Download Understanding Prostate Cancer and treatment options A GUIDEBOOK FOR PATIENTS AND CAREGIVERS

Understanding
Prostate Cancer
and treatment options
A GUIDEBOOK FOR PATIENTS AND CAREGIVERS
Provided as an educational service by
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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
What Is Cancer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
What Should I Know About Prostate Cancer? . . . . . . . . . . . . . . . . . . . . 4
Diagnosis and Staging Tests . . . . . . . . . . . . . . . . . . . . . . . . . . 10
The Gleason Grading System . . . . . . . . . . . . . . . . . . . . . . . . . 11
TNM Staging System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
How Is Prostate Cancer Treated? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Prostatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Cryotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Watchful Waiting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Hormonal Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Chemotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Investigational Therapy (Clinical Trials) . . . . . . . . . . . . . . . . . . 31
What Happens After I Receive Treatment? . . . . . . . . . . . . . . . . . . . . . 32
Ways to Cope With Your Diagnosis and Treatment . . . . . . . . . . . . . . . 33
Support Services and Resources for More Information
on Prostate Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Glossary of Medical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Some Questions to Discuss With Your Doctor . . . . . . . . . . . . . . . . . . . 40
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Introduction
When a man learns
that he has prostate
cancer, he usually has
many questions about
what prostate cancer is
and how the disease
can be treated.
It is also normal for men with
prostate cancer, their families,
and others close to them to
have fears and concerns.
Most men and those who care
about them often find that
their distress eases as they gain
an understanding of the
disease and its treatment.
This booklet is designed for
you and those close to you.
To help you understand and
cope with your illness, this
booklet
• Explains prostate cancer,
how it develops and
its effects
• Discusses the possible
impact prostate cancer may
have on your life and some
ways to cope
• Provides general information
about what doctors and
other health care professionals
know regarding how to treat
this disease
Because this booklet probably
will not answer all of your
questions, you may wish to
write down any questions that
you have so that you can ask
your doctor or health care
professional at your next visit.
Words in this booklet that
may be unfamiliar to you are
underlined and italicized and
may be briefly defined in the
text. More complete
definitions, as well as space
for you to write notes and
questions, can be found at
the end of the booklet.
No booklet can provide all
the information needed to
determine if a treatment is
right for you. This booklet
does not take the place of
careful discussions with your
doctor. Only your doctor has
the right training to weigh
the risks and benefits of
a treatment.
In addition to this booklet,
there are several sources of
information about prostate
After you read this booklet,
you will probably want to talk
further about your illness and
treatment. By working
together, you and your doctor
will plan the treatment that is
best for you.
cancer available to patients,
such as local libraries, cancer
societies, and support groups.
Additional information can
be found on the Internet;
you can find patient-friendly
information at
www.PROSTATEinfo.com.
1
What Is Cancer?
The human body is made up of
billions of cells. Normally, cells
function for a while, then die and
are replaced by new cells in an
orderly fashion. This results in an
appropriate number of cells that
are organized by the body to
perform specific functions.
Tumors
Occasionally, however, cells are replaced in an
uncontrolled way and are unable to be organized
by the body to perform their normal function.
As a result, there is an abnormal growth of cells
that form a tumor. There are two kinds of
tumors: malignant tumors (cancerous) and
benign tumors (noncancerous).
Because of their increasing size, benign tumors
squeeze surrounding parts of the body and
expand into nearby areas. This can cause pain
and interfere with normal function, but it is
seldom life threatening.
Malignant tumors can not only cause pain and
interfere with normal function, but they can
also cause other systems in the body to act
abnormally. Malignant tumors can invade
nearby groups of cells or tissues, crowding out
and destroying normal cells.
2
Lymph Nodes
Cancer cells can also break away from the main
or primary malignant tumor and travel to other
parts of the body. The body fluids that can
carry cancer cells from the primary tumor to
other parts of the body are the blood and the
lymph. Lymph is a nearly clear fluid that drains
waste from cells. The lymphatic system transports
fluid through vessels and into small bean-shaped
structures called lymph nodes.
One function of the lymph nodes is to filter
unwanted substances, such as cancer cells, out
of the lymph fluid. However, if there are too
many cancer cells, the lymph nodes cannot
remove all of them.
• There are more than 100 different types of
cancer. In the United States, men have a 1 in
2 chance that they will develop some type of
cancer during their lifetime. Men in the
United States have about a 1 in 6 chance
of eventually being diagnosed with
prostate cancer1
• In American men, the most common cancer
(aside from skin cancer) is prostate cancer.
For more specific cancer statistics, please visit
www.cancer.org
Isolated or disseminated tumor cells are single
or small groups of tumor cells that have
separated from the primary tumor and can be
found in the blood, lymph, or bone marrow.
They can develop into life-threatening
metastatic disease if they are left untreated.
3
What Should I Know About Prostate Cancer?
What Is the Prostate?
The prostate is one of the male sex glands. The prostate adds nutrients and fluid to the sperm.
During ejaculation, the prostate secretes a fluid that is part of the semen. The other major sex
glands in men are the
testes and the seminal
Seminal Vesicle
Urinary Bladder
vesicles. Together, these
glands store and secrete
Rectum
the fluids that make
Prostate
Urethra
up semen.
Anus
Scrotum
Penis
The prostate is about the
Testes
size of a walnut and can
be divided into two parts
referred to as the right and left lobes. It lies just below the urinary bladder and surrounds the
upper part of the urethra. The urethra is the tube that carries urine from the bladder and
semen from the sex glands out through the penis. As one of a man’s sex glands, the prostate is
affected by male sex hormones. These hormones stimulate the activity of the prostate and the
replacement of the prostate cells as they wear out. The chief male hormone is testosterone,
which is produced almost entirely by the testes.
4
The cause of prostate cancer is
unknown. However, it is known
that the growth of cancer cells in
the prostate, like that of normal
prostate cells, is stimulated by male
sex hormones, especially testosterone.
Testosterone is produced almost
entirely by the testes (about 95%),
with only a small percentage (about
5%) being produced by the adrenal
glands (small glands that sit above
each kidney).
Compared with other types of cancer, generally,
prostate cancer is relatively slow growing. A
man with prostate cancer may live for many
years without ever having the cancer discovered.
In fact, many men with prostate cancer will not
die from it but with it. As a man gets older, his
risk of developing prostate cancer increases.
More than 70% of prostate cancers are
diagnosed in men over 65 years of age.2
As the cancer grows, it may eventually squeeze
the urethra, which is surrounded by the
prostate (see illustrations on page 7). Then,
symptoms such as difficulty urinating may
develop. This is usually the first clinical
symptom of prostate cancer. (It is important to
note, however, that difficulty in urinating can
be caused by other, noncancerous conditions of
the prostate and does not always mean that
prostate cancer is present.) With or without
symptoms, a growing prostate cancer can also
attack cells close to the prostate.
As mentioned, cells can break off from the
cancer and spread. Sites where prostate cancer
tends to spread are the lymph nodes, various
bones (especially the bones of the hip and
lower back), lungs, and occasionally the brain.
Cancer cells that have spread to other areas of
the body can form tumors that can expand and
squeeze other body parts. For example, when
prostate cancer spreads to the bones, the most
common symptom is bone pain.
How Is Prostate Cancer
Detected and Diagnosed?
The American Cancer Society (ACS) has developed
guidelines to help doctors detect prostate cancer
during its early stages. The ACS has recently
revised these guidelines to reflect new scientific
literature. The guidelines recognize that prostate
cancer screening, including a digital rectal
examination (DRE) and a test to measure
5
What Should I Know About Prostate Cancer? (cont’d)
prostate-specific antigen (PSA) in the blood,
should be offered yearly to the general male
population 50 years of age and older.2
You and your doctor can discuss the ACS
guidelines together and determine if screening is
right for you, and if so, when you should begin.
In addition, males at increased risk for developing
prostate cancer, such as men with a first-degree
relative (father, brother, or son) affected by the
disease or those of African-American descent,
should consider annual screenings beginning at
age 45. Men at even higher risk because they
have several first-degree relatives who had prostate
cancer at an early age should begin annual
screenings at age 40.2
Digital Rectal Exam (DRE)
There are some instances in which screening may
not be recommended. Because prostate cancer can
be a slow-growing cancer, a man with a less than
10-year life expectancy would most likely die of
some other illness, and therefore, is not very likely
to benefit from prostate cancer screenings and
treatment. For this reason, the new ACS guidelines
include a statement for patients explaining the risks
and benefits of prostate cancer screening. These
guidelines can be found on the Internet at
www.cancer.org or by calling the
American Cancer Society at 1-800-ACS-2345.
6
A digital rectal examination (DRE) is a quick
and safe screening technique in which a doctor
inserts a gloved, lubricated finger into the
rectum to feel the size and shape of the prostate.
The prostate should feel soft, smooth, and
even. The doctor examines for lumps or hard,
irregular areas of the prostate that may indicate
the presence of prostate cancer. The entire
prostate cannot be felt during a DRE, but most
of it can be examined, including the area where
most prostate cancers are found.
When a tumor is small and located only within
the prostate, it often is not detected during a
DRE. However, if an abnormality is found
during the DRE, the new ACS guidelines
suggest a prostate biopsy, even if the PSA
is normal.
Prostate-specific Antigen (PSA)
Prostate-specific antigen (PSA) is a substance
produced by both normal and cancerous
prostate cells. When prostate cancer grows or
when prostate diseases are present, the amount
of PSA in the blood often increases.
• A PSA test is generally said to be in the
normal range when it is reported to be
between 0 and 4 nanograms per milliliter,
sometimes abbreviated as ng/mL on the
lab report
• If the results are greater than 4 ng/mL, your
doctor may suggest a biopsy, which is the
only test available to diagnose prostate cancer
• Guidelines published in 2005 by the
National Comprehensive Cancer Network
(NCCN) suggest that the threshold for
consideration of a biopsy should be lower.
The NCCN guidelines now recommend
consideration of biopsies for men with PSA
levels in the ranges of 2.5 to 4.0 ng/mL3
• It may also be useful to keep track of how
your PSA level changes over a period of time.
If your PSA level is rising your doctor may
suggest a biopsy
• PSA test results can be confusing and do not
mean that cancer is present. Certain other
conditions, such as benign prostatic hyperplasia
(also called BPH – a type of noncancerous
prostate enlargement) and prostatitis
(inflammation of the prostate), may cause an
abnormal PSA result
Because borderline PSA test results may not
be sufficient, your doctor may advise you to
consider having one or more of the newer
PSA tests. These are described below:
Percent Free-PSA Ratio
Percent free-PSA ratio is a blood test that measures
how much PSA circulates by itself (unbound) in
the blood and how much is bound together with
other blood proteins. If PSA results are
borderline and percent free-PSA ratio is low
Urinary Bladder
Seminal Vesicle
Tumor
Prostate
Urethra
7
What Should I Know About Prostate Cancer? (cont’d)
(25% or less), then prostate cancer is more likely
to be present. If this is the case, a biopsy may
be needed.
If the results of the percent free-PSA ratio are
greater than 25%, even with a borderline PSA,
you may be able to avoid a biopsy.
Complexed PSA (cPSA) is another blood test
that measures PSA bound to a substance called
alpha-1-antichymotrypsin.
The Age Factor
Another way of looking at PSA involves
age-specific PSA reference ranges. PSA levels
increase with age; therefore, higher PSA levels
are normally seen in older men more often
than in younger men, even without cancer.
An age-specific PSA reference range compares
the results of men in the same age group. If a
man’s PSA levels are high compared to his
own age group, then there is a greater chance
that prostate cancer could be present. In older
men with borderline PSA results, this
comparison can be more confusing than
useful. As a result, age-specific PSA reference
ranges are not routinely done.
8
PSA Density
If you have had your PSA measured and have
also had a transrectal ultrasound (TRUS), then
PSA density (PSAD) can be determined. To
calculate PSAD, your doctor will divide the
PSA by the size, or volume, of the prostate
(determined from the TRUS). There is a
greater chance that prostate cancer is present
with a high PSAD.
PSA Velocity
Finally, PSA velocity shows how quickly the
PSA level rises over a period of time. Two or
more PSA tests are required, often over a period
of several months. Although PSA velocity may
be useful in helping your doctor better interpret
borderline PSA results, it is not really used to
diagnose prostate cancer. Instead, it is used
more as a tool to keep track of how your PSA
levels compare over a period of time.
PSA often rises as part of the natural aging
process; an increase in PSA levels from time to
time does not necessarily indicate that prostate
cancer is present. On the other hand, if PSA
increases too quickly (as determined by your
doctor), prostate cancer is a possibility.
PSA-DT
If you have been diagnosed with prostate
cancer, another factor your doctor may
consider is PSA doubling time (PSA-DT), which
is the time it takes your measured blood PSA
levels to double. Generally, a shorter PSA-DT
indicates that the prognosis of your prostate
cancer may be worsening.
Newer PSA tests can be useful, but they are still
too new for doctors to agree on when and how
they should be used. If your PSA is borderline
or abnormal, your doctor can help you
determine which tests, if any, are right for you.
A high PSA doesn’t necessarily mean that
prostate cancer is present, and a low or normal
PSA doesn’t always mean that prostate cancer
isn’t present. In other words, the PSA test may
provide false results. Therefore, it is used along
with the results of the DRE to provide more
accurate screening.
TRUS
If your PSA test results are borderline high, but
your DRE results are normal, then your doctor
may recommend a transrectal ultrasound
(TRUS). During a TRUS, a small probe is
placed in the rectum. This procedure typically
causes little discomfort.
As illustrated below, this is a procedure that
uses sounds waves to create a picture of the
prostate, which can be used to help identify
abnormal areas requiring a biopsy. If the results
of the TRUS are normal, you may be able to
wait and
repeat the PSA
test a few
months later
and have a
biopsy then if
needed.
Biopsy
A DRE and PSA cannot diagnose prostate
cancer. Abnormal results of a DRE or PSA only
indicate that further testing is needed. If you
have abnormal results in one of these tests,
your doctor may require that you have a
biopsy. A biopsy is a procedure in which the
doctor uses TRUS to view and guide a needle
into the prostate to take multiple small samples
of tissue. These tissues are then examined
under a microscope for the presence of cancer.
A biopsy is the only way to confirm or
diagnose the presence of prostate cancer.
The biopsy procedure is short and you can
usually go home the same day. There may be
some discomfort during the procedure.
After a biopsy, you may experience some blood
in your urine, semen, and/or bowel movements,
but these symptoms should resolve after a
few weeks.
Transrectal ultrasound of the prostate.
9
Diagnosis and Staging Tests
Examinations and Visualizations
Digital rectal examination (DRE)
A procedure in which a physician inserts a
gloved, lubricated finger into the rectum to
feel some areas of the prostate.
Computed tomography (CT)
A picture produced by a computer from
X rays, showing the prostate and other nearby
parts of the body.
Chest X ray
An image that may show whether cancer has
spread to the lungs or other structures, such as
the ribs.
Intravenous pyelogram (IVP)
An X ray of the kidneys, ureters, and bladder
that is taken after the patient has been
injected with a special dye.
Magnetic resonance imaging (MRI)
A picture produced by a computer and a
high-powered magnet that shows the
prostate and other nearby parts of the body.
Bone scan
A picture taken using radioactive material
that may show whether cancer has spread to
the bone.
Transrectal ultrasonography (TRUS)
A procedure in which an instrument is
inserted into the rectum and produces sound
waves directed at the prostate; from these
sound waves, a picture is created.
ProstaScint Scan
Uses radioactive material to detect the presence
of a prostate-specific substance in the body.
Detecting the substance outside of the prostate
may suggest the prostate cancer has spread.
Tissue Samples
Prostate biopsy
The removal and microscopic examination of
multiple small samples of the prostate tissue
to determine whether it contains cancer cells.
Blood Tests
Prostate-specific antigen (PSA)
A blood substance produced by normal and
cancerous prostate cells that often may
increase in cases of prostate cancer and other
prostate diseases. It is useful both in diagnosis
and follow-up of prostate cancer.
10
Pelvic lymph node dissection
(also called pelvic lymphadenectomy)
Surgical removal of lymph nodes in the pelvis;
used to help determine whether prostate cancer
has spread – typically done during surgery to
remove the prostate (radical prostatectomy).
The Gleason Grading System
On the other hand, if the cells in question
look fairly irregular and very different from
the normal prostate cells, then they are very
poorly differentiated and are assigned a
Gleason grade 5.
Grades 2-4 are used for tumors that fall
between grades 1 and 5, with higher numbers
corresponding to faster-growing tumors.
If your diagnostic tests and
other examinations reveal a
malignant tumor of the
prostate, your physician may
use the Gleason grading system
to help describe the appearance
of the cancerous prostate tissue.
In order to do this, a pathologist will look at
the biopsied tissue under a microscope. He or
she will examine the way that the cancerous
cells look compared to normal prostate cells.
If the cancerous cells appear to resemble the
normal prostate tissue very closely, they are
said to be very well differentiated and are
considered to be Gleason grade 1. This
means that the tumor is not expected to be
fast growing.
Because prostate cancer tissue is often made
up of areas that have different grades, the
pathologist will closely examine the areas
that make up the largest portion of the
tissue. Gleason grades are then given to the
two most commonly occurring patterns
of cells.
Once the two grades have been assigned, a
Gleason score can be determined by adding
together the two Gleason grades. The Gleason
score that results will be a number from
2 to 10.
Gleason scores should be discussed with your
doctor. Your doctor can explain what your
Gleason score, along with your other test
reports, mean for you as an individual.
Scores on the higher end of the Gleason
grading system (7 through 10) usually indicate
a more serious prognosis.
11
What Should I Know About Prostate Cancer? (cont’d)
What Is Staging in
Prostate Cancer?
In developing a treatment plan, you and your
doctor must discuss the advantages and
disadvantages of each treatment option. The
benefits of treatment depend on how large
the cancer already is and how far it may have
spread – in other words, its stage.
To detect and diagnose prostate cancer and to
determine the size and extent of the spread –
or stage – of the disease, your doctor may
perform tests that involve feeling the prostate,
looking at internal parts of the body,
measuring the levels of substances in the blood,
and examining samples of prostate tissue.
Specific tests are described on page 10.
Why is it important for your doctor to
determine the stage of your prostate cancer?
Only by knowing how the cancer is growing
and exactly where it is located in the body can
you and your doctor choose the best treatment
for you. There are two systems used to stage
prostate cancer:
• TNM Staging
• A, B, C, D, or Whitmore-Jewett Staging
12
TNM Staging
The most common method of staging
prostate cancer is by using a system called the
TNM staging system, which stands for
Tumor, Node, Metastases.
It is an international system that was developed
by The American Joint Committee on Cancer.
The tables on pages 14 and 15 describe the TNM
staging system in more detail.
A, B, C, D Staging
In addition, the equivalent stages in the A, B, C, D,
or Whitmore-Jewett staging system are given in
parentheses (in the table).
How Are Treatment
Methods Chosen?
The method selected to treat prostate cancer
depends on your stage and other factors.
When talking with your doctor, you will
frequently hear the following terms regarding
the stages of prostate cancer: localized, locally
advanced, and metastatic. Localized prostate
cancer is a cancer that is contained within the
prostate gland. Locally advanced prostate
cancer is a cancer that has spread beyond the
prostate to surrounding tissue and may also
have spread to pelvic lymph nodes. Metastatic
prostate cancer is a cancer that has spread
beyond the prostate and pelvic lymph nodes
into other distant parts of the body, such as
the bones.
The benefits of early detection of prostate
cancer and effective treatment can be
substantial. In the United States, 92% of men
diagnosed with prostate cancer survive at least
10 years after diagnosis, and 61% survive at
least 15 years.2
As a result of screening and earlier diagnosis of
prostate cancer, patients with prostate cancer
are living longer.
It is also important to consider the benefits and
potential side effects for each treatment option
that is available to you. These factors should be
discussed thoroughly by you and your doctor.
Certain treatments are chosen more frequently
than others for each stage of prostate cancer.
Detailed prostate cancer stages are listed on
pages 14 and 15; the treatments are described
more completely in the following sections.
13
TNM Staging System*
T refers to the size of the primary tumor
N describes the extent of regional lymph node involvement
M refers to the presence or absence of metastases
T Staging
Stage TX, TO, T1
Stage T2
Stage T3
TX
T2 (B)
T3 (C1 — tumor < 6 cm)
Tumor palpable and
extends beyond prostate
capsule.
T3a (C1) Tumor extends beyond
prostate capsule, either
on one side (unilaterally)
or both sides (bilaterally).
Primary tumor cannot
be assessed.
TO
No evidence of primary
tumor.
T1 (A)
Tumor not clinically
apparent.
T1a (A1) Tumor incidentally
found in ≤ 5% of
prostate sample.
T1b (A2) Tumor incidentally
found in > 5%
of prostate sample.
T1c
Tumor identified at
needle biopsy
performed to
investigate PSA
elevation.
Palpable tumor
confined to prostate.
T2a (B1N) Tumor involves less
than half of one
prostate lobe.
T2b (B1)
Tumor involves more
than half of one lobe
but not both lobes.
T3b (C1) Tumor invades
seminal vesicles.
Seminal
vesicle
PROSTATE
T2c (B2)
Tumor involves both
prostate lobes.
* According to 1992 American Joint
Committed on Cancer staging system.
14
N Staging
M Staging
Stage T4
Stage NX, NO, N1
Stage MX, MO, M1
T4 (C2 — tumor > 6 cm)
Tumor is fixed or
invades adjacent anatomy
other than seminal
vesicles: bladder neck,
external sphincter,
rectum, levator muscles,
and/or pelvic wall.
NX
MX
NO
N1 (D1)
Regional lymph nodes
cannot be assessed.
No regional lymph
node metastasis.
Metastasis in regional
lymph node or nodes.
MO
M1 (D2)
M1a (D2)
M1b (D2)
M1c (D2)
Presence of distant
metastasis cannot
be assessed.
No distant metastasis.
Distant metastasis.
Metastasis to nonregional
lymph nodes.
Metastasis to bone.
Metastasis to other
distant sites.
A bone scan image. Dark spots
(“hot spots”) represent an
accumulation of radioactive
material which may indicate
the presence of bone metastases.
15
How Is Prostate Cancer Treated?
Treatments of Curative Intent
In general, treatments of curative
intent are performed for prostate
cancer that has not yet spread
(metastasized) and is still localized,
or locally advanced, at the time of
initial diagnosis.
Treatments of curative intent aim to remove
and eliminate all prostate cancer tissues and
cells from the body. Treatments of curative
intent for localized prostate cancer include
radical prostatectomy, certain forms of external
beam radiation therapy, brachytherapy, and
cryotherapy. Treatments of curative intent for
locally advanced prostate cancer may include
combinations of the options mentioned above,
and under certain circumstances, additional
hormonal therapy.
In some cases, treatments of curative intent are
not chosen and instead the patient undergoes
watchful waiting, also known as expectant
therapy or surveillance. Watchful waiting is the
decision not to treat localized prostate cancer
with surgery, radiation, hormonal therapy, or
any other treatment options. The doctor
monitors the patient’s prostate cancer by
checking PSA levels and looking for signs and
symptoms of cancer growth. If the PSA levels
start to go up, or the signs and symptoms of
cancer growth become more obvious, treatment
may be started.
Treatments of curative intent for metastatic
prostate cancer, even at the time of initial
diagnosis, do not eliminate the prostate cancer
completely. Currently, metastatic prostate
cancer is usually treated with hormonal
therapy, which is frequently effective for a
certain period of time, but not curative. At this
time, chemotherapy is generally used at the
later stages of metastatic prostate cancer.
Palliative Treatment
A treatment that can help reduce
the severity of advanced prostate
cancer is called palliative treatment.
This treatment is also used to treat symptoms
of advanced prostate cancer such as bone pain.
16
Treatment Options
Prostate cancer can be treated with one or
more of the following methods:
• Prostatectomy
• Radiation therapy
• Cryotherapy
• Watchful waiting (expectant therapy)
• Hormonal therapy
• Chemotherapy
• Investigational therapy (clinical trial)
Each of these methods is described in more
detail below.
Prostatectomy
Prostatectomy is the surgical removal of the
prostate, and is performed by an urologist. A
radical prostatectomy can be performed to
remove the prostate and the nearby areas where
the cancer has spread. This type of surgery may
help prevent further spread of the cancer.
If the tumor is small and has not spread outside
of the prostate, then surgery may optimally
treat the disease. However, complete surgical
removal of the prostate is not common when
the cancer has spread to the lymph nodes or
other sites.
Radical Prostatectomy
Radical retropubic prostatectomy and radical
perineal prostatectomy are the two most common
types of radical prostatectomy procedures. The
entire prostate gland, attached seminal vesicles,
and some nearby tissues are removed during
these surgeries.
A radical retropubic prostatectomy involves a
surgical incision in the lower abdomen. The
surgeon can then remove the cancer through
this incision. The entire prostate and attached
seminal vesicles are removed, along with a
small part of the bladder next to the prostate.
When possible, depending on the size of the
tumor, a version of this technique called
nerve-sparing radical prostatectomy is performed.
This allows the surgeon to identify the nerves
on either side of the prostate so that they can
be left alone, if possible. In general, there is a
lower risk of certain adverse effects if the
nerve-sparing technique can be used. These
side effects will be discussed in the section
titled “Disadvantages.” If necessary, a pelvic
lymphadenectomy is also performed to remove
nearby pelvic lymph nodes.
17
How Is Prostate Cancer Treated? (cont’d)
The latest development in this surgery includes
a nerve transplant, where the nerve is generally
taken from the patient’s leg, in an attempt to
preserve the ability to have erections in those
patients where nerve-sparing surgery is
not possible.
Radical perineal prostatectomy is similar to
radical retropubic prostatectomy except that
the cancer is removed through an incision in
the perineum. A surgical incision is made in
the area between the scrotum and the anus.
The entire prostate is removed along with
any nearby cancer. Pelvic lymphadenectomy
cannot be performed during this procedure.
What to expect: Radical prostatectomy
procedures often last anywhere from 1.5 to
about 4 hours. The perineal type is generally
a shorter operation than the retropubic type.
A catheter is usually inserted into the urethra
after these procedures while the patient is still
asleep. The catheter will help to enable
urination during the healing process and
should only be needed for a few weeks or less.
18
After the catheter is removed, the patient
should be able to urinate on his own. Both
types of radical
prostatectomies
require
approximately 3
days of recovery
in the hospital,
followed by
about 3 to 5
weeks of rest at
.4 inches
home. Your
doctor and/or
.2 inches
surgeon will
provide
specific
The diagram shows where the
surgical cuts are made in a pelvic
guidelines.
lymphadenectomy.
After the prostate is removed, it is sent for an
evaluation, where the margins or edges of the
prostate are inspected. If the margins of the
prostate do not have cancer cells (negative
margins), it is assumed that the cancer was
confined within the prostate and has not
spread outside of the prostate. This is called
localized prostate cancer. However, if the
margins are found to contain cancer cells
(positive margins), cancer may remain in the
body and further treatment, such as radiation
or hormonal therapy, may be necessary. This
is called locally advanced prostate cancer.
Advantages: Prostatectomy is a one-time
procedure that may optimally treat prostate
cancer in its early stages.
Disadvantages: Prostatectomy is a major
operation that requires general anesthesia and
hospitalization, and can produce some side
effects. Possible side effects include impotence,
urinary incontinence, bowel complications, and
sometimes narrowing of the urethra that can
make urination difficult.
Impotence can occur in a large number of
patients immediately after surgery, but may go
away with time. However, the chance of
impotence is lower with the newer nerve-sparing
technique. Urinary incontinence occurs in only a
small percentage of patients.
The most recent advancements in prostate cancer
surgery, which are still considered experimental
and performed only in a few centers, are
laparoscopic and robotic prostatectomy. Talk to
your doctor if you’d like to learn more about
these surgical treatment options.
Transurethral Resection of the
Prostate (TURP)
A transurethral resection of the prostate (TURP)
is another type of prostate surgery. It is
sometimes used in men who have prostate
cancer but cannot have a radical prostatectomy,
either because of advanced age or a serious
illness (other than cancer). TURP is also used
to treat the symptoms of benign prostatic
hyperplasia (BPH).
Radiation Therapy
Radiation therapy uses high-energy rays to kill
prostate cancer cells, shrink tumors, and
prevent cancer cells from dividing and spreading.
It is difficult to direct these rays only at the
cancer cells. As a result, both cancer cells and
healthy cells nearby may be damaged.
Radiation therapy is not given all at once; it is
usually given in small doses spread out over
time. This potentially allows the healthy cells to
recover and survive, while the cancer cells
eventually die.
19
How Is Prostate Cancer Treated? (cont’d)
Radiation therapy may also be used for pain
relief in prostate cancer that has spread to the
bones (Stage M+) or that is no longer
responding to hormonal therapy.
There are two ways in which the high-energy
rays can be delivered. Radiation therapy
involves either external beam radiation or a type
of internal radiation called brachytherapy.
These types of radiation therapy are
discussed next.
External Beam Radiation Therapy
In external beam radiation therapy, a machine
delivers the radiation in brief sessions, usually
one session each weekday for several weeks.
Many patients compare the treatments to
having an X ray. The procedure itself is painless
and lasts for just a few minutes.
Advancements in external beam radiation
therapy have led to three methods of treatment
that are described below. These developments
may help reduce side effects and increase
treatment success. Your doctor can advise you
on the right treatment for you.
20
3-Dimensional Conformal Radiation
Therapy (3D-CRT)
One type of external beam radiation therapy
is 3-dimensional conformal radiation therapy,
in which computers are used to identify the
location of the prostate and the cancer inside
the prostate gland.
The next step involves the creation of a
special protection device that the patient
wears during the treatments. This device is
similar to a body cast, but is molded out of
Styrofoam® and helps to keep the body still
during treatment while the radiation is aimed
at the cancer.
When the patient wears the body mold during
the treatments, the radiation beams can be
aimed more accurately to target the entire
prostate gland. The idea is to be able to direct a
high dose of radiation only toward the prostate,
while reducing the amount of radiation that
surrounding healthy areas receive.
If the healthy tissue can be spared from the
effects of radiation, side effects should be lower
and therapy success higher.
Conformal Proton Beam Radiation Therapy
Conformal proton beam radiation therapy is
another type of radiation therapy. This
technique is similar to 3-dimensional conformal
radiation therapy, except that it uses protons to
produce the radiation beam. Protons are
microscopic particles that produce energy in
the form of a radiation beam. The proton
beams can pass through healthy tissue without
damaging it, yet still be aimed at cancerous
tissue to destroy cells.
Intensity Modulated Radiation Therapy (IMRT)
Intensity modulated radiation therapy (IMRT) is
another form of external beam radiation therapy.
Computed tomography (CT) is used to create a
3-D picture of the prostate and surrounding
organs so the radiation can be delivered only to
the prostate gland.
IMRT is more precisely targeted than
3-dimensional conformal radiation therapy
(3D-CRT). IMRT uses many thinner beams
to precisely target the prostate gland and spare
other nearby organs from radiation. Therefore,
IMRT allows for an increased radiation dose to
be delivered to the prostate gland, potentially
resulting in better elimination of cancer cells.
IMRT is administered in short sessions five
times a week for approximately seven weeks.
Advantages: Prostatectomy is usually avoided by
using external beam radiation therapy. External
beam radiation therapy may optimally treat
prostate cancer in its early stages and may help
extend life in later stages. It rarely causes loss of
urinary control.
IMRT is a technological advancement in the use
of external beam radiotherapy. It allows doctors to
treat tumors with a higher dose of radiation,
retreat cancers that have previously been treated
with radiotherapy, and more safely treat tumors
that are located close to other organs. IMRT also
reduces the amount of radiation administered to
nearby organs compared to other forms of external
beam radiotherapy, thereby decreasing side effects.
The techniques mentioned above are promising in
terms of less chance for adverse effects and greater
chance for success than older methods of external
beam radiation therapy.
Disadvantages: External beam radiation
therapy can cause a variety of side effects. Many
of these disappear after therapy stops. These side
effects include tiredness, skin reactions in the
treated areas, frequent and painful urination,
upset stomach, diarrhea, and rectal irritation
or bleeding.
21
How Is Prostate Cancer Treated? (cont’d)
There is a chance of some permanent side
effects. Bowel function may not return to normal
even after treatment is complete.
Development of impotence may occur up to
2 years later in some patients and can become a
permanent side effect. This is especially important
for the younger patient to consider when
thinking about different treatment options.
Radiation therapy may be inconvenient because
patients need to make frequent visits to the
hospital or clinic for treatment (about 5 times
per week for 6-8 weeks).
If the prostate cancer doesn’t respond to or
progresses with radiation therapy, the cancer
cannot be retreated with radiation. Surgical
removal of the prostate is complicated after
radiation, but may sometimes be performed if
radiation therapy fails.
Finally, some types of radiation therapy
mentioned above may not be available at all
radiation therapy centers.
Your doctor and local radiation center will be
able to tell you the specific types of treatment
offered at your center.
22
Brachytherapy (sometimes called
interstitial radiation therapy or “seeds”)
In brachytherapy (sometimes called interstitial
radiation therapy or “radioactive seeds”), the
radiation comes from tiny radioactive seeds
inserted directly into the prostate. Specialized
equipment is used to view the tumor so the
surgeon can place the seeds correctly. The seeds
are inserted into the
tumor during a
minor surgical
procedure under
some form of
anesthesia, so
brachytherapy is
usually performed as
The seeds used in brachytherapy an outpatient
can be very small. A type of
procedure. The seeds
palladium seed is shown on
top of the penny.
are too small to be
felt by the patient
and do not cause any discomfort. The picture
shown here depicts one type of seed used
during brachytherapy. You will notice that the
seeds are very small.
Brachytherapy often allows the doctor to use a
higher dose of radiation than is possible with
external beam radiation. The seeds give off rays
continually for hours, weeks, months, or up to
a year, and some can remain safely in place for
the rest of a person’s life. The amount of time
that the seeds remain radioactive depends on
the dose and what type of radioactive material
is used. The seeds used during brachytherapy
contain different radioactive substances that
may include radium, iridium, cesium, phosphorus,
iodine, and palladium. Brachytherapy, however,
does not make the patient radioactive.
By using brachytherapy, radiation is placed
as close as possible to the cancerous cells so
that less of the normal tissue is exposed to
the radiation.
Because it is designed to target the cancerous
cells and not harm the surrounding area,
brachytherapy is usually not recommended
when the cancer has spread beyond the prostate
gland. Brachytherapy may be used alone or can
be combined with external beam radiation
therapy. Thus far, some studies show that
brachytherapy for the treatment of prostate
cancer that has not spread beyond the prostate
gland has similar effectiveness when compared
to radical prostatectomy and advanced
EBRT methods.
High-dose Rate Brachytherapy
High-dose rate brachytherapy is a newer form of
brachytherapy involving seeds that are placed
only temporarily. These seeds stay in place for
less than a day and contain more radioactive
material than the seeds that stay in place longer.
This type of brachytherapy may even be
performed in a clinic as an outpatient visit and
may not require hospitalization.
Advantages: Brachytherapy has shown some
promising results. In general, there are often
fewer complications with brachytherapy than
with extensive surgeries like prostatectomy.
The brachytherapy procedure itself is well
tolerated in most cases. This type of therapy
typically requires fewer visits to the hospital or
doctor’s office than other treatments for
prostate cancer.
Disadvantages: Temporary side effects may
include diarrhea, rectal pain, and burning in
some patients.
Brachytherapy can also be associated with
impotence, urinary incontinence, and
bowel problems.
As mentioned earlier, seed insertion usually is
not an option for treatment of prostate cancer
that has spread beyond the prostate gland.
23
How Is Prostate Cancer Treated? (cont’d)
Injectable Radioactive Compounds
Prostate cancer that has spread to the bones
often causes pain. There are various options
available to treat this pain. As mentioned
previously, external beam radiation therapy can
be given to treat certain localized spots of bone
pain. An alternative form of radiation therapy
is an injectable radioactive compound. There
are several types of these radioactive compounds
that are given intravenously. They work more
generally throughout the entire body, but not
on every type of tumor.
Cryotherapy
Cryotherapy, also called cryosurgery, is a
procedure where the tumor is frozen, allowed
to thaw, and then frozen again. In cryotherapy,
a probe is inserted through a small incision in
the perineum. TRUS imaging is used to guide
the probe into the prostate where it will freeze
the tumor and the surrounding tissues.
Cryotherapy kills the cancer cells as well as
some surrounding healthy cells.
Recent improvements in equipment for this
procedure have allowed this technique to
become a comparable alternative to other
treatment options for certain types of patients.
24
Although cryotherapy has shown some
promising results, there is limited information
on the long-term effectiveness of the improved
procedure currently being used.
Advantages: Cryotherapy has a short recovery
time, and it may have fewer complications than
prostatectomy. Unlike radiation, the procedure
may be repeated again if it fails the first time.
Prostatectomy and radiation can still be
performed if cryotherapy fails. Previously there
were numerous complications with cryotherapy;
however, they have decreased with the improved
procedure currently being used.
Disadvantages: Cryotherapy may result in
incontinence or impotence.
Watchful Waiting
(Expectant Therapy)
For some patients with prostate cancer, the
recommended treatment may simply be to
“watch and wait.” This means that you won’t
receive any immediate therapy. Instead, your
doctor will monitor the cancer by performing
routine DRE and PSA tests. Watchful waiting
may be used when prostate cancer is diagnosed
later in life (age 70 or older), at a very early
disease stage, and is not expected to progress
quickly. Watchful waiting may also be used in
patients who are not expected to tolerate
therapy and suffer from other serious
health conditions.
Hormonal Therapy
The primary strategy of hormonal therapy is to
decrease the production of testosterone by the
testes or block the actions that testosterone has
on the prostate cells. Hormonal therapy cannot
cure prostate cancer. Instead, it slows the cancer’s
growth and reduces the size of the tumors.
The types of hormonal therapy that may be
used in prostate cancer are orchiectomy and
hormonal drug therapy.
Orchiectomy
Orchiectomy or surgical castration is the
surgical removal of the testes, which produce
about 95% of the body’s testosterone.
Since the testes are the major source of
testosterone in the body, this procedure is a
form of hormonal therapy. The goal of an
orchiectomy is to deprive the prostate cancer
cells of testosterone, thereby causing the cancer
to shrink and/or prevent further growth of the
tumor. Surgical castration is generally reserved
for patients with hormonal-responsive advanced
metastatic prostate cancer who do not choose
medical castration.
Disadvantages: The surgery is permanent and
the effects cannot be reversed, therefore, many
patients prefer a nonsurgical option since the
success rates are similar.
Many men find it difficult to accept this type
of surgery. Patients will often experience side
effects that result from the lack of male
hormone in the body.
Following the procedure, men will notice
decreased sexual desire as well as impotence.
This can be very upsetting for the patient and
his significant other.
Many men may experience hot flashes, similar
to those experienced by women during
menopause. Some men may experience breast
tenderness and/or breast growth over time.
Hormonal Drug Therapy
There are drugs that prevent the production
or block the action of testosterone and other
male hormones. Three classes of drugs most
commonly used as hormonal therapy in prostate
cancer include:
Advantages: Orchiectomy is an effective
procedure that is relatively simple. The
patient is usually given a local anesthetic and
allowed to go home the same day as the surgery.
25
How Is Prostate Cancer Treated? (cont’d)
• LHRH analogs (luteinizing
hormone-releasing hormone analogs) or medical
castration— a class of drugs that prevent
testosterone production by the testes
• LHRH antagonists—another class of drugs
that prevent testosterone production by the
testes (yet work differently than LHRH analogs)
• Antiandrogens (also called nonsteroidal
antiandrogens)—a class of drugs that block
the action of testosterone at the prostate
Hormonal therapy is most commonly used to
treat locally advanced and advanced metastatic
prostate cancer. In locally advanced prostate
cancer, hormonal therapy may be used in
combination with radiation therapy.
LHRH Analog Therapy
LHRH analog therapy consists of administering
a drug called a luteinizing hormone-releasing
hormone analog, which prevents testosterone
production by the testes.
LHRH analogs may be used alone or in
combination with an antiandrogen. This will
be discussed in more detail in the “combined
androgen blockade” section.
26
There are currently a number of different
LHRH analogs available. Talk to your doctor
about which LHRH analog treatment may be
right for you. If you are treated with an LHRH
analog, your doctor will inform you of how
often you need to receive it. Treatment intervals
vary from 1 month up to 1 year (depending on
which LHRH analog the doctor prescribes).
Advantages: LHRH analogs are generally
administered in a doctor’s office or clinic as an
injection or a surgical implant. Treatment with
LHRH analogs (medical castration) is an
effective alternative to orchiectomy (surgical
castration). Unlike orchiectomy, where the
testes are surgically removed, LHRH analog
therapy is minimally invasive. Once the LHRH
analog is stopped, its effects may be reversible.
Therefore, men generally find it easier to accept
treatment with LHRH analogs than surgical
castration.
Disadvantages: Patients may experience
decreased sexual desire and/or ability to have
erections, hot flashes, fatigue, and decreased
muscle strength. Other side effects may include
anemia, altered lipid levels, decreased cognitive
function, and decreased bone mineral density.
When first starting LHRH analog therapy,
testosterone levels temporarily increase
(called “testosterone surge”). In a small
percentage of patients with advanced
metastatic prostate cancer, testosterone
surge may cause a brief worsening of cancer
symptoms (called “flare”) for a few weeks
before the testosterone level begins to
fall. These symptoms may include bone
pain, spinal cord compression, and
urinary retention.
LHRH Antagonist Therapy
LHRH antagonists are another class of drugs
that also prevent testosterone production by the
testes, yet they work differently than LHRH
analogs. It is used only in special circumstances
to treat metastatic prostate cancer.
Antiandrogen Therapy
Another type of hormonal drug therapy
used in prostate cancer is an antiandrogen.
Antiandrogens do not prevent testosterone
production; instead, they block the action
of male hormones at the prostate.
There are a number of antiandrogens
currently available. They are pills taken orally
one to three times per day (depending on
which antiandrogen the doctor prescribes).
Antiandrogen Withdrawal
Prostate cancer may start to progress after
patients have been on combined androgen
blockade (CAB) therapy (therapy with an LHRH
analog and an antiandrogen) for a
certain period of time. In other words, the
cancer has become resistant to the combined
hormonal therapy. When this occurs, the
antiandrogen therapy may be stopped
(antiandrogen withdrawal) while the LHRH
analog is continued. In some cases, stopping
the antiandrogen for a while may make the
cancer respond to hormonal therapy again.
Combined Androgen Blockade (CAB)
Antiandrogens are used with an LHRH analog
or orchiectomy. This combination therapy is
called combined androgen blockade (CAB),
total androgen blockade (TAB) or maximal
androgen blockade (MAB). LHRH analogs and
orchiectomy prevent testosterone production
from the testes; however, they do not suppress
the production of androgens that are secreted by
the adrenal glands. Therefore, there is still a
small amount of androgen present in the body
after LHRH analog administration or
orchiectomy. Antiandrogens may be added to
block the actions of the remaining androgens.
27
How Is Prostate Cancer Treated? (cont’d)
Advantages: When an LHRH analog or
orchiectomy and an antiandrogen are given
together (CAB), they work together to reduce
the effect of testosterone. An LHRH analog
reduces the quantity of testosterone while an
antiandrogen works to block the remaining
testosterone. Clinical studies in men with
advanced prostate cancer suggest that CAB may
provide small improvements in survival over
LHRH analogs or orchiectomy alone.
The effects of CAB with an LHRH analog (not
orchiectomy) and an antiandrogen may be
reversible once CAB is stopped. Therefore,
most men find it easier to accept treatment
with an LHRH analog and an antiandrogen,
than treatment with orchiectomy and an
antiandrogen. Treatment with an LHRH
analog and an antiandrogen is minimally
invasive, since LHRH analogs are given as an
injection or implant and antiandrogens are
given as pills.
Disadvantages: In addition to an LHRH
analog or orchiectomy, the patient has to
remember to take their antiandrogen every day.
CAB treatment is more expensive than medical
28
castration (LHRH analog) or surgical castration
(orchiectomy) alone.
There have been reports of liver injury in
association with the use of antiandrogens.
Therefore, liver function tests should be
measured prior to starting treatment with CAB,
at regular intervals for the first 4 months of
treatment, and periodically thereafter.
Patients may experience any of the side effects
associated with LHRH analogs or orchiectomy,
as well as side effects related to antiandrogens.
Depending on the antiandrogen used, these
side effects may include diarrhea, breast
tenderness,
breast
enlargement,
and sometimes
liver function
problems.
Additionally, it
is important to
remember that
if an LHRH
analog or orchiectomy is used in combination
with an antiandrogen and radiation therapy, it
can be difficult to know for sure which
component of therapy, if any, is responsible for
the side effects that may occur. Sometimes, a
worsening of the actual disease may be
confused for a side effect of a particular
treatment regimen.
Finally, the length of hormonal therapy
influences the type and degree of side effects a
patient may experience. Patients should always
discuss any symptoms with their doctor or
other health care provider. He/she may have
some practical recommendations to help
alleviate symptoms that are in fact due to
the treatment regimen.
Hormone Refractory Prostate Cancer
A patient becomes what is referred to as
hormone refractory when the majority of
hormonal therapies have been exhausted and
patient stops responding to all hormonal
therapy, and the cancer progresses again. The
patient’s PSA level rises despite the use of CAB,
antiandrogen withdrawal, or other hormonal
therapies. When this happens, other treatments
may be considered including chemotherapy,
investigational therapy, or palliative treatment
to relieve symptoms.
Chemotherapy
Chemotherapy is the use of powerful and toxic
drugs to attack cancer cells, and is usually
administered by a medical oncologist. The drugs
circulate throughout the body in the
bloodstream and may kill any rapidly growing
cells, including healthy ones. Chemotherapy
drugs are carefully controlled in both dosage
and frequency so that cancer cells are destroyed
while minimizing the risk to healthy cells.
The drugs used for chemotherapy come in
many different forms. While some are given
directly into a vein or a muscle, others may be
taken by mouth. Some of the drugs must be
given in a clinic; others can be administered
while the patient is at home.
• There are many different chemotherapy
drugs, each with their own strengths and
weaknesses. Often the drugs are used
in combinations
• Sometimes hospitalization may be needed for
certain types of chemotherapy that require
special monitoring of both the treatment and
its possible side effects
29
How Is Prostate Cancer Treated? (cont’d)
Chemotherapy is generally reserved for patients
with advanced stage prostate cancer (Stage M+)
that no longer responds to hormonal therapy.
However, it is being studied in earlier stages of
prostate cancer.
Advantages: Chemotherapy provides an
additional means of relieving the symptoms
of advanced prostate cancer that generally no
longer respond to hormonal therapy. It can
reduce pain and may slow tumor growth.
Disadvantages: Because the drugs circulate
throughout the whole body, they can affect
both healthy and cancerous cells. This can lead
to many side effects. The specific side effects
will depend upon which drugs and combinations
are used.
30
• For the majority of chemotherapy drugs, side
effects may include hair loss, nausea, vomiting,
diarrhea, lowered blood counts, reduced
ability of the blood to clot, and an increased
risk of infection. Some of these side effects
occur only temporarily or are more noticeable
when treatment is first started. Most of the
side effects disappear when the drugs are
stopped. For instance, hair will grow back
once chemotherapy has stopped
Bisphosphonates
The newest form of treating bone complications
due to prostate cancer that has spread to the
bones is with injectable drugs called
bisphosphonates. In general, there are 2 types
of metastatic bone lesions; osteoblastic (bone
producing) and osteolytic (bone breakdown).
Bisphosphonates may be helpful in treating
one type of such lesions. Generally, a patient
who suffers from metastatic prostate cancer and
has already been treated with hormonal therapy
that failed may be treated with bisphosphonates.
Investigational Therapy
(Clinical Trials)
A clinical trial, also known as a research study,
is used to answer specific questions about an
investigational therapy or to study new ways of
using an existing therapy. The purpose of a
clinical trial is to determine whether a therapy
is both safe and effective in treating humans for
a particular disease or condition. This includes
looking at the benefits as well as the potential
risks of the therapy.
If you decide to participate in a prostate cancer
clinical trial, you may obtain expert medical
care by leading doctors in the field of cancer
research and may gain access to new drugs or
treatments not available to other patients.
If you participate in a clinical trial, you may
experience side effects from the therapy or
procedure. You may receive a therapy that may
be less effective than standard therapy. In
addition, you may receive a therapy that may
be beneficial to others but ineffective for you.
Also, you may receive a placebo (sugar pill),
but this does not apply to all clinical trials.
You may want to discuss participation in a
clinical trial with your doctor so that you know
all available treatment options to help you
make a decision. Your doctor can help you
determine if a clinical trial is right for you.
Also, your general health will be closely
monitored, and you will be evaluated for any
side effects you may experience from therapy.
You may be one of the first to benefit from a
medication if the treatment is found to be
effective and gain personal satisfaction in
knowing that you are contributing to the
advancement of cancer research. However,
there are also risks with participating in
a clinical trial.
31
What Happens After I Receive Treatment?
After you receive treatment for
your prostate cancer, you’ll have
routine checkups with your doctor
for the rest of your life. You will be
evaluated to determine if your
treatment remains effective, or if
the cancer has recurred or
progressed. In addition, your
doctor will evaluate any side effects
you may be experiencing from
your treatment(s).
Generally, a PSA test is used to make sure the
cancer hasn’t come back after treatment. You
will also be required to have follow-up PSA
tests to evaluate the effectiveness of your
treatment. Your PSA should remain stable at a
low level. If your PSA is rising, this may mean
that the cancer has come back or is progressing,
and further testing and treatment may
be needed.
32
Ways to Cope With Your Diagnosis and Treatment
Learning that you have prostate
cancer brings up a lot of feelings
that you may find hard to deal
with. It’s only natural to be
concerned about your treatment,
side effects, the future, and how
your illness will affect you and your
loved ones. Take advantage of all
the help you can find, especially
from your health care team. Tell
them what you are feeling and
what you need.
How am I expected to feel?
There is no one way to react to prostate cancer
and every man is entitled to his own experience.
One common worry is about treatments that
affect sexual performance, which causes many men
to feel a threat to their masculinity. Others find
prostate cancer embarrassing to talk about.
Whatever you feel, try not to push your feelings
away. That can cause even more stress.
What’s the best way to cope with my diagnosis?
Become a partner with your health care team
(your urologist, radiation oncologist, medical
oncologist, nurse, technician, counselor). Ask
questions about your condition, the risks, benefits,
and side effects of each treatment option, and the
impact your choice will have on your life. It’s a
good idea to write down all your questions and
answers so you can refer to the information at any
time. Once you have decided on a treatment
option, follow your health care team’s advice and
let them know about any new symptoms or
other concerns.
How will prostate cancer affect my relationships?
Talk about your illness with your family and close
friends. Some people may shy away at first because
they want to help you but don’t know how. Being
open about what you need can help you maintain
relationships that will support you.
How much should I tell my partner?
The honest sharing of thoughts and feelings can
create an even greater intimacy. It’s important to
talk to each other about how certain decisions will
affect your life together. For example, if a possible
side effect of your treatment is impotence
(inability to have an erection), you and your
partner may decide to talk about other ways you
each can still enjoy sex.
If you need help starting conversations with your
partner, you may each want to first write down
your feelings and concerns. Or, you may want to
talk to a professional counselor specializing in
erectile dysfunction. Your health care team can
help you find a counselor.
33
Support Services and Resources for More Information on Prostate Cancer
Here’s a list of local and national
support groups and resources that
may be of interest to you:
American Cancer Society
1599 Clifton Road, NE
Atlanta, GA 30329-4251
1-800-ACS-2345
www.cancer.org
Call your local chapter of the American Cancer
Society at 1-800-ACS-2345
American Urologic Association Foundation
1000 Corporate Boulevard
Linthicum, MD 21090
410-689-3990
1-800-828-7866
www.afud.org
Founded in 1987, The American Foundation
for Urologic Disease (AFUD) is a nonprofit
organization dedicated to supporting research,
education, and patient support services for those
who are affected by, or may be at risk for developing,
urologic disease or disorder. The organization
provides educational information about urological
diseases and conditions to the general public and
to health care providers. Materials are available
that discuss prostate disease, prostate cancer,
enlarged prostate (BPH), and prostatitis.
34
CancerCare
275 Seventh Avenue
New York, NY 10001
1-800-813-HOPE
www.cancercare.org
A national nonprofit organization that
provides free, professional services including
counseling, education, financial assistance, and
practical help to anyone affected by cancer.
National Cancer Institute
1-800-4-CANCER
www.cancer.gov
The National Cancer Institute's Web site
provides accurate, up-to-date information
about many types of cancer, information about
clinical trials, resources for people dealing with
cancer, and information for researchers and
health professionals.
Prostate Cancer Foundation
(formerly CaP CURE)
1250 4th Street
Santa Monica, CA 90401
1-800-757-CURE
www.prostatecancerfoundation.org
Prostate Cancer Foundation (formerly CaP
CURE) is the world's largest private source
of prostate cancer research funding. The
organization was founded in 1993 and is
involved in the identification, funding, and
support of prostate cancer research.
Prostate Cancer Research and Education
Foundation (PC-REF)
5480 Baltimore Drive, Suite 202
La Mesa, CA 91942
619-461-8181
www.pcref.org
PC-REF's mission is to provide seed money for
innovative prostate cancer research, to seek out
new diagnostic and therapeutic tools, to
provide support to prostate cancer patients and
loved ones, and to provide education to the
general public with the goal of increasing
awareness of prostate cancer, its management
and the need for patient involvement in
treatment decisions.
Us TOO International Prostate Cancer
Education & Support Network
5003 Fairview Avenue
Downers Grove, IL 60515
Patient Hotline: 1-800-80-UsTOO
(1-800-808-7866)
Phone: 630-795-1002
www.ustoo.org
This organization provides prostate cancer
survivors and their families emotional and
educational support through an international
network of local support groups; offers
literature on prostate cancer, a monthly
newsletter, weekly E-Mail NEWS, and a
toll-free hotline.
Prostate Cancer Information
AstraZeneca Pharmaceuticals LP
www.PROSTATEinfo.com
A patient-friendly Web site created and
maintained by AstraZeneca Pharmaceuticals LP.
This site explains the disease and gives
information about diagnosis, treatment, and
support groups.
35
Glossary of Medical Terms
The following is a list
of some medical terms
that may not be familiar
to you.
adrenal glands: two small, triangle
shaped glands located on the top
of each kidney that secrete various
hormones, including androgens.
age-specific PSA reference range:
a PSA range that is designed to
compare the results of men in the
same age group. If a man’s PSA
levels are high compared to others
in his age group, then there is a
higher chance that prostate cancer
could be present.
androgen: any substance that
produces male physical
characteristics (facial hair, deep
voice). The main androgen
hormone is testosterone.
anesthesia: absences of sensation,
especially pain.
antiandrogen: drugs that fight
prostate cancer by blocking the
action of testosterone.
36
anus: the opening at the lower
end of the rectum through which
stool is eliminated.
benign: a noncancerous,
nonspreading tumor that is
generally not life threatening.
benign prostatic hyperplasia
(BPH): a noncancerous
enlargement of the prostate
caused by an overgrowth of cells.
biopsy: a small sample of tissue
that is taken and examined under
microscope for the presence
of cancer.
brachytherapy: a procedure in
which tiny “seeds” made up of
radioactive material are placed
directly into the prostate.
cancer: a term for diseases in
which abnormal cells grow and
divide without control and
possibly spread to other parts of
the body.
capsule: a layer of cells covering
an organ such as the prostate.
castration: treatment that
suppresses most testosterone
production. Castration can be
achieved surgically (orchiectomy)
or medically (using an
LHRH analog).
catheter: a tube that is temporarily
inserted through the urethra into
the bladder to withdraw urine or
to empty the bladder.
cell: the basic structural and
functional units of the body.
chemotherapy: treatment with
anticancer drugs that primarily
attack cancer cells.
clinical trials: formal studies
conducted on patients with cancer
or other diseases, usually to evaluate
a new or investigational treatment.
Each study is designed to answer
specific questions and to find
better ways to treat patients.
combined androgen blockade
(CAB): hormonal therapy that
involves combining an
antiandrogen drug with an
LHRH analog or orchiectomy.
Also called maximum androgen
blockade (MAB): or total
androgen blockade (TAB).
concomitant hormonal therapy:
therapy that is given during
radiation in order to improve the
results of the procedure.
conformal proton beam
radiation therapy: similar to
3-dimensional conformal
radiation therapy except that it
uses protons to produce
the radiation.
cryosurgery: see cryotherapy.
cryotherapy: repeated freezing
and thawing of the tumor cells
which result in cell death as cells
rupture when they begin to thaw.
digital rectal examination (DRE):
an examination performed by a
physician in which a gloved,
lubricated finger is inserted into
the rectum to check to feel for
lumps, enlargement, or areas of
hardness that might indicate the
presence of cancer.
duct: a tube-like structure that
carries secretions from one organ
to another.
ejaculation: to eject sperm and
seminal fluid from the penis.
erection: enlargement of the
penis due to increased blood flow;
this most often occurs during
physical stimulation.
external beam radiation therapy:
radiation therapy provided by
machines that aim special
radiation beams at the prostate
to destroy cancer cells.
hormonal-responsive: cancer
that responds to treatment with
hormones or orchiectomy.
hormonal therapy: in prostate
cancer, treatment that interferes
with the production of male
hormones or block the action of
male hormones that promote
prostate tumor growth.
impotence: inability to have
an erection.
intensity modulated radiation
therapy (IMRT): a form of
external beam radiation therapy
that uses computed tomography
to create a 3-D picture of the
prostate and surrounding organs
so radiation rays can be delivered
only to the prostate gland. IMRT
precisely delivers many thin
radiation beams to the prostate
gland. It allows for a high dose of
radiation to be administered to
the prostate while minimizing
effects on nearby organs.
interstitial radiation therapy:
treatment with high-energy
radiation from tiny radioactive
seeds inserted into the prostate;
see brachytherapy.
investigational therapy: therapies
that are in the process of being
evaluated for use to treat a disease
or condition.
lesion: general term for any
visible, local abnormality of tissue
(eg, injury, wound, boil,
sore, rash).
LHRH analog: see luteinizing
hormone-releasing hormone
analog.
luteinizing hormone (LH):
a substance produced by the
pituitary gland that stimulates the
secretion of sex hormones in both
men and women.
luteinizing hormone-releasing
hormone (LHRH): a hormone
secreted by a part of the brain
that triggers the release of LH.
luteinizing hormone-releasing
hormone analog (LHRH
analog): drugs that treat prostate
cancer by preventing the testes
from producing testosterone.
lymph: a nearly clear fluid
collected from tissues around the
body and returned to the blood
by the lymphatic system. Lymph
drains waste from cells.
lymphadenectomy: surgical
removal of lymph nodes.
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. A network
of vessels, nodes, ducts and organs
that help maintain the body’s
fluid environment and protect the
body by producing lymph.
37
Glossary of Medical Terms (cont’d)
lymph nodes: small bean-shaped
structures scattered along the
vessels of the lymphatic system.
The lymph nodes filter out or
remove waste, bacteria, and cancer
cells that may travel through the
lymphatic system.
malignant: a cancerous tumor
that can grow and spread, and
may be life threatening.
margins: edges or borders.
medical oncologist: a doctor who
specializes in diagnosing and
treating cancer using
chemotherapy, hormone therapy,
or biological therapy.
metastatic: cancer that has spread
from its primary site to nearby or
distant areas of the body through
the lymphatic system or blood.
neoadjuvant hormonal therapy:
therapy that is given before
radiation in order to improve the
results of this procedure.
nerve-sparing radical retropubic
prostatectomy: surgical removal
of the prostate, through an incision
in the lower abdomen, in which
the nerves on either side of the
prostate are spared, if possible.
nonsteroidal antiandrogen:
antiandrogens that do not have a
steroid component.
orchiectomy: the surgical removal
of the testes, the major source of
male hormones.
palliative therapy: therapy that is
given to reduce the severity of
advanced prostate cancer and
provide symptom relief.
palpable: able to be felt by a
doctor during a digital rectal
examination.
pathologist: a doctor who
specializes in the diagnosis of
disease by studying cells and
tissues with a microscope.
percent free-PSA ratio: compares
the amount of PSA in the blood
by itself (unbound) and the
amount that is attached to other
blood proteins (bound).
38
perineum: the area between the
scrotum and the anus.
pituitary gland: a gland located
at the base of the brain. It
produces hormones that stimulate
the testes and other organs to
release hormones.
prognosis: a prediction made
about the potential outcome of a
disease.
prostatectomy: the surgical
removal of the prostate gland.
prostate-specific antigen (PSA):
a blood substance that often
increases in patients with prostate
cancer and other prostate diseases.
prostatitis: inflammation of
the prostate.
PSA density (PSAD): determined
by dividing the PSA level by the
size or volume of the prostate.
PSA doubling time: refers to the
time during which PSA measured
in blood doubles.
PSA velocity: measures how
quickly the PSA level rises over a
period of time.
radiation therapy: treatment
for prostate cancer that uses
radiation to kill cancer cells and
shrink tumors.
sperm: mature male sex cell.
stage: the size and extent to
which the cancer may have grown
and spread.
tumor: an abnormal mass of cells
that result from uncontrolled and
disorderly cell division and
growth. Tumors may be cancerous
(malignant) or noncancerous
(benign).
radical perineal prostatectomy:
surgical procedure in which the
prostate is removed through an
incision in the perineum.
testes: male reproductive glands
that produce the sperm and
testosterone.
radical prostatectomy: an
operation to remove the entire
prostate gland, seminal vesicles,
and some of the tissue around it.
testosterone: a male sex hormone
produced primarily by the testes,
responsible for the sexual
characteristics of men.
radical retropubic prostatectomy:
surgical procedure in which the
prostate is removed through an
incision in the lower abdomen.
3-dimensional conformal
radiation therapy (3D-CRT):
the use of high-tech computers
and a body mold to more
accurately deliver radiation to
the prostate.
urinary bladder: the hollow
organ that stores urine.
tissue: a collection of cells
specialized to perform a
particular function.
urologist: a doctor who
specializes in diseases of the
urinary and sex organs in males
and the urinary organs in females.
rectum: the last 5 or 6 inches of
the large intestine leading to the
outside of the body (anus).
scrotum: the external sac, or
pouch, of skin containing
the testicles.
semen: the fluid that is ejaculated
during sexual climax; it contains
the sperm and fluids from other
glands, including the prostate.
seminal vesicles: pouches
located above the prostate that
store semen.
transrectal ultrasonography
(TRUS): a procedure in which a
special probe is inserted rectally
and uses sound waves to produce
a picture of the prostate and the
surrounding organs.
transurethral resection of the
prostate (TURP): a surgical
procedure to remove the excess
tissue from the prostate with a
special instrument that is inserted
through the urethra.
ureter: the tube that carries
urine from each kidney to the
urinary bladder.
urethra: the tube that carries
urine from the urinary bladder
and semen from the sex glands.
urinary incontinence: inability
to control the flow of urine from
the bladder.
watchful waiting: also called
expectant management or
surveillance; the decision not to
treat prostate cancer with surgery,
radiation, hormonal therapy, or
any other treatment options.
Instead, the physician monitors
the patient’s prostate cancer by
checking PSA levels and looking
for signs and symptoms of
cancer growth.
39
Some Questions to Discuss With Your Doctor
Prostate cancer and its treatment is a complex subject. If you do not
understand certain aspects of your disease, treatment options, their side
effects, and outcomes, be sure to ask your doctor questions about it.
Before your visit, prepare yourself by writing down the things you do not understand.
Here are some suggested questions you might want to ask:
1. What is prostate cancer?
2. How common is prostate cancer in my age group?
3. How is prostate cancer diagnosed? What kind of tests do I need to undergo?
4. What is the prostate-specific antigen (PSA) blood test and what does it tell us?
5. What is the stage of my prostate cancer? What is the Gleason score of my prostate cancer?
6. Can the prostate cancer spread to other areas of my body?
7. What are my treatment options?
8. Is the hormonal therapy treatment option appropriate for me?
9. What are the benefits and risks (side effects) of each of the treatment options?
10. Which treatment options for the stage and type of my prostate cancer provide me a
likelihood of living longer?
11. What is watchful waiting?
12. What if the prostate cancer progresses or comes back after I receive therapy of curative intent?
13. Are there any clinical trials that may be appropriate for me?
14. Where can I get more information about my diagnosis?
40
41
References
1. American Cancer Society. Estimated New Cancer Cases and Deaths by Sex for All Sites,
US, 2005. Available at: www.cancer.org. Accessed July 11, 2005.
2. American Cancer Society. Detailed Guide: Prostate Cancer. 2005. Available at: www.cancer.org.
Accessed July 11, 2005.
3. Prostate Cancer Early Detection Clinical Practice Guidelines in Oncology. JNCCN, 2005.
Available at: www.nccn.org. Accessed July 11, 2005.
42
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