Prostate Cancer - Facts & Treatment

CANCER OF THE PROSTATE: FACTS AND TREATMENT

Fletcher C. Derrick, Jr., M. D. - Urology Offices
641 St Andrews Blvd
Charleston, South Carolina 29407

843-766-9747

INTRODUCTION:

It is estimated that about 180,000 men in the United States will be diagnosed as having cancer of the prostate per year. This number will probably rise simply because men have become more aware of prostate cancer and are seeking examinations and treatment sooner. As recently as fifteen years ago, when the diagnosis of cancer of the prostate was made, the cancer had already spread outside the prostate gland, making cure virtually impossible. With 1, increased awareness, 2, the PSA (prostatic specific antigen), a blood test which is specific for prostate diseases and particularly cancer of the prostate, 3, patients coming in for the rectal examination, and 4, ultrasound of the prostate, ( a painless rectal examination of the prostate done in the office), Urologist are finding the cancer earlier.

If the cancer is found in the early stages, and if by all testing it has not spread outside of the prostate gland itself, with surgical removal of the prostate, there is a 93% , 10 year disease specific survival.

WHO GETS CANCER OF THE PROSTATE?

Cancer of the prostate occurs in men, rarely before the age of 50 and very often after the age of 80. It has been estimated that if all men over the age of 80 were tested, as many as 70% would be found to have prostate cancer. The cancer that occurs in the 80 plus year old man seems to be a less aggressive cancer than those in the younger men. Because of this fact, Urologist feel that if the cancers that occur in the younger men can be found early enough, then a good chance of cure can be offered. The incidence of cancer of the prostate is about 1 in 10 or 11 men. If a man has a grandfather, father, or brother who had cancer of the prostate, then the incidence doubles to about 1 in 5 or 6 men. Men of the Black race have a higher incidence of prostate cancer: about 1 in 9.

WHEN, AND WHO SHOULD BE TESTED FOR CANCER OF THE PROSTATE?

All men in the 50 - 55 age group should go for PSA and rectal exam by their Urologist or Family Physician, and then have the testing yearly.

All Black men and men with a family history of cancer of the prostate should have their testing starting as early as 40 years of age, continuing thereafter on a yearly basis.

As a service to the community, Urologist at various hospitals participate in PROSTATE AWARENESS WEEK. This is usually in September of each year. If patients do not have a regular Family Physician or Urologist they can go for the exam and PSA at these times. This testing is free, and if the test are suspicious or positive, a Urologist can be found who will help with further testing and determining if the patient has cancer or not.

HOW ACCURATE IS THE PSA?

The PSA is very specific for prostate disease. It can be elevated with 1, cancer, 2, so called benign prostate hypertrophy, (which is very common in the aging male), and even 3, acute prostatitis. We do not recommend that the PSA be done as a screening test alone. A rectal exam of the prostate is necessary also, for the most accurate assessment of the gland and any problems which may be present. The "split PSA" method is now being done in those cases where the PSA is between 4 and 10 with no nodule or irregularity on the prostate exam.

WHAT CAUSES CANCER OF THE PROSTATE?

There is no known specific cause of cancer of the prostate. Several theories exist, from excessive smoking to excessive fat in the diet. The most likely reason is some changing hormonal pattern or some genetic influence in the aging male.

WHAT ARE THE SYMPTOMS OF CANCER OF THE PROSTATE?

Very early cancer of the prostate has no symptoms. Although not specific, certain symptoms may include:

1. Frequent urination.

2. Weak urinary stream.

3. Painful urination.

4. Pain in the prostate area just before or just after climax.

5. Blood in the urine or semen.

6. Persistent pain in the low back or hips.

7. Loss of sex drive.

Some of these symptoms are indications of late cancer of the prostate, or can be symptoms of other problems. I stress once again the importance of the yearly PSA and rectal examination, and visiting a physician if you have any of the above symptoms.

HOW IS THE DIAGNOSIS OF CANCER OF THE PROSTATE MADE?

The diagnosis is made by examining tissue taken from the prostate by either a needle biopsy of the prostate or through an operating type cystoscope. The Urologist will most likely perform a transrectal ultrasound of the prostate, This procedure is usually done in the office. It is uncomfortable but is usually not painful. Certain instructions will be given to you prior to and after the ultrasound exam.

AFTER THE DIAGNOSIS IS MADE, WHAT IS THE NEXT STEP?

Once the diagnosis is made, the Urologist will probably order some other testing, usually a bone scan and CT scans or in some cases a MRI scan. Sometimes, testing of the bone marrow is indicated.

Testing the lymph nodes may also be indicated and this may require an operation or use of the laparoscope. All of this testing is done to determine if the cancer is still confined to the prostate or has spread to some other part of the body. These tests are necessary because once the type, location, and extent of the cancer is known by the Urologist, then a treatment plan can be recommended. The technical terms for these tests are staging and grading of the cancer.

Staging is the extent of the cancer in your prostate gland or body.

Stage A or T1: Cancer that is usually not felt by exam, may or may not have an elevated PSA, or is discovered when tissue is removed at surgery of the prostate.

Stage B or T2: A nodule felt at rectal exam, but with the cancer still confined to the prostate gland. May of may not have an elevated PSA.

Stage C or T3: The cancer has grown into nearby tissues of the bladder or rectum.

Stage D or T4 or M1: The cancer has spread to some other part of the body...in the case of cancer of the prostate, most often bones or lymph nodes.

Grading is done by the Pathologist as he looks at the cancer specimens under the microscope.

The Gleason's grading system is used by most Pathologist, grading the cancer from 1-5. Grade 1, is the most favorable cancer, Grade 5, is the most malignant.

The stage and grade of the cancer must be known in order to discuss a treatment plan.

WHAT FACTORS DETERMINE A TREATMENT PLAN?

Age of the patient.

Health of the patient.

PSA.

Stage of the cancer.

Grade of the cancer.

Bone scan, CT, MRI etc results.

Lymph node or bone marrow results.

Desires of the patient and his family.

USING THE ABOVE FACTORS, HOW DO WE START TREATMENT?

As a general rule, men 70 years of age or younger, in good health, with low to medium grade cancer confined to the prostate gland, are best treated with surgical removal of the prostate. Now I quickly remind you that other factors play a part in the decision, and each patient must be treated individually. A good conversation between the patient and his family, and his Urologist, is the best way to start to try to understand the problem and what will be best for each person.

WHAT TREATMENT PLANS ARE AVAILABLE?

1. Close observation with treatment later when troublesome symptoms develop.

2. Total surgical removal of the prostate and seminal vesicals.

        Abdominal Surgery

        Perineal Surgery

        Laparoscopic Surgery with or without the Robot.

 3. Radiation treatment:

          Brachytherapy,  (placement of internal seed).

          External beam radiation.

4. Cryoablation of the prostate (freezing).

5. Hormone therapy.

6. Chemotherapy.

WHAT CAN ONE EXPECT IF CLOSE OBSERVATION IS DONE?

This depends on the grade and stage of the cancer and the general condition of the patient. Close observation is usually recommended for patients who are elderly, in poor health and/or the cancer poses no immediate problem. Said another way, this type treatment may depend on the life expectancy of the patient. If other health problems are more likely to cause problems before the cancer of the prostate does, then, "no treatment right now", may the best treatment for the cancer.

WHAT CAN ONE EXPECT WITH TOTAL REMOVAL OF THE PROSTATE GLAND AT SURGERY?

There are two methods of total prostate removal: 1, Radical retropubic prostatectomy, and 2, Radical perineal prostatectomy. In the retropubic type, a midline abdominal incision is made below the naval. The lymph nodes can be examined through the same incision. In the perineal type, separate incisions may be done on the abdomen to take some lymph nodes for testing, and if they are negative then the prostate is removed through an incision between the scrotum and the rectum.  In Laparoscopic Surgery, healing time and hospital time will be shortened.  The Robot is being used by many medical centers now.

With the radical prostatectomy, by either method, there is a large possibility that a man will lose his potency; not his sex drive, but his ability to get an erection. There is a variation on the operation which is called a "nerve sparring" prostatectomy, after which a man may have his potency preserved about 50% of the time.

I always tell my patients, that even if they lose potency while we are curing the cancer with the necessary surgery, there are several methods of regaining an erection.

After radical prostatectomy, there is also about a 2-3% chance that one will have some trouble with urinary control. I always tell my patients that 95% of them will have 95% control within 3 months. There are exceptions to this guideline...some dry in a week...others taking 4-6 months to gain complete control. If one does not gain complete control, there are medications which may help, collagen implants, microcarbon implants and even a silicone sphincter implant available.

WHAT CAN ONE EXPECT IF X-RAY TREATMENT IS DONE?

External beam radiation therapy usually is given daily for about 30-35 treatments. One may feel lousy and weak during the treatment. If needles and radiation seed are used, you may have an incision or in some centers, the needles and seed are placed through the skin. At times a combination of seed and external beam therapy is used.

There is less chance of impotency with radiation therapy, but the long term effects of the radiation on the bladder and rectum can be very annoying. A combination of surgery and radiation therapy is sometimes necessary.

Radiation therapy is also useful in treating areas of spread, particularly painful bone sites.

WHAT IS THE STATUS OF CRYOABLATION (FREEZING) OF THE PROSTATE CANCER?  (Also see the page on Cryoablation of the Prostate)

About 25 years ago, some investigation was done on freezing of prostate cancer. The results were unpredictable. With a newer technique using Argon and ultrasound guided probes, freezing of prostate cancer is once again being used. At this writing, 10 year data is available. Some recent reports are very favorable and lead us to believe cryoablation will be better than radiation. We are using the technique of freezing twice with a thaw in between. The side effects of freezing can be some degree of impotence, temporary numbness of the penis, but only a small chance of incontinence, since the new technique also includes placement of thermal probes to monitor vital areas. The one good aspect of freezing is that it only requires an overnight stay in the hospital and one can return to work in a few days. As of July 1, 1999, insurance companies and Medicare are paying for the treatment, since they no longer consider it an investigational therapy.  As of July 1, 2001, Medicare will pay for Cryoablation of the Prostate for salvage in radiation failure patients

IF NEEDED, HOW DOES ONE RECEIVE HORMONE THERAPY?

Since testosterone is the "gasoline that feeds the fire of cancer of the prostate", there are several methods of lowering or eliminating the hormone. 1, orchiectomy, (removal of the testicles), 2, female hormones by either "shot" or pill, 3, a new type hormone which stops the pituitary gland from stimulating the testes, (Zolodex or Lupron), 4, antiandrogens, medications which act against testosterone (Eulexin, Casodex, or Nilandrone).

With any of the hormone treatments, one can experience hot flashes, and some breast development. Also, with the hormone therapy, sex drive and potency will disappear.

Hormones are occasionally used prior to surgery, x-ray treatment, and cryoablation to "down-stage" the cancer.

WHEN IS CHEMOTHERAPY USED?

Chemotherapy is used when the hormone therapy seems to not be working. Several different drugs have been used with varying results, some very good and some not so good.

WHAT CHANCE OF CURE DOES ONE HAVE WITH CANCER OF THE PROSTATE?

If one has low grade, low stage cancer of the prostate, according to the latest results of several centers in the United States, the following can be stated:

1. Surgery: A 93% 10 year disease specific survival.

2. Close observation: Usually recommended for patients who are older or have other serious medical problems. A 70-75% 8-10 year survival. Bear in mind that left untreated, cancer of the prostate will probably spread within 3-5 years. At that time hormone therapy can put the cancer in remission for another 3-5 years. Most patients who select observation as their form of treatment die with the cancer, not of it.

3. Radiation: External beam irradiation seems to give about a 60% 10 year, disease specific survival. This may have improved with conformal treatment and with the "Cyberknife".  The newer applications of using Iodine-131 and Paladium-203 seeds into the prostate are showing results of 73% to 83% 10 year survival without cancer.

4. Cryoablation (freezing) : The treatment results are being followed very closely, but the most recent data indicates that it will better than external beam radiation therapy alone and as good as or better than the seed implantation, interpreted (82-85%) 10 year survival without recurrence).

WHAT SHOULD ONE DO WHEN HE IS TOLD HE HAS CANCER OF THE PROSTATE.

Of course, consult with the Urologist who made the diagnosis. In my opinion, one of the best things one can do is to get a second opinion. This second opinion may be the best time and money you will every spend. Nothing may change in your mind about the proposed treatment, but you will at least be exposed to a second approach and to a second personality.

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Dr. Derrick is a Board Certified Urologist and a Fellow of The American of Surgeons with many years experience treating cancer of the prostate and other diseases of the male reproductive and urinary systems. He is Clinical Professor of Urology at The Medical University of South Carolina with a private practice in Charleston, South Carolina. He was formerly Professor and Chairman of Urology at George Washington University in Washington, D. C.

Original: August 1993

Revised: March 14, 2008

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