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STAGING PROSTATE CANCER: A WORD ON NATURAL HISTORY
We’ve said that it’s impossible to predict the course of prostate cancer. This dilemma is at the heart of the treatment debate. However, some research has shown that the volume of a prostate tumor has a lot to do with its behavior. Scientists who studied 100 radical prostatectomy specimens (tissue removed in surgery) found that the volume of cancer corresponded with the extent (or lack) of cell differentiation, with capsular penetration (cancer that has reached beyond the prostate wall), invasion of the seminal vesicles, and metastases to distant tissue. These researchers showed that tumors less than 1 cubic centimeter (just smaller than a half-inch) rarely metastasize, and that most tumors less than 3.5 cubic centimeters stay inside the prostate. But as a tumor gets bigger, they found, it tends to get more aggressive—and when prostate cancer is bigger than 5 cubic centimeters, its chances of being curable dwindle.
This is how prostate cancer spreads: First, of course, it grows inside the prostate. Most—about 72 percent of cancers—begin in the peripheral zone, 20 percent start in the transition zone, and 8 percent originate in the central zone. (For a look at the prostate’s zones, see figure 1.8.) It reaches, and then penetrates, the prostate wall (also called the capsule). Then it continues to creep, reaching into the seminal vesicles, bladder, urethra and pelvic sidewalls. It also can expand in leaps, by metastases—invading the lymph system (channels that run throughout the body) or hitching a ride to far-off sites via the bloodstream to bone. When doctors speak of “distant metastases” of prostate cancer, they generally mean it has reached the lymph nodes, bone—the spine, ribs, or pelvic bones—or the lungs.
As prostate tumors grow, they become more heterogeneous, or poorly differentiated. Prostate cancer generally is a slow grower; in its early stages, it can take longer than four years for a tumor to double in size. Before a tumor even gets big enough for a doctor to feel—about one cubic centimeter in volume— it has to double at least thirty times. But after this, it only takes about ten more doublings for prostate cancer to become fatal—when it reaches 1 kilogram in volume.
Once again, to hammer home a point, this time of silent early growth is the ideal time to detect and strike prostate cancer.
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