About Prostate Cancer

Prostate cancer is the most common cancer in men, other than sun induced skin cancers. Over 220,000 men will be diagnosed with prostate cancer this year in the United States. Surprising to many is the fact that prostate cancer is more common in men than breast cancer is in women. It is almost true that if you live long enough you will get prostate cancer. Actually, one study showed that one out of two men living beyond their eighth decade had prostate cancer when looked for. This illustrates not only that prostate cancer is extremely common, but also that this disease can sometimes be an insignificant problem that is not a threat to a person's health or longevity.

In most cases, however, it's not good advice to "let the cancer go." If your health is good, if you have many years of life expectancy, or if you have a tumor with a mid Gleason Score or higher (click here for more information about Gleason Scores), then treatment is usually recommended. Even if you're lucky and have a slow growing cancer, it is cancer nonetheless. If not treated it can progress locally causing destruction of the bladder, rectum, and/or urethra. Eventually distant spread will also occur - usually into the bones. Ultimately, about _ of those who don't treat their prostate cancer will die because of the disease.

Understanding the Anatomy of the Pelvis

Here is a picture looking into a man's pelvis from the side.

Note the location of the bladder and rectum in relation to the prostate gland.
Note the location of the penis and testicles.
Note the urethra, which is the urinary tube draining urine out of the bladder through the penis. The urethra travels right through the center of the prostate.
Some men have had a TURP (Trans -Urethral Resection of the Prostate) or a "reaming out" of the inside part of the prostate to improve the flow of urine.

When your doctor performs a digital rectal exam (DRE), they reach in with a finger through the anal opening and feel the backside of the prostate. It's this back region where most prostate cancers begin. Some prostate cancers don't make PSA (click here for more information about PSA), and if the DRE is not done, the cancer will be missed.

Treatment Choices

Watchful Waiting
Hormonal Therapy
Surgical removal (called Radical Prostatectomy)
Radiation Therapy
External Beams alone
External Beams in conjunction with Brachytherapy
Permanent seed Brachytherapy (also called LDR or Low Dose Rate Brachytherapy)
Temporary Brachytherapy (also called HDR or High Dose Rate Brachytherapy

Watchful Waiting

Watchful waiting is a reasonable choice for those who are elderly, for those very sick with other serious health problems, and for those who have a Gleason score on the tumor that is a very low number. If all of these criteria are met, then the person will likely live out his normal life and die of some other problem before the cancer ever causes him any harm.

On the other hand, if your health is good, if you have many years of life expectancy in front you, or if you have a tumor with a mid Gleason Score or higher, then treatment is usually recommended. One reason for saying this is that our ability to cure prostate cancer is quite high, but declines as the disease progresses. The other reason is that treatment - particularly with brachytherapy - can be done with relatively minor side effects.

Prostate cancers are located right next to very important normal tissues. If the cancer is neglected, and it begins to infiltrate the nearby bladder, urethra, and or rectum, then very distressing symptoms will result. These symptoms would usually consist of pain and bleeding with voiding of bowel and bladder, and eventually complete obstruction to urine flow. Cure at this point will be more difficult because the disease has progressed from an early to a more advanced stage. Very often, by the time the cancer is this big in the prostate, it has spread to distant areas of the body and is no longer at a point where it can be cured at all.

In our experience, most who start out on a "watchful waiting" approach eventually change their mind and come back for treatment. Either their nerves can't take watching their PSA continue to increase, or they have progressive disease and are beginning to have symptoms.

Hormone Therapy

The testicles make a very important hormone called testosterone. Testosterone is responsible for a man's sex drive, it helps with erections, and it contributes to the motivation and energy needed for daily activities. Testosterone, however, also stimulates prostate cancer growth. This treatment referred to as "Hormone Therapy" is designed to block the production and/or effects of the testosterone hormone. Perhaps a better name for it would be "Hormonal Deprivation Treatment", or "Anti-Hormone Therapy."

Hormone therapy is accomplished by giving a shot of medicine that turns off the production of the testosterone hormone. In addition, there are pills taken to block the effect of the hormone at the receptor level. The pills are sometimes given just at the beginning of the shot to help get the shot working sooner; at other times, the pills continue for as long as 4 months or more.

Hormone therapy is a very powerful anti-cancer treatment. It will lower the PSA, it will shrink a nodule, and it will shrink the prostate. The main problem with hormone therapy is that it is not a permanent treatment. It will put the cancer into a state of remission or dormancy, and will hold it there for around 2 years (sometimes longer, but sometimes shorter). Eventually, however, the cancer will get resistant to hormone therapy, and will begin growing again despite the fact that there is no testosterone around to stimulate it. The cancer at that point is considered "hormone resistant", and it will usually behave in a more aggressive way from then on.

Hormone therapy is looked at by some as a very easy treatment. All it is, they say, is getting a shot every few months, and sometimes taking some pills. Losing the testosterone hormone, however, can have a tremendous impact on quality of life. Without testosterone, you will lose much of your energy and get-up-and-go that helps you get things done each day. You won't have much of a sex drive, erections will be poor or non-existent, and most will have intermittent hot-flashes to varying degrees. When hormone therapy continues for a year or more, most men will lose muscle mass and bone density at a faster rate than when the hormone is present.

The main uses of hormone therapy are:

To treat cancer that is widespread throughout the body.
To shrink a very large prostate prior to Brachytherapy, or sometimes prior to surgery.
To give the man time to decide among treatment options without the worry of cancer spreading while he makes up his mind.
To improve the cure rate of those with high-risk features who are being treated with radiation therapy.

Radical Prostatectomy

Surgical removal of the prostate is called Radical Prostatectomy. Any surgical procedure beginning with the word "radical" is a strong hint that it is a very big operation not to be entered into lightly. Your Urologist will tell you what you need to know about the radical prostatectomy procedure. However, there are a few things we'd like to emphasize.

Whether or not surgery leads to cure depends greatly on whether or not the cancer is confined to the prostate. Surrounding the prostate is a tough fibrous capsule, which acts as a barrier helping to keep the cancer confined within the prostate. Most surgeons attempt to do a nerve-sparing radical prostatectomy to try to preserve sexual function. These nerves sit right against the prostate capsule. When this kind of prostatectomy is done, the only thing removed is the prostate and it's capsule - not any extra tissue beyond this. Therefore, the only people cured are those whose cancer is organ confined. If cancer extended through the capsule into the nearby fat or beyond, then surgery is not likely to be curative.

Patients understandably want to know whether or not there cancer is organ confined. The surest way to know is to have the radical prostatectomy, after which the prostate can be sectioned up and looked at in its entirety, and then you'll know.

Can we predict what the surgeon will find without putting you through the operation? The answer is YES, and it's found in the Partin Tables, the closest thing we have to a crystal ball. These tables were put together by prostate surgeons at Johns Hopkins University. Johns Hopkins University is the most famous surgical center for prostate cancer in the entire world. Thousands of men have gone there over the years because of their expertise. These doctors took the Gleason scores, the PSA values, and whether or not a tumor nodule was present on all those men they operated on, and showed who had cancer confined to the prostate and who didn't based on those features.

Here is the most current Partin Table showing the probability of having organ-confined disease:

The table is divided into different PSA ranges. First, find the PSA range that matches your PSA.
Next, find your Gleason score down the left hand column within that PSA range. The Gleason score is a determination of how aggressive the cancer appears to be based on its appearance under the microscope. The range that a Gleason Score could be is from 2-10. The more towards 2, the slower growing the cancer is. The more towards 10, the faster growing and more aggressive it tends to be.
Finally, go over to the vertical column that represents your clinical stage. The clinical stage is basically what the doctor feels at the time of a digital rectal exam. Stage T1c means no lump is palpable. Stage T2a means that a small lump is present. Stage T2b means a bigger lump is present, and fills up greater than _ of the involved side. Stage T2c means that the lump is felt on both sides of the prostate.
The number at the intersection of these 3 variables is the percentage of patients with those cancer features who were organ-confined at the time of radical prostatectomy, or in other words, who are likely to be cured with surgery.

A common misperception regarding surgery is that the worse the disease, the more important it is to have it removed. Actually, just the opposite is true. Surgery is most appropriate when features are good, and there is a high probability of having organ-confined disease. Surgery is less appropriate, and in some cases not appropriate at all, when higher risk features are present.

To remove the prostate, the surgeon has to cut through the urethra at the top of the prostate (at it's junction with the bladder), and has to cut through it again at the bottom of the prostate. One potential side effect of prostate removal is bladder incontinence (inability to fully control your urine). All surgical patients will have this side effect for a short time, though most will recover. Less than full recovery is seen more often in those who are overweight, have diabetes, or are age 70 and above. Incontinence is not a life-threatening side effect, but it certainly has a great impact on quality of life. Partly because of this risk, Johns Hopkins University uses an age cut-off of 65 to determine who is and who is not a candidate for radical prostatectomy.

Radiation Therapy

There are a number of ways of giving radiation to the prostate:

External Beams alone

3D-Conformal
Intensity Modulated Radiation Therapy or IMRT
Proton beams

Brachytherapy alone

Permanent or Low Dose Rate (LDR)
Temporary or High Dose Rate (HDR)

External Beams in conjunction with Brachytherapy

External Beams

External beam radiation is what you'll get at most radiation centers. Treatments are given while you lay flat on your back on a treatment table. As you lay still, beams from a large radiation machine are pointed at the prostate from many different directions. These different beams will penetrate in, and will overlap or intersect with each other right over the prostate region. Treatments take about 15 minutes, and are repeated Monday through Friday for about 8 weeks. In other words about 40 individual treatments are given.

The difficult thing about external beams is that the beams have to penetrate through normal tissues before getting in to the prostate. Also, as the beam exits the body, again it passes through normal tissue. As you can imagine, it is nearly impossible to give high radiation doses to the prostate without those same high doses going to at least part of the bladder and rectum.

Different technologies are in place at most centers to help external beams be as safe as possible. 3D-Conformal radiation treats with shaped radiation beams. The beams from each of the different directions are individually shaped to conform to the shape of the target. The beam coming from the front, for example, would have a different shape than beams coming from the side. The shape of the "target" is determined by CT images that are obtained prior to treatment.

Intensity Modulated Radiation Therapy or IMRT is the newest kind of external radiation. IMRT not only changes the shape of the beam for each of the radiation treatment fields, but the intensity of the radiation beam is changed or "modulated" as well. This is accomplished by having tiny little lead fingers travel across the beam as the beam is turned on. (Click here for a demonstration of IMRT). These lead fingers, called collimators, not only create beam shapes of any size, but determine the amount of radiation, or intensity, of the radiation penetrating into the patient.

Proton Beam therapy is a very uncommon type of external radiation that is only available at two places in the United States. It has some very important uses in tumors of the brain and central nervous system, but for prostate cancer it is not considered to be any better than the other versions of external beams. The potential advantage of proton beams is that the outer edge of the beam is very sharp, thus allowing the treating physician to conform the beams a little tighter around the tumor area. With a typical photon radiation beam (the kind of radiation given most places), there is a distance of a centimeter or two from the inside edge of the beam where dose is 100%, to the outside beam edge where there is finally no radiation dose. This means that when patients are treated with photon radiation beams, the radiation fields have to be enlarged slightly so that the edge of the tumor does not lie at the beams border where the dose may not be 100%. Protons, in theory, can be a centimeter tighter around the tumor because of a sharper beam edge. If people were treated with only one radiation treatment, proton's sharp beam edge may be useful. But radiation treatments are repeated daily for many weeks, and the variations in the day-to-day set up will "blur" this sharp edge, thus negating any advantage of the beams sharp edge in the first place.

Common to all of the external beam treatments is the fact that the beams have to penetrate through normal tissues before getting inside to the prostate area. The only technology that can bypass these normal tissues completely is Brachytherapy.

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