Examples

Zoladex, Lupron, Trelstar Depot

How It Works

Luteinizing hormone-releasing hormone (LH-RH) agonists and gonadotropin-releasing hormone (GnRH) agonists are hormone therapy drugs that lower the production of testosterone in a man’s body. This drop in testosterone usually slows or stops the growth of prostate cancer for a period of time.

These drugs work by causing the pituitary gland to release the hormones that cause the testicles and adrenal glands to make testosterone. The pituitary gland then runs out of its hormones, and testosterone production drops.

These drugs are usually given by injection. They may be given once a month, once every 3 to 4 months, or once a year.

Side Effects

Side effects from LH-RH agonists and GnRH agonists may include:

• Erection problems.
• Decreased sex drive.
• Hot flashes.
• Thin or brittle bones (osteoporosis.)
• Spontaneous bone fractures.
• Breast enlargement (gynecomastia).
• Anemia.
• Fatigue.
• Weight gain.
• Loss of muscle mass.

Because these drugs work on the pituitary gland to release its hormones, the testicles may temporarily produce extra testosterone, causing a temporary growth in the tumor. This is called a tumor flare. Tumor flare may be accompanied by bone pain, urinary blockage, or other symptoms of rapid cancer growth. This may indicate that the drug is working, and although the tumor may grow initially, it will shrink over time. Tumor flare can be prevented by taking a different hormone drug called an antiandrogen before or during treatment with the LH-RH agonist.

One study found that treating prostate cancer with drugs to block androgen may increase the risk for gum disease.

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.

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.

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.

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.

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.

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.

What are androgens?

Androgens are male sex hormones responsible for characteristics such as facial hair, a deepened voice and increased muscle bulk. They come from two sources: the testicles (accounting for 90 to 95 percent of the male hormones) and the adrenal glands that produce several other androgens (accounting for 5 to 10 percent of male hormones).

Stimulating sexual development while also strengthening muscle tone and bone mass, testosterone is the most potent androgen. It is the product of a controlled process that begins when the hypothalamus, a cherry-sized control mechanism in the brain, releases a substance called luteinizing hormone-releasing hormone (LH-RH). It, in turn, stimulates the pituitary gland to manufacture and secrete luteinizing hormone (LH), the hormone that actually activates the testicles in producing testosterone.

What causes prostate cancer?

The prostate may be no bigger than a walnut, but it is a major male sex gland. Weighing just a few grams, it discharges substances into the semen as the seminal fluid passes through ejaculatory ducts connecting the seminal vesicles to the urethra.

Prostate cancer occurs when abnormal cells, fueled by male hormones such as testosterone, grow uncontrollably to form tumors. Since it frequently produces no symptoms in its earliest stages, you may only become aware of the cancer during routine screening. But the tumor eventually interferes with normal bladder and sexual function, producing both ejaculatory and urinary problems.

Diagnosis can be made using any or all of a variety of tests: digital rectal examination (DRE), prostate-specific antigen (PSA), biopsy, X-ray and other imaging techniques such as transrectal ultrasound and CT scan.

What is hormone therapy for prostate cancer?

If detected early, prostate cancer is curable. While treatment choices are still controversial, they are generally based on the stage of the disease. Surgical removal of the gland is used for early and confined tumors. Radiotherapy or small pellet radioactive implants (brachytherapy) is also used in patients with earlier stage prostate cancer or whose health makes surgery unacceptable.

When the prostate cancer is advanced, spreading to other parts of the body, treatment shifts to reducing the testosterone (male hormone) that feeds the prostate and its tumors. By depleting it, hormone therapy reduces symptoms and prevents further growth. But while hormonal manipulation causes prostate cancer to shrink in 85 to 90 percent of advanced prostate cancer patients, it does not cure the disease. In addition, the effects only last between 24 and 36 months.

Scientists believe the results are only short-lived because prostate cancer contains different genetically identical cells, some of which may respond to hormone deprivation, while others do not. It is those androgen-insensitive cells that scientists believe eventually grow, reproduce and ultimately cause death. The good news is that there is now evidence that hormonally sensitive cells may influence hormonally insensitive cells, decreasing their rate of progression.

Androgen deprivation is usually achieved by either surgery or medication, in what is commonly referred to as monotherapy because one method is used. Testosterone can be reduced by removing the testes during a bilateral orchiectomy — surgically opening the scrotum, and freeing blood vessels and nerves before cutting the testicles away from surrounding tissue. The other commonly used option, however, is chemical castration — injecting synthetic LH-RH agonists (blocks an action) or antagonists (stimulates an action) into the body every three to four months to suppress the natural production of testosterone.

A second option focuses on interfering with the effects of other adrenal hormones in addition to testicular testosterone. Referred to as complete androgen blockade (CAB), this treatment choice combines an orchiectomy or LH-RH antagonist with anti-androgens, drugs that block the effects of adrenal gland hormones by influencing a receptor in the nucleus of the prostate cancer cell. These medications include flutamide, bicalutamide and nilutamide. Some urologists add a third drug, finasteride, which blocks the conversion of testosterone to a more potent androgen, dihydrosterstosterone (DHT). In doing so, it deprives the cancer cells of an element needed for growth.

How effective is hormone therapy for prostate cancer?

While scientists and urologists agree on many aspects of hormone deprivation in the treatment of prostate cancer, there is still controversy concerning when and how to use these options. For instance, research continues in the debate over:

Monotherapy vs. complete androgen blockade (CAB): CAB has not yielded dramatic increases in survival for advanced prostate cancer patients. (At best, improvement is seven months.) But there is evidence that it may be more advantageous for patients with minimal disease, or those undergoing medical therapy. On the other hand, orchiectomy does not seem to benefit from adding the anti-androgen flutamide.

Early vs. late hormonal deprivation: Research has not provided a clear indication that early, compared to delayed, hormonal therapy improves survival. There is little argument, however, that a person with prostate cancer that has distant spread (e.g. to their bones) should be treated promptly to prevent potentially crippling effects like bone fractures and spinal cord paralysis. There is also evidence that prostate cancer patients whose disease has spread to the lymph nodes will encounter prolonged progressive-free survival and a better quality of life with early hormonal therapy. In fact, research suggests that men suffering from prostate cancer that has spread without symptoms experience fewer serious complications if they undergo hormonal therapy earlier, rather than later.

Continuous vs. intermittent androgen deprivation: The current hormonal therapy standard of care is to continue the treatment until the disease progresses or ends in death. In fact, most physicians prescribetestosterone-suppressing monotherapy even after other second-line hormonal agents or chemotherapies are introduced. But recently, research has focused on intermittent androgen deprivation (IAD), irregular hormonal therapy to possibly inhibit the molecular pathways that allow cells to become cancerous. The idea is that by stopping and starting therapy, IAD delays that transformation and may even improve quality of life. But until a current randomized National Cancer Institute trial yields its findings, scientists will not know which offers patients the best survival with the least complications — IAD or continuous hormonal therapy.

What can be expected after hormone therapy for prostate cancer?

While hormonal therapy can put your cancer in check, there are unpleasant side effects: nausea and vomiting, hot flashes, anemia, lethargy, osteoporosis, swollen and tender breasts and erectile dysfunction.

Also, if your cancer is resistant to hormonal treatments, your doctor may order chemotherapy, which consists of single drugs or a cocktail of several medications aimed at killing the cancer cells, even though this regimen causes numerous side effects.

While preliminary evidence suggests that hormonal treatment may improve cure rates when combined with radiation or surgery, that theory is still under investigation.

Can prostate cancer be cured with hormonal therapy?

At this time, there is no evidence that prostate cancer is cured with hormonal therapy. Withdrawing androgens, however, can keep the disease from progressing and relieve symptoms.

What is cryoablation?

Cryoablation is a form of cryotherapy for the prostate that involves the controlled freezing of the prostate gland in order to destroy cancerous cells. The damage caused by freezing occurs at several levels: molecular, cellular and whole tissue structure. Important factors influencing freezing injury are the rate of temperature reduction after the initiation of freezing, the time cells remain frozen and the subsequent heating rate during thawing.

The cells are not the only structures damaged during freezing. During cryoablation of the prostate, the surrounding connective tissue (stroma) and the smallest blood vessels (capillaries) are damaged and subsequently have an inadequate blood supply that is believed to slow the growth of cancer.

Who are the most suitable candidates for cryoablation of the prostate?

Suitable candidates for this procedure are patients who have organ-confined prostate cancer or those who have minimal spreading beyond the prostate.

How is the procedure performed?

Under anesthesia, an ultrasound probe is guided into the rectum. The prostate is imaged and its dimensions measured. An aiming grid software program is then activated and images of the prostate are projected on a screen. Under continuous monitoring with ultrasound imaging, cryoablation probes are placed at predetermined sites within the prostate. The freezing starts at the front part of the prostate by activating the front probes, followed by the middle and finally the back probes. This sequence allows continuous monitoring (by visualizing the freezing process through the transrectal ultrasound). Two freezing cycles are usually done. Between them, the prostate is allowed to thaw either passively or actively by using helium gas. If the prostate is more than 26 to 27 mm. long, an apical pullback maneuver is usually done to freeze the lower part of the prostate. Double freezing is performed again. Each of the commercially available cryosurgical systems has a different type of probe and placement strategy, but all aim to freeze the prostate, tumor(s) and surrounding tissue — except the urethral area. By keeping the urethra warm during prostate freezing, the urethral wall remains viable. This is important, as it minimizes the risk of urethral damage, obstruction and urinary incontinence. Using a flexible cystoscope, the bladder and urethra are examined meticulously for evidence of injury. If a probe is found piercing the urethra it is repositioned. A suprapubic catheter (a small catheter that is pierced into the bladder through a small opening in the lower abdomen) is inserted and secured in place by a suture. The urethral warming catheter is introduced through the urethra with its end in the bladder. During the procedure, the bladder is kept nearly full by keeping the open suprapubic catheter at a slightly higher level than the bladder. The urethral warming catheter keeps the urethra warm throughout the procedure and is kept active for about 20 minutes after complete thawing to prevent the urethra from freezing.

What can be expected after treatment?

The patient is usually kept overnight, allowed some food and encouraged to walk. The patient is usually discharged the next morning with a catheter in place for drainage.

The patient can attempt to urinate at first desire. Most patients are able to urinate in about 10 to 15 days but some may require longer recovery periods. When the patient is able to urinate well and empty the bladder satisfactorily, the suprapubic catheter is removed. Some surgeons use a urethral catheter instead of the suprapubic catheter. In that case, the urethral catheter is removed seven to ten days and trial unination is attempted. If the patient is unable to urinate, the catheter is reinserted for a few more days. Oral antibiotics are usually given for 10 to 14 days. Other symptoms and signs the patient may experience are generalized fatigue that usually persists for seven to 10 days, urethral discharge, scrotal swelling, numbness at the tip of the penis, passage of flecks of tissue, pain or burning sensation during urination and increased urinary frequency and/or urgency.

A PSA test is usually done at three months. Also, a prostatic biopsy may be done at three to six months to assess for prostate destruction and absence of viable cancer cells especially if PSA level is detectable. If the biopsy proves negative, PSA measurements are obtained monthly for one to two years, then every six months for the next one to three years and every year thereafter.

What type of results can be expected?

Five U.S. institutions reported their experience with the use of cryoablation. The results were compared to those of conformal radiotherapy and brachytherapy. Patients with a previous history of failed radiotherapy were excluded and androgen deprivation was determined and categorized separately. Patients were classified as low risk, moderate risk or high risk according to the cancer characteristics (stage of the disease, Gleason grade and PSA level). The procedure was not consistent at all institutions. Differences included the number of probes used, number of freeze cycles per patient, length of apical pullback maneuver, real-time monitoring during freezing and the system used for freezing. A total of 975 patients were studied, of whom 238 were low risk, 321 were moderate risk and 385 were high risk; risk was not determined in 38 patients. The five-year rate for non-rising postoperative PSA levels for low and medium risk patients ranged between 60 and 76 percent and for high-risk patients it was 41 percent. Only about 18 percent of the patients were found to have a positive biopsy following the procedure. These results are encouraging and may place cryoablation therapy between radical prostatectomy and radiotherapy in effectiveness.

What are the risks associated with this procedure?

New technological advances have resulted in a significant reduction of the rate of complications. Improved urethral warming devices have minimized urethral complications. Better spacing of the probes now contributes to the effectiveness and safety of the procedure. Improved monitoring of the freezing with transrectal ultrasound is also helpful. However, some risks still exist. Perhaps one of the most critical is the risk of urinary rectal fistula, which creates a channel between the prostate or the bladder and the rectum and may cause diarrhea due to urine in the rectum and possibly severe infection due to bacteria in the bladder. There is also a high incidence of erectile dysfunction. Other complications, although uncommon given technological advances, include urinary incontinence, urinary retention requiring transurethral resection of the prostate (TURP) and inflammation of the testicle. Almost all patients have a temporary need for a catheter to empty the bladder for an average of 15 days. Permanent, severe incontinence is rare (approximately 1 percent) and other rare complications include prostatic abscess and permanent penile numbness.

What are the advantages and disadvantages of cryoablation of the prostate?

Cryoablation therapy offers:

• a minimally invasive procedure
• favorable success rate and complication rates
• a short recuperation period
• procedure can be repeated if the first cryoablation has failed
• radiation therapy or radical prostatectomy is still an option if the procedure fails
• less than half the cost of the traditional treatment

The disadvantages are:

• insurance may not cover this procedure
• extensive experience and training by the surgeon are required

Is cryoablation therapy ever used after other prostate cancer treatments have been tried?

Yes. An important use of cryoablation therapy is for patients who fail or develop recurrence after radiation therapy.

What is the prostate?

The prostate, a part of the male reproductive system, is about the same size and shape as a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum, and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What is prostate cancer?

Prostate cancer is a significant health care problem in the United States due to its high incidence. It is the most common cancer in men affecting approximately 234,000 American men each year with approximately 27,000 of diagnosed men dying each year. Prostate cancer is different from most cancers in that a large considerable percentage of men, particularly older men with a shorter life expectancy, may have a “silent form” of this cancer—it will not cause symptoms or spread beyond the prostate gland during their lifetime. Sometimes this cancer can be small, slow growing and present limited risk to the patient. Clinically important prostate cancers can be defined as those that threaten the well-being or life span of a man.

What is chemotherapy?

Although surgery and radiation therapy remove, destroy or damage cancer cells in a specific area, chemotherapy works throughout the body. Chemotherapy can destroy cancer cells that have metastasized, or spread to parts of the body far away from the primary (original) tumor. Chemotherapy is the use of specific drugs that can destroy cancer cells. The drugs circulate throughout the body in the bloodstream and can kill any rapidly growing cells, including potentially non-cancerous ones. Chemotherapy drugs are carefully controlled in both dosage and frequency so that cancer cells are destroyed while the risk to healthy cells is minimized. Often, it is not the primary therapy for prostate cancer patients, but may be used when prostate cancer has spread outside of the prostate gland or in combination with other therapies.

What are some of the side effects of chemotherapy?

Common side effects of chemotherapy depend on the type of drug used, dosage and length of treatment. The most common side effects are fatigue, nausea and vomiting, diarrhea, hair loss and increased susceptibility to infection. To minimize the side effects, chemotherapy drugs are carefully monitored according to the amount and number of times they are administered by your physician. Supportive medication is also given to further help offset the side effects caused by the drugs. For instance, new drugs to prevent nausea and vomiting can minimize these side effects. Most side effects disappear once chemotherapy is stopped.

How is chemotherapy administered?

The drugs used for chemotherapy can be administered directly into a vein while others may be taken orally. Some of the drugs must be given in the doctor’s office or clinic; others can be administered while the patient is at home. Hospitalization is rarely needed unless side effects occur.

What are some of the new chemotherapy drugs currently being tested?

Several promising new anticancer drugs are under study and are being added to surgery or radiation therapy for men with stage III (cancer has spread to surrounding tissue or seminal vesicles) prostate cancer. Chemotherapy is also being tried in conjunction with hormone therapy for men whose advanced cancers are no longer responsive to hormonal therapy alone.

Historically, chemotherapy has not proven particularly effective against slow-growing prostate cancer cells. However recent studies show significant promise in advanced prostate cancer. There are now two published clinical trials in which men with metastatic, advanced prostate cancer progressing despite hormone therapy received a chemotherapy drug called docetaxel or mitoxantrone. In each of these trials, symptom improvement, substantial PSA reduction, and increased survival were significantly more likely to occur in the group of men who received docetaxel versus another drug called mitoxantrone. Thus the current standard of care is to use docetaxel as the first chemotherapy drug in the treatment of metastatic prostate cancer.

A number of interesting new drugs are being developed to combine with docetaxel. They include bevacizumab (Avastin), atrasentan (Xinlay) and calcitriol (DN 101) and GVAX In preliminary studies, each of these drugs, when combined with docetaxel, caused substantial PSA declines in more than 50 percent of men as well as symptomatic improvement in men with advanced disease. The four combined drug regimens are now being compared to docetaxel alone in four separate phase III clinical trials. All men with metastatic prostate cancer who are considering chemotherapy are encouraged to enter one of those 4 trials.

The encouraging results of these trials have caused the initiation of other studies investigating various chemotherapy regimens in both early and late prostate cancer. For example, there are many studies underway adding docetaxel to surgery or radiation therapy for men with stage III (cancer has spread to surrounding tissue or seminal vesicles) or high-risk prostate cancer. Other studies will determine if vaccines which induce immune responses against prostate specific targets will improve outcomes for men with advanced cancers. In addition, there are new drugs in clinical trials which will target the testosterone (androgen) signaling pathway in advanced prostate cancer, as more evidence suggests that many cancers remain sensitive to better androgen deprivation, including abiraterone, and MDV3100, both of which are new approaches to androgen deprivation.

For patients whose disease has progressed despite docetaxel chemotherapy, there are currently no FDA approved agents and participation in clinical trials is highly encouraged. Current options include best supportive care, alternative chemotherapeutic regimens, bisphosphonates (bone-strengthening agents), radiation therapy, additional hormonal manipulations, and steroids. One agent being evaluated in phase III trials is an oral form of chemotherapy called satraplatin, and while it has shown early signs of benefit in terms of delaying progression, we await more long term survival results in 2007.

What are the advantages and disadvantages of chemotherapy? How do I know if it’s right for me?

Chemotherapy provides an additional means of relieving the symptoms of advanced prostate cancer possibly by reducing pain and slowing tumor growth. However, because chemotherapy is an aggressive treatment with side effects, it is important to discuss your treatment options with your doctor.

Can I take other medicines while I am getting chemotherapy?

Some medicines may interfere with the effects of your chemotherapy drugs. To ensure that your treatment is the most effective that it can be, tell your doctor about any and all prescription and non-prescription medicines you are taking. Your doctor will tell you if you should stop taking any of these medicines before you start chemotherapy. After your treatments begin, check with your doctor before taking any new medicines or stopping the ones you already take.

Can I continue with my normal activities while I am getting chemotherapy?

Whether you can continue work, school and other activities depends on your treatment and how it affects you. Hospitalization is not needed for the treatments and most people are able to continue their activities during treatment. You might be able to schedule your treatments late in the day or before the weekend to minimize their interference with your activities.