Prostate Cancer

Prostate cancer is a malignant disease that develops as a result of the genetic sequences of cells in the prostate gland, an important part of the male reproductive system, becoming disrupted and multiplying uncontrollably. This cellular deterioration, which generally remains completely silent for a long time and progresses insidiously, begins to manifest itself over time with various symptoms that deeply affect the reproductive and urinary systems when it grows and places pressure on surrounding tissues. Current prostate cancer treatment, shaped in light of innovative technological developments in the medical world, is planned specifically according to the biological structure of the disease and the person’s general health condition, enabling this health problem to be overcome safely.

What Is Prostate Cancer and in Whom Is It More Common?

The prostate is a gland approximately the size of a walnut, located immediately below the urinary bladder in men and surrounding the urinary tract almost like a ring. Its primary function is to produce the fluid component of semen, preserve the vitality of sperm, and ensure their motility. Cells in a healthy prostate gland grow, age, and die in a certain order. However, sometimes disruptions occur in the DNA structure located in the nuclei of these cells. These disruptions prevent the cells from dying and, on the contrary, cause them to continue dividing and multiplying. This group of uncontrollably proliferating cells grows over time and forms masses called tumors.

One of the most striking aspects of this disease is its direct connection with the aging process. The disease may exist silently not only in a specific group but in a very large proportion of the aging male population. Medical examinations performed on people who died from entirely different causes show that microscopic foci of cancerous cells can be found even in some men in their thirties. When the age exceeds the seventies, this rate reaches much higher levels, almost approaching one in two. This reality clearly demonstrates how widespread the disease is and how carefully this issue should be considered as age advances.

What Symptoms Does Prostate Cancer Show When It First Begins?

The initial stages of the disease create one of the greatest misconceptions in medicine because at this stage the disease literally causes no symptoms. As men age, a natural enlargement occurs in the prostate gland, and this is called benign prostatic enlargement. Since benign enlargement compresses the urinary tract, it causes complaints such as difficulty urinating, reduced urinary pressure, intermittent urination, or frequently getting up to use the toilet at night. However, because cancer cells generally begin to develop in the outer capsule of the prostate, which is distant from the urinary tract, they do not compress the urinary passage.

Therefore, a small tumor that is still in its initial stage causes no disruption that the person can notice in daily life. Urination habits may be completely normal, and no pain or discomfort is felt. This silent nature of the disease is the most fundamental reason why regular check-ups are essential without waiting for any complaints. Waiting for symptoms to begin may create the conditions for a delayed diagnosis.

What Complaints Does Advanced Prostate Cancer Cause in the Body?

When the tumor that has grown silently over time crosses the capsule defining the outer boundaries of the prostate and begins to attack the surrounding tissues, nerves, and organs, the silent picture is disrupted and quite serious problems emerge.

The main symptoms that may be encountered during this process are as follows:

• Erectile dysfunction
• Blood in the urine
• Blood in the semen
• Severe constipation
• Bone pain
• Swelling of the kidneys
• Flank pain

Very thin nerve bundles that travel to the male sexual organ and provide erection pass immediately next to the prostate. When the cancer infiltrates these nerves, suddenly developing erectile problems appear in the person’s sexual life. When cancer cells spread to the sacs that store semen, blood is seen in the semen, while when they spread toward the urinary tract, blood begins to appear in the urine. When there is spread toward the large intestine, which is located behind the prostate, bowel movements are obstructed and serious constipation problems occur. When the disease progresses and blocks the openings of the urinary ducts coming from the kidneys, urine accumulates in the kidneys. This condition causes the kidneys to swell, severe flank pain, and deterioration in blood values.

At What Age and How Should Prostate Cancer Screening Begin?

The only way to detect this disease, which causes no complaints, at an early stage is for men in certain age groups to undergo regular health screening. These screenings consist of two basic steps that are highly practical, take a short time, and require no preparation. The first of these steps is a simple blood test, and the other is a physical evaluation.

When screening should begin varies according to the risks the person carries. If a man’s father, uncle, or brother has had this disease, he is considered to be at genetic risk, and screening should definitely begin at the age of forty-five. For individuals in the standard-risk group who have no family history of cancer, the age of fifty is considered the turning point. During the physical evaluation, the size and structure of the prostate, whether its surface is smooth, and whether there is any hardness or lump on it are checked. Cancerous tissues generally feel much harder and more asymmetrical than normal prostate tissue.

What Does the PSA Blood Test Mean in the Diagnosis of Prostate Cancer?

The value examined in the blood test during screening is called PSA. This is actually a type of protein produced by prostate cells that helps semen remain fluid. In a healthy man, a very small amount of this protein enters the bloodstream. However, when cancerous cells proliferate in the prostate tissue, the natural structure of the tissue is disrupted, and much more of this protein begins to leak into the blood. In other words, an increase in this value in the blood can be compared to a smoke detector sounding in a building.

For many years, a value below a certain level in the blood was considered completely safe, while a value above it was considered dangerous. However, these strict rules have become more flexible today. This is because the disease can sometimes be detected even in men whose blood value appears completely normal. Likewise, a very high value does not necessarily mean that the person has cancer. Prostate inflammation, urinary tract infections, or benign enlargement may also increase this value. Therefore, when the value is high, it is a much more appropriate approach not to panic immediately, to wait for a certain period, repeat the test, and determine whether the elevation in the blood is permanent.

Why Is MRI Imaging So Important in the Diagnosis of Prostate Cancer?

The latest point reached by medical technology has placed imaging methods at the very heart of the diagnostic stage. While in the past only blood tests and manual examinations were used, today the inside of the prostate is visualized almost like a high-resolution map thanks to Multiparametric Magnetic Resonance Imaging, or advanced MRI devices for short. This method has raised the accuracy rates in detecting the disease to incredible levels.

Thanks to advanced MRI scanning, not only the anatomical structure of the prostate but also the movement of water molecules within the cells and how the tissue is supplied with blood are analyzed in detail. Since cancer cells multiply in a highly compact arrangement, they prevent the free movement of water within the tissue. The MRI device detects this density immediately. In addition, cancerous tissues form new and irregular blood vessels for themselves in order to grow very rapidly. Thanks to the medication administered intravenously during MRI, this irregular vascular network is clearly revealed. All these data are combined in a computer environment, a risk score is assigned to suspicious areas in the prostate, and the subsequent procedures are shaped entirely according to this map.

How Is a Biopsy Performed When Prostate Cancer Is Suspected?

If the elevation in blood values is persistent and suspicious areas with high risk scores are detected on MRI, the only way to make a definitive diagnosis is to take a small sample from that tissue and examine it under a microscope. This procedure is called a biopsy. In previous years, because the cancerous area could not be clearly visualized during this procedure, random samples were taken from different regions of the prostate, and this could cause small tumors to be overlooked.

Today, much more intelligent and targeted biopsy methods that combine MRI images with ultrasound images obtained during the procedure are used.

Advanced biopsy applications are as follows:

• Software-based fusion biopsy
• Cognitive biopsy
• Direct in-bore MRI biopsy

In the software-based method, the patient’s previously obtained MRI images are superimposed on real-time ultrasound images using a special computer program. A three-dimensional virtual model of the prostate is created, and points that appear risky on MRI are marked on the screen with a bright color. In this way, with the guidance of the device, a sample is taken directly from the exact center of the target without even a millimetric deviation. In the direct in-bore MRI method, the needle is guided through real-time imaging while the patient is inside the enormous magnet.

Which Side Effects May Occur After a Prostate Cancer Biopsy?

The biopsy procedure is generally performed under local anesthesia by numbing the area around the prostate with thin needles. Since small pieces are removed from the tissue, it is completely natural for some temporary conditions to occur afterward. These conditions may vary between patients, but they are generally harmless and tend to resolve spontaneously within a short period.

The most common conditions after biopsy are as follows:

• Blood in the urine
• Discoloration of the semen
• Mild leakage from the rectal area
• Temporary difficulty urinating
• Fever accompanied by chills
• Tenderness in the prostate area

The condition that requires the greatest attention during this process is a fever that suddenly appears in the days after the procedure and rises with chills. An unexpected rise in body temperature may be a sign of a possible infection and requires immediate intervention. Discoloration of the semen or mild pink coloration in the urine is a natural part of the tissue-healing process and may continue for weeks while gradually decreasing.

How Is the Risk Level Determined After a Prostate Cancer Diagnosis?

When the collected samples reach the laboratory, pathology specialists examine these tissues under very powerful microscopes. The most important thing evaluated here is how different the cells have become from normal prostate cells and how much they have deteriorated. The more the cells have lost their original shape, the more aggressive the cancer is and the greater its potential to spread rapidly. Internationally accepted numbering systems are used to express this level of deterioration.

Doctors combine the result of this microscopic examination with the patient’s blood value and the extent of the disease within the prostate to create an overall risk map. The cancer is divided into three main categories as low, intermediate, or high risk. If the disease has not spread beyond the prostate, the shape of the cells has not deteriorated significantly, and the value measured in the blood is at low levels, this is the low-risk group. However, if the cancer has crossed the prostate capsule, the cells have completely changed shape, and warning signs are present in the blood, this indicates a high-risk condition requiring rapid action.

Where Does Advanced Prostate Cancer Tend to Spread in the Body?

When the disease takes on an aggressive character and exceeds the boundaries of its original location, it gains the ability to spread to other regions by following certain migration pathways within the body. This situation completely changes the character of the disease and transforms it from a regional problem into a systemic condition involving the entire body. Comprehensive clinical follow-up studies conducted in our country have revealed the anatomical map of this spread very clearly.

The areas to which the disease most commonly spreads in the body are as follows:

• Fatty tissue around the prostate
• Lymph nodes in the pelvic region
• Base of the urinary bladder
• Final part of the large intestine
• Pelvic bone and spine
• Lungs and liver

When cancer cells penetrate the outer membrane of the prostate, they first infiltrate the protective fat layer immediately surrounding it. They then enter the lymphatic pathways, which work like the body’s wastewater network, collect in the lymph nodes in the groin region, and form new tumor colonies there. Growth toward neighboring organs such as the urinary bladder and intestine is a regional invasion. The most prominent location to which the disease spreads through the bloodstream is the bones. The spine, ribs, and hip bones in particular are among the areas where cancer cells most commonly settle and cause serious skeletal pain.

What Does Active Surveillance Mean for Low-Risk Prostate Cancer?

When the word cancer is added to the word disease, human psychology naturally assumes that the most intensive treatments should be applied immediately. However, in some cases of this disease, waiting without doing anything may be the most appropriate treatment approach. If the detected tumor is very small, its level of aggressiveness is at the lowest degree, and it grows slowly enough that it will not threaten the person’s health during their lifetime, a careful waiting process is initiated instead of immediately proceeding to surgery.

This process is medically called active surveillance. The basic logic here is to protect the patient from side effects such as possible urinary incontinence or loss of sexual function that may be caused by surgery or radiation therapy. This is because treatment can sometimes cause more difficulty than the disease itself. However, this waiting process does not mean leaving the condition completely uncontrolled. The person follows an extremely strict schedule, undergoes regular blood tests, has MRI scans at intervals, and if necessary, new tissue samples are taken so that any change in the character of the tumor is monitored closely. The tumor is left untouched as long as it remains dormant, but intervention is performed immediately as soon as it is understood to be awakening and becoming aggressive.

How Is Localized Prostate Cancer Surgery Performed With Robotic Surgery?

If the disease has not yet spread to other organs and remains confined within the prostate gland, the most definitive and permanent known solution is to remove the entire prostate from the body. In the past, this procedure was performed through large and deep incisions made in the lower abdomen. However, with the introduction of technologically advanced robotic systems into medicine, these operations have almost become works of art. The procedure is performed using a minimally invasive method through thin robotic arms inserted into the patient’s body through several small openings.

During the operation, the abdomen is gently inflated with a special gas. The pressure of this gas stops minor bleeding from the vessels and allows the operation to proceed almost completely without blood loss. The surgeon sits at a special console immediately beside the patient’s bed and views the prostate area in detail, down to the finest capillary vessel, on a high-resolution, three-dimensional giant screen. The robot’s fine-tipped scissors and graspers can bend at angles that the human hand could never achieve and do not experience problems such as tremor. Thanks to this extraordinary precision, while the cancerous organ is detached and removed, the urinary continence muscles and nerve fibers responsible for erection passing immediately beside it are preserved through millimetric maneuvers, helping to ensure that the patient’s quality of life remains high after surgery.

How Does the Recovery Process Progress After Prostate Cancer Surgery?

After a successful operation, because the prostate gland has been completely removed, the level of the cancer marker protein in the patient’s blood is expected to decrease to a point very close to zero and remain there for life. In modern surgeries performed with robotic systems, the sutures are placed internally using a watertight technique, so the thin catheter inserted into the urinary tract is generally removed within a very short period of approximately one week, and the patient rapidly returns to normal life.

After the operation, the condition is monitored through blood tests performed at certain intervals. If tests performed in later years show that the blood value that had fallen to zero has slowly begun to rise again, this means that cancer cells have started to reactivate somewhere at a microscopic level. This is called biochemical recurrence in medical terminology. In such a situation, there is no reason for despair because the process can successfully be brought under control again with radiation treatments directed to that area or protective medications to eliminate the remaining cells.

How Is Early-Stage Prostate Cancer Treated With Non-Surgical Methods?

In selected patients whose tumor is completely confined within the prostate, exists as only a single focus, and does not have a very high level of aggressiveness, modern organ-preserving treatments that destroy only the diseased area are used instead of sacrificing the entire prostate gland. These approaches aim to target only the cancerous area without impairing the function of the organ.

The main focal treatment methods applied are as follows:

• High-intensity focused ultrasound devices
• Focal freezing procedure
• Targeted laser ablation

In the focused ultrasound method, sound waves sent externally through a special device are adjusted to intersect precisely at the center of the cancerous tissue. When these sound waves converge at a single point, they create a temperature close to the boiling point of water within seconds and literally burn and destroy only that small cancerous area without causing any damage to surrounding tissues. The freezing procedure works with the opposite principle. Very thin needles advanced through the skin are placed inside the cancerous tissue, and special gases passed through them create an ice ball at subzero temperatures in the area of the tumor. When the cancer cells freeze and then thaw again, their cell membranes break apart and they are destroyed. Both methods are non-surgical, and the patient may be discharged walking within a very short time after the procedure.

How Are Radiation and Medications Used in the Treatment of Advanced Prostate Cancer?

If the disease has completely spread beyond the prostate gland, extended into surrounding tissues, or spread to the lymph nodes and bones, the treatment strategy is fundamentally changed. Since surgical intervention alone would be insufficient at this stage, more comprehensive tools that target the disease throughout the entire body at the same time are used. Modern radiation therapy devices and next-generation smart medications form the backbone of this process.

Systemic treatment options commonly used in advanced stages are as follows:

• Surgical removal of the testicles
• Subcutaneous hormone-suppressing injections
• Tablets that stop androgen production
• Bone-protective supportive agents

The main fuel that cancer cells need to survive and multiply is the male hormone. Cutting off this fuel is the most effective way to stop the progression of the disease. Through hormone-suppressing injections or special enzyme-blocking tablets taken orally, the production of male hormones in the body is completely shut down. Cancer cells deprived of fuel begin to shrink rapidly and lose their effect. At the same time, high-dose radiation therapy is applied to the prostate area and the lymph nodes to which the disease has spread, reducing the tumor burden. These medications and radiation not only cause the tumor to regress but also eliminate the bone pain caused by the disease, dramatically improving the patient’s quality of life.

What Should Be Considered to Make the Most Appropriate Decision in Prostate Cancer Treatment?

As can be seen, this disease is a multifaceted problem that appears differently in every person, remaining silently dormant for years in some and progressing rapidly in others. Therefore, there is no single correct treatment; each person requires a treatment plan tailored specifically for them. In order to make a sound treatment decision, the character of the disease must first be mapped completely.

Today, when we have moved far beyond a simple blood test and digital examination, decisions should be shaped according to high-technology MRI images and biopsy results with millimetric accuracy. Whether the tumor should be treated, whether surgery or non-surgical methods should be used, should be determined entirely according to the person’s age, the grade and extent of the disease, and social expectations. The important point is to establish the ideal balance that eradicates the disease while preserving the person’s quality of life, urinary function, and sexual function at the highest possible level.

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