PROSTATE CANCER. Get the facts, know your options. Samay Jain, MD, Assistant Professor,The University of Toledo Chief, Division of Urologic Oncology

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1 PROSTATE CANCER Get the facts, know your options Samay Jain, MD, Assistant Professor,The University of Toledo Chief, Division of Urologic Oncology i

2 What is the Prostate? Unfortunately, you have prostate cancer but there is no reason to lose hope. Survival rates for prostate cancer are among the highest, and you have many treatment options available. This booklet will help guide you through the process from diagnosis to treatment. While information about prostate cancer is widely available from books, newspapers, the Internet or even friends and family, please be aware that not all of that information is valid for you. No two prostate cancers are the same, just as no two people are the same so what worked for a friend or family member may not be the best treatment strategy for you and your cancer. The treatment for your prostate cancer should focus on three main outcomes: cancer control, maintenance of continence (urinary control), and, if applicable, a healthy sex life. As urologists, we understand that all three of these outcomes are important to you and so we work to maximize all three. However, keep in mind that your treatment should be focused on a cure, and that cancer control should never be compromised to ensure the other two outcomes. Figure 1 Male urinary tract The prostate is a gland that resides below the bladder in the pelvis. It is in front of the rectum and under the pubic bone. The prostate s main function is to secrete the seminal fluid that makes up a majority of semen. An illustration of the prostate can be seen in Figure 1. The exact reason why men develop cancer in the prostate is not well understood, but seems to be a function of aging and possible genetic factors. ii 1

3 What kind of cancer do I have? All prostate cancer management strategies depend on the individual characteristics of your tumor and the risk category of your cancer. We are going to spend a little time reviewing what you should know about your cancer before deciding on a strategy for managing your disease. These characteristics are all listed concisely in Table 1. Cancer Characteristic Low Risk Intermediate Risk High Risk PSA greater than 20 Gleason Score or 4+3 Volume less than 2 cores positive PSA Density less than 0.15 Rectal Exam Findings At some point prior to your biopsy, your doctor should have checked your prostate with his or her finger; this is called a digital rectal exam (DRE). The results of a DRE refer to whether or not your cancer can be felt, and if so, where it is detected. If your cancer cannot be felt, it considered low risk (stage T1c). If a nodule is palpated on DRE, but it is confined to the borders of the prostate, your cancer is considered intermediate risk (stage 2a or b). If your cancer is large enough to be palpated and is growing outside of the prostate, this is indicative of high-risk disease (stage T3 or T4). These findings are represented in Figure or any component of 5 greater than 2 cores positive greater than 0.15 Rectal Exam Findings T1c T2a or T2b T3 or T4 Table 1 Risk Categories for Prostate Cancer Figure 2 Stages of Prostate Cancer PSA You should know your PSA. This value can be used to gauge, or risk stratify your cancer. A value of 0 to 10 is indicative of low-risk prostate cancer. A value between 10 and 20 represents intermediate risk and a value greater that 20 indicates high-risk disease. Gleason Score Donald Gleason was a pathologist who determined that the architectural structure of prostate cancer glands as viewed under the microscope indicated the aggressiveness of the disease. He came up with a scoring system numbered from 1 to 10. The system has been modified since then, and we now use only scores from 6 to

4 What options do I have? The higher the Gleason number, the more aggressive the cancer, so Gleason 6 (3+3) prostate cancer is less aggressive than Gleason 7 (3+4, 4+3) which, in turn, is less aggressive than Gleason 8, 9 or 10 (4+4, 4+5, 5+5). Just like golf, you want the lowest number when it comes to a Gleason score. Prostate Cancer Volume When you receive your prostate biopsy report, one important finding you should note is the relative volume of your cancer. Most modern biopsy schemes entail 12 cores that are taken during the prostate biopsy. A low-volume cancer is one in which no more than 2 cores are positive for cancer. Intermediate and highvolume diseases are a bit more difficult to discern, but typically, cancer that is present in greater than 6 cores is considered high volume. PSA Density When your urologist performs your prostate biopsy, a measurement is made of your total prostate volume. PSA density is a simple ratio calculated from your PSA value and prostate volume. Expressed as an equation, it is: PSA Density = PSA/Prostate Volume For example, a man with a PSA of 4.0 and a prostate volume of 40gm will have a PSA density of PSA density has been shown to be a predictor of risk status, with a lower density (low PSA, larger prostate) being associated with a lower-risk cancer. A density of 0.15 is usually regarded as the maximum for low-risk disease. Now that you have a basic understanding of the risk of your prostate cancer, we can discuss what management strategies are appropriate. We ll start with the least invasive strategies first and then move to the more invasive options. One bit of advice: don t judge any treatment strategy too harshly. Depending on your cancer, you may require more than one treatment option to control your cancer and give you the best opportunity for a cure. But, first things first: before deciding whether or not to treat your cancer, your doctor should assess your overall health status. Most prostate cancers are slow growing and will not metastasize or spread for years after your diagnosis. As a result, your doctor should determine the risk of this happening in your lifetime. If the risk is extremely low, treatment may not be necessary. We ll discuss this concept a little more in detail below. Watchful Waiting This management strategy involves doing nothing for the prostate cancer and waiting until it becomes symptomatic from growing or spreading. Should that occur during one s lifetime, the symptoms of the disease would be managed to allow for the greatest quality of life. Watchful waiting was developed for men with limited life expectancies. For example, a man of advanced age or a man with multiple, significant medical problems (such as other, more aggressive cancers, heart disease, emphysema, etc.) should be offered watchful waiting. 4 5

5 Because the risk of dying from prostate cancer is low for such an individual, there would be no reason for him to undergo treatment that could otherwise affect his quality of life. Androgen Deprivation Therapy (ADT) Prostate cancer growth is fueled by the sex hormones in your body (androgens such as testosterone). We know that limiting or eliminating testosterone from the body can help slow the growth of prostate cancer, and can even cause regression of the cancer in certain instances. However, ADT does not cure or kill cancer on its own. All cancers eventually become resistant to ADT and will grow, even in the absence of androgens. As a result, we do not recommend ADT as a primary treatment strategy for men with curable prostate cancer. Instead, we reserve ADT for men with aggressive disease that has already spread beyond the prostate. Active Surveillance (AS) This is a relatively new management strategy and is very different and distinct from watchful waiting. Think of AS as a way of deferring your treatment until the time is right to cure your cancer. Prior to offering AS, your doctor should ensure that your cancer is very low risk: low Gleason score, low PSA, low PSA density, low volume on biopsy and low risk on DRE. If your cancer falls within this risk category, as most men s does, you are a perfect candidate for AS. With AS, a partnership is made between you and your urologist. The two of you determine the best method by which to track your cancer through time to ensure that it remains low risk. Should anything change in your cancer characteristics that indicates more aggressive disease, you and your physician should discuss options for cure. Many men worry that AS sounds too much like doing nothing. However, large medical studies have shown that AS does not increase your risk of dying from prostate cancer and does not decrease your ability to cure the disease. In fact, the National Comprehensive Cancer Network (NCCN) lists AS as the optimal management strategy for men with very low-risk disease because it is associated with the fewest treatment side effects, since you are not actively being treated. Think of AS as the strategy that allows you to live your life just as you are living it now, without compromising cancer cure and longevity. Ablative Therapy Ablation is a minimally invasive treatment strategy that can be used to cure your cancer. It is usually carried out under anesthesia by placing needles into the skin between your scrotum and anus, and inserting them into the prostate with ultrasound guidance. There are two basic methods used with ablation: ultracooling (cryotherapy) and ultraheating (HIFU/RFA). Both seem to work reasonably well for killing prostate cancer cells. There are many advantages to ablative therapy. The procedure is minimally invasive and involves minimal recovery. You can usually be discharged from the hospital the same day and, if you need a urinary catheter, it only stays in overnight. However, ablative therapy has its own risks. It is probably not appropriate for high-volume and high-risk disease. It can cause damage to the nerves responsible for erections and could possibly damage structures around the prostate, including the rectum, urethra and bladder. The use of PSA as a tumor marker after 6 7

6 ablative therapy is not well understood. We believe that PSA should fall rapidly and land close to zero, which indicates complete ablation of the prostate. However, a value greater than zero does not necessarily indicate persistence of cancer, which is why PSA is not a fully reliable tumor marker after ablation. Overall, ablative therapy is a reasonable option for men with low-risk and intermediate-risk disease. Surgery (Radical Prostatectomy) Surgical removal of the prostate remains a mainstay of treatment for cure. It is a time-tested procedure that offers excellent cure rates for almost all risk categories of disease. Surgery for prostate cancer involves removing the prostate and seminal vesicles (Figure 1) and the lymph nodes (Figure 1) at highest risk for being involved with the cancer. After removal of the prostate has been completed, the bladder is re-attached to the urethra and a catheter is left in place to allow for this attachment to heal. Traditionally, this procedure was completed in an open fashion, in which an incision was made from the navel to the pubic bone. Advancements in laparoscopic and robotic technology now allow this procedure to be performed laparoscopically with robotic assistance. Using these newer closed techniques, we have seen a decrease in post-operative pain, blood loss, and hospital stay compared to the days when we did this procedure open. In fact, most men who have robot-assisted laparoscopic procedures can be discharged from the hospital the day after surgery. Surgical removal of the prostate offers many advantages. As a matter of convenience, it is a one-time treatment for cure. Also, in removing the prostate gland, we generate a specimen for the pathologists to review. They are able to determine whether the cancer was more or less aggressive than it appeared, and whether it was completely removed. After surgery, PSA becomes an excellent tumor marker, as it should fall to undetectable values post operatively. Should your PSA rise after surgery, it is a very early indicator that your cancer has returned and that you may need additional treatment. However, surgery is not risk free. Your doctor should determine whether or not you are a good surgical candidate based on your overall health status, as someone with a number of medical conditions may not be able to tolerate the surgery. Also, surgery is relatively invasive, as we have to go inside your body to remove the prostate, even when done robotically. After surgery, most surgeons will leave a catheter for about one week to allow the bladder and urethra to heal, and this can be uncomfortable for many men. With surgery, there is always a risk of damaging structures around the prostate, specifically the rectum, blood vessels and nerves that go to the lower legs. With modern techniques and technology, however, these risks are extremely low. 8 9

7 Surgery also carries a risk of incontinence and impotence. The rates for incontinence following robotassisted laparoscopic surgery are quite low. When looking at national averages, the rate is somewhere in the 5-10% range. This is similar to that following radiation therapy. The rates of erectile dysfunction are harder to determine, as not all men have the same erectile capacity prior to surgery. With a nerve-sparing prostatectomy, the rates of erectile dysfunction have fallen dramatically, but are not zero. Make sure to have a very detailed discussion with your surgeon that is personalized to your current erectile function and the impact surgery will have on your future ability to maintain those erections. If you decide to have surgery, make sure you spend time getting to know your surgeon and his or her level of comfort with surgery. Ideally, your surgeon will be well trained on the technique you choose and will have done enough of these surgeries to offer excellent results. The more you do your due diligence in selecting a surgeon, the better your outcome will be. Radiation Therapy Radiation therapy for the treatment of prostate cancer offers excellent opportunities for cure. There are two main options for the delivery of the radiation: implantable seeds (brachytherapy) and external radiation generator (external beam radiation therapy). We will review each briefly here, but a full consultation with a radiation oncologist is warranted prior to choosing a treatment modality. Brachytherapy With brachytherapy, radioactive metallic seeds are implanted into the prostate while you are under anesthesia. These are placed with ultrasound guidance via needles placed in the skin between the anus and scrotum. Brachytherapy offers the advantages of being minimally invasive and a one-time treatment. Brachytherapy is usually reserved for men with low to intermediate risk cancers and those with normalsized glands. Solo brachytherapy is not ideal for more aggressive forms of prostate cancer, or for men with urinary symptoms resulting from enlarged prostates. Finally, the brachytherapy seeds are not removed after treatment. Most data suggests that the rates of bladder and bowel damage are higher for brachytherapy when compared to external beam radiation therapy. Damage to these structures can be devastating and, in most cases, irreversible. Following brachytherapy, PSA is a reasonable tumor marker, but patients should be aware that PSA may rise and fall for up to 18 months following treatment. A recurrence for brachytherapy, and external beam, is defined as a PSA value that is the lowest-ever PSA value plus 2. For example, if your PSA falls to 0.6 after radiation therapy, a diagnosis of a recurrence would be at a PSA value of 2.6. External Beam Radiation Therapy (EBRT) With EBRT, an external source of radiation is used to eradicate prostate cancer. The beams of radiation are focused on the prostate based on CT scan imaging techniques. The amount of radiation and the 10 11

8 number of treatments vary by treatment center, but usually involve anywhere from 28 to 40 treatments. If you choose to treat your cancer with EBRT, make sure to ask the same questions you would of a surgeon regarding outcomes of continence, potency and cancer control. You should also ask questions regarding rates of damage to structures surrounding the prostate, such as the bladder, rectum and urethra. Keep in mind that, depending on the aggressiveness of your cancer, you may require concurrent androgen deprivation therapy (ADT) for 6 months up to 3 years. The advantage of EBRT is the fact that it is non-invasive, so there is no recovery for treatment. Also, side effects of the therapy are typically not immediate, so you can continue to live your life as normal for some time following EBRT. The most common immediate side effect from EBRT is fatigue. The need for multiple consecutive treatments is usually seen as the major disadvantage of EBRT, especially if travel and taking time off work is difficult. Also, just as with brachytherapy, damage to the bladder and rectum can result in debilitating side effects that can have a major impact on your quality of life. Following EBRT, PSA is a good marker to assess for cancer recurrence. The definition of recurrence is the same for EBRT as it is for brachytherapy: the lowest-ever PSA value plus 2. Again, before deciding on any form of radiation therapy, be sure to meet with a radiation oncologist to discuss treatment options and possible complications. Suggestions Once diagnosed with prostate cancer, I tell all of my patients the same things: 1) Obtain your complete medical records, including all PSAs and biopsy reports. 2) Get a copies of your imaging studies (CT, MRI, etc.) and radiologist s interpretations. 3) Place this information in a three-ring binder and take it with you to your medical appointments. 4) Put blank paper in your binder for notes. 5) Write down questions you have for your doctor and make sure he or she takes the time to answer them. 6) Take loved ones to your appointments. Remember, they are your advocates. As the patient, it can be difficult to follow what your physician is telling you, especially in the face of cancer. Loved ones may hear things differently, and may be able to give you a more objective assessment of options. Plus, they are available for support and to ask questions that may not occur to you. Conclusions The diagnosis and treatment of prostate cancer is complex. No two men are exactly the same, and, similarly, no two prostate cancers are exactly the same. Once you have your diagnosis, it is important that you gather as much information as possible prior to making a decision regarding treatment. Remember to take time to meet with a specialist regarding your care and never hesitate to ask questions and get answers. 2015, UT Health. All rights reserved. The information contained herein is not meant to be used for self-diagnosis or to replace the services of a medical professional

9 Notes Notes 14 15

10 Notes Notes 16 17

11 Arlington Ave. Toledo, Ohio uthealth.utoledo.edu/centers/cancer

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