Download Understanding Prostate Cancer

Understanding
Prostate Cancer
A Guide to Treatment and Support
1
Table of Contents





Introduction
A Brief Overview of Prostate Cancer
Assessing the Prostate: PSA, Grading, and
Staging
Treatment Options
If Prostate Cancer Progresses After Local
Treatment
2
Introduction

You are not alone
 Prostate cancer is the second most common
type of cancer diagnosed in American men1,2
 The projected risk of a 50-year-old man being
diagnosed with prostate cancer during his lifetime is
almost 10%1
 In 2003, an estimated 220,900 new cases of prostate
cancer will be diagnosed in the US2
3
Introduction, cont.

The good news is that over the past 20 years,
overall survival rates for all stages of prostate
cancer combined have gone up from 67% to
97%2
 The purpose of this presentation is to provide
the information needed to make informed
decisions about treatment options
4
A Brief Overview of Prostate Cancer
Who gets Prostate Cancer?

More than 70% of all prostate cancers are
diagnosed in men over the age of 652
 Genetics are an important factor2,3
 Men with one or more first-degree relatives
(ie, father, brother) who have had prostate cancer
have a 2- to 11-times greater chance of being
diagnosed with prostate cancer3
5
A Brief Overview of Prostate Cancer, cont.
Who gets Prostate Cancer?

The death rate for prostate cancer is more than
twice as high in African-American men than in
Caucasian men2
 Earlier screening for prostate cancer (beginning at
age 45) is recommended for men at high risk, such
as African-American men2
6
A Brief Overview of Prostate Cancer, cont.
What causes prostate cancer?

Prostate cancer results from damaged DNA
(the genetic blueprint for the body’s cells)3
 This damage can either be inherited or acquired
during one’s lifetime3
7
A Brief Overview of Prostate Cancer, cont.
What causes prostate cancer?

Researchers don’t know exactly what causes
this damage, but have identified some risk
factors3:





Age
Race
Environment
Diet
Genetics and family history
8
A Brief Overview of Prostate Cancer, cont.
Symptoms of Prostate Cancer

Early prostate cancer usually does not cause any
symptoms1
 As the tumor grows, the following symptoms
may appear, but may be alleviated by reducing
the body’s production of testosterone2,4,5




Frequent urination (especially at night)2
Weak urinary stream2,4
Inability to urinate2,4
Interruption of urinary stream (stopping and
starting)2,4
 Pain or burning on urination2
 Blood in the urine2
 Pain in the lower back, pelvis, or upper thighs2,4
9
A Brief Overview of Prostate Cancer, cont.
What is the prostate?

A chestnut-sized
gland that produces
fluid for semen5
 Located just below
the bladder, in front
of the rectum, and
wraps around the
urethra, the tube that
carries urine from the
bladder to the tip of
the penis5
10
A Brief Overview of Prostate Cancer, cont.
What is cancer?

The uncontrolled growth and potential spread of
abnormal cells6
 Cells that grow abnormally and become a mass
are called a tumor6
 Benign (noncancerous) tumors may interfere with
bodily functions, like urinating, but are seldom lifethreatening1,6
 Malignant tumors invade and destroy surrounding
tissue6
 Prostate cancer is a malignant tumor that begins
growing in the prostate gland4
11
A Brief Overview of Prostate Cancer, cont.
What is metastasis?

When cells break away from a cancerous
tumor and spread through the blood and
lymphatic system to other parts of the body4,6
 As a result of metastasis, many men with
prostate cancer experience aches and pains in
the pelvis, hips, ribs, back and other bones2,4
 Cancer can grow and spread slowly or
rapidly6
12
A Brief Overview of Prostate Cancer, cont.
What role does testosterone play?

Testosterone, a male sex hormone, is an
important factor in the normal growth and
function of the prostate gland4
 Testosterone can stimulate hormone-dependent
prostate cancer3
 As long as the body produces testosterone, prostate
cancer is likely to continue to grow and possibly
spread4
 For advanced prostate cancer, physicians may
prescribe a class of drugs called luteinizing hormonereleasing hormone agonists (LH-RHa) that stop the
production of testicular testosterone4,5
13
Assessing the Prostate:
PSA, Grading, and Staging
Before determining therapy, physicians
normally assess the state of the prostate and
the stage of the cancer

Doctors may perform the following tests
 A digital rectal exam (DRE)
 A PSA blood test
 A biopsy

Men aged 50 or older, and those in highrisk groups over the age of 45, should have
a PSA blood test and DRE once every year2
14
Assessing the Prostate:
PSA, Grading, and Staging, cont.
What is the DRE (digital rectal examination)?

A test in which the physician inserts a gloved
finger into the patient’s rectum to examine the
prostate by touch7
 If the doctor determines that the prostate feels
abnormal, he or she may recommend more
tests7
15
Assessing the Prostate:
PSA, Grading, and Staging, cont.
What is PSA (prostate-specific antigen)?
A substance produced by prostate cells1
 The PSA test measures the amount of PSA
in the blood1,8
 Very little PSA escapes from a healthy
prostate1,8
 Some prostate conditions can cause a large
amount of PSA to leak into the blood8

16
Assessing the Prostate:
PSA, Grading, and Staging, cont.
PSA Levels

PSA levels of up to 4.0 ng/mL are considered
the upper limit of normal8
 However, high PSA does not always indicate
prostate cancer and normal PSA levels do not
always mean that cancer is not present8
 Up to 25% of men with prostate cancer have PSA
levels below 4.0 ng/mL8
 Some other conditions, such as benign prostatic
hyperplasia (BPH), can also lead to high PSA levels
in the blood8
17
Assessing the Prostate:
PSA, Grading, and Staging, cont.
What is a biopsy?

A test that may be necessary if the results of the
PSA or DRE tests suggest prostate cancer4,8
 A needle is used to remove a small amount of
tissue from the prostate4,8
 Typically, multiple samples are taken4,8
 Only a biopsy can definitely confirm prostate
cancer4,8
 It is still possible to have cancer even if the biopsy is
negative8
18
Assessing the Prostate:
PSA, Grading, and Staging, cont.
What is the Gleason grade?

If prostate cancer is found at biopsy, the tumor
is graded in a medical lab
 The grade indicates the difference in
appearance between normal cells and cancer
cells when seen through a microscope9
19
Assessing the Prostate:
PSA, Grading, and Staging, cont.

Gleason grades range from 1 to 5 and are
based on the degree of differentiation among
the cells9
 A Gleason grade of 1 indicates
a cluster of cancer cells that
resemble the small, regular,
evenly spaced prostate tissue9
 A Gleason grade of 5 indicates
tissue completely composed of
sheets, strings, cords and nests
of tumor cells9
 If a prostate tumor has areas
with different grades, the two
grades are added together to
yield a Gleason score between
2 and 109
20
Assessing the Prostate:
PSA, Grading, and Staging, cont.
What is staging?

The assessment of the size and location of the
cancer (how far the cancer has already spread)8
 Staging is an important factor in determining the most
appropriate treatment8

Two different staging systems are currently in
use8
 The A-D system classifies the disease into 4 clinical
categories rated A through D8
 The TNM (tumor-nodes-metastases) system is based
on tumor size and the locations to which it has
spread8
21
Assessing the Prostate:
PSA, Grading, and Staging, cont.
A-D Staging

Stage A is early
cancer – the tumor
is located within the
prostate gland and
can’t be detected by
a DRE8
22
Assessing the Prostate:
PSA, Grading, and Staging, cont.
A-D Staging

In Stage B, the
tumor is confined
to the prostate but
large enough to be
felt during a DRE8
23
Assessing the Prostate:
PSA, Grading, and Staging, cont.
A-D Staging

By Stage C, the
tumor has spread
outside the
prostate to some
surrounding areas
and can be felt
during a DRE8
24
Assessing the Prostate:
PSA, Grading, and Staging, cont.
A-D Staging

In Stage D, the
cancer has spread
to the nearby and
distant organs,
such as bones and
lymph nodes8
25
Assessing the Prostate:
PSA, Grading, and Staging, cont.
TNM Staging is based on tumor size (T) and
on whether the cancer has spread to lymph
nodes (N) or metastasized to distant sites (M)8

Tumor size is graded from 1 to 48
 T1 tumors are confined to the prostate gland and
can’t be detected by DRE8
 T2 tumors are confined to the prostate but are big
enough to be detected by DRE or ultrasound8
 T3 and T4 tumors have spread beyond the prostate
into surrounding tissues8
26
Assessing the Prostate:
PSA, Grading, and Staging, cont.
TNM Staging is based on tumor size (T) and
on whether the cancer has spread to lymph
nodes (N) or metastasized to distant sites (M)8

Lymph node involvement is graded from 0 to
3, with 0 indicating that the cancer has not
spread into lymph nodes8
 Metastasis is rated 0 or 1, with 0 indicating
absence of metastasis8
27
Treatment Options

Treatment options
for prostate cancer
depend on several
factors, including
age, the stage of
the disease, and the
advice of a
physician
28
Treatment Options:
Surgical Techniques
Radical prostatectomy





Involves removal of the entire prostate gland1
Performed to remove early-stage prostate
cancer before it can spread to other parts of
the body1
Takes about two hours and requires general or
epidural anesthesia10,16
Complications include incontinence and
impotence1
Some physicians may use hormonal therapy to
shrink the tumor before surgery so that it can
be removed more effectively10
29
Treatment Options:
Surgical Techniques, cont.
Radical prostatectomy

Often, biopsies are taken of the pelvic lymph
nodes to determine if the cancer has spread10
 If the lymph node biopsy is positive and the cancer
has spread outside the prostate, it can’t be cured with
surgery. Other treatment options are available that
may stop the spread of the disease2
30
Treatment Options:
Surgical Techniques, cont.
Cryosurgery

Treats localized prostate cancer by freezing
and destroying prostate cancer cells13
 A probe filled with liquid nitrogen is guided
through a skin incision into the cancer tissue
using transrectal ultrasound (TRUS), which
allows the physician to monitor the freezing
process13
31
Treatment Options:
Surgical Techniques, cont.
Cryosurgery

Some complications can result from the
procedure, including13:




Impotence
Incontinence
Penile numbness
Urinary bladder obstruction
32
Treatment Options:
Surgical Techniques, cont.
TURP (transurethral resection of the prostate)

Remove tissue from the prostate by inserting
an instrument into the urethra while the patient
is under general or local anesthesia11
 Sometimes necessary to relieve the symptoms
of BPH or prostate cancer and to make
urination easier11
33
Treatment Options:
Alternatives to Surgery
For some men with prostate cancer, surgery
may not be the appropriate choice, and some
of the following options may be considered:

Radiation therapy
 Hormonal therapy
 Chemotherapy
 Watchful waiting
34
Treatment Options:
Radiation Therapy

Exposes cancer cells to high doses of radiation
with the goal of killing the tumor14
 External beam radiation treats the prostate and
other selected tissues with a carefully targeted
beam of radiation administered from a machine
outside the body14
35
Treatment Options:
Radiation Therapy, cont.

With brachytherapy, tiny radioactive seeds are
implanted in the prostate through a surgical
procedure14
 Allows the radioactive seeds to be implanted into
the tumor very precisely1
 Allows a higher dose of radiation to be used with
potentially less damage to surrounding tissue1
36
Treatment Options:
Radiation Therapy, cont.

One study showed urinary incontinence was
more frequent following radical
prostatectomy than following external beam
radiation therapy15
 Other potential side effects include: skin
reaction in the treated area, frequent and
painful urination, diarrhea, impotence,
rectal irritation or bleeding1,14,16
 Physicians may choose to combine other
treatment options, such as hormonal
therapy, with radiation therapy
37
Treatment Options:
Hormonal Therapy

Physicians sometimes use hormone therapy
before radical prostatectomy or radiation to
shrink the tumor14
 Also used to slow the spread of cancerous cells
and alleviate the symptoms associated with
advanced prostate cancer14
38
Treatment Options:
Chemotherapy

Targets and destroys rapidly dividing cancer
cells17
 Unfortunately, chemotherapy also destroys normal
cells that divide rapidly, such as blood cells
forming in the bone marrow, hair follicles, and
cells in the intestines and mouth17
 The destruction of normal cells causes side effects
such as fatigue, hair loss, nausea and vomiting,
diarrhea, mouth sores, and a low white blood cell
count17

Supportive medication may be given to help
offset the side effects caused by chemotherapy
drugs17
39
Treatment Options:
Watchful Waiting
Careful observation of the patient’s condition,
without immediate treatment for prostate
cancer1,10
 May be appropriate for men who have less
aggressive tumors, which typically grow
slowly1,10

40
If Prostate Cancer Progresses
After Local Treatment
Prior to beginning treatment for localized
cancer, such as radical prostatectomy or
radiation therapy, it may be possible for a
physician to make his or her assessment of the
anticipated success of specific treatments

Disease progression means prostate cancer
was not eliminated and that there is a risk
of it metastasizing1
 If the prostate cancer has progressed, there
are other treatment options available
41
If Prostate Cancer Progresses
After Local Treatment, cont.
How doctors determine whether the treatment
was successful

The doctor may consider the Gleason score,
PSA level, and stage rating
 PSA level is an indicator of disease
progression because, according to the
American Society for Therapeutic Radiology
and Oncology Consensus Panel, PSA “warns
of recurrent disease long before other clinical
signs…”18
42
If Prostate Cancer Progresses
After Local Treatment, cont.
Physicians may evaluate the success or failure
of radical prostatectomy based on19,20:

Gleason score
 The amount of, and time to, initial PSA
increase, and/or
 The length of time it takes for the PSA number
to double
43
If Prostate Cancer Progresses
After Local Treatment, cont.
Physicians may evaluate the success or
failure of radiation therapy based on:
The lowest PSA number after treatment14,21
 PSA value that fails to decline following radiation
therapy22, and
 The number of consecutive rises in PSA level
following radiation therapy14,18

44
If Prostate Cancer Progresses
After Local Treatment, cont.

Remember that even if prostate cancer
progresses, there may be other treatment
options
 Discuss treatment alternatives with a doctor
45
Hormonal Therapy
Used to decrease the production of testosterone
or block its effects, which, in turn, slows cancer
cell growth1,3

A first-line treatment for patients with advanced
prostate cancer1
 Used when radiation therapy or radical
prostatectomy has failed10,14
 Types of hormonal therapy12:
 Drugs that reduce testosterone to castrate levels
(ie, LH-RH agonists)
 Antiandrogens
 Surgical removal of the testicles, which produce
testosterone
46
Hormonal Therapy, cont.
LH-RH agonists

Shut down the production of testosterone by
the testicles, possibly slowing prostate cancer
spread12
 The most common side effect is hot flashes,
and they may also cause impotence12
 Symptoms may worsen during the first few weeks
of treatment4
 Periodic monitoring of PSA and testosterone levels
in the blood is recommended12
47
Hormonal Therapy, cont.
Antiandrogen therapy
Blocks the effect of testosterone12
 An antiandrogen may be administered in
combination with an LH-RH agonist to counteract
the small amount of testosterone produced by the
adrenal glands
 Side effects include breast tenderness/enlargement,
fatigue, liver function abnormalities, and diarrhea1

48
Hormonal Therapy, cont.
Orchiectomy

A surgical procedure that removes the
testicles, resulting in immediate and
permanent reduction in testosterone12
 Considered hormonal therapy because, like
certain prescription drugs, it reduces
testosterone levels12
 Common side effects include impotence,
decreased libido, breast
tenderness/enlargement, and hot flashes10
 LH-RHa therapy has been shown to be
comparable to orchiectomy in decreasing
the body’s supply of testosterone12
49
Risk of Complications May Decrease
With Immediate Hormonal Intervention
for Advanced Prostate Cancer
Study results from 934 patients with advanced prostate cancer have shown that the risk
of serious complications decreased with early hormonal therapy23
23
50
Salvage Radiation
Used postoperatively in an effort to destroy
remaining tumor cells24

Can lower the local recurrence rates of prostate
cancer to 0%-10% when used as an additional
form of treatment after the initial surgery24
 May also be used to treat specific sites of bone
pain1
51
There are many treatment options
available to men diagnosed with
prostate cancer

Information about prostate cancer and the
options available can be very helpful in
making an informed decision about the course
of therapy
 Discuss all of these options with a physician
52
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2.
3.
4.
5.
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57