Prostate Cancer

If you are diagnosed with prostate cancer, you may be overwhelmed with emotions and options. It's a good idea to talk frankly and openly with your doctor. Give yourself time to process your diagnosis, learn about the disease and discuss your treatment choices with family or friends.

You may want to seek additional opinions. This is common and should cause no hard feelings between you and your physician.

You may be given more than one possibility for treatment. Think carefully about the pros and cons of each alternative and discuss them with your doctor and family before picking the best one for you. In deciding which treatment to recommend, your doctor will consider:

• Your age and general health
• Stage and grade of cancer (see below)
• Whether the cancer has spread
• Side effects of treatment

This section includes more information on:

• Risk assessment
• Surgery
• Radiation therapy
• Hormone therapy
• Chemotherapy
• Active surveillance or watchful waiting
• Clinical trials of new drugs and agents

Risk assessment

If you are diagnosed with prostate cancer, your doctor will make a series of estimates about the risk the disease may be harmful in the future. Factors include:

• Gleason score (see below)
• Blood PSA level
• Clinical stage, which is based on findings of the digital rectal exam (DRE)

Low risk:

• Less than 10 percent chance of having spread to other parts of the body
• Low risk of progressing if not treated
• PSA less than 10 ng/nL
• Gleason score of 3+3 or lower
• Tumor can be felt in DRE or feels contained within and making up a minority of the prostate gland

Intermediate risk:

• 10 to 15 percent chance of having spread
• Higher chance (up to 70 percent over 15 years) of progressing if not treated
• PSA of 10 to 20 ng/mL
• Gleason score of 7 (3+4 or 4+3)
• Tumor can be felt in DRE on both sides of the prostate, but it seems to be contained in gland

High risk:

• Aggressive features that increase the chance of spreading now or in the future
• PSA over 20 ng/mL
• Gleason score of 8-10
• Tumor can be felt in DRE and seems to have spread outside the gland

Gleason grading system

If a biopsy finds cancerous prostate tissue, it will be classified using the Gleason grading system. This helps doctors choose the best treatment options and predict how quickly the cancer is growing.

Prostate cancers contain several types of cells. The Gleason system uses the numbers 1 to 5 to grade the most common (primary) and next most common (secondary) cell types found in a tissue sample. The sum of these two numbers is the Gleason score, which indicates how aggressive the tumor is. The higher the Gleason score, the more aggressive the cancer.

Gleason grades 1 and 2 rarely are used when men have abnormal PSA or DRE tests. That means the usual lowest grade for each type of cell is 3. Gleason scores of:

• 3+3 are low grade and have the lowest risk of harm
• 3+4 and 4+3 are intermediate risk—the latter being the more aggressive type
• 4+4 through 5+5 are the highest risk

If the cancer is determined to be intermediate or high risk, imaging tests such as bone density scans and CT or CAT (computed axial tomography) scans may be used to determine if the cancer has spread.

Taken together, the disease risk status and imaging results will help your doctor plan the best treatment.

Surgery

Surgery is the most frequent treatment for fit and youthful patients with prostate cancer.

The most common procedure is radical prostatectomy, which is removal of:

• The entire prostate gland
• Both seminal vesicles, which play a part in making semen
• A short segment of the urine tube that passes through the prostate

The urinary system is reconstructed by suturing (sewing) the bladder opening to the urethra.

In some patients, one or more lymph node groups in the pelvic area may be removed to further define the extent of the cancer. This is called lymphadenectomy or lymph node dissection.

Many cancer operations are termed “radical,” meaning the involved organ plus a margin of tissue around it are surgically removed to ensure all the cancer has been taken out.

However, the prostate is adjacent to several important parts of the body including the:

• Urinary sphincter muscle, which aids in control of urine
• Two neurovascular bundles, which play a part in erectile function
• Bladder
• Rectum

Because of the location and position of the prostate, the surgeon has limited room for removal of surrounding tissue. Fortunately PSA screening often detects prostate cancer in the early stages, allowing many surgeries to be less radical. In most cases, the operation is limited to the prostate gland, preserving to a large extent other critical structures including the neurovascular bundles. In more advanced tumors, one or both neurovascular bundles may be partially or completely removed. 

Prostate surgery techniques

The two main surgical techniques for removal of the prostate are:

• Open: A large incision is made in the lower abdomen, and the prostate is removed.
• Robot-assisted (laparoscopic): Multiple small incisions are made in the abdomen, and then an endoscope (tiny hollow tube) connected to robotic arms is inserted. A miniature video camera and surgical tools are attached to the end of the endoscope. The surgeon, seated at a console, can view the surgery site on a video screen and control the robotic arms.

Studies show robotic-assisted surgery may result in:

• Less blood loss
• Shorter hospital stays
• Less urinary tract scarring
• Fewer complications

However, the techniques are fairly equal in retaining urinary and sexual function and controlling cancer. The experience of the surgeon probably will affect your result more than which set of tools is used.

Despite a lack of high-quality clinical data comparing the two procedures, the robotic technique has become the most common in the United States.

Recovery from surgery

Surgery for prostate cancer generally takes two to four hours and requires a stay in the hospital of one or two nights. Recovery involves three factors:

• Access: Incisions may cause a few days of soreness, and pain medications often are required. Strenuous activity is limited for four weeks to prevent a hernia, but light activity, such as office-based work, can resume in two weeks.
• Bowel function: Surgery and anesthesia may delay bowel function for a few days, but usually patients can begin drinking liquids the next day. 
• Urinary reconstruction: The bladder-to-urethra suturing heals in three days, but it is often seven to 10 days before swelling goes away. Most patients will wear urinary catheters (a thin tube placed in the bladder to assist in passing urine) during this period. You will need to wait until the catheter is removed to begin driving again.

Recovery of function

Urinary control: Most men have stress urinary incontinence (leakage of a small amount of urine when laughing, sneezing, coughing, etc.) after a radical prostatectomy.

• Within a few days to three months, most men have 90 percent or more of the urinary function they had before surgery.
• At one year, approximately 95 percent of men have pre-surgery levels of urinary control or are very close.
• Approximately 10 percent have rare urinary accidents and wear protective pads.
• Fewer than 5 percent have permanent significant leakage problems.

Sexual function: Since the prostate and seminal vesicles produce the majority of semen, sexual climax after a prostatectomy does not produce fluid. However, the climax response is preserved in almost all cases. 

The success of preserving sexual function (the ability to maintain erections for sex) depends on:

• Age, sexual function before surgery and medical history
• Number of nerve bundles spared
• Experience and expertise of the surgeon

Have a frank discussion with your doctor before surgery about your chances for preserving sexual function.

Prostate surgery risks

As with any type of surgery, procedures to treat prostate cancer or its symptoms carry potential side effects. Talk to your doctor before the surgery about any possible side effects.

Risks for any type of surgery include a small chance of:

• Stroke
• Heart attack
• Blood clots
• Infection
• Bleeding

Your risk depends on many factors including your general health, your age and your doctor’s skill.

If you choose to treat the cancer with surgery, look for a surgeon with as much experience as possible in performing the procedure. Studies have shown this increases odds for successful surgery with fewer side effects.

Radiation therapy

Radiation can be used to kill prostate cancer cells and eradicate the tumor. It often is used to treat prostate cancer that is contained within the prostate or the surrounding area. For early-stage disease, patients often have a choice between surgery and radiation with similar outcomes.

For larger or more aggressive tumors, radiation therapy may be used in combination with hormone therapy. 

Radiation also may be used to treat tumors that are not completely removed or that come back after surgery.

Radiation therapy may be:

• External beam radiation (EBRT)—X-ray treatment
• Proton therapy—positively charged particles
• Brachytherapy—implanted radioactive material

External beam radiation (EBRT) is the most commonly used radiation therapy for prostate cancer. Before treatment, a CT or CAT (computed axial tomography) scan is done to determine the treatment field and where radiation beams will be aimed.

For treatment, the patient lies on a table in a device to keep the body from moving. The radiation machine, or gantry, moves around the patient to deliver beams from multiple (usually six to eight) angles. Lead-blocking devices enter the radiation field at the appropriate time to spare the nearby tissues from high doses of radiation. This technique is called intensity-modulated radiation (IMRT). Treatment typically takes 15 to 20 minutes.

Because the prostate can move within the body from day to day, techniques are used to ensure the radiation is being given to the exact location. These include:

• Ultrasound imaging through the abdomen
• Implanting gold markers that show up on X-rays
• CT or CAT (computed axial tomography) scan

Proton therapy is another type of radiation that is delivered externally. This is a beam of high-energy positively charged particles (protons). Protons are able to stop abruptly at a programmed depth in tissue so adjacent non-cancerous organs can be spared high doses of radiation. Proton therapy requires highly specialized equipment and is available at only a few locations in the country.

Brachytherapy involves tiny, permanent radioactive seeds, each smaller than a grain of rice, which are implanted directly into the prostate. Radiation then is delivered constantly over a period of several months. They often are left in place permanently. Radioactive isotopes include iodine, palladium and a newer seed, cesium.

Temporary or high-dose brachytherapy is another way to deliver external radiation therapy. Catheters (tiny tubes) are inserted into the prostate. A radioactive material is placed in the catheters for several minutes, then removed. The catheters remain in place only until treatment is complete. This method can require two to three days in the hospital.

Brachytherapy is most effective in early-stage prostate cancers that are small and not aggressive.

The advantage of brachytherapy is that it is a one-time procedure. Externally delivered radiation (EBRT or proton therapy) requires seven to eight weeks of brief daily visits.

Radiation therapy side effects

Treatment side effects tend to be similar for all forms of radiation therapy, although urinary side effects may be slightly more intense with brachytherapy shortly after the procedure. Overall, patients may experience mild to moderate side effects, which usually go away once treatment is complete. 

Possible side effects include:

• Irritation of the bladder, urethra and/or rectum
• Bladder problems including frequent urination, burning when urinating, stronger urge to urinate
• Rectal soreness and slight bleeding
• More frequent bowel movements
• Fatigue or feeling more tired than usual

Long-term problems may include bowel or urinary problems and erectile dysfunction.

Be sure to discuss with your health care provider any side effects you experience. Treatments are available to help with many of these problems.

Hormone therapy

The majority of prostate cancers are hormone-sensitive, which means male hormones (androgens) such as testosterone fuel growth of the cancer.

About one-third of prostate cancer patients require hormone therapy (also called androgen deprivation), which removes all traces of testosterone from the body in an effort to reduce the tumor size or make it grow more slowly.

While hormone therapy may help control prostate cancer, it does not cure it.

Hormone therapies work best on early-stage, high-grade tumors (Gleason score of 8 or higher). However, doctors have different opinions about the length and timing of hormone therapy.

Hormone therapy may be used if:

• Surgery or radiation is not possible
• Cancer has metastasized (spread) or recurred (come back after treatment)
• Cancer is at high risk of returning after radiation
• Shrinking the cancer before surgery or radiation increases the chance for successful treatment

Intermittent hormone therapy is a variation of hormone therapy in which drugs are used for a period of time, then stopped and started again. For some men, this approach causes fewer side effects. The effectiveness of this approach is still being studied.

The types of hormone therapies for prostate cancer are:

Anti-androgens or androgen-ablation drugs: These drugs, which include Eulexin® (flutamide or flutamin) and Casodex® (bicalutamide), block the ability of cancer cells to interact with testosterone. They are taken by mouth every day for up to three years.

Anti-androgens are used most often in combination with LHRH agonists (see below), although this approach is favored less than in the past. Occasionally, anti-androgens are used as a less effective but acceptable alternative to LHRH agonists if the side effects are excessive. 

Occasionally, anti-androgens accelerate the rate of PSA increase and cancer progression. If the agents are stopped, the patient will have withdrawal symptoms. 

If anti-androgens are used, they usually are given at least two months before radiation therapy. The drugs make the tumor more responsive to radiation treatment and reduce the number of cancer cells.

LHRH agonists (or analogs) work by over-stimulating the pituitary gland to release luteinizing hormone-releasing hormone (LHRH). This signals the testicles to suppress testosterone production. Treatments are injections or implants of small pellets just under the skin.

LHRH agonists may cause a spike or flare in testosterone levels before treatment takes effect. This may cause an increase in side effects, including bone pain. To offset this effect, anti-androgens may be given for a few weeks before each treatment.

The effects of LHRH are not permanent, so patients who cannot cope with treatment side effects can be taken off the drug and resume testosterone production.

Orchiectomy is surgical removal of the testicles. Although orchiectomy is surgery, the result is hormone therapy because the production of testosterone is stopped. Orchiectomy is an efficient, cost-effective and convenient method of reducing testosterone, and it is an option for certain patients, particularly elderly men. After this surgery, most men cannot have erections.

Side effects of hormone therapies include:

• Impotency, loss of sex drive
• Inability to get or maintain an erection
• Hot flashes
• Growth of breast tissue and tenderness of breasts
• Loss of muscle mass, weakness
• Decreased bone mass (osteoporosis)
• Shrunken testicles
• Depression
• Loss of self-esteem, aggressiveness/alertness and higher cognitive functions such as prioritizing or rationalization
• Anemia (low red blood cells)
• Weight gain
• Fatigue
• Higher cholesterol levels
• Increased risk of heart attacks, diabetes and high blood pressure (hypertension)

If you are treated with hormone therapy and have side effects, be sure to mention them to your health care providers. Many of these side effects can be treated successfully.

Chemotherapy

Most physicians reserve the use of chemotherapy for prostate cancer that is progressing rapidly or causing symptoms.

• Taxotere® (docetaxel) is the standard chemotherapy agent for adenocarcinoma (a type of cancer) of the prostate that does not respond to hormone therapy.
• Cisplatin-based chemotherapy is used to treat the small-cell variant of prostate cancer.

Doctors don’t know for certain if chemotherapy is useful in earlier stages of prostate cancer, but this is being investigated.

Chemotherapy drugs are given by injection into a vein or in pills.

Side effects of chemotherapy include:

• Vomiting and nausea
• Fatigue and tiredness
• Loss of appetite
• Loss of hair
• Sores in the mouth
• Higher risk of infection
• Easier bleeding and bruising

If you experience side effects during chemotherapy, tell your health care provider. Drugs and other methods are available to help many of these problems.

Active surveillance or watchful waiting

Because prostate cancer usually grows slowly, some men with prostate cancer —especially those who are older or have other health problems—may never be treated for it. Instead, their doctors may recommend active surveillance, an approach commonly known as "watchful waiting.”

This approach involves closely monitoring the cancer without active treatment such as surgery or radiation therapy. Biopsies and PSA tests are repeated at set intervals, and treatment may be recommended if they show an increase in the volume or grade of the tumor.

Long-term studies of active surveillance for men with low-volume, low-grade tumors show that approximately 70 percent can maintain this approach for up to 10 years without requiring treatment.

Clinical trials of new drugs and agents

Research studies of new drugs and agents or procedures to treat prostate cancer and its side effects, as well as ways to prevent the disease, are available in many cancer centers, especially larger ones.

Some of the therapies being studied are:

• Vaccines that help your body fight cancer
• Monoclonal antibodies, which are proteins that target specific cells
• Angiogenesis, a process that stops the growth of blood vessels that cancer needs to grow

If you are interested in participating in a clinical trial, speak to your health care provider.

Last reviewed on 5/27/10

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