Prostate Cancer Canada Just Diagnosed Guide


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A guide for men and loved ones.

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Prostate Cancer Canada Just Diagnosed Guide

  1. 1. JUST DIAGNOSED A GUIDE FOR MEN AND LOVED ONESFor additional copies and information please or call 1-888-255-0333 June/09
  2. 2. ProstateCancer JUST DIAGNOSED: A GUIDE FOR MEN AND LOVED ONES Table of Contents What’s the prostate?................................................2 Is it cancer?.............................................................3 What is the prognosis or “How bad is it, doc”?........5 Digital rectal exam..............................................5 Prostate-specific antigen (PSA) test......................5 Biopsy & transrectal ultasound (TRUS).................7 Grading prostate cancer.......................................7 The Gleason Grading System......................8 Staging prostate cancer.....................................10 TNM staging............................................11 Whitmore-Jewett staging..........................13 Other test................................................14 Putting it all together: prediction tools & risk.....15 What are the treatment options?...........................18 Active surveillance............................................18 Surgery............................................................19 Radiotherapy.....................................................22 Brachytherapy...........................................24 Hormonal therapy..............................................27 Antiandrogen therapy..............................29 Chemotherapy..................................................31 Complementary therapies.................................33 What next?...........................................................34 Questions to ask about follow up.......................34 Living well after treatment.................................35 Where can I turn for more information or help?.......39 Prediction tools and nomograms..............................40
  3. 3. Prostate Cancer What’s the prostate? Is it cancer? The prostate is a gland located deep inside a man’s Prostate cancer is only one of a number of pelvis below his bladder and in front of his rectum. problems that can occur within the prostate. The prostate surrounds the upper part of the urethra, the channel that lets urine and semen pass Prostatitis, an infection or inflammation of the through the penis. The prostate’s function is to prostate, is not cancer. And there is no evidence produce a part of the semen that nourishes and that prostatitis leads to prostate cancer. protects sperm. It also helps regulate the flow of Prostatitis is usually categorized as acute or urine, and, during a man’s orgasm, its muscle cells chronic and as either bacterial (being caused by contract to help propel the semen out the penis. bacteria) or nonbacterial. The most severe and least common form is acute bacterial prostatitis. A healthy prostate is the size of a golf ball, but it is The most common form is chronic nonbacterial actually more like a small, ripe plum. Its outer prostatitis. Prostatitis treatment can include covering is soft, and it is spongy to the touch. If, antibiotics, anti-inflammatory drugs, alpha while doing a digital rectal exam (DRE), your doctor blockers (tamsulosin), 5-alpha- reductase discovers an enlarged, irregularly shaped, or hard, inhibitors (Proscar® or Avodart®), bed rest, and lumpy, or tender prostate, you may have a prostate drinking plenty of fluids. problem. The prostate also produces an enzyme that helps Benign prostatic hyperplasia (BPH) is also the semen remain in liquid form after ejaculation. not prostate cancer. BPH is a non-cancerous This enzyme, prostate-specific antigen (PSA), is (benign) overgrowth of cells (hyperplasia) in the usually produced only in the prostate gland itself prostate gland (prostatic). Basically, BPH is an and can be found in semen or blood. enlarged prostate, and the condition is common in older men. Luckily, many men with enlarged prostates experience no symptoms. But, for some men, the growing prostate can progressively squeeze the urethra, which lets urine travel from the bladder, through the prostate, and out the penis. This narrowing of the urethra can reduce or obstruct the flow of urine and lead to a gradual loss of bladder function. BPH is treated through changes in diet and lifestyle; through medications such as alpha blockers and 5-alpha-reductase inhibitors; and through surgery. Prostatic intraepithelial neoplasia (PIN) is not cancer either, but it is an abnormal and uncontrolled growth of prostate cells, specifically, of the cells that line the external and internal surfaces of the prostate gland. PIN cells do not have the ability to invade surrounding tissue, so they are not malignant (not cancerous), but they are atypical. The most abnormal cells are2 3
  4. 4. Prostate Cancer classified as high grade PIN, and cells that appear What’s the prognosis or almost normal are classified as low grade PIN. Low “How bad is it, doc”? grade PIN (sometimes called mild dysplasia) does not appear to increase a man’s risk of prostate A prognosis is an educated assessment of the cancer. But high grade PIN, in which cells can be severity and nature of your cancer, as well as a very irregular and share some of the genetic medical forecast about the probable course of abnormalities of prostate cancer cells, is sometimes your illness and the best way to treat it. Your called a pre-cancerous condition (defined as a medical team will use many tools to evaluate condition that leads to cancer). Still, having high your condition: grade PIN does not mean that you will develop prostate cancer inevitably. But, because evidence Digital rectal exam (DRE) tells us that most prostate cancers start out as high A digital rectal exam (DRE) is most frequently grade PIN, men with this condition are monitored used in diagnosing prostate cancer, but it can carefully for prostate cancer, usually through help indicate how serious prostate cancer is or biopsies. Other than the vigilant monitoring of men how it might be treated. During a DRE, the with high grade PIN, no other follow-up or therapy physician inserts a gloved and lubricated finger is usually required. into the rectum to feel the rear of the prostate for Prostate cancer is a disease in which some of the hard, lumpy areas. If an abnormality is felt, the cells of the prostate, the cancerous ones, have lost examiner can note whether it seems contained normal control of cell growth and division. The within the prostate, is distorting the gland, or natural processes of cell growth and death no appears to be pushing through and growing longer apply to them. They lose their normal outside the prostate. The larger a tumour is and structure, so they cannot function properly. Also the closer it is to escaping the prostate the more they can escape the prostate and invade other parts potentially dangerous it is if a biopsy shows that of the body, growing there and crowding out the it is cancerous. As biopsies can cause swelling normal cells necessary for the body’s health. and discomfort, which can make subsequent DREs difficult to conduct or inconclusive, the To be cancerous, a prostate cell has to have all of physical exam you had before the biopsy may be these characteristics: uncontrolled growth, very important in assessing your cancer. abnormal structure, and invasiveness (ability to invade and escape the prostate, where it originally Prostate-specific antigen (PSA) test grew). This test detects the amount of prostate-specific Tumours (clusters of cells growing into a mass in an antigen (PSA) in the blood. Each man’s normal uncontrolled way) are not necessarily cancer. They level depends on individual factors such as his can be benign. A benign tumour does not spread to age or the size of his prostate. Although, in the other parts of the body; it is not invasive. past, most doctors considered PSA levels below 4 nanograms per millilitre of blood (4.0 ng/mL) to A prostate cell can be abnormal in structure and be normal, recent research has found prostate not cancerous. PIN or prostatic intraepithelial cancer in men with PSA levels below this. neoplasia is a condition in which prostate cells are Currently, in men 49 and younger, PSA levels abnormal but not malignant or invasive. above 2.5 ng/mL might be considered elevated, and for men aged 50 to 59, the cut-off level might be 3.5 ng/mL. If you have an elevated PSA level, it does not mean that you have prostate4 5
  5. 5. Prostate Cancer cancer, but your doctor may counsel you to have Biopsy & transrectal ultrasound (TRUS) further tests done to investigate the possibility. In In a biopsy of the prostate, the physician inserts general, the higher the cancer-related PSA level, the into the rectum a device that incorporates an poorer the prognosis. ultrasound probe and can also hold biopsy PSA density (PSAD) compares a man’s PSA level needles. The transrectal ultrasound allows the to the size of his prostate, which is measured when physician to position the biopsy needles close to he undergoes a transrectal ultrasound (TRUS). suspicious areas of the prostate, and then these Higher PSA densities (i.e., above 0.15) indicate needles are deployed to remove samples of the increased risk. prostate tissue. The microscopic analysis of these tissue samples is a powerful diagnostic and The percentage of free to total PSA may be prognostic tool. It can give information on measured too, because, as a general rule, cancer • The areas from which tissue samples were cells make less free PSA than healthy prostate cells. taken and the dimensions of these samples What is free PSA? It is prostate-specific antigen • Whether prostatic intraepithelial neoplasia that is not bound to other proteins in the blood. So (PIN) is present the lower the percentage of free PSA the worse the • Whether the tissue samples are positive or prognosis. (Readings between 10 per cent and 25 negative for cancer and, if they do show cancer per cent are difficult to assess, but readings under (if they are positive), how much cancer was 10 per cent are worrisome.) found in each sample PSA velocity (PSAV), which is a measurement of • What type of cancer is present how quickly levels of prostate-specific antigen • How abnormal the cancer cells look under the increase over time, is another tool. A rise in PSA microscope (the grade or Gleason score of the level of more than 0.75 ng/mL per year will often cancer) trigger a biopsy. • Whether there is evidence that the cancer has PSA doubling time (PSA-DT) measures the time spread along the nerves within the prostate it takes for the amount of PSA detected in your (perineural invasion) blood to double. The shorter the doubling time the more aggressive the cancer and the worse the Grading prostate cancer prognosis, in most cases. Grading prostate cancer means describing how closely its cells resemble the normal cells of the PSA levels, PSA velocity, and PSA doubling time can prostate. The lower the grade, the better the be used in assessing prostate cancer that recurs news. Low grade prostate cancer has highly after treatment. If the cancer recurs at least 2 years differentiated cells, which means these cells still after treatment, the PSA doubling time is greater retain many of the qualities that make prostate than 12 months, and the PSA velocity is less than cells unique. In intermediate grade prostate 0.75 ng/mL per year, the likelihood is that the cancer, cells look more abnormal. These cells are cancer is recurring in the prostate or in the area moderately differentiated, which means that they where the prostate was before its removal and can still be recognized as prostate cells but look further local treatment (e.g., radiotherapy) may be odd and disorganized. High grade prostate helpful. A time of recurrence that is less than 2 cancer cells are poorly differentiated and barely years, a PSA doubling time of less than 6 months, resemble prostate cells. The Gleason grading and a PSA velocity of greater than 0.75 ng/mL per system is commonly used. year suggest a more distant site for the cancer and the need for systemic therapy.6 7
  6. 6. Prostate Cancer The Gleason Grading System Gleason score: A man will often have a number of different grades of cancer present within his biopsy sample, so Gleason developed a scoring system to take this into account. The Gleason score is equal to the sum of the two most common grades of cancer evident in a patient’s biopsied tissue. For example, if cells with a Gleason grade of 4 are the most common, but about 10 percent of the cells have a Gleason grade of 3, the Gleason score would be 7. (If the secondary grade makes up less than 5 per cent of the cancer cells, it is considered insignificant, so the grade of the dominant and only significant pattern would be added to itself.) Grade 1 • a Gleason score of 2 to 6 is usually considered • Well-differentiated; cells resemble normal low prostate cells • a Gleason score of 7 is considered intermediate • Tiny glands of the prostate are round, have • a Gleason score of 8 to 10 is considered high defined edges, and are tightly packed; Tumour not expected to grow quickly. Note, however, that even scores considered low Grade 2 may be composed of poorly differentiated cells • Less well-differentiated; cells not as normal with a Gleason grade of 4 or 5. The presence of looking these cells is worrisome, and a Gleason score of • The glands are still round but are loosely packed 6 that has grade 4 cells as its dominant pattern with less distinct edges (Grade 4 + Grade 2 = Gleason 6) is riskier than Grade 3 the same score based on grades that indicate the • Moderately differentiated presence of only moderately differentiated cells • The glands are larger with irregular shapes and (Grade 3 + Grade 3 = Gleason 6). spacing. Their edges are badly defined and show infiltration. Grade 4 • Poorly differentiated • Glands are of different sizes and shapes; they are fused together in masses or chains Grade 5 • Poorly differentiated; Cells are very strange looking • Glands are not really visible; Tissue appears composed of solid cellular sheets, single cells, or nests of tumour8 9
  7. 7. Prostate Cancer Staging prostate cancer metastases. Two main methods of staging are The stage of prostate cancer is determined by the TNM and the Whitmore-Jewett system, which uses tumour size, whether the cancer has spread to the letter designations A through D. pelvic lymph nodes that drain the prostate, or TNM staging: In this method, the T represents whether cancer has spread to an area of the body the primary tumour, the N represents the nodes remote from the prostate. In other words, important of the lymphatic system (lymph nodes), and the factors are how big the tumour is and how much the M represents metastasis (or whether there is cancer has spread: whether there are any distant evidence of the cancer’s spread to distant areas). T STAGE TX & T0 T1 T2 T3 T4 Tumour is not Tumour is confined Tumour extends Tumour has invaded palpable nor visible to the prostate beyond the prostate neighbouring tissues by imaging TX T1a T2a T3a The tumour is fixed or Tumour T1a Tumour found Tumour involves Tumour extends invades areas cannot incidentally in less 50% or less of one beyond the prostate adjacent to the be than 5% of prostate lobe capsule on one side prostate other than assessed. tissue sample (unilateral the seminal vesicles, T2b extracapsular e.g., the bladder neck, T1b Tumour involves extension) or on both the external sphincter, Tumour found more than 50% of sides (bilateral the rectum, and the TO incidentally in more one lobe but not extension) pelvic wall No than 5% of prostate both lobes evidence tissue sample T3b of T2c Tumour has invaded tumour T1c Tumour involves the seminal vesicles Tumour found during both lobes needle biopsy (e.g., because of elevated PSA)10 11
  8. 8. Prostate Cancer N STAGE Whitmore-Jewett staging: In the Whitmore- Jewett staging system, prostate cancer is specified NX & N0 N1/N+ first by letter (A through D) and then by number. Metastasis in regional lymph nodes NX WHITMORE-JEWETT STAGING Lymph nodes near the prostate were not or A A1 Cancer cells look very cannot be assessed. Early stage cancer much like normal cells (well confined to the differentiated) and are NO prostate, not focused in one area of the No regional lymph detectable by DRE prostate node metastasis and producing no A2 Cancer cells are more symptoms abnormal (moderately or poorly differentiated), and M STAGE cancer is in several locations Testis in the prostate MX & M0 M1 There are distant Penis B B0 Cancer cells are confined metastases; the cancer Cancer is confined to the prostate, are not MX has spread beyond the to prostate but is detected by DRE, but cause Distant metastasis of regional lymph nodes detectable by either elevated PSA cancer cannot be determined or DRE or because of B1 There is one area (nodule) M1a The cancer has elevated PSA of cancer in one lobe assessed. spread to non-regional B2 There is extensive cancer MO lymph nodes in one lobe or some cancer in No metastasis of the both lobes cancer beyond the M1b The cancer has regional lymph nodes spread to the bone C C1 The cancer extends Cancer has extended beyond the prostate M1c The cancer has out of the prostate C2 The cancer extends spread to other distant capsule but has not beyond the prostate and sites, with or without spread to regional obstructs the bladder or metastasis to the bone lymph nodes or urethra more distant areas. D D1 The cancer has spread Metastatic prostate only to regional lymph nodes cancer; the cancers D2 The cancer has spread has spread to to distant lymph nodes, regional lymph bones, organs, or tissues nodes or to more D3 Designation for D2 distant areas patients who have relapsed after treatment12 13
  9. 9. Prostate Cancer Other tests Putting it all together: Your medical team may use other tools to assess Prediction tools and risk your cancer and determine the best treatments. Most important in gauging the risk posed by Many of these diagnostic or staging procedures prostate cancer is whether it has spread beyond the investigate whether prostate cancer has spread prostate. If all indications are that it has not, you beyond the prostate: have clinically localised prostate cancer, and Bone scans provide images of the skeleton to statistics indicate that between 75 % and 93 % of investigate whether prostate cancer has spread to men in this situation survive their disease for 10 to the bone. During a bone scan, injected low-level 15 years. This stage of prostate cancer development radioactive material is taken up in the bone more is called “clinically localised” because there is still a rapidly by fast growing cells, producing “hot spots” risk that microscopic cancer cells have escaped the on the scan and indicating the possibility of cancer prostate—and escaped detection by clinical tests. in the bone. Because the clinical stage of a man’s prostate Chest x-rays are often ordered to see whether cancer is often difficult to gauge, especially before cancer has spread to the lungs or the ribs. surgery, physicians have developed mathematical models that put together all known information Computerized axial tomography (CT or CAT) about a man’s cancer and make predictions about scans use computers to combine pictures gathered his risk based on statistical data gathered from by rotating x-ray beams, creating cross-sectional other men’s experiences with the disease. These are and three-dimensional images of organs. These called nomograms. Partin tables use your PSA scans are useful for finding enlarged lymph nodes level, Gleason score, and estimated clinical stage or other abnormalities. (e.g., T1c) to calculate probability percentages that Magnetic resonance imaging (MRI) uses a large, your cancer has spread. Han tables use similar powerful magnet, radio waves, and a computer to information to estimate the probability that your create images of the prostate and pelvic area or cancer will recur after a radical prostatectomy. other body regions; these images are sometimes Modern computer technology has made possible used to provide information about cancer spread the development of new tables and nomograms outside the limits of the prostate gland or into the (representations of numerical relations). See the lymph nodes, bone, or elsewhere. section “Where do I go for more information?” to find online versions of some of the prediction tools Pelvic lymph node dissection, or the surgical useful for men with prostate cancer. removal of the lymph nodes in the pelvis and their microscopic analysis, is the most accurate way of Remember, however, that these tools base determining whether prostate cancer has spread to predictions on only a few factors. They do not know, the lymph nodes. This procedure is typically for example, much about your general health, your performed during surgery to remove the prostate. life, or your medical history. Your own medical team is your best resource in assessing your prognosis ProstaScint scans use radioactive monoclonal and in recommending appropriate treatment. antibodies to investigate prostate cancer spread. These antibodies attach to suspect cells and expose Still, most predictions of prostate cancer risk are “hot spots”– where cancer may be present. The based on three clinical factors. The larger the test is not always reliable, and results can be tumour, the higher the Gleason score, and the more difficult to analyse. It is not widely used nor detectable prostate-specific antigen (PSA) in the available in Canada. blood, the greater this risk.14 15
  10. 10. Prostate Cancer What are the treatment options? Surgery A radical prostatectomy is one of the most common As is evident from the chart connecting risk and effective treatments of localised prostate category and standard treatments, the usually cancer—prostate cancer that has not left the recommended treatments for prostate cancer that prostate gland. In this procedure, a surgeon seems to be confined to the prostate are either removes the prostate gland, the seminal vesicles, surgery to remove the prostate (radical and, sometimes, the lymph nodes in the pelvis. prostatectomy) or radiation to kill prostate cells. The There are various methods of performing a radical greater the chance that your cancer has spread prostatectomy: outside of the prostate, the more significant • In a radical retropubic prostatectomy, the becomes a systemic (system-wide) treatment such surgeon makes an incision that begins just under as hormone therapy. the navel and runs to just above the public bone. • In a radical perineal prostatectomy, the surgeon Active surveillance makes the incision in the area between the This strategy, which is sometimes called watchful scrotum and the anus. Although less used waiting, involves monitoring a man’s prostate because it gives a poorer view of the bladder and cancer carefully and only treating the cancer if it other significant anatomical features, this becomes aggressive. This monitoring is done approach makes sense in some cases, for through regular digital rectal exams, PSA tests, and example, when a man has extensive scar tissue biopsies of the prostate. from previous abdominal surgeries. • Nerve-sparing techniques are now commonly Is it for me? If your cancer is unlikely to threaten used with radical retropubic prostatectomy, as your health during your lifetime, it might be. long as the cancer is not too close to the Perhaps your life expectancy is less than ten years cavernous nerves. These nerves and and your cancer is non-aggressive. Perhaps all tests accompanying veins run in two bundles from indicate that the cancer is slow growing and will behind the bladder, along the sides of the not escape the prostate or cause symptoms. prostate, and into the penis. Surgeons try to leave Perhaps you have other health problems that make these nerves and veins intact because both are aggressive treatment an inferior option. Or you may involved in achieving and maintaining erections. decide that, given the anticipated low risk currently, • In a laparoscopic radical prostatectomy, a scope you are not ready to undergo other treatments and inserted through a small incision in the abdomen can cope with the knowledge that cancer remains lights and magnifies the area surrounding the in your body. prostate, sending an enlarged view of the surgical field to a monitor in the operating room. Disadvantages: Monitoring cancer is far from an Then, microsurgical instruments are inserted exact science, as all bodies are unique. Your cancer through four or five other small incisions made might grow more rapidly than expected, escape the on each side of the abdomen, and the prostate prostate, and reach an incurable stage before your gland and seminal vesicles are removed. Pelvic medical team has a chance to react. Although this lymph nodes may also be removed. theoretical situation does not occur very often, you • Robotic-assisted radical prostatectomy also may be unwilling to live with the possibility that it uses a laparoscope and microsurgical instruments might occur at all. inserted through multiple, small incisions in the18 19
  11. 11. Prostate Cancer abdomen. In this case, though, the instruments with localised prostate cancer, a radical are connected to robotic arms that perform the prostatectomy offers one of the best chances for a operation, guided by the surgeon’s movements, cure. If your cancer has spread to the lymph nodes or which the robot converts into micro-movements. if there are distant metastases, then hormone The patient and the surgeon need not be in the therapy or another system-wide treatment will same room. usually be recommended, either on its own or with a radical prostatectomy. If, after the surgery, there is Surgery without laparoscopes or robotic systems is evidence that cancer cells have been left behind often called “open surgery.” And, in the hands of (e.g., positive surgical margins), post-operative an experienced surgeon, an open nerve-sparing radiotherapy may be useful. radical prostatectomy can have excellent results in terms of cure, continence, and potency. Less blood Disadvantages: Radical prostatectomy is a fairly loss, faster postoperative recovery, and shorter serious surgical operation, no matter how it is hospital stays are advantages of laparoscopic or performed. It will require two to five days of robotic-assisted prostatectomy. But the verdict is hospitalization and three to six weeks of recovery out concerning which surgical approach offers the time at home. You will need a catheter and urine best treatment of prostate cancer and the least collection bag, which can usually be disposed of likelihood of long-term side effects. after one to three weeks. You will most likely experience some short-term lack of control over urination. But, in most cases, things return to normal in one month to a year. A more serious consideration for some men is that, after a prostatectomy, they will no longer be able to father children without the use of a sperm bank. Men can reach orgasm but no longer ejaculate after this surgery. Other long-term consequences of the operation can include erectile dysfunction (impotence), chronic incontinence, and narrowing of the urethra. A common long-term side effect is erectile dysfunction. Estimates are that, by two years after surgery, approximately half of the men who were fully functional before surgery have recovered erections. Penile rehabilitation and nerve- sparing surgical techniques are improving these incision location for a radical retropubic odds. A smaller percentage of men will suffer prostatectomy permanent stress incontinence (the leakage of urine location of small incisions for a when sneezing or engaging in strenuous activity). An laparoscopic radical prostatectomy even smaller percentage will experience total and permanent incontinence and may require an Is it for me? Surgery may be for you if your cancer implanted artificial sphincter. Another complication, is confined to the prostate or the tissues immediately the narrowing of the urethra because of scar tissue, surrounding it, and there is no evidence of distant can make urination difficult. Minor surgery can spread (metastasis). The clinical stages T1, T2, or a usually correct this problem. small T3 tumour would fit this description. For men20 21
  12. 12. Prostate Cancer Radiotherapy • 3-dimensional conformal radiation therapy (3D- Radiation therapy directs radioactive energy to a CRT) This form of external beam radiation therapy particular area to kill cells by causing breaks in their is now a standard treatment for prostate cancer. DNA. Because cancer cells generally replicate It uses a CT scan or MRI to measure the prostate quickly, they are more susceptible to radiation than in three dimensions and computers to calculate healthy cells, which divide and multiply more slowly. how the radiation should be delivered. An Still, radiation usually causes some damage to individualized plan emerges from this healthy tissue and, in some patients, may produce information, one that directs radioactive beams radiotherapy-induced side effects. so they conform or shape to the area targeted to receive radiation. Before the plan is followed, a Radiation therapy is given in one of two main ways: radiation oncologist will check its safety by using by focussing an external beam of radioactive energy all data to estimate the radiation dose required at the cancer (external beam radiation) or by to kill cancerous cells and the amount of implanting radioactive material near the cancer. radiation this would deliver to neighbouring External beam radiation: In external beam healthy cells. radiation, a computer-guided machine delivers high • Intensity modulated radiation therapy (IMRT) energy x-rays to the prostate gland containing Like 3D-CRT, this form of external beam radiation cancer cells in brief sessions (called “fractions”) therapy uses a CT scan or and MRI to create a that are usually scheduled five days a week over three dimensional picture of the prostate and a about seven to eight weeks. As much as possible, computer to calculate how to irradiate cancerous the rays are focussed toward the location and areas while sparing healthy ones. Unlike 3D-CRT, depth of the prostate cancer, but some healthy cells intensity modulated radiation therapy can deliver will be affected as well. Both the benefits and the radiation at varying intensities or doses possible side effects of radiation therapy are throughout the targeted area being irradiated. gradual and cumulative because cell death or IMRT fine-tunes 3D-CRT by enabling the inflammation from radiation continues for several radiation’s intensity (dose) to be modulated months after treatment stops. Many techniques are (varied), so cancerous areas can receive high commonly practiced today in order to enable intensity radiation while radiation to other areas precision in external beam radiation therapy, is minimized. thereby increasing treatment efficacy and reducing damage to healthy cells: • Image-guided radiation therapy (IGRT) Over the years, doctors have used steadily improving technology to view the prostate and to mark the location of a prostate cancer tumour. X-rays, ultrasounds, CT scans, and MRI technology all provide images that can help guide radiation therapy. Typically, during radiation therapy planning, radiation oncologists will consult these images and use drops of permanent ink on a patient’s skin or small metallic markers inserted into a patient’s prostate gland to indicate the area that should receive radiation. To compensate for movement of the prostate during treatment or22 23
  13. 13. Prostate Cancer possible changes to the tumour’s shape or size the tumour cells the desired dose of radiation and between treatments, doctors expand the to avoid, as much as possible, damage to healthy treatment area slightly—to be as sure as they cells. After treatment, the radioactive material and can that all the cancer cells are irradiated. In catheters are removed. some cancer centres today, a technology known Is radiation therapy for me? If you have as image-guided radiation therapy (IGRT) allows localised prostate cancer and a life expectancy of doctors to see the tumour’s location just before between 7 and 10 years, external beam radiation the delivery of radiotherapy or even during a therapy may be for you. It may also be the treatment, enabling them to adjust the radiation recommended treatment for younger men with low beams to hit a tumour more precisely and reduce or intermediate risk cancers who have health the amount of healthy tissue exposed to problems that make them poor candidates for radiation. prostate surgery. An advantage of external beam radiation is that no hospitalization is necessary, and Brachytherapy: This form of radiation therapy daily treatments are fast, causing minimal involves introducing radioactive material directly disruption in a man’s day if the radiation facility is into the prostate so as to deliver radiation at close nearby. range. Seed brachytherapy as a treatment on its own is • Seed brachytherapy, the most common method, usually recommended only to men diagnosed with uses surgery to implant tiny radioactive pellets or early prostate cancer who are in the low risk “seeds” into the prostate through the perineum category. Also, if you have a large prostate or a (the region between the scrotum and the anus). A history of urinary problems, or if you have had a transrectal ultrasound (TRUS) helps surgeons view transurethral resection of the prostate to remove a the prostate so the seeds can be placed urinary blockage, this treatment is not the best appropriately. The procedure is usually done while a option for you. man is under a general or an epidural (waist down) anaesthetic and does not normally require HDR brachytherapy is a relatively new treatment that may not be available locally. It is sometimes hospitalization. The seeds, each one smaller than a offered in combination with external beam grain of rice, stay in the prostate permanently, radiation (as a boost). Research into its emitting radiation steadily for about 6 months or effectiveness as a therapy for men with stages T1 to more until they lose their radioactivity. T3b prostate cancer is ongoing. • High dose rate (HDR) brachytherapy involves Convenience is a major benefit of brachytherapy; it similar surgical procedures but it delivers allows men to avoid both the lengthy recovery time significantly higher doses of radiation over a much necessary after major surgery and the long-term shorter period. Thin tubes or catheters (12 to 18 or treatment schedule needed for external beam more) are inserted into the patient’s prostate using radiation. a transrectal ultrasound probe for guidance. Doctors verify the position of these catheters using a CT Disadvantages: The major disadvantage of all scan and then connect them to the treatment forms of radiation therapy is that, because the machine, which releases radioactive material into prostate is not removed, cancer cells that are not the catheters. A computer helps doctors assess how killed by treatment can re-grow and new prostate long the prostate cells adjacent to each part of each cancer cells may grow. Short-term side effects of catheter should be exposed to radioactivity to give external beam radiation can include fatigue, skin24 25
  14. 14. Prostate Cancer reactions, and hair loss in the area receiving Hormonal therapy radiation. Brachytherapy, which involves piercing Hormonal therapy works by depriving prostate the prostate in several places, can cause the gland cancer cells of the male hormones (androgens, to swell temporarily. Radiation treatment can also including testosterone) that they need to grow and affect the bladder and rectum, and a man may have flourish. This androgen deprivation can be difficulty with urination, diarrhoea, or rectal accomplished through undergoing an orchiectomy bleeding. that removes the testicles or by taking medication A common long-term complication of radiation that either prevents the production of androgens therapy is erectile dysfunction. Erectile difficulties (LHRH analogue therapy) or blocks their effects on caused by radiation develop gradually in the prostate cells (antiandrogen therapy). By itself, months following treatment, unlike those caused by hormonal therapy cannot cure prostate cancer, but surgery. Also, radiation therapy “dries out” the it can slow or stop cancer growth for many years. It prostate, which, in many cases, stops making the is also a systemic rather than a local therapy, substances that constitute semen and nourish meaning that it can arrest prostate cancer cells no sperm. Most men become infertile, although still matter where they are in the body. able to achieve an orgasm. Incontinence and bowel problems are rare long-term complications. Orchiectomy: This procedure, also known as surgical castration, involves removing the testicles, which produce most of a man’s testosterone, the principle male hormone. Although an orchiectomy is a relatively quick and simple operation that causes less long-term inconvenience and expense than drug-based hormonal therapy, few men choose this option today, possibly because its effects are not reversible. LHRH analogue therapy (medical castration): Paradoxically, luteinizing hormone-releasing hormone (LHRH) analogues interfere with the production of androgens by over-stimulating the pituitary gland to produce luteinizing hormone (LH). The gland exhausts itself and shuts down LH production altogether, thus depriving the testicles of what they need to manufacture testosterone. The therapy is usually administered by injection every 2 to 6 months or monthly. In Canada, the most used LHRH analogues are Eligard® (leuprolide acetate), Lupron Depot® (leuprolide acetate), Suprefact® (buserelin), and Zoladex® (goserelin). Because LHRH analogues initially stimulate the production of LH and, consequently, of testosterone, a man may experience a testosterone surge that heightens cancer symptoms in the first weeks of treatment.26 27
  15. 15. Prostate Cancer After about two weeks, the level of testosterone Antiandrogen therapy: Antiandrogens are drugs falls dramatically and remains at extremely low that block or otherwise interfere with the normal levels as long as the drug is continued. effects of male hormones on prostate cells. There are two types: steroidal and non-steroidal. Steroidal antiandrogens, which act like female sex hormones, Common are usually taken orally each day. They include LHRH Injection Route Usual time between megestrol acetate (Megace®) and cyproterone Analogues injections acetate (Androcur®). Non-steroidal antiandrogens Buserelin Subcutaneous 2 or 3 months include fultamide (Euflex®), bicalutamide (Suprefact®) (Casodex®), and nilutamide (Anandron®). Non- steroidal antiandrogens are sometimes used in Goserelin Subcutaneous 1, 3 months (Zoladex®) combination with LHRH analogue therapy or orchiectomy to block the effects of androgens Leuprolide Intramuscular 1, 3, or 4 months produced outside of the testicles (in the adrenal (Lupron®) glands, for example). Leuprolide Subcutaneous 1, 3, 4, or 6 months (Eligard®) Hormonal therapy is used at various times for a variety of purposes. It may be given before a local treatment, such as radiation or a radical prostatectomy, to reduce the size of a tumour, for example. This is called neoadjuvant hormonal therapy. More commonly, it is used directly after surgery or radiation to treat any microscopic cancerous cells that may remain in the body. Doctors often use the term minimal residual disease (MRD) to refer to these isolated or disseminated cancer cells. Hormonal therapy after prostatectomy or radiation is called adjuvant hormonal therapy, and studies confirm that it can prolong survival for men with locally advanced prostate cancer. Besides the different timing of hormonal therapy, there are various treatment regimes, and new ones, as well as new drugs, are being tested all the time. • Combined androgen blockade (CAB) combines the use of antiandrogens with either chemical or surgical castration. The idea is to block the action of even the small amount of androgens present in the body during LHRH analogue therapy or after an orchiectomy. Research suggests that men treated with CAB, which is sometimes called maximal androgen blockade (MAB) or total androgen blockade (TAB), may live longer, on average, than men treated by LHRH analogue therapy alone.28 29
  16. 16. Prostate Cancer • Intermittent androgen blockade (IAB), often Chemotherapy referred to as intermittent hormonal therapy or Before 2004, no chemotherapy agent had been intermittent androgen suppression (IAS), is still proven to extend the lives of men with prostate being investigated as a treatment option. It cancer. In that year, two international studies involves administering hormone therapy drugs confirmed that docetaxel (Taxotere®), a until a man’s prostate cancer seems in check, chemotherapy drug made from the needles of the e.g., his PSA levels drop and stabilize. Then, the European yew tree, improves the survival time and man stops hormonal therapy until his PSA rises to quality of life for men with advanced stage prostate a predetermined level or at a certain speed. The cancer that is resistant to hormone therapy. hope is that stopping hormone therapy Generally, chemotherapy uses drugs that circulate periodically and then restarting it will enable men throughout the body to destroy cancer cells. to enjoy a better quality of life during off- Taxotere®, which has been used since 1995 in the treatment times and may postpone the day when treatment of breast and lung cancer, kills cancer hormone therapy no longer works well to control cells by disrupting the formation of their internal their cancer (i.e., they develop hormone resistant structures, thereby stopping cells from dividing and or hormone refractory prostate cancer). multiplying. Still, in the treatment of prostate Is it for me? Hormone therapy is the treatment of cancer, chemotherapy drugs are used mainly at the choice for men whose prostate cancer has spread hormone refractory stage, when a man’s cancer no to the lymph nodes, bones, or elsewhere in the longer responds to hormone therapy. Some body (N1 or M1). It is also recommended for those chemotherapy agents, such as mitoxantrone whose cancer returns after radical prostatectomy or (Novantrone® and Onkotrone®), are used primarily radiation therapy, or for those who are at a high to relieve the pain associated with the late stages risk of experiencing such a recurrence. of this disease. This palliative chemotherapy greatly improves the quality of life of men with advanced Disadvantages: The main disadvantages are that disease, but it does not prolong their lives. The hormone therapy does not cure prostate cancer and discovery that docetaxel (Taxotere®) does prolong that treatments only work for a certain amount of patients lives (usually by about 25 % compared to time, until prostate cancer cells become hormone similar patients not taking the drug) and also resistant or hormone refractory. (Hormone resistant reduces the pain associated with advanced disease prostate cancer may respond to a change in has led to research that provides better options for hormonal therapy while hormone refractory men with hormone refractory prostate cancer. prostate cancer progresses in spite of any hormone therapy treatment regimen.) Men on hormonal What about clinical trials therapy may experience hot flashes, swelling or or new therapies? tenderness of their breasts, lack of energy, anaemia, Promising new prostate cancer therapies are being mood swings, or depression. Over the long term, tested right now. And some treatments once hormone therapy can cause a loss of muscle considered promising just a few years ago have strength and bone density, which can lead to faded from view. One way to discover relevant osteoporosis. Many patients are placed on Vitamin innovations in prostate cancer treatment is to D and calcium to prevent bone loss. The most research what clinical trials are being offered to common side effects are a decreased sex drive patients like you. (A clinical trial is a carefully (libido) and the eventual loss of erections (erectile designed investigation into the effects and dysfunction). effectiveness of a drug, treatment, or medical30 31
  17. 17. Prostate Cancer device on a particular group of people, e.g., men • PRX302 uses prostate-specific antigen (PSA) to with clinically localised prostate cancer.) The Clinical activate a series of steps leading to cell death. It Trials Group of the National Cancer Institute of may prove effective in treating either prostate Canada provides an online listing of all current cancer or benign prostatic hyperplasia. cancer trials in the country. You might even consider • Trans perineal microwave ablation of the participating in such a trial. prostate uses microwave energy to heat the Some of the more unusual or experimental prostate prostate and destroy cells; the microwaves are cancer treatments that you might hear about delivered through needles positioned in the include the following: prostate with the help of an ultrasound probe. It has been used to treat men who still have • Angiogenesis inhibitors are drugs that may be localised prostate cancer after radiation therapy. useful in stopping prostate cancer growth by keeping new blood vessels from forming; Remember, you should always consult impartial prostate cancer tumours depend on the growth medical experts when making treatment decisions. of blood vessels (angiogenesis) to feed cancer Also be aware that the efficacy and long-term cells. consequences of many of these emerging therapies have yet to be tested against those of more • Cryotherapy or cryosurgery uses liquid nitrogen standard prostate cancer treatments. or Argon gas, delivered to the prostate through probes positioned using transrectal ultrasound, to freeze and kill prostate tissue, including cancer cells. It may be used to treat early prostate cancer What about or when radiation therapy is not successful. complementary therapies? Cryotherapy is offered in very few Canadian A complementary therapy is one that is used in centres. addition to standard treatment. Complementary therapies for men with prostate cancer can include • Gene therapy attempts to alter the genetic anything from unconventional approaches such as structure of cancer cells, so they can be killed acupuncture, massage, and meditation to strategies more easily, either by other cancer treatments or that are recommended by physicians, such as by the body’s own defence mechanisms. lifestyle and dietary changes or other therapies that • High-intensity focused ultrasound (HIFU) help relieve certain symptoms of the disease or side destroys prostate tissue and prostate cancer cells effects of its treatment. using focused, high-energy ultrasound waves to generate intense heat. Men treated with HIFU Men on hormonal therapy may need generally have low to intermediate risk prostate complementary therapies to minimize the risk of cancer. Treatments are not covered by provincial other health problems e.g., cardiovascular disease, medical plans. diabetes, and osteoporosis. Men treated with • Immunotherapy or biotherapy is designed to chemotherapy may need to address pain or nausea. repair, stimulate, or enhance the body’s immune And some who have undergone surgery or system so it can fight prostate cancer. Vaccines radiation may require complementary therapies to such as the experimental Provenge are often improve their quality of life, for example, to treat used in immunotherapy. incontinence or erectile dysfunction. (See “Living well after treatment” and “Life as a couple.”)32 33
  18. 18. Prostate Cancer Always consult your medical team before adding a Living well after treatment complementary therapy to your treatment plan. Most treatments for prostate cancer can cause both Some can interfere with both the effectiveness and short-term and long-term side effects. Surgery and side effects of standard treatments and increase radiation can result in incontinence or, more rarely, your risk. damage to the bowels. Men on hormone therapy may experience hot flashes, fatigue, mood swings, What next? and, over time, a decrease in muscle mass and an increased risk of osteoporosis. Although it is Questions to ask about follow up important for you to be aware of these risks, keep How will we judge whether the treatment has in mind that treatment saves lives and that the worked or is working? possible side effects of treatment can also be treated. What follow-up medical appointments and tests should we arrange to monitor my health, and how Incontinence, or the loss of the ability to control often should these take place? urination, can be a side effect of prostate cancer What signs or symptoms of prostate cancer surgery because the prostate is close to the bladder recurrence should I watch for? and surrounds the tube that allows urine to flow What are my options if the cancer comes back? outside the body (the urethra). Urinary incontinence is rare following radiotherapy. Still, When can I expect to recover from some of the any treatment that removes the prostate or short-term side effects of treatment? destroys its tissue carries the risk of interfering with Can I do anything to encourage my recovery? the process of urination, although more precise techniques minimize this risk. Treatments for urinary Are there lifestyle changes, strategies, or therapies incontinence include that will help me maintain or regain urinary control • Kegel exercises, which strengthen the muscles and erectile function or combat fatigue, anaemia, you squeeze to stop urinating and bone and muscle mass loss? • Lifestyle changes, such as drinking fewer liquids, What are my options if I experience long-term avoiding caffeine and alcohol, not drinking complications or secondary health issues because before bed, and losing weight of essential prostate cancer treatment? • Medication, such as decongestants to tighten the muscles of the urethra or anticholinergic drugs (e.g., oxybutynin) to block messages to the bladder nerves and prevent bladder spasms • Bulking agents, e.g., collagen, injected into the bladder neck to reduce urinary leakage • Opening up any stricture (narrowing) of the urethra caused by scar tissue, which can be done by cutting into the scar tissue or by stretching the urethra • Surgically introducing a sling that compresses the urethra below the sphincter • Surgically implanting an artificial urinary sphincter34 35
  19. 19. Prostate Cancer Bowel side effects that last are rare with surgery Decreased libido: For a man diagnosed with but may occur following radiotherapy. You may prostate cancer, a lowered interest in sex should experience some temporary decrease in rectal tone not be treated with testosterone, which feeds the after a prostatectomy, so it is important to avoid growth of cancerous cells. Talking things over with constipation. Radiation therapy that exposes a your partner or visiting a counsellor or sex therapist significant area of the rectal wall can cause bowel together is very useful. A couple may find that the inflammation, urgency, and faecal incontinence. need to discuss desire and not take it for granted However, new imaging techniques, more precise enables a more honest and giving sexual intimacy. methods of delivering radiation, and using neoadjuvant hormonal therapy to shrink tumours Erectile dysfunction (ED): Erectile dysfunction is reduce the risk of these complications even further. defined as the inability to achieve or maintain an erection adequate for sexual intercourse. Varying Hormonal therapy side effects can also be degrees of ED are common following radical addressed. Hot flashes can be controlled with prostatectomy, even when the surgeon spares the medication or by making lifestyle changes. Exercise nerve bundles upon which a man’s erections (both aerobic and weight-bearing) and proper depend. After all, prostate surgery is quite nutrition are good ways to reduce fatigue, weight traumatic. Most men treated with nerve-sparing gain, and the risk of bone or muscle mass loss. surgery experience an improvement in their Bisphosphonates such as pamidronate (Aredia®) or erections over time. Some, however, never recover zoledronic acid (Zometa®), as well as calcium and the ability to get a spontaneous erection. Men who vitamin D are possible treatments to reduce the risk have radiation therapy also develop erectile of osteoporosis or to treat it. difficulties, but these occur slowly and over time, as the benefits and negative side effects of radiation Life as a couple accrue. Erectile dysfunction can be treated in the Many men feel that the challenges posed by following ways: prostate cancer and its treatment eventually • Oral medications such as sildenafil (Viagra®), strengthen their loving relationships, even though vardenafil (Levitra®), and tadalafil (Cialis®) can changes in self-perception, in family role, and in help prevent the natural breakdown of chemical patterns of sexual intimacy often result. substances emitted by erectile nerves. These Maintaining open and honest communication with substances (neurotransmitters) are produced partners and getting timely medical and counselling when a man is sexually stimulated, and they help are essential when it comes to weathering bring about a dilation of the blood vessels in the these changes, which can include infertility, penis, which causes engorgement of penile tissue decreased sex drive, and erectile dysfunction. and an erection. • Injecting drugs such as alprostadil, papaverine, Infertility: Most men will be infertile after surgery or phentolamine into the side of the penis or radiation therapy. Ejaculation (but not orgasm) is (intracavernous injections) can cause blood impossible after radical prostatectomy, and the vessels to relax and the penis to fill with blood, radiated prostate and seminal vesicles could creating an erection even in the absence of produce semen that cannot transport sperm well. sexual stimulation. Hormonal therapy, which can reduce sexual desire, • The medicated urethral system of erection poses its own difficulties. Men who want to start a (MUSE) involves inserting a small suppository of family after prostate cancer treatment should alprostadil into the urethra through the opening consider having their sperm frozen.36 37
  20. 20. Prostate Cancer in the tip of the penis. Once the penis is Where can I turn for more massaged lightly to speed absorption, blood information or help? vessels expand and an erection occurs. • Constricting rings are adjustable or elastic bands Prostate Cancer Canada that a man can place around the base of his Tel: 416-441-2131 penis before it is aroused. The ring assists by Toll Free: 1-888-255-0333 retaining blood in the penis once an erection is Fax: 416-441-2325 achieved. E-mail: • A vacuum erection device (VED) works by drawing blood into the penis and keeping it there by means of a constricting ring, but VEDs do not Canadian Prostate Cancer Network produce a physiological erection. Consequently, Tel: 705-652-9200 erections neither look nor feel normal, and they Toll Free: 1-866-810-CPCN (2726) do not promote the healing circulation of fresh, Français: 1-888-322-5735 oxygenated blood to the organ. (service fourni par La fondation québécoise • A penile implant is a prosthetic device du cancer) introduced into the penis during surgery. It can Fax: 705-652-0663 be semi-rigid or inflatable. E-mail: Procure Alliance Tel; 514-985-1320 Toll Free: 1-866-899-CURE (2873) Fax: 514-985-1363 La fondation québécoise du cancer (French only) Téléphone: 418-657-5334 Sans frais: 1-800-363-0063 Service en français pour CPCN: 1-888-322-5735 Télécopieur: 418-657-5921 Courriel: http://www.fqc.qc.ca38 39
  21. 21. Prediction tools and nomograms Partin tables (Johns Hopkins) Han tables (Johns Hopkins) Prostate cancer nomograms (Memorial Sloan-Kettering) Prostate Cancer Risk Calculator (Sunnybrook Health Sciences Centre) Prostate Cancer Assessment Tools (Prostate Cancer Canada) Risk Assessment Quiz (Prostate Cancer Canada) Prostate Cancer Canada thanks Dr. Robert G. Bristow for his contributions to the production of this booklet. This publication has been made possible through an unrestricted educational grant from sanofi aventis.40