Prostate Cancer - SI

[My Flight Surgeon]

This is another in the series of condition for which the FAA grants Special Issuance certificates.

As with all other conditions, the FAA will want to review the entire medical record. Your AME or www.faaspecialissuance.com can assist you in preparing your records for submission.

The topic today is Prostate Cancer.
Prostate cancer is the second most common type of cancer among men in this country. Only skin cancer is more common. Out of every three men who are diagnosed with cancer each year, one is diagnosed with prostate cancer.
The prostate is part of a man's reproductive system. It is located in front of the rectum and under the bladder. It surrounds the urethra, the tube through which urine flows. A healthy prostate is about the size of a walnut.
The prostate makes part of seminal fluid. During ejaculation, seminal fluid helps carry spermout of the man's body as part of semen.
Male hormone (androgens) make the prostate grow. The testicles are the main source of male hormones, including testosterone. The adrenal gland also makes testosterone, but in small amounts.
If the prostate grows too large, it squeezes the urethra. This may slow or stop the flow of urine from the bladder to the penis.
Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organsof the body.
Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place.
Sometimes, this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.
Tumors can be benign or malignant::

• Benign tumors are not cancer:
  • Benign tumors are rarely life-threatening.
  • Generally, benign tumors can be removed. They usually do not grow back.
  • Cells from benign tumors do not invade the tissues around them.
  • Cells from benign tumors do not spread to other parts of the body.

Benign prostatic hyperplasia (BPH) is the abnormal growth of benign prostate cells. The prostate grows larger and squeezes the urethra. This prevents the normal flow of urine.
BPH is a very common problem. In the United States, most men over the age of 50 have symptoms of BPH. For some men, symptoms may be severe enough to need treatment.
 Malignant tumors are cancer:

• Malignant tumors are generally more serious than benign tumors. They may be life-threatening.
• Malignant tumors often can be removed. But sometimes they grow back.
• Cells from malignant tumors can invade and damage nearby tissues and organs.
• Cells from malignant tumors can spread (metastasize) to other parts of the body. Cancer cells spread by breaking away from the original (primary) tumor and entering the bloodstream or lymphatic system. The cells invade other organs and form new tumors that damage these organs. The spread of cancer is called metastasis.

When prostate cancer spreads, cancer is often found in nearby lymph nodes. If cancer has reached these nodes, it also may have spread to other lymph nodes, the bones, or other organs.
When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if prostate cancer spreads to bones, the cancer cells in the bones are actually prostate cancer cells. The disease is metastatic prostate cancer, not bone cancer. For that reason, it is treated as prostate cancer, not bone cancer. Doctors call the new tumor "distant" or metastatic disease.
Risk factors for prostate cancer:

• Age: Age is the main risk factor for prostate cancer. This disease is rare in men younger than 45. The chance of getting it goes up sharply as a man gets older. In the United States, most men with prostate cancer are older than 65. As men age, the risk rises. 80% of men age 80 have at least microscopic prostate cancer present.
• Family history: A man's risk is higher if his father or brother had prostate cancer.
• Race: Prostate cancer is more common in African American men than in white men, including Hispanic white men. It is less common in Asian and American Indian men.
• Certain prostate changes: Men with cells called high-grade prostatic intraepithelial neoplasia (PIN) may be at increased risk for prostate cancer. These prostate cells look abnormal under a microscope.

Screening
Your doctor can check you for prostate cancer before you have any symptoms. Screening can help doctors find and treat cancer early. But studies so far have not shown that screening tests reduce the number of deaths from prostate cancer. You may want to talk with your doctor about the possible benefits and harms of being screened. The decision to be screened, like many other medical decisions, is a personal one. You should decide after learning the pros and cons of screening.
Your doctor can explain more about these tests:

• Digital rectal exam: The doctor inserts a lubricated, gloved finger into the rectum and feels the prostate through the rectal wall. The prostate is checked for hard or lumpy areas.
• Blood test for prostate-specific antigen (PSA): A lab checks the level of PSA in a man's blood sample. A high PSA level is commonly caused by BPH or prostatitis (inflammation of the prostate). Prostate cancer may also cause a high PSA level.

The digital rectal exam and PSA test can detect a problem in the prostate. They cannot show whether the problem is cancer or a less serious condition. Your doctor will use the results of these tests to help decide whether to check further for signs of cancer.
Symptoms
A man with prostate cancer may not have any symptoms. For men who have symptoms of prostate cancer, common symptoms include:

• Urinary problems
  • Not being able to urinate
  • Having a hard time starting or stopping the urine flow
  • Needing to urinate often, especially at night
  • Weak flow of urine
  • Urine flow that starts and stops
  • Pain or burning during urination
• Difficulty having an erection
• Blood in the urine or semen
• Frequent pain in the lower back, hips, or upper thighs

Most often, these symptoms are not due to cancer. BPH, an infection, or another health problem may cause them. Any man with these symptoms should tell his doctor so that problems can be diagnosed and treated as early as possible. He may see his regular doctor or a urologist. A urologist is a doctor whose specialty is diseases of the urinary system.
Diagnosis
If you have a symptom or test result that suggests cancer, your doctor must find out whether it is due to cancer or to some other cause. Your doctor will ask about your personal and family medical history. You will have a physical exam. You may have lab tests. Your visit may include a digital rectal exam, a urine test to check for blood or infection, and a blood test to measure PSA level.
You also may have other exams:

• Transrectal ultrasound: The doctor inserts a probe into the man's rectum to check for abnormal areas. The probe sends out sound waves that people cannot hear (ultrasound). The waves bounce off the prostate. A computer uses the echoes to create a picture called a sonogram.
• Cystoscopy: The doctor uses a thin, lighted tube to look into the urethra and bladder.
• Transrectal biopsy: A biopsy is the removal of tissue to look for cancer cells. It is the only sure way to diagnose prostate cancer. The doctor inserts a needle through the rectum into the prostate. The doctor takes small tissue samples from many areas of the prostate. Ultrasound may be used to guide the needle. A pathologist checks for cancer cells in the tissue.

Staging
To plan your treatment, your doctor needs to know the extent (stage) of the disease. The stage is based on the size of the tumor, whether the cancer has spread outside the prostate and, if so, where it has spread.
You may have blood tests to see if the cancer has spread. Some men also may need imaging tests:

• Bone scan: The doctor injects a small amount of a radioactive substance into a blood vessel. It travels through the bloodstream and collects in the bones. A machine called a scanner detects and measures the radiation. The scanner makes pictures of the bones on a computer screen or on film. The pictures may show cancer that has spread to the bones.
• CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of areas inside your body. Doctors often use CT scans to see the pelvis or abdomen.
• MRI: A strong magnet linked to a computer is used to make detailed pictures of areas inside your body.

These are the stages of prostate cancer:

• Stage I: The cancer cannot be felt during a digital rectal exam. It is found by chance when surgery is done for another reason, usually for BPH. The cancer is only in the prostate.
• Stage II: The cancer is more advanced, but it has not spread outside the prostate.
• Stage III: The cancer has spread outside the prostate. It may be in the seminal vesicles. It has not spread to the lymph nodes.
• Stage IV: The cancer may be in nearby muscles and organs (beyond the seminal vesicles). It may have spread to the lymph nodes. It may have spread to other parts of the body.
• Recurrent cancer is cancer that has come back (recurred) after a time when it could not be detected. It may recur in or near the prostate. Or it may recur in any other part of the body, such as the bones.

Treatment Methods
Men with prostate cancer have many treatment options. The treatment that is best for one man may not be best for another.
Treatment may involve surgery, radiation therapy, or hormone therapy. You may have a combination of treatments. If your doctor recommends watchful waiting, your health will be monitored closely. You will have treatment only if symptoms occur or get worse.
Cancer treatment is either local therapy or systemic therapy:

• Local therapy: Surgery and radiation therapy are local treatments. They remove or destroy cancer in the prostate. When prostate cancer has spread to other parts of the body, local therapy may be used to control the disease in those specific areas.
• Systemic therapy: Hormone therapy is systemic therapy. Hormones are given to control cancer that has spread.

The treatment that is right for you depends on the stage of the cancer, the grade of the tumor, your symptoms, and your general health. Your doctor will describe your treatment choices and the expected results.
Because cancer treatments often damage healthy cells and tissues, side effects are common. Side effects depend mainly on the type and extent of the treatment.
Surgery
Surgery is a common treatment for early stage prostate cancer. Your doctor may remove the whole prostate or only part of it. In some cases, your doctor can use a method known as nerve-sparing surgery. This type of surgery may save the nerves that control erection. But if you have a large tumor or a tumor that is very close to the nerves, you may not be able to have this surgery.
Each type of surgery has benefits and risks. Your doctor can further describe these types:

• Da Vinci robotic prostatectomy: This is now the Gold Standard for prostate surgery. It is performed using five small incisions and the surgeon controls the surgical instruments robotically. The patient goes home the following day. Not all urologists are trained to perform this surgery. (Editorial note: One of the best in the country is Dr. Borhan in Phoenix, Arizona.) The link is to a video of an actual robotic prostatectomy. http://www.ucihs.uci.edu/urology/prostate/prostate_videos/videos.htm
• Radical retropubic prostatectomy: The doctor removes the entire prostate and nearby lymph nodes through an incision (cut) in the abdomen.
• Radical perineal prostatectomy: The doctor removes the entire prostate through a cut between the scrotum and the anus. Nearby lymph nodes may be removed through a separate cut in the abdomen.
• Laparoscopic prostatectomy: The doctor removes the entire prostate and nearby lymph nodes through small incisions, rather than a single long cut in the abdomen. A thin, lighted tube (a laparoscope) is used to help remove the prostate.
• Transurethral resection of the prostate (TURP): The doctor removes part of the prostate with a long, thin device that is inserted through the urethra. The cancer is cut from the prostate. TURP may not remove all of the cancer. But it can remove tissue that blocks the flow of urine.
• Cryosurgery: This type of surgery for prostate cancer is under study at some medical centers.
• Pelvic lymphadenectomy: This is routinely done during prostatectomy. The doctor removes lymph nodes in the pelvis to see if cancer has spread to them. If there are cancer cells in the lymph nodes, the disease may have spread to other parts of the body. In this case, the doctor may suggest other types of treatment.

The time it takes to heal after surgery is different for each man and depends on the type of surgery he has had. You may be uncomfortable for the first few days. However, medicine can help control the pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain relief.
After surgery, the urethra needs time to heal. You will have a catheter. A catheter is a tube put through the urethra into the bladder to drain urine. You will have the catheter for 5 days to 3 weeks. Your nurse or doctor will show you how to care for it.
Surgery may cause short-term problems, such as incontinence. After surgery, some men may lose control of the flow of urine (urinary incontience). Most men regain bladder control after a few weeks.
Some men may become impotent. Nerve-sparing surgery is an attempt to avoid the problem of impotence. If a man can have nerve-sparing surgery and the operation is a success, impotence may not last. In some cases, men become permanently impotent. You can talk with your doctor about medicine and other ways to help manage the sexual effects of cancer treatment.
If your prostate is removed, you will no longer produce semen. You will have dry orgasms.
Radiation Therapy
Radiation therapy (also called radiotherapy) uses high-energy rays to kill cancer cells. It affects cells only in the treated area.
For early stage prostate cancer, radiation treatment may be used instead of surgery. It also may be used after surgery to destroy any cancer cells that remain in the area. In later stages of prostate cancer, radiation treatment may be used to help relieve pain.
Doctors use two types of radiation therapy to treat prostate cancer. Some men receive both types:

• External radiation: The radiation comes from a large machine outside the body. Men go to a hospital or clinic for treatment. Treatments are usually 5 days a week for several weeks.
• Internal radiation(implant radiation orbrachytherapy): The radiation comes from radioactive material usually contained in small seeds. The seeds are put into the tissue. They give off radiation for months. The seeds are harmless and do not need to be removed.

Side effects depend mainly on the dose and type of radiation. You are likely to be very tired during radiation therapy, especially in the later weeks of treatment. Resting is important, but doctors usually advise patients to try to stay as active as they can.
If you have external radiation, you may have diarrhea or frequent and uncomfortable urination. Some men have lasting bowel or urinary problems. Your skin in the treated area may become red, dry, and tender. You may lose hair in the treated area. The hair may not grow back.
Internal radiation treatment may cause incontinence. This side effect usually goes away. Lasting side effects from internal radiation are not common.
Both internal and external radiation can cause impotence. Internal radiation is less likely to have this effect.
Hormone Therapy
Hormone therapy keeps prostate cancer cells from getting the male hormones (androgens) they need to grow. The testicles are the body's main source of the male hormone testosterone. The adrenal gland makes a small amount of testosterone.
Hormone treatment uses drugs or surgery:

• Drugs: Your doctor may suggest a drug that can block natural hormones.
  • Luteinizing hormone-releasing (LH-RH) agonists: These drugs can prevent the testicles from making testosterone.
  • Antiandrogens: These drugs can block the action of male hormones.
  • Other drugs: Some drugs can prevent the adrenal gland from making testosterone.
• Surgery: Surgery to remove the testicles is called orchiectomy.

After orchiectomy or treatment with an LH-RH agonist, your body no longer gets testosterone from the testicles. However, the adrenal gland still produces a small amount of male hormones. You may receive an antiandrogen to block the action of the male hormones that remain. This combination of treatments is known as total androgen blockade. Studies have not shown whether total androgen blockade is more effective than surgery or an LH-RH agonist alone.
Hormone therapy is likely to affect your quality of life. It often causes side effects such as impotence, hot flashes, loss of sexual desire, and weaker bones. An LH-RH agonist may make your symptoms worse for a short time when you first take it. This temporary problem is called "flare." The treatment gradually causes your testosterone level to fall. Without testosterone, tumor growth slows. Your condition may improve. (To prevent flare, your doctor may give you an antiandrogen for a while along with the LH-RH agonist.)
Antiandrogens (such as nilutamide) can cause nausea, diarrhea, or breast growth or tenderness. Rarely, they may cause liver problems (pain in the abdomen, yellow eyes, or dark urine). Some men who use nilutamide may have difficulty breathing. Some may have trouble adjusting to sudden changes in light.
Watchful Waiting
You may choose watchful waiting if the risks and possible side effects of treatment outweigh the possible benefits. Your doctor may offer this choice if you are older or have other serious health problems. Your doctor may also suggest watchful waiting if you are diagnosed with early stage prostate cancer that seems to be slowly growing. Your doctor will offer you treatment if symptoms occur or get worse.
Watchful waiting avoids or delays the side effects of surgery and radiation, but this choice has risks. It may reduce the chance to control cancer before it spreads. Also, it may be harder to cope with surgery and radiation therapy as you age.
You may decide against watchful waiting if you do not want to live with an untreated cancer. If you choose watchful waiting but grow concerned later, you should discuss your feelings with your doctor. A different approach is nearly always available.
Complementary and Alternative Medicine
Some men with prostate cancer use complementary and alternative medicine (CAM):

• An approach is generally called complementary medicine when it is used along with standard treatment.
• An approach is called alternative medicine when it is used instead of standard treatment.

Accupuncture, massage therapy, herbal products, vitamins or special diets, visualization, meditation, and spiritual healing are types of CAM.
Many men say that CAM helps them feel better. However, some types of CAM may change the way standard treatment works. These changes could be harmful. And some types of CAM could be harmful even if used alone.
Some types of CAM are expensive. Health insurance may not cover the cost.
Follow-up Care
Follow-up care after treatment for prostate cancer is important. Even when the cancer seems to have been completely removed or destroyed, the disease sometimes returns because undetected cancer cells remained somewhere in the body after treatment. Your doctor will monitor your recovery and check for recurrence of the cancer. Checkups help ensure that any changes in your health are noted and treated if needed. Checkups may include lab tests, x-rays, biopsies, or other tests. Between scheduled visits, you should contact your doctor if you have any health problems.
FAA Special Issuance
AME Assisted Special Issuance (AASI) is a process that provides Examiners the ability to re-issue an airman medical certificate under the provisions of an Authorization for Special Issuance of a Medical Certificate (Authorization) to an applicant who has a medical condition that is disqualifying under Title 14 of the Code of Federal Regulations
(14 CFR) part 67.

An FAA physician provides the initial certification decision and grants the Authorization in accordance with 14 CFR 67.401. The Authorization letter is accompanied by attachments that specify the information that treating physician(s) must provide for the re-issuance determination. If this is a first time issuance of an Authorization for the above disease/condition, and the applicant has all of the requisite medical information necessary for a determination, the Examiner must defer and submit all of the documentation to the AMCD or Regional Flight Surgeon for the initial determination.

Examiners may re-issue an airman medical certificate under the provisions of an Authorization, if the applicant provides the following:

• An Authorization granted by the FAA;
• A current status of the medical condition to include any testing deemed necessary; and
• A current PSA level performed within last 90 days.

The Examiner must defer to the AMCD or Region if:

• The PSA rises at a rate above 0.75 ng/ml per year;
• A new treatment is initiated; or
• Any metastasis has occurred.