation when passing urine, and presence of blood in the urine or semen.

Prostate screening tests might include urine sample to check for infection, digital rectal exam (DRE), and prostate-specific antigen (PSA) test. If the digital rectal exam or prostate-specific antigen test results show an abnormality.

The physician may recommend certain diagnostic tests, such as transrectal ultrasound (TRUS), prostate biopsy, lymph node biopsy (lymphadenectomy), and imaging tests to look for prostate cancer spread such as bone scan, computed tomography (CT) scan, magnetic resonance imaging (MRI), and positron emission tomography (PET) scan.

Treatment options for prostate cancer may include radiation therapy that delivered from outside of the body or placed inside your body (brachytherapy), hormone therapy , surgery to remove the testicles, transurethral resection of the prostate (TURP), cryosurgery , chemotherapy , biological therapy , and surgery to remove the prostate (radical prostatectomy), and laparoscopic prostatectomy.

If not well managed, prostate cancer can lead to various complications include metastasizes, incontinence, and erectile dysfunction. The number of men who survived prostate cancer has been largely increased.

If cancer has not spread beyond the prostate gland, treatment can be effective and successful. According to the American Cancer Society, about 1 man in 7 will be diagnosed with prostate cancer during his lifetime.

Prostate cancer is the cancerous growth of prostate gland’s cells in which the cells start to grow uncontrollably. The prostate gland is found only in males and it is responsible for producing some of the fluid that is part of semen. The prostate is located below the bladder and in front of the rectum with size equal to a large walnut. Prostate cancer is considered as one of the most common types of cancer in men.

Most of the prostate cancer cases are adenocarcinomas that arise in the peripheral zone of the prostate gland. These cancers develop from the gland cells (the cells that make the prostate fluid that is added to the semen).Other uncommon types of prostate cancer may include Sarcomas, small cell carcinomas, neuroendocrine tumors, and transitional cell carcinomas.

There is an uncertain belief among investigators stating that prostate cancer may start out as a pre-cancerous condition. These conditions can appear sometimes when performing a prostate biopsy, these conditions are:

• Proliferative inflammatory atrophy (PIA): In this condition, the prostate cells appear smaller than usual with evidence of inflammation in the area. This condition is not cancer; however, some investigators advocate the idea that proliferative inflammatory atrophy may cause high-grade prostatic intraepithelial neoplasia (PIN) eventually.
• Prostatic intraepithelial neoplasia (PIN): In this condition, changes in the appearance of prostate gland cells may be observed under a microscope, but the way these abnormal cells behave does not match the way cancer behaves. These abnormal cells can be classified into a low-grade PIN (cells appear almost normal) and a high-grade PIN (cells look more abnormal).

The exact cause of prostate cancer is still unknown. However, basically, prostate cancer results from DNA abnormalities in the normal prostate cells. DNA abnormalities can either be inherited from a parent or can be acquired during a person’s lifetime. These inherited and acquired mutations can be classified as the following:

• Inherited gene mutations: Cancer caused by inherited genes is called hereditary cancer and it constitutes about 5% to 10% of prostate cancers according to the American Cancer Society. Investigators have found many inherited mutated genes that linked to hereditary prostate cancer, including:

• BRCA1 and BRCA2: These tumor suppressor genes are function by eliminating mistakes in DNA of cells or stimulating death of cells if mistakes are irreparable. Abnormal mutations in these genes (especially BRCA2) are responsible for a small percentage of prostate cancers. However, it is more common for these inherited mutations to cause breast and ovarian cancer in women.
• DNA mismatch repair genes: When a cell is preparing to divide into 2 new cells, these genes are function by repairing mistakes (mismatches) in DNA at that time.
• Ribonuclease L (RNASEL): This tumor suppressor gene functions by stimulating death of cells when detecting an abnormal pattern inside them. Inherited mutations in this gene might keep these abnormal cells alive which may increase the risk of turning these cells into cancerous cells.
• Homeobox B13: This gene has a noticeable contribution to the development of the prostate gland. Mutations in this gene are rare, but they have been linked to prostate cancer diagnosed at young age and which runs in some families.

• Acquired gene mutations: Most gene mutations related to prostate cancer are acquired not inherited, which mean that they develop during a man’s life. Generally, the chance for these mutations to occur increases as prostate cells grow and divide more quickly.

There are several factors that can increase the risk of prostate cancer include:

• Age: The risk of prostate cancer increases as age advances. In men under age 40, the disease is extremely rare. The majority of cases are diagnosed in men over age 65.
• A family history of prostate or breast cancer: The risk of developing prostate cancer increases for a person if there is a man with prostate cancer in his family. In addition, a very strong family history of breast cancer or certain genes (BRCA1 or BRCA2) can increase the risk. Men with Lynch syndrome (an inherited condition that increases the risk of colon cancer and other cancers) have an increased risk for a number of cancers, including prostate cancer.
• Geographical region: Although the reasons still unclear, prostate cancer tends to be more common among populations of northwestern Europe, North America, Caribbean islands, and Australia.
• Ethnicity: Black men have a greater risk of developing prostate cancer than other men. In addition, Prostate cancer tends to be more aggressive in black men. In Asian-American and Hispanic/Latino men, the prostate cancer tends to occur less often than in non-Hispanic whites and the reasons for this variation among different ethnicities are still unidentified.
• Overweight and obesity: Treating prostate cancer may become more challenging for obese men diagnosed with the condition.
• Insulin-like growth factor (IGF-1): High level of IGF-1 hormone in the body can increase the risk of prostate cancer. This hormone regulates normal cell growth and death.
• Height: The risk of getting faster-growing prostate cancer increases among taller men.
• Other risk factors: Medical researchers still studying other possible factors that may increase the risk of developing prostate cancer such as diet, lack of physical activities, smoking, radiation exposure, inflammation of the prostate, sexually transmitted infections, and vasectomy. However, more evidence-based studies are needed to confirm the effect of each of these factors in prostate cancer.

Small glands which make 20 % of the fluid that makes up the semen are found in the prostate.When prostate cancer occurs, the cells of these prostate glands mutate into cancer cells. Androgens male hormones are essential for prostate glands to function properly. Androgens include:

• Testosterone hormone
• Dehydroepiandrosterone
• Dihydrotestosterone

Prostate cancer growth and progression are dependent upon androgen receptor (AR) signaling. Therefore, Androgen-deprivation therapy has been considered as an essential treatment for advanced prostate cancer. Most of the time, cases of prostate cancer are classified as an adenocarcinoma, or glandular cancer and the peripheral zone of the prostate gland is where adenocarcinoma is most common.The prostate cancer stages are:

Stage I: At this stage, cancer cells can be seen as unaggressive when viewing them under a microscope. In addition, the cancer is restricted in a small area of the prostate.

Stage II: At this stage, cancer cells can be seen as small in size but they could appear aggressive when analyzed under a microscope. However, they may grow larger and may reach both sides of the prostate gland.

Stage III: At this stage, cancer cells spread beyond the prostate and it may reach the seminal vesicles or other nearby tissues.

Stage IV: At this stage, cancer cells have grown uncontrollably and they invade nearby organs, such as the bladder, lymph nodes, bones, lungs or other organs.

Usually, early prostate cancer causes no noticeable symptoms. However, prostate cancer symptoms can cause the following symptoms:

• Pain during ejaculation and difficulty in having an erection,
• The feeling that the bladder cannot be fully emptied,
• Urinating more often than usual, especially at night,
• Pain or a burning sensation when passing urine,
• Difficulties starting and stopping urination,
• Presence of blood in the urine or semen,
• Dribbling urine.

Symptoms that may indicate metastasizes (a spread of cancer) include:

• Bone and back pain,
• Pain in the testicles,
• Loss of appetite,
• Unexplained weight loss.

There are several diagnostic steps to screen and to investigate prostate cancer, these steps may include:

• Medical /family history: When a physician suspects prostate cancer, he may ask about any symptoms concerning urinary or sexual problems. In addition, he may ask about possible risk factors, including family history.
• Digital rectal exam (DRE): This type of physical examination performed when a doctor or nurse inserts a finger into the rectum to feel for abnormalities. If any abnormalities in the texture, shape or size of prostate gland detected, the physician may recommend more tests.
• Prostate-specific antigen (PSA) test: PSA is an enzyme that is naturally produced by the prostate gland.The test performed by taking a blood sample from the patient and send it to the lab to measure PSA levels. PSA can be found normally in the bloodstream. However, if an abnormal level is found, it may be a sign of prostate inflammation, enlargement or cancer. According to the American Cancer Society, 25% of Men with prostate-specific antigen level between 4 and 10 are at risk of having prostate cancer. If the prostate-specific antigen is more than 10, the chance of having prostate cancer is over 50% (14).
• Urine sample to check for possible infection.

If the digital rectal exam or prostate-specific antigen test results show an abnormality, the physician may recommend certain diagnostic tests, such as:

• Transrectal ultrasound (TRUS): This procedure can be done in a doctor’s office or outpatient clinic and it can take less than 10 minutes. This test carried out by lubricating and placing a small probe about the width of a finger in the rectum. The probe can generate sound waves that infiltrate the prostate and can create echoes. Black and white images of the prostate can be seen on the screen of a computer after picking up the echoes by the probe.
• Prostate biopsy: A biopsy is a performed by removing small samples of the prostate and analyzing them under a microscope. Usually, 6 to 12 tissue samples are taken from the prostate and analyzed in a laboratory to detect cancer cells. Most cancers are grade 3 or higher in Gleason score which based on how much the cancer looks like normal prostate tissue.
• Lymph node biopsy (lymphadenectomy): This procedure is performed by removing lymph nodes and analyze them to detect cancer cells. This procedure is carried out mostly to figure out whether the cancer has spread to nearby lymph nodes. Another related biopsy procedures may include:

• Laparoscopic biopsy: In this procedure, a small cut through the abdomen will be made to insert a laparoscope which is a long, slender tube with a small video camera on the end. Also, long instruments will be used to remove lymph nodes around the prostate gland through other small incisions. The removed tissues will be sent to the laboratory for more investigations.
• Fine needle aspiration (FNA): In this procedure, the physician will be guided by a CT scan image to insert a long, hollow needle through the skin in the lower abdomen and into the enlarged lymph node.

• Imaging tests to look for prostate cancer spread: The imaging tests used most often to look for prostate cancer spread include:

• Bone scan: This test can tell if the cancer has reached the bones. In this test, a small amount of low-level radioactive material will be injected to settles in damaged areas of bone throughout the body. The radioactivity will be detected by using a special camera that able to create a picture of the skeleton.
• Computed tomography (CT) scan: This test uses x-rays to create detailed and cross-sectional images of the human body. It can sometimes detect the spreading of prostate cancer to nearby lymph nodes. However, magnetic resonance imaging (MRI) is more useful than CT scans for looking at the prostate gland itself.
• Magnetic resonance imaging (MRI): This test is used essentially to provide detailed images of soft tissues in the body. However, MRI scan does not use x-rays, it uses radio waves and strong magnets. MRI can tell if the cancer has spread to other areas such as the seminal vesicles or other nearby structures, also, it can provide a very clear picture of the prostate.
• Positron emission tomography (PET) scan: This test can detect abnormalities that relate to the functioning of tissues and organs. This test uses a radioactive drug to show this activity.

The treatment journey of a patient with prostate cancer may pass through many stations and steps including:

• Active surveillance: Healthcare provider may only recommend active surveillance. In active surveillance, certain steps to monitor the progression of the cancer such as regular follow-up rectal exams, blood tests, and possibly biopsies may be performed. If tests show that the cancer is getting worse, then, other treatment options such as surgery or radiation may be suggested.
• Radiation therapy: Radiation therapy can kill cancer cells by using high-powered energy. Radiotherapy is an important and valid alternative to surgery. Side effects of radiation therapy can include painful urination, frequent urination, and urgent urination. Radiation therapy can be delivered in two ways:

• Radiation that comes from outside of the body (external beam radiation): This form of treatment is conducted by ordering the patient to lay down on a table and machine moves around his body and targeting prostate cancer by directing high-powered energy beam such as X-rays. Usually, the treatment plan will cover five days a week for several weeks.
• Radiation placed inside the body (brachytherapy): This form of treatment is conducted by placing a temporary or permanent radioactive seed inside the prostate to target cancer cells. Physician implants the radioactive seeds in the prostate by using a needle guided by ultrasound images to deliver a low dose of radiation over a long period of time. The implanted seeds will stop delivering radiation and there will be no need to remove them.

• Hormone therapy: Hormone therapy is used to prevent the body from producing the male hormone testosterone. Decreasing levels of testosterone may cause cancer cells to die or prevent their growth because cancer cells are relying on testosterone to grow. Hormone therapy options include:

• Medications that prevent the production of testosterone: The most common used medications that prevent the testicles from receiving messages to make testosterone is called luteinizing hormone-releasing hormone (LH-RH) agonists. Such medications may include:

1. Leuprolide (Lupron, Eligard)
2. Triptorelin (Trelstar)
3. Goserelin (Zoladex)
4. Histrelin (Vantas)
5. Other drugs sometimes used include ketoconazole and abiraterone (Zytiga).

• Medications that prevent testosterone from reaching cancer cells: The most common used medications prevent testosterone from reaching cancer cells called anti-androgens. Such medications may include :

1. Bicalutamide (Casodex),
2. Flutamide,
3. Nilutamide (Nilandron),
4. Enzalutamide (Xtandi) may be an option if other hormone therapies show negative results.

• Surgery to remove the testicles (orchiectomy): There will be a significant drop in testosterone levels when testicles removed.
• Transurethral resection of the prostate (TURP): This procedure is performed to remove blockages in the prostate in order to solve urination problems when removing of the prostate is difficult or not allowed.
• Cryosurgery or cryoablation: The first part of this surgery involves freezing tissues to kill cancer cells by using small needles that contain a very cold gas that will be placed in the prostate. The second part of this surgery involves placing a second gas in the needles to reheat the tissue. The repeated cycles of freezing and heating will cause damage to cancer cells and some surrounding healthy tissue. This surgery is performed with the assistance of ultrasound images.
• Chemotherapy: This form of treatment uses drugs to stop the rapid growth of cancer cells and other cells. Some chemotherapy drugs can be given intravenously while other can be given orally.
• Biological therapy: This kind of therapy stimulates body's immune system to seek out cancer cells and kill it. A drug called sipuleucel-T (Provenge) has been approved to treat advanced, recurrent prostate cancer.
• Surgery to remove the prostate (radical prostatectomy): The surgery can be done by an open surgery (the traditional way), or by a ‘keyhole’ (laparoscopic) approach. A newer type of keyhole surgery called ‘robotic surgery’ is available in some cancer hospitals and clinics. Hospitalization period is normally between 1 and 10 days and it depends on whether the surgery is open or ‘keyhole’. Full recovery can take up to 6 weeks. The radical prostatectomy procedure can be performed in many ways including:

1. Robot-assisted surgery: During this medical operation, several small incisions will be made in the abdomen and instruments will be attached to a mechanical device (robot) that will be inserted through the incisions. The instruments will be controlled by a surgeon who will guide the robot to perform the tasks and make the required precise movements.
2. Making an incision in the abdomen: During this medical operation, the prostate gland will be removed by a retropubic surgery in the lower abdomen. A lower risk of nerve damage has been reported when performing this surgery.
3. Making an incision between the anus and scrotum: In order to access the prostate, a perineal surgery will be performed by making an incision between the anus and scrotum. This surgery may allow quicker recovery times, but removing the nearby lymph nodes and nerve damage will be more difficult to avoid.
4. Laparoscopic prostatectomy: This procedure requires high surgical precision on the part of the surgeon.This surgery performed by making small incisions in the abdomen with using a laparoscope (a tiny camera) as a guidance.

• Complementary and alternative therapies: Some of the alternative therapies can improve quality of life of cancer patients when used alongside the conventional cancer therapies. Several complementary therapies can help develop coping mechanisms with distress, including art therapy, physical exercises, music therapy, relaxation techniques, dance or movement therapy, meditation, and spirituality.

Complications of prostate cancer and its treatments include:

• Metastasizes (: Prostate cancer can be spread to other several areas of the body including the bladder, bones or other organs. When prostate cancer spreads to the bones, it can cause bones pain and broken bones. Once prostate cancer has spread to other organs, complete treatment will be difficult.spread of cancer)
• Incontinence: Urinary incontinence can be caused by both prostate cancer and its treatment. Treatment options for urinary incontinence may include medications, catheters, and surgery. Factors such as type and severity of the urinary incontinence will determine best treatment option.
• Erectile dysfunction: Prostate cancer or its treatments (including radiation or hormone treatments)   can cause erectile dysfunction. Treatment options for erectile dysfunction may include surgery, medications, or vacuum devices that assist in achieving erection.
• Acute kidney injury, urinary tract obstruction, and chronic kidney disease.

There are no proven measures to prevent prostate cancer. However, many suggested steps that may help reduce the risk of prostate cancer may include:

• Healthy diet: A diet that full of fruits and vegetables and that which contain less amount of high-fat foods is recommended. Although more research is needed, some reports indicate lower cancer rates in men who consume foods that rich with lycopene (found in cooked tomatoes and other red fruit), and selenium (found in Brazil nuts ). Also, some reports advocating the idea that prostate cancer is less common in people who do not eat meat (vegetarians).A significant role for supplements in reducing the risk of prostate cancer have not yet shown by reliable studies and investigations. Instead, a diet that rich in vitamins and minerals is essential to maintain healthy levels of vitamins in the human body.
• Physical exercises: Practicing physical activity can improve overall health, helps maintain weight and improves the mood. Some evidence indicating higher PSA levels in men who practicing less physical activity. Experts suggesting physical exercise on most days of the week.
• Healthy weight: Maintain a healthy weight by exercising most days of the week is recommended. In addition, if the person needs to lose weight, he can reduce the number of calories he eats each day and he can practice more physical exercise.
• Physician consultation: Taking medications such as alpha reductase inhibitors, including finasteride (propecia, proscar) and dutasteride (avodart) may be suggested by physicians for many men who have a high risk of prostate cancer.

Today, the number of men who survived prostate cancer have been largely increased. If the cancer has not spread beyond the region of the prostate, treatment can be effective and successful. Hormone therapies can improve survival, even if a cure is not possible.

Unlike many other types of cancer, men with prostate cancer can have it for many years without showing any symptoms and it can get worse slowly with time. During this time, treatment may not be needed in men with low-risk prostate cancer which has not spread beyond the prostate gland. Fast-growing prostate cancer has been reported in about 1 in 5 men who developed prostate cancer. Surgery or radiotherapy may be suggested as possible treatment for men whose cancer is more likely to spread beyond the prostate gland. However, these treatments can have side effects.

According to a study published in IOSR Journal of Dental and Medical Sciences, In the United States, reports indicating that prostate cancers that are local or regional at the time of diagnosis have a 5-year survival rate of 100%, while those with distant metastasis have a 5-survival rate of 28%.

• The following are prostate cancer - related facts taken from a study that published in The Canadian Journal of Urology:
  • The most frequently diagnosed non-skin cancer in the US is prostate cancer.
  • The United States has the highest incidence rates of prostate cancer, particularly among African American men. China has some of the lowest incidence rates.
  • Mortality rates that related to prostate cancer remain highest in Scandinavian countries. In many areas of the world, but particularly in the United States, a decline in mortality rates of prostate cancer has been reported during the last decade.
  • Prostate cancer prevalence rates were lowest among men of Mediterranean origin.
• According to a study published in the Prostate International journal, nearly 900,000 men (33 per 100,000 population) were estimated to have been diagnosed with prostate cancer during 2008 worldwide. About 14% (122,000) were diagnosed within the Asia-Pacific region (10 per 100,000), with three out of every four of these prostate cancer cases diagnosed in either Japan (32%), China (28%) or Australia (15%).
• According to office for national statistics in the UK, prostate cancer is the most common cancer diagnosed in males in 2015 with 40,331 cases registered, which accounted for 1 in 4 (26.3%) male cancer registrations.
• According to the American Cancer Society, about 1 man in 7 will be diagnosed with prostate cancer during his lifetime. Prostate cancer is the third leading cause of cancer death in American men, behind lung cancer and colorectal cancer. About 1 man in 39 will die of prostate cancer.
• According to data published by Joint Research Centre (JRC) or the European Commission's science and knowledge service, in the European Union, prostate cancer is ranked first among the most frequently diagnosed cancer among men, with around 345,000 new cases estimated in 2012.
• According to the Australian Institute of Health and Welfare, in 2014, prostate cancer was the third most common cause of cancer deaths in Australia. The number of deaths from prostate cancer increased from 963 in 1968 to 3,102 in 2014. In 2017, it is estimated that the risk of a male being diagnosed with prostate cancer by his 85th birthday will be 1 in 7. Estimated number of new cases of prostate cancer diagnosed in 2017 is 16,665 males.