Learning About Prostate Cancer

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1 Learning About Prostate Cancer

2 Table of Contents Introduction... 1 Clinical services... 1 Appointment scheduling information... 1 Follow-up and support... 2 Prostatectomy... 2 External beam radiation... 5 Brachytherapy (seed implantation)... 7 Cryosurgery... 9 Glossary... 12

3 Prostate Cancer Prostate cancer is one of the most commonly diagnosed cancers in men today, but it is highly curable when detected early. Physicians at the Allegheny Health Network Prostate Center, together with specialists from the AHN Cancer Institute, successfully provide innovative prostate cancer treatments to hundreds of men each year. Our specialists are leaders in their field and have helped advance prostate cancer treatments through their research and use of state-of-the-art techniques. The Prostate Center, which opened in 1996, has a multidisciplinary team of physicians from various medical specialties who work closely with each patient to tailor a treatment plan to your unique needs, health situation and preferences. Our goal is to help you detect prostate cancer early, provide you with the most effective treatment options and help you to maintain an active, healthy life after treatment. This booklet is intended to provide general background information about prostate cancer and its treatment. It is our hope that you will learn as much as possible about your condition and the treatment options available to you so that you may be more comfortable with making decisions about how to proceed with your care and recovery. Clinical Services The Prostate Center is designed to specifically meet the needs of patients with recently diagnosed or recurrent prostate cancer. At your first appointment, you will spend two to four hours at the center, where you will typically be evaluated by both a urologist and a radiation oncologist. These physicians will review your medical records, imaging studies and pathology slides. The center is equipped to perform transrectal ultrasound of the prostate, if necessary. During your visit, the physicians will discuss your unique situation with each other and share their impressions and recommendations with you and any family/friends in attendance. Possible treatment options include: Prostatectomy: Standard retropubic prostatectomy or da Vinci prostatectomy (robotic) External beam radiation Brachytherapy (seed implantation) Cryosurgery Hormonal ablation therapy alone or in combination with other treatments Observation (watchful waiting) Chemotherapy Research protocols The physicians will provide a description of each approach and will make a recommendation as to which treatment or treatment combinations they believe are most appropriate in your case, along with the reasoning behind their advice. You and your family/friends in attendance are encouraged to ask questions and voice any concerns. Our philosophy is that, although we can provide you guidance, you ultimately must make the decision he believes that is best for you and your own situation. 1

4 Appointment Scheduling 1. To be seen at the Allegheny Prostate Center, please call , weekdays between 9 a.m. and 5 p.m. 2. The main clinical site for the Prostate Center is located at 1307 Federal St., Suite 300 (Third Floor). 3. Parking is available on site. 4. What to bring to your first appointment: All pertinent medical records, including operative reports, X-ray reports and pertinent office records, particularly PSA reports. Copies of actual films from your bone scan, CT scan and MRI scan, if these have been done. Pathology slides and reports. A significant other or a friend you trust. It always helps to have a second set of ears and another person to ask questions. Support Services When a man is diagnosed with prostate cancer, it means more than having a physical condition; it is an emotional experience, too. We understand that fighting cancer can take every ounce of a patient s physical strength and mental health. And we know that treatment is about much more than battling the disease; it s about addressing the other challenges that arise along the way. Our physicians, nurses and comprehensive team of health-care professionals are committed to providing you and your family with the comfort, resources and support needed while receiving treatment and managing your recovery. We ensure that your care is seamless, as we help you to navigate the treatment process whether it s at one of our hospitals, one of our outpatient cancer centers, or your home. Our services include: Psychological and/or psychiatric counseling to help handle emotions that arise during and after the course of treatment. Social work services to help you locate services, programs and other resources in your community, such as support groups and financial assistance programs. Treatment Options Prostatectomy Prostatectomy has been practiced for more than 100 years as a treatment for prostate cancer. However, it has been refined greatly in recent years such that results and patient-experience are much better than they were only a decade or two ago. Currently, the great majority of prostate removal surgeries are performed in a minimally invasive way. In other words, the surgery is performed via several small punctures rather than a large incision. Our doctors have extensive experience with all of the major techniques for prostate removal and currently are employing robotic assist laparoscopic prostatectomy (DaVinci prostatectomy), including nerve sparing for the great majority of men who opt for prostate removal as treatment. Men who are good candidates for this type of treatment have prostate cancer that is likely confined to the prostate. These men should also have adequate health and fitness such that surgery and anesthesia do not pose a major risk. Prostatectomy tends to be the most popular choice for men who are younger at the age of diagnosis. 2

5 What exactly is the prostate and what does it do? The prostate is a walnut-sized gland located between the bladder and the penis that helps to make semen. What is a PSA? PSA stands for prostate-specific antigen, which is a substance made by cells in the prostate gland (both normal cells and cancer cells). PSA is mostly found in semen, but a small amount is also found in the blood. Most healthy men have levels under 4 nanograms per milliliter (ng/ml) of blood. The chance of having prostate cancer goes up as the PSA level goes up. When prostate cancer develops, the PSA level usually goes above 4. Still, a level below 4 does not guarantee that a man doesn t have cancer about 15 percent of men with a PSA below 4 will have prostate cancer on a biopsy. Men with a PSA level between 4 and 10 have about a 1 in 4 chance of having prostate cancer. If the PSA is more than 10, the chance of having prostate cancer is over 50 percent. The American Cancer Society recommends that men make an informed decision with their doctor about whether to be tested for prostate cancer. Research has not yet proven that the potential benefits of testing outweigh the harms of testing and treatment. The American Cancer Society believes that men should not be tested without learning about what we know and don t know about the risks and possible benefits of testing and treatment. Starting at age 50, men should talk to a doctor about the pros and cons of testing so they can decide if testing is the right choice for them. If they are African American or have a father or brother who had prostate cancer before age 65, men should have this talk with a doctor starting at age 45. If men decide to be tested, they should have the PSA blood test with or without a rectal exam. How often they are tested will depend on their PSA level. What is a prostatectomy? It is the removal of the entire prostate, the seminal vesicles (small sac-like organs attached to the back side of the prostate) and some surrounding tissue. In some cases, some lymph nodes are removed at the time of surgery as well. Why is prostatectomy still popular when there are non-surgical and less-invasive treatments available? Some of this has to do with physician and patient preference, but the major factor is probably the prostatectomy s long history of effectiveness. Cure rates in the 90+ percent range are expected when the tumor proves to be confined to the prostate. Although there is certainly some debate in this area, long-term (15-year) survival rates are generally believed to be somewhat better than with the other treatment options. PSA is expected to be undetectable after prostatectomy, and this makes follow-up fairly simple and worry-free. Prostatectomy does not carry any of the long-term risks associated with radiation therapy such as secondary malignancy or bleeding problems that can occur in a small percentage of patients many years after radiation. What happens during a typical hospitalization for a prostatectomy? You are admitted to the hospital on the same day as the surgery, having taken laxatives at home in the days prior to arrival. The surgery itself is performed under general anesthesia and typically takes about two hours. Following surgery, you spend several hours in the recovery room and are then transferred to a regular hospital room for the remainder of their stay. The typical stay in the hospital is one to two days if there are no complications. 3

6 You have a catheter draining your bladder, which stays in for approximately 10 days. You are taught how to care for this. Very quickly after surgery, you are encouraged to do deep breathing exercises, to get out of bed and to begin walking. The diet is slowly advanced, first to clear liquids and then usually to full liquids (things like pudding) before discharge. IV lines and drains are removed prior to discharge. What is follow-up care like? An office appointment at about 10 days after surgery is necessary to remove any skin staples and the catheter. After this, you are instructed to get PSA blood tests at regular intervals, usually every three to four months for the first two years and then less frequently thereafter. You are taught exercises that aid in recovery of urinary control and given the option of medicine or injections for the purpose of sexual rehabilitation. This is highly recommended to begin soon after surgery for patients who wish to resume having sexual intercourse in the future. How long does full recovery take? This varies widely from patient to patient, but there are some general rules of thumb. You should not drive a car for 10 days after surgery and should not lift anything over 10 pounds for three weeks. After the catheter is removed, there is a period of incontinence (involuntary urinary leakage) lasting from a few days to several months, depending on the individual. You may feel tired and require extra rest for about a month after surgery. If you have a non-strenuous job and desire to return to work quickly, you can usually go back to work part-time after the catheter is removed. Patients who do heavy manual labor typically need to be off work for six to eight weeks. What are some of the drawbacks of prostatectomy? Even though prostatectomy has been refined and considerably improved during the past two decades, it is still a major operation and has significant risks (see below). An additional drawback is that despite our best testing and effort before the surgery, we will discover in about 20 percent of the cases after the prostate is removed that the tumor goes beyond the capsule of the prostate. For these men, the long-term cure rate is lower than the 90+ percent cure rate when the cancer is contained. What risks and complications are associated with prostatectomy? Certainly most patients do just fine, but some of the most important and most frequent risks are: Bleeding: This surgery always involves some blood loss. Our experience with robotic prostatectomy has shown dramatically lower blood loss than with open prostatectomy. We no longer recommend self-donation of blood or directed donation from a family member. Only about 2 percent of patients will bleed enough that they will need a transfusion. Infection: Wound infections or urinary infections are unusual. The medical literature shows that the risk of infection with robotic surgery is lower than it is with open surgery. Impotence: Even with modern nerve-sparing techniques, loss of potency is experienced in about 30 percent of patients who were potent before surgery. The younger the patient and the better his potency before surgery, the more likely he is to get good recovery of erectile function after surgery. We recommend a specific erectile rehabilitation program after the surgery to encourage return of function. It is important to remember that recovery is occurring for at least 18 months after surgery. Incontinence: All patients have some leakage immediately after the catheter comes out. About 2 percent of patients will still have enough leakage that they require a pad for more than a year after surgery. About 20 percent of patients will have a slight or very infrequent amount of leakage not requiring pads. We recommend a specific exercise program after surgery to hasten return of urinary control. At least half of patients will not require pads by their six-week post-operative office visit. Damage to adjacent organs: Less than 1 percent of the time, structures such as the rectum or ureters can be damaged during the operation. Usually these injuries can be repaired at the same time as the initial surgery. 4

7 Death: Less than 1 percent of the time, a patient can have a catastrophic problem such as a heart attack or embolus (blood clot to the lungs) during or after surgery that can lead to the patient s death. How will my lifestyle be changed by having my prostate removed? Your life should change very little. After the initial post-op period, you should feel well. You should urinate normally and carry on all activities as you did before. You will no longer be fertile and may need assistance to be potent. There will also be no semen produced when you ejaculate. Other than these changes, you will likely be back to normal. Da Vinci Prostatectomy Da Vinci prostatectomy refers to a technique in current widespread use to remove the prostate. It is performed with a sophisticated surgical device called the da Vinci robot that assists the surgeon to remove the prostate laparoscopically. The operation itself is very similar to the standard prostatectomy, with the same structures being removed. The da Vinci robot assists the surgeon by providing excellent visibility and fine movements of small surgical arms within your body. The robot does not do any surgery on its own, and is not programmed to do any operating by itself; it is completely controlled by the surgeon. Advantages include less blood loss, less postoperative discomfort, and faster return to full activities. It is important to note that not all patients with prostate cancer are good candidates for robotic prostatectomy. It is also important to know that the same types of complications are possible with robotic prostatectomy as with standard prostatectomy as noted above. External Beam Radiation External beam radiation therapy (EBRT) has the advantage of being the only completely non-invasive treatment for prostate cancer. No anesthesia is involved, and the treatment is painless. Effectiveness is similar to the other major treatments in patients who have low-risk prostate cancer. EBRT has several subtypes with names like IMRT (intensity modulated radiation therapy), IGRT (image guided radiation therapy), Cyberknife, and proton beam radiation therapy. Your radiation oncologist can explain the differences between these. EBRT is a popular choice for patients who cannot tolerate or who wish to avoid anesthesia. What is external beam radiation? External beam radiation involves the use of focused beams of radiation that are produced electronically by a treatment machine (linear accelerator) to treat malignant and nonmalignant tumors. External beam radiation is a completely non-invasive technique; radiation is invisible, tasteless and odorless. No radiation remains with the patient after treatment. External beam radiation is typically delivered on a daily basis, five days a week over several weeks (seven to nine) for 15 to 20 minutes each day. Radiation can also be delivered internally with radioactive sources (brachytherapy). How does radiation work? Radiation works by damaging cancer cells and interfering with their ability to grow and divide. Normal cells can repair the effects of radiation but cancer cells cannot. By delivering radiation over several weeks, we take advantage of the damaging effect on tumor tissues and the ability of normal tissues to repair. The 5

8 other way that we increase the radiation effect on tumor tissues is by accurately focusing radiation on the prostate and minimizing the dose to nearby normal tissues. How is radiation directed at the prostate? We combine precise imaging (CAT scans), using our dedicated simulator, sophisticated computerized treatment planning (IMRT) and accurate daily prostate localization (8-Mode Acquisition and Targeting, or BAT) to enable us to focus the radiation on the prostate and minimize the dose to the rectum and bladder, which are near the prostate. With IMRT, we are able to assess, monitor and limit the dose of radiation to the bladder and rectum. With BAT ultrasound localization, we can adjust the location of the radiation beam to the exact location of the prostate at the time of treatment. By combining these two modalities, we can deliver high doses of radiation to the prostate while substantially decreasing the risk of rectal bleeding (from 15 percent to less than 2 percent, according to published studies). We are thus able to significantly reduce the use and side effects of hormone deprivation (Lupron and Zoladex) and achieve high cure rates for prostate cancer. Who is involved in the radiation therapy process? Due to the technically sophisticated nature of external beam radiation, many staff members are involved in developing the individualized plan for treatment and in the delivery of the treatment. These staff members include: Radiation oncologist, the physician who oversees all aspects of your care while you undergo radiation therapy. Physicists and dosimetrists who create the plan for treatment and perform the quality assurance on the treatment plan and its delivery. Radiation therapists who deliver the daily radiation treatment. Radiation oncology nurse who helps with scheduling and provides side-effect teaching and management. What are the steps involved in receiving external beam radiation? After consultation with your urologist and radiation oncologist, and once a decision to proceed with external beam radiation is made, the first step is to schedule a simulation. The simulation is a specialized radiation planning CT scan, which is performed with you lying on you back on the simulator table. First, a mold is made to hold you in the same position throughout the treatment, and we then conduct a CT scan, which takes less than a minute. The CT images are downloaded into the simulator computer where the prostate is outlined by the radiation oncologist. Small localization tattoos are placed on the treatment site, and this concludes the first visit. The computerized treatment planning process begins. All of the pelvic organs are delineated and the anatomy is recreated in the computer in 3-D. The physicist and dosimetrist, along with the radiation oncologist, develop a treatment plan that optimizes the dose to the prostate and minimizes the dose to the bladder and rectum. The dose limitations are known, and the plan is modified as needed to maintain the prescribed dose limitations. The planning and quality assurance process can take a week to complete. After the plan meets the established, rigorous standards, you return to the hospital for verification films, and then the daily treatment begins. Each day, you arrive for treatment at the designated time, and the therapist positions you on the treatment couch. Before treatment, prostate localization is performed using a trans-abdominal ultrasound probe. The therapist can visualize the prostate, and the couch position is 6

9 adjusted based on the prostate location. This takes less than two minutes. The therapist then leaves the room and the treatment is given. Typically, five treatment angles are used, and the treatment takes 15 to 20 minutes. After treatment, you can resume normal activity without limitations. What are the side effects and risks? Since external beam radiation is entirely non-invasive, you will not feel anything immediately after treatment. As treatments progress, some side effects may occur. The typical side effects include mild fatigue, which resolves in one to two months; possible bladder irritation or difficulty initiating a urinary stream, which can be commonly relieved with medications; rectal irritation or diarrhea, which can be controlled with diet or medications; and mild skin irritation, which is rare. The radiation oncologist and nurse will evaluate you weekly to help monitor and treat possible side effects. Long-term (more than five years after treatment) side effects and complications from radiation therapy are uncommon. An example of this would be rectum or bladder damage that could result in bleeding or the need for surgery. Impotence commonly occurs several years after receiving radiation. There is also a low incidence of a secondary malignancy, such as bladder cancer, that can occur eight years or longer after receiving radiation therapy. What are some of the drawbacks of radiation therapy? One drawback is that if the cancer is not eliminated by the radiation treatment, that surgical removal of the prostate is usually not possible later. This is why prostate cancer doctors recommend radiation therapy for patients who have a high chance of cure. For patients with a lower chance of cure, additional treatment combinations may be recommended. An additional drawback is the need for seven to nine weeks of treatments at a center, five days a week. What type of follow-up care is necessary? Your urologist and radiation oncologist will typically follow you after radiation therapy, at intervals of three to six months. Follow-up usually entails a PSA blood test and physical examination. It can take two years or more for PSA to decline to its minimum value after radiation therapy. Brachytherapy (Seed Implantation) Prostate brachytherapy, or seed implantation, is a popular treatment choice in the United States for men with localized prostate cancer. It essentially works by concentrating radiation within the target organ (the prostate in this case) while minimizing radiation to surrounding structures, such as the bladder and rectum. Advantages of this treatment include its highly effective concentration of radiation and the fact that only one treatment is necessary. Brachytherapy has been a good solution for many patients who cannot take much time away from work or other obligations for surgical recovery or for weeks of trips to the radiation treatment center. The effectiveness (or cure rate) for brachytherapy is similar to the other major treatment options for patients with low-risk prostate cancer. What is seed implantation? Seed implantation, otherwise known as brachytherapy, refers to the placement of radioactive material into tissues. Prostate brachytherapy refers to utilizing a minimally invasive technique to place radioactive sources (contained within a metallic casing) directly into the prostate. Hollow needles are placed into the prostate in the operating room, and the radioactive seeds are inserted into the prostate through the hollow needles. Ultrasound and computerized treatment planning in the operating room achieve accurate placement of seeds. 7

10 The advantage to this approach of delivering radiation is the ability to accurately deliver a high dose of radiation directly into the prostate while minimizing the radiation dose to the nearby tissues and organs. Patients are usually discharged from the hospital within hours of the procedure, and patients return to normal function within several days. Is seed implantation a new procedure? The concept of seed implantation into tumors was first utilized more than 100 years ago. The treatment of prostate cancer with brachytherapy dates back to the 1970s, using relatively primitive techniques. Modern prostate brachytherapy techniques were developed in the late 1980s and were further perfected in the 1990s with the advent of improved ultrasound technology. In 2000, we implemented real-time 3-D intraoperative computerized treatment planning to assure optimal placement of radioactive sources and minimize the dose to the bladder and rectum. These tools have enabled us to minimize side effects and maximize cure rates. Follow-up data have recently been published with excellent 15-year results, making prostate brachytherapy a viable treatment option for select patients. Who is a candidate for seed implantation? Men with prostate cancer that is localized to the prostate (i.e., PSA<10, Gleason Score 6 or under, or clinical staget1c or T2a) are candidates for prostate brachytherapy. Men with more advanced disease (disease just beyond the capsule of the prostate) may be candidates for seed implantation after five weeks of external beam radiation. Patients might not be candidates if their prostate is larger than 50 grams in size or if the patient has had the transurethral resection of the prostate (TURP) procedure. How is seed implantation performed? A urologist performs a volume measurement of the prostate using transrectal ultrasound. Appropriate seeds are ordered, and the date of the procedure is determined. On the day of the procedure, you are admitted to the hospital as an outpatient. General or spinal anesthesia can be used. Hollow steel needles are placed into the prostate through the perineum (the skin in front of the rectum and behind the scrotum). The radiation oncologist then uses a specialized gun to place rows of seeds into the prostate through the needles. The intraoperative computer is used to model the prostate and determine where additional needles and seeds should be placed. Once this is accomplished, the urologist looks into the bladder and inserts a Foley catheter. The entire procedure takes less than one hour. Once you wake up from the anesthetic, the Foley catheter is removed, and you are discharged from the hospital. What happens to the seeds? The radioactive seeds stay inside the prostate forever. The radiation produced by the seeds goes away (decays) over time. If Palladium Pd 103 seeds are used, the radiation decays to nearly undetectable traces in three months; if Iodine I125 seeds are used, the radiation decays to nearly undetectable amounts in six months. Do radiation precautions need to be followed? The body blocks most of the radioactivity that is produced by the implant. However, some radioactivity may be given off during the time periods listed above. Bodily fluids are never radioactive. The Nuclear Regulatory Commission (NRC) has not recommended radiation precautions for implant patients. Nevertheless, we recommend the following: Children should not sit on your lap for more than five minutes a day for two months after an implant. Pregnant women should avoid close contact with you for more than a few minutes up to two months after an implant. 8

11 What are the side effects/risks? Ten percent of patients will require a catheter for several days after the implant. Very few patients will need a catheter for an extended period. You may experience blood in the urine, which will resolve on its own. Few, if any patient, develop an infection, as all patients receive antibiotics before the procedure. The most common side effects are related to urinary symptoms. You will likely experience some degree of urinary frequency and urgency. You may also experience a sensation of burning during urination and the need to get up at night to urinate more frequently. After a palladium implant, urinary symptoms usually last from two weeks to six months, and after an iodine implant, these symptoms can last from two weeks to nine months. There are medications that can help alleviate these symptoms in most cases. Patients rarely experience rectal irritation or bleeding, and it is rare for an implant to result in damage to the bladder or rectum causing bleeding and/or pain. It is also reported, but unusual, for patients to develop bladder cancer years after radiation to the prostate with seed implant. Impotence has been reported in 15 percent of patients two years after the implant and 40 percent of patients four years after the implant. Patients often experience a dry ejaculate, whereby they are able to have a normal-feeling erection and intercourse, but their ejaculation is dry. What type of follow-up care is necessary? Your urologist and radiation oncologist will schedule an appointment to see you after the implant. A CT scan of the pelvis will be performed one month after the implant to evaluate dosimetry, as well as a PSA test and physical exam at least every six months. We expect the PSA to decline to its minimum level, usually less than one, by two years after implant. What about diet and activity after the procedure? Usual diet can be resumed the day after the procedure. We ask that you avoid heavy lifting or strenuous physical activity for the first two days after the procedure. After that, normal activity (including driving) can be resumed. What are some of the drawbacks of seed implantation? Most patients are cured by seed implant and are pleased with the results. For the low percentage of patients who are not cured, surgical removal will probably not be possible later. Also, a small percentage of patients have much more than the usual amount of urinary side effects. Prostate Cryosurgery Prostate cryosurgery is a minimally invasive treatment for prostate cancer that does not employ surgical removal or radiation to treat prostate cancer. Advantages include rapid return to normal activities with an absence of surgical or radiation side effects. Cryosurgery is also sometimes used to treat cancer that has recurred in the prostate after radiation treatment. What is cryosurgery? Cryosurgery of the prostate means freezing of the prostate to eradicate cancer. This procedure is currently being performed in a minimally invasive way by inserting specialized cryoneedles into the prostate via the perineum (the small space between the back of the scrotum and the anus). These needles are inserted, and the freezing process is monitored, in a very precise way using ultrasound guidance. Temperature sensors also are used to guide the process. There is no incision needed. The procedure can be done under general or spinal anesthesia and it takes about an hour. 9

12 What are the risks, complications and potential benefits of cryosurgery? As cryosurgery has evolved over the past 15 years, there has been a significant drop in the risk of complications associated with the procedure historically. Incontinence occurs in less than 2 percent of patients treated, although the risk is higher in patients who have had previous radiation to the prostate. Damage to the bladder or rectum occurs in less than 1 percent of cases. Impotence is quite common after cryosurgery (approximately 80 percent chance) though newer protocols are being developed to address this issue in selected patients. How long will I have to be in the hospital? The average length of stay for our patients is one day. Some patients can even go home the same day as the surgery. Immediately after surgery, you are taken to the recovery area and monitored until we determine that you can safely return to your regular room. Most of our patients are able to eat a small meal that same night. You can get up and move about. Some patients will have a suprapubic tube a small tube below the belly button to drain urine after the procedure. This tube will be removed at a subsequent office visit, and you will be taught before your discharge how to use this tube until it is removed. Other patients with have a Foley catheter the type of tube that exits the penis will also have it removed at a subsequent office visit. What about follow-up testing? We recommend a PSA blood test every three months after cryosurgery for the first two years and then every six months after that. Sometimes a follow-up prostate biopsy will also be recommended. Tests such as bone scans and CT scans are ordered on an as-needed basis. How successful is cryosurgery? Prostate cryosurgery appears to have very similar long-term results compared to external radiation or brachytherapy. The odds of being cancer-free 10 years after treatment is about 81 percent for low-risk patients, 74 percent for intermediate-risk patients, and 46 percent for high-risk patients. These percentages refer to patients treated with cryosurgery only, and increase when other treatments are added in combination. What type of patient is a good candidate for cryosurgery? In our experience with cryosurgery, we have found that this procedure often works well in patients who are at high risk of failing more conventional treatments. Such patients include those with large, bulky tumors (Stage T3), patients with high-grade tumors (Gleason score 8, 9 and 10) and in patients with a high initial PSA, such as greater than 15. Cryosurgery is often used in combination with other treatments for high-risk patients to improve odds of success. Cryosurgery is also often used for patients who have failed radiation therapy. Active Surveillance Prostate cancer is, in most (but not all) cases, a very slowly growing type of cancer. It is often said that if a man lives long enough, that he will likely develop prostate cancer at some point. This is said because autopsy studies show that nearly all men ages 90 and older have at least a little prostate cancer. Most men who have prostate cancer do not die of prostate cancer. This is especially true of elderly men diagnosed late in life. These facts lead to an attractive option for some patients: if a man has a small amount of a slow-growing type of prostate cancer, and his age or health is such that his life expectancy is 10 years or less, he may consider not having any treatment at all for the cancer, at least initially. Under these circumstances we can 10

13 often safely follow these patients conservatively by checking a PSA and an exam at intervals. Sometimes follow-up biopsies are recommended as well. Treatment can, of course, be started at any time that the patient and physician choose. Reference Materials In addition to this booklet, the AHN Prostate Center maintains an informative website at We also recommend the following websites: Contact Us Allegheny Health Network Prostate Center 1307 Federal Street Suite 300 Pittsburgh, PA

14 Glossary Androgen (AN-dro-jen): Any hormone that produces male physical characteristics and supports a wide range of physiologic functions. The main androgen hormone is testosterone. Benign: A term for a tumor or tissue that does not behave like cancer. Brachytherapy (bray-kee-ther-uh-pee): Another name for various types of internal radiation therapy; sometimes called seeds. Cancer: A tumor with abnormal cells that grow and divide without control. Cancer cells can sometimes spread through the blood and lymph to other organs, or grow invasively into surrounding structures. Capsule: The layer of cells around an organ, such as the prostate, that forms the boundary of the organ. Cells: The basic structural and functional unity of the body. Chemotherapy (key-mo-ther-a-pee): Treatment with drugs that attack cancer cells. These drugs may be administered by IV or by mouth. Clinical trials: Studies conducted on patients with cancer or other diseases, usually to evaluate a new treatment. Each study is designed to answer specific questions and to find better ways to treat patients. Digital rectal examination or DRE: An examination performed by a physician in which a gloved, lubricated finger is inserted into the rectum to feel the prostate. External beam radiation therapy: Radiation therapy directs rays from a machine to different parts of the body to kill cancer cells. See section on Radiation Therapy. Grade: Cancer grade is a subjective estimate about how aggressive a cancer is likely to be. The grade is based on how biopsy tissue appears under the microscope. The most common grading system used for prostate cancer is the Gleason Grade. This is a numerical scale ranging from Cancers rated as 2 are the slowest growing and least likely to spread, and cancers rated as 10 are the most rapidly growing and most likely to spread. In practice, most cancers that we see are rated 6 or above. Grade 6 cancer tends to grow slowly and be unlikely to spread. Hormone therapy: By using medication or surgery to reduce the amount of testosterone produced by the body, prostate cancer can be stopped or slowed down. Impotence (IM-po-tens): Inability to have an erection. Incontinence (in-kon-tin-nens): Loss of urinary control. Internal radiation therapy: Treatment with high-energy radiation from tiny radioactive seeds inserted into the prostate to kill the cancer. Low-risk prostate cancer: A type of prostate cancer as defined by low grade (Gleason grade 6 or less), low stage (stage T2a or less), and low PSA at diagnosis (less than 10). 12

15 Lymph: A nearly clear fluid collected from tissues around the body and returned to the blood by the lymphatic system. Lymphatic system: Vessels that carry lymph are part of this system. Other parts include lymph nodes and several organs that produce and store infection-fighting cells. Lymph nodes: Small bean-shaped structures scattered along the vessels of the lymphatic system. The nodes filter out bacteria and cancer cells that my travel through the system. Malignant: A term for a tumor that can invade surrounding tissues and/or spread to other parts of the body. Medical oncologist: A doctor who specializes in treating cancer with chemotherapy or other medications. Metastasis (meh-tass-tuh-sis): The spread of cancer from its original site to distant areas via blood or lymph. Orchiectomy (or-key-eck-toe-mee): The surgical removal of the testicles, the major source of male hormones. Prostate Specific Antigen or PSA: This is a substance that is produced both by normal prostate tissue and by prostate cancer tissue. Tiny amounts of this substance leak into the bloodstream and can be measured by a blood test. Men with prostate cancer tend to have higher levels of PSA in their bloodstream. The PSA blood test is used both as a screening test to detect prostate cancer at its earliest stages, and also as a follow-up test after treatment to assess how successful treatment has been to cure the condition. Palliative therapy (pa-lee-a-tive): A therapy that is intended to provide relief but is unlikely to cure a disease. Pathologist (pah-thal-o-jist): A doctor who specializes in diagnosis disease by studying cells and tissues with a microscope. Perineal prostatectomy (pair-in-nee-al prah-stah-tek-toemee): An operation to remove the prostate gland through an incision made in the perineum, the area between the scrotum and the anus. Prognosis: A prediction made as to the potential outcome of a disease. Prostatectomy (prah-stah-tek-toe-mee): The surgical removal of the prostate gland. Radiation oncologist: A doctor who specializes in treating cancer with radiation therapy. Radiation therapy: Treatment with high-energy rays, such as those from X-rays or other sources of radiation. Rectum: The last five or six inches of the intestine leading to the outside of the body. Retropubic prostatectomy: (reh-tro-pyoo-bik): An operation to remove the prostate gland through an incision made in the lower abdomen. Scrotum (SKRO-tum): The external sac, or pouch, containing the testicles. 13

16 Seminal vesicles: Small organs attached to the back of the prostate gland that also produce semen and which are removed as part of a prostatectomy. Occasionally cancer that starts in the prostate can grow in to the seminal vesicles. Stage: A term used to describe the size, extent and spread of cancer. The stage is like a snapshot in time of how much cancer is present and if it is confined to the primary organ (prostate in this case) or not. This is different from the grade of the cancer. See definition of Grade above. Testicles: Two egg-shaped glands that produce sperm and sex hormones. Testosterone (tes-tos-ter-own): A male sex hormone produced chiefly by the testicles. Testosterone has many normal functions, and also can stimulate the growth of prostate cancer in men who have that condition. Tissue: A group of cells organized to perform a specialized function. Transrectal ultrasonography: Using sound waves produced by a device inserted into the rectum to produce a picture of the prostate. Transurethral resection of the prostate: The use of a special instrument inserted through the urethra in the penis to remove noncancerous prostate tissue. Also called TUR or TURP. Tumor: An excessive growth of cells resulting from uncontrolled and disorderly cell replacement causing the formation of a mass or lump. Ureter (YUR-e-ter): The tube that carries urine from each kidney to the bladder. Urethra (ye-reeth-rah): The tube running through the penis to the outside of the body. It carries urine from the bladder and semen from the sex glands. Urologist: A doctor who specializes in diseases of the genitourinary system. Watchful waiting and active surveillance: This is when doctors follow a man with slow-growing prostate cancer conservatively by checking his PSA and performing an exam at intervals. Sometimes follow-up biopsies are recommended as well. 14

17 Prostate Center 1307 Federal Street Suite 300 Pittsburgh, PA AHN An equal opportunity employer. All rights reserved. AHN /15 cd/sb

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