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GE Healthcare TiP-TV™ Training in Partnership Program Supplement and Test for Imaging Professionals US: Men’s Health Publication Date: August 5, 2004 Revised/Reissued: August 12, 2005 Revised/Reissued: August 12, 2006 Revised/Reissued: January 20, 2011 1.0 ASRT-approved Category A CE Credit imagination at work GE Healthcare REV 3 US: Men’s Health Program Supplement and Test TABLE OF CONTENTS Program Summary .......................................................................................................................................................................3 Continuing Education Credit and Video File Download................................................................................................4 Testicular Cancer ..........................................................................................................................................................................5 Testicular Cancer...................................................................................................................................................................6 Testicular Cancer Testing...................................................................................................................................................7 Imaging......................................................................................................................................................................................8 Testicular Cancer Treatment ............................................................................................................................................9 Images..................................................................................................................................................................................... 10 Prostate Cancer.......................................................................................................................................................................... 12 Prostate Anatomy............................................................................................................................................................... 12 Prostate Diseases ............................................................................................................................................................... 13 Prostate Testing .................................................................................................................................................................. 14 Prostate Cancer Treatment............................................................................................................................................ 16 Appendix A: Lance Armstrong Foundation ............................................................................................................................ 18 Appendix B: Men’s Health Guidelines ....................................................................................................................................... 19 Appendix C: "Think Again" Answers ........................................................................................................................................... 23 Appendix D: Resources .................................................................................................................................................................... 23 Appendix E: Presenter Biographies ............................................................................................................................................ 24 Appendix F: Post-Test ....................................................................................................................................................................... 25 ICON LEARNING SYSTEMS NETTER IMAGE COPYRIGHT Electronic files of Images created by Dr. Frank H. Netter or Images created in the style established by Dr. Frank H. Netter from The Netter Collection of Medical Illustrations. Some graphics may have been adapted with permission from the publisher, Icon Learning Systems. Copyright 2004. Icon Learning Systems, LLC. A division of MediMedia USA, Inc. All rights reserved. ICON LEARNING SYSTEMS NETTER IMAGE DISCLAIMER The Netter images included in this program supplement were licensed from Icon Learning Systems for illustration and educational purposes only. These images should not be used for diagnostic or clinical purposes or for the treatment of any medical condition. There is no guarantee that these images do not contain errors, incomplete, or out of date information. © 2004 General Electric Company. All rights reserved. 2 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Program Summary This page provides an overview of the program content and learning objectives. Please refer to the Table of Contents for a detailed list of the topics covered. We encourage you to file a copy of this Program Summary and the Table of Contents with your continuing education certificate. We also recommend you provide your manager with a copy of this information as a record of your educational achievement. Program Description Often left undiagnosed due to fear and embarrassment, many of the men's health concerns that sonographers deal with progress without detection. In 2003, the American Cancer Society estimated that more than 220,000 new cases of prostate cancer and about 7,600 new cases of testicular cancer would be diagnosed in the United States. This program looks at the latest in imaging technology and the advancements in treatment of these and other diseases. Program Objectives By the end of this program, the viewer should be able to: • Review normal prostate and testicular anatomy. • Describe the etiology of prostate and testicular cancer. • Discuss what role ultrasound plays in the evaluation of male specific diseases. • Identify the different stages of prostate and testicular cancer through ultrasound imaging. • Discuss treatments of male specific cancer and other medical conditions. Target Audience Course objectives for this program specifically target diagnostic medical sonographers. While not limited to this audience group, the technical content is most effective when applied to people with this training. NOTE: Regardless of your imaging specialty, you may apply for continuing education credit. Refer to the Continuing Education Credit page for additional information. Continuing Education Credit 1.0 ASRT-approved Category A CE Credit NOTE: Effective February 1, 2005, the ARDMS accepts credits for ASRT-approved CE activities. ARDMS registrants may claim ASRT-approved Category A credit to meet their CE requirements. For more information, visit: www.ardms.org © 2004 General Electric Company. All rights reserved. 3 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Continuing Education Credit and Video File Download Online Process for CE Credit (hls.gehealthcare.com) In order to receive continuing education credit, you must log into the GE Healthcare Learning System (HLS) and complete all of the required steps. Please refer to the online TiP-TV Quick Start User Guide (click the User Guides link on the HLS Welcome page) for additional information on how to use the GE HLS as needed. 1. View the entire program video online or download the video file for later viewing (refer to the process below). This supplement is not intended to replace watching the video. 2. Go to the GE HLS web site at hls.gehealthcare.com and complete the feedback form. NOTE: The Feedback Form link is not activated until the View Video Now module has been completed. This provides valuable information regarding your thoughts on the program’s quality and effectiveness. 3. Complete the program post-test without aids or assistance of any kind; this is an individual effort. You have up to three attempts to successfully complete the test with a minimum passing score of 75% (ASRT and CBRN approved programs) or 80% (SNM-approved programs). The post-test measures knowledge gained and/or provides a self-assessment on a specific topic. 4. Upon successful completion of the online CE information, you can instantly print a certificate. Video Download Process For programs with an original start date of September 1, 2008 or later, the GE HLS includes an option to download the TiP-TV program video file. You can then watch the program on your personal computer or transfer the video file to your portable video player for viewing. NOTE: Please refer to the TiP-TV Video Download Quick Start Guide for complete details (click the User Guides link on the GE HLS Welcome page). 1. With the desired program in your GE HLS Learning Plan, launch the program content to view the Online Content Structure. In the Video Download (Optional) area, click the Download Video to View Later link. 2. Save the video file on your personal computer, using your existing video download software. 3. View the program on your personal computer or transfer it to your portable video player for later viewing. 4. After viewing the entire program, log into the HLS and complete the CE activities as noted above. Continuing Education Credit Eligibility — Important Notice! A GE Healthcare TiP-TV course may be available in several different formats, such as an online web course or CD/DVD. You may be able to receive CE credit only once for a particular course, regardless of the format in which it was viewed. If you have already received credit for a course, you are encouraged to contact your CE certification organization (ARRT, NMTCB, ARDMS, CBRN, etc.) to determine if you can repeat this course for CE credit. Thank you for choosing GE Healthcare as your continuing education partner. We hope you will join us for other TiP-TV programs in the future. For more details and program schedule information, please visit our education web site (www.gehealthcare.com/education). Please forward any questions or comments to: [email protected] © 2004 General Electric Company. All rights reserved. 4 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Testicular Cancer "Testicular cancer, if diagnosed early and treated appropriately, can be cured in the vast majority of cases. Depending on the extent of the tumor and the type of the tumor at presentation, upwards of 98% of young men can be rendered long-term cures with this tumor. So, it is important to make the appropriate diagnosis as early as possible and institute the appropriate therapy. Now, how do we do that? I think one of the really important components of the healthcare team is the sonographer." – Dr. William See As the male sex glands, the testicles are the main source of the hormone testosterone in men and are responsible for the production of sperm – between 50 to 100 million sperm per milliliter (ml) of semen. The testicles or testes reside within several layers of connective and supporting tissues of the scrotum. Sensitive to body temperature, the muscle tissue within the scrotum allows for the testicles to be closer or farther away from the core temperature of the body. They need to maintain a 3 to 5 degree lower temperature for effective sperm production. Sperm quantity and quality can be adversely affected by an increase in temperature of only a few degrees. Emerging from each testicle is a series of tightly coiled tubules and ducts that carry sperm (Figure 1). After meiosis in the seminiferous tubules, which produces about 1,500 sperm per second per testicle, it takes about 70 days for sperm to mature in the testicles. When semi motile, they then travel about 20 days through the epididymis, which is about 6 meters in length, to continue their maturity for several more days. The vas deferens or ductus deferens transport the sperm to be stored in the seminal vesicles posterior to the bladder and prostate. Figure 1 Coronal Section of Testicle and Ducts Vas deferens Efferent ductules Rete testis Aberrant ductule { Head Epididymis Body Tail © 2004 General Electric Company. All rights reserved. Septa Tunica albuginea Lobules (seminiferous tubules) 5 of 27 GE Healthcare US: Men’s Health REV 3 Program Supplement and Test Testicular Cancer The American Cancer Society (ACS) estimates that about 8,980 new cases of testicular cancer will be diagnosed in the United States in 2004. Of those cases, the ACS estimates that 360 men will die of testicular cancer, which is 24.9% of those diagnosed. Testicular cancer can occur in males from the late teens through the mid 50s (years of age). Risk factors include: cryptorchidism, Klinefelter’s syndrome, personal history, and family history. There are different types of cells within the testes: • Germ cells • Stroma cells Each type may develop into a different form of cancer. More than 90% of testicular cancers develop in certain germ cells, the cells that are responsible for producing sperm. Germ cell tumors (GCT) can be either seminomas or nonseminomas. RISK FACTORS FOR TESTICULAR CANCER • Cryptorchidism: Undescended testicle(s). • Klinefelter’s syndrome: A genetic disorder caused by an extra X chromosome. • Personal history: History of previous testicular cancer. • Family history: Having a brother or father with testicular cancer. Seminomas Seminomas occur in men in the age range of 35 to 55 years, grow slowly, and tend not to metastasize. Stroma cells, found in supportive and hormone-producing tissues of the testes, may form tumors referred to as gonadal stromal tumors. Stroma tumors may often be benign if localized to the testes. If they do metastasize elsewhere in the body, they tend to be resistant to radiation and chemotherapy treatment. Stroma tumors are composed of two types of cells: • Leydig cells, which are responsible for producing the male hormone androgen and can produce the female hormone estrogen. • Sertoli cells, which nourish the sperm-producing germ cells. Stroma tumors tend to stay within the testes as they grow, but in rare cases can metastasize and can be resistant to treatment other than surgery. © 2004 General Electric Company. All rights reserved. 6 of 27 GE Healthcare US: Men’s Health REV 3 Program Supplement and Test Nonseminomas Nonseminomas occur in younger men in the age range of late teens to late 30s and early 40s, and include the faster spreading forms of testicular cancer. These tumors grow in an arrangement resembling a human embryo with rounded sacs and layered outer membranes. Metastases of these types of tumors tend to spread to the lungs, bone, and brain. Table 1 Types and Characteristics of Nonseminomas Nonseminoma Characteristics Embryonal carcinomas Rapid-growing and can spread Yolk sac carcinomas Most common in young boys Choriocarcinomas Aggressive but rare Teratomas Comprised of three layers Mature teratomas Less likely to spread Immature teratomas Can spread and relapse Teratomas with malignant transformation Resemble tumors found elsewhere in the body Secondary Testicular Tumors A cancer that starts in another part of the body and then spreads to the testicles is referred to as a secondary testicular tumor. The most common secondary testicular cancer is lymphoma. Lymphoma is more common than primary testicular cancer types among men older than age 50. Testicular Cancer Testing During a consultation, the physician obtains a patient history and performs a physical examination that includes the testicles and the abdomen. Part of the diagnosis is to rule out conditions that are not testicular cancer, but may present with similar symptoms. The following need to be ruled out during the initial examination: • Epididymitis (inflammation or infection of the surface of the epididymis). • Hydrocele (an accumulation of fluid in the testicle). • Lymphoma (cancer of the lymphatic system). • Spermatocele (a cyst on the surface of the testicle that contains sperm). • Varicocele (enlarged veins in the testicle). • Testicular torsion (twisting of the testicle). © 2004 General Electric Company. All rights reserved. 7 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test "Epididymitis is the most common cause of an intrascrotal mass lesion in the testicular cancer age group. Now, epididymitis means an infection or an inflammation of the epididymis, which is a structure adjacent to the testicle. In the face of that inflammation, there's some edema, some swelling, often some tenderness, and it's difficult under those circumstances to get a truly accurate examination. The patient may be sensitive. "At the same time, epididymitis is the most common misdiagnosis for patients that, in fact, have an underlying testicular tumor. In that the ultrasonographer can distinguish a testicular process from a paratesticular process, in other words something in the testicle vs. something in the epididymis, it is really crucial to the appropriate treatment of that patient. The treatment for epididymitis is antibiotics and the treatment for testicular cancer, at the first cut, is perhaps the surgical removal of the testis, and then chemotherapy or radiation or second surgery. So, there are two very different treatments driven by a clear understanding of what the disease process is that’s, in fact, being treated and was found by ultrasound." - Dr. William See Blood Tests In diagnosing testicular cancer, a blood test can be ordered to look for traces of tumor markers. Blood tests for tumor markers are usually not the sole means of diagnosis. Some cancer types do not generate tumor makers and the blood tests may be accompanied by an ultrasound exam. The following is a list of potential findings: • Proteins (alpha-feta protein levels can be raised by nonseminomas). • Hormones (human chorionic gonadotropin levels can be raised by seminomas and nonseminomas). • Enzymes (lactate dehydrogenase levels can be raised by advanced seminomas and nonseminomas). THINK AGAIN... How long does it take sperm to travel through the maze of ducts and tubules before it is mixed with seminal fluid? ___________________________________________________________ What is the age range for patients with nonseminoma testicular cancer? __________________ Name the two types of cells in which seminoma tumors form. 1) ___________ 2) ___________ See Appendix C for answers. Imaging The importance of the ultrasound exam is to confirm physical examination findings and to establish the intratesticular location of suspected scrotal lesions that cannot be determined by a physical exam. Ultrasound is considered an extension of physical examination. Ultrasound evaluation of the testicles should find normal sized, smoothly contoured, and homogeneously echo-textured testicles. Each testis and epididymis should be examined in the transverse and longitudinal planes. Color Doppler can be used to determine vascularity in the testes as well as within the vas deferens. © 2004 General Electric Company. All rights reserved. 8 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test When intratesticular neoplasm is suspected after physical examination, ultrasound can be used to differentiate the lesion as intra- or extratesticular. Sonographic findings in the testicles are nonspecific and require histologic examination of removed tissue (see "Orchiectomy" in the Testicular Cancer Treatment section of this supplement). Ultrasound is often the modality of choice to help diagnose the following testicular conditions: • Evaluation of scrotal masses. • Measurement of testicular size/volume. • Evaluation of scrotal pain or trauma. • Evaluation of testicular neoplasm. • Follow-up of patients with prior testicular neoplasm, leukemia, or lymphoma. • Assessment of testicular/epididymal infection and follow-up. • Searching for undescended testes. Testicular Cancer Treatment Orchiectomy The removal of a testicle is often the only treatment of testicular cancer. Even if there is only suspicion of malignant cells, the removal of the testicle will most likely be the decision of the doctor and the patient. Biopsy of the testicles is generally not performed, as a precaution to keep potential malignant cells from spreading, and the testicle needs to be removed if there are positive findings. Certain portions of the surrounding lymph nodes may also be removed near the bladder or in the abdomen during this procedure. A sperm sample is saved in advance and a prosthetic testicle may be implanted to replace the removed anatomy. The removed testicle is then examined by a pathologist for malignancy. An orchiectomy is also sometimes referred to as an "orchidectomy." Chemotherapy Chemotherapy may be an option if cancer cells have spread to the lymphatic system. It may also be offered after any tumor removal surgery to kill any residual cancerous tissue. © 2004 General Electric Company. All rights reserved. 9 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Images Figure 2 Spermatocele in Scrotum A firm, smooth, well-circumcised mass of the scrotum, a spermatocele is a benign cystic accumulation of sperm. It is often found in the head of the epididymis, the posterior lateral border of the testicle. Spermatoceles must be differentiated from hydroceles, varicoceles, epididymal cysts, and other scrotal masses during a physical exam. The location of the mass is a good indicator of what the mass actually is. The mass can be imaged well with ultrasound, but the only way to differentiate a spermatocele from an epididymal cyst is to aspirate and identify the presence of sperm. Figure 3 Hydrocele Hydroceles are located superior and anterior to the testicles. They are a collection of serous fluid that results from a defect or irritation in the tunica vaginalis of the scrotum. Adult-onset hydrocele may be secondary to orchitis or epididymitis and may be due to testicular torsion. Germ cell tumors or tumors of the testicular adnexa may also cause a hydrocele. © 2004 General Electric Company. All rights reserved. 10 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Figure 4 Testicular Neoplasm This ultrasound of the scrotum shows an intratesticular mass. Typically, the diagnoses for a solid intratesticular mass in a young patient include seminoma and germ cell tumors. No calcifications are visible. © 2004 General Electric Company. All rights reserved. 11 of 27 GE Healthcare US: Men’s Health REV 3 Program Supplement and Test Prostate Cancer "Ultrasonography plays a role in the care of the prostate cancer patient from diagnosis through, in some circumstances, treatment… In both brachytherapy and cryosurgery, good imaging and real-time ultrasonography are critical to the successful treatment within these two modalities." - Dr. William See Prostate Anatomy Located in the pelvic cavity and inferior to the bladder and posterior to the pubic bone, the prostate is about the size of a walnut and surrounds the urethra. Its function is involved in the reproductive process of ejaculation; the prostate gland produces seminal fluid and is the entry point for sperm that have been stored in the seminal vesicles through the ejaculatory ducts. While it functions as a gland, it is comprised of about one-third muscle tissue that contracts during ejaculation. Figure 5 Coronal Section of Prostate Bladder Prostate Ejaculatory duct Urethra Penis The Prostate • Produces seminal fluid. • Composed of gland and muscle tissue. • Adjacent to the rectum. • Surrounds the urethra. The prostate is not involved in normal urination function. Muscle tissue in the bladder controls the flow of normal urination. Figure 6 Sagittal Plane of Prostate and Pelvic Region Pelvic bone Bladder Urethra Seminal vesicle Prostate Rectum Ejaculatory duct Penis © 2004 General Electric Company. All rights reserved. 12 of 27 GE Healthcare US: Men’s Health REV 3 Program Supplement and Test Prostate Diseases Prostate Cancer Prostate cancer typically begins as abnormal gland cell growth contained within the glandular body as prostatic intraepithelial neoplasia (PIN) and then may advance into an adenocarcinoma. The American Cancer Society estimates that 230,900 men will be diagnosed with prostate cancer in 2004, and 29,900 men will actually die from it. In other words, close to 13% of those diagnosed with prostate cancer do in fact die from it. Lung cancer fatalities are the only form of cancer-caused death higher than prostate cancer. Autopsies have shown that a large portion of elderly men who had died from other causes also had some stage of prostate cancer with no apparent symptoms. Prostate cancer can grow very slowly in some men, but it can also grow quite rapidly in others. Many men in their 70s and 80s who are diagnosed with early stages of prostate cancer may not require any radical treatment because they may not live as long as it would take for the cancer to reach its end stages. The primary risk factors include: age, race, nationality, diet, inactivity, and family history. Prostatitis RISK FACTORS FOR PROSTATE CANCER • Age: 1 in 6 men eventually gets prostate cancer in his lifetime. • Race: African-American men. • Nationality: North America and northwestern Europe. • Diet: Diets high in red meats or fatty dairy foods and low in fruits, vegetables, soy, and grains. • Inactivity: Low levels of exercise and being overweight. • Family history: Father, brother, and/or uncle with history of prostate cancer. Prostatitis is an acute or chronic bacterial inflammation of the prostate gland. It may also be caused by nonbacterial inflammation, but the cause is difficult to diagnose. Indications of prostatitis include pelvic, perineal, lower abdominal, and testicular pain. BPH AND AGE • More than half of men over the age of 50 years develop benign prostatic hyperplasia. • By the age of 80, about 80% of men have BPH. • However, only 40% to 50% of men actually develop any symptoms due to their BPH. Benign Prostatic Hyperplasia (BPH) Commonly known as an "enlarged prostate," benign prostatic hyperplasia is a noncancerous growth of prostate tissue. While BPH is not a precursor to prostate cancer, it can occur parallel with malignant growth. BPH may exhibit similar symptoms to prostate cancer. The chance of developing BPH increases with age. A typical symptom of BPH is complications with urination. As the prostate expands, it interferes with the normal flow of urine through the urethra. This causes the patient to strain to empty his bladder or have to urinate more frequently. © 2004 General Electric Company. All rights reserved. 13 of 27 GE Healthcare US: Men’s Health REV 3 Program Supplement and Test Prostatic Abscess Although rare, due in part to strong antibiotics used to treat other illnesses, abscess of the prostate may still be found in some human immunodeficiency virus (HIV) positive patients. Other risk factors include: • Diabetes mellitus • Urethral treatment procedures • Catheterization • Prostatitis • Men between 50 and 60 years old • BPH • Bladder neck obstruction • Urine tract infection along prostatic ducts Notes: Prostate Testing Prostate Specific Antigen (PSA) TYPES OF PSA TESTS • Percent free-PSA ratio: Compares the amount of unbound PSA in the blood by itself with the bound PSA amount that is attached to other blood proteins. • Age-specific PSA reference range: A PSA range compared to the results of men in the same age group. • PSA density: Determined by dividing the PSA level by the volume of the prostate. This test is in conjunction with a transrectal ultrasound exam to obtain the volume of the prostate. • PSA velocity: Measures how quickly the PSA rises over a period of time, usually over several months. Produced by both normal and cancerous prostate cells, prostate specific antigen can be detected in the blood. PSA in the blood often increases when prostate cancer grows or when other prostate diseases are present, such as benign prostatic hyperplasia and prostatitis, an inflammation of the prostate. The normal range for a PSA test is generally between 0 and 4 nanograms per milliliter (ng/ml). If the results are in the high range, greater than 10 ng/ml, then a biopsy may be required to accurately diagnose prostate cancer. Depending on the situation, any of four types of PSA tests can be used in the diagnostic process. Digital Rectal Examination (DRE) During a DRE, the doctor inserts a lubricated, gloved finger into the patient's rectum to feel for lumps, enlargements, irregularities, or areas of hardness that might be consistent with prostate cancer. Most of the prostate can be examined during a DRE, including the area where most prostate cancers are found, but not the entire gland. It is typical to have a PSA test along with a DRE. © 2004 General Electric Company. All rights reserved. 14 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Gleason Scoring System This common prostate cancer scoring or grading system assigns numbers to cancerous prostate tissue and is performed on malignant biopsy samples. The Gleason grades range from 1 through 5, comparing how the cancer cells resemble normal prostate cells for the patient. If the cancerous cells resemble the normal prostate tissue very closely and are well-differentiated, they get a Gleason of 1. On the other end of the scale, a Gleason grade of 5 indicates that the cells appear fairly irregular and different from the normal prostate cells, are poorly differentiated, and are considered fast-growing. Two grades are assigned to the most commonly appearing patterns of representative cells and are then added together to determine the Gleason score ranging from 2 to 10. BIOPSY IN CONJUNCTION WITH PSA AND DRE The PSA and DRE cannot diagnose prostate cancer alone. Abnormal results of a PSA or DRE only indicate that further testing is needed and the doctor may order a biopsy. A biopsy is a procedure in which the doctor uses a transrectal ultrasound transducer to scan and guide a needle into the prostate to take small samples of tissue from several areas. These tissues are then examined histologically for the presence of malignant cells and to establish a Gleason score. Transrectal Ultrasound (TRUS) With the prostate located adjacent to the rectum, transrectal ultrasound is an efficient way to image the prostate gland. Volume measurements can be obtained that are then applied in the Gleason scoring method. Transrectal ultrasound is also used as a biopsy needle guide. Typically, the transducer is in the 4 to 10 megahertz (MHz) frequency range. THINK AGAIN... What structure does the prostate completely surround? ______________________________ What is the typical age of men who have prostate cancer? __________________________ How life-threatening is BPH? _____________________________________________________ Which PSA test also needs a transrectal ultrasound examination? _____________________ See Appendix C for answers. © 2004 General Electric Company. All rights reserved. 15 of 27 GE Healthcare US: Men’s Health REV 3 Program Supplement and Test Prostate Cancer Treatment Transurethral Resection of the Prostate (TURP) A surgical procedure used to treat the constricting results of BPH, transurethral resection of the prostate removes part of the prostate gland surrounding the urethra. An electrical wire loop tool is passed into the penis and through the urethra to the location of the prostate gland. The wire is electrified to cut the tissue. A biopsy sample of the prostate tissue removed during TURP is then examined for malignancy. Radical Prostatectomy Radical prostatectomy is a surgical procedure performed to remove the entire cancerous prostate gland. This procedure is effective when the malignant tumor is localized near the prostate gland and has not metastasized to other areas of the body. The seminal vesicles and the vas deferens are then reattached to maintain normal function. Focused Pulse Ultrasound French researchers recently conducted a study on the effects of a few seconds of concentrated ultrasound to obliterate a tumor – without invasive surgery. Their study showed less collateral damage from the procedure and reduced nerve damage side effects, such as impotency and incontinence. © 2004 General Electric Company. All rights reserved. FOCUSED PULSE ULTRASOUND TRIAL RESULTS A recent trial of 243 prostate cancer patients showed that use of focused pulse ultrasound to treat prostate tumors resulted in: • An 80% success rate in eradicating tumors. • Half the incidence of impotence typically associated with surgical removal. • Three times less incontinence when compared to surgical removal. 16 of 27 GE Healthcare US: Men’s Health REV 3 Hormone Therapy Testosterone is an androgen sex hormone produced by the testicles and, to a lesser extent, in the adrenal glands. Testosterone encourages the growth of prostate tumors. Suppression of this hormone through hormonal therapy can control localized prostate cancer tumors and help in disease management of growth to other areas of the body. Hormone therapy is not a cure, however, and only can benefit patients for a few years. Hormone therapy may be prescribed before (or after) other treatment options, such as radiotherapy, to shrink the tumor so there is less area to be treated. Both pituitary down-regulators and anti-androgens are used in hormone therapy. Each type of hormone treatment has its own side effects, length of use, and result expectations. Chemotherapy Anti-cancer drugs to kill cancer cells are typically not the primary therapy for prostate cancer, especially for the earlier stages. They may be effective if the tumor has spread beyond the prostate gland or in combination with other therapies. Chemotherapy may slow down the growth of spreading tumors, but it has had limited success treating advanced stages of prostate cancer. Program Supplement and Test PRIMARY TYPES OF HORMONE THERAPY The primary types of hormone therapy are pituitary down-regulators and anti-androgens. • Pituitary down-regulators work by forcing the pituitary gland in the brain to stop signaling the testes from producing testosterone. • Anti-androgens attach to receptor proteins on the surface of cancer cells in the prostate and block testosterone from entering and encouraging malignant cell growth. Applying both of these hormonal therapies for advanced disease treatment is considered a complete androgen blockade (CAB). Another means of hormone therapy is removing the testicles altogether by a bilateral orchiectomy (see "Orchiectomy" in the Testicular Cancer Treatment section of this supplement). With the testicles removed, the majority of testosterone production is eliminated. Anti-androgen hormonal therapy may also be combined with an orchiectomy. Radiotherapy Radiotherapy, or radiation therapy, for prostate cancer is given by external beam radiation that is applied daily for 4 to 6 weeks. Hormonal therapy may be prescribed to reduce the tumor size before radiotherapy is administered. There is a moderate rate of impotence as a side effect. There is a high rate of success for the first 10 years after treatment. Brachytherapy Brachytherapy is the insertion of small radioactive pellet implants right into the prostate tumor mass. It has been as effective as conventional radiotherapy. One advantage over other radiotherapy is that a higher radiation dose can be administered with less adverse effects, and the patient does not need the typical daily radiation therapy for 4 to 6 weeks. There is still a moderate rate of impotence as a side effect. © 2004 General Electric Company. All rights reserved. 17 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Appendix A: Lance Armstrong Foundation Reproduced with permission from the Lance Armstrong Foundation (LAF); all content is from the LAF web site: www.laf.org Lance Armstrong’s Story "Before cancer I just lived. Now I live strong." -- Lance Armstrong At age 25, Lance Armstrong was one of the world's best cyclists. He proved it by winning the World Championships, the Tour Du Pont, and multiple Tour de France stages. Lance Armstrong seemed invincible, and the future ahead was bright indeed. Then they told him he had cancer. Next to the challenge he now faced, bike racing seemed insignificant. The diagnosis was testicular cancer, the most common cancer in men aged 15 to 35 years. If detected early, its cure rate is a promising 90%. Like most young, healthy men, Lance ignored the warning signs, and never imagined the seriousness of his condition. Going untreated, the cancer had spread to Lance's abdomen, lungs, and brain. His chances dimmed. Then, with a combination of physical conditioning and a strong support system, Lance's competitive spirit took over. He declared himself not a cancer victim, but a cancer survivor hell bent on living strong. He took an active role in educating himself about his disease and the treatment. Armed with knowledge and confidence in medicine, he underwent aggressive treatment and beat the disease. During treatment, before his recovery, before he even knew his own fate, he created the Lance Armstrong Foundation. This marked the beginning of Lance Armstrong's life as a leader for cancer survivors and a world representative for the cancer community. Although Lance Armstrong's victories in the 1999–2003 Tours de France are sweet, the battle against cancer has just begun – not just for him – but for all cancer survivors and people just like him who think cancer could not affect them. Lance Armstrong plans to lead this fight, and he hopes that you join him. This is a life he owes to cancer. This is a choice to live strong. Facts about Lance's Cancer Diagnosis and Treatment • Lance was diagnosed with an aggressive form of testicular cancer, containing 60% choriocarcinoma, 40% embryonal and less than 1% teratoma. • Lance's treatment lasted from October to December 1996. • Lance underwent two surgeries, one to remove his cancerous testicle and another to remove two cancerous lesions on his brain. • Lance received one round of BEP (Bleomycin, Etoposide and Platinol) chemotherapy, followed by three rounds of VIP chemotherapy (Ifostamide, Etoposide and Platinol.) • Lance's cancer in the lungs and brain was a result of spreading from the original testicular cancer. As a result, his treatment protocols were to combat that specific strain of cancer. Different cancers originating from different sources in the body will likely require other treatments than the one described above for Lance. © 2004 General Electric Company. All rights reserved. 18 of 27 GE Healthcare REV 3 • US: Men’s Health Program Supplement and Test Lance was treated at Indiana University Medical Center by Drs. Larry Einhorn and Craig Nichols. (Dr. Einhorn can be reached at the Indiana University Medical Center at 317/274-8157; Dr. Nichols at the Oregon Cancer Center at 503/494-8311.) The Lance Armstrong Foundation The Lance Armstrong Foundation (LAF) believes that in your battle with cancer, knowledge is power and attitude is everything. Founded in 1997 by cancer survivor and cycling champion Lance Armstrong, the LAF provides the practical information and tools people living with cancer need to live strong. We serve our mission through four core program areas: • Education – The LAF informs cancer patients, health care professionals and the public about the physical, emotional and practical issues that people face in their battle with cancer. We provide the information and resources people need to live strong. • Advocacy – The LAF represents people living with cancer on Capitol Hill. We are increasing awareness, encouraging the government to take action, and addressing the health policy concerns of people battling cancer and their families. • Public Health – The LAF plans, develops and funds programs that provide after-treatment support and services for people living with cancer and their families. • Research – The LAF supports scientific and clinical research that seeks to better understand cancer's physical, emotional and practical effects, and the challenge of living with the disease. Today there are nearly 10 million people living with cancer. Through these four program areas, LAF provides the practical information and tools that people need to battle cancer and live strong. The Lance Armstrong Foundation is a registered 501(c)(3) nonprofit organization located in Austin, Texas. Appendix B: Men’s Health Guidelines Men: Stay Healthy at Any Age Checklist for Your Next Checkup What can you do to stay healthy and prevent disease? You can get certain screening tests, take preventive medicine if you need it, and practice healthy behaviors. Top health experts from the U.S. Preventive Services Task Force suggest that when you go for your next checkup, talk to your doctor or nurse about how you can stay healthy no matter what your age. © 2004 General Electric Company. All rights reserved. 19 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Screening Tests: What You Need and When Screening tests, such as colorectal cancer tests, can find diseases early when they are easier to treat. Some men need certain screening tests earlier, or more often, than others. Talk to your doctor about which of the tests listed below are right for you, when you should have them, and how often. The Task Force has made the following recommendations, based on scientific evidence, about which screening tests you should have. • Cholesterol Checks: Have your cholesterol checked at least every 5 years, starting at age 35. If you smoke, have diabetes, or if heart disease runs in your family, start having your cholesterol checked at age 20. • Blood Pressure: Have your blood pressure checked at least every 2 years. • Colorectal Cancer Tests: Begin regular screening for colorectal cancer starting at age 50. Your doctor can help you decide which test is right for you. How often you need to be tested will depend on which test you have. • Diabetes Tests: Have a test to screen for diabetes if you have high blood pressure or high cholesterol. • Depression: If you've felt "down," sad, or hopeless, and have felt little interest or pleasure in doing things for 2 weeks straight, talk to your doctor about whether he or she can screen you for depression. • Sexually Transmitted Diseases: Talk to your doctor to see whether you should be screened for sexually transmitted diseases, such as human immunodeficiency virus (HIV). • Prostate Cancer Screening: Talk to your doctor about the possible benefits and harms of prostate cancer screening if you are considering having a prostate specific antigen (PSA) test or digital rectal examination (DRE). Should You Take Medicines to Prevent Disease? • Aspirin: Talk to your doctor about taking aspirin to prevent heart disease if you are older than 40, or if you are younger than 40 and have high blood pressure, high cholesterol, diabetes, or if you smoke. • Immunizations: Stay up-to-date with your immunizations: • Have a flu shot every year starting at age 50. • Have a tetanus-diphtheria shot every 10 years. • Have a pneumonia shot once at age 65 (you may need it earlier if you have certain health problems, such as lung disease). • Talk to your doctor to see whether you need hepatitis B shots. What Else Can You Do To Stay Healthy? Don't Smoke. But if you do smoke, talk to your doctor about quitting. You can take medicine and get counseling to help you quit. Make a plan and set a quit date. Tell your family, friends, and co-workers you are quitting. Ask for their support. Eat a Healthy Diet. Eat a variety of foods, including fruit, vegetables, animal or vegetable protein (such as meat, fish, chicken, eggs, beans, lentils, tofu, or tempeh) and grains (such as rice). Limit the amount of saturated fat you eat. Be Physically Active. Walk, dance, ride a bike, rake leaves, or do any other physical activity you enjoy. Start small and work up to a total of 20–30 minutes most days of the week. © 2004 General Electric Company. All rights reserved. 20 of 27 GE Healthcare US: Men’s Health REV 3 Program Supplement and Test Stay at a Healthy Weight. Balance the number of calories you eat with the number you burn off by your activities. Remember to watch portion sizes. Talk to your doctor if you have questions about what or how much to eat. Drink Alcohol Only in Moderation. If you drink alcohol, have no more than 2 drinks a day. A standard drink is one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits. Screening Test Checklist Take this checklist with you to your doctor's office and fill it out when you have had any of the tests listed below. Talk to your doctor about when you should have these tests next, and note the month and year in the right-hand column. Also, talk to your doctor about which of the other tests listed below you should have in the future and when you need them. The last time I had the following screening test was: (mm/yy) I should schedule my next test for: (mm/yy) Cholesterol Blood pressure Colorectal cancer Sexually transmitted diseases Prostate cancer More Information For more information on staying healthy, order the following free publications in the Put Prevention Into Practice (PPIP) program from the Agency for Healthcare Research and Quality (call the AHRQ Publications Clearinghouse at 1-800-358-9295), or find them at: www.ahrq.gov/clinic/ppipix.htm More copies of this fact sheet, Men: Stay Healthy at Any Age – Checklist for Your Next Checkup (in English and Spanish), Publication Nos. APPIP 03-0011 and APPIP 03-0013, February 2004. The Pocket Guide to Good Health for Adults (in English and Spanish), Publication Nos. APPIP 03-0001 and APPIP 03-0010, May 2003. The Pocket Guide to Staying Healthy at 50+ (in English and Spanish), Publication Nos. AHRQ 04-IP001-A and AHRQ 04-IP001-B, January 2000. Revised November 2003. The information in this fact sheet is based on research from the U.S. Department of Health and Human Services (HHS) and the U.S. Preventive Services Task Force (USPSTF), the leading independent panel of private-sector experts in prevention and primary care. The Task Force conducts rigorous scientific assessments of the effectiveness of a broad range of clinical preventive services. Its recommendations are considered the "gold standard" for preventive services delivered in the clinical setting. Additional details about © 2004 General Electric Company. All rights reserved. 21 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test the recommendations can be obtained from the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality U.S. Preventive Services Task Force Web site (www.ahrq.gov/clinic/uspstfix.htm) or by calling the AHRQ Publications Clearinghouse (1-800-358-9295). The Put Prevention Into Practice (PPIP) program of the Agency for Healthcare Research and Quality is designed to increase the appropriate use of clinical preventive services, such as screening tests, chemoprevention and immunizations, and counseling. The PPIP program is based on the recommendations of the U.S. Preventive Services Task Force. PPIP tools and resources enable doctors and other health care providers to determine which preventive services their patients should receive and make it easier for patients to understand and keep track of their preventive care. U.S. Department of Health and Human Services Agency for Healthcare Research and Quality AHRQ Publication No. APPIP 03-0011 Current as of February 2004 © 2004 General Electric Company. All rights reserved. 22 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Appendix C: "Think Again" Answers THINK AGAIN... (Page 8) Q: How long does it take sperm to travel through the maze of ducts and tubules before it is mixed with seminal fluid? A: About 100 days Q: What is the age range for patients with nonseminoma testicular cancer? A: Between 18 and 50 years old Q: Name the two types of cells in which seminoma tumors form. A: 1) Germ 2) Stroma THINK AGAIN... (Page 15) Q: What structure does the prostate completely surround? A: The urethra Q: What is the typical age of men who have prostate cancer? A: Between 70 and 80 years old Q: How life-threatening is BPH? A: Benign prostate hyperplasia is non life-threatening Q: Which PSA test also needs a transrectal ultrasound examination? A: PSA density Appendix D: Resources American Cancer Society, Inc. http://www.cancer.org © 2004 AstraZeneca Pharmaceuticals LP. http://www.prostateinfo.com 12/03. © 2004 Chapelon, Jean-Yves. "Ultrasound is kinder prostate cancer treatment." French Institute of Health and Medical Research in Paris. NewScientist.com 2/16/04. © Reed Business Information Ltd. Healthcommunities.com, Inc. http://www.oncologychannel.com 3/09/2004. © 2004 University of Pittsburgh Medical Center. http://www.upmccancercenters.com 10/2/03. © 2004 NOTE: The Internet is an ever-evolving environment and links are subject to change without notice. © 2004 General Electric Company. All rights reserved. 23 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Appendix E: Presenter Biographies William A. See, M.D. – Chairman of the Department of Urology, Medical College of Wisconsin, Milwaukee Dr. See was recently appointed as Chairman of the new Department of Urology at the Medical College of Wisconsin in Milwaukee, where he has been a professor of urology since 1999. He also serves as Chief of Urology at the Froedtert Memorial Lutheran Hospital in Milwaukee. He earned a bachelor’s of arts from Coe College, Iowa, graduating magna cum laude. His medical degree is from the Pritzker School of Medicine at the University of Chicago, where he graduated cum laude. Dr. See served his residencies at the University of Washington School of Medicine, Seattle, Washington, in the Department of Surgery and Department of Urology. He served as Chief Resident of the Department of Urology in 1987. Dr. See is a nationally known cancer researcher and clinical expert in genitourinary cancer and urology. He is currently the principal investigator in several ongoing research studies and sits on numerous university and national committees. Andrew Stonefield – GE Healthcare Ultrasound TiP-TV Program Manager Andrew worked as a registered vascular sonographer with Medicalab, Inc. throughout New England and acquired diverse experience in imaging technology and techniques. Following that position, he worked as an applications consultant for MEDITECH, Inc., where he was responsible for the training of several hospital teams in the United States and Canada in integrated radiology department software. Andrew joined GE Healthcare as a contractor in 2000 and worked with the ultrasound marketing team producing web content for various ultrasound products and service technical training programs. In 2002, he became the Program Manager of Clinical Ultrasound TiP-TV programs and related eLearning products. In addition, he has responsibility for product offerings for the GEMS IT, OEC, and Lunar businesses. Andrew earned a bachelor’s degree in biology from Coastal Carolina University and is currently working on a Master of Business Administration degree at the Keller Graduate School of Management. He has earned both Telly and Communicator awards in broadcasting. Special Contributor Cindy Owen Ultrasound Consultant/Vascular Specialist Memphis, Tennessee © 2004 General Electric Company. All rights reserved. 24 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test Appendix F: Post-Test US: Men’s Health LMS Course Number: 2725 To be eligible for CE credit, you MUST view the video presentation first. Then complete the post-test on the GE Healthcare Learning System (hls.gehealthcare.com) by the due date listed online. 1. Testicular cancer affects only older men. a. True b. False 2. The scrotal anatomy includes all of the following, EXCEPT _____. a. gland tissue b. muscle tissue c. ducts and tubules d. corpus cavernosum 3. The two types of testicular tissue cells that can form tumors are _____ and _____. a. germ; stroma b. squamous; ganglion c. prostatic; hepatic d. pelvic; penile 4. One of the major risk factors for testicular cancer is _____. a. trauma b. cryptorchidism c. history of prostate cancer d. incontinence 5. Ultrasound imaging is ideal in the diagnosis of testicular cancer because _____. a. it is the gold standard in differentiating between benign and malignant tumors b. it can establish the intratesticular location of suspected scrotal lesions that cannot be determined by a physical exam c. the exam is complete in only a few seconds d. the prostate can also be scanned with the same probe while the patient is on the examining table 6. Epididymitis is _____. a. an inflammation of the epididymis within the scrotum b. a cancerous growth in the lymphatic system c. fluid collection within the scrotum d. an enlargement of the veins in the testicle 7. All of the following are possible treatment decisions a patient can make when diagnosed with prostate cancer, EXCEPT _____. a. do nothing and watch for worsening symptoms b. receive brachytherapy c. undergo a radical prostatectomy d. get a vasectomy © 2004 General Electric Company. All rights reserved. 25 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test 8. Biopsy of the testicles is NOT typically practiced because _____. a. the patient would experience severe pain b. there are no benign conditions, so the testicles have to be removed anyway c. there is a concern about any malignant cells seeding surrounding lymph nodes and other tissues d. biopsy studies cannot differentiate between benign and malignant testicular cells 9. The prostate surrounds which anatomical structure? a. Ureter b. Urethra c. Vas deferens d. Epididymis 10. The prostate is about the size of a _____. a. kidney b. grape c. walnut d. grapefruit 11. Muscle tissue in the _____ controls the flow of normal urination. a. prostate b. abdominal wall c. pelvic floor d. bladder 12. The function of the prostate includes all of the following, EXCEPT _____. a. produces seminal fluid b. contracts during ejaculation c. facilitates normal urination d. connects the seminal vesicles to the urethra 13. Benign prostatic hyperplasia (BPH) is a precursor to prostate cancer. a. True b. False 14. What is the leading risk factor for prostate cancer? a. Alcohol abuse b. Smoking c. History of testicular cancer d. Age 15. What is the major physical complication caused by BPH? a. sterility b. increased production of testosterone c. difficulty urinating d. impotence 16. Which of the following is NOT considered a primary risk factor for prostate cancer? a. history of STD b. age c. race d. inactivity © 2004 General Electric Company. All rights reserved. 26 of 27 GE Healthcare REV 3 US: Men’s Health Program Supplement and Test 17. Symptoms of _____ include pelvic, perineal, lower abdominal, and testicular pain. a. prostatitis b. renal calculi c. BPH d. early prostate cancer 18. Which prostate specific antigen (PSA) calculation incorporates an ultrasound volume measurement? a. Percent free-PSA ratio b. PSA velocity c. Age-specific PSA reference range d. PSA density 19. The principle hormone that promotes prostate tumor growth is _____. a. testosterone b. estrogen c. adrenaline d. melatonin 20. _____ cancer is the most common cancer in men aged 15 to 35 years. a. Prostate b. Male breast c. Testicular d. Bladder © 2004 General Electric Company. All rights reserved. 27 of 27
