My Penis Stuff

Examples

Casodex (bicalutamide), Eulexin (flutamide), Megace (megestrol), Nilandron (nilutamide)

How It Works

Androgens are hormones. Antiandrogens are drugs that block the action of these hormones. In prostate cancer, they block the action of testosterone made by the testicles and/or adrenal glands. This usually slows prostate cancer growth.

What To Think About

Antiandrogens may improve a man’s quality of life when bone pain caused by prostate cancer is severe.

Sometimes flutamide has an effect called a “withdrawal response” in which the tumor shrinks and the PSA level improves when a man stops taking the medication.

A prostate-specific antigen (PSA) test measures the amount of prostate-specific antigen in the blood. PSA is released into a man’s blood by his prostate gland. Healthy men have low amounts of PSA in the blood. The amount of PSA in the blood normally increases as a man’s prostate enlarges with age. PSA may increase as a result of an injury, a digital rectal exam, sexual activity (ejaculation), inflammation of the prostate gland (prostatitis), or prostate cancer.

Prostate cancer often grows very slowly, without causing major problems. Detecting prostate cancer early and treating it may prevent some health problems and reduce the risk of dying from the cancer. However, some treatments for prostate cancer can cause other problems, such as controlling urination (incontinence) or erection problems (erectile dysfunction). Some men may choose not to have a PSA test or treat prostate cancer if it is detected. For example, a man older than age 75 who has no bothersome symptoms of prostate cancer may choose not to treat the cancer if it is found, so he would not need a PSA test.

Why It Is Done

The prostate-specific antigen (PSA) test is done to:

• Watch prostate cancer and see if treatment is working. If PSA levels increase, the cancer may be growing or spreading. PSA is usually not present in a man who has had his prostate gland removed. A PSA level that rises after prostate removal may mean the cancer has returned or has spread.
• Check if cancer may be present when results from other tests, such as a digital rectal exam, are not normal. A PSA test does not diagnose cancer, but it can be used along with other tests to determine if cancer is present.
• Check men for prostate cancer. Experts disagree on the usefulness of PSA testing as a screening tool for prostate cancer. If a PSA test is used for screening, it is usually done for men older than age 50 or for those at high risk for prostate cancer, such as men with a family history of prostate cancer, or for African-American men who have a higher chance of developing cancer than other men. Since other common medical conditions, such as prostatitis, can cause high PSA levels, a prostate biopsy is needed to confirm a diagnosis of cancer.

How To Prepare

Before you have a prostate-specific antigen (PSA), tell your doctor if you have had a:

• Test to look at your bladder (cystoscopy) in the past several weeks.
• Prostate needle biopsy in the past several weeks.
• Prostate infection (prostatitis) or an urinary tract infection (UTI) that has not gone away.
• Tube (catheter) inserted into your bladder to drain urine recently.

Do not ejaculate during the 2 days before your PSA blood test, either during sex or masturbation.

Talk to your doctor about any concerns you have regarding the need for the test, its risks, how it will be done, or what the results will indicate.

How It Is Done

The health professional taking a sample of your blood will:

• Wrap an elastic band around your upper arm to stop the flow of blood. This makes the veins below the band larger so it is easier to put a needle into the vein.
• Clean the needle site with alcohol.
• Put the needle into the vein. More than one needle stick may be needed.
• Attach a tube to the needle to fill it with blood.
• Remove the band from your arm when enough blood is collected.
• Put a gauze pad or cotton ball over the needle site as the needle is removed.
• Put pressure to the site and then a bandage.

How It Feels

The blood sample is taken from a vein in your arm. An elastic band is wrapped around your upper arm. It may feel tight. You may feel nothing at all from the needle, or you may feel a quick sting or pinch.

Risks

There is very little chance of a problem from having a blood sample taken from a vein.

• You may get a small bruise at the site. You can lower the chance of bruising by keeping pressure on the site for several minutes.
• In rare cases, the vein may become swollen after the blood sample is taken. This problem is called phlebitis. A warm compress can be used several times a day to treat this.
• Ongoing bleeding can be a problem for people with bleeding disorders. Aspirin, warfarin (Coumadin), and other blood-thinning medicines can make bleeding more likely. If you have bleeding or clotting problems, or if you take blood-thinning medicine, tell your doctor before your blood sample is taken.

Results

A prostate-specific antigen (PSA) test measures the amount of prostate-specific antigen in the blood. Normal values may vary from lab to lab.

Normal

Because normal PSA levels seem to increase with age, age-specific ranges may be used. However, the use of age-specific ranges is controversial, and some doctors prefer to use one range for all ages. For this reason, it is important to discuss your test results with your doctor. This table is a reference for white males. Results for black and Asian males are slightly different.

High values

• PSA levels from 4 to 10 ng/mL: About 20% to 30% of men (20 to 30 men in 100) with PSA levels in this range may have prostate cancer. A transrectal ultrasound (TRUS) and prostate biopsy are needed to confirm a diagnosis of cancer.
• PSA levels above 10 ng/mL: About 40% to 60% of men (40 to 60 men in 100) with PSA levels in this range may have prostate cancer. A transrectal ultrasound (TRUS) and prostate biopsy are needed to confirm cancer.
• High levels do not always mean prostate cancer is present. PSA levels may be high if the prostate gland is enlarged (benign prostatic hypertrophy, or BPH) or inflamed (prostatitis).

A follow-up test, percent free prostate-specific antigen (free PSA), may be used to see if a prostate biopsy should be done to check for cancer. Men with a low percentage of free PSA have a higher chance of developing cancer as shown in the table below.

Low free PSA values (less than 15%) are more likely to be caused by prostate cancer than high free PSA values.

What Affects the Test

Factors that can interfere with your test or the accuracy of the results include:

• Recent sexual activity (ejaculation) or a cystoscopy.
• Recent use of a tube (catheter) to drain urine.
• Recent urinary tract infection (UTI) or prostatitis.
• Large doses of medicines, such as cyclophosphamide (Cytoxan, Neosar), diethylstilbestrol, and methotrexate for cancer treatment.
• The medicine finasteride, such as Proscar or Avodart, which is used to prevent further enlargement of the prostate gland in men with BPH.

What To Think About

• When combined with a digital rectal exam, the prostate-specific antigen (PSA) test increases the chance of detecting prostate cancer. For more information, see the medical test Digital Rectal Examination (DRE).
• A PSA level within the normal ranges does not mean that prostate cancer is not present. Some men with prostate cancer have normal PSA levels.
• Experts disagree about the frequency of PSA testing to screen for prostate cancer.
  • The American Cancer Society (ACS) recommends an annual PSA test and DRE for men age 50 and older. ACS also recommends annual screening, beginning at age 45, for men who are at high risk for prostate cancer, such as black men and men who have a family history of prostate cancer.
  • Other expert groups, such as the National Cancer Institute and the U.S. Preventive Services Task Force, believe there is not enough evidence to recommend routine screening with the PSA test for all men. Experts that do not recommend annual screening say the high rate of false-negative and false-positive results and the costs and risks of further tests do not support annual screening tests.
• Experts disagree about the type of testing that is appropriate if the PSA level is high. The decision may depend on:
  • Results of your digital rectal exam.
  • Results of any PSA tests you have had in the past. If your PSA level gets higher in a short amount of time, follow-up testing may be recommended.
  • Your age and health.
  • The costs and risks of more tests and treatments.
• Other prostate tests are being evaluated to determine how well they tell the difference between prostate cancer and benign prostatic hypertrophy.
  • The prostate-specific antigen density (PSAD) test compares the PSA value to the size of the prostate gland. The size of the prostate is measured using transrectal ultrasound (TRUS).
  • The PSA velocity test is a measure of how rapidly PSA levels increase over time. PSA levels increase more rapidly in men with prostate cancer and more slowly in men with prostate enlargement (benign prostatic hypertrophy).
• Complexed prostate-specific antigen (cPSA) when used in combination with a digital rectal exam can detect prostate cancer. The cPSA test currently is not widely available.

A prostate gland biopsy is a test to remove small samples of prostate tissue to be examined under a microscope.

For a prostate biopsy, a thin needle is inserted through the rectum (transrectal biopsy), through the urethra, or through the area between the anus and scrotum (perineum). A transrectal biopsy is the most common method used. The tissue samples taken during the biopsy are examined for cancer cells.

A biopsy may be done when a blood test shows a high level of prostate-specific antigen (PSA) or after a digital rectal examination finds an abnormal prostate or a lump.

Why It Is Done

A prostate biopsy is done to determine:

• If a lump found in the prostate gland is cancer.
• The cause of a high level of prostate-specific antigen (PSA) in the blood.

How To Prepare

Tell your doctor if you:

• Have had any bleeding problems.
• Are allergic to any medications, including anesthetics.
• Take any medications regularly. Be sure your doctor knows the names and doses of all your medications.
• Are taking any blood-thinning medications, such as warfarin (Coumadin), heparin, enoxaparin (Lovenox), aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).

You will need to sign a consent form that says you understand the risks of a prostate biopsy and agree to have the biopsy done. Talk to your health professional about any concerns you have regarding the need for the biopsy, its risks, how it will be done, or what the results will indicate.

If a prostate biopsy is done under local anesthesia through the area between the anus and scrotum (perineum), no other special preparation is needed.

If the biopsy is done through the rectum, you may need to have an enema before the biopsy.

If the biopsy is done under general anesthesia, do not eat or drink anything for 8 to 12 hours before the biopsy. During preparation for the biopsy, an intravenous line (IV) is inserted in your arm, and a sedative medication is given about an hour before the biopsy.

How It Is Done

This biopsy is done by a doctor who specializes in men’s genital and urinary problems (urologist) in the doctor’s office, a day surgery clinic, or a hospital operating room.

Before your prostate biopsy, you may be given antibiotics to prevent infection. You may be asked to take off all of your clothes and put on a hospital gown.

Your skin at the biopsy site is cleaned with an antiseptic solution, and the area around it is covered with sterile cloth. Your doctor will wear sterile gloves. It is very important that you do not touch this sterile area.

Transrectal ultrasound (TRUS) is commonly used to guide the placement of the needle during a prostate biopsy.

Through the rectum (transrectal biopsy)

Several positions are possible for this method. You may be asked to kneel, lie on your side, or lie on your back with your feet resting in stirrups. Your doctor may inject a local anesthetic around the prostate gland before the biopsy is taken.

Transrectal ultrasound (TRUS) is generally used to guide the needle to the correct biopsy location. A prostate biopsy is usually done with a spring-loaded needle. The needle quickly enters the prostate gland and removes a tissue sample.

The biopsy can also be done with a needle guide attached to your doctor’s finger. He or she inserts the finger into the rectum. Then the needle is slid along the guide, through the wall of the rectum, and into the prostate gland. The needle is turned to collect a tissue sample and then pulled out.

A transrectal biopsy takes about 30 minutes. See an illustration of transrectal prostate biopsy.

Through the urethra (transurethral biopsy)

For this method, you will lie on your back with your feet resting in stirrups. General or local anesthesia may be used.

A lighted scope (cystoscope) is inserted into your urethra. It allows your doctor to look directly at the prostate gland. A cutting loop is passed through the cystoscope to remove small pieces of prostate tissue.

A transurethral biopsy usually takes about 30 to 45 minutes.

Through the perineum (transperineal biopsy)

Transperineal biopsy is not done as commonly as transrectal or transurethral biopsy. You will lie on an examining table either on your side or on your back with your knees bent. General or local anesthesia may be used.

A small incision is made in your perineum. Your doctor inserts a finger into the rectum to hold the prostate gland and then inserts the needle through the incision and into the prostate gland. To collect a sample of tissue, the needle is gently turned and then pulled out. Biopsy samples may be taken from several areas of the prostate. Pressure is applied to stop the bleeding, and a small bandage is placed over the cut. The biopsy usually takes about 15 to 30 minutes.

How It Feels

You may feel a slight sting when you receive an injection of medication to numb your skin. You may feel a dull pressure as the biopsy needle is inserted. For a transrectal biopsy, you may feel pressure in the rectum while the ultrasound probe or guiding finger is in place. You also may feel a brief, sharp pain as the biopsy needle is inserted into the prostate gland. Usually several biopsy samples are collected.

Following the biopsy, you will be asked to avoid strenuous activities for about 4 hours. You may have mild pain in the pelvic area and blood in your urine for up to 5 days. Also, you may have some discoloration of your semen for up to one month after the biopsy. If you had a transrectal biopsy, you may experience a small amount of bleeding from your rectum for 2 to 3 days after the biopsy.

If you have a transurethral biopsy, you may have a urinary catheter in place for a few hours after the biopsy. You also may need to take an antibiotic medication for several days after the biopsy.

If you have a general anesthetic, you will be in a recovery room for a few hours after the biopsy. You will need someone to drive you home when you are released. When you get home, your muscles may ache and you may feel tired for the rest of the day.

Risks

A prostate biopsy has a slight risk of causing problems such as:

• Infection. This is more common in men who have undiagnosed prostatitis. Usually, taking antibiotic medication before the biopsy prevents an infection from developing.
• Bleeding into the urethra or bladder. This can cause a blood blister (hematoma), an inability to urinate, or a need to urinate often.
• Bleeding from the rectum. If you have a transrectal biopsy, you may experience a small amount of bleeding from your rectum for 2 to 3 days after the biopsy.
• An allergic reaction to the anesthetic medications used during the biopsy.

After the biopsy

Call your doctor immediately if you:

• Have heavy bleeding or bleeding continues longer than 2 to 3 days.
• Have increased pain.
• Have a fever.
• Are unable to urinate within 8 hours or have blood in the urine for longer than 2 to 3 days.

Results

A prostate gland biopsy is a test to remove small samples of prostate tissue to be examined under a microscope. Results are usually available within 10 days.

If cancer cells are present, a grade (Gleason score) will be given, which your doctor will discuss with you. The Gleason score is considered a tool for predicting how aggressive the cancer is.

What Affects the Test

Factors that can interfere with your test or the accuracy of the results include:

• The biopsy may not contain enough tissue to make a diagnosis.
• A chance that a cancer may be missed since the biopsy takes a small amount of tissue.

What To Think About

• Normal prostate biopsy results do not rule out cancer.
• If the prostate biopsy results show cancer, other tests may be needed to determine the spread of the cancer. These tests may include a blood test (prostate-specific antigen), bone scan, lymph node biopsy, or computed tomography (CT) scan. For more information, see the medical tests Prostate-Specific Antigen (PSA), Bone Scan, Lymph Node Biopsy, and Computed Tomography (CT) Scan.
• Not all types of prostate cancer are treated. There are many factors to consider when deciding on a treatment plan. For more information, see the topic Prostate Cancer.
• A prostate gland biopsy does not cause problems with erections and will not make a man infertile.

Radiation therapy uses high doses of radiation, such as X-rays, to destroy cancer cells. The radiation damages the genetic material of the cells so that they can’t grow. Although radiation damages normal cells as well as cancer cells, the normal cells can repair themselves and function, while the cancer cells cannot.

Radiation therapy may be used alone or combined with hormonal treatment to treat prostate cancer. It is most effective in treating cancers that have not spread outside the prostate. But it also may be used if the cancer has spread to nearby tissues. Radiation is sometimes used after surgery to destroy any remaining cancer cells and to relieve pain from metastatic cancer.

Radiation is delivered in one of two ways.

• External-beam radiation therapy uses a large machine to aim a beam of radiation at your tumor. Once the area of cancer is identified, an ink tattoo no bigger than a pencil tip is placed on your skin so that the radiation beam can be aimed at the same spot for each treatment. This helps focus the beam on your cancer to protect nearby healthy tissue from the radiation. External radiation treatments usually are done 5 days a week for 4 to 8 weeks. If cancer has spread to your bones, shorter periods of treatment may be given to specific areas to relieve pain.
• Brachytherapy, or internal radiation therapy, uses dozens of tiny seeds that contain radioactive material. It may be used to treat early-stage prostate cancer. Needles are used to insert the seeds through your skin into your prostate. As the needles are pulled out, the seeds are left in place. The surgeon uses ultrasound to locate your prostate and guide the needles. The seeds release radiation for weeks or months, after which they are no longer radioactive. The radiation in the seeds can’t be aimed as accurately as external beams, but on the other hand, they are less likely to damage normal tissue. Once the seeds have lost their radioactivity, they become harmless and can stay in place indefinitely.

Sometimes treatment involves a combination of brachytherapy and low-dose external radiation. In other cases, treatment combines surgery with external radiation.

A newer form of radiation therapy, called 3D-CRT (three-dimensional conformal radiation therapy), allows doctors to use higher doses of radiation that are more accurately aimed to avoid damaging normal tissue. Use of 3D-CRT causes less serious side effects than radiation therapy. It is preferred over ordinary radiation therapy for the treatment of prostate cancer.

Before radiation therapy is scheduled, your doctor probably will order a bone scan and CT scan to find out whether the cancer has spread to distant parts of your body. If it has, your doctor may offer you the option of a clinical trial for treatment.

What To Expect After Treatment

Side effects may last only as long as the treatment, or they may continue and become chronic. Side effects include:

• An irritated rectum and an urgent need to pass a stool. This is called proctitis.
• An inflamed bladder and urination problems. This is called cystitis.
• An inflamed intestine and diarrhea. This is called enteritis.
• Being unable to have an erection. This is called impotence.
• Being unable to control urination. This is called incontinence.
• Painful urination. This is called dysuria.
• Bleeding from the rectum or blood in the urine.

Why It Is Done

Radiation therapy is used for:

• Cancer that has not spread in generally healthy men who are younger than 70.
• Cancer that has spread to the bones, is not getting better with hormonal treatment, and is causing pain.
• Cancer that has come back in the prostate after surgery.
• Additional therapy after surgery to destroy cancer cells that may remain, especially if all the cancer cannot be removed. This is done very rarely.

How Well It Works

For curing early stage prostate cancer, the evidence seems to show that radiation works as well as surgery. (No studies have directly compared radiation with surgery.)

For treating advanced prostate cancer that has grown beyond the prostate but not into lymph nodes or bones, external-beam radiation combined with hormone drugs can work better than surgery. This treatment often results in controlling cancer growth and in many years of disease-free survival.

For stage III prostate cancer, there is evidence that combining radiation with hormone drugs improves survival rates. One study that followed men with stage III prostate cancer for 20 years after radiation therapy showed that:

• 44% had no problems with prostate cancer for the rest of their lives.
• 47% eventually died of prostate cancer.

Risks

Side effects are common. Some men develop long-term problems that may have a significant impact on their quality of life. Long-term problems that can be caused by radiation treatment include:

• An irritated rectum and an urgent need to pass a stool. This is called proctitis.
• An inflamed bladder and urination problems. This is called cystitis.
• An inflamed intestine and diarrhea. This is called enteritis.
• Being unable to have an erection. This is called impotence.
• Being unable to control urination. This is called incontinence.
• Painful urination. This is called dysuria.

What To Think About

A newer form of brachytherapy involves placing radioactive material into the prostate and then removing the material.

This technique—also called high-dose rate, or HDR, brachytherapy—uses tiny tubes that are placed through your skin into your prostate. Radioactive material is injected into the tubes, which are left in place for 5 to 15 minutes. The tubes are removed at the end of each treatment. Generally, about 3 brief treatments are given over 1 or 2 days.

• Prostate cancer is common among men older than 65. Most cases are treatable because they are found with screening tests before the cancer has spread to other parts of the body. Most men do not die from it.
• The most common way to check for prostate cancer is to have a digital rectal exam and a prostate-specific antigen (PSA) blood test. A higher level of PSA may mean prostate cancer, but it could also mean an enlargement or infection of the prostate.
• Experts disagree on whether regular PSA testing is right for all men. Testing could lead to cancer treatment that can cause other health problems, especially loss of bladder control and not being able to have an erection. The decision to have a PSA test for prostate cancer depends on your doctor’s opinion and your preferences.
• Because other problems can also cause your PSA to be high, your doctor may do a biopsy to figure out the cause. A biopsy means your doctor takes a sample of tissue from your prostate gland and sends the sample to a lab for testing.
• Choosing treatment for prostate cancer can be confusing. You and your doctor may decide to treat your cancer with surgery or radiation. Or, if the cancer has not spread, you may be able to wait and watch to see what happens. During watchful waiting, you will have regular checkups with your doctor to see if your cancer has changed.

What is prostate cancer?

Prostate cancer is the abnormal growth of cells in a man’s prostate gland. The prostate sits just below the bladder. It makes part of the fluid for semen. In young men, the prostate is about the size of a walnut. It usually grows larger as you grow older.

Prostate cancer is common in men older than 65. It usually grows slowly and can take years to grow large enough to cause any problems. Most cases are treatable, because they are found with screening tests before the cancer has spread to other parts of the body. Although most men may die with prostate cancer, most men do not die from it.

Experts don’t know what causes prostate cancer, but they believe that your age, family history (genetics), and race affect your chances of getting it. Eating a high-fat diet may also play a part.

What are the symptoms?

Prostate cancer usually does not cause symptoms in its early stages. Most men don’t know they have it until it is found during a regular medical exam.

When problems are noticed, they are most often problems with urinating. But these same symptoms can also be caused by an enlarged prostate (benign prostatic hyperplasia). An enlarged prostate is common in older men.

See your doctor for a checkup if:

• You have trouble starting your urine stream.
• You have a weaker-than-normal urine stream.
• You cannot urinate at all.
• You have to urinate often.
• You feel like your bladder is not emptying completely when you urinate.
• You have to get up at night to urinate.
• You have pain or burning when you urinate.
• You have blood in your urine.
• You have a deep pain in your lower back, belly, hip, or pelvis.

How is prostate cancer diagnosed?

The most common way to check for prostate cancer is to have a digital rectal exam, in which the doctor puts a gloved, lubricated finger in your rectum to feel your prostate, and a prostate-specific antigen (PSA) blood test. A higher level of PSA may mean that you have prostate cancer, but it could also mean that you have an enlargement or infection of the prostate.

If your PSA is high, or if your doctor finds anything in the rectal exam, he or she may do a biopsy to figure out the cause. A biopsy means your doctor takes a sample of tissue from your prostate gland and sends it to a lab for testing.

Because many men have regular checkups, about 9 out of 10 prostate cancers are found in the early stages. The 5-year survival rate is almost 100%. The 5-year survival rate shows the percentage of men still alive 5 years or longer after diagnosis. It’s important to remember that everyone’s case is different, and these numbers may not show what will happen in your case.

Should you have regular tests for prostate cancer?

It is important to have regular health checkups, including a digital rectal exam. But experts disagree on whether regular PSA testing is right for all men. Testing could lead to cancer treatment that can cause other health problems, especially loss of bladder control and not being able to have an erection.

Talk with your doctor about the reasons for and against having a PSA test for prostate cancer. The decision to have a PSA test depends on your doctor’s opinion and your preferences.

How is prostate cancer treated?

Your treatment will depend on what kind of cancer cells you have, how far they have spread, your age and general health, and your preferences.

You and your doctor may decide to treat your cancer with surgery, radiation, hormone therapy, or a combination. Or, if the cancer has not spread and you are around age 70 or older, you may be able to wait and watch to see what happens. During watchful waiting, you will have regular checkups with your doctor to see if your cancer has changed.

Choosing treatment for prostate cancer can be confusing. Talk with your doctor to choose the treatment that is best for you.

How can treatment affect your quality of life?

Both surgery and radiation can cause urinary incontinence (not being able to control urination) or impotence (not being able to have an erection).

Nerves that help a man have an erection are right next to the prostate. Surgery to remove the cancer may damage them. Many times a special form of surgery, called nerve-sparing surgery, can be used to try to avoid damaging the nerves. But if the cancer has spread to the nerves, they may have to be removed during surgery.

These same nerves can also be damaged by the X-rays that are used in radiation therapy.

Drugs and mechanical aids may help men who are impotent because of treatment. Many men recover their ability to have an erection several months or years after surgery.

Introduction

This information will help you understand your choices, whether you share in the decision-making process or rely on your doctor’s recommendation.

Key points in making your decision

Radiation therapy and surgery are both used successfully to treat localized prostate cancer. The decision between surgery and radiation often is based on balancing the benefits with the possible side effects of each treatment option, including its effects on sexual activity, bladder control, and other aspects of your quality of life.

• If one of your biggest concerns is that prostate cancer might come back after treatment, you may want to have a radical prostatectomy. Your doctor will be able to evaluate your cancer more accurately by looking at it during surgery and taking tissue samples that can be tested. This information will help your doctor decide how likely it is that your cancer will return.
• If the possibility of having bladder problems and erection problems is a major concern, you may want to consider radiation therapy because these problems are less common with radiation than with surgery.

Treatment choices are different for prostate cancer that is more advanced (has grown or spread outside the prostate gland). For more information, see the topic Prostate Cancer, Advanced or Metastatic.

Medical Information

What is localized prostate cancer?

Prostate cancer is the abnormal growth of cells in the tissues of the prostate gland. Localized prostate cancer is cancer than has not spread beyond the prostate gland.

Prostate cancer is the most common cancer in men. Most men who get it are older than 65. If your father, brother, or son has had prostate cancer, you have a higher-than-average risk for developing the disease.

Unlike many other cancers, prostate cancer is usually slow-growing. Most men will die with prostate cancer but not of prostate cancer.

African-American men have higher rates of both prostate cancer and deaths caused by prostate cancer.

Early prostate cancer usually does not cause symptoms. When prostate cancer is diagnosed early, before it has spread outside the prostate gland, it may be cured with radiation or surgery to remove the prostate. As prostate cancer grows or spreads, symptoms may develop, including urinary problems (such as blood in the urine) and bone pain.

Prostate cancer that has grown through the prostate is called advanced prostate cancer, and treatment choices are different for that stage of cancer. For more information, see the topic Prostate Cancer, Advanced or Metastatic.

What are the treatment choices for localized prostate cancer?

Localized prostate cancer may be treated with radiation therapy, surgery, or drugs. You may also choose to watch and wait.

• Watchful waiting, also called surveillance or observation, means you are being monitored closely by your doctor, but you are not receiving active treatment such as surgery or radiation therapy as long as symptoms do not occur or get worse.
• Radical prostatectomy is an operation to remove the entire prostate as well as any nearby tissue that may contain cancer. It may be done as open surgery, by making a large incision, or as laparoscopic surgery, by making several very small incisions in the belly and using a tiny camera and special instruments to remove the prostate. Sometimes lymph nodes in the area also are removed so they can be checked for signs of cancer.
• Radiation therapy uses X-rays and other types of radiation to kill the cancer cells. This may be done with:
  • External-beam radiation, in which a machine aims high-energy rays at the cancer.
  • Brachytherapy, in which tiny pellets of radioactive material are injected directly into or near the cancer.
  • A combination of external radiation and brachytherapy.

If you are young and in good health or if your prostate cancer is fast-growing (higher-grade), your doctor probably will recommend surgery and/or radiation therapy to remove or destroy the cancer. Even though prostate cancer is usually slow-growing, it may eventually spread and cause symptoms and may threaten your life.

Age is not a reason to not have surgery or other treatment. But if you are around 70 or older, it is important to consider other medical conditions you may have, such as heart disease, as you make your treatment decisions.

When is prostatectomy used to treat prostate cancer?

Radical prostatectomy is most often recommended when a man is in good general health and has a life expectancy of at least another 10 years. In addition, there should be an expectation that the cancer can be entirely removed. If testing suggests that the cancer may have spread outside the prostate, or if you have other health problems that may add to the risks of major surgery, prostatectomy usually is not recommended.

Radical prostatectomy generally is effective in treating cancer that has not spread beyond the prostate gland. In follow-up PSA tests done in the years after prostatectomy, most men show no evidence of cancer.

Laparoscopic radical prostatectomy sometimes is used instead of open prostatectomy, which requires a larger cut in the belly.

A few surgeons do robotic-assisted laparoscopic radical prostatectomy. The surgeon controls the arms that hold the surgery tools and laparoscope. There are reports that it helps the surgeon see very well and work with less error.

When is radiation therapy used to treat prostate cancer?

Radiation therapy is most effective in treating cancers that have not spread outside the prostate. It may be used alone or combined with hormonal treatment. Rarely, it is used with surgery. Radiation therapy works as well as surgery for the treatment of early-stage localized prostate cancer.

What are the risks of prostatectomy?

A radical prostatectomy is a surgical procedure and carries all the risks of any major surgery, including heart attack, pulmonary embolism, bleeding, infection, and reactions to anesthesia or medications.

In addition, prostatectomy may cause bladder problems and erection problems. Increasingly, this surgery is done in a way that helps preserve the nerves that control erections. Most men who have nerve-sparing prostatectomies will regain the ability to have an erection within 4 to 6 months after surgery. It takes some men up to 2 years to regain full function.

More than 30% of men who have a radical prostatectomy develop bladder problems, ranging from a need to wear pads to occasional dribbling during stressful activities. Between 2% and 5% still have severe problems 6 months after having a prostatectomy. After 1 year, 92% no longer have problems.

Other possible complications include scar tissue that may narrow the outlet to your bladder and injury to the rectum or the ureters.

Evidence shows that the side effects of prostate surgery are lessened when the prostatectomy is done by a surgeon who is very experienced in this particular operation.⁷

What are the risks of radiation therapy?

About half of men who have external radiation develop erection problems within 5 years of treatment. Erection problems following radiation therapy increase over time.

Most other side effects generally go away when treatment is finished. In some cases, however, they may become chronic. Other side effects include:⁴

• An irritated rectum and an urgent need to pass a stool. This is called proctitis.
• An inflamed bladder and urination problems. This is called cystitis.
• An inflamed intestine and diarrhea. This is called enteritis.
• Being unable to have an erection. This is called impotence.
• Being unable to control urination. This is called incontinence.
• Painful urination. This is called dysuria.

Follow-up treatment

Any type of treatment for prostate cancer will need to be followed by regular checkups. Your follow-up care probably will include physical exams, prostate-specific antigen (PSA) tests to monitor PSA levels and measure the speed of any changes, digital rectal exams, and biopsies as needed to examine suspicious tissue.

Your Information

This discussion focuses your choice between:

• Having radiation therapy.
• Having a radical prostatectomy.

The decision about whether to have surgery or radiation treatment takes into account your personal feelings and the medical facts.

Prostate cancer is one of the most common forms of cancer in men. Over 230,000 American men are diagnosed with prostate cancer each year. In recent decades, there has been a steady increase in the incidence of prostate cancer but doctors are making progress in treatment and survival rates are improving. What are its symptoms? How do you know if surgery is the best treatment for you? The following information should help you better understand this condition.

What happens under normal conditions?

The prostate gland is about the size of a walnut. It is located between the bladder and the penis, and surrounds the urethra (the tube that carries urine from the bladder out through the penis). The prostate gland is part of the male reproductive system. The prostate is responsible for the production of semen, the milky white substance which nourishes the sperm. The semen is stored in small pouches, called seminal vesicles, which are attached to the prostate gland.

What is prostate cancer?

Prostate cancer is a disease that affects the cells of the prostate. It occurs when the normal process of cell growth within the prostate becomes abnormal. This causes uncontrolled cell growth resulting in a mass of tissue called a tumor. Like many cancers, the cause of prostate cancer is unknown. But doctors do know that it is more common as men age, in African-American men and men with a family history of the disease. Its growth is also enhanced by the male sex hormone testosterone. Prostate cancer is very common, with every man having a one in six chance of getting prostate cancer within their lifetime. Thanks to widespread knowledge about prostate cancer which has resulted in increased efforts at early detection (prostate cancer screening), about 80 percent of the men who are found to have prostate cancer have a disease which seems to be confined to the prostate and is therefore responsive to treatments, including surgery.

What are the symptoms of prostate cancer?

In its early stages, prostate cancer may not cause any symptoms. But as the cancer grows, the following symptoms may appear: frequent urination (especially at night), problems with urination (inability, weakened flow, pain, burning, etc.), painful ejaculation, blood in urine or semen and/or frequent pain or stiffness in the back, hips or upper thighs.

How is prostate cancer diagnosed?

Ideally, prostate cancer should be detected when it is so small that there are no symptoms. Early detection can be achieved by a digital rectal examination (DRE) and a PSA test. If either the DRE and/or the PSA is abnormal, a prostate biopsy is recommended. This biopsy uses an ultrasonic probe that is inserted into the rectum and a biopsy needle that is directed into various areas of the prostate gland. Believe it or not, this procedure is relatively painless and does not require hospitalization.

Once prostate cancer has been diagnosed by a prostate biopsy, the physician seeks to stage the disease; that is, to determine the extent of the cancer (i.e., the “T” stage) and whether it has spread to the lymph nodes and/or the bones. The clinical T stage is determined by the DRE and can be divided into the following categories:

T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed

T1b: Cancer is found after TURP but is present in more than 5% of the tissue removed

T1c: Cancer is found by needle biopsy that was done because of an elevated PSA

T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still appears to be confined to the prostate

T2a: Cancer is found in one half or less of only one side (left or right) of the prostate

T2b: Cancer is found in more than half of only one side (left or right) of the prostate

T2c: Cancer is found in both sides of the prostate

T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles

T3a: Cancer extends outside the prostate but not to the seminal vesicles

T3b: Cancer has spread to the seminal vesicles

T4: Cancer has spread to tissues next to the prostate (other than the seminal vesicles), such as the sphincter, rectum and/or wall of the pelvis

To determine if the cancer has spread to the lymph nodes or bones, the physician may order a CT scan of the pelvis, an MRI of the pelvis, and/or a bone scan.

In addition to clinical staging, the physician seeks to determine the so-called “aggressiveness” of the cancer. This is done in two ways. The first way is by determining the grade of the cancer; that is, how “angry” it looks under the microscope. Briefly, the most popular prostate cancer grading system is the Gleason system. Each area of cancer in the biopsy is assigned a Gleason grade between 1 and 5. The two most common Gleason grades within a biopsy are added together to give the Gleason score which is designated between two and 10. Gleason scores of two to four designate well differentiated cancers that tend to be slow growing. Gleason scores of five or six are moderately differentiated while Gleason scores of seven to 10 are poorly differentiated. The second sign of aggressiveness is the PSA level before biopsy. In general PSA levels less than 10 are ideal, levels between 10 and 20 are somewhat worrisome for more extensive disease while levels greater than 20 are worrisome though cure is still sometimes possible.

What is a radical prostatectomy?

A radical prostatectomy is the removal of the entire prostate, the seminal vesicles, and the tissue immediately surrounding them. Because prostate cancer may be scattered throughout the prostate gland in an unpredictable way, the entire prostate must be removed so that cancer cells are not left behind. The pelvic lymph nodes, small oval or round bodies located along vessels that filter lymphatic fluid, are usually the first site of any spread of the cancer beyond the prostate gland. Normally, these lymph nodes are also removed during the operation. Fortunately, you have many other lymph nodes, so your body will not miss these few.

When is surgery the best treatment for prostate cancer?

In general, prostate cancer surgery is best performed in patients with clinical stage T1 or T2 prostate cancer (confined to the prostate gland) and in selected men with clinical stage T3 disease. While there are no absolute cut-offs, men with a PSA level less than 20 and a Gleason score of less than eight have a higher likelihood of cure. In certain circumstances, patients with more serious parameters are offered surgery. Finally, prostate cancer surgery is usually restricted to men who have a 10-year or more life expectancy. Life expectancy is assessed by both patient age and health.

What are some risk factors associated with prostate cancer surgery?

Radical prostatectomy has the potential for both early and late complications. Early complications occur either at the time of surgery or shortly thereafter. Bleeding can occur in any major operation including radical prostatectomy. Some surgeons will recommend that the patient donate their own blood before surgery or to receive a hormone (epogen, EPO) that boost the patient’s blood count to reduce the risk of the patient requiring blood from an anonymous donor. Injury to nearby structures like the rectum and ureters (tubes that drain urine from the kidney to the bladder) is uncommon. Infection in the incision site and/or urinary tract is also rare. Lastly, deep venous thrombosis (blood clot) and pulmonary embolism (blood clot that goes to the lung) occur in approximately 2% of patients after radical retropubic prostatectomy.

Long-term complications after surgery are primarily urinary incontinence (urine leakage) and erectile dysfunction (impotence). Short-term incontinence after radical prostatectomy is common. Many men will require a protective pad for several weeks to months after surgery. Fortunately, most men will recover urinary control. Long-term (after 1 year) incontinence is rare with occurrence in less than 5 percent of all surgical cases. However, when it does occur, there are procedures that can solve the problem.

Erection of the penis occurs because of the stimulation through the cavernous nerves, which send signals to dilate the blood vessels in the penis, allowing it to fill with blood and become rigid. The two nerve bundles responsible for erection run along either side of the prostate, only a few millimeters away from the area where prostate cancer most commonly arises. Although preserving these nerves at the time of surgery is always possible, it is not always wise. The less tissue removed around the prostate, the greater the chance that cancer cells will remain. Since the primary goal of the operation is to remove all of the cancer, one or both of these nerves may have to be completely or partially resected. Unless both nerves are resected, the chance of recovering erectile function exists, but recovery may be slow. The average time until recovery of erections sufficient for intercourse is four to nine months, but in some men it takes longer. Erections usually improve with time, for as long as two to three years after the operation, because nerve fibers recover slowly. Of course, the operation will not make your erections better than they were before surgery, even if both nerves are spared. Even with full recovery, most men find the erections are a bit less firm and durable than before surgery. Younger men recover sooner than older men and those with stronger erections before the operation have a better chance of recovery than if the erections were weak.

Impotence, if experienced post-surgery, can also be treated by a variety of medications and/or technical devices like penile prostheses.

What are the different types of prostate cancer surgery?

Retropubic prostatectomy: During this procedure, the surgeon makes an incision through the lower abdomen that is about 3 to 4 inches in length. The surgeon can remove the prostate, surrounding tissue and pelvic lymph nodes (if necessary).

Perineal prostatectomy: During this procedure, the surgeon removes the prostate through an incision in the skin between the scrotum and the anus. In general, the perineal surgery is a little easier on the patient, but it may be somewhat inefficient if the cancer is serious and the lymph nodes need to be examined before the prostate is removed.

Laparoscopic prostatectomy is a type of ‘minimally-invasive’ surgery that uses several small incisions rather than one larger incision to remove the prostate. Through the small incisions surgical instruments, including a camera, are inserted. The camera allows the surgeon to view inside the abdomen and perform the surgery. Because the surgery uses smaller incisions, the patient may experience less pain and scarring and a faster recovery than with the retropubic approach. This procedure is technically demanding and requires a surgeon with special training to perform the operation successfully.

Robotic-assisted laparoscopic prostatectomy is similar to laparoscopic prostatectomy but rather than the surgeon directly holding the instruments, a robot serves as an interface between the surgeon and the instruments. Advantages for the patient are similar to laparoscopic surgery.

What can be expected after surgical treatment?

At the time of surgery, the urinary tract is sutured back together over a catheter, a thin flexible tube to drain urine. This gives the anastomosis, or union between the bladder and the urethra, time to heal completely. The catheter will remain in place for one to two weeks after the surgery. The catheter is removed on a return visit to the surgeon’s clinic, and exercises (called Kegel exercises) are begun by the patient to strengthen the urinary control valve. Urinary control (continence) can be immediate but usually takes several weeks to months to recover.

One or two suction drains are left beside the bladder, deep in the pelvic cavity, to drain any fluid that accumulates. The drains will exit from a small incision in your lower abdomen (or pelvic area). They help to decrease the risk of infection and pressure from fluid in the operated area. The drains are usually removed before you are discharged from the hospital.

While in the hospital, the patient begins his physical recovery. After the operation you will be in the Post-Anesthesia Care Unit (PACU) for a recovery period of several hours. You can have ice chips and water as soon as you are fully awake. Family members may also visit you in the PACU. You will be taken to your hospital room after the recovery period.

Fluids will be given to you through an intravenous (IV) line in a vein. The IV line will remain in place until you can tolerate fluids and food by mouth and you begin to eat a regular diet. You can progress to a clear liquid diet that evening or the next morning after the surgery. When your intestinal activity begins to recover, about 24 - 36 hours after the operation, you can eat solid food. Most people do not pass flatus (intestinal gas) for one to two days and do not have a bowel movement for four to five days. The goal during the first few days after your operation will be to prevent the breathing and circulation problems that can develop after any surgery. You must walk at least three to four times a day to help your breathing and circulation.

After the surgery, the surgeon reviews the final assessment of the removed prostate and (if applicable) the lymph nodes. Based on this “final pathology,” a follow-up plan is developed. If the pathology is especially serious (e.g., spread to the seminal vesicles or lymph nodes) additional therapy may be recommended. This may include radiation therapy and/or hormone treatment. If the pathology is not especially serious, the follow-up plan entails regular visits to a physician and a regular PSA test. The PSA level should be non-detectable.

Erectile function may recover soon after the operation or may take up to one year to return. Usually, if erections are not sufficient for intercourse at one month, additional therapies are used until the erections become sufficient. One does not lose the ability to have an orgasm. However the orgasm is “dry”—very little (if any) ejaculation comes out—so the ability to procreate is generally lost.

When can I resume normal activity after the surgery?

The time varies, but usually it is between three to six weeks.

Will I know if I am cured after surgery?

Not completely and it certainly varies depending on the severity of the cancer removed. In general, one must have PSA test values of less than 0.1 ng/ml for ten years before cure is certain.

I worry about potency but I am most afraid of incontinence. What are the odds?

That depends mostly on the surgeon and his/her experience. But age and your current level of continence and potency are also key factors. Usually, incontinence is temporary and does not last long although it can persist for as much as six to twelve months. With more experienced surgeons, the risk of permanent incontinence is rare after prostate cancer surgery.

Radiation therapy is used in a variety of settings to treat prostate cancer. Many prostate cancer patients are benefiting from radiation therapy techniques that decrease side effects and may lead to higher cure rates. What technique is appropriate for you? What are the risks? The following information should help answer these questions and prepare you to discuss radiation therapy with your urologist and/or oncologist.

What is radiation therapy?

Radiation therapy, also sometimes referred to as radiotherapy, is a general term used to describe several types of treatment, including the use of high-powered X-rays, placement of radioactive materials into the body or injection of a radioactive substance into the bloodstream. These various types of radiation treatments are used in a wide range of settings. These circumstances include primary treatment of localized prostate cancer, secondary treatment for cancer recurring within the region of the prostate and for relief of pain and other symptoms related to prostate cancer that has spread to other parts of the body.

What are the different types of radiation therapy?

External beam radiation therapy (EBRT): This is the most commonly used type of radiation therapy. The emergence of EBRT as a treatment for prostate cancer occurred in the 1950s with the development of high-powered X-ray machines called linear accelerators. Linear accelerators produce very powerful X-rays that penetrate deep into the body. These X-rays destroy tumor cells by damaging their DNA. Just as with a diagnostic X-ray, there is a brief exposure to the radiation, typically lasting several minutes. Once the treatment is over, there is no radiation in the patient’s body. The treatment is completely non-invasive, so there is no discomfort to the patient during the delivery of the radiation. EBRT is typically given once per day, five days per week. Primary treatment for localized prostate cancer usually requires about eight weeks of treatment.

Brachytherapy: Is also referred to as  “seed therapy” or a “prostate implant.” Brachytherapy involves the insertion of a radioactive material, commonly referred to as a source, into the body. Attempts to treat prostate cancer by placing radioactive materials into the prostate date back to the early 20th century. However, the lack of a reliable way to ensure that the radioactive materials were placed in their desired locations limited the use of brachytherapy to treat prostate cancer. In the 1980s, a technique was developed using ultrasound to guide the placement of tiny radioactive “seeds” into the prostate. This technique was first made available in the United States in the late 1980s.

There are two approaches to brachytherapy for prostate cancer: low-dose rate (LDR) and high-dose rate (HDR). Prostate brachytherapy is most commonly performed using the LDR technique. With LDR brachytherapy, the seeds are permanently placed into the prostate. The radiation is given off gradually over a period of months. HDR brachytherapy involves the temporary placement of a highly radioactive source into the prostate. The radiation treatment is given off over a period of minutes and typically repeated two or three times over the course of several days. Both LDR and HDR brachytherapy may be combined with EBRT.

An ultrasound study may be performed prior to the day of the procedure to ensure there are no bones interfering with the placement of needles into the prostate. The ultrasound probe is placed into the rectum to obtain pictures of the prostate and surrounding structures. This study is commonly referred to as a transrectal ultrasound (TRUS). The information obtained from the TRUS can also be used to generate a road map for seed implantation. Ultrasound imaging is typically used to define the prostate although newer approaches using CT scan or MRI may be used.

The LDR seed implant procedure is performed under anesthesia. Radioactive seeds (which are smaller than a grain of rice) are loaded in individual needles that are passed into the prostate gland through the skin between the scrotum and anus. As the needles penetrate the prostate they are seen on a monitor and can be accurately guided to their predetermined position. Once the position of the needle in the prostate matches the intended position the needle is withdrawn leaving the seeds behind in the prostate. The radioactivity of the seeds slowly decays during the months after the operation, and there are few long-term risks associated with this treatment.

Alternatively, HDR brachytherapy may be utilized to place a highly radioactive source temporarily into the prostate. Hollow plastic tubes called catheters are pre-positioned in the prostate using a technique similar to LDR brachytherapy. The patient is then awakened and typically two or three treatments are given over the next several days after which the catheters are removed. A remote control device is used to move the radioactive material, which rests for a calculated period of time at various positions within each catheter. A computerized treatment-planning program is used to determine the required time the radioactive material must stay at each position and the sequential positioning of the radioactive material at each location needed to achieve coverage of the prostate with the prescribed radiation dose.

Radionuclide therapy: Radioactive substances may also be used for treatment of prostate cancer that has spread to the bones. These radioactive drugs, known as radiopharmaceuticals or radionuclides, are injected intravenously (IV). These radionuclides are absorbed by the bones. The radiation given off is weak and does not penetrate very far into surrounding tissues and organs. A single injection is given in the doctor’s office after which the patient may return home. Additional injections may be given after a period of a few months once the effects of the prior injection have diminished.

What are some of the side effects of radiation therapy?

External beam radiation therapy (EBRT): The principal side effects of EBRT are related to the treated area. Common side effects of EBRT for prostate cancer include increased urinary frequency; mild burning with urination; weakened urinary stream; bowel irritability including mild diarrhea, gas, bowel urgency and tenderness; mild irritation of the skin around the rectum; lower blood counts; and fatigue. Diet modification and medication may be used to manage symptoms. Within one or two months following completion of treatment, most men notice that symptoms disappear. If changes in bladder or bowel function persist, they are typically mild. About 20 percent of men, however, do experience more significant long-term bowel irritability. Relatively rare complications include significant rectal bleeding, bladder irritability and urethral stricture. The loss of sexual function is also a relatively common side effect of radiation. However, the risk of erectile dysfunction (ED) following radiation varies widely, depending on use of other treatments such as hormonal therapies and the presence of other medical conditions that may affect sexual function.

Brachytherapy: Like EBRT, urinary irritation effects are very common. Obstructive symptoms including difficulty with urination are somewhat more common, however, as the prostate usually swells due to the insertion of needles into the prostate for the procedure. Approximately 5 to 15 percent of men will experience complete urinary obstruction within several weeks of the procedure requiring use of a catheter. Usually this problem disappears within weeks as the swelling subsides. Since the radioactive seeds are placed directly into the prostate, short-term bowel side effects are also relatively uncommon. However, as the front part of the rectum lies close to the prostate, over time bowel side effects similar to those of EBRT may occur. As with other radiation treatments, erectile dysfunction may occur.

Radionuclide therapy: The principal side effect of radionuclide therapy is a decrease in blood counts following treatment. Serious side effects including infection and bleeding are fortunately rare. However, an increase in pain may occur in the first several days or weeks after radionuclide therapy but can be managed with increased use of pain medications until the therapy begins to have its desired effect.

Which treatment is appropriate for each stage of prostate cancer?

In order to guide patients in choosing an appropriate treatment, doctors depend in part on an understanding of prognostic factors that suggest how extensive or aggressive the cancer may actually be. Such factors include digital rectal examination (DRE), PSA test, Gleason score and biopsy. Given the impact on prognosis that each of these factors may have, a combination of these factors is often more useful in understanding the potential for treatment success or failure than the use of any one factor alone. Within the realm of clinically localized cancer, a combination of these factors may be used to categorize patients as “low risk,” “intermediate risk” and “high risk” in terms of treatment failure. It is important to note that while prognostic factors are helpful in guiding treatment choices, there is no “cookbook” for selection of treatment, and other factors including age, overall health, urinary and bowel function and each patient’s own concerns about treatment need to be taken into account. Therefore, a thorough discussion with an individual’s urologist and oncologist is an important part of the decision-making process.

Prostate cancer that has not spread outside the immediate area around the prostate is often referred to as clinically localized cancer. An important distinction within the realm of clinically localized cancer is between prostate cancers confined to the prostate, referred to as organ-confined disease, and prostate cancer that has spread directly outside the prostate or into the seminal vesicles. The term “clinical” is applied to the setting where the determination that cancer has not spread to other sites, including lymph nodes or distant tissues and organs, is based on the findings of physical exam and diagnostic imaging tests that may include CT scan, MRI and/or bone scan. Proof of cancer stage is only obtained by invasive procedures such as surgical removal of the prostate or biopsy.

Treatment of low-risk clinically localized prostate cancer: The “low-risk” category generally includes patients with T1 or T2a cancer (normal examination or small abnormality limited to one side of the prostate), PSA less than 10 ng./ml. and/or Gleason grade less than or equal to six. These men are the most likely to have cancer confined to the prostate. Treatment options may include radical prostatectomy, external beam radiation therapy (EBRT), prostate brachytherapy or in certain circumstances observation. Given that almost all men with early detection of prostate cancer are without symptoms, the impact that treatment may have on quality of life is an important consideration.

Treatment of intermediate-risk clinically localized prostate cancer: The “intermediate-risk” category generally includes patients with bulky T2a disease, PSA greater than 10 ng./ml. but less than or equal to 20 ng./ml. and/or Gleason grade seven. In addition, recent studies have suggested that the extent of tumor on biopsy, often referred to as “percent positive biopsies” may help sort out which men in this category have outcomes more similar to the low or high-risk group. Men with just a little cancer found on biopsy might have outcomes more in line with low-risk patients while men with extensive cancer may be at greater risk for treatment failure. Overall, many men in this category may still have cancer confined to the prostate or along the edge of the prostate. The risk of spread outside the prostate is greater, however, than that for men with all low-risk features.

Given the many nuances in the presentation of intermediate-risk disease a number of treatment options may be appropriate. These options may include radical prostatectomy, EBRT, prostate brachytherapy or a combination of EBRT and brachytherapy. Androgen suppression therapy, commonly referred to as hormonal therapy, may also have a role in treatment of intermediate-risk prostate cancer when combined with radiation. While in men with high-risk prostate cancer the role of hormonal therapy with radiation is now established, the role in treatment of intermediate-risk prostate cancer remains to be fully defined. The results of two large clinical studies now completed are awaited in the next several years and hopefully will provide answers. In the meantime, a large study of previously treated patients at the Dana-Farber Cancer Institute did suggest a benefit to the addition of six months of hormonal therapy to EBRT in this patient group and therefore at least warrants consideration when radiation therapy is used.

Treatment of high-risk clinically localized prostate cancer: The “high-risk” category includes men with any of the following features: T2c, T3 or T4 disease (abnormal examination on both sides of the prostate or cancer that has spread outside of the prostate as determined by digital rectal examination), PSA greater than 20 ng./ml. and/or Gleason grade between eight and 10. Men in this category have a substantial risk of spread of cancer outside of the prostate. Nevertheless, some men in this category do have cancer confined to the prostate and therefore local treatment including prostatectomy may be appropriate. In men deemed to be at greater risk for disease spread, the most standardized radiotherapeutic approach to treatment is the combination of EBRT and hormonal therapy. Other treatments, including combination of EBRT and brachytherapy with or without hormonal therapy, may be considered but the long-term results of newer approaches remain to be fully defined. Two national studies started in the 1980s in the United States and a third large study in Europe all showed benefit to the use of hormonal therapy when combined with EBRT in men with various high-risk features. The European study was the first to show an overall survival benefit to the addition of hormonal therapy to radiation. Early results of another study indicate a benefit to longer duration hormonal therapy in men with high-risk prostate cancer. The use of chemotherapy in this group of men remains to be defined and is now the focus of a few national studies. Given the variety of presentations within the high-risk group, the right treatment for any given individual needs to be carefully considered in consultation with a urologist and/or oncologist.

Should radiation therapy be used as treatment following surgical removal of the prostate (prostatectomy)?

External beam radiation therapy (EBRT) may be used following prostatectomy when there is concern that cancer may remain in the region of the prostate. The use of radiation in this setting to destroy residual cancer has been sporadic for many years but only in the past five to 10 years has this approach started to gain widespread acceptance. The possibility of success with radiation following prostatectomy depends on the likelihood that any remaining cancer is confined to the region of the prostate where radiation is aimed. Therefore, the success rate varies widely depending on the presentation at the time treatment is contemplated. Diagnostic studies may be helpful but unfortunately no test can exclude the possibility of microscopic spread of the cancer. The physician must therefore assess a number of factors including the pretreatment prognostic factors, pathological findings at the time of prostatectomy and the post-surgical PSA history in determining which patients are most likely to have localized cancer versus cancer that has spread (metastasized).

How successful is radiation therapy in the treatment of metastatic cancer?

Radiation is often an effective treatment for preventing or managing symptoms of prostate cancer that has spread. External beam radiation therapy is typically very helpful in decreasing or relieving pain related to prostate cancer that has spread to the bones. A short course of therapy usually no longer then two weeks is sufficient in most cases. In other cases, radiation may be used to prevent debilitating symptoms related to the uncontrolled spread of cancer near critical organs or tissues.

How do I know if radiation therapy is the right treatment for me?

Talk to your urologist and/or oncologist. Every tumor is different, and it is important that your doctor evaluate all aspects of your tumor (such as localization, size, position) in order to prescribe the best treatment.

Will radiation therapy affect my sexual function?

Possibly. The risk of erectile dysfunction following radiation varies widely, and is dependent on the use of other treatments – such as hormonal therapy – and other medical conditions (such as diabetes and heart disease) that may affect sexual function.

Since the doctors aren’t removing my tumor, how will I know if it’s gone?

Followup testing is very important in order to be sure that the tumor has been killed. You may require regular ultrasound, a PSA test or a digital rectal examination to be sure that the cancer has not recurred. Sometimes, you may require additional treatment if the initial radiation does not work.

Currently, digital rectal examination (DRE) and prostate specific antigen (PSA) are used for prostate cancer detection. The age at which time screening for prostate cancer should begin is not known with certainty. However, most experts agree that healthy men over the age of 50 should consider prostate cancer screening with a DRE and PSA test. Screening should occur earlier, at age 40, in those who are at a higher risk of prostate cancer such as African-American men or those with a family history of prostate cancer. Men who are concerned about their future risk of prostate cancer should be screened to assess their base-line risk for developing the disease.

Digital rectal exam (DRE): The DRE is performed with the man either bending over, lying on his side or with his knees drawn up to his chest on the examining table. The physician inserts a gloved finger into the rectum and examines the prostate gland, noting any abnormalities in size, contour or consistency. DRE is inexpensive, easy to perform and allows the physician to note other abnormalities such as blood in the stool or rectal masses, which may allow for the early detection of rectal or colon cancer. However, DRE is not the most effective way to detect an early cancer, so it should be combined with a PSA test.

Prostate specific antigen test: The PSA test is usually performed in addition to DRE and increases the likelihood of prostate cancer detection. The test measures the level of PSA, a substance produced only by the prostate, in the bloodstream. The PSA should be less than 1.0 ng/ml The median for men in their 40s is 0.7 ng/ml. If the PSA is higher than the age-specific median, the risk of developing prostate cancer and the risk of having an aggressive form of the disease are increased. Accordingly, the patient might be well advised to have more frequent screening to detect a rise in the PSA level over time.

This blood test can be performed in a clinical laboratory, hospital or physician’s office and requires no special preparation on the part of the patient. Ideally, the test should be taken before a digital rectal examination is performed or any catheterization or instrumentation of the urinary tract. Furthermore, because ejaculation can transiently elevate the PSA level for 24 to 48 hours, men should abstain from sexual activity for two days prior to having a PSA test. A tourniquet or rubber strap is tied around the upper arm to mildly restrict the flow of blood and keep blood in the vein. Then, a needle with a tube-like container attached is inserted into a vein, usually in the bend of the elbow or the top of the hand. After a sufficient sample of blood is obtained, the needle is withdrawn, a bandage is placed on the puncture site and firm pressure is held until the bleeding stops. The entire test takes less than five minutes and produces only mild discomfort. After, the patient may experience slight bruising at the puncture site.

Very little PSA escapes from a healthy prostate into the bloodstream, but certain prostatic conditions can cause larger amounts of PSA to leak into the blood. One possible cause of a high PSA level is benign (non-cancerous) enlargement of the prostate, otherwise known as BPH. Inflammation of the prostate, called prostatitis, is another common cause of PSA elevation, as is recent ejaculation. Prostate cancer is the most serious possible cause of an elevated PSA level. The frequency of PSA testing remains a matter of some debate. The American Urological Association (AUA) encourages men to have annual PSA testing starting at age 50. The AUA also recommends annual PSA testing for men over the age of 40 who are African-American or have a family history of the disease (for example, a father or brother who was diagnosed with prostate cancer), or for those who are interested in an early risk assessment. Some experts have suggested that men with an initial normal DRE and PSA level of less than 2.5 ng/ml can have PSA testing performed every two years. However, a disadvantage of infrequent testing is that it limits the ability to detect a rapidly rising PSA level that can signal aggressive prostate cancer. Recently, several refinements have been made in the PSA blood test in an attempt to determine more accurately who has prostate cancer and who has false-positive PSA elevations caused by other conditions like BPH. These refinements include PSA density, PSA velocity, PSA age-specific reference ranges and use of free-to-total PSA ratios. Such refinements may increase the ability to detect cancer and these should be discussed with your physician.

Currently, it is recommended that both a DRE and PSA test be used for the early detection of prostate cancer. It is important to realize that in most cases an abnormality in either test is not due to cancer but to benign conditions, the most common being BPH or prostatitis. For instance, it has been shown that only 18 to 30 percent of men with serum PSA values between 4 and 10 ng/ml have prostate cancer. This number rises to approximately 42 to 70 percent for those men whose PSA values exceeding 10 ng/ml.

Prostate cancer is the most common non-skin cancer among American men. Public health records indicate that one in six American men will be faced with the diagnosis of prostate cancer during their lifetime. On average, about 189,000 men are diagnosed with prostate cancer each year with about 32,000 cases being fatal.

Prostate-specific antigen (PSA) is a protein almost exclusively produced by the prostate. Initially approved by the Food and Drug Administration for the purpose of monitoring the status of prostate cancer in 1986, PSA has become an integral part of prostate cancer screening along with a digital rectal examination (DRE). Men with prostate cancer often have elevated levels of serum PSA which correlate with the extent of cancer spread. With the introduction of PSA screening in the late 1980s, there has been a dramatic rise in the number of men diagnosed with localized prostate cancer; approximately 80 percent of newly diagnosed men are considered to have a clinically organ-confined disease that is potentially amenable to cure.

Once diagnosed, men with localized prostate cancer face a difficulty choosing amongst various treatment options. Several factors come into play when selecting an appropriate therapy. The stage (extent of local spread) and grade (aggressiveness) of prostate cancer, as well as competing medical co-morbidities and age at diagnosis, can all influence the decision regarding the choice of therapeutic intervention.

What are the current treatment options for men with localized prostate cancer?

Surgery (Radical Prostatectomy)

Surgery remains the primary option for many men with localized prostate cancer. Compared to other treatment methods such as radiotherapy and cryotherapy, a radical prostatectomy has an advantage of providing accurate local staging as well as assessment of pelvic lymph nodes through a detailed pathologic analysis. For patients with prostate cancer pathologically confined to the prostate, the chance of cure with surgery alone at 10 years (undetectable PSA) is more than 90 percent. The risk of cancer progression in men with extracapsular disease (cancer beyond the capsule of the prostate gland) and/or positive surgical margins is much higher ranging from 30 to 50 percent, and these patients may benefit from additional therapy such as external radiotherapy or androgen ablation. Although the incidence of surgical complications is quite low, the main postoperative issues remain urinary incontinence (5 percent) and erectile dysfunction (20 to 50 percent).

Open Radical Prostatectomy: In radical prostatectomy, the entire prostate gland is removed as a unit with the seminal vesicles and the nearest portions of the vas deferens. There are several different surgical techniques in performing a radical prostatectomy. The retropubic approach utilizes a midline incision below the umbilicus and allows simultaneous access to the prostate and pelvic lymph nodes. Based on precise anatomical delineation, the prostate gland can be safely removed with limited blood loss and preservation of the neurovascular bundles, which are responsible for maintaining erectile function. With the surgical steps clearly defined, the retropubic approach remains the most popular technique used by practicing urologists.

In perineal approach, the prostate is removed through a small semi-lunar incision in the perineum. By avoiding the pelvic vein complex, which can lead to significant bleeding in the retropubic approach, bleeding is usually minimal. Other advantages include precise urethra-vesical anastomosis (re-attaching the urethra to the bladder), a smaller incision, a shorter hospital stay and faster overall recovery. The main disadvantages are a higher incidence of rectal injury, difficulty of preserving the neurovascular bundles and a separate incision for pelvic lymphadenectomy. Typically, the perineal approach is preferred in obese individuals or those with prior lower abdominal surgery.

Robotic Assisted Laparoscopic Radical Prostatectomy: With recent advances in minimally invasive surgery and computer technology, the prostate gland can now be removed through a small one- to two-inch incision in the patient’s abdomen. Introduced in 2001, robotic prostatectomy utilizes a surgical robotic system—named the da Vinci Robot (Intuitive Surgical, Inc., Sunnyvale, CA)—to remove the prostate gland through laparoscopic access in which surgeons make keyhole openings rather than a single 6 to 8-inch midline incision. The da Vinci Surgical System is the first surgical robotic system approved by the Food and Drug Administration for performing robotically assisted, minimally invasive surgery.

The system incorporates a surgeon’s console and four interactive, robotic arms equipped with a camera and miniaturized surgical instruments. A surgeon controls the da Vinci’s arms from a remote console that precisely translates his hand, wrist and finger movements to the robotic arms inside the patient’s body while providing a three-dimensional view of those movements; the enhanced views offered by the da Vinci mean less chance of damaging surrounding nerves and tissue and a reduced risk of scarring. As a result, the incidence of postoperative erectile dysfunction and urinary incontinence appear to be much less than that of open radical prostatectomy. Furthermore, these small skin incisions result in less pain, less blood loss, faster catheter removal and a shorter hospital stay, with some patients returning to work as early as two weeks after the procedure. Patients who undergo this surgery generally leave the hospital the next day, and their overall recuperation time is reduced by half compared to that of standard open radical prostatectomy.

Despite its promising clinical results of robotic prostatectomy, the main caveat of this procedure is a steep learning curve in acquiring the surgical skills by the practicing urologists. It is estimated that the surgeon typically needs to perform 50 to 100 robotic prostatectomies before becoming facile with this approach.

Radiotherapy

Traditionally, radiotherapy has been reserved for an elderly population (over 70 years), men with locally advanced prostate cancer, and those with a short life expectancy (less than 15 years). Recent retrospective studies have shown that radiotherapy and surgery can offer comparable long-term outcomes up to 10 years, and as a result, the applicability of radiotherapy is no longer limited to the traditional indications. It is estimated that an equal number of patients undergo radical prostatectomy and radiotherapy at the present time.

Radiotherapy for prostate cancer can be divided into two modalities: external beam radiation (EBRT) and brachytherapy (PB). In external beam radiotherapy, a small amount of radiation is delivered incrementally to the prostate over a course of 6 to 7 weeks. The total radiation dose received is usually over 70 Gy. Currently, three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) is used to deliver high-dose radiation to the prostate while minimizing toxicity to the surrounding normal structures such as the bladder and rectum.

Prostate brachytherapy is a method in which radioactive seeds are implanted directly into the prostate. The seeds are delivered percutaneously into the prostate via the specially designed needles under real time ultrasound imaging. Both low-dose rate (but high-dose) permanent prostate seeds and high dose rate (HDR) temporary implants can be used to treat the gland successfully. PB is typically performed in an outpatient setting under either general or regional anesthesia. The procedure is usually well tolerated with minimal perioperative morbidity.

The relative effectiveness of EBRT and PB appear to be similar for early stage prostate cancer. Some patients are offered the combination therapy in which both EBRT and PB are utilized. For those with locally advanced cancer and/or highly aggressive cancer, androgen deprivation is also added to optimize cancer control.

The main side effects of radiotherapy include bladder and rectal toxicities which can result in urinary and bowel dysfunction. The incidence of erectile dysfunction also appears to be similar to that of surgery, ranging in 20 to 50%. The long-term effects of radiation to normal tissues remain unknown though an incidence of secondary malignancy appears to be higher in this population.

Cryotherapy

Cryoablation of the prostate is a treatment in which prostate cancer is eradicated by freezing the prostate gland. Cryotherapy has a similar setup to that of prostate brachytherapy in that special needles called “cryoprobes” are placed into the prostate transperineally under the guidance of transrectal ultrasound. Argon gas is then used to create an “iceball” which results in instant cell death within the predefined area. Real time ultrasound monitoring of cryoablation combined with the use of thermocouples prevents cryo injuries to the surrounding normal tissues. Although prostate cryotherapy is most commonly offered after failed radiotherapy, there is emerging data supporting its use as a single treatment option in men with newly diagnosed prostate cancer. Cryotherapy currently has a limited role as an initial therapy in newly diagnosed men. In addition, cryotherapy should only be employed in men with erectile dysfuction as virtually all patients experience impotence following cryotherapy.

Androgen Ablation Therapy

Prostate cancer is androgen sensitive in early stages. As such, androgen ablation can result in a dramatic reduction in cancer burden in the vast majority of cases. Unfortunately, most prostate cancers eventually progress despite effective medical or surgical castration and become androgen independent. In the management of localized prostate cancer, the role of androgen ablation is usually limited to a neoadjuvant or adjuvant setting. Two most common scenarios are 1) to reduce the prostate size prior to prostate brachytherapy and 2) to sensitize malignant cells to radiation during EBRT. For patients who are at high risk for cancer recurrence, a prolonged use of androgen ablation (up to 3 years) combined with EBRT has resulted in improved survival compared to EBRT alone.

Watchful Wait or Expectant Management

Prostate cancer is often a slowly progressive disease, and many men with prostate cancer will die from causes other than prostate cancer. Several nomograms (decision charts) have been established in order to distinguish men with clinically significant cancers from those with clinically indolent tumors. In general, older men with a limited life expectancy and those with low-grade, small-volume disease may benefit from expectant management, and a therapeutic intervention should be reserved for those demonstrating clinical progression.