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Upplýsingar fyrir sjúklinga sem greinast með blöðruhálskirtilskrabbamein

Upplýsingar fyrir sjúklinga sem greinast með blöðruhálskirtilskrabbamein

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  • Prostate Cancer NCCN Guidelines for Patients™ Version 1.2011 Also available at NCCN.com
  • Table of contentsPart 1 About these guidelines..................... 4 Part 4 Treating prostate cancer................. 271.1 NCCN Guidelines for Patients™ 4.1 Your treatment team1.2 NCCN Clinical Practice Guidelines in Oncology ® 4.2 Risk assessment1.3 NCCN Guidelines Panel Members 4.3 Active surveillance1.4 How to use this booklet 4.4 Treatments for prostate cancer 4.5 What are clinical trials?Part 2 About prostate cancer....................... 82.1 What is the prostate? Part 5 Treating signs and symptoms........ 412.2 What is prostate cancer? 5.1 Common side effects2.3 Am I at risk? 5.2 Symptom control2.4 Prostate cancer screening 5.3 Supportive carePart 3 Tests of prostate cancer................. 16 Part 6 Beyond usual treatment ................. 483.1 Do I have prostate cancer? 6.1 Aren’t there other treatments?3.2 Tests after diagnosis 6.2 What else can I do?3.3 The pathology report 6.3 Caring for caregivers3.4 Gleason score3.5 Stages of prostate cancerNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 2
  • Table of contentsPart 7 A step-by-step treatment guide...... 54 Part 8 How do I choose my treatment?.... 797.1 Clinical assessment of prostate cancer 8.1 I have to choose?7.2 Treatment options by risk group 8.2 Opinions of doctors, partners, and others 7.2.1 Very low recurrence risk 8.3 Getting a 2nd opinion 7.2.2 Low recurrence risk 8.4 Benefits and downsides of treatment options 7.2.3 Intermediate recurrence risk 7.2.4 High and very high recurrence risk Part 9 Dictionary.......................................... 84 7.2.5 Metastatic disease7.3 Follow-up tests Part 10 Tools.................................................. 92 7.3.1 Active surveillance 10.1 Questions to ask about testing for prostate cancer 7.3.2 Monitoring after treatment 10.2 Questions to ask about treating prostate cancer7.4 Persistent or recurrent prostate cancer 10.3 Questions to ask about clinical trials 7.4.1 Salvage treatment after primary prostatectomy 10.4 Suggestions for taking care of yourself 7.4.2 Salvage treatment after primary radiotherapy 10.5 Suggestions for taking care of caregivers7.5 Systemic therapy for prostate cancer 10.6 Personal treatment record 7.5.1 First-line hormone therapy 7.5.2 Castration-recurrent prostate cancer without metastases 7.5.3 Castration-recurrent prostate cancer with metastases7.6 Small cell prostate cancer © 2011 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines for Patients™ and illustrations herein may not be reproduced in any form for any purpose without the express written permission of NCCN.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 3
  • Part 1: About these guidelines NCCN Guidelines for Patients™1.1  NCCN abbreviations and acronymsNCCN aims to offer the most current and trustworthycancer information to patients and their families in a NCCN®manner that is easy to understand. To reach this goal,  National Comprehensive Cancer Network®NCCN has developed the NCCN Patient Guidelines™.These guidelines are meant to help patients talk with NCCN Patient Guidelines™doctors and make the best decisions possible. They are NCCN Guidelines for Patients™based on the NCCN Guidelines® that are developed for NCCN Guidelines®doctors. For more information on NCCN or the most NCCN Clinical Practice Guidelines in Oncology®recent NCCN Patient Guidelines, visit NCCN.com1.2  NCCN Clinical Practice Guidelines in Oncology ®The NCCN Guidelines are the most complete and on the guidelines that match their area of expertise.frequently updated clinical practice guidelines in Altogether, members volunteer more than 15,000 hoursmedicine. They give a step-by-step course of action that each year to revise the NCCN Guidelines. Their effortmany cancer doctors follow so that their decisions are allows new information to be quickly added.well-informed. The NCCN Guidelines are developed by Doctors use the NCCN Guidelines to inform their46 group panels. These panels include nearly 900 well- decisions when diagnosing and treating people withknown experts from the 21 NCCN Member Institutions cancer. There are guidelines for 97% of the tumors seen(Figure 1). The panel members include experts from in cancer clinics. All guidelines are updated as newdifferent fields of medicine, such as medical oncology, information becomes available. The NCCN Guidelinesradiology, and surgery. Some panels also have other allow others to have access to the information thattypes of health care workers and patient advocates to is used by NCCN Panel Members. Doctors in yourinclude other points of view. community may or may not perform research, but byRecommendations in the NCCN Guidelines are based on using the NCCN Guidelines, they have access to theclinical trials and the experience of the panel members. newest information from clinical trials.Most panel members have jobs that include clinicalresearch and treating men with cancer. Members workNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 4
  • Part 1: About these guidelinesBy identifying what is the standard of care, the NCCN it may not be right for everyone. This is becauseGuidelines can help patients in two ways. First, they each patient has his or her own medical history andidentify which treatments work best. Second, they give circumstances.treatment options so that patients can get the best care On the other hand, if a treatment isn’t in the NCCNfor their situation. Guidelines, it means that there isn’t enough proof at thisThe treatments in the NCCN Guidelines are the ones time to use it as standard of care. Because of differencesthe NCCN doctors feel are most useful for most patients between patients and other factors, the NCCN Guidelinesbased on science and their experience. It is important don’t replace the expertise and clinical judgment of yourto note that a treatment may not be right for all patients. doctors.Thus, even if a treatment is part of the NCCN Guidelines,Figure 1.NCCN Member InstitutionsNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 5
  • Part 1: About these guidelines1.3 NCCN Guidelines Panel MembersJames L. Mohler, MD/Chair Eric Mark Horwitz, MD Mack Roach, III, MDRoswell Park Cancer Institute Fox Chase Cancer Center UCSF Helen Diller Family Comprehensive Cancer CenterAndrew J. Armstrong, MD, ScM Philip W. Kantoff, MDDuke Cancer Institute Dana-Farber/Brigham and Women’s Eric Rohren, MD, PhD Cancer Center |Massachusetts General The University of TexasRobert R. Bahnson, MD Hospital Cancer Center MD Anderson Cancer CenterThe Ohio State University ComprehensiveCancer Center - James Cancer Hospital Mark H. Kawachi, MD Stan Rosenfeld and Solove Research Institute City of Hope Comprehensive University of California San Francisco Cancer Center Patient Services Committee ChairBarry Boston, MDSt. Jude Children’s Research Hospital/ Michael Kuettel, MD, MBA, PhD Sandy Srinivas, MDUniversity of Tennessee Cancer Institute Roswell Park Cancer Institute Stanford Cancer InstituteJ. Erik Busby, MD Richard J. Lee, MD, ScM Seth A. Strope, MD, MPHUniversity of Alabama at Birmingham Dana-Farber/Brigham and Women’s Siteman Cancer Center at Barnes-Comprehensive Cancer Center Cancer Center |Massachusetts General Jewish Hospital and Washington Hospital Cancer Center University School of MedicineAnthony Victor D’Amico, MD, PhD Dana-Farber/Brigham and Women’s Gary R. MacVicar, MD Jonathan Tward, MD, PhDCancer Center |Massachusetts General Robert H. Lurie Comprehensive Cancer Huntsman Cancer InstituteHospital Cancer Center Center of Northwestern University at the University of UtahJames A. Eastham, MD Arnold W. Malcolm, MD, FACR Przemyslaw Twardowski, MDMemorial Sloan-Kettering Cancer Center Vanderbilt-Ingram Cancer Center City of Hope Comprehensive Cancer CenterCharles A. Enke, MD David Miller, MD, MPHUNMC Eppley Cancer Center at University of Michigan Patrick C. Walsh, MDThe Nebraska Medical Center Comprehensive Cancer Center The Sidney Kimmel Comprehensive Cancer Center at Johns HopkinsThomas Farrington Elizabeth R. Plimack, MD, MSPatient Advocate Fox Chase Cancer CenterCelestia S. Higano, MD, FACP Julio M. Pow-Sang, MDFred Hutchinson Cancer Research H. Lee Moffitt Cancer Center &Center/Seattle Cancer Care Alliance Research InstituteNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 6
  • Part 1: About these guidelines1.4 How to use this booklet This booklet and your doctor can help you decide which choices best meet your medical and personalThe NCCN Guidelines for Patients™: Prostate Cancer needs. Decisions about treatment are important for yourare written to help you better understand cancer long-term health and quality of life. Every choice hastreatment. These guidelines cover all the stages of risks and benefits. Getting enough information to makeprostate cancer, so not all of the information will apply informed decisions is an important first step.to you. Also, your treatment plan may differ from theguidelines recommendations because of your healthand personal issues. To give you the information you need, these guidelines cover most aspects of cancer care. Many medical termsThe guidelines have several important parts: are included that describe cancer, tests, and treatments.• In Part 2, you’ll find information about what prostate These are terms that you will likely hear your treatment cancer is. team use in the months and years ahead. Most of the information may be new to you, and it may be a lot to• The tests and treatments for prostate cancer are learn. Don’t be discouraged as you read. Keep reading explained in Part 3 through Part 6. and review the information. There is a Dictionary in Part 9• Part 6 also has information about caring for that may help you. With time, you’ll become more familiar caregivers. with the medical information in these guidelines.• A step-by-step treatment guide from diagnosis to after treatment is in Part 7. Reading the guidelines in order from beginning to end• Information that may help you make a decision about may be the most helpful. The first half of the guidelines treatment is in Part 8. has basic information to help you understand the detailed treatment guide in Part 7. As you learn about prostate• Medical terms are defined throughout the guidelines cancer, you may want to create a list of questions to ask and in Part 9. your doctor. There is a list of suggested questions in Part 10, but you may think of more questions to ask.• In Part 10, there are pages to help you talk with your doctor and track your treatment.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 7
  • Part 2: About prostate cancer The prostate is located below the bladder near the base of Main Points the penis (Figure 2). The urethra passes from the bladder through the prostate and into the penis. Above the prostate •  he prostate gland makes a fluid that is part T and behind the bladder are the seminal vesicles. These of semen. vesicles are also glands that make a fluid that is part of semen. On both sides of the prostate, there are bundles •  ou’re more likely to get prostate cancer if your Y of cavernous nerves and blood vessels. These nerves are father or brother had it, you’re African-American, needed to achieve penile erections. or you’re older than age 65. The prostate begins to form while a baby is inside his •  rostate cancer grows slowly in some men P mother’s womb. After birth, the prostate keeps growing and fast in others. and reaches nearly full size during puberty. At this point, it is about the size of a walnut. Testosterone causes the •  ests can find prostate cancer early. T prostate to grow, so young men with low testosterone will T •  esting at age 40 can help you plan when and likely have a smaller prostate. After age 40, the prostate how often to be tested for prostate cancer. grows a bit more but may grow to a large size in some men. An enlarged prostate may be caused by benign prostatic hypertrophy or other medical problems. If the prostateProstate cancer is the most common type of cancer in grows too large, it can slow or stop the flow of urine bymen living in the United States. About 217,730 men were squeezing the urethra. diagnosed with prostate cancer in 2010. Women don’t The prostate gland is covered by tissue called the prostaticget prostate cancer because they don’t have a prostate. capsule. Inside the prostate, 30 to 50 small sacs makeMost men with prostate cancer will not die of this disease. and hold prostatic fluid. The sacs and ducts that transportHowever, prostate cancer is the second most common the fluid make up the glandular tissue of the prostate.cause of death from cancer in men. Around the sacs is non-glandular tissue that contains blood vessels, lymph vessels, elastic fibers, and muscle. The2.1 What is the prostate? muscle helps move the prostatic fluid into the urethra.The prostate is a gland that makes a white-colored fluid.Sperm mixes with prostatic and other fluids to form semen.Semen is ejected from the body through the penis duringejaculation. The prostatic fluid protects sperm from the acidin a woman’s vagina.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 8
  • Part 2: About prostate cancer Definitions: Benign prostatic hypertrophy: A non-cancerous overgrowth of the prostate Bladder: An organ that holds and expels urine from the body Cavernous nerves: Nerves that send signals to start penile erections Lymph: A clear fluid containing white blood cells Penile erection: The stiffening of the penis from blood filling its sacs Penis: A male organ used for sexFigure 2. and urination Body parts in the pelvis Puberty: The time when teensIllustration Copyright © 2011 Nucleus Medical Media, All rights reserved. www.nucleusinc.com sexually develop Rectum: The last part of the largeDoctors often talk to one another about the prostate by referring to its zones. The intestineprostate has four zones and the capsule. The back of the prostate near the rectumis the peripheral zone. The transition zone is in the middle of the prostate near the Sperm: Cells containing maleurethra. The central zone surrounds the transition zone, and the anterior zone is in genes that are needed to makethe front of the prostate. babies Testosterone: A hormone thatThe other way doctors talk about the prostate is referring to its lobes. Sometimes, helps sexual organs in men workthe lobes simply refer to the left and right halves of the prostate. For cancer stagingdiscussed in Part 3.5, this definition is used. Similar to the zones, the prostate has Urethra: A tube that expels urinealso been divided into four lobes—the anterior, posterior, lateral, and median lobes. and semen from a man’s bodyYou may also read elsewhere that the prostate has three lobes and a capsule. Vagina: The birth canal in womenNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 9
  • Part 2: About prostate cancer2.2 What is prostate cancer? Over time, cancer cells grow and divide enough to form a tumor. Prostate tumors can grow large and take overCells are the building blocks that form tissue in the body. most of the prostate. They can also grow through theNormal cells grow and then divide to form new cells. New prostate capsule and invade nearby tissues. This growthcells are formed as the body needs them. When normal is called extracapsular extension.cells grow old or get damaged, they die. Cancer cellsdon’t do this. Cancer cells make new cells that aren’t There are blood and lymph vessels in the prostate. Someneeded and don’t die when old or damaged (Figure 3). prostate tumors even cause new blood vessels to form in order to receive nutrients for growth. If prostate cancerUnlike normal cells, cancer cells can spread to other invades blood or lymph vessels, it can metastasize. Ifparts of the body. This process is called metastasis. The prostate cancer metastasizes, it often spreads first to theuncontrolled growth and spread of cancer cells makes bones and lymph nodes. While treatment may controlcancer dangerous. Cancer cells can replace or deform prostate cancer after it metastasizes, it is not considerednormal tissue causing vital organs to stop working. curable. For more information on the lymphatic system,Most prostate cancer occurs in the epithelial cells read Part 3.2.of the glandular tissue. This type of cancer is calledadenocarcinoma. It usually first appears in the peripheralzone of the prostate. The second most common cancersite is in the transition zone.There are rare types of prostate cancer that occurin neuroendocrine cells. One of the neuroendocrineprostate cancers is small cell prostate cancer. It is treateddifferently than adenocarcinoma. Figure 3. Normal versus cancer cell growth Illustration Copyright © 2011 Nucleus Medical Media, All rights reserved. www.nucleusinc.comNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 10
  • Part 2: About prostate cancer2.3 Am I at risk? Definitions:Doctors haven’t found the causes of prostate cancer. However, some risk factors Adenocarcinoma: Cancerare known. Risk factors can be activities that men do, things in the environment, or in cells that line organs andbiological traits passed down from parents to children through genes. New research make fluids or hormonessuggests that the risk factors for slow-growing prostate cancer are different from Aggressive cancer:those for aggressive cancer. If one or more risk factors apply to you, it doesn’t mean A cancer that spreads fastyou’ll get prostate cancer. Likewise, prostate cancer occurs in some men who haveno known risk factors. The major risk factors for prostate cancer are as follows: Diagnose: To identify a diseaseGeographyFewer men living in Asia get prostate cancer than men living in the United States Epithelial cells: Cells that form glandular tissueor Europe. In the United States, 17 out of every 100 men are likely to be diagnosedwith prostate cancer. In contrast, 2 out of every 100 men in China will likely develop Genes: Information in cellsthe cancer. for building new cellsRace Lymph nodes: Small groupsAfrican-American men are more likely to be diagnosed with prostate cancer than of special immune cellsother men. African-American men are also more likely to have aggressive Metastasis: The growth ofcancer and die from prostate cancer. It is unknown why there are differences cancer beyond local tissuebetween races. Neuroendocrine cells:Older age Cells that receive messagesYour risk for prostate cancer increases as you age. Most cases of prostate cancer from nerves and sendoccur in men older than age 65. After age 65, you’re at higher risk for prostate chemical messages tocancer than for any other cancer. the blood Risk factors: Something that increases the chance of getting a disease Tumor: A tissue mass made from an abnormal growth of cellsNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 11
  • Part 2: About prostate cancerFamily history The pattern of prostate cancer growth varies among menIf you have a father or brother with prostate cancer, like no other cancer. For some men, prostate canceryou’re at risk, especially for aggressive disease. Your risk grows slowly and never causes problems. For others,is even higher if one of them had cancer before age 55 prostate cancer grows faster and can cause severe painor if multiple relatives have had prostate cancer. Prostate and even death.cancer that runs in families may be due to a shared To date, screening tests find both slow-growing andenvironment, genetics, or both. aggressive cancers but can’t tell them apart. The idealObesity test would be able to do so. Such a test would allowIf your body weight is high, you’re at risk for fast-growing men with slow-growing cancer to avoid treatment and itsprostate cancer. This is true even if you eat healthfully troublesome side effects until needed—if needed at all.and exercise. On the other hand, a lack of exercise and However, at this time, there is no good method to detectnot eating enough vegetables increases your risk for aggressive cancers early on, so some men with slow-aggressive disease even when your body weight growing cancer have been getting unnecessary treatment.is normal. On the positive side, screening tests appear to help find prostate cancer early. At present, about 75 out of every2.4 Prostate cancer screening 100 men with prostate cancer don’t have extracapsularThe decision to take part in an early detection program extension at diagnosis. This is good news sincefor prostate cancer is complex. Doctors don’t always treatments work best when prostate cancer is onlyagree on who, when, and how to test for prostate cancer. in the prostate.This part of the guidelines discusses screening tests and In recent years, the number of men dying from prostatewhen to start screening. For more information, see the cancer has decreased. It isn’t clear if screening lowersNCCN Guidelines for Prostate Cancer Early Detection, the chances of living with severe cancer symptoms oravailable at NCCN.org. These guidelines were written for dying from prostate cancer. However, some researchyour doctor, so he or she will likely be able to answer your suggests that the lower death rates may be due in partquestions about this information. to screening.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 12
  • Part 2: About prostate cancerScreening tests Definitions:Medical history. It is important for doctors to know the medical history of their Biopsy: A medicalpatients. At your doctor’s office, you may be given a form to complete. Your doctor will procedure that collectsalso ask questions about your health. A medical history includes any symptoms and tissue to test for diseasemedical conditions that you have had. Tell your doctor about problems with urination Obesity: A high amount ofand erections. This may make you feel uneasy but it is important. It is also important body fat compared to bodyfor your doctor to know all the medications you’re taking. It might help to bring a list heightof old and new medications to your doctor’s visit. Your doctor will also ask about the Screening: Testing donemedical history of your family and about other risk factors for prostate cancer. on a regular basis to detectPhysical exam. Doctors often give a physical exam along with taking a medical a diseasehistory. A physical exam is an inspection of your body for signs of disease. During this Side effect: An unplannedexam, your doctor will listen to your lungs, heart, and gut. Parts of your body are often physical or emotionalfelt to see if organs are of normal size, are soft or hard, or cause pain when touched. response to treatmentDigital rectal exam. This test is oftencalled a DRE. It is usually done as part ofa physical exam. For a DRE, your doctorwill put a glove on his hand and then putlubricant on his fingers. Next, he will insert afinger into your rectum to feel your prostate(Figure 4). Your prostate can be easily feltsince it is on the other side of the rectumwall. The peripheral zone of the prostate,where most cancers start, faces the rectum.If your doctor feels that your prostate islarge, bumpy, or hard, you will likely bereferred for a prostate biopsy. Figure 4. Digital rectal exam Illustration Copyright © 2011 Nucleus Medical Media, All rights reserved. www.nucleusinc.comNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 13
  • Part 2: About prostate cancerProstate-specific antigen test. A prostate-specific • PSA doubling time is the time it takes for the PSAantigen is a protein made by the cells where most level to double. A fast-growing cancer can cause theprostate cancers start. The protein is often called PSA. PSA level to rise quickly. After treatment, your doctorPSA turns semen that has clotted after ejaculation back may use this value to decide if you need to be testedinto a liquid. PSA can be measured from a blood sample for recurrence.since some of it enters the blood vessels in the prostate. • Percent-free PSA is the percentage of the unboundMultiple PSA values can be used for cancer screening form of PSA in the blood. Many studies have shownand monitoring after diagnosis, such as: that percent-free PSA is much lower in men who have• Total PSA level is the number of nanograms of PSA prostate cancer. This PSA value is used for men who per milliliter (ng/mL) of blood. Most men without have PSA levels between 4 and 10 ng/mL. A large disease have a PSA level of 4ng/mL or less. However, study showed that a 25% free PSA cutoff found 95 out 1 in every 7 men with normal levels has prostate of 100 prostate cancers while avoiding 20 out of 100 cancer. It is more likely that you have cancer if your unnecessary prostate biopsies. PSA level is between 4 and 10, but less then 50 out of The larger the prostate, the more PSA it can make. 100 men with these levels have cancer. A PSA level Enlarged prostates can be a result of cancer, benign higher than 10 is due to prostate cancer at least in 1 prostatic hypertrophy, prostatitis, or other problems. PSA of every 2 men. can also increase after ejaculations, so try not to ejaculate• PSA density is the PSA level in comparison to the for 48 hours before PSA testing. Some medications can size of the prostate. It is calculated by dividing the also affect the PSA level. PSA is only used to screen for PSA level by the size of the prostate. The size of the cancer since it can’t tell without a doubt if you have prostate is measured with a transrectal ultrasound cancer or not. (also called a TRUS).• PSA velocity is how much PSA levels change within a period of time. This PSA value isn’t useful when PSA levels are above 10 ng/mL, and works best among men younger than age 50. A cutoff of 0.35 ng/ mL/year is currently used to decide if a biopsy is needed, but it is only one of multiple factors to consider.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 14
  • Part 2: About prostate cancerWhen should I start? Definitions:In the past, doctors thought men who wanted prostate cancer screening should start Prostatitis: Swelling of theat age 50. Now, doctors know that this age isn’t right for all men. Many factors should prostatebe considered when starting a new detection program, such as: Transrectal ultrasound:• Your medical health, A test that takes pictures of the prostate through the• Your age, rectum• Your risk of getting prostate cancer, especially aggressive disease,• Symptoms of cancer and other diseases of the prostate,• Any prior screening test results, and• The pros and cons of early detection and treatment for prostate cancer.Most experts believe that men older than age 75 and very sick, younger men willbenefit little from screening. Still, how old is too old for screening can vary fromperson to person. How long you’ll live is an important factor when deciding whetherto be tested, but correctly assessing how long one person will live is hard to do. Earlyand regular screening may benefit men at high risk, men with questionable prior testresults, and men taking drugs that affect PSA levels.For men interested in screening, the NCCN Guidelines Panel recommends gettingtested for the first time at age 40. These baseline test results can then be usedfor comparison with future test results. Getting baseline testing at age 40 seemsreasonable based on research. One study suggests that prostate cancer is presentin 25 out of every 100 men in their 40s. Another large study found that some menin their 40s die from prostate cancer. A third study found that tests done in your 40scan predict fairly well if you will develop prostate cancer many years later. Thus,early baseline tests are useful for planning when and how often to have more tests.Following a screening plan can help, especially if you have aggressive cancer.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 15
  • Part 3: Tests of prostate cancer 3.1 Do I have prostate cancer? Main Points Your doctor may refer you for more testing based on your •  he only way to know for sure if you have T screening tests. A biopsy is the only way to know if you have prostate cancer. A prostate biopsy removes small prostate cancer is to test prostate tissue. samples of prostate tissue from the body. The samples •  ests that take pictures of the inside of your T are then assessed for the presence of cancer cells. body can find cancer that has spread. Prostate biopsy To prepare for the biopsy, you may need to stop taking T •  ests of tissue from your lymph nodes can some medications and start taking others. Medications show if cancer is present. to stop taking include blood thinners like warfarin •  rostate cancers are grouped into Gleason P (Coumadin®). Taking antibiotics may prevent infection scores 6 – 10 based on how the cells look. from the biopsy. A lower grade score is less likely to spread. Right before the biopsy, local anesthesia will be given to numb the area. Tell your doctor if you’ve had any •  rostate cancers are also grouped into stages P reactions to anesthesia in the past. With local anesthesia, I – IV based on test results. Early stages of you’ll feel a small needle stick and a little burning with prostate cancer are more likely to be cured. some pressure for less than a minute. A numbing gel may also be applied to the area. Afterward, you will have a loss of feeling in that area for a short time. You may feel pressure during the biopsy but no pain.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 16
  • Part 3: Tests of prostate cancerThe most common type of prostate biopsy is the transrectal method using a spring- Definitions:loaded needle. For this biopsy, a probe is inserted into the rectum. The needle Epididymis: The tubetravels through the probe to reach the prostate. To make sure the best tissue sample through which sperm travelis collected, a transrectal ultrasound is used (Figure 5). This device is also inserted after leaving the testiclesinto the rectum. It uses sound waves to make a picture of the prostate that is seenby your doctor on a computer. Epididymitis: Swelling of the epididymisThe needle removes tissue about the length of a dime and the width of a toothpick.Typically, 12 samples—called cores—are taken. This is done to check for cancer Hematospermia: Blood inin different areas of the prostate. Prostate biopsies aren’t perfect tests. They semensometimes miss cancer when it’s there. If no cancer is found, your doctor may order Hematuria: Blood in urinea second set of biopsies or may wait until your PSA level rises. Local anesthesia: A lossProstate biopsies often occur with of feeling due to drugs in ano problems. However, side effects specific area of the bodyare possible. You may experiencehematospermia, hematuria, rectal Transrectal: Through the rectumbleeding, prostatitis, fever, epididymitis,or urinary retention. Urinary retention: Inability to empty the bladder Figure 5. Transrectal ultrasound Illustration Copyright © 2011 Nucleus Medical Media, All rights reserved. www.nucleusinc.comNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 17
  • Part 3: Tests of prostate cancer3.2 Tests after diagnosis Imaging tests Imaging tests take pictures of the inside of your body.To plan your treatment, it is important to know the status These tests are often easy to undergo. Imaging machinesof your cancer. Prostate cancer can metastasize before are large and have a tunnel in the middle. You will lie ontreatment has started or any time after. Your doctor will a table that will move slowly through the tunnel. Imagingassess your chances of having metastases based on tests are done by technicians, and the results are latersymptoms, PSA tests, and biopsies. After treatment, tests read by radiologists. There are usually no side effects. Ifcan show if the cancer was cured or has returned. For radiation is used, the amount is small.long-term treatment, tests can show if the cancer is undercontrol or if treatment is harming your body. Bone scan. This scan may show if you have bone metastases. For this test, you will receive an injectionBlood tests of a radioactive dye into your vein. The dye will travelBlood tests may help tell if your prostate cancer has to diseased bone cells throughout your skeleton withinspread and if your organs are working properly. The PSA several hours. A special camera will then take picturestest was described in Part 2.4 as a screening test. It can of the dye in the bones. Disease will show as dark areasalso be used to monitor disease after diagnosis. PSA called “hot spots.” Hot spots may be metastatic cancer,testing done on a regular basis is recommended for any but many abnormal results aren’t cancer. Arthritis,man with known prostate cancer. A rising PSA level may infection, and other bone diseases can also causeserve as an early warning sign of cancer growth when hot spots.you have no symptoms.Other common tests include a complete blood cell countand blood chemistry. When prostate cancer spreads, itcan cause chemicals in the blood to be abnormal. Anexample of the chemicals that doctors look for is a highlactate dehydrogenase level. Such results may swayyour doctor to order imaging tests. Changes in your livercaused by some cancer treatments can also be detectedby blood chemistry tests. Blood cell counts show if youhave a normal number of blood cells. Blood cell countsare often repeated during chemotherapy since it canaffect cells in the marrow that make blood.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 18
  • Part 3: Tests of prostate cancerComputed tomography. This test Definitions:is often called a CT or CAT scan. Arthritis: Swelling of theIt tells if cancer has spread or if bone jointscancer has returned after treatment.A CT scan takes many pictures of Bone metastases: Cancera body part from different angles that has spread to theusing x-rays (Figure 6). As the bonesmachine takes pictures, you may Chemotherapy: Drugs thathear buzzing, clicking, or whirring kill cancer cellssounds. A computer combines thex-rays to make detailed pictures. Figure 6. Endorectal coil: A thin Computed tomography wire covered with a latexFor the second set of scans, a Illustration Copyright © 2011 Nucleus Medical Media, All rights reserved. balloon www.nucleusinc.comcontrast dye may be used to makethe pictures clearer. The dye can be Enema: Injection of liquidinjected into your vein or mixed with a liquid you drink. The dye may cause you to into the rectum to clear the bowelfeel flushed or get hives. Rarely, serious allergic reactions occur. Tell your doctor andthe technicians if you have had bad reactions in the past. In addition to the dye, you Lactate dehydrogenase:will need to drink enough liquid to have a full bladder. A full bladder helps keep the An enzyme found in thebowel away so the prostate can be seen more easily. bloodMagnetic resonance imaging. You may hear people call this test an MRI. Instead Radioactive: Containingof x-rays, MRI uses radio waves and powerful magnets to take pictures inside the a powerful energy calledbody. Getting an MRI is like getting a CT scan. A contrast dye may be used. radiationFor prostate cancer, two other types of MRI may be used. An endorectal MRI can Radiologist: A doctortake better pictures of the prostate and nearby tissues. For this test, an endorectal who specializes in reading imaging testscoil is placed inside the rectum for 30 to 45 minutes. This can cause discomfort.Eating less on the days before the test may make it easier to place the coil. Youmay also be asked to use an enema. Another MRI test used with an endorectal coilis magnetic resonance (MR) spectroscopy. This test measures chemicals in cellswithout removing tissue from the body.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 19
  • Part 3: Tests of prostate cancerLymph node biopsyLymph is a clear fluid that returns fluid andprotein to the blood. It travels betweentissues, blood, and lymph nodes in long,tube-shaped vessels. Lymph vessels andnodes are everywhere in the body, whichallows prostate cancer to spread to otherorgans (Figure 7). Prostate cancer oftenspreads first to the lymph nodes in thepelvis. Cancer continues to grow insidelymph nodes causing them to increase insize. A CT or MRI scan can show if lymphnodes are enlarged.The lymph node biopsy is performed byfine-needle aspiration. This biopsy usesa very thin needle to remove very smallpieces of a lymph node. A CT scan is usedto guide the needle into the lymph node.With a local anesthetic, this test causeslittle discomfort and doesn’t leave a scar. Figure 7. Selected lymph nodes Illustration Copyright © 2011 Nucleus Medical Media, All rights reserved. www.nucleusinc.comNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 20
  • Part 3: Tests of prostate cancer3.3 The pathology report Definitions:The tissue removed during the biopsy or surgical treatment will be reviewed by a Scar: A permanent markpathologist. A pathologist is a doctor who specializes in looking at cells to identify after an injury or surgerydisease. First, the pathologist will prepare the tissue to be looked at under amicroscope. The tissue will be covered in a waxy material and cut into very thinslices. The slices will then be stained with dyes to help see the differences betweenparts of a single cell and differences between multiple cells. These stained sampleswill be placed on glass slides and then examined under a microscope.Next, the pathologist will write one or more reports for your doctor. The pathologyreports will include many important results. They will state whether cancer cells werefound and, if so, what types of cancer cells. Other results will be used to stage yourcancer, which is discussed in Part 3.5. The steps to prepare and test the tissue andwrite the report usually takes 1 to 2 days. At times, the pathologist may request a 2ndopinion from another pathologist.It is a good idea to ask for a copy of the pathology reports. If you have questions,talk with your doctor. It is important that you understand how the results will beused to decide treatment choices. You can also request that your tissue samplesbe reviewed by a pathologist at an NCCN Member Institution or another specialistsuggested by your doctor.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 21
  • Part 3: Tests of prostate cancer3.4 Gleason scoreNot all areas of a prostate tumor look the same. Someareas may look normal while other areas may look verydifferent from prostate tissue. The pathologist will gradeyour tumor based on how the cells look in different areas.This grading system for prostate cancer is called theGleason score. This score is a sign of how aggressivethe cancer is likely to be and is used to suggest treatmentoptions.The Gleason score is the sum of two grades. Gradesrange from 3 for cancer cells that look almost normal to5 for very abnormal cells that have spread throughoutthe prostate (Figure 8). Cells with a grade of 1 or 2 aren’tthought to be cancerous. The primary grade is the mostcommon pattern, and the secondary grade is the secondmost common pattern.The Gleason scores for prostate cancer range from 6to 10. Higher Gleason scores mean the cancer is morelikely to grow and spread quickly. A higher primary gradealso means more aggressive cancer. For example, aGleason score of 7 summed from primary and secondarygrades of 4 + 3 is worse than a grade of 3 + 4. Figure 8. Gleason grades Adapted from Gleason DF. The Veteran’s Administration Cooperative Urologic Research Group: Histologic grading and clinical staging of prostatic carcinoma. In Tannenbaum M (ed.) Urologic Pathology; The Prostate. Lea and Febiger, Philadelphia, 1977: 171-198. Illustration Copyright © 2011 Nucleus Medical Media, All rights reserved. www.nucleusinc.comNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 22
  • Part 3: Tests of prostate cancer3.5 Stages of prostate cancer Definitions:Prostate cancer is divided into different groups called stages. There are four main Criteria: Standards forstages based on tumor growth within and beyond the prostate, pre-treatment PSA making a decisionlevels, and Gleason scores. Your cancer stage will be decided by the physical exams Prognosis: The patternand tests described in Parts 2.4, 3.1, and 3.2. and outcome of a diseaseCancer doctors developed the criteria for cancer staging using information from Surgical margin: Normalthousands of patients. Your cancer stage is important. However, since it is based on tissue around a tumor thatlarge numbers of patients, it may not tell the outcome for one person. Some men will is removed during surgerydo better than expected. Others will do worse. Other factors are very important indetermining your prognosis. Some of these factors include your general health andthe surgical margin status.This section provides very specific information on prostate cancer staging. It may havemore details than some men want, but others may wish to know the details. If youhave any questions, ask your cancer care team to explain.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 23
  • Part 3: Tests of prostate cancerSystem to define cancer stage T category. The T category tells you how far the mainThe TNM staging system is most often used to describe tumor has grown. Within this category, scores forthe growth of prostate cancer. In this system, each of the malignant tumors range from 1 to 4. Each score hasletters—T, N, and M—describes a different area of growth subscores that are identified by letters. A second T score(Figure 9). For each area, your cancer is scored twice. isn’t given to men who don’t have surgery.The first scores are based on the DRE, biopsy results, T1 tumors can’t be felt or seen with imaging tests. Theyand any imaging tests. The second scores are based on are found in tissue samples from biopsies or surgicaltests of the tissues removed during surgical treatment. treatment. For example, prostate cancer may be found in men who had surgery for urinary problems caused by an enlarged prostate. Discovering cancer this way is called an incidental finding. • T1a means that incidental cancer was found in 5% or less of the tissue. • T1b means that incidental cancer was found in more than 5% of the tissue. • T1c tumors are found by needle biopsy that was done after a high PSA score. T2 tumors can be felt by your doctor during a DRE. They also may be seen with an imaging test. T2 tumors haven’t grown outside the prostate gland. • T2a tumors haven’t grown beyond half of one lobe. • T2b tumors have grown beyond half of one lobe but not to the other lobe. • T2c tumors have grown into both lobes.Figure 9.TNM examplesIllustration Copyright © 2011 Nucleus Medical Media, All rights reserved.www.nucleusinc.comNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 24
  • Part 3: Tests of prostate cancerT3 tumors have grown through the prostate capsule. They have reached the connective Definitions:tissue next to the prostate, the seminal vesicles, or both but don’t involve any other Aortic lymph nodes:organs. This group is subdivided into T3a and T3b. Lymph nodes near the• T3a tumors haven’t grown into the seminal vesicle(s). There is cancer in the heart along the aorta neck of the bladder. Cervical lymph nodes:• T3b tumors have grown into the seminal vesicle(s). Lymph nodes in the neckT4 tumors have spread to nearby tissues other than the seminal vesicles. These External sphincter:tissues include the external sphincter, rectum, bladder, levator muscles, and pelvic Muscle that controls the flow of urine from thewall. Otherwise, biopsy or imaging results show that these tumors are fixed— bladder through the urethraattached to organs.• T4 tumors are fixed or have grown into nearby tissues other than seminal vesicles. Iliac lymph nodes: Lymph nodes in the pelvic areaN category. The N category reflects how far the prostate cancer has spread to nearby Inguinal lymph nodes:lymph nodes. The internal iliac, external iliac, and sacral lymph nodes are located near Lymph nodes in the groin areathe prostate.• N0 means that there is no cancer in the nearby lymph nodes. Levator muscles: Muscles that support the prostate• N1 means that the cancer has spread into the nearby lymph nodes. and control the flow of urine Pelvic wall: A layer ofM category. The M category tells you if there are metastases to distant lymph nodes or muscles and tissue thatother organs. Aortic, common iliac, inguinal, supraclavicular, cervical, and retroperitoneal helps organs in the pelvislymph nodes are distant from the prostate. Prostate cancer tends to metastasize to bone. to stay in place• M0 means that there is no growth to distant sites. Retroperitoneal lymph nodes: Lymph nodes• M1 means that the cancer has spread to distant organs. behind the intestines • M1a is cancer that has spread to distant lymph nodes. Supraclavicular lymph • M1b is cancer that has spread to bone(s). nodes: Lymph nodes above the collarbone • M1c is cancer that has spread to distant organs.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 25
  • Part 3: Tests of prostate cancerThe 4 stages of prostate cancer Table 1. Staging of prostate cancer TNM scores with PSA levels and Gleasonscores are used to assign the cancer Anatomic stage/prognostic groupsa stage. Each stage is represented by Group T N M PSA GleasonRoman numerals ranging from I to IV I T1a – c N0 M0 PSA <10 Gleason ≤6(Table 1). Stage II is divided into two T2a N0 M0 PSA <10 Gleason ≤6substages—stages IIA and IIB. Thestages identify tumor types that have a T1 – 2a N0 M0 PSA X Gleason Xsimilar prognosis and thus are treated in IIA T1a – c N0 M0 PSA <20 Gleason 7a similar way. T1a – c N0 M0 PSA ≥10 <20 Gleason ≤6Your two sets of TNM scores will be used T2a N0 M0 PSA ≥10 <20 Gleason ≤6to assign a cancer stage twice. The first T2a N0 M0 PSA <20 Gleason 7set of scores is used for clinical staging.The clinical stage is used for making T2b N0 M0 PSA <20 Gleason ≤7an initial treatment plan. However, the T2b N0 M0 PSA X Gleason Xclinical stage may be wrong about how IIB T2c N0 M0 Any PSA Any Gleasonfar the cancer has spread. The secondset of scores is used for pathologic T1 – 2 N0 M0 PSA ≥20 Any Gleasonstaging. Most of the time, the pathologic T1 – 2 N0 M0 Any PSA Gleason ≥8stage is the most important stage. III T3a – b N0 M0 Any PSA Any GleasonThis is because your lymph nodes can IV T4 N0 M0 Any PSA Any Gleasononly be completely examined under amicroscope. In general, earlier stages of Any T N1 M0 Any PSA Any Gleasonprostate cancer have a better prognosis. Any T Any N M1 Any PSA Any Gleason Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer Science+Business Media, LLC, www.springer.com.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 26
  • Part 4: Treating prostate cancer Part 4: Treating prostate cancer Notes: Main Points •  reating prostate cancer takes a team of health care workers. T T •  o suggest treatment options, doctors estimate your risk for cancer spreading. • f your tumor is small, ongoing testing to watch for cancer growth I may be better than getting treated. •  urgery and radiotherapy treat cancer in or near the prostate. S •  ystemic therapy treats cancer beyond the prostate. It includes S hormone therapy, chemotherapy, and immunotherapy. • There may be research on new treatments that you can take part in.A diagnosis of prostate cancer can be overwhelming. You will likely have manyquestions. It is important to know that not all prostate cancers have the same riskof spreading. Some men with prostate cancer will require treatment. Other mencan wait to see if treatment becomes necessary. Your decision about treatmentis important for your long-term health and quality of life since there are risks andbenefits to every option. Part 4 gives a brief overview of the treatments for prostatecancer and other key issues.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 27
  • Part 4: Treating prostate cancer4.1 Your treatment team 4.2 Risk assessmentCancer care is a team effort. Who is on your team How far your cancer has spread may only be knowndepends on the treatment plan you choose. Your after the start of treatment. Likewise, how aggressiveprimary doctor will refer you to one or more doctors who your cancer is might only be known over time. Becausespecialize in cancer. Along with doctors, you may receive of these limitations, doctors use nomograms and riskcare from nurses, social workers, and other health care groups to predict your prognosis. You’ll be matched to aworkers. Deciding your treatment plan will require talking risk group based on your TNM scores, Gleason score,to doctors about possible results. Your team of doctors and PSA level. Treatment options differ by risk group. Formay include: example, active surveillance is an option for patients in low-risk but not high-risk groups. Active surveillance is• A urologist to perform surgery, follow-up discussed more in Part 4.3. Risk groups can help start testing, or both, treatment planning by suggesting treatment options.• A radiation oncologist to provide treatment A nomogram can predict risk better than a risk group. It with radiation, and predicts your prognosis by taking into account differences• A medical oncologist to provide treatment and similarities between test results. An example of a using drugs. nomogram is the prediction of lymph node metastases before treatment. If your doctor thinks you have lymphSome men find it helpful to bring their spouse, partner, or node metastases, a biopsy will be recommended. Whena friend to appointments. It may also help to bring a list available, nomograms can be used to suggest tests andof questions with you when you meet with the doctors. A treatments that are specific to you.list of possible questions can be found in Part 10. Aftermeeting with the doctors, you may feel uncertain aboutwhich treatment plan is best for you. Part 8 discussesissues to consider when making a decision abouttreatment.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 28
  • Part 4: Treating prostate cancer4.3 Active surveillance Definitions:Small prostate tumors have been often found with PSA screening tests. They are Medical oncologist: Aalso found in prostates removed because of benign prostatic hyperplasia. If small doctor who specializes intumors grow slowly, they may not cause any health problems, especially if you’re all types of cancer older. The NCCN Guidelines Panel is concerned that if low-risk prostate cancers are Radiation oncologist: Atreated, some men will suffer needlessly from treatment side effects. Another option doctor who specializes inis active surveillance. Active surveillance requires ongoing testing without treatment the treatment of canceruntil there’s proof that the cancer will cause problems. Active surveillance is also with radiationcalled watchful waiting or expectant management. Urologist: A doctor who specializes in the urinary system of men and women4.4 Treatments for prostate cancer and in male sex organsProstate cancer is a serious disease that can be treated. Knowing what thetreatments are will help you read the treatment guide in Part 7. Not every manwith prostate cancer will receive every type of treatment listed. There are severalterms used to describe when treatment is given. For example, some men receiveradiotherapy after surgery. In this case, surgery is the primary treatment, andradiotherapy is an adjuvant treatment.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 29
  • Part 4: Treating prostate cancer Radical retropubic prostatectomy. The standard Terms describing the order of a treatment retropubic surgery is the open prostatectomy. This surgery removes tissue through an incision that runs fromPrimary treatment your belly button down to the base of your penis (FigureThe main treatment for cancer 10). Before removing the prostate, some veins and theNeoadjuvant treatment urethra are cut to clear the area. Next, the cavernousTreatments given before the primary treatment nerves are checked for cancer cells. If cancer-free, a nerve-sparing prostatectomy will be done. However,Adjuvant treatment if cancer is found, one or both bundles of nerves willTreatment that follows primary treatment be removed. At this point your prostate is removed,First-line treatment sometimes with the seminal vesicles and lymph nodes. After removing the prostate the urethra is re-attached toThe first treatment given the bladder. This surgery can take between 90 minutesSecond-line treatment and 3 hours. It often requires 1 to 3 days in the hospitalThe treatment given after the first treatment fails and a recovery at home for about 2 weeks.Salvage therapyThe treatment given after standard treatment failsRadical prostatectomy A radical prostatectomy is a surgery that removes theentire prostate gland and nearby tissue. This surgeryis often used as a primary treatment when the canceris confined to the gland. There are a few steps toprepare for the surgery. You may need to stop taking Figure 10.some medications to reduce the risk of severe bleeding. Open retropubic approachEating less, changing to a liquid diet, or using enemas or Illustration Copyright © 2011 Nucleus Medical Media, All rights reserved. www.nucleusinc.comlaxatives will empty your colon for surgery. Right beforesurgery, you will be given anesthesia. Anesthesia may begeneral, spinal, or epidural. There are two types of radicalprostatectomy:NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 30
  • Part 4: Treating prostate cancerA newer retropubic surgery is the laparoscopic radical prostatectomy. Definitions:This surgery removes body tissue through a small incision in the pelvis. Catheter: A tube placed into theA laparoscope is inserted through another incision to view the area. A urethra to drain urine from thelaparoscopic prostatectomy can be done with the help of a “robot.” During a bladderrobotic-assisted prostatectomy, the surgeon controls the surgical tools withtwo or three robotic arms. Robotic arms make more precise cuts compared Epidural anesthesia: Loss of feeling in the lower half of theto a surgeon’s hand. However, surgeons can detect changes in the tissue by body from an ongoing injection oftouching your organs. These changes aren’t detected when a robot is used. drugs into the outermost part of the spinal canalIt is still unclear whether laparoscopic surgery has betterresults than open surgery. Results may be related to the General anesthesia: A controlledexperience of your surgeon. Before you choose, ask how loss of consciousness from drugsmany of these surgeries the surgeon has done. Incision: A surgical cut intoRadical perineal prostatectomy. This surgery removes the bodythe prostate through an incision in the perineum (Figure Laparoscope: A thin, long tube11). During surgery, you will lie on your back with your legs with a light and camera used tospread open and supported with stirrups. The prostate is see into the bodyremoved sometimes along with the seminal vesicles after Laxatives: Drugs used to cleanbeing separated from nearby tissues. Nerve sparing is out the intestinespossible but difficult. Lymph nodes can’t be removed. Afterthe prostate has been removed, the urethra is re-attached Pelvis: The body area between the hipbonesto the bladder. This surgery takes between 60 minutes and2 hours. It often requires 1 to 2 days in the hospital and Perineum: The area in menrecovery at home for about 1 week. between the scrotum and anusAfter retropubic and perineal prostatectomy, a catheter is Spinal anesthesia: Loss of feeling in the lower half of theinserted into your urethra to allow your urethra to heal. It body from a shot of drugs into thestays in place for 2 to 3 weeks. You will be shown how to spongy tissue of the spineuse it while you’re at home. If removed too early, you may Figure 11. Perineal approach Urinary incontinence: Inabilitydevelop urinary incontinence or be unable to urinate due toscar tissue. Illustration Copyright © 2011 Nucleus Medical Media, All rights reserved. to control the release of urine www.nucleusinc.com from the bladderNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 31
  • Part 4: Treating prostate cancerCryosurgery RadiotherapyCryosurgery treats tumors in the prostate with local This treatment uses high-energy rays (or particles) to killfreezing. Very thin needles are inserted through the cancer cells. It is used as a primary treatment for cancerperineum into the prostate. Imaging tests are used that hasn’t spread far beyond the prostate. Radiotherapyto place the needles. Argon gas flows through the may also be used as an adjuvant treatment after surgeryneedles and freezes the prostatic tissue to below-zero and as supportive care to relieve pain caused by cancertemperatures. Freezing of the tissue kills the cancer in your bones. There are two ways to give radiation to acells. The urethra is spared by use of a catheter filled specific area:with warm liquid. This treatment is often done as an External beam radiation therapy. This treatmentoutpatient procedure. Cryosurgery isn’t suggested as delivers a beam of radiation from a machine outside theprimary treatment due to a lack of proof that it is as good body. It is often called EBRT. EBRT is usually done onover time as surgery or radiotherapy. Its suggested use is an outpatient basis 5 days per week for several weeks.addressed in Part 7.4.2. When EBRT is used to control bone pain, fewer sessionsLymph node surgery may be required.The surgery to remove lymph nodes is called a pelvic Before EBRT, your radiotherapy doctors will plan the bestlymph node dissection (or PLND). The decision to have treatment for you. Treatment planning involves decidinga PLND is based on your risk for metastases. A PLND the 1) radiation dose; 2) type, number, and angle ofis done during a retropubic prostatectomy with either radiation beams; and 3) finding the exact location of youra limited or extended method. More lymph nodes are tumor. Pictures of your tumor with CT or MRI scans areremoved in an extended PLND. Research suggests that used in a computer program to design the whole coursemen live longer with an extended PLND because nodes of treatment. This planning helps target the radiationwith tiny amounts of cancer are removed. This prevents beam at the tumor and avoid damaging healthy tissue.further cancer spread. Likewise, you may wear a body cast during radiotherapy to prevent you from moving. For prostate cancer, the NCCN Guidelines Panel recommends three-dimensional conformal radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT), or image-guided radiation therapy (IGRT). In 3D-CRT, the radiation beams match the shape of theNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 32
  • Part 4: Treating prostate cancertumor to avoid healthy tissues. IMRT is a more precise type of 3D-CRT for tumorsthat are oddly shaped. The radiation beam is divided into smaller beams, and These NCCN Guidelinesthe strength of each beam can vary. Each session of this type of EBRT takes don’t recommend EBRTlonger to finish. with proton beams at thisIGRT uses imaging during treatment. This allows the radiation beams to be moved time. Research hasn’tto the current position of the tumor. This is important since tumors can possibly shown proton beamschange shape, size, and position between and during treatment visits. A variety of to be the same or betterIGRT imaging methods can be used. A CT scan or ultrasound may be done just for prostate cancerprior to each session. Markers seen on imaging tests can also be inserted into the than photon beamsprostate during a quick outpatient visit. Two other IGRT imaging methods include and conventionalelectromagnetic tracking and an endorectal balloon. external beams. Brachytherapy. This treatment involves placing radioactive seeds inside your prostate. You may also hear this treatment be called interstitial radiation. Brachytherapy is used alone or combined with ERBT, hormone therapy, or both. The seeds are about the size of a grain of rice Definitions: (Figure 12). They are inserted into your body Particles: Small pieces through the perineum and guided into your prostate of matter with imaging tests. Treatment planning is done Photon beam: A stream of beforehand to design the best course of treatment. particles that have no mass You will be under general or spinal anesthesia or electric charge when the seeds are placed. Brachytherapy can be given either as permanent low-dose rate (LDR) or Proton beam: A stream of positively charged particlesFigure 12. temporary high-dose rate (HDR). that emit energy within aBrachytherapy seeds short distanceIllustration Copyright © 2011 Nucleus MedicalMedia, All rights reserved. www.nucleusinc.com Supportive care: Treatment for symptoms of a diseaseNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 33
  • Part 4: Treating prostate cancerLDR brachytherapy uses thin needles to place 40 to 100 Systemic therapyseeds into your prostate. The seeds consist of either Prostate cancer is able to spread beyond the prostate toradioactive iodine or palladium. They will remain in your other parts of the body. Doctors use drugs to treat cancerprostate to give low doses of radiation for weeks or cells that have spread to distant sites. This treatment ismonths. The radiation travels a very short distance. called systemic therapy.This allows for a large amount of radiation within a smallarea while sparing nearby healthy tissue. Over time, the It is important to understand the goal of systemic therapy.seeds decay. After a radical prostatectomy, there may be signs that the cancer may have spread. In this case, systemic therapyHDR brachytherapy places seeds made of iridium-194 would be suggested as an adjuvant treatment to preventwith soft catheters. The seeds are removed after or slow down cancer growth. On the other hand, systemicradiation has been given. This treatment requires staying therapy may be given as a primary treatment for knownin the hospital for 1 to 2 days. HDR brachytherapy is metastatic disease at diagnosis.often given with EBRT. There are different types of systemic therapy. First-line systemic therapy often is hormone therapy. Other systemic therapies are chemotherapy and immunotherapy. Some chemotherapy drugs are pills that are swallowed. Others are liquids that are injected into a vein or implants that are placed under the skin. These drugs travel in the blood to all parts of the body, where they attack cancer cells. Table 2 lists the systemic drugs used for prostate cancer.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 34
  • Part 4: Treating prostate cancerTable 2. NCCN recommended systemic therapies Notes:Generic name Brand name Drug typeAbiraterone acetate Zytiga™ Hormone therapyBicalutamide Casodex® Hormone therapyCabazitaxel Jevtana® ChemotherapyCarboplatin None ChemotherapyCisplatin Platinol®, Platinol®-AQ ChemotherapyDegarelix Firmagon® Hormone therapyDocetaxel Taxotere® ChemotherapyEtoposide phosphate Etopophos® Preservative Free ChemotherapyFlutamide – Hormone therapyGoserelin acetate Zoladex® Hormone therapyHistrelin acetate Vantas® Hormone therapyKetoconazole Nizoral® Hormone therapyLeuprolide acetate Eligard®, Lupron Depot®, Lupron® Hormone therapy ®Mitoxantrone Novantrone ChemotherapyhydrochlorideNilutamide Nilandron® Hormone therapyPrednisone – Adrenocortical steroidSipuleucel-T Provenge® ImmunotherapyTriptorelin pamoate Trelstar® Hormone therapyLHRH = luteinizing hormone-releasing hormoneNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 35
  • Part 4: Treating prostate cancerHormone Therapy. Prostate cancer cells need • Ketoconazole is an anti-fungal drug that stopsandrogens to grow. The main androgen is testosterone. the adrenal glands and other tissues from makingHormone therapy for prostate cancer stops the body from testosterone. It is a second-line therapy.making testosterone or stops the action of testosterone. • Abiraterone acetate stops the action of a proteinIt can slow tumor growth or shrink the tumor for a periodof time. Hormone therapy is also called androgen involved in the making of testosterone. Thus, the level of testosterone is decreased. It may be useddeprivation therapy or ADT. First-line and second-line as a second-line therapy under two conditions: 1)hormone therapy include: your cancer has metastasized and 2) your first-line• Bilateral orchiectomy is the surgical removal of both hormone therapy has failed. testicles. They are removed since they make most of the testosterone in the body. Hormone therapy may be used alone on a long-term basis. It also can be used with EBRT on a short- or long-• Luteinizing hormone-releasing hormone (LHRH) term basis. For long-term hormone therapy, your doctor agonists are drugs used to stop the testicles from may consider intermittent therapy to reduce side effects. making testosterone. They are either injected into a More information on hormone therapy can be found in vein or implanted under the skin every 1, 3, 4, or 12 Part 7.5. months. Chemotherapy. These drugs treat cancer cells by• Antiandrogens are another class of drugs that stop stopping them from making new cells. Many people refer the action of testosterone. For first-line treatment, they to chemotherapy as “chemo.” Sometimes chemotherapy are used with orchiectomy or LHRH agonists. They is one drug, called a single agent. Other times a mix of are used alone for second-line therapy. drugs is used. This is called a chemotherapy regimen.• Estrogens can stop the adrenal glands and other Chemotherapy is given in cycles of treatment days tissues from making testosterone. They are often followed by days of rest. These cycles vary in length used with orchiectomy or LHRH agonists. depending on which drugs are used. Typically, the cycles are 14, 21, or 28 days long. These cycles give the body• Steroids can stop the adrenal glands and other a chance to recover before the next treatment. Thus, tissues from making testosterone. They are often a regimen of 3 to 6 months has rest periods between used with orchiectomy or LHRH agonists. treatments.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 36
  • Part 4: Treating prostate cancerChemotherapy is an option for men with metastatic prostate cancer when hormone Definitions:therapy fails. It is also used for small cell prostate cancer. Chemotherapy isn’t Androgen: A hormoneexpected to destroy all cancer cells. Instead, it may shrink or slow the growth of found in high levels intumors and reduce pain. In some men, it can prolong life. males that is involved in sexual development andImmunotherapy. Sipuleucel-T is a new drug that uses your white blood cells to functioningdestroy prostate cancer cells. In a lab, your white blood cells from a blood sampleare changed by a protein so they will recognize and destroy prostate cancer cells. Intermittent therapy: Alternating periods of time on and off treatment4.5 What are clinical trials?Many new cancer treatments are available because patients have been willing totake part in clinical trials. In these studies, new treatments are compared to currenttreatments, such as those described in Part 4.4. The purpose of the clinical trial is tofind out if the new or current treatment is better at fighting cancer. Clinical trials mayalso look at new ways to diagnose or prevent a disease, make current treatmentsbetter, or assess whether a new treatment is safe. NCCN believes that the bestmanagement for any patient with cancer is in a clinical trial.Your doctor may ask you if you would like to be in a clinical trial. There are severalbenefits. First, you’ll receive the most current cancer care according to a veryspecific treatment plan. Second, doctors who work with clinical trials know thenewest cancer treatments. They also track the results of treatment—both good andbad—and compare their results with other doctors to improve treatment.There are many decisions to make after your diagnosis of cancer. One may be if aclinical trial is right for you. A brief review of clinical trials is given next. Talking withyour cancer care team, your family, and your friends can help you make the besttreatment choice.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 37
  • Part 4: Treating prostate cancerThe purpose of clinical trials Phases of clinical trialsClinical trials are done to test new treatments to see There are four phases of clinical trials, which arewhether they are better than the current treatments. A numbered I, II, III, and IV. The phases are describedclinical trial is only done when there is good reason to below using the example of a drug treatment:believe that a new treatment, test, or procedure may be • Phase I clinical trials are done to find the best waybetter than the current one. Treatments tested in clinical to safely give a new treatment to patients. The cancertrials are often found to have benefits and may become care team closely watches patients for any harmful sidetomorrow’s standard treatment. However, there is no way effects. In phase I studies, the drug has already beento know whether this will be the case before the results of tested in lab and animal studies. However, it needs tothe trial are known. be tested in humans to know the best dose with theClinical trials can focus on many things, such as: fewest side effects.• New uses of medications that are already approved Phase I trials are usually the first type of trial in by the U.S. Food and Drug Administration (FDA). For humans. Thus, most patients in these trials have been example, drugs that are used in one type of cancer previously treated with current treatments. Doctors may be tested in another type of cancer. start by giving very low doses of a new drug to the first• Different ways of giving chemotherapy, such as by patients and increase the doses for later groups of mouth instead of by a needle in the arm. patients until side effects appear or the desired effect is seen. Doctors are hoping to help patients, but the main• New drugs that haven’t yet been approved by the FDA. purpose of a phase I trial is to test the safety of the For example, research to know the best dose that drug. If a drug is found to be reasonably safe in phase I treats the disease and has the fewest side effects. studies, it can be tested in a phase II clinical trial.• Alternative medicines, such as herbs and vitamins.• New diagnostic tests, such as genetic tests, to assess which patients are the best candidates for certain treatments.• Medicines or procedures that relieve symptoms.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 38
  • Part 4: Treating prostate cancer• Phase II clinical trials assess if a drug works for a specific type of cancer. They Definitions: are done in larger groups of patients for whom standard treatments aren’t working. Alternative medicine: Often, phase II trials involve new combinations of drugs. Patients are closely Treatments used in place watched to see if the treatment has an effect, such as shrinking of the tumor. The of ones usually given by cancer care team also looks for side effects. If a drug or combination of drugs is doctors found to work in phase II studies, it can be tested in a phase III clinical trial. Control group: Research• Phase III clinical trials include large numbers of patients. Often, these studies participants who don’t are randomized. This means that patients are put into a treatment group by receive a new treatment chance. There can be more than two treatment groups in a clinical trial. The Randomized: Assignment control group gets the standard treatment and the other groups get a new to a group by chance treatment. Neither you nor your doctor can choose your group. This may make U.S. Food and Drug you feel uneasy. Your doctor will explain to you the reason for the clinical trial Administration (FDA): A and the risks and benefits of all treatments. Every patient in phase III studies is federal government agency watched closely. The study will be stopped early if the side effects of the new that regulates drugs and treatment are too severe or if one group has much better results. Phase III food clinical trials are usually needed before the FDA will approve the use of a new drug for the general public.• Phase IV clinical trials test new drugs approved by the FDA. Treatment is tested in a very large number of patients with different types of cancer. This allows for better research on short-lived and long-lasting side effects and safety. For example, some rare side effects may only be found in large groups of men. Doctors can also learn more about how well the drug works and if it is helpful when used in other ways, such as in combination with other treatments.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 39
  • Part 4: Treating prostate cancerDeciding to enter a clinical trial How can I find out more about clinical trials thatIf you would like to take part in a clinical trial, talk with might be right for me?your doctor. There may be clinical trials where you’re You can get a list of clinical trials by calling the Nationalgetting treatment. If you join a clinical trial, you’ll be tested Cancer Institute (NCI) Cancer Information Service. Theto see if you qualify for the study. Study participants are toll free number is 1-800-4-CANCER (1-800-422-6237).usually alike in terms of their tumor and general health. You can also get this information at www.cancer.gov/The purpose of this is to know that any improvement is clinicaltrials. Based on your type of cancer, this servicebecause of the treatment and not because of differences will give you a list of clinical trials. The service will alsobetween patients. Even if you meet the conditions of the ask where you live and whether you’re willing to travel sostudy, it is still your choice whether to participate. a nearby treatment center can be foundAll study participants need to sign a paper called aninformed consent form (ICF). The ICF describes thestudy in detail, including the risks and benefits. You willbe able to review the ICF before deciding whether toparticipate. Also, your doctor will explain why the clinicaltrial may be right for you.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 40
  • Part 5: Treating signs and symptoms Part 5: Treating signs and symptoms Definitions: Main Points Colitis: Swelling of the •  ll treatments for prostate cancer can cause unwanted signs A colon and symptoms. Defecation: The releases of stool (feces) from the •  ot all people have the same symptoms or severity of symptoms. N body •  ome side effects of treatment are serious and need to be S Dry orgasm: Having an checked regularly. orgasm without ejaculation Dysorgasmia: Pain during T •  alk with your treatment team about ways to treat symptoms of orgasm prostate cancer and its treatment. Erectile dysfunction: • f you don’t want treatment for prostate cancer, you can still I The inability to achieve full receive treatment for symptoms. erections Fatigue: Severe tiredness despite getting enough sleep5.1 Common side effects Fistula: A passageEach treatment for prostate cancer has possible side effects. Side effects are between two organs that aren’t normally connectedunpleasant physical or emotional conditions or symptoms caused by treatment. Howyour body responds to cancer and its treatment is as unique as your fingerprints. Inorgasmia: Inability toNo one can be certain how you’ll respond. You can have different side effects than have an orgasmsomeone else on the same treatment. The severity of side effects can also varybetween men. It is very important to consider how side effects may change your wayof life when choosing treatment for prostate cancer. Also, knowing about possibleside effects can help you know what to expect from treatment and how to respond.Part 5.1 covers common side effects. You may have other side effects that aren’treviewed here.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 41
  • Part 5: Treating signs and symptomsSide effects of radical prostatectomy During surgery, you may have complications. A seriousAlmost every man has urinary incontinence and erectile loss of blood can occur and require a transfusion. Risksdysfunction after radical prostatectomy. These two of anesthesia include heart attack and blood clots. Afterside effects may be short lived, but for some men they surgery, you will have pain and swelling that often fadeare lifelong issues. You’re at higher risk for erectile away within weeks. Scars from surgery are permanent.dysfunction if 1) you’re older; 2) you had erectileproblems before surgery; and 3) your cavernous nerveswere damaged or removed during surgery. See Figure 13for a picture of the nerve bundles. If both your prostateand seminal vesicles were removed, you will experiencedry orgasms. When the seminal vesicles are notremoved, you still may experience a dry orgasm becauseof retrograde ejaculation. Although not as common aserectile dysfunction, other sexual changes may includedysorgasmia, inorgasmia, penile curvature, and penileshrinkage.Bladder control often returns within months, but you maynot have full control. Leaking a small amount of urinewhen coughing, laughing, sneezing, or exercising iscalled stress incontinence. It is caused by damage to themuscle at the base of the bladder. Overflow incontinenceoccurs when there is too much urine in the bladderbecause scarring from surgery blocks the full release ofurine. Some men also have problems with defecatingafter surgery. Figure 13. Cavernous nerves Illustration Copyright © 2011 Nucleus Medical Media, All rights reserved. www.nucleusinc.comNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 42
  • Part 5: Treating signs and symptomsSide effects of cryotherapy Definitions:The full range of side effects from cryotherapy is unknown. More research is needed. Lymphedema: SwellingKnown short-term side effects include urinary retention, painful swelling, penile due to buildup of lymphparesthesia. Long-term side effects include fistulas, stress incontinence, erectiledysfunction, and blockage of the urethra with dead prostatic tissue. Paresthesia: Sensations of burning, tingling, or pinSide effects of lymph node surgery pricksPLND has risks common to any surgery. You may have serious bleeding or a bad Penile curvature: Thereaction to anesthesia. After surgery, you may develop venous thromboembolism. shape of the penis curvesLymphedema in the legs or arms can also occur and may be permanent. during erectionSide effects of radiotherapy Penile shrinkage: TheSimilar to surgery, a common side effect of radiotherapy is erectile dysfunction. length or girth of the penisUnlike surgery, erectile dysfunction after radiotherapy may develop over 1 – 2 years. decreasesAlthough not as common as erectile dysfunction, other sexual changes may include Retrograde ejaculation:difficulty achieving orgasm, thicker semen, dry orgasm, discolored semen, and a Semen isn’t ejaculated butdecreased sperm count. These side effects often stop after a short period of time. flows into the bladderUrinary problems right after EBRT may include frequent urination, urge incontinence, Transurethral resectiona burning sensation while urinating, and hematuria. Despite the best treatment of the prostate (TURP): Surgical removal of someplanning and delivery, your rectum will be exposed to some radiation during EBRT. prostatic tissue through theYou may have rectal pain, diarrhea, blood in the stool, and colitis. Other EBRT side urethraeffects are swelling, heaviness, and sunburn-like changes in the skin. Urge incontinence: TheAfter brachytherapy, you may have burning with urination, urinary retention, a slow feeling of having to urinateor weak urinary stream, overflow incontinence, and hematuria. Rectal problems are all the timeuncommon. Pain, soreness, and bruising may be felt in the perineum and testicles. Urinary retention: InabilityLong-term urinary incontinence isn’t common for either EBRT or brachytherapy. to urinateHowever, your risk after brachytherapy is higher if you have had a transurethral Venousresection of the prostate (known as TURP). Fatigue is also a common side effect of thromboembolism:radiotherapy. Rarely, a second cancer is caused by radiation. Dangerous blood clot in a veinNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 43
  • Part 5: Treating signs and symptoms Possible side effects Radical prostatectomy Lymph node surgery Hormone therapy • Erectile dysfunction • Lymphedema • Erectile dysfunction • Urinary incontinence • Venous thromboembolism • Low desire for sex • Dry ejaculations • Reaction to anesthesia • Osteoporosis • Smaller or curved penis • Severe bleeding • Bone fractures • Painful orgasm • Pain, swelling, scars • Obesity • Inability to orgasm • Loss of muscle mass • Problems defecating Radiotherapy • Diabetes • Reaction to anesthesia • Erectile dysfunction • Heart disease • Severe bleeding • Urinary retention or • Hot flashes • Pain, swelling, scars incontinence • Breast tenderness or growth • Frequent or painful urination Cryotherapy • Hematuria or bloody stools Chemotherapy • Erectile dysfunction • Diarrhea, colitis • Infections, fevers • Urinary retention or • Difficulty having orgasms • Low white blood cell counts incontinence • Thicker or discolored semen • Bleeding, bruising • Penile paresthesia • Low sperm count • Nausea, vomiting • Fistulas • Sunburn-like skin changes • Loss of appetite • Reaction to anesthesia • Aches, swelling, heaviness • Fatigue • Pain, swelling, scars • Fatigue • Mouth sores • Second cancer • Hair loss Immunotherapy • Chills, fever • Nausea • Headache • Heart problemsNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 44
  • Part 5: Treating signs and symptomsSide effects of hormone therapy Definitions:Hormone therapy has multiple side effects. It can disrupt sexual functioning by Autoimmune disorders:decreasing your desire for sex and causing erectile dysfunction. These sexual Diseases that cause theside effects don’t seem to lessen with time. The longer you take hormone therapy, immune system to attackthe more your risk for osteoporosis, bone fractures, obesity, loss of muscle mass, the bodydiabetes, and heart disease increases. Most men have hot flashes but these may Diabetes: A disease thatdecrease over time. You may have breast tenderness and if you take estrogens, causes high levels of bloodgrowth of breast tissue. sugarSide effects of chemotherapy Hot flashes: A medicalSide effects of chemotherapy depend on the drug type, amount taken, length of condition of feeling intensetreatment, and the person. Some men have many side effects. Others have few. heat and body sweat forSome side effects can be very serious, while others can be unpleasant but not short periodsserious. Side effects include: Osteoporosis: A disease that causes thinning,Infections, fevers, and low white blood cell counts. Many common chemotherapy weakened bonesdrugs can cause these side effects. This is because they target cells that quicklymake new cells. White blood cells are among the fastest of these, so they are more Platelets: A type of bloodeasily destroyed by chemotherapy. Your doctor will check the number of your blood cell responsible for blood clottingcells before each chemotherapy cycle. If too low, a dose of chemotherapy might bedelayed or the amount of chemotherapy might be reduced. White blood cells: A type of blood cell that fightsBlood cell counts are the lowest several days after chemotherapy. As a result, disease as part of theyour body’s ability to fight off an infection is weakened during this time. You should immune systemcontact your doctor right away if you have a fever of 101˚F or higher. A high fever isa sign of infection.Bleeding and bruising. Platelets are another type of blood cell. They stop a woundfrom bleeding by forming blood clots. A shortage of platelets is fairly common duringchemotherapy. Your doctors will check your platelet count and change your cancertreatment if needed.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 45
  • Part 5: Treating signs and symptomsNausea and vomiting. These side effects are fairly to decrease or prevent symptoms after cancer treatment.common. However, your doctor can order drugs for For other symptoms, ongoing tests can track if treatmentyou that greatly reduce these problems. Your doctor is needed. Depending on the symptom, changes inmay recommend drugs for nausea and vomiting before behavior, diet, or medications, or having additionalstarting chemotherapy. If so, it is important to take them. surgery or radiotherapy may help. Below are somePreventing nausea and vomiting is much easier than common ways to control symptoms of prostate cancerstopping them once they start. and its treatment:Other side effects. Short-lived side effects often include • Taking calcium and vitamin D daily may help preventloss of appetite, fatigue, mouth sores, and hair loss. Your or control osteoporosis,doctor or nurse can suggest ways to help with them. • Your doctor may suggest certain drugs to help strengthen bones when on hormone therapySide effects of immunotherapy (see Part 7.5.3),Common side effects are chills, fever, nausea, andheadache. These effects don’t appear to last for long. • Radionucleides are radioactive drugs that maySerious heart problems rarely occur. reduce widespread bone pain (see Part 7.5.3), • Viagra®, Levitra®, or Cialis® can improve erections5.2 Symptom control by increasing blood flow to the penis,Most of these guidelines cover ways to treat prostate • Vacuum devices, penile implants, and injections ofcancer. However, having a good quality of life is also prostaglandin E1 can create erections (Figure 14),very important. You may be able to help yourself feelbetter by taking an active role in your care. If you know • TURP may help improve urine flow,the side effects of treatment, you’re more likely to quickly • Stool softeners or laxatives can ease rectal pain,notice them and tell your treatment team. You should • Surgery and Kegel exercises can help urinaryalso take part in your hospital’s system for tracking and incontinence,treating symptoms. These systems are often called a riskevaluation and mitigation strategy (REMS) program. • Elastic stockings or sleeves can help prevent or control lymphedema,There are useful and safe ways to treat many symptomsof prostate cancer and the problems caused by its • Anti-inflammatory drugs can help relieve pain, andtreatment. Your doctor may give you instructions on how • Exercise may help reduce fatigue.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 46
  • Part 5: Treating signs and symptomsSymptom relief can help you to be more active. It also may, indirectly, help you Notes:to live longer. Don’t hesitate to talk with your cancer care team about symptomsor other concerns. If you don’t tell your treatment team, they may not know howyou’re feeling.Figure 14.Erectile dysfunction aidsIllustration Copyright © 2011 Nucleus Medical Media, All rights reserved. www.nucleusinc.com5.3 Supportive careSome men with advanced prostate cancer may decide not to continue treatment. Inthis case, supportive care is an option. Supportive care includes treatments intendedto stop suffering rather than to control the spread of the cancer. Pain medicationsare one example of supportive care. Removing tumors or killing cancer cells mayalso make you feel better. However, even when such treatment isn’t possible, theremay be other choices. There is no reason to endure pain or other discomfort whensupportive care treatments are available. Some men assume that nothing can bedone to help them. This is not the case. Talk with your cancer care team about anydiscomfort you’re having. If you don’t, you may miss your chance to keep your bestquality of life for as long as possible.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 47
  • Part 6: Beyond usual treatment 6.1 Aren’t there other treatments? Main Points You may hear about other treatments from your family •  ell your doctor about any alternative and T and friends. They may suggest complementary and alternative medicine (CAM), such as vitamins or herbs. complementary medicines you’re taking. CAM is used as a treatment for your cancer or to help •  here is help for the many challenges you’ll T you feel better. However, CAM is a group of treatments face as a patient with cancer. that aren’t usually given by doctors. There is a great deal of interest today in CAM for cancer. •  aregivers who don’t ignore their own needs C Complementary medicines are treatments given along will likely give better care to their loved ones. with usual medical treatments. Examples include acupuncture for pain management or yoga for relaxation. Many CAMs are being studied to find out if they are truly helpful. While some of these treatments may not be designed to kill cancer cells, they may be helpful if they improve your comfort and well-being. Alternative medicine is used in place of usual medicine. Some alternative medicines are promoted as cures, though they often haven’t been proven to work. If there was good proof that CAM or other treatments cured cancer, it would be included in these guidelines. It is important that you let your cancer care team if you’re using CAMs. They should know for two key reasons: 1) Your team can tell you which CAMs are and aren’t helpful; and 2) Some CAMs may limit how well treatment for your cancer or other medical conditions works.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 48
  • Part 6: Beyond usual treatment6.2 What else can I do? Notes:For most patients with cancer, their primary concern is that their treatment works.However, having cancer is complex and brings many physical and emotionalchallenges. It is important to know about these challenges, talk about them withyour cancer care team, and use what support is available. Don’t wait until you feeloverwhelmed to ask questions or raise issues. There are ways of dealing with mostof the problems you’ll face.It is also important to know that there is no norm for how men cope with their cancer.Everyone reacts differently. Your reaction can be shaped by your type of cancer,personality, overall health, the support you have, and other factors. You can helpyourself by knowing possible challenges and taking an active role in managingthem. Below are some of the issues you may face, and, in Part 10, there is a list ofsuggestions for taking care of yourself.Becoming a “cancer patient”Hearing the words, “you have cancer,” is life changing. Having prostate cancer alsomeans dealing with major changes in your life. These can include managing doctor’svisits, figuring out how to care for your kids, missing work, feeling a loss of controlover life, and, possibly, considering the end of life itself. Some men try to keeptheir life as normal as they can. Others change their life drastically. However, manycancer survivors will tell you that during the active treatment period, being a patientwith cancer becomes your job. It’s a job that requires a major commitment of timeand energy and can be a difficult adjustment. Understanding how large of an impactcancer has on your life may help you reach out for support.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 49
  • Part 6: Beyond usual treatmentHaving a treatment plan Anxiety and depressionOne of the best ways to make sure that you agree Feelings of anxiety and depression are common amongwith your treatment plan is to have it written on paper. patients with cancer. Many men experience anxietyTreatment plans include information about your cancer, before their biopsy and while waiting to hear the results.treatment, side effects, physical and emotional issues, For some men, their anxiety or depression may be aand a statement about what is important to you in minor problem. It may be normal like the anxiety feltdeciding future treatment goals. It can also include how while sitting in the doctor’s office or a passing depressionyou can help in your own recovery. during a hard part of treatment. However, you may have longer lasting, more serious distress that limits yourIf you use tobacco, the treatment plan may include ability to live and interact with others.strategies to quit. Quitting will improve your overallhealth. It’ll also return your sense of smell so you can If you’re having anxiety or depression, tell your treatmentbetter enjoy a healthy diet. If you use alcohol, the team. Too many men hesitate to talk about emotionaltreatment plan can outline how much you can drink. concerns when there is excellent help. This might include support groups, “talk” therapy, or medication. Some menTreatment plans are useful for anyone at any stage also benefit from physical exercise, talking with family orbut are critical for men who may not survive cancer. friends, and using relaxation and meditation techniques.A treatment plan allows you to be clear about your Your cancer care team has information to help you.wishes for treating advanced disease and for end-of-lifedecisions. Treatment plans are also valuable when you Sexualitychange your care from one doctor to another, such as Concerns about sexuality are often no small issue forfrom your cancer care team back to your primary doctor. men with prostate cancer. Some treatments for prostateAsk your cancer care team for help with creating a written cancer can diminish sexual interest, response, or both.treatment plan. You may find this very difficult if you aren’t in a stable relationship or still want to have babies. Partners often have concerns too. Some will struggle with a change in your sexual relationship. Others will only care that you’re taking steps to save your life. Talking about these issues with each other and seeking help as a couple may help.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 50
  • Part 6: Beyond usual treatmentFatigue Notes:Fatigue is one of the most common problems for patients with cancer. It can occurduring treatment and beyond, and can have a serious impact on life. Cancer-relatedfatigue differs from normal tiredness in that it comes on suddenly and isn’t relievedby sleep. Researchers aren’t sure what causes cancer-related fatigue. Surprisingly,clinical trials have found that physical exercise can help with cancer-related fatigue.Talk with your treatment team about an exercise program that is right for you.Be aware of your energy levels and try to conserve your energy. Plan ahead, rest,limit activities, and prioritize. Good nutrition and stress management can also behelpful. Also, remember that there are many fun activities that don’t require muchenergy. Solving puzzles, visiting with friends, reading books, watching TV or movies,and even sitting outside can improve how you feel. If you’re fatigued, talk with yourcancer care team about making a treatment plan to help you.PainPatients with cancer fear pain more than any other symptom. The good news is thatit is usually possible to control cancer pain with the right drugs at the right doses.Pain medication also allows most men to function better than when they aren’ttaking these drugs. If you have bone metastases, radiotherapy is another optionfor relieving pain. Don’t suffer in silence. Talk with your doctors and nurses aboutpain control.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 51
  • Part 6: Beyond usual treatmentNutrition Being a survivorSome men with prostate cancer lose weight while Cancer survivorship begins on the day you learn ofothers gain weight during treatment. In every case, having prostate cancer and continues throughout life.good nutrition is always important. Depending on your For many men, the end of active treatment signalstype of cancer and treatment, you may have changes in a time of celebration but also of great anxiety. Thistaste, loss of appetite, or problems eating and digesting is a very normal response. You may need support tofood, or you may become much less active. For some address issues that arise from not having regular visitsmen, eating is related to stress or anxiety. Be aware of with your treatment team.your dietary needs during and after treatment. Talk to a You may have different challenges than the ones listed.nutritional specialist. Meeting your calorie needs, getting It is important to remember that everyone has strengthsplenty of fluids, and eating a balanced diet are and talents. Use yours to help cope with cancer and itsall important. treatments. Maintain warm relationships with family andExercise friends. Make a list for them of things that would helpUntil very recently, most patients with cancer were you. Most people would be happy to hear what you need.told not to exercise during treatment. New research, If you’re a person of faith, your personal faith and faithhowever, has shown that many patients benefit from community can help. There are also professionals inmoderate exercise. Exercise helps men maintain muscle mental health, social work, and pastoral services who aretone and overall health, build good nutritional habits, and able to assist you. You can also start attending supportlower stress. Exercise programs vary depending on each groups to receive help from other cancer survivors.person’s situation, so talk with your treatment team about Visit NCCN’s resources page (NCCN.com) for morewhich exercises would be best for you. information.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 52
  • Part 6: Beyond usual treatment6.3 Caring for caregivers Notes:No one experiences cancer alone. Having cancer deeply affects a patient’s familyand friends, especially those who provide care. This care can take many formsand changes with the stage of the disease. It can range from providing emotionalsupport to giving medical services in the home. Caregivers often take on extraduties to keep day-to-day life normal for the family. Caregivers also play a centralrole in explaining what is happening to the patient to others, including kids, friends,and the treatment team.It is natural to focus on the needs of their loved one, but caregivers should payattention to their own needs as well. Cancer treatment can last from months toyears. Caregivers often describe themselves as exhausted by trying to meet thephysical and mental challenges related to their loved one having cancer. It isn’tsimple, but caregivers need to take care of themselves. If they don’t, they will likelybe unable to give their loved one the best support and care. In Part 9, there is a listof suggestions for caregivers on how to take care of themselves.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 53
  • Part 7: A step-by-step treatment guide The treatment guide for prostate cancer can be found Main Points on the following pages. The goal of this guide is to increase your understanding of the treatment pathways • maging tests and a lymph node biopsy may I for prostate cancer. These pages show under which be done to fully stage your cancer. conditions which tests and treatments are recommended. This information is taken from the NCCN Guidelines •  elaying treatment until tests show D written for your doctors. cancer growth is an option for low- and intermediate-risk cancers. Every effort has been made to make this treatment guide easy to read. Charts are used to map the treatment •  urgery to remove the prostate is an option S pathways. The pathways are further described in the text. when there are no metastases. Some words that you may not know are defined on the page and in the Dictionary in Part 9. More information •  adiotherapy is a primary treatment option for R about the tests and treatments in this guide can be found all prostate cancers. Hormone therapy may in Parts 2 through 6. be added for intermediate-risk, high-risk, and Keep in mind that this guide is meant to help you talk with some metastatic cancers. your doctor about your treatment options. Your doctor •  ormone therapy alone is used for prostate H knows your medical history and personal wishes and cancer that can’t be cured. how these factors might change your options. In Part 10, there is a personal treatment record that you may want to • f the first hormone therapy fails, another I bring with you to your next doctor’s visit. hormone therapy may be tried. Other options include chemotherapy and immunotherapy. •  ollow-up tests for prostate cancer may F include a digital rectal exam, tests of prostate-specific antigen, and biopsies.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 54
  • Part 7: A step-by-step treatment guide7.1 Clinical assessment of prostate cancer Definitions: Biopsy: A medical procedureTests at diagnosis Expected years to live Other clinical tests that collects tissue to test for No other tests or treatment until disease ≤5 years because symptoms appear unless at high Clinical staging: A cancer of older age or risk for symptoms stage given by a doctor other illness and have no cancer Bone scan if: before surgery• DRE, symptoms • T1 tumor with PSA >20, DRE: A medical exam of the• PSA level, and • T2 tumor with PSA >10, prostate by feeling it through• Gleason score • Gleason score ≥8, the wall of the rectum • T3 or T4 tumor, or • If you have symptoms Possible Hormone therapy: lymph Treatment that stops the >5 years or Imaging test of pelvis if: making or action of hormones have symptoms node • T3 or T4 tumor, or biopsy in the body • T1 or T2 tumor with a Imaging: Medical tests that >20% chance of cancer take pictures of the inside of in lymph nodes the body No other tests: Lymph nodes: Small groups • All other tumors of special immune cells located throughout the bodyFor treatment options by risk group, see Part 7.2. Metastasize: The growth of cancer beyond local tissue Prognosis: A prediction of the pattern and outcome of a disease PSA: A protein called prostate-specific antigen which is made by the prostate Radiotherapy: Treatment with radiationNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 55
  • Part 7: A step-by-step treatment guideYou’ve been diagnosed with prostate cancer. The How many years you may live is estimated with twosuggestions in this treatment guide start at this point. sources of information. First, research on the generalAfter diagnosis, the clinical stage of your cancer will population tells how long the average man may livebe determined. This information is used to predict your based on his age. This information can be found atprognosis. A DRE of the prostate area, Gleason score www.ssa.gov/OACT/STATS/table4c6.html. The secondof the biopsy sample, and PSA level are used for source is your general health. If you’re in excellent health,clinical staging. the number of life years from the general population research is increased by half. If you’re in poor health,Other tests can help show if the cancer has spread to the the number of years is decreased by half. If you havelymph nodes or bones. However, not every man needs average health, no change is made. This method maymore tests and/or treatment. NCCN doctors use two correctly predict length of life for a large group of men,conditions to make this decision. These conditions are but it can’t predict without a doubt what will happen to1) the number of years you will likely live and, 2) if your you. Even so, it gives a starting point for suggestingcancer is causing symptoms. It may be hard to talk about treatment choices.how long you might live. However, this information is veryimportant for planning treatment. If you’re likely to die within 5 years and have no cancer symptoms, more testing and cancer treatment aren’tProstate cancer often grows slowly within the gland. If needed. Wait to see if symptoms appear. At that point,you’re likely to die of other causes, having more tests and talk with your doctors about the pros and cons of testingcancer treatment may have little or no benefit. Likewise, and treatment. On the other hand, your chances ofif your cancer isn’t causing symptoms, there may be no having symptoms caused by cancer growth may be high.benefit to having more tests. Having a T3 or T4 tumor or a Gleason score of 8 – 10 puts you at higher risk. Hormone therapy or radiotherapy may prevent your cancer from spreading to the bones and causing much pain.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 56
  • Part 7: A step-by-step treatment guideIf you’re likely to live more than 5 years or have symptoms, testing for metastases Definitions:may help with treatment planning. Prostate cancer often spreads to the bones. Criteria: Standards forA bone scan is suggested if you have signs or symptoms of bone metastases. making a decisionSee the chart for a list of possible signs. An imaging test—CT or MRI scan—is recommended if you have a large tumor because cancer cells may have Fine-needle aspiration:metastasized. A scan is also suggested if your tumor is small but there’s a 20% or Use of a thin needle tohigher chance based on a nomogram that it has metastasized. These scans will remove fluid or tissueshow if the lymph nodes are enlarged, and a fine-needle aspiration can confirm if from the bodycancer is present. Gleason score: The grading system for7.2 Treatment options by risk group prostate cancerThis guide uses recurrence risk groups to recommend treatment options. There Nomogram: A tool thatare six groups based on tumor growth, Gleason score, and PSA scores. These risk uses clinical informationgroups have been tested and were found to predict recurrence well. They provide a to predict an outcomebetter basis for treatment suggestions than your clinical stage. You must know yourlevel of risk to find which treatment suggestions are best for you. If you don’t knowyour risk, ask your doctor for your test results. The criteria for each risk group areshown first in the charts.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 57
  • Part 7: A step-by-step treatment guide7.2.1 Very low recurrence riskCriteria Expected years to live Primary treatment Adjuvant treatment• T1c tumor, No treatment, start <20 years• PSA level <10, active surveilance• PSA density <0.15, No treatment, start• Gleason score ≤6, and active surveilance• <3 biopsy cores positive, ≤50% ≥20 years Radiotherapy, or cancer in any core Adverse features: Radical prostatectomy • Radiotherapy, or • Ongoing monitoring PLND if ≥2% Cancer in lymph nodes: chance of cancer • Ongoing monitoring, or in lymph nodes • Hormone therapyFor active surveillance, see Part 7.3.1.For monitoring after treatment, see Part 7.3.2.The criteria for very low recurrence risk include a T1c There are three treatment approaches if you’re likely totumor. This tumor can’t be felt with a DRE but is found live more than 20 years. The first is to postpone treatmentbecause of high PSA levels. The NCCN Guidelines Panel and start active surveillance. This option may be popularis concerned about over-treatment of this early cancer. if you’re younger and want to avoid treatment side effectsAs a result, their suggestion is not to have treatment until treatment is clearly needed. If older, treating yourright after diagnosis if you’re expected to live less cancer may not be an urgent concern in light of otherthan 20 years since your cancer may never cause any more serious medical problems. However, you may wantproblems. Instead of treatment, begin active surveillance immediate treatment since, in time, the cancer may growas discussed in Part 7.3.1. outside your prostate and/or cause symptoms.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 58
  • Part 7: A step-by-step treatment guideOne immediate treatment option is radiotherapy. Very low-risk cancers may be Definitions:treated with permanent LDR brachytherapy as a monotherapy. They can also be Active surveillance: Delaytreated with EBRT to the prostate and possibly to the seminal vesicles. If you’re at of treatment with ongoinglow risk of recurrence, you shouldn’t receive radiotherapy to the pelvic lymph nodes. testing to watch for cancerFor more information, read the Principles of radiotherapy. growthThe second immediate treatment option is a radical prostatectomy. For low-risk Brachytherapy: Thecancers, the time span after treatment during which there is no cancer progression placement of radioactiveis the same for surgery and radiotherapy. For more information, read the objects near or in the tumorPrinciples of surgery. EBRT: RadiotherapyFollowing surgery, the pathologist will examine your prostate tissue under a received from a machinemicroscope and your PSA level will be tested. If adverse features are found, outside the bodyadjuvant radiotherapy is suggested, but careful monitoring with testing is always a Extracapsular extension:choice. Adverse features include cancer in margins, cancer growth to the seminal Cancer growth through thevesicle(s), extracapsular extension, or detectable PSA levels. These findings prostatic capsulesuggest the surgery didn’t remove all the cancer. Adjuvant radiotherapy is given tothe areas where the cancer cells have likely spread. LDR brachytherapy: The long-term placement ofIf you choose prostatectomy, the lymph nodes in your pelvis may also be removed. radioactive seeds into theA PLND is suggested if there’s at least a 2% chance of metastases according to prostatea nomogram. If the pathologist finds cancer, you may want to have immediatehormone therapy to treat any remaining cancer cells. However, the benefits of Monotherapy: The use of one type of therapy to treat aadjuvant hormone therapy for positive nodes are unclear, so careful monitoring is disease also an option. PLND: Removal of the lymph nodes in the pelvis Radical prostatectomy: Surgery to remove the entire prostate Seminal vesicles: A pair of male glands that makes fluid used by sperm for energyNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 59
  • Part 7: A step-by-step treatment guide Principles of radiotherapyDefinitions: EBRT is a long-established type of radiotherapy for prostate cancer. The prostate3D-CRT: Radiotherapy that can slightly shift within the body, so its position needs to be identified correctly foruses beams that match the the best results. The accuracy of the radiation beam can be improved with use ofshape of the tumor imaging machines during treatment or markers placed in the area before treatment.Gray (Gy): Dose of For EBRT, 3-D and IMRT techniques should be used. IGRT is needed if the radiationradiation dose will be 78 Gray (Gy) or more.HDR brachytherapy: The Brachytherapy is another standard radiotherapy for local prostate cancer. Forshort-term placement and permanent LDR brachytherapy, seed placement is harder if you have a very largeremoval of radioactive or small prostate, your urine flow is blocked, or you had a prior TURP. Moreover,seeds into the prostate your risk for side effects is higher. Neoadjuvant hormone therapy can shrink largeIGRT: Radiotherapy that prostates. After the seeds are implanted, your doctor should measure the radiationuses imaging tests during dose for quality assurance. When HDR brachytherapy is combined with EBRT,treatment doses can be safely increased in patients with intermediate- or high-risk prostate cancer. Urinary and erectile problems may be less likely with HDR than LDRIMRT: Radiotherapy that brachytherapy.uses small beams ofdifferent intensities Research supports giving adjuvant or salvage radiotherapy to all men with signs of aggressive disease that hasn’t metastasized. More than 10 mm of cancer inSurgical margin: Normal the surgical margin or cancer in 3 or more margin sites is considered to be a signtissue around the edge ofa tumor that is removed of aggressive disease. Persistently high PSA levels are another sign. It is best toduring surgery receive adjuvant radiotherapy before PSA levels exceed 1.5 ng/mL.TURP: Surgical removal Radiotherapy works well for reducing symptoms of bone metastases. Some menof some prostatic tissue have bone pain in multiple areas. Radiopharmaceuticals—systemic targetedthrough the urethra treatment—offer pain relief with few side effects. This type of treatment includes strontium-89 (89Sr) and samarium-153 (153Sm).NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 60
  • Part 7: A step-by-step treatment guide Principles of surgery Definitions:Radical prostatectomy is recommended under 4 conditions: 1) Your cancer hasn’t spread far beyond the prostate, Cavernous nerves: 2) Your cancer can be completely removed with surgery, Nerves that send signals to start penile erections 3) You’re expected to live another 10 or more years, and 4) You have no other medical conditions that could cause harm from surgery. Erectile dysfunction:There are ways to control blood loss during a radical prostatectomy. However, it is important The inability to achieve fullthat you know that even with careful blood control, you could lose a lot of blood. Salvage erectionsradical prostatectomy may be a treatment option for local recurrence with no metastases Laparoscopic radicalafter radiotherapy. However, side effects after salvage prostatectomy are almost always prostatectomy: Removalworse than after primary prostatectomy. of the prostate using aMen treated by very experienced surgeons at cancer centers where many radical laparoscopeprostatectomies are done have better results. Laparoscopic and robot-assisted radical Nerve grafts: Theprostatectomies are common surgical methods. In experienced hands, results of these transplant of nerves frommethods are similar to open retropubic prostatectomies. Most men have long-term cancer one area of the body tocontrol with either the retropubic or the perineal approach into the body. anotherTwo common side effects of a radical prostatectomy are urinary incontinence and erectile Open retropubicdysfunction. Your chance of urinary incontinence may be lowered if your surgeon saves prostatectomy: Removalthe length of the urethra, the bladder opening into the urethra, and the muscles that control of the prostate through oneurine flow and there is no narrowing of the urethra when reattached. Your ability to have long incisionerections after surgery is related to your age at surgery, your ability to have erections before Robotic-assistedsurgery, and the function of your cavernous nerves after surgery. After surgical removal of prostatectomy: Athe cavernous nerves, there is no good proof that nerve grafts will help restore your ability laparoscopic prostatectomyto have erections. However, drugs that help you have erections may help you recover your that uses a machine to helpnatural ability. the surgeon make incisionsAn extended PLND removes more lymph nodes in the pelvis area than a limited PLND. Side effect: An unplannedIt finds metastases about two times as often as a limited PLND. It stages cancer more physical or emotionalcompletely and may cure some men with very tiny metastases that haven’t spread further. response to treatmentTherefore, an extended PLND is preferred if you’re to undergo a PLND. It can be done withan open, laparoscopic, or robotic method.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 61
  • Part 7: A step-by-step treatment guide7.2.2 Low recurrence riskCriteria Expected years to live Primary treatment Adjuvant treatment <10 years No treatment, start active surveilance• T1 – T2a tumors,• PSA level <10, and No treatment, start active surveilance• Gleason score ≤6 Radiotherapy, or ≥10 years Adverse features: Radical prostatectomy • Radiotherapy, or • Ongoing monitoring PLND if ≥2% Cancer in lymph nodes: chance of cancer • Ongoing monitoring, or in lymph nodes • Hormone therapyFor active surveillance, see Part 7.3.1.For monitoring after treatment, see Part 7.3.2.The criteria for low recurrence risk include small T1 – T2a 7.2.3 Intermediate recurrence risktumors within the prostate. If you’re likely to live less than The criteria for intermediate recurrence risk include large10 years, no treatment is suggested at this time since T2b and T2c tumors that haven’t grown outside theyour cancer may not cause any problems. Instead, start prostate. If your test results meet more than one criterion,active surveillance. If you’re expected to live 10 or more your risk is higher. In this case, the treatment options foryears, active surveillance is still an option but your cancer the high recurrence risk group are a better fit for you.will likely cause problems in time. Thus, you may want to For intermediate risk, active surveillance instead ofbe treated. Radiotherapy and a radical prostatectomy are treatment is an option for men expected to live less thanrecommended primary treatments. Read Part 7.2.1 for 10 years. It is not recommended if you may live longermore information on these treatments. since the cancer will likely decrease your length of life and cause unpleasant symptoms. For all men with intermediate risk, one curative treatment option is radiotherapy. Research has shown that EBRT alone controls intermediate-risk prostate cancer. EBRT combined withNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 62
  • Part 7: A step-by-step treatment guide7.2.3 Intermediate recurrence risk Notes:Criteria Expected years to live Primary treatment Adjuvant treatment No treatment, start <10 years active surveilance• T2b – T2c tumors,• Gleason score 7, or Radiotherapy with or• PSA level 10 – 20 without hormone therapy for 4 – 6 months Adverse features: ≥10 years • Radiotherapy, or Radical prostatectomy • Ongoing monitoring PLND if ≥2% Cancer in lymph nodes: chance of cancer • Ongoing monitoring, or in lymph nodes • Hormone therapyFor active surveillance, see Part 7.3.1.For monitoring after treatment, see Part 7.3.2.For first-line hormone therapy, see Part 7.5.1.brachytherapy may better treat your cancer but will likely cause more side effects. Consider gettingradiotherapy to your pelvic lymph nodes and/or a short course of hormone therapy if your cancer haspossibly spread beyond the prostate. See Principles of radiation for more information.For men expected to live 10 or more years, surgery is the other option to radiotherapy. Radicalprostatectomy should include a PLND if nomograms predict a 2% or higher chance of metastases.See Principles of surgery for more information.You may receive adjuvant radiotherapy if there are adverse features, which suggest that some cancerremains. Adverse features include cancer in the margins, cancer growth to the seminal vesicle(s),extracapsular extension, or detectable PSA level. Adjuvant radiotherapy is given to the areas wherethe cancer cells have likely spread. If cancer is found in your lymph nodes, one option is to startimmediate hormone therapy to treat the remaining cancer cells. However, the benefits of adjuvanthormone therapy for positive nodes are unclear, so careful monitoring with tests is another option.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 63
  • Part 7: A step-by-step treatment guide7.2.4 High and very high recurrence riskCriteria Primary treatment Adjuvant treatment EBRT and hormone therapy for 2 – 3 years (preferred)High risk:• T3a tumors, EBRT and brachytherapy with or without• PSA level >20, or hormone therapy for 4 – 6 months• Gleason score 8 – 10 Adverse features: Radical prostatectomy with PLND if the • Radiotherapy, or cancer isn’t fixed to nearby organs • Ongoing monitoring Same options as Cancer in lymph nodes:Very high risk: high risk, see above • Hormone therapy, or• T3b – T4 tumors • Ongoing monitoring Hormone therapy when a cure is not possibleFor monitoring after treatment, see Part 7.3.2.For persistent or recurrent prostate cancer, see Part 7.4.For first-line hormone therapy, see Part 7.5.1.The criteria for high recurrence risk include T3a tumors There are three common treatment options for high- andthat have grown outside the prostate. If your test results very high-risk tumors. The preferred treatment is EBRTmeet more than one criterion, your risk is very high. Men with long-term hormone therapy. High-risk patients areat very high recurrence risk also include those with T3b usually not good candidates for permanent brachytherapyand T4 tumors. For high-risk cancers, research supports but it may have benefits when used with EBRT andimmediate treatment after diagnosis except if you’re likely short-term hormone therapy. With either radiotherapyto live less than 5 years. option, you may receive more radiation to treat cancer in the pelvic lymph nodes. For more information, read the Principles of radiotherapy.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 64
  • Part 7: A step-by-step treatment guideIf the tumor can be easily removed, a third option is a radical prostatectomy with Notes:PLND. For more information, read the Principles of surgery. However, for veryhigh-risk cancers, radiotherapy with hormone therapy is better because the canceroutside the prostate will likely be treated. Although better for survival, the risk of thistreatment is erectile dysfunction. If you have a very high-risk cancer that can’t becured, hormone therapy alone may control cancer growth.A detectable PSA level after surgery is a sign that not all of the cancer was removed.In this case, you may want to have adjuvant radiotherapy to destroy any remainingcancer. Likewise, if cancer is found in your lymph nodes, immediate hormonetherapy may treat any cancer that has spread to distant areas. If your PSA levelsremain high after adjuvant treatment, more tests and treatment may be needed.7.2.5 Metastatic diseaseMetastatic groups Primary treatment Hormone therapyAny T, N1, M0 EBRT and hormone therapy for 2 – 3 yearsAny T, Any N, M1 Hormone therapyFor first-line hormone therapy, see Part 7.5.1.Metastatic prostate cancer refers to cancer that has spread to nearby lymph nodesand/or any distant site. Metastatic cancer can be well controlled with treatment. Ifthe cancer has only spread to nearby lymph nodes, there are two treatment options.Hormone therapy alone is one option, and, based on strong evidence from research,the other is EBRT with long-term hormone therapy. If you have distant metastases,hormone therapy alone is recommended.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 65
  • Part 7: A step-by-step treatment guide7.3 Follow-up tests In general, PSA testing should occur at least every 6 months, and a DRE and needle biopsy at least every 127.3.1 Active surveillance months. If you have had less than 10 biopsy cores, a biopsy should be repeated within 6 months of diagnosis.Recurrence risk and Active surveillance Consider repeat biopsies if your PSA level increases orexpected years to live changes are felt during the DRE.Very low risk with • PSA every 3 months, Surveillance testing may occur less often for some men.<20 or ≥20 years • DRE every 6 months, and If you have had 10 or more prostate biopsies, a repeat • Prostate biopsy at least biopsy may be done within 18 months and as often asLow risk with every 12 months. If you’re likely to live less than 10 years≥10 years every 12 months or are older than 75 years of age, PSA testing and DRE may be done as often as every 6 – 12 months and repeatLow risk with prostate biopsies are rarely needed.<10 years • PSA every 6 months, and There is debate over which events should signal the • DRE every 6 months start of treatment. The decision to start treatment shouldIntermediate riskwith <10 years be based on your doctor’s judgment and your personal wishes. The NCCN Guidelines Panel suggests theFor re-staging and primary treatment if following triggering events:cancer progresses, see Parts 7.1 and 7.2. • A Gleason grade of 4 or 5 on repeat biopsy, • A larger amount of cancer within biopsy samples orInstead of prostate cancer treatment, the other option a greater number of biopsy samples with cancer, oris active surveillance. This approach consists of regular • A PSA doubling time of less than 3 years.testing so that treatment can be started when needed.Treatment is given when there is still a chance for a cure.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 66
  • Part 7: A step-by-step treatment guide7.3.2 Monitoring after treatment Definitions:Risk and cure Monitoring Diabetes: A disease that causes high levels of blood • PSA every 6 to 12 months sugar If on long-term hormoneVery low – very high for 5 years, then every 12 therapy: Osteoporosis: A diseaserisk treated for cure months, and • Osteoporosis, diabetes, that causes thinning, • DRE every 12 months and cardiovascular weakened bones • Physical exam with DRE disease tests Testosterone: A hormoneVery high risk, N1,or M1 not treated every 3 – 6 months, and • Testosterone levels if that helps sexual organs infor cure • PSA every 3 – 6 months PSA rises men workFor persistent or recurrent prostate cancer, see Part 7.4.For castration-recurrent prostate cancer, see 7.5.2 and 7.5.3.The goal of primary treatment for very low- to very high-risk cancers is to cure you ofthe disease. A cure is possible when the cancer has not spread far. Your cancer mayhave been cured if tests find no signs of cancer after treatment. However, prostatecancer returns in some men. Regular DRE and PSA tests are suggested to catchany recurrence early. The DRE can find recurrence near the prostate. An increase inthe PSA level can be a sign of recurrence either near the prostate or in other areas.If your treatment wasn’t curative, you should be checked often by a doctor aftertreatment has begun. In addition to a DRE and PSA levels, a complete physicalexam is recommended. A physical exam may tell if your cancer is still growingdespite undergoing treatment.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 67
  • Part 7: A step-by-step treatment guideIt is known that the side effects of ongoing hormone Prostate cancer often responds very well to hormonetherapy increase with time. However, more research is therapy, but over time your PSA levels may increase.needed to fully study the side effects of long-term ADT. This increase is called a biochemical relapse. At thisOne known side effect is osteoporosis. Calcium (1200 point, your testosterone should be tested to see if it is atmg daily) and vitamin D (800 –1000 IU daily) may help castrate levels (<50 ng/dL).prevent or control osteoporosis. Regular bone mineraldensity tests can help you decide when zoledronic acid(4 mg IV annually) or alendronate (70 mg PO weekly) isneeded. Diabetes and cardiovascular disease are otherpossible side effects. Screening and treatment to preventthese diseases are recommended.7.4 Persistent or recurrent prostate cancer7.4.1 Salvage treatment after primary prostatectomySigns Tests Results Treatment • Radiotherapy with or without Possible tests: No metastases hormone therapy, orPSA didn’t drop toundetectable levels • Bone scan, • Ongoing monitoring • CT or MRI scan,Tests found rising • PSA doubling time, or • Hormone therapy with orPSA levels two or • Biopsy of the prostate area Metastases without radiotherapy, ormore times in a row • Ongoing monitoringFor monitoring after treatment, see Part 7.3.2.For first-line hormone therapy, see Part 7.5.1.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 68
  • Part 7: A step-by-step treatment guide7.4.1 Salvage treatment after primary prostatectomy Definitions:After a radical prostatectomy, your PSA level should fall to near zero since the whole Aggressive cancer: Aprostate was removed. If this doesn’t happen, it may be a sign of persistent cancer. If cancer that spreads fasttests find that your PSA level increases twice in a row after falling to near zero, yourcancer may have returned. Since high PSA levels don’t always mean persistent or Biochemical relapse: Arecurrent cancer, tests that find distant metastases may be done. A bone scan shows rise in PSA level while onif the cancer has spread to the bone. It is usually done when there are symptoms of hormone therapybone metastases or when your PSA level is rising quickly. A CT or MRI scan looks Persistent cancer: Cancerfor spread to lymph nodes or other organs. A high PSA doubling time is a sign of not completely removed oraggressive cancer with possible spread to the bone. A biopsy detects cancer in the destroyed by treatmentarea of the prostate. Recurrent cancer: TheIf there is little reason to suspect distant metastases, radiotherapy with or without return of cancer afterhormone therapy is suggested. For known or highly suspected distant metastases, treatmenthormone therapy alone is the main treatment, and radiotherapy may be useful forbone metastases. At times, monitoring rather than more treatment is acceptable forpersistent or recurrent cancer depending on your health and personal wishes.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 69
  • Part 7: A step-by-step treatment guide7.4.2 Salvage treatment after primary radiotherapySigns Tests Results Treatment Cancer isn’t • Ongoing monitoring, found in • Hormone therapy, prostate or • Clinical trial, or • Prostate biopsy, and other areas • More testing Able to have • Bone scanRising PSA local therapy: Cancer is • Ongoing monitoring, Possible tests: • Stages I or II found in • Radical prostatectomy, • CT or MRI scan of • Expected to prostate but • Cryosurgery, or abdomen and pelvis, hasn’t spread • Brachytherapy live >10 years, and • Endorectal MRI, or • PSA is now <10 • PSA doubling time Metastases • Ongoing monitoring, or Unable to have • Hormone therapyPositive DRE local therapyFor monitoring after treatment, see Part 7.3.2.For first-line hormone therapy, see Part 7.5.1.After radiotherapy, PSA levels usually fall to 0.3 ng/mL To confirm local therapy is the right treatment for you,or below. If your PSA increases by at least 2 ng/mL after more tests are needed. A biopsy of the prostate alongfalling to low levels, your cancer may have returned. with a bone scan should be done. Possible other testsSigns of cancer may also be found by a DRE. Local include a CT or MRI scan of the abdomen and pelvis,therapy is an option if: 1) your clinical stage was T1 or T2; an endorectal MRI, and a PSA doubling time. A fast PSA2) initial tests for lymph node metastases were negative doubling time suggests spread beyond the prostate.or weren’t done; 3) you’re likely to live at least another Sometimes the prostate biopsy and tests for metastases10 years; and 4) your current PSA level is below 10. If can be negative despite signs of recurrence. One optionyou don’t meet these criteria or have metastases, your in this situation is to continue with monitoring until cancerchoices are either no immediate treatment or hormone growth is confirmed by tests. Another option is to starttherapy.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 70
  • Part 7: A step-by-step treatment guidelong-term hormone therapy early, but the benefit of hormone therapy in this situation Definitions:is unclear. When to start hormone therapy should be influenced by PSA velocity, Clinical trial: Researchyour anxiety as well as your doctor’s concern about cancer growth, and your feelings comparing new and currentabout side effects. A third option is to enroll in a clinical trial. A fourth option is to treatmentshave more tests to try to find the source of the rising PSA level. These tests caninclude another biopsy and a MR spectroscopy. Cryosurgery: Treatment that freezes tissue to killThere are four options if cancer has returned in the prostate but has unlikely spread cancer cellsto distant sites. The first option is to continue with monitoring until further cancergrowth is found. Another option is radical prostatectomy even though the side effects Endorectal MRI: A typeof salvage surgery are worse than primary surgery. Other options for local treatment of MRI that takes picturesinclude cryotherapy and brachytherapy. Which treatment you receive needs to be through the rectumbased on your chances of further cancer growth, treatment being a success, and the MR spectroscopy: A testrisks of the treatment. that measures chemicals in cells without removing tissue from the body7.5 Systemic therapy for prostate cancerSystemic therapy is given for different stages of prostate cancer. It is sometimesgiven after surgery or with radiotherapy for earlier stages. On the other hand,prostate cancer may be at an advanced stage when you’re first diagnosed or mayprogress after treatment for local disease.Disseminated disease is an advanced cancer that may be controlled with systemictherapy. It includes stage IV prostate cancer. Tests can find disseminated disease.Even so, your doctors may suspect disseminated disease when tests are negative.Usually, the first treatment strategy for known or suspected disseminated diseaseis hormone therapy. Part 7.5.1 discusses hormone therapy options for men who’venever received this treatment.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 71
  • Part 7: A step-by-step treatment guide7.5.1 First-line hormone therapy pain if there are bone metastases, but the pain doesn’t mean the cancer is growing. To prevent the flare, an First-line therapies Additional first-line antiandrogen can be given for 7 or more days, starting before or along with the LHRH agonist. Orchiectomy • Estrogen, LHRH agonist • Steroids, or Antiandrogens can also be used with either medical orNo prior surgical castration on a longer-term basis. This type with or without • Antiandrogenshormone of hormone therapy is called a combined androgen antiandrogentherapy for ≥7 days blockade. However, combined androgen blockade is no to prevent better than castration alone for metastases. Moreover, it testosterone may lead to higher costs and worse side effects. flare Over time, your testosterone levels may increase with Combined medical or surgical castration. If so, your doctor will androgen consider adding estrogens, antiandrogens, or steroids. blockade However, the clinical benefit of adding these drugs isFor monitoring after treatment, see Part 7.3.2. unclear. Table 4 lists the ways that hormone therapy drugs canFirst-line hormone therapy can consist of drugs, surgery, be used for prostate cancer. Although more research isor both. Luteinizing hormone-releasing hormone (LHRH) needed, hormone therapy may be considered for use inagonists are a medical form of castration. Bilateral the following ways:orchiectomy is a surgical form of castration. Castration by • Addition of an antiandrogen for either short- oreither drugs or surgery works equally as well. long-term neoadjuvant hormone therapy,Some metastases can be seen with imaging tests. When • Long-term (2 – 3 years) adjuvant use afterthese overt metastases are treated with LHRH agonists, radiotherapy for intermediate risk, andthere can be an increase in testosterone for several • Intermittent use that may reduce side effects withoutweeks. This increase is called a “flare.” It can cause shortening survival.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 72
  • Part 7: A step-by-step treatment guideTable 4. Common first-line hormone therapy drugs and their uses Definitions:Generic name Possible uses based on NCCN recommendations Estrogen: A hormone used in men to stopLuteinizing hormone-releasing hormone (LHRH) agonists cells from making Degarelix •  eoadjuvant treatment before brachytherapy for high risk or N testosterone large prostates Steroids: Drugs used Goserelin acetate • Short-term (4 – 6 months) use with primary radiotherapy for to stop cells from intermediate-, high-, and very high-risk disease making testosterone Histrelin acetate • Long-term (2 – 3 years) use with primary radiotherapy for high-risk, very high-risk, and metastatic disease Leuprolide acetate • Primary monotherapy for very high-risk or metastatic disease •  hort-term (4 – 6 months) adjuvant treatment after primary surgery SNilutamide if lymph node metastases found •  ith radiotherapy for recurrence without metastases after WTriptorelin pamoate primary surgery • With or without radiotherapy for metastatic recurrence after primary surgery • After primary radiotherapy if PSA increases but tests don’t find cancer •  or recurrence after primary radiotherapy if local therapy is not F possible • For disease progression among men with no prior hormone therapyNonsteroidal antiandrogensBicalutamide • Combined androgen blockade to improve radiotherapy • Combined androgen blockade to fully suppress testosteroneFlutamide •  ith LHRH agonist for ≥7 days to prevent symptoms from W testosterone flare in men with overt metastasesNilutamide •  icalutamide 150 mg daily to save erectile function in men with local B prostate cancer (not FDA approved)NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 73
  • Part 7: A step-by-step treatment guide7.5.2 Castration-recurrent prostate cancer without metastasesTests Results Treatment • Clinical trial (preferred), • Ongoing monitoring,• Bone scan, • If on combined androgen blockade, stop antiandrogen, or• CT or MRI scan, No proof of metastases but PSA is rising • Second-line hormone therapy despite castrate testosterone levels• PSA doubling time, or ▪ Antiandrogen alone• Biopsy ▪ Ketoconazole ▪ Steroids ▪ EstrogensFor castration-recurrent prostate cancer with metastases, see Part 7.5.3.For small cell prostate cancer, see Part 7.6.Castration-recurrent prostate cancer may occur because second. If you’re taking combined androgen blockade,androgen cell receptors in the prostate cancer cells stopping your use of the antiandrogen may curb cancerbecome active again. Mutations in androgen receptors growth. This effect is called the antiandrogen withdrawalallow cancer cells to receive signals from unusual response.sources that activate growth. One unusual source is Second-line hormone therapies may also beantiandrogens. Activation of androgen receptors may tried since the androgen receptor may be active.also occur because the cancer cells or nearby cells start Second-line therapies include an antiandrogen aloneto make testosterone. if first-line therapy was castration. Ketoconazole may alsoA sign of recurrence during primary hormone therapy help when combined with steroids. Estrogens also reduceis rising PSA levels. Rising PSA levels can occur testosterone levels. These second-line drugs may helpeven when tests find no proof of metastases. In these control the cancer for a while; however, they haven’t beencases, joining a clinical trial is the preferred treatment shown to extend life when given before chemotherapy.choice, and ongoing monitoring with no treatment is theNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 74
  • Part 7: A step-by-step treatment guide7.5.3 Castration-recurrent prostate cancer with metastases Definitions:No symptoms or visceral disease Ketoconazole: An anti-Tests Results Treatment fungal drug used to stop cells from making Denosumab or zoledronic testosterone acid if bone metastases Mutations: Changes in • Sipuleucel-T, genetic structure • Bone scan, Metastases • Second-line hormone therapy, found but ▪ Antiandrogen alone• CT or MRI scan, you have no ▪ Ketoconazole or abiraterone acetate• PSA doubling time, or symptoms ▪ Steroids• Biopsy and there is ▪ Estrogens no cancer in • Antiandrogen withdrawal, or your abdomen • Clinical trialFor small cell prostate cancer, see Part 7.6.In 2010, the FDA approved sipuleucel-T for metastatic castration-recurrent prostatecancer. It is an immunotherapy drug. Research suggests that it may slightly extendyour life. Based on the research, the NCCN Guidelines Panel recommends its use ifthe following describes you:• In good health other than prostate cancer,• Able to do most everyday life activities,• Expected to live more than 6 months,• No metastases in the abdomen, and• Have no or very few symptoms of metastases.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 75
  • Part 7: A step-by-step treatment guideFor other treatments, a drop in PSA levels or Prostate cancer often spreads to the bones. Whenimprovement in imaging tests occurs if a treatment prostate cancer invades your bones, they are at risk foris working. Be aware that these signs of treatment injury and disease. Such problems include bone fractures,benefit don’t occur during sipuleucel-T. Thus, don’t be bone pain, and spinal cord compression. Denosumab 120discouraged if your test results don’t improve. After mg every 4 weeks or zoledronic acid every 3 – 4 weekssipuleucel-T, the next treatment should be based on any may help to prevent or delay these problems.new symptoms and test results. Denosumab and zoledronic acid have possible sideSecond-line hormone therapy, antiandrogen withdrawal, effects. They have been linked to osteonecrosis—boneand a clinical trial are other options to sipuleucel-T. See tissue death—of the jaw, hypocalcemia, and arthralgias.Part 7.5.2 for more information on hormone therapy. You may be at higher risk of jaw osteonecrosis if you haveAbiraterone acetate may be considered for men who dental problems now. Get a dental exam and treatmentcan’t take chemotherapy. Not all NCCN Panel Members before starting denosumab and zoledronic acid. Yoursupport its use before chemotherapy at this time, as doctor may suggest taking calcium with vitamin D withresearch on its use without prior chemotherapy isn’t these drugs.finished.Symptoms and/or visceral diseaseTests Result Treatment Denosumab or zoledronic acid if bone metastases • Docetaxel (preferred), • Abiraterone acetate, • Mitoxantrone, • Cabazitaxel,• Bone scan, • Abiraterone acetate, • Mitoxantrone, Metastases found • Salvage chemotherapy,• CT or MRI scan, • Radiotherapy for and you have • Docetaxel rechallenge, symptoms of bone• PSA doubling time, or symptoms or metastases, or • Other second-line hormone therapies cancer in abdomen• Biopsy • Clinical trial • Anti-androgen withdrawal, or • Clinical trialFor small cell prostate cancer, see Part 7.6.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 76
  • Part 7: A step-by-step treatment guideWhen your cancer has advanced to this level, chemotherapy may help. Docetaxel Definitions:with prednisone on an every 3-week schedule is the preferred treatment. Research Arthralgias: Joint painstudies found that men taking docetaxel live longer. These studies gave patients upto 10 cycles if no cancer growth was noted and no severe side effects occurred. If Hypocalcemia: High levelsyour PSA level rises, it doesn’t mean without doubt that docetaxel has failed. Your of calcium in the blooddoctor may suggest that you keep taking docetaxel until it is clear that your cancer Osteonecrosis: Death ofhas grown or side effects are too severe. bone tissueIf you’re unable to take docetaxel, mitoxantrone with prednisone is another option. Spinal cord compression:This chemotherapy may improve your quality of life, but it isn’t likely to increase how The bundle of nerves in thelong you will live. Abiraterone acetate, a hormone therapy, may be considered for spine is squeezed causingmen who can’t take chemotherapy, but most NCCN Panel Members don’t support painroutine use at this time. Research on its use without prior chemotherapy isn’tfinished. Another option to docetaxel is to take part in a clinical trial.Denosumab and zoledronic acid may prevent or delay problems related to bonemetastases as already discussed. If you have pain from bone metastases,radiotherapy may help. EBRT may be used when pain is limited to a specific areaor your bones are about to fracture. Radionucleides with either 89Sr or 153Smmay relieve pain from widely spread bone metastases that isn’t responding to othertreatments. Be aware that your body may make less bone marrow because ofradionucleides, which could prevent you from being treated with chemotherapy.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 77
  • Part 7: A step-by-step treatment guideIf docetaxel fails, there is no strong agreement on what 7.5.4 Small cell prostate canceris the next best treatment. Research found an extendedlength of life for two treatments after docetaxel. One Treatmentof these treatments is abiraterone acetate (1000 mg • Cisplatin/etoposide,per day without food) with low-dose prednisone (5 mg Biopsy confirmstwice daily). The other is cabazitaxel with prednisone. small cell • Carboplatin/etoposide, orCabazitaxel can cause severe side effects so ongoing prostate cancer • Docetaxel-based regimentesting is needed. You shouldn’t use cabazitaxel if youhave liver problems. Small cell prostate cancer is rare. Possible signs ofIf you can’t use a taxane-based chemotherapy like this type of cancer include an initial Gleason score ofcabazitaxel, mitoxantrone with steroids may be 9 or 10, hormone therapy failure, and metastases, butconsidered. Mitoxantrone and other chemotherapy only a biopsy can tell if you have the disease. If youagents haven’t extended the lives of men after docetaxel do have small cell prostate cancer, it may respond tofailure but may help you feel better by reducing chemotherapy such as cisplatin/etoposide or carboplatin/symptoms. Other options include docetaxel rechallenge, etoposide.second-line hormone therapy, antiandrogen withdrawal,and clinical trials. See Part 7.5.2 for more information onhormone therapy options. NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 78
  • Part 8: How do I choose my treatment? Part 8: How do I choose my treatment?You’re almost at the end of the NCCN Patient Guidelines for prostate cancer. Parts Notes:2 through 7 aimed to give you the best information on prostate cancer and itstreatment. The goal of Part 8 is to address some issues related to choosing yourtreatment.8.1 I have to choose?Choosing a treatment option may be hard. You may not want to have treatment, butwithout treatment, you risk having the cancer spread. Four factors are often used todecide if active surveillance is a good choice. First, treatment may not be neededif your cancer has not spread outside the prostate. Second, a low Gleason scoremay indicate that your cancer won’t be aggressive. Third, if you’re of advanced age,your cancer may not cause any problems. Last, if you have another serious disease,treating cancer may not be a priority. Consider these four factors when decidingabout active surveillance.If you choose to have treatment, the next step is to choose which treatment to have.This choice may be harder. Science doesn’t always help. In many cases of prostatecancer, one treatment hasn’t been shown to work better than another. You will haveto carefully weigh the benefits and downsides of the treatment choices in light ofyour personal situation.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 79
  • Part 8: How do I choose my treatment?8.2  Opinions of doctors, partners, 8.3 Getting a 2nd opinion and others The time around a cancer diagnosis is very stressful.Based on test results, meetings with doctors from People with cancer often want to get treated as soon asdifferent fields will follow. Be ready to ask tough possible. They want to make their cancer go away beforequestions. Many men find it helpful to have their spouse, it spreads further. While cancer can’t be ignored, there ispartner, or a friend with them at these visits. They can time to think about and choose which treatment plan ishelp to ask questions and remember what was said. best for you.The doctors you see may have different opinions You may wish to have another doctor review youron which treatment is best for you. This can be very test results and the treatment plan your doctor hasconfusing. The NCCN Guidelines are developed by recommended. This is called getting a 2nd opinion.a panel of doctors, other health care workers, and Prostate cancer is a serious disease, and newpatient advocates with many areas of expertise. The information may have been published about whichtreatments in these guidelines are suggested by the treatments work best and are safe. You may completelypanel without any major internal dissent unless noted. trust your doctor, but a 2nd opinion on which treatment isThis allows you to have an unbiased point of view about right for you can help.treatment options. Compare these guidelines to the Copies of the pathology report and other test resultsrecommendations of the doctors you visit. need to be sent to the doctor giving the 2nd opinion. SomeYou may be leaning toward choosing one treatment over men feel uneasy asking for copies from their doctors.another. However, your partner may disagree. Share However, a 2nd opinion is a normal part of cancer care.with one another the reasons for preferring a treatment. When doctors have cancer, most will talk with more thanListening to each other’s opinions may shed light on an one doctor before choosing their treatment. What’s more,issue you haven’t considered. It may also be helpful to some health plans require a 2nd opinion. If your healthgo together or alone to a local support group. At these plan doesn’t cover the cost of a 2nd opinion, you have themeetings, you can ask questions and hear about the choice of paying for it yourself.experiences of other men with prostate cancer.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 80
  • Part 8: How do I choose my treatment?Choosing your cancer treatment is a very Notes:important decision. It can affect your lengthand quality of life. There are few cancersthat are so aggressive that you can’t takea few weeks to get a 2nd opinion and selectthe best treatment for you.8.4 Benefits and downsidesof treatment optionsEvery treatment option has benefitsand downsides. Consider these whendeciding which option is best for you.Some outcomes for each option are listednext. Most were taken from the NCCNGuidelines written for doctors. There maybe other outcomes than those listed on thefollowing pages.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 81
  • Part 8: How do I choose my treatment?Benefits and downsides of treatment optionsActive surveillance Prostatectomy External beam radiation therapyBenefits Benefits BenefitsAvoid treatment that may not be Long-established treatment of Doesn’t have complications likeneeded prostate cancer surgery (eg, bleeding and heart May cure local cancer attack)Avoid side effects of treatment Short hospital stay Can be used with men of manyMaintain your quality of life different ages Multiple surgery optionsLower initial costs Very low risk of urinary incontinence Removal of cancerous lymph nodes and strictureNew treatments may become if radical approach used Maintain erectile function in theavailable short term Downsides Unlike surgery, may treat cancerDownsides Requires anesthesia beyond the prostateCancer may spread/Miss chance tocure cancer Risk of severe bleeding and heart Downsides attackGreater anxiety when not treated Takes 8 to 9 weeks to complete Doesn’t treat distant cancerFrequent doctor’s visits and tests Injury to skin Inexperienced surgeons have poorer Short-term bladder or bowelLong-term results of untreated results problemsprostate cancer aren’t known Immediate erectile dysfunction at Low but real risk of rectal symptomsWhen needed, treatment may be least in the short term Risk of erectile dysfunction increasesdifficult over time Immediate urinary incontinence atGreater odds of erectile dysfunction Salvage surgery for recurrence has least in the short termafter surgery greater risk of complicationsNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 82
  • Part 8: How do I choose my treatment? Notes:Brachytherapy Hormone therapyBenefits BenefitsOne day to complete Treats prostate cancer throughoutFast recovery the bodySimilar cancer control as surgery for Prolongs lifelow-risk cancer Easy to take drugs compared toLow risk of incontinence when no prior surgery or radiotherapytransurethral resection of the prostate Can reduce cancer symptomsMaintain erectile function in theshort term Intermittent use may be consideredDownsides DownsidesRequires anesthesia and sometimesa catheter Sexual problems including low sex drive and erectile dysfunctionRisk of urinary retention right aftertreatment Hot flashes that may bother youUncomfortable voiding for as long Weight gain and loss of muscleas 1 yearHigher risk of incontinence when prior Risk of serious health problems liketransurethral resection of the prostate diabetes and heart diseaseRisk of erectile dysfunction increases Therapy may stop workingover time Can’t cure prostate cancerMore genital and urinary side effectsthan intensity-modulated radiotherapyNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 83
  • Part 9: DictionaryActive surveillance Anterior zone Biochemical relapseDelay of treatment with ongoing The front of the prostate near A rise in PSA level while on hormonetesting to watch for cancer growth; the penis. therapy.watchful waiting, expectant Antiandrogens Biopsymanagement. Drugs used to stop the action of A medical procedure that collectsAdenocarcinoma testosterone. tissue to test for disease.Cancer in cells that line organs and Antiandrogen withdrawal response Bladdermake fluids or hormones. Level of prostate-specific antigen An organ that holds and expels urineAdjuvant treatment decreases when the antiandrogen from the body.Treatment that follows primary is stopped. Blood cell counttreatment. Aortic lymph nodes The number of red blood cells, whiteAggressive cancer Lymph nodes near the heart along blood cells, and platelets in blood.A cancer that spreads fast. the aorta. Blood chemistry testAlternative medicine Arthralgias A test to show unusual amountsTreatments used in place of ones Joint pain. of chemicals in the body.usually given by doctors. Arthritis Bone metastasesAndrogen Swelling of the bone joints. Cancer that has spread toA hormone found in high levels in the bones. Autoimmune disordersmales that is involved in sexual Diseases that cause the immune Bone scandevelopment and functioning. system to attack the body. A test for bone diseases.Androgen deprivation therapy Benign prostatic hypertrophy Brachytherapy(ADT) (BPH) The placement of radioactive objectsTreatment that stops the making A non-cancerous overgrowth of the near or in a tumor.or action of hormones in the body; prostate that often causes urinationhormone therapy. Castration therapy problems. Orchiectomy or drugs that greatlyAnterior lobe Bilateral reduce the level of testosterone.The part of the prostate in front of Involving both sides or parts.the urethra.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 84
  • Part 9: DictionaryCatheter Computed tomography (CT) Dry orgasmA tube that drains fluid from A test that uses x-rays to view Having an orgasm withoutthe body. body parts. ejaculation.Cavernous nerves Contrast DysorgasmiaNerves that send signals to start A substance put into your body Pain during orgasm.penile erections. to make better pictures during Ejaculation imaging tests.Central zone The ejection of semen from theThe inner part of the prostate around Control group male body.the transition zone. Research participants who don’t Endorectal coil receive a new treatment.Cervical lymph nodes A thin wire covered with a latexLymph nodes in the neck. Criteria balloon. Standards for making a decision.Chemotherapy Endorectal MRIDrugs that kill cancer cells. Cryosurgery A type of MRI that takes pictures Treatment that freezes tissue to kill through the rectum.Clinical staging cancer cells.A cancer stage given by a doctor Enemabefore surgery. Defecation Injection of liquid into the rectum to The release of stool (feces) from clear the bowel.Clinical trial the body.Research comparing new and current Epididymistreatments to find out which Diabetes The tube through which sperm travelis better. A disease that causes high levels of after leaving the testicles. blood sugar.Colitis EpididymitisSwelling of the colon. Diagnose Swelling of the epididymis. To identify a disease. Combined androgen blockade (CAB) Epidural anesthesiaCastration therapy combined with an Digital rectal exam (DRE) Loss of feeling in the lower half ofantiandrogen. A medical exam of the prostate the body from an ongoing injection of by feeling it through the wall of drugs into the outermost part of the the rectum. spinal canal.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 85
  • Part 9: DictionaryEpithelial cells Fine-needle aspiration Gleason scoreCells that form the lining of organs or Use of a thin needle to remove fluid The grading system for prostateform glandular tissue. or tissue from the body. cancer.Erectile dysfunction First-line treatment Gray (Gy)The inability to achieve full The first treatment given. Dose of radiation.erections. Fistula HematospermiaEstrogen A passage between two organs that Blood in semen.A hormone used in men to stop cells aren’t normally connected. Hematuriafrom making testosterone. General anesthesia Blood in urine.Expectant management A controlled loss of consciousness High-dose rate (HDR)Delay of treatment with ongoing from drugs. brachytherapytesting to watch for cancer growth; Genes Radioactive objects are removed fromactive surveillance, watchful Information in cells for building the tumor after the radiation dose haswaiting. new cells. been given.External beam radiation therapy Gland Hormone therapy(EBRT) A small organ that makes Treatment that stops the makingRadiotherapy received from a chemicals. or action of hormones in the body;machine outside the body. androgen deprivation therapy. Glandular tissueExternal sphincter Groups of cells that are able to Hot flashesMuscle that controls the flow of make fluid. A medical condition of feeling intenseurine from the bladder through the heat and body sweat for shorturethra. Gleason grade periods. A score made by a pathologistExtracapsular extension based on how prostate cancer cells HypercalcemiaCancer growth through the look. The primary grade is the most High levels of calcium in the blood.prostatic capsule. common pattern, and the secondary Iliac lymph nodesFatigue grade is the second most common Lymph nodes in the pelvic area.Severe tiredness despite getting pattern.enough sleep.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 86
  • Part 9: DictionaryImage-guided radiation therapy Intensity-modulated radiation Laxatives(IGRT) therapy (IMRT) Drugs used to clean out theRadiotherapy that uses imaging Radiotherapy that uses small beams intestines.tests during treatment to better target of different intensities. Levator musclesthe tumor. Intermittent therapy Muscles that support the prostateImaging Alternating periods of time on and and control the flow of urine.Medical tests that take pictures of the off treatment. Local anesthesiainside of the body. Interstitial radiation A loss of feeling due to drugs inImmunotherapy A type of brachytherapy that places a specific area of the body.Treatment that uses the immune radioactive objects in the tumor. Low-dose rate (LDR)system to fight disease. Ketoconazole brachytherapyIncidental finding An anti-fungal drug used to stop Radioactive objects are inserted intoAn unplanned medical discovery cells from making testosterone. the tumor and left to decay.different from the presenting Lactate dehydrogenase Luteinizing hormone-releasingillness. An enzyme found in the blood and hormone (LHRH) agonistsIncision other body tissues. Drugs used to stop the testicles fromA surgical cut into the body. making testosterone. LaparoscopeInformed consent form (ICF) A thin, long tube with a light and LymphA document describing a study and camera used to see into the body. A clear fluid containing whiterequiring a signature from participants blood cells. Laparoscopic radicalafter review. prostatectomy Lymph nodesInguinal lymph nodes Removal of the prostate using a Small groups of special immune cellsLymph nodes in the groin area. laparoscope. located throughout the body.Inorgasmia Lateral lobe LymphedemaInability to have an orgasm. The largest part of the prostate on Swelling due to buildup of lymph. the left and right sides.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 87
  • Part 9: DictionaryMagnetic resonance imaging (MRI) Nerve graphs OsteonecrosisA test using radio waves and powerful The transplant of nerves from one Death of bone tissue.magnets to view the parts of the body area of the body to another. Osteoporosisand how they are working. Nerve-sparing prostatectomy A disease that causes thinning,Magnetic resonance (MS) One or both bundles of cavernous weakened bones.spectroscopy nerves aren’t removed during a Overflow incontinenceA test that measures chemicals in prostatectomy. Leakage of urine due to a fullcells without removing tissue from Neuroendocrine cells bladder.the body. Cells that receive messages from ParesthesiaMedian lobe nerves and send chemical messages Sensations of burning, tingling, orThe part of the prostate near to the blood. pin pricks.the urethra. Neuroendocrine prostate cancer ParticlesMedical oncologist Cancer in the neuroendocrine cells of Small pieces of matter.A doctor who specializes in all the prostate.types of cancer. Pathologic staging Nomogram A cancer stage given by a pathologistMetastasis A tool that uses clinical information to based on surgery samples.The growth of cancer beyond predict an outcome.local tissue. Pathologist Obesity A doctor who specializes in testingMonotherapy A high amount of body fat compared cells to identify disease.The use of one type of therapy to to body height.treat a disease. Pelvic lymph node dissection Open retropubic prostatectomy (PLND)Mutations Removal of the prostate through one Removal of the lymph nodes inChanges in genetic structure. long incision. the pelvis.Neoadjuvant treatment Orchiectomy Pelvic wallTreatments given before the primary Surgical removal of the testicles from A layer of muscles and tissuetreatment. the body. that helps organs in the pelvis to stay in place. NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 88
  • Part 9: DictionaryPelvis Photon beam ProstatitisThe body area between the A stream of particles that have no Swelling of the prostate.hipbones. mass or electric charge. Proton beamPenile curvature Platelets A stream of positively chargedThe penis is curved and not straight A type of blood cell responsible for particles that emit energy within aduring erections. blood clotting. short distance.Penile erection Posterior lobe PSA densityThe stiffening of the penis from blood The back of the prostate near Comparison of the level of prostate-filling its sacs. the rectum. specific antigen to the size of the prostate.Penile shrinkage Primary treatmentThe length or girth of the penis The main treatment for cancer. PSA doubling timedecreases. The time during which the prostate- Prognosis specific antigen doubles.Penis A prediction of the pattern andA male organ used for sex and outcome of a disease based on PSA levelurination. clinical information. Number of nanograms per milliliter of prostate-specific antigen.Percent-free PSA ProstateThe percentage of unbound form of A male gland that makes fluid PSA velocityprostate-specific antigen. for protecting sperm from acid in How much the level of prostate- the vagina. specific antigen changesPerineum over time.The area in men between the scrotum Prostate-specific antigen (PSA)and anus. A protein made by the prostate. Puberty The time when teens sexuallyPeripheral zone Prostatic capsule develop.The back of the prostate near The tissue that covers thethe rectum. prostate. Radiation oncologist A doctor who specializes in thePersistent cancer Prostatic fluid treatment of cancer with radiation.Cancer not completely removed or A whitish, thick liquid made bydestroyed by treatment. the prostate.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 89
  • Part 9: DictionaryRadical perineal prostatectomy Retrograde ejaculation SemenRemoval of the prostate through the Semen isn’t ejaculated but flows A mix of fluids and sperm. perineum. into the bladder. Seminal vesiclesRadical prostatectomy Retroperitoneal lymph nodes A pair of male glands that makes fluidSurgery to remove the entire Lymph nodes behind the used by sperm for energy.prostate. intestines. Side effectRadical retropubic prostatectomy Retropubic An unplanned physical or emotionalRemoval of the prostate through one Behind the pubic bone. response to treatment.or more incisions in the pelvis. Risk factors Small cell prostate cancerRadioactive Something that increases the chance A type of neuroendocrineContaining a powerful energy called of getting a disease. prostate cancer.radiation. Robotic-assisted prostatectomy SpermRadiologist A laparoscopic prostatectomy that Cells containing male genes that areA doctor who specializes in reading uses a machine to help the surgeon needed to make babies.imaging tests. make incisions. Spinal anesthesiaRadionucleides Salvage therapy Loss of feeling in the lower half of theRadioactive drugs that enter bones to The treatment given after standard body from a shot of drugs into thekill cancer cells. treatment fails. spongy tissue of the spine.Radiotherapy Scar Spinal cord compressionTreatment with radiation. A permanent mark on the prostate The bundle of nerves in the spine is after an injury or surgery. squeezed causing pain.RandomizedAssignment to a group by chance. Screening Staging Testing done on a regular basis to Grouping of cancer according to howRectum detect a disease in someone without far it has spread in the body.The last part of the large intestine. symptoms. SteroidsRecurrent cancer Second-line treatment Drugs used to stop cells from makingThe return of cancer after The treatment given after the first testosterone.treatment. treatment fails.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 90
  • Part 9: DictionaryStress incontinence Transition zone Urinary incontinenceLeakage of urine when pressure is The inner part of the prostate around Inability to control the release of urineexerted on the bladder from sneezing, the urethra. from the bladder.coughing, exercise, and so forth. Transrectal Urinary retentionSupportive care Through the rectum. Inability to empty the bladder.Treatment for symptoms of a Transrectal ultrasound Urologistdisease. A type of ultrasound that takes A doctor who specializes in theSupraclavicular lymph nodes pictures of the prostate through the urinary system of men and womenLymph nodes above the rectum. and in male sex organs.collarbone. Transurethral resection of the U.S. Food and Drug AdministrationSurgeon prostate (TURP) (FDA)A doctor who specializes in Surgical removal of some prostatic A federal government agency thatoperations. tissue through the urethra. regulates drugs and food.Surgical margin Triple androgen blockade VaginaNormal tissue around the edge Finasteride or dutasteride with A muscular tube at the base of theof a tumor that is removed combined androgen blockade. uterus with an opening to the outsideduring surgery. of the body; birth canal. TumorSystemic therapy A tissue mass made from an Venous thromboembolismTreatment to destroy cancer cells abnormal growth of cells. Dangerous blood clot in a vein.throughout the body. Tumor flare Watchful waitingTestosterone An increase in testosterone after Delay of treatment with ongoingA hormone that helps sexual organs starting castration therapy. testing to watch for cancer growth;in men work. Active surveillance, expectant Urethra management.Three-dimensional conformal A tube that expels urine from theradiation therapy (3D-CRT) body; it also expels semen in men. White blood cellsRadiotherapy that uses beams that A type of blood cell that fights disease Urge incontinencematch the shape of the tumor. as part of the immune system. The feeling of having to urinate all the time.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 91
  • Part 10: Tools10.1 Questions to ask about testing for prostate cancer• What tests will I have?• Where will the tests take place? Will I have to go to the hospital?• How long will it take? Will I be awake?• Will it hurt? Will I need local anesthesia?• What are the risks? What are the chances of infection or bleeding afterward?• How much will the tests cost? How can I find out how much my insurance company will cover?• How do I prepare for it? Will I need to avoid taking aspirin to reduce the chance of bleeding? Should I not eat beforehand?• Should I bring a list of my medications?• Should I bring someone with me?• How long will it take for me to recover? Will I be given an antibiotic or other medicine afterward?• How soon will I know the results and who will explain them to me? If a biopsy is done, will I get a copy of the pathology report?• If I do have cancer, who will talk with me about the next steps? When?NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 92
  • Part 10: Tools10.2 Questions to ask about treating prostate cancer• What are the available treatments for prostate cancer?• What are the risks and benefits of each treatment for prostate cancer?• How will my age, general health, stage of prostate cancer, and other medical conditions influence treatment choices?• Do I have to get treated?• Would you help me get a 2nd opinion?• Where will I be treated? Will I have to stay in the hospital or can I go home after each treatment?• What can I do to prepare for treatment? Should I stop taking my medications? Should I store my blood in case I need a transfusion?• How many prostatectomies have you done? How many of your patients have had complications?• How soon should I start treatment? How long does treatment take?• How much will the treatment cost? How can I find out how much my insurance company will cover?• How likely is it that I’ll be cancer-free after treatment?• What symptoms should I look out for while being treated for prostate cancer?• When will I be able to return to my normal activities?• What is the chance that my cancer will come back and/or spread?• What should I do after I finish treatment?• Are there supportive services that I can get involved in? Support groups?NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 93
  • Part 10: Tools10.3 Questions to ask about clinical trials• Is there a clinical trial that I could take part in?• What is the purpose of the study?• What kinds of tests and treatments does the study involve?• What does the treatment do?• Has the treatment been used before? Has it been used for other types of cancers?• Will I know which treatment I receive?• What is likely to happen to me with, or without, this new treatment?• What are my other choices? What are their benefits and risks?• How might the study change my daily life?• What side effects can I expect from the study? Can the side effects be controlled?• Will I have to stay in the hospital? If so, how often and for how long?• Will the study cost me anything? Will any of the treatment be free?• If I’m harmed as a result of the research, what treatment might I get?• What type of long-term follow-up care is part of the study?NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 94
  • Part 10: Tools10.4 Suggestions for taking care of yourself• Let other people help you. This is the time to take advantage of offers for rides, meals, childcare, or just good company.• Be as healthy as you can—eat well, get enough rest, exercise, and stop smoking.• Talk with your family and friends about your concerns and needs. Let them know what is important to you, including your feelings about end-of-life decisions.• Do the things that help you cope—keep a journal, garden, play music, or take that trip you’ve been wanting to take.• Don’t be afraid to take medications that can help your emotional and physical symptoms. Let your cancer care team help you.• Talk with your treatment team about what you’re experiencing. Don’t wait until you’re feeling overwhelmed.• Know the resources that are available to you and use them.• Be your own advocate—ask questions, take notes, and be active in your treatment.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 95
  • Part 10: Tools10.5 Suggestions for taking care of caregivers• Take the time to understand your loved one’s cancer and its treatment. Educating yourself will help you know what to expect and how you can be supportive.• Help provide eyes and ears and sometimes a voice for your loved one. It is extremely useful for patients to have someone with them at doctor visits to listen, ask questions, take notes, process what is said, and sometimes speak up on their behalf.• Talk about the important issues. Do it from the very beginning. Don’t wait until a patient is too sick or has lost too much ability to address important matters.• Help develop a treatment plan, and, if appropriate, an advance directive. Such plans help everyone involved understand what is important to the patient in terms of treatment goals and end-of-life decisions.• Take care of yourself. Find the time to get away—take a walk, have lunch with a friend, see a movie, and do something that feels normal. In addition, eat well, try to sleep well, and exercise. You’ll be a better caregiver if you’re taking care of yourself.• Let other people help you. Take advantage of those offers to make a meal, provide a ride, watch the kids, or just give you a break. Let your friends know what they can do.• Take advantage of the resources that are available. There are many approaches to dealing with the complex issues you may face as a caregiver. You should know what support is there for you and use these resources.• Understand that caregivers are survivors just as much as patients are. Cancer is life-changing whether you’re the patient or the person caring for the patient.NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 96
  • 10.6 Personal treatment recordGeneral InformationPatient informationName: _______________________________________________________ Hospital ID number: _________________________________________Emergency contact: ____________________________________________ Emergency telephone: _______________________________________Provider InformationName: _____________________________________ Address: ____________________________________ Telephone: _________________Name: _____________________________________ Address: ____________________________________ Telephone: _________________Name: _____________________________________ Address: ____________________________________ Telephone: _________________Name: _____________________________________ Address: ____________________________________ Telephone: _________________Clinical AssessmentTestsName/Date: ___________________________________________________ Result: _____________________________________________________Name/Date: ___________________________________________________ Result: _____________________________________________________Name/Date: ___________________________________________________ Result: _____________________________________________________Name/Date: ___________________________________________________ Result: _____________________________________________________Name/Date: ___________________________________________________ Result: _____________________________________________________Cancer informationCancer site: ___________________________________________________ Diagnosis date: _____________________________________________(T)umor score: ________________ (N)ode score: ________________ (M)etastasis score: _________________ Stage: ________________ Histology: _______________Tumor TreatmentName: _____________________________________ Start date: __________________________________ End date: _________________Name: _____________________________________ Start date: __________________________________ End date: _________________Name: _____________________________________ Start date: __________________________________ End date: _________________Name: _____________________________________ Start date: __________________________________ End date: _________________Symptom TreatmentName: _____________________________________ Start date: __________________________________ End date: _________________Name: _____________________________________ Start date: __________________________________ End date: _________________Name: _____________________________________ Start date: __________________________________ End date: _________________Name: _____________________________________ Start date: __________________________________ End date: _________________Post-Treatment PlanDescribe: _________________________________________________________________________________________________________________________________NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 97
  • NCCN Member InstitutionsCity of Hope Robert H. Lurie Comprehensive Cancer Stanford Cancer InstituteComprehensive Cancer Center Center of Northwestern University Stanford, CaliforniaLos Angeles, California Chicago, Illinois 877.668.7535800.826.4673 866.587.4322 www.cancer.stanfordhospital.comwww.cityofhope.org www.cancer.northwestern.edu University of Alabama at BirminghamDana-Farber/Brigham and Memorial Sloan-Kettering Cancer Center Comprehensive Cancer CenterWomen’s Cancer Center | New York, New York Birmingham, AlabamaMassachusetts General Hospital 800.525.2225 800.822.0933Cancer Center www.mskcc.org www.ccc.uab.eduBoston, Massachusetts800.320.0022 H. Lee Moffitt Cancer Center UCSF Helen Diller Familywww.dfbwcc.org • www.massgeneral.org/cancer & Research Institute Comprehensive Cancer Center Tampa, Florida San Francisco, CaliforniaDuke Cancer Institute 800.456.3434 800.888.8664Durham, North Carolina www.moffitt.org http://cancer.ucsf.edu888.275.3853www.cancer.duke.edu The Ohio State University Comprehensive University of Michigan Cancer Center - James Cancer Hospital Comprehensive Cancer CenterFox Chase Cancer Center and Solove Research Institute Ann Arbor, MichiganPhiladelphia, Pennsylvania Columbus, Ohio 800.865.1125888.369.2427 800.293.5066 www.mcancer.orgwww.foxchase.org http://cancer.osu.edu UNMC Eppley Cancer Center atHuntsman Cancer Institute Roswell Park Cancer Institute The Nebraska Medical Centerat the University of Utah Buffalo, New York Omaha, NebraskaSalt Lake City, Utah 877.275.7724 800.999.5465877.585.0303 www.roswellpark.org www.unmc.edu/cancercenterwww.huntsmancancer.org Siteman Cancer Center at Barnes- The University of TexasFred Hutchinson Cancer Research Center/ Jewish Hospital and Washington MD Anderson Cancer CenterSeattle Cancer Care Alliance University School of Medicine Houston, TexasSeattle, Washington St. Louis, Missouri 877.632.6789206.288.7222 • www.seattlecca.org 800.600.3606 www.mdanderson.org206.667.5000 • www.fhcrc.org www.siteman.wustl.edu Vanderbilt-Ingram Cancer CenterThe Sidney Kimmel Comprehensive St. Jude Children’s Research Hospital/ Nashville, TennesseeCancer Center at Johns Hopkins University of Tennessee Cancer Institute 800.811.8480Baltimore, Maryland Memphis, Tennessee www.vicc.org410.955.8964 901.595.4055 • www.stjude.orgwww.hopkinskimmelcancercenter.org 877.988.3627 • www.utcancer.orgNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 98
  • Also Available at NCCN.com! Breast, Lung, and Ovarian Cancers,NCCN Guidelines staff Chronic Myelogenous Leukemia, Malignant Pleural Mesothelioma,Maria Ho, PhDOncology Scientist/Senior Medical Writer Melanoma, and Multiple Myeloma. Breast Cancer NCCN Guidelines for Patients™NCCN Patient Guidelines staffDorothy A. Shead, MS Version 2.2011Director Malignant Pleural Mesothelioma Also available at NCCN.comPatient and Clinical Information Operations NCCN Guidelines for Patients™Laura J. Hanisch, PsyD Chronic Myelogenous LeukemiaMedical Writer/Patient Information Specialist Version 2011 NCCN Guidelines for Patients™ NCCN Guidelines for Patients™: Malignant Pleural Mesothelioma Presented with support from the national law firm of Baron & Budd Also available at NCCN.com Version 1.2011 Also available at NCCN.com The same authoritative source referenced by physicians and other health care professionals is now available for patients at NCCN.com.The NCCN Foundation gratefully acknowledges the followingorganizations for their charitable contributions to the printingand distribution of these NCCN Guidelines for Patients™:Sanofi Oncology and United Health Foundation. Visit NCCN.com today for free access to the NCCN Guidelines for Patients™NCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 99
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