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1 The Prostate Cancer Center at Roswell Park Connects You to Nationally Recognized Experts for State-of-the-Art Treatment Options and Compassionate, Evidence-based Care Founded in 1898, Roswell Park Cancer Institute is the nation s first cancer research and treatment center. The importance of strong connections between research and clinical care is evident in our history. Roswell Park scientists and clinicians: Developed the prostate-specific antigen (PSA) test that can detect prostate cancer 5-10 years earlier than a digital rectal exam Developed LNCaP, the most studied prostate cancer cell line in the world Developed photodynamic therapy (PDT) that uses lasers to activate photosensitive drugs that kill cancer cells Created the gene library used to map and sequence the human genome Have developed the nation s leading robotic surgery program for the treatment of bladder cancer Roswell Park is recognized by the National Cancer Institute (NCI) as one of only 41 Comprehensive Cancer Centers in the U.S., which signifies that all research, treatment, prevention and educational programs meet rigorous national standards and that Roswell Park contributes substantially to the fight against cancer. Roswell Park is a member of the prestigious National Comprehensive Cancer Network (NCCN), comprised of leading cancer centers that generate guidelines for diagnosis, evaluation, treatment and follow up of the more common cancers. Roswell Park s urologic cancer experts, Dr Donald Trump, Dr. Roberto Pili, Dr. Ellis Levine, Dr. James Mohler, Dr. Robert Huben and Dr. Michael Kuettel are members of the NCCN guidelines committees that establish the standards of care for prostate and other urologic cancers. 1

2 Leadership in Prostate Cancer Care and Research The Prostate Cancer Center at Roswell Park concentrates on the diagnosis, management and treatment of malignant tumors of the prostate. As an NCIdesignated Comprehensive Cancer Center, Roswell Park offers the broadest range of treatment options to meet your individual needs and preferences. Seamless Care from a Multidisciplinary Team Our Prostate Cancer Center integrates surgical, radiation and medical oncology specialists to offer individualized treatment plans. The team works closely with your primary care physician to ensure continuity of care from diagnosis through long-term follow-up. No single treatment choice is right for everyone, so it is important for men to be actively involved in the decision-making process with their healthcare team. The team approach to prostate cancer care at Roswell Park provides peer review of each patient s medical case by expert members of the prostate team with treatment options that follow recommended standards of care. For example, a patient s case will be reviewed by urologic surgeons, radiation oncologists and medical oncologists all working together with a support team that includes pathologists, nurses, nurse practitioners, nutritionists, pharmacists, psychosocial specialists, pain management experts, among others. Choices will depend on the PSA level, stage and grade of the cancer, the chance that it will become life-threatening, medical history and age. One or a combination of treatment options may be recommended. Only by taking a multidisciplinary approach to treatment planning can we reduce the possibility of bias and pinpoint the best treatment options for our patients. Pathology Services: Diagnostic Accuracy, Better Treatment Planning Because Roswell Park focuses only on cancer, our pathologists are highly skilled in the diagnosis of cancer and accurate staging. The Roswell Park Pathology Department has the only subspecialty fellowship-trained genitourinary (prostate and other urologic cancers) pathologists in Western New York. This expertise is particularly important for prostate cancer patients because subtle differences on the microscopic appearance (Gleason Score) of a man s cancer can make an important difference in the recommended treatment plan. 2

3 Superior Imaging for Safer, More Efficient Treatment Roswell Park s highly skilled radiologists provide images of unparalleled clarity. This technology provides finer precision of measurement and guides the surgeon and radiation treatment physician in planning more targeted treatment. Leader in Robot-Assisted Surgery: The Most Advanced Treatment Available In 2004, Roswell Park began using Intuitive Surgical s da Vinci Surgical System, which combines superior 3D visualization, greatly enhanced dexterity, precision, control and breakthrough surgical capabilities. Robotic-assisted surgery, a type of minimally invasive surgery, uses surgical robotic equipment which imitates movements initiated by the surgeon. MIS procedures allow surgeons to operate through small rather than large incisions, resulting in less blood loss, shorter recovery times, fewer complications and reduced hospital stays. Surgical robotics combines minimally advanced surgery with highly advanced clinical technology. The success rate for the removal of cancer of the prostate is identical to "open", or traditional, prostate cancer surgery. A patient s recovery of urinary control is faster. Preservation of sexual function is at least as good as traditional surgery. In general, these are the advantages for this procedure: Less pain Less scarring Quicker recovery of urinary control Decreased blood loss and risk of infection Shorter hospital stay Faster recovery (many men can return to work in only two weeks) Providing a Full Range of Radiation Therapy Radiation Therapy uses high-energy rays (such as x-rays) or particles (such as electrons or protons) to kill cancer cells. Radiation is sometimes used to treat prostate cancer that is still confined to the prostate gland or has spread to nearby tissue. If the disease is more advanced, radiation may be used to reduce the size of the tumor or to provide pain relief when cancer has spread to the bones. The two main types of radiation therapy are external beam radiation and brachytherapy (internal radiation). 3

4 External beam radiation is focused from a source outside the body to the area affected by the cancer. Roswell Park uses a Varian Trilogy linear accelerator. This state-of-the-art machine is the world s first image-guided radiation therapy (IGRT) system, optimized for both conventional and stereotactic approaches for treating cancer. This system can target the prostate more accurately, thus reducing side effects to surrounding normal tissue, particularly the rectum and bladder. The Department uses sophisticated computers to precisely map the location of the cancer within the prostate. The Trilogy linear accelerator is the most technically advanced linear accelerator manufactured by Varian Medical Systems ( The Department has two Trilogy units allowing for easy transfer of patients, should one machine be down for any reason. The power of Trilogy yields treatment times that are shorter, making the experience more comfortable for the patient. The precision of Trilogy allows the sparing of healthy tissue to the extent that was unimaginable until recently. Roswell Park provides both high- and low-dose-rate brachytherapy for men with prostate cancer. Low-dose brachytherapy involves the introduction of radioactive material, usually seeds, into the prostate gland through tiny plastic catheters. The seeds emit low doses of radiation, which dissipates over the course of several months. High-dose-rate brachytherapy makes it possible to deliver higher doses of radiation to the tumor and lower doses to the urethra and rectum, thus increasing the therapy s effectiveness against the tumor while reducing the possibility of damaging healthy tissue. Nationally Regarded Medical Oncology Experts Provide Individualized Evidence-based Treatment Plans Medical oncologists work collaboratively with the prostate cancer multidisciplinary team to provide a treatment plan that is based on recent scientific evidence and meets national standards. Treatment is individualized to meet the needs of each patient and may include the use of androgen deprivation (hormone) treatment or chemotherapy or a combination of these treatments. Medical oncologists at Roswell Park are studying new approaches to hormone therapy with novel agents, the study of new chemotherapy drugs, and evaluating the use of vitamin D compounds in the treatment of prostate cancer. Discovery of Innovative New Therapies Means More Choices, More Effective Treatments As a National Cancer Institute-designated Comprehensive Cancer Center, Roswell Park conducts a world-class research program aimed at continuously improving methods of preventing, detecting, and treating cancer. 4

5 Each year, the faculty attracts more than $87 million in research grants and contracts from such agencies as the National Cancer Institute, Cancer and Leukemia Group B, Radiation Therapy Oncology Group, and the Department of Defense Cancer Research Program. Current areas of research include: Vitamin D-based therapies focusing on the potential of vitamin D to halt the growth of new blood vessels that feed the tumor; to slow the growth of prostate cancer in men pursuing a watchful waiting program; and, either alone or in combination with other agents, to treat prostate cancer that is progressing despite androgen deprivation therapy. The use of chemotherapy and androgen deprivation therapy for men who plan radical prostatectomy for very aggressive prostate cancer The effects of diet on the prevention and treatment of prostate cancer The use of selenium in the prevention of prostate cancer Why African-American men have higher mortality rates for prostate cancer How prostate cancer becomes able to make its own androgens to stimulate growth in spite of androgen deprivation therapy How the prostate cancer stem cell and prostate cancer blood vessels cooperate to survive androgen deprivation therapy The use of virtual reality to train robotic surgeons more effectively. 5

6 6

7 National Comprehensive Cancer Network (NCCN) Treatment Summary for Men with Prostate Cancer The NCCN Treatment Summaries for People with Cancer are designed to give patients with cancer a better understanding of cancer, including diagnosis and treatment options, so they can work with their health care providers to achieve longer and better-quality lives. The NCCN Treatment Summaries are based on the NCCN Clinical Practice Guidelines in Oncology treatment recommendations most widely used by oncologists and other cancer care providers in the U.S. and the world. The NCCN Guidelines combine the best available medical evidence with expert experience on 97% of the cancers that affect people and are continually updated. NCCN Treatment Summaries for People with Cancer translate the information doctors use for patients, to help you and your family understand your treatment options, discuss them with your health care team, and make care decisions that are right for you. I. Prostate Cancer Overview Prostate cancer is the most common cancer in men, with lung cancer the second most common. African-American men are known to have a greater risk for developing prostate cancer. Because of significant improvements in screening and early detection of prostate cancer over the past 30 years, the outlook for many men diagnosed with this disease has improved. If you have been diagnosed with localized prostate cancer (stage I or II), you probably have many questions and concerns about your disease and its treatment. This treatment summary, which is based on the NCCN Clinical Practice Guidelines in Oncology, will help you understand the best available treatments for localized prostate cancer. Talk to your doctor about these options so that together you can decide on a treatment plan that is right for you. Prostate Cancer Background The prostate gland lies just below the bladder and produces a fluid that forms part of the semen. Men older than 65, those with a family history of prostate cancer (especially if a brother or father has been diagnosed with prostate cancer), and those of African descent are at higher risk for prostate cancer. Prostate cancer is often detected at a very early stage with both a prostatespecific antigen (PSA) blood test and digital rectal examination (DRE). 7

8 Diagnosis Some men worry that they may have prostate cancer when they develop a noncancerous enlargement of the prostate called benign prostatic hyperplasia (BPH). This treatable condition may cause difficulties with urination but is not associated with cancer. Because the initial signs and symptoms of BPH may be the same as prostate cancer, it is important that your prostate cancer diagnosis be confirmed with a biopsy, in which a specimen of your prostate tissue is removed and looked at under a microscope to determine whether it contains cancer cells. If prostate cancer is present, it will be given a grade, which is based on whether the cancer can form normal-appearing glands when looked at by a pathologist under a microscope. The most commonly used grading system for prostate cancer is called the Gleason score, which ranges from 2 to 10. In general, the lower the Gleason score, the more likely that the tumor is growing slowly and that it is less likely to spread. Staging Staging is an important part of developing the best treatment plan for you. Doctors divide prostate cancer into stages I to IV. Each stage characterizes the size of the tumor and whether and how much it has spread to other parts of the body. Localized prostate cancer is stage I or II cancer, which means it has not spread beyond the prostate based on physical exam or X-ray studies. In stage III or IV, the cancer has spread beyond the prostate. 8

9 II. Treatment Summary for LOCALIZED Prostate Cancer Because men with localized prostate cancer may live with the disease for many years, you and your doctor must carefully evaluate both the effectiveness of the treatments and their side effects. Factors to consider include: The likelihood that the cancer will recur (come back) after treatment, which is predicted by stage, Gleason score, and PSA level; localized prostate cancer usually has a low risk of recurring Your age and life expectancy Other diseases and conditions you may have that may make certain treatments risky or unnecessary The potential side effects of treatment Your personal preferences You should expect to have a detailed conversation with your doctor regarding both your preferences for treatment and about your general health. The goal of this conversation is to determine whether your prostate cancer is likely to become life-threatening during your expected lifetime. Your doctor will use a set of statistical tables that estimate the typical life expectancy of someone your age with your general state of health. Your doctor will also look at the Gleason score for your tumor and how long it has taken for your PSA value to double. Together, these factors will enable your doctor to estimate your life expectancy, and the likelihood that treatment will cure your cancer. Although none of these estimations may be precisely correct for you, they provide information about what would happen to the average patient in your situation. Your doctor will also talk with you about treatment options and help you make an informed decision about whether and how to be treated. Your doctor should provide you with a written care plan explaining what treatments you will have, when they will occur (and how often, if you are receiving radiation), and what type of side effects you may experience. Some side effects can be anticipated and you can undergo pretreatment to minimize them. You will be asked to sign an informed consent form indicating that you have been told about your treatment and the side effects one might expect. Your doctor should also tell you how often his or her patients have complications from treatment. The percentage of patients who eventually have bowel or bladder incontinence or impotence after therapy given by a particular doctor is an important consideration in selecting the doctor who will take care of you. Active Surveillance For men whose cancer is small, localized and not causing any symptoms, and whose PSA and Gleason scores are in the low ranges, active surveillance (also 9

10 known as watchful waiting ) may be an option. Active surveillance is also called observation or expectant management. Together, you and your doctor can carefully weigh several factors to determine whether active surveillance that is, not treating the cancer, but instead watching for any indication that the cancer is growing might be the best course of action. Prostate cancer often occurs in older men who may or may not have other serious health conditions. Because prostate cancer often progresses very slowly, it may not be a significant threat to a man s life or health. For this reason, one important consideration is whether treatment for localized prostate cancer might make other conditions more serious or whether the side effects of treatment might decrease your quality of life. You and your doctor should look at what effect treatment might have on your quality of life and life expectancy. Some men prefer to take a wait-and-see attitude, and feel comfortable that there is only a small chance that the cancer will become more serious; others prefer to undergo treatment. If your prostate cancer makes you a good candidate for active surveillance, or if you have other serious health concerns, the decision is up to you and your doctor. Each man has different concerns. If you decide to forego treatment for a period of time, your doctor will actively monitor the course of your disease with the expectation that treatment will begin only if and when the cancer progresses or causes symptoms. Active monitoring is an option for men whose cancer has a low risk of recurrence and for older or less-healthy men who have an intermediate or moderate risk of recurrence. Men who are being actively monitored must make sure to see their doctor at regular, agreed-upon intervals, typically every six months, but of course should contact their doctor immediately if they begin having symptoms such as pain, swelling, or difficulty urinating. A digital rectal exam (DRE) and PSA testing should be performed during each visit. Sometimes a needle biopsy, in which tissue or fluid from the prostate is removed with a needle, may be required. Changes in the results of these tests and exams may indicate that treatment would be beneficial. The advantage of active surveillance is that there are no side effects or complications from treatment. The disadvantages are that the tumor may be larger or more aggressive than originally thought or that the cancer may grow, and rarely spread, undetected between doctor visits. Radiation Therapy (Radiotherapy) Radiotherapy, the use of high-energy radiation from X-rays, gamma rays, and other sources to kill cancer cells and shrink tumors, is effective in treating localized prostate cancer. The types of radiotherapy include external beam radiation therapy and brachytherapy. 10

11 1. External Beam Radiation Therapy (EBRT): With EBRT, high-energy rays are used to kill the prostate cancer cells and shrink the tumor. The equipment used is similar to an X-ray machine, and the treatment is often performed on an outpatient basis 5 days per week for several weeks. With EBRT, the risks for bladder obstruction and bladder control problems are low. In the short term, the risk for erectile dysfunction (impotence) is also low, but problems with impotence may occur later. In addition, other side effects may occur long after treatment is completed and last for an undetermined amount of time. These may include urinary or bowel problems involving frequency, urgency, or pain. 2. Brachytherapy: In this therapy, many small radioactive seeds are implanted into the prostate, usually under ultrasound guidance and anesthesia. Brachytherapy alone is appropriate only for men with a low risk for recurrence. The time it takes to recover from brachytherapy is short, and this treatment produces very low rates of erectile dysfunction (impotence). Side effects may be similar to those seen with external radiation. For men at low risk for cancer recurrence, either EBRT or brachytherapy is an appropriate treatment option. Men at moderate (intermediate) risk for recurrence may be treated with EBRT alone, or in combination with brachytherapy. Short-term androgen deprivation therapy (ADT), the use of drugs to block the hormones that promote tumor growth, may also be used in addition to radiation therapy for men at intermediate risk. These drugs can shrink the tumor and make EBRT more effective. High-risk prostate cancer requires EBRT and 2 to 3 years of androgen deprivation therapy. Surgery: Radical Prostatectomy: Surgical Removal of the Prostate Removing the entire prostate is a highly effective treatment for localized prostate cancer, but it is associated with more side effects in the short term than radiotherapy. It is an option for men with intermediate risk for recurrence, or young men at low risk who have many more years to live and want to ensure that the cancer does not come back. High risk prostate cancer may be treated with radical prostatectomy especially in younger men but additional treatment is often required. The pelvic lymph nodes may also be removed during surgery to determine whether the cancer has spread outside the prostate. There are three major types of operations to remove the prostate: 1. Open/traditional surgery: In open surgery, the surgeon makes an incision either through the lower abdomen or through the perineum (the area between the rectum and the scrotum) and removes the prostate and any nearby tissue where cancer may have spread. The success of this surgery depends on the skill and experience of the surgeon; ask your doctor how many of these operations he or she has performed. 11

12 2. Laparoscopic surgery: In this technique, four or five tiny incisions are made in the abdomen, and a long tube-like camera (laparoscope) is used to view the area while the surgeon uses long instruments to remove the prostate and affected tissues. The smaller incisions allow for quicker healing than open surgery, but there is a risk of incomplete tumor removal. It is still unclear whether laparoscopic surgery can give a better outcome than open surgery. Again, success depends a great deal on the skill and experience of the surgeon; ask your doctor how many of these operations he or she has performed. 3. Robotic nerve-sparing surgery: This method is also laparoscopic, as described above. However, in this technique, the doctor performs the operation by controlling a system made up of a laparoscope and two or three robotic arms. Robotic arms can make more precise movements with delicate instruments than can a surgeon s hand. Such precise manipulation creates less damage to surrounding tissue and may more reliably leave the nerves intact that control erections, although the lack of the sense of touch may also affect the surgeon s performance. It is still unclear whether robotic surgery can give a better outcome than open or laparoscopic surgery. Again, success depends heavily on the skill and experience of the surgeon. If you opt for this surgery, ask the surgeon how many of these operations he or she has performed. After surgery, the urethra, which is the tube through which urine leaves the body, needs time to heal. You will have a catheter, a tube that is put through the urethra into the bladder to drain urine. This will need to remain in place for 3 to 10 days. Your nurse or doctor will show you how to use it when you are at home. If your prostate is removed, you will no longer produce semen. If you want to father children, talk to your doctor before your treatment about sperm banking before surgery or a sperm-retrieval procedure after surgery. Removal of the prostate prevents the spread of cancer and cures the disease if cancer cells have not spread outside the prostate. Many men who undergo nerve-sparing surgery will be able to have erections. After surgery, some men may have urinary problems, but these are usually temporary. Although some men may become impotent, nerve-sparing surgery is done with the hope of avoiding this. If any prostate surgery or treatment results in impotence, there are ways to manage and live well with this effect. Talk to your doctor about these before surgery. 12

13 III. Treatment Summary for ADVANCED Prostate Cancer Before deciding on treatment, you and your doctor must consider: The risk of the cancer recurring (coming back) or progressing after treatment, which is predicted by stage, Gleason score, and PSA level; locally advanced prostate cancer (it has spread to the lymph nodes but not to distant organs) typically has a high risk of coming back; metastatic prostate cancer (it has spread to distant organs, often bones) is not curable, but can be treated to give you a longer, higher quality life. Your general health, including other diseases you may have that could make certain treatments risky or unnecessary The potential side effects of treatment Your personal preferences Your doctor should provide you with a written care plan explaining what treatments you will have, when and how often they will occur, and what type of side effects you may experience. Some of the side effects can be anticipated and you can get pretreatment to minimize them. You will be asked to sign an informed consent indicating that you have been told about your treatment and what to expect. It is very important that you ask questions. Treatment for advanced prostate cancer can include a number of options, including: External beam radiation therapy Androgen-deprivation therapy Chemotherapy External Beam Radiation Therapy (EBRT) In EBRT, high-energy rays are used to kill the prostate cancer cells and shrink the tumor. This is appropriate for men with locally advanced prostate cancer. The equipment used is similar to an X-ray machine and the treatment is usually performed on an outpatient basis. EBRT is usually given in combination with androgen-deprivation therapy (ADT; see next section) for patients with advanced prostate cancer that has not spread to a distant organ. Radiation therapy is also used to help control bone metastases. With EBRT, the risks for bladder obstruction and bladder control problems are low. In the short term, the risk of erectile dysfunction (impotence) is also low, but problems with impotence may occur later. In addition, other side effects can happen long after treatment is completed and last for an undetermined amount of time. These may include urinary or bowel problems involving frequency, urgency, or pain. 13

14 Androgen Deprivation Therapy (ADT or Hormone Therapy) Prostate cancer cells need male hormones, called androgens (e.g., testosterone), to grow. Blocking the hormones with androgen deprivation therapy (also known as ADT or hormone therapy) can slow tumor growth or shrink the tumor. This is usually accomplished with drugs called luteinizing hormonereleasing hormone (LHRH) agonists, which prevent the testicles from making more testosterone. ADT controls tumor growth for variable amounts of time in different patients. Although it has significant side effects, ADT is the principal treatment for advanced prostate cancer. Testosterone can also be blocked by removal of the testicles (a surgical procedure called orchiectomy). ADT may be given for a short time (4 to 6 months) or long term (2 to 3 years). ADT, usually in combination with EBRT, is the treatment of choice for patients with high risk of recurrence or locally advanced disease. Long-term ADT alone is often given to patients with metastatic cancer. If long-term ADT is recommended for you, talk with your doctor about the possibility of intermittent ADT. If this is right for you, you will receive between 6 and 18 months of ADT, stopping when your PSA is less than 4 and starting again when your PSA rises to more than 10, 20, or 40. While you are receiving this treatment, your doctor will monitor you every 3 to 6 months. Evidence from studies suggests that patients live as long when ADT is given intermittently as when it is given continuously. Of course, if you develop symptoms between scheduled doctor visits, you should let your doctor know immediately. Drugs called antiandrogens, which block the effect of male hormones in the body, are sometimes used with LHRH agonists. Their effectiveness, however, has not been proven, so get more information from your doctor about this treatment if it is recommended. ADT can help slow tumor growth for a limited amount of time, but it does not cure the disease and causes impotence. Some doctors use the intermittent or on-off approach described above to try to manage impotence. There are also other ways to manage and live well with impotence, so it is important to talk to your doctor about them. ADT also has other potential side effects such as increased risk of osteoporosis, diabetes, and cardiovascular disease. Be sure to talk to your doctor about these risks before starting treatment. Chemotherapy Drugs that limit the growth and survival of cancer cells may be used when the cells continue to spread to distant organs (such as the bones) despite use of ADT. Common chemotherapy drugs given (usually in combinations) include docetaxel, prednisone, estramustine, and mitoxantrone. If your cancer responds to chemotherapy, it may extend the length of your life. However, chemotherapy also produces significant side effects that can worsen 14

15 the quality of your life. Because many of these side effects can be anticipated and reduced with other treatments, you should always speak with your doctor or nurse about side effects you may be experiencing. IV. Life after Treatment Because prostate cancer can return even after treatment, follow-up care is very important. Make sure to see your doctor for an exam and PSA testing at regular, agreed-upon intervals, typically every three to six months. If you have metastatic cancer (disease that has spread to other parts of the body), you may need to see the doctor more frequently. Prognosis In determining a prognosis (the likely course or outcome of a disease and its treatment), a doctor may look at cancer survival statistics taken from studies of large groups of patients. However, these statistics: Are estimates only Can vary widely with each cancer stage Are sometimes based on older data that do not reflect recent advances in early detection and treatment Cannot be used to precisely predict your survival Your individual prognosis will be affected by many factors, including: Your age Your overall health The type, stage, grade, and other characteristics of your cancer Your response to the treatment(s) being used New therapies and combinations of therapies are enabling people with cancer to live longer, better quality lives than ever before. Ask your doctor which treatment(s), in his or her judgment, will give you the best life expectancy and quality of life. You may want to find out whether you are eligible to participate in a clinical trial in which new and experimental therapies are compared against standard treatments. 15

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