Reporter s Guide to. Prostate Cancer

Transcription

1 Reporter s Guide to Prostate Cancer

2 Table of Contents What is Prostate Cancer? 3 Who is at Risk for Prostate Cancer? 3 How is Prostate Cancer Diagnosed? 3 How is Prostate Cancer Treatment Determined? 4 Current Prostate Cancer Treatments 5 Prostate Cancer Treatments by Recurrence Risk 6 Challenges in Advanced Prostate Cancer Treatments 6 Can Prostate Cancer be Prevented? 7 Glossary of Terms 7 Additional Resources 9 2

3 What is Prostate Cancer? Cancer occurs when the process of normal cell division is disrupted; new cells form when the body doesn t need them or when old and damaged cells don t die as they should. The buildup of extra cells often forms a mass of tissue called a growth, or tumor, and can either be benign (non-cancerous) or malignant (cancerous). 1 Called prostate cancer or cancer of the prostate, this disease occurs when cancer cells form in the tissues of the prostate, a gland located around the urethra (under the bladder) in men that produces part of the seminal fluid. It tends to grow slowly compared with most other cancers. However, depending on factors including characteristics specific to the patient and the tumor, prostate cancer can manifest as a slow-growing tumor to a very aggressive, metastatic and potentially fatal disease. 2 This shows the prostate and nearby organs National Cancer Institute Who is at Risk for Prostate Cancer? Although any man can develop prostate cancer, there are certain factors that increase the risk. These include: 1 Age Those older than age 65 are at higher risk. Family history Risk increases if a father, brother or son developed prostate cancer. Race African Americans are at higher risk than Caucasians and Hispanics. It is less common in Asians, Pacific Islanders, American Indians and Alaskan Natives. Pre-cancerous prostate changes Changes such as prostatic intraepithelial neoplasia, a prostate lesion, can be a precursor to cancer. Genetic (chromosomal) abnormalities Abnormalities such as an altered or missing gene may contribute to risk. This shows the inside of the prostate, urethra, rectum, and bladder Excluding skin cancer, prostate cancer is the most frequently diagnosed cancer in men in the United States. 1 In 2010, more than 217,000 new cases of prostate cancer were estimated, and more than 32,000 men died from the disease, making it the second leading cause of cancer death behind lung cancer. 3,4 How is Prostate Cancer Diagnosed? There are certain symptoms that may be associated with prostate cancer and should be checked with a health care provider, including: 5 Trouble passing urine or a frequent urge to urinate, especially at night Weak or interrupted urine stream Pain, burning or blood when urinating Painful ejaculation or blood in the semen Nagging pain in the back, hips or pelvis 3

4 There are prostate cancer screening tests that are used to help detect the disease at an early stage 5 before symptoms are present, confirm diagnosis or monitor progression of the disease. These include: Digital rectal examination (DRE): Insertion of a lubricated, gloved finger into the rectum by a physician to check for hard or lumpy areas in the prostate through the rectal wall. 1 Prostate-specific antigen (PSA): PSA, a protein produced by the prostate that is released in very small amounts into the bloodstream, can often signify when the prostate doesn t function properly. Typical range references are laboratory, age and race dependent. However, levels over 4 nanograms per milliliter (ng/ml) may require additional monitoring and follow-up. 6 Transrectal ultrasound: Insertion of a probe that acts as an ultrasound into the rectum to check the prostate for abnormal areas. 1 A biopsy is a definitive way to confirm or rule out prostate cancer: Transrectal biopsy: Insertion of needles through the rectum into the prostate to remove small tissue samples that are evaluated by a pathologist for cancer. 1 How is Prostate Cancer Treatment Determined? Many factors are taken into consideration to determine a treatment plan for prostate cancer. These can include a man s life expectancy, age, co-morbidities (additional health risks), his preference regarding treatment and the potential side effects of treatments. 7 Clinically, among the most important factors in considering a treatment plan are the combination of PSA level, Gleason score and staging of prostate cancer. 5 Gleason score is an assessment of the aggressiveness of the tumor under the microscope. Gleason score is rated on a scale from 2 to 10. A lower Gleason score (2 to 4) may mean the cancer is less aggressive. A higher Gleason score (7 to 10) suggests a more aggressive cancer. 6 Staging determines the extent, or spread, of prostate cancer. There are four stages: 1 { Stage I: The tumor is confined to the prostate. { Stage II: The tumor is more advanced or a higher grade than Stage I, but doesn t extend beyond the prostate. { Stage III: The tumor extends beyond the prostate and may have invaded the seminal vesicles (tubular glands above the prostate), but cancer cells haven t spread to the lymph nodes. { Stage IV: The tumor may have invaded the bladder, rectum or nearby structures (beyond the seminal vesicles), and may have spread to the lymph nodes, bones or other parts of the body. This is known as advanced, or metastatic, prostate cancer. Taken together, PSA levels and rate of change, Gleason score and staging can help determine the prognosis and risk of progression or recurrence of disease. This relative recurrence risk is an important factor when fashioning a treatment plan. 7 4

5 Current Prostate Cancer Treatments Prostate cancer treatment options, depending on recurrence risk and other factors, include: Active Surveillance The cancer is carefully monitored for signs of progression through regular PSA blood tests and DREs at least every six months and a biopsy at least yearly. Treatment may be started if symptoms develop or additional tests are abnormal. Active surveillance may avoid or delay side effects related to treatment, but may reduce the chance to control the cancer before it spreads. 7 Surgery Surgery is an option for early prostate cancer. A radical prostatectomy removes the entire prostate gland and some surrounding tissue. 6 If there is concern the cancer has spread beyond the prostate, a doctor may perform a pelvic lymph node dissection to remove lymph nodes near the prostate for signs of cancer. 1 Since the testicles are a primary source of testosterone, they may be surgically removed a procedure called an orchiectomy for treatment of advanced prostate cancer. 6 There can be significant side effects from surgical procedures, including erectile dysfunction and urinary incontinence. However, the latest surgical techniques for early stage disease have shown improvement in cure rates and tolerability. 6 Radiation Therapy Radiation therapy uses directed radioactive exposure to kill the cancer cells and surrounding tissues. Radiation can be administered from outside the body (external beam) or inside the body via pellets placed in the prostate (brachytherapy). In the later stages of prostate cancer, radiation may be used to reduce pain. High doses of radiation can increase the rate of side effects, such as urinary problems, erectile dysfunction and rectal bleeding. However, technology improvements have allowed for precise targeting of radiation, which can minimize side effects. 6 Hormone (Androgen Deprivation) Therapy Androgens are masculinizing sex hormones, which play a critical role in the development and progression of prostate cancer. 8 A prime target for therapeutic intervention in men with prostate cancer is halting or slowing the body s testosterone production, which can slow the growth of cancer, or even shrink it. Hormone therapy is used alone for prostate cancer that has returned after previous treatment; before, during or after radiation therapy; or for prostate cancer that has metastasized. 9 Therapy that blocks natural hormones includes orchiectomy, luteinizing hormone-releasing hormone (LHRH) agonists and antiandrogens. Typically, once the disease has become resistant to initial hormone therapy, manipulation with antiandrogenic agents is employed. 9 Side effects of hormone therapy include decreased libido, breast tenderness and enlargement, loss of bone density and muscle mass, weight gain and hot flashes. 6 Androgen deprivation therapy has also been shown to increase elevated fasting plasma glucose and to increase risk of cardiovascular events. 10 Side effects may be managed by making changes in the treatment regimen or using additional therapies that may address these side effects. 6 Immunotherapy Novel treatment approaches are emerging to stimulate a patient s own immune system to help manage prostate cancer progression. 11 5

6 Chemotherapy When the cancer has metastasized, or advanced, beyond the prostate area and no longer responds to hormone therapy, chemotherapy may be used to kill the circulating cancer cells. Side effects of chemotherapy, which kills fast-growing cancer cells but can also harm rapidly dividing normal cells, may include hair loss, nausea and vomiting, diarrhea, fatigue and an increased risk of infection, bruising and bleeding. Most side effects generally stop when chemotherapy is stopped. 1 Supportive Care Also known as palliative care, this involves providing care, both physical and psychosocial, for a person with prostate cancer who is no longer eligible for, or desires, aggressive medical treatment. The intention is not a cure but to provide comfort and pain relief. 1 Prostate Cancer Treatments by Recurrence Risk Recurrence risk looks at factors such as the likelihood that prostate cancer is confined to the prostate or has spread to lymph nodes, or will advance or metastasize after treatment. 7 Low Prostate cancer remains in the prostate area. Treatment may include active surveillance or radiation therapy, or a radical prostatectomy possibly accompanied by a pelvic lymph node dissection for staging the cancer. 7 Intermediate Treatment options are similar to low recurrence risk, but androgen deprivation therapy with or without brachytherapy may be used. Treatment path will depend in part on whether the cancer has spread into the lymph nodes. 7 High, Very High or Metastatic (Advanced) Treatment may include a combination of hormone therapy, radiation therapy or radical prostatectomy with pelvic lymph node dissection. Ongoing follow-up or treatment is then determined by laboratory parameters, x-ray and/or presence of clinical signs and symptoms. 7 Challenges in Advanced Prostate Cancer Treatments One of the greatest challenges facing health care providers is how to treat a person whose prostate cancer has spread following treatment with hormone therapy. Metastatic advanced prostate cancer, also referred to as castration-resistant prostate cancer or CRPC, occurs when cancer has metastasized beyond the prostate and disease progresses despite conventional hormone therapies. 12 This occurs because testosterone continues to be produced by the adrenal glands and tumor tissue and thus can help fuel the 13, 14 tumor s growth. Men with asymptomatic metastatic CRPC may be treated with a secondary hormone therapy or immunotherapy. Men with symptomatic metastatic CRPC may receive chemotherapy or palliative radiation therapy. If the tumor continues to progress after chemotherapy, additional chemotherapy or a secondary hormone therapy may be used. 7 6

7 Can Prostate Cancer be Prevented? Currently, there is no way to prevent prostate cancer. Eating a wide variety of vegetables and fruits each day, limiting intake of red meats and dairy products, maintaining an active lifestyle and healthy weight, refraining from smoking and consuming only moderate amounts of alcohol may reduce the risk of 15, 16, 17, 18, 19 prostate cancer. Glossary of Terms Active surveillance A treatment option for prostate cancer that involves careful monitoring for signs that the disease has advanced and includes: regular PSA tests, DREs and other tests such as routine biopsies, but not medical treatment. 6 Adrenal glands Glands located near the kidneys that produce male hormones, including 5 to 10 percent of a man s testosterone. In prostate cancer treatment, antiandrogens are used to block testosterone produced by the adrenal glands. 20 Advanced prostate cancer Cancer has moved beyond the prostate region to the lymph nodes, bones or other parts of the body. 21 Androgen Category of sex hormones which stimulate activity of secondary male sex organs and encourage development of male sex characteristics. 1 Androgen receptors A protein molecule that carries androgen s messages or instructions to prostate cells. Androgen receptors are over-expressed in advanced prostate cancer contributing to prostate cancer growth even if androgen has been blocked. 22 Antiandrogens Compounds that block the biologic effects of androgens, such as testosterone, produced by the adrenal glands. 1 Brachytherapy (internal radiation) Placement of tiny radioactive seeds inside the prostate to attack the cancer; used for early stage prostate cancer that is relatively slow-growing. 6 Castrate level Occurs when the level of a man s testosterone drops by 90 to 95 percent due to surgical or chemical (drug) therapy. 9 Chemotherapy Treatment with drugs that kill cancer cells. Side effects of chemotherapy, which kills fast-growing cancer cells but can also harm rapidly dividing normal cells, may include but are not limited to: hair loss, nausea and vomiting, diarrhea, fatigue and an increased risk of infection, bruising and bleeding. Most side effects generally stop when chemotherapy is stopped. 1 7

8 Digital rectal examination (DRE) Insertion of a lubricated, gloved finger into the rectum by a physician to check for hard or lumpy areas in the prostate through the rectal wall. 1 External beam radiation Prostate cancer treatment in which radiation is focused on the prostate gland from a source outside the body. 6 Gleason score An assessment of the aggressiveness of the tumor under the microscope. Gleason score is rated on a scale from 2 to 10. A lower Gleason score (2 to 4) may mean the cancer is less aggressive. A higher Gleason score (7 to 10) suggests a more aggressive cancer. A Gleason score report may consist of two numbers (e.g., 3, 4). The first number is the grade assigned to the cancer type that is most numerous in the tissue sample. The second number is the grade assigned to the cancer type that is the second-most numerous. To determine the total Gleason score, these two numbers are added 6, 20 together. Hormone therapy Therapy used to reduce levels of male hormones, or androgens (including testosterone), that feed prostate cancer growth. Hormone therapy can include surgery (orchiectomy) to remove the testicles or drugs such as antiandrogens, which are given in conjunction with other medicines. 1 Androgen deprivation therapy This is another term for a class of medications that compete with androgens to stimulate the androgen receptor, which drives prostate cancer growth. 20 Luteinizing hormone-releasing hormone (LHRH) agonists/antagonists A type of hormone therapy that prevents the pituitary gland from releasing LHRH, which regulates the production of testosterone by the testicles. 20 Orchiectomy Surgical removal of the testicles to stop the body s production of testosterone, a hormone that can feed prostate cancer growth. Orchiectomy is not frequently used compared to treatment with drugs, but its effect on testosterone levels is used as a benchmark for the drop that should be achieved with the use of LHRH agonists. 20 Immunotherapy Treatment to boost or restore the ability of the immune system to fight cancer, infections and other diseases. 11 Pelvic lymph node dissection Removal and evaluation of lymph nodes near the prostate gland to determine if the prostate cancer has spread. Lymph nodes are small glands that fight infections but can also serve as vehicles for transporting cancer cells throughout the body. 1 8

9 Prostate-specific antigen (PSA) test Measures the level of PSA, a protein produced by prostate gland cells, in the blood. Used as a screening tool, as prostate cancer or benign (not cancerous) conditions can also increase a PSA level. 6 Radiation therapy Use of high-energy rays or particles to kill cancer cells. The two main types of radiation therapy are external beam radiation and brachytherapy (internal radiation). 6 Radical prostatectomy Surgery to remove the entire prostate gland plus some surrounding tissue to remove the cancer. 6 Recurrence Risk An assessment of how likely it is that prostate cancer will come back, depending on a combination of factors that include changes in the blood PSA level, Gleason score and staging of the tumor. Recurrence risk is an important consideration when determining treatment options. 7 Transrectal biopsy Insertion of needles through the rectum into the prostate to remove small tissue samples that are evaluated by a pathologist for cancer. 1 Transrectal ultrasound Insertion of a probe that acts as an ultrasound into the rectum to check the prostate for abnormal areas. 1 Additional Resources Non-Profit Support and Advocacy Organizations American Cancer Society CancerCare Cancer Support Community Men s Health Network Prostate Cancer Foundation Prostate Conditions Education Council Prostate Health Education Network 9

10 Prostate Net The Prostate Cancer Research Institute Us TOO International Prostate Cancer Education and Support Network Women Against Prostate Cancer ZERO - The Project to End Prostate Cancer Government and Professional Societies American Society of Clinical Oncology (ASCO) American Urological Association (AUA) American Urological Foundation National Comprehensive Cancer Network (NCCN) National Cancer Institute 10

11 References 1. National Cancer Institute. What you need to know about prostate cancer. Published September Accessed September 29, Joniau S, Van Poppel H. Localized prostate cancer: can we better define who is at risk of unfavourable outcome? Br J Urol Int Mar;101(suppl 2): Jemal A, Siegel R, Xu J, Ward E. Cancer Statistics, CA Cancer J Clin. 2010; 60; American Cancer Society. Cancer Facts & Figures Atlanta, GA: American Cancer Society; National Cancer Institute. Understanding prostate changes: a health guide for men. booklet.pdf. Published September Accessed September 29, Prostate Cancer Foundation. An introduction to prostate cancer. E15C5D8BB6B1%7D/IntroProstateCancer.pdf. Accessed September 29, National Comprehensive Cancer Network. NCCN guidelines for patients, prostate cancer. V Accessed February 3, Chen Y, Clegg NJ, Scher HI. Anti-androgens and androgen-depleting therapies in prostate cancer: new agents for an established target. Lancet Oncol. 2009;10: Perlmutter MA, Lepor H. Androgen deprivation therapy in the treatment of advanced prostate cancer. Rev Urol. 2007;9(suppl 1):S3-S Levine GN, D Amico AV, Berger P, et al, on behalf of the American Heart Association Council on Clinical Cardiology and Council on Epidemiology and Prevention, the American Cancer Society, and the American Urological Association. Androgen-deprivation therapy in prostate cancer and cardiovascular risk. A science advisory from the American Heart Association, American Cancer Society, and American Urological Association. Circulation. 2010;121: Immunotherapy. Dictionary of Cancer Terms. U.S. Department of Health and Human Services. National Institutes of Health. National Cancer Institute. cancer.gov/dictionary/?cdrid= Accessed September 15, Hotte SJ, Saad F. Current management of castrate-resistant prostate cancer. Curr Oncol. 2010;17(suppl 2):S72-S Brawer M. New treatments for castration-resistant prostate cancer. Rev Urol. 2008;10(4): Hofland J, van Weerden WM, Dits NF, et al. Evidence of limited contributions for intratumoral steroidogenesis in prostate cancer. Cancer Res. 2010;70(3): Chan R, Lok K, Woo J. Prostate cancer and vegetable consumption. Mol Nutr Food Res Feb;53(2): Venkateswaran V, Haddad AQ, Fleshner NE, et al. Association of diet-induced hyperinsulinemia with accelerated growth of prostate cancer (LNCaP) xenografts. J Natl Cancer Inst. 2007;99(23): Antonelli JA, Jones LW, Bañez LL, et al. Exercise and prostate cancer risk in a cohort of veterans undergoing prostate needle biopsy. J Urol. Epub 2009 Sep Huncharek M, Haddock KS, Reid R, Kupelnick B. Smoking as a risk factor for prostate cancer: a meta-analysis of 24 prospective cohort studies. Am J Public Health. 2010;100(4): Gong Z et al. Alcohol consumption, finasteride, and prostate cancer risk: results from the Prostate Cancer Prevention Trial. Cancer, 2009 Aug 15;115(16): Carroll PR, Carducci MA, Zietman AL, Rothaermel JM. Report to the nation on prostate cancer: a guide for men and their families. Santa Monica, CA: Prostate Cancer Foundation; National Comprehensive Cancer Network. Prostate cancer--advanced. Accessed May 16, Heinlein CA, Chang C. Androgen Receptor in Prostate Cancer. Endocrine Reviews April;25(2):