Understanding Prostate Cancer A Guide to Treatment and Support 1

UnderstandingProstate CancerUnderstandingProstate Cancer

A Guide to Treatment and Support

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Table of ContentsTable 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

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Introduction 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

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Introduction, cont.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

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A Brief Overview of Prostate CancerA Brief Overview of 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

Who gets Prostate Cancer?

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A Brief Overview of Prostate Cancer, cont.A Brief Overview of Prostate Cancer, cont.

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

Who gets Prostate Cancer?

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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

What causes prostate cancer?

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Researchers don’t know exactly what causes this damage, but have identified some risk factors3: Age Race Environment Diet Genetics and family history

What causes prostate cancer?

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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

Symptoms of Prostate Cancer

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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

What is the prostate?

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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 life-threatening1,6

Malignant tumors invade and destroy surrounding tissue6

Prostate cancer is a malignant tumor that begins growing in the prostate gland4

What is cancer?

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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

What is metastasis?

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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 hormone-releasing hormone agonists (LH-RHa) that stop the production of testicular testosterone4,5

What role does testosterone play?

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Assessing the Prostate:PSA, Grading, and StagingAssessing the Prostate:PSA, Grading, and Staging

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 high-risk groups over the age of 45, should have a PSA blood test and DRE once every year2

Before determining therapy, physicians normally assess the state of the prostate and the stage of the cancer

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Assessing the Prostate:PSA, Grading, and Staging, cont.


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

What is the DRE (digital rectal examination)?

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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

What is PSA (prostate-specific antigen)?

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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

PSA Levels

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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

What is a biopsy?

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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

What is the Gleason grade?

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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

Gleason grades range from 1 to 5 and are based on the degree of differentiation among the cells9

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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

What is staging?

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Stage A is early cancer – the tumor is located within the prostate gland and can’t be detected by a DRE8

A-D Staging

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In Stage B, the tumor is confined to the prostate but large enough to be felt during a DRE8

A-D Staging

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By Stage C, the tumor has spread outside the prostate to some surrounding areas and can be felt during a DRE8

A-D Staging

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In Stage D, the cancer has spread to the nearby and distant organs, such as bones and lymph nodes8

A-D Staging

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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

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

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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

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

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Treatment OptionsTreatment Options

Treatment options for prostate cancer depend on several factors, including age, the stage of the disease, and the advice of a physician

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Treatment Options:Surgical TechniquesTreatment Options:Surgical Techniques

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

Radical prostatectomy

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Treatment Options:Surgical Techniques, cont.


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

Radical prostatectomy

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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

Cryosurgery

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Some complications can result from the procedure, including13: Impotence Incontinence Penile numbness Urinary bladder obstruction

Cryosurgery

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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

TURP (transurethral resection of the prostate)

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Treatment Options:Alternatives to SurgeryTreatment Options:Alternatives to Surgery

Radiation therapy Hormonal therapy Chemotherapy Watchful waiting

For some men with prostate cancer, surgery may not be the appropriate choice, and some of the following options may be considered:

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Treatment Options:Radiation TherapyTreatment 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

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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

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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

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Treatment Options:Hormonal TherapyTreatment 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

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Treatment Options:ChemotherapyTreatment 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

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Treatment Options:Watchful WaitingTreatment 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

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If Prostate Cancer ProgressesAfter Local TreatmentIf Prostate Cancer ProgressesAfter Local TreatmentPrior 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

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If Prostate Cancer ProgressesAfter 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

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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

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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

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Remember that even if prostate cancer progresses, there may be other treatment options

Discuss treatment alternatives with a doctor

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Hormonal TherapyHormonal Therapy

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

Used to decrease the production of testosterone or block its effects, which, in turn, slows cancer cell growth1,3

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Hormonal Therapy, cont.Hormonal Therapy, cont.

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

LH-RH agonists

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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

Antiandrogen therapy

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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

Orchiectomy

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Risk of Complications May Decrease With Immediate Hormonal Intervention for Advanced Prostate Cancer

Risk of Complications May Decrease With Immediate Hormonal Intervention for Advanced Prostate CancerStudy results from 934 patients with advanced prostate cancer have shown that the risk of serious complications decreased with early hormonal therapy23

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Salvage RadiationSalvage Radiation

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

Used postoperatively in an effort to destroy remaining tumor cells24

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There are many treatment options available to men diagnosed withprostate cancer

There are many treatment options available to men diagnosed withprostate 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

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ReferencesReferences1. Scher HI. Hyperplastic and malignant disease of the prostate. In:

Braunwald E, Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill; 2001:608-616.

2. American Cancer Society. Cancer Facts & Figures 2003. Atlanta, Ga: American Cancer Society; 2003.

3. Reiter RE, deKernion JB. Epidemiology, etiology, and prevention of prostate cancer. In: Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:3003-3024.

4. Goldspiel BR, Kolesar JM, Kuhn JG. Prostate cancer. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 3rd ed. Stamford, Conn: Appleton & Lange; 1997:2539-2557.

5. Marieb E. The reproductive system. Human Anatomy & Physiology. 4th ed. Menlo Park, Calif: Benjamin/Cummings Science Publishing; 1998:1030-1077.

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References, cont.References, cont.

6. Balmer C, Valley AW. Basic principles of cancer treatment and cancer chemotherapy. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 3rd ed. Stamford, Conn: Appleton & Lange; 1997:2403-2465.

7. Gerber GS, Brendler CB. Evaluation of the urologic patient: history, physical examination, and urinalysis. In: Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia, Pa: Saunders; 2002: 83-110.

8. Carter HB, Partin AW. Diagnosis and staging of prostate cancer. In: Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:3055-3079.

9. Epstein JI. Pathology of prostatic neoplasia. In: Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:3025-3037.

10. Leewansangtong S, Crawford ED. Prostate. In: Haskell CM, ed. Cancer Treatment. 5th ed. Philadelphia, Pa: WB Saunders Company; 2001:806-828.

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11. Fitzpatrick JM, Mebust WK. Minimally invasive and endoscopic management of benign prostatic hyperplasia. In: Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia, Pa: Saunders, 2002:1379-1422.

12. Schröder FH. Hormonal therapy of prostate cancer. In: Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:3182-3208.

13. Shinohara K, Carroll PR. Cryotherapy for prostate cancer. In: Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:3171-3181.

14. D’Amico AV, Crook J, Beard CJ, et al. Radiation therapy for prostate cancer. In: Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:3147-3170.

15. McCammon KA, Kolm P, Main B, et al. Comparative quality-of-life analysis after radical prostatectomy or external beam radiation for localized prostate cancer. Urology. 1999;54:509-516.

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16. Bulbul MA, Catton PA, Klotz LH. Treatment of localized disease. In: Klotz LH, ed. Managing Prostate Cancer: Current Approaches and Techniques in the Early Detection, Staging and Treatment of Prostate Cancer. Montreal, Quebec: Grosvenor House Press Inc; 1992:42-55.

17. Balmer CM, Valley AW. Cancer treatment and chemotherapy. In: DiPiro JT, Talbert RL, Yee GC, et al. Pharmacotherapy: A Pathophysiologic Approach. 5th ed. New York, NY: McGraw-Hill; 2002:2175-2222.

18. American Society for Therapeutic Radiology and Oncology Consensus Panel. Consensus statement: guidelines for PSA following radiation therapy. Int J Radiat Oncol Biol Phys. 1997;37:1035-1041.

19. Pound CR, Partin AW, Eisenberger MA, et al. Natural history of progression after PSA elevation following radical prostatectomy. JAMA. 1999; 281:1591-1597.

20. Eastham JA, Scardino PT. Radical prostatectomy. In: Retik AB, Vaughan ED Jr, Wein AJ, eds. Campbell’s Urology. 8th ed. Philadelphia, Pa: Saunders; 2002:3080-3106.

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21. Critz FA, Levinson AK, Williams WH, et al. Prostate-specific antigen nadir: the optimum level after irradiation for prostate cancer. J Clin Oncol. 1996;14:2893-2900.

22. Chauvet B, Felix-Faure C, Lupsascka N, et al. Prostate-specific antigen decline: a major prognostic factor for prostate cancer treated with radiation therapy. J Clin Oncol. 1994;12;1402-1407.

23. The Medical Research Council Prostate Cancer Working Party Investigators Group. Immediate versus deferred treatment for advanced prostatic cancer: initial results of the Medical Research Council trial. Br J Urol. 1997;79:235-246.

24. Sarosdy MF. Prostate adenocarcinoma: the management of pelvic confined disease. In: Krane RJ, Siroky MB, Fitzpatrick JM, eds. Clinical Urology. Philadelphia, Pa: JB Lippincott Co; 1994:980-995.

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Understanding Prostate Cancer A Guide to Treatment and Support 1