Download Prostate Cancer OVERVIEW Prostate cancer is the second most

Prostate Cancer
OVERVIEW
Prostate cancer is the second most common cancer diagnosed among American men,
accounting for nearly 200,000 new cancer cases in the United States each year.
Greater than 65% of all cases of prostate cancer are diagnosed in men 65 years and
older. The incidence of prostate cancer increases with age with the lifetime risk for the
average American man is about one-in-six. Well-established risk factors include older
age, family history, and race (African Americans are at greater risk). Other potential
risk factors thought to be associated prostate cancer include a Western diet high in
saturated fat and obesity.
The overwhelming majority of prostate cancers are adenocarcinomas, which arises
from the glandular component of the prostate. Other rare forms of prostate cancer
include:
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Ductal carcinoma
Mucinous carcinoma
Signet-ring cell carcinoma
Small cell carcinoma
Clear cell adenocarcinoma
Giant cell carcinoma
These rare variants often act aggressively and may respond differently to therapy than
the more common prostate adenocarcinoma.
The face of prostate cancer has changed significantly over the past 2 decades.
Largely due to the widespread use of serum prostate specific antigen (PSA) assay.
Most prostate cancers are now diagnosed at an earlier stage and younger age
compared to 20 years ago because of PSA assay. Although prostate cancer deaths
have decreased in recent years, PSA screening continues to be controversial.
However both the American Cancer Society and American Urologic Association
recommend prostate cancer screening beginning at age 50 for most men and at 40
years of age for African American men and those with a family history.
Localize prostate cancer
Approximately 90% of prostate cancers are diagnosed at a localized stage (cancer
confined to prostate without evidence of spread). Localized cancers are most
commonly detected through an elevation in PSA without causing symptoms. Less
commonly, prostate cancer may be detected by an abnormal digital rectal exam
(DRE). Not all local prostate cancers are the same. Some are indolent and will not
cause problems while others are clinically significant and require treatment. Even
among clinically significant cancers, there are differences that further separate cancers
by risk (for example, low, intermediate and high risk prostate cancer). Factors that
determine the risk and thus clinical significance of prostate cancers include serum
PSA, Gleason score and clinical stage. There are several effective treatment options
for men with localize prostate cancer, including surgery, external beam radiation
therapy and interstitial brachytherapy. Treatment recommendations are usually made
based on a number of factors, including overall health, disease characteristics, risk
category, candidacy for a particular treatment, and patient preference. In some cases
(low- and intermediate-risk prostate cancer, for example), a single treatment may be
adequate for disease control. For others, particularly in high-risk prostate cancer, a
combination of treatments may be required. For low-risk prostate cancer and among
older men, active-surveillance (observation) is another management option. All
prostate cancer treatments carry some risk of impacting urinary, sexual and bowel
function. Newer treatment methods, however, continue to be developed to minimize
the risks of these side effects (for example, nerve-sparing radical prostatectomy and
image guided radiation therapy). Following treatment, approximately 15% to 25% of
patients with early-stage (localized) prostate cancer experience a biochemical (PSA)
recurrence (that is treatment failure). These individuals may require additional
therapy. However, the overall 5-year survival for patients with localized prostate
cancer is nearly 100%.
Advanced prostate cancer
Approximately 10% of prostate cancers are diagnosed at an advanced stage
characterized by involvement of surrounding structures, spread to lymph nodes or
spread to more distant sites (metastatic disease). Advanced prostate cancer more
commonly causes some symptoms, such as hematuria, urinary obstruction or bone
pain. Treatment options for patients with advanced prostate cancer are more limited,
although in some settings, surgery or radiation therapy may still be indicated. More
commonly, androgen deprivation therapy (ADT), also known as hormone therapy, is
used to control the disease and slow the growth of these cancers. Chemotherapy may
also be used to manage patients with metastatic prostate cancer. Common sites of
metastatic spread include the bone, liver and lungs. The overall 5-year survival for
regionally advanced and metastatic prostate cancer is approximately 32%.
Signs & Symptoms
For most men, prostate cancer does not cause symptoms but is detected because of
an elevation in serum prostate specific antigen (PSA). However, symptoms of the
lower urinary tract, such as hematuria (blood in the urine), frequency (need to urinate
frequently) and dysuria (discomfort or pain with urination) may be signs of prostate
problems, including prostate cancer. Other uncommon symptoms of prostate cancer
can include urinary retention, weight loss, abdominal pain, bone pain, or fracture.
Lower Urinary Tract Symptoms
Frequency
Urgency
Hematuria (visible or microscopic)
Dysuria
Urinary retention
Pain Symptoms
Back pain
Pelvic pain
Bone pain
Constitutional symptoms
Weight loss
Diagnosis
Physical examination
Serum PSA test
Prostate biopsy
Abdominal and pelvic CT scan (if indicated)
Bone scan (if indicated)
After taking a detailed medical history and performing a physical examination, including
a digital rectal examination, a PSA blood test will be performed. If the PSA level is
elevated, a prostate biopsy may be recommended. The biopsy is an outpatient
procedure that is performed with local anesthesia. Several samples of tissue are
obtained from the prostate. These samples are sent to pathology, where the samples
are reviewed under a microscope to detect cancerous cells. If the biopsy is positive,
other tests may be performed based on your PSA level, cancer grade and findings on
exam. In high-risk cases, a bone scan and/or CT scan of the pelvis may be
recommended to determine if there has been spread to the bones or local organs.
Staging for prostate cancer
Clinical staging is performed with Physical Examination and Pelvic CT scan. In cases
of advanced or high-risk disease, additional testing such as Bone Scan may be
necessary.
The prognosis of prostate cancer is directly linked to the grade and stage of disease.
Staging is a process that demonstrates how far the cancer has spread. Both treatment
options and prognosis (or outlook) for prostate cancer depend significantly on the stage
of disease.
T0
T1
T1a
T1b
TNM SYSTEM
Status
No evidence of primary kidney tumor
Clinically inapparent tumor not palpable or visable by
imaging
Tumor incidental histologic finding in <5% of removed
tissue
Tumor incidental histologic finding in >5% of removed
tissue
T1c
T2
T2a
T2b
T2c
T3
T3a
T3b
T4
N0
N1
M0
M1
M1a
M1b
M1c
Tumor identified by needle biopsy because of elevated
PSA
Tumor confined with the prostate
Tumor involves one-half of one lobe or less
Tumor involves > one-half of one lobe but not both lobes
Tumor involves both lobes
Tumor extends through the prostate capsule
Extracapsular extension (unilateral or bilateral)
Tumor invades seminal vesicle(s)
Tumor fixed or invades adjacent pelvic structures
No regional lymph node metastasis
Metastasis in regional lymph node or nodes
No distant metastasis
Distant metastasis
Metastasis to non-regional lymph node(s)
Metastasis to bone(s)
Metastasis to other site(s)
Treatment
Most prostate cancers are localized and can be treated with surgery, external radiation
therapy or interstitial brachytherapy. In low-risk disease, observation or active
surveillance may also be an option. Focal therapy using ablative technology is less
common and is currently under investigation. Treatments for localized prostate cancer
include:
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Radical retropubic prostatectomy
Robotic-assisted laparoscopic prostatectomy
Intensity-modulated radiation therapy
Interstitial brachytherapy
Focal therapy
Active Surveillance (observation)
Radical retropubic prostatectomy (RRP) – consists of removal of the prostate gland
and surrounding lymph nodes through an 8 cm open incision above the pubic bone.
Radical retropubic prostatectomy is the most common open surgical approach to
treating prostate cancer, and can be used to treat a range of prostate cancer, including
low, intermediate and high-risk localized prostate cancer, as well as radiation refractory
prostate cancer (termed salvage prostatectomy). Patients spend 2 nights in the
hospital and are sent home with a urinary (Foley) catheter, which stays in for a week
following surgery to assist healing of the urethra. Depending on the stage and risk of
the disease, radical retropubic prostatectomy can be performed with nerve-sparing.
Nerve-sparing prostatectomy provides the best chance of return of erections following
surgery in men with good erectile function prior to treatment, and is typically used in
low and intermediate-risk disease. In setting of high-risk disease, however, nerve-
sparing may not be indicated as it may adversely affect cancer control. Like other
types of surgical therapy, outcomes following radical retropubic prostatectomy (cancer
control, urinary continence, erectile function and complications) tend to be better, on
average, when performed by high-volume and fellowship-trained surgeons.
Robotic-assisted laparoscopic prostatectomy (RALP) is one of the most common types
of surgical treatments for prostate cancer and its use has increased rapidly over the
recent years. Similar to radical retropubic prostatectomy, robotic-assisted laparoscopic
prostatectomy is used in the management of localized prostate cancer. The robotic
approach takes advantage of the benefits of laparoscopy as well as small surgical
working elements that replicate the movement of the human hand. In general, RALP is
associated with less blood loss, decreased pain post-operatively, and shorter
convalescence. As with RRP, lymph nodes are removed with the prostate for
pathologic staging. Patients tend to spend 1-2 nights in the hospital and are sent home
with a urinary (Foley) catheter that stays in place for 7 to 10 days. As with open
surgery, this procedure should be performed by a surgeon familiar with the robot and
who is trained in performing radical prostatectomy.
Intensity-Modulated Radiation Therapy – Radiation therapy is an effective treatment for
prostate cancer and can be used to manage low and high-risk cases. Current state of
the art includes Intensity-modulated RT (IMRT), which uses more advanced technology
to reduce dose to the areas of the bladder, rectum and bowel and boost dose to the
prostate. In addition, the newer technology allows image guiding to more accurately
deliver radiation dose to the prostate with less radiation therapy exposure to
surrounding tissues. A total radiation dose of >76 Gy should be administered and
some studies have shown that higher doses are more effective. Radiation therapy is
typically given in daily fractions over the course of 10 weeks. Helical tomotherapy is
currently the most advanced method of delivering IMRT to patients. This method uses
a constantly modulated rotating beam of radiation that targets the exact size and shape
of the tumor. This treatment is completely integrated so physicians know exactly what
took place and where in the patient's previous treatment session. In intermediate- and
high-risk prostate cancer, radiation should be administered with ADT to maximize the
treatment effect.
Interstitial prostate brachytherapy involves placement of small radioactive pellets, or
“seeds” into the prostate. In general, this treatment can be used for small to normal
sized prostates and for Gleason grade 6 or less tumors. In settings of higher risk
disease (PSA>10 ng/mL or Gleason grade >7) where there is concern for
extraprostatic extension, external radiation therapy should be used to ensure adequate
cancer control. In some cases, hormone therapy may be used before brachytherapy to
help reduce the size of the prostate.
Active surveillance (observation) is used in some cases of low-risk disease, as well as
among older patients for whom active treatment with surgery or radiation therapy may
not be possible or necessary. Active surveillance is most often used because some
prostate cancers may never become life threatening. PSA and DRE are typically
checked routinely, in addition repeat prostate biopsies are usually necessary to ensure
the cancer is not progressing.
Focal therapy – ablative therapies such as cryoablation are currently being studied as
a way to limit treatment to the focal location of the cancer instead of treating the entire
prostate with the hopes that focal therapy will be associated with fewer side effects
than other non-focal treatments. Selection of appropriate, low-risk patients is critical
because less therapy may not be adequate to control higher-volume or high-risk
prostate cancer.
Salvage therapy – In cases of prostate cancer recurrence following primary treatment,
a secondary local therapy can lead to cure (salvage therapy). Depending on which
type of treatment was first used, salvage surgery, radiation therapy or cyroabalation
may be used to control recurrent disease.
Treatment for advance prostate cancer
Hormone therapy uses medications to decrease testosterone, a hormone that
promotes growth of prostate cancer. This therapy may be done in cases of advanced
prostate cancer. Hormones may also be given in conjunction with radiation therapy or
surgery. Watchful waiting is another option that may be recommended, as prostate
cancer generally grows slowly. Talk with your doctor about selecting your treatment
and balancing the expected benefits.
Chemotherapy is anticancer medications that are injected into a vein or given by
mouth.