The ABCs of male reproductive cancer

Abstract

Reproductive cancer represents a significant risk to the male population. Prostate cancer is the most common nonskin cancer in the United States, testicular cancer is the most common solid malignancy affecting men ages 15 to 35, and penile cancer comprises 20% of cancers in men in Africa, Asia, and South America. We'll take a look at all three.

Mr. B is a 67-year-old retired attorney in New York, Mr. T is a 21-year-old college student in Southern California, and Mr. K is a 63-year-old farmer in Kenya. What could all three of these men have in common? They represent groups of men most at risk for developing reproductive cancer, more specifically, prostate, testicular, and penile cancer.

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Figure. No caption available.

The male population is at significant risk for reproductive cancer. Prostate cancer is the most common nonskin cancer in America, affecting one in six men (see Picturing prostate cancer). Testicular cancer is the most common solid malignancy affecting men ages 15 to 35. The National Cancer Institute (NCI) estimates that one in 271 men will be diagnosed with cancer of the testis in their lifetime (see Picturing testicular cancer). Penile cancer is rare in developed countries, but comprises 20% of cancers in men in Africa, Asia, and South America. In this article, I'll give you an overview of all three types of male reproductive cancer.

Prostate cancer

At his annual checkup, Mr. B mentions to his physician that he has been having trouble urinating and is experiencing some pain in his pelvic area. His physician performs a digital rectal exam and feels some areas that are tender and hardened in the prostate. Because of this finding, in addition to Mr. B's age and symptoms, the physician orders a prostate-specific antigen (PSA) test, which comes back elevated with a level of 23 ng/mL. Mr. B is scheduled for a transrectal biopsy.

Testing for prostate cancer

* PSA. This blood test measures PSA (a protein produced by prostate cells) levels in the bloodstream. It's normal for men to have a level under 4 ng/mL. According to the American Cancer Society, there's a 25% chance of prostate cancer with PSA levels of 4 to 10 ng/mL, and a 50% chance of prostate cancer with levels greater than 10 ng/mL. This test is meant to be a screening; there are some issues that can elevate the PSA that are noncancerous, such as ejaculation (no ejaculation for at least 2 days before the test), advancing age, inflammation of the prostate gland, and benign prostatic hyperplasia (an enlarged prostate).

* Digital rectal exam. During this test, the healthcare provider inserts a lubricated, gloved finger into the rectum to feel the back wall of the prostate gland to determine if it's enlarged, tender, or has any lumps or hard areas.

* Transrectal ultrasound. During this test, a small probe, which uses sound waves to create a picture of the prostate gland, is inserted into the rectum.

* Transrectal biopsy. A biopsy gun is inserted into the rectum to obtain biopsies of the prostate gland. The gun retrieves small sections of tissue through a thin needle, and the samples are analyzed in the lab to determine if cancer is present.

Staging

The Gleason grading system is a scoring system based on microscopic tumor patterns that are measured by the pathologist. The system is subjective by nature and requires considerable skill by the pathologist. Scores range from 2 to 10, and the prognosis becomes poorer as the score increases.

Staging describes the severity of a person's cancer and whether it has spread to other parts of the body. It's useful in determining the most effective plan of care (see NCI prostate cancer staging).

Table. Male reproduc... - Click to enlarge in new window

Table. Male reproductive cancer

The results are in...

Mr. B's biopsy comes back positive for cancer. The prostate samples are evaluated and graded at Stage II, with a Gleason score of 2. These results indicate that the cancer hasn't yet spread outside his prostate. His physician explains the results of the biopsy and together they discuss treatment options, including "watchful waiting," radiation therapy, hormone therapy, chemotherapy, and surgical removal of the prostate.

Treatment options

If prostate cancer is in the very early stage, hasn't spread, and is slow growing, watchful waiting may be an appropriate treatment option in consultation with a physician. This is also sometimes called active surveillance. The patient has regular follow-up screenings and testing to monitor the progression of the cancer.

According to the National Comprehensive Cancer Network's Clinical Practice Guidelines in Oncology for prostate cancer, additional treatment may be indicated based on the following PSA test results:

* for men who've been in the watchful waiting phase and whose PSA level has doubled in fewer than 3 years, or they have a PSA velocity (change in PSA level over time) of greater than 0.75 ng/mL per year, or they have a prostate biopsy showing evidence of worsening cancer

* for men who've had a radical prostatectomy (removal of the prostate gland) whose PSA level doesn't fall below the limits of detection after surgery, or they have a detectable PSA level (greater than 0.3 ng/mL) that increases on two or more subsequent measurements after having no detectable PSA

* for men who've had other initial therapy, such as radiation therapy with or without hormonal therapy, whose PSA level has risen by 2 ng/mL or more after having no detectable PSA or a very low PSA level.

The goal of radiation therapy is to kill the cancer cells. Adverse reactions include painful urination and frequency, erectile dysfunction, and rectal symptoms such as loose stools or pain. There are two types of radiation (grouped by method of delivery) that can be considered:

* external beam radiation therapy. Computed tomography (CT) scans and magnetic resonance imaging (MRI) are used to identify where the cancer cells are located. For therapy, the patient lies on a table and a machine delivers the radiation treatment to the area of the body where the cancer has been located. Treatment is usually 5 days a week for several weeks as an outpatient.

Figure. Picturing pr... - Click to enlarge in new window

Figure. Picturing prostate cancer

* brachytherapy. Radioactive iodine or palladium in metal pellets, about the size of a grain of rice, is placed in the prostate tissue using an ultrasound-guided needle. Over several months, these pellets deliver a low-dose, constant delivery of radiation. After a year or so, the pellets will stop giving off radiation and can remain in the prostate. This therapy allows the patient the freedom to not have to return to the hospital as frequently as external beam radiation therapy.

Proton therapy allows for extreme precision in targeting prostate cancer cells. The machines to deliver this therapy cost between $25 and $150 million, and are consequently not widely available. As technology advances, this may become a more accessible option.

Hormone therapy is another treatment option. Most prostate cancer cells need the male hormone testosterone to grow. Adverse reactions include erectile dysfunction, decreased libido, loss of muscle and bone mass, and weight gain. There's also some concern regarding the long-term use of hormone therapy and increased risk of cardiovascular problems. Some prostate cancer cells aren't dependent on testosterone and don't respond to hormone therapy. However, for those cells that do respond to testosterone, the goal of hormone therapy is to significantly decrease the amount of hormone available in the body. This can be accomplished in one of three ways:

* medication to decrease testosterone production. Gonadotropin-releasing hormone agonists inhibit the pituitary gland from stimulating the testicles to make testosterone. Examples of these medications include leuprolide and histrelin.

* medications to block testosterone. Anti-androgen medications are antagonists that block testosterone from reaching the cancer cells. Examples of these types of drugs are bicalutamide and flutamide.

* removal of the testicles (orchiectomy). Although it seems odd to remove the testicles to treat prostate cancer, the testicles are responsible for producing 90% of the body's testosterone. Removing the testicles will significantly lower the testosterone level. This procedure is done on an outpatient basis, and is permanent and irreversible.

Chemotherapy drugs are aimed at rapidly growing cancer cells. Adverse reactions include hair loss, gastrointestinal upset, fatigue, leucopenia, thrombocytopenia, and some neuropathy. Chemotherapy may be considered in conjunction with other therapies, especially for treating cancers that aren't responsive to testosterone-limiting therapies. Docetaxel has been shown to prolong the survival of men with advanced prostate cancer that no longer responds to hormonal therapy. Cabazitaxel was approved in 2010 for patients who no longer respond to docetaxel.

Table. NCI prostate ... - Click to enlarge in new window

Table. NCI prostate cancer staging

Surgical options include:

* radical prostatectomy. This procedure is the removal of the entire prostate gland and some of the surrounding tissue through an open incision in the abdomen or scrotum. The abdominal approach has a lower risk of nerve damage that can cause erectile dysfunction and bladder control problems. The perianal approach has a quicker recovery time, but has an increased risk of nerve damage and lymph nodes aren't as easily accessible.

* laparoscopic radical prostatectomy. This procedure is similar to the radical prostatectomy, but there's no open incision. The prostate is removed via a laparoscope. A surgical robot may also be used to assist the surgeon. Incisions are made that are only large enough to insert the tools and scope. Recovery time is usually quicker than an open incision surgery.

Keeping up with our patient

Mr. B opts for undergoing a prostatectomy. As his post-op nurse, you're aware that pain control, wound management, preventing immobility complications, and facilitating urination are the most important priorities following his surgery. You'll need to work closely with the physician and Mr. B to manage his pain at an appropriate level. Mr. B may have abdominal drains in place for 3 to 5 days, depending on the amount of output. His dressings should be changed according to the surgeon's orders. Encourage Mr. B to sit up and ambulate as soon as possible following surgery to decrease the chance of deep vein thrombosis and pulmonary complications.

The prostate gland is very close to the rectum; following surgery, the rectum is vulnerable for injury. Stool softeners and laxatives will be given to reduce the amount of straining. Enemas and rectal thermometers should be avoided.

If the surgeon determines that the nerve bundles on the sides of the prostate that are responsible for erections are cancer-free, these may not have to be removed during the procedure. This is called a nerve-sparing radical prostatectomy (NSRP). NSRP has significantly decreased the incidence of erectile dysfunction. After a radical prostatectomy, male patients will no longer experience fluid ejaculation, but can still experience sexual desire and arousal and achieve orgasm.

Because the urethra runs through the middle of the prostate, the urethra has to be cut above and below the prostate and then reattached to the bladder. In an effort to decrease incontinence and prevent urethral strictures from scar tissue, the patient will require a urinary catheter until the reconnection has had time to heal, sometimes up to 2 to 3 weeks. After prostatectomy, 25% of patients report leakage or lack of control requiring pads for 6 months. Routine in-hospital urinary catheter protocols should be followed, and you should teach Mr. B in-home care, as he'll be discharged with the urinary catheter in place.

Mr. B is discharged home with his drains removed and a urinary catheter in place. He has decided after consulting with his physician to begin an active surveillance plan of treatment. He'll be returning for post-op follow-up in addition to regular screenings to monitor any potential advance of the disease.

Testicular cancer

Mr. T notices a swelling and a lump in his left testicle over the past several weeks, and a dull ache in his lower abdomen has recently developed. Because Mr. T is a college student, he makes an appointment with the university's nurse practitioner, who refers him to his primary care physician. After ruling out other possible causes, such as inguinal hernia, orchitis (inflammation of the testicles), epididymitis (inflammation of the epididymis), and torsion, and based on his symptoms and physical exam, the physician orders a testicular ultrasound.

Testing for testicular cancer

* Scrotal ultrasound. During this test, the patient lies on his back with his legs spread and a handheld ultrasound probe is placed on the scrotum to obtain the ultrasound images. The ultrasound helps the physician evaluate the lump in the testicle to determine if it's solid or filled with fluid and if it's inside the testicle.

* Lab tests. These tests include a complete blood cell count and tumor markers used for testicular cancer (alpha-fetoprotein, beta-human chorionic gonadotropin, and lactate dehydrogenase). These tests may detect a tumor that isn't large enough to be felt on exam or X-ray, but negative markers don't guarantee that there isn't a tumor. Tumor markers are also used in the follow-up of the disease after treatment.

* Radiographic imaging. A high-resolution CT scan of the abdomen and pelvis and a chest X-ray are used to look for evidence of regional lymph node metastasis.