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  1. 1. Prostate Cancer NCCN Guidelines for Patients™ Version 1.2011 Also available at
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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 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
  8. 8. 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
  9. 9. 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. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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 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 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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, Guidelines for Patients™: Prostate CancerVersion 1.2011 26
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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 from the bladderNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 31
  32. 32. 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
  33. 33. 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. Supportive care: Treatment for symptoms of a diseaseNCCN Guidelines for Patients™: Prostate CancerVersion 1.2011 33
  34. 34. 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