Combined Practice Times

Understanding
Prostate Cancer
and treatment options
A Guidebook for Patients & Caregivers
Contents
3
4
7
10
13
24
36
54
57
61
64
70
78
Introduction
The Prostate Gland
Prostate Cancer
Risk Factors
Identification and Screening for Prostate Cancer
Stages of Prostate Cancer
Treatment of Prostate Cancer
Treatment Options by Stage
Prognosis
Living with Prostate Cancer
Additional Information About Prostate Cancer
Glossary
References
Introduction
Introduction
A diagnosis of prostate cancer can raise many questions
and fears. You, your family, and others close to you may not
know what prostate cancer is or how it can be treated. As you
learn about prostate cancer and its treatment, these concerns
may be eased.
No booklet can provide all the information you need to
decide if a treatment is right for you. This booklet does
not take the place of careful discussions with your doctor.
By working together, you and your doctor will plan the
treatment that is best for you.
This booklet is designed for you and those close to you.
To help you understand and cope with the diagnosis of
prostate cancer, this booklet:
In addition to this booklet, several helpful sources of
information about prostate cancer are available at local
libraries and from cancer societies and support groups.
A list of support groups and resources is also provided.
• Explains how prostate cancer develops and describes
its various stages;
• Provides information about how prostate cancer
is treated;
• Discusses the effects that prostate cancer may have on
your life and offers some ways to cope.
Introduction
3
The Prostate
Gland
The Prostate Gland
Function..................................................................4
Anatomy............................................................4
Changes in the Prostate with Age.....................5
Function
Anatomy
The prostate gland is a muscular, walnut-sized gland that
surrounds part of the urethra, the tube that transports urine
and sperm out of the body. A gland is a group of cells that
secretes chemicals that act on or control the activity of other
cells or organs.
The prostate is a gland in the male reproductive system located
underneath the bladder and in front of the rectum.
The main function of the prostate is to produce semen,
the milky fluid that transports sperm. Sperm is produced in
the testicles, which also produce the main male hormone,
testosterone. Testosterone stimulates the growth and function
of the prostate during puberty, as well as the production of
prostatic fluid for semen.
During sexual climax (orgasm), the muscles of the prostate
contract to push the semen through the urethra and out
through the penis.
4
The Prostate Gland
Figure 1. Anatomy of the male reproductive and urinary systems, showing the
prostate, testicles, bladder, and other organs. Photo courtesy of the National
Cancer Institute.
Physicians refer to the left and right lobes of the prostate
gland, particularly when discussing what they can actually
feel or palpate during a digital rectal examination.
Changes in the Prostate with Age
At birth, the prostate has a system of ducts that forms a large
part of the gland. During the first 12–14 years of life, there are
very few anatomical changes.
At puberty, which generally occurs between the ages of 14
and 18 years, the prostate gland begins to mature under the
influence of hormones. During this period, its size increases
more than twofold. This allows the prostate gland to function
in the reproductive process.
The Prostate Gland
5
The Prostate Gland
It may enlarge as a man gets older, a process called
hypertrophy or hyperplasia. As a result of an enlarged
prostate gland, a man may find it difficult to urinate normally
because the gland surrounds the urethra. Because of its close
proximity to the rectum, the prostate gland is relatively easy
to examine using what is called a digital rectal examination
or DRE, discussed later in this brochure, which is performed
to determine the size of the prostate gland.
As shown in Figure 2, a normal prostate allows the flow of
urine from the bladder. An enlarged prostate presses on the
bladder and urethra, and blocks the flow of urine. When a
man is between the ages of 30 and 40, the glandular portion
of the prostate begins to enlarge. After that, the size of the
prostate remains virtually the same until 45–50 years of age,
when the prostate gland begins to change in ways that make
it less functional (called prostatic involution). After 45–50
years of age, in some men, the prostate tends to develop what
is called benign prostatic hyperplasia or BPH. While it can
have symptoms similar to those of prostate cancer, BPH is not
prostate cancer.
Figure 2: Normal prostate and benign prostatic hyperplasia (BPH). Photo
courtesy of the National Cancer Institute.
6
The Prostate Gland
Prostate
Cancer
Prostate Cancer
Who Gets Prostate Cancer?..................................................................8
New Cases per Year (Incidence).....................................................8
Number of Cases at Any One Time (Prevalence)..........................9
Prostate cancer occurs when cells in the prostate become
abnormal and grow without control. Metastatic prostate
cancer, otherwise known as stage IV prostate cancer, is the
most advanced stage of prostate cancer and means that the
cancer has spread from its original location.
In metastatic prostate cancer, prostate cancer cells break
away from the main tumor and travel, or metastasize, through
the blood or another body fluid, called lymph, to other parts
of the body. The most common places to which these tumor
cells travel are the bones.
Prostate Cancer
Prostate cancer is a disease in which
cancer cells form in the tissues
of the prostate.
Figure 3. Prostate cancer as shown on a colored computed tomography
(CT) scan
Prostate Cancer
7
Figure 3 is a colored CT scan representing a cross-section
through the pelvis. This CT scan shows an enlarged prostate
gland with cancer. At center is the prostate (green) seen
between the bones of the pelvis (red). At lower center, next to
the prostate, is the rectum (light blue). Above the prostate is
the bladder (yellow) which has been indented by the enlarged
prostate.
Who Gets Prostate Cancer?
Prostate cancer is a major health care challenge. It is the
second most common cancer in men (behind skin cancer) and
the second leading cause of cancer death (behind lung cancer).
It is estimated that 241,740 men will be diagnosed with and
28,170 men will die of cancer of the prostate in 2012.
8
Prostate Cancer
New Cases Per Year (Incidence)
US government data provide insights into factors such as age,
race, and survival by stage of cancer. Almost 10% of men
with prostate cancer receive a diagnosis between the ages of 45
and 54, about 68% are diagnosed between the ages of 45 and
75, and about 20% above the age of 75. Above the age of 75,
men are often dying of other causes before prostate cancer is
detected.
Table 1: Incidence Rates by Race, 2005-2009
Race/Ethnicity
Number per
100,000 Men
All Races
154.8
White
146.9
Black
236.0
85.4
American Indian/Alaska Native
78.4
Hispanic
125.9
On January 1, 2009, in the United States there were
approximately 2,496,784 men alive who had a history of
cancer of the prostate. This includes any person alive on
January 1, 2009, who had been diagnosed with cancer of the
prostate at a particular point prior to January 1, 2009, and
includes persons with active disease and those who had been
cured of their disease.
Prostate Cancer
Asian/Pacific Islander
Number of Cases at Any One Time (Prevalence)
Another way of understanding how common prostate cancer
really is, is reflected in the statement that 1 out of every 6
men born today will be diagnosed with cancer of the prostate
at some time during his lifetime.
Prostate Cancer
9
Risk Factors
Although the exact cause of prostate cancer has not been
identified, it is believed to be related to a variety of factors
such as age, race, testosterone and other androgens (male
hormones), heredity and certain lifestyle factors.
Risk Factors
Aging.................................................................10
Obesity and Diet................................................11
Hormones..........................................................11
Race and Ethnicity............................................12
Heredity.............................................................12
Aging
As mentioned previously, prostate cancer is a disease of older
men. The rates of prostate cancer diagnosis and death increase
with age. Although screening men with the prostate-specific
antigen (PSA) test has helped to identify patients earlier in
life than was possible a generation ago, death from prostate
cancer is still largely confined to men who are at least 70 years
of age—with some exceptions, of course. As people are
10
Risk Factors
living longer due to better nutrition and health practices,
prostate cancer has become an even more important health
care consideration, both from the standpoint of its effect on
patients’ lives, as well as on the cost of care. This has generated
a sense of urgency among physicians to manage prostate cancer
more effectively and to be able to provide therapy to patients
who need it.
Obesity and Diet
Factors such as diet, caloric intake, and obesity have been
implicated in the development of prostate cancer. Obesity,
defined as body mass index (BMI) above 30, is characterized
by an excess of what is called “white fat” or “white adipose
tissue.” Obesity has been associated with progression of
several types of cancer, including prostate cancer.
• Obese patients with prostate cancer are more likely to
develop a recurrence following removal of the prostate
gland (radical prostatectomy) or radiation therapy for
disease that is confined to the prostate gland.
Hormones
Androgens are important to the normal growth and
development of the prostate gland as well as to the growth
of prostate cancer. Some patients can be treated with
drugs that decrease the availability of androgens such
as testosterone. However, for reasons not completely
understood, some prostate cancers become able to survive
and grow with little or no androgen stimulation, requiring
different approaches to treatment.
Risk Factors
11
Risk Factors
• It is believed that genetic traits associated with
both obesity and cancers are influenced by lifestyle
components such as diet and physical activity.
• Prostate cancer can also be accelerated in obese
patients independent of their physical activity and
type of diet, suggesting that white fat may have a
direct effect on cancer progression.
Race and Ethnicity
Heredity
African Americans have a higher frequency of death from
prostate cancer than Caucasian and Hispanic Americans,
although the reasons are unclear. Chinese and Japanese
Americans have a decreased frequency of prostate cancer,
although it is higher than in Chinese and Japanese men who
remain in their native countries. Men from northern Europe
have a higher frequency of prostate cancer than men from
southern Europe.
There appears to be a familial tendency for prostate cancer,
although it is not a direct genetic link to a specific gene
or chromosome. In fact, no specific genetic abnormalities
or profiles have been identified that would make genetic
screening for prostate cancer feasible for early identification.
Men carrying BRCA1/BRCA2 mutations—which are
important in the development of breast and ovarian cancer
in some women—have been shown to be at increased risk of
developing prostate cancer, although the exact mechanisms
are not known.
12
Risk Factors
Possible Signs of Prostate Cancer
The following symptoms may be caused by prostate
cancer as well as by other conditions:
• Weak or interrupted flow of urine;
• Frequent urination (especially at night);
• Trouble urinating;
Identification and Screening
for Prostate Cancer
Possible Signs of Prostate Cancer.....................................13
Screening for Prostate Cancer ......................................14
To Screen or Not to Screen........................................14
More about Prostate Cancer Screening.....................15
Digital Rectal Exam (DRE)........................................16
Prostate-Specific Antigen (PSA) Test.......................17
More about PSA Testing............................................18
Diagnostic Tests................................................................19
Transrectal Ultrasound...............................................19
Biopsy..........................................................................20
Transrectal Biopsy.......................................................21
Transperineal Biopsy...................................................22
The Gleason Grading System..........................................22
• Pain or burning during urination;
• Blood in the urine or semen;
• Pain in the back, hips, or pelvis that doesn’t go away;
• Painful ejaculation.
Identification and Screening for Prostate Cancer
13
Identification and Screening
for Prostate Cancer
Identification
and Screening
for Prostate
Cancer
Screening for Prostate Cancer
Whether screening for prostate cancer results in a decrease
in rates of death due to the disease is the subject of much
debate. The screening tests currently available include digital
rectal examination (DRE) and prostate-specific antigen
(PSA) testing. Most cancers detected by DRE alone are
advanced, so most physicians currently use a combination of
DRE and PSA testing.
To Screen or Not to Screen
For a variety of reasons there has been considerable discussion
about the benefit of screening men at average risk of prostate
cancer.
14
Identification and Screening for Prostate Cancer
• Whether screening for prostate cancer results in a
decrease in rates of death due to the disease is the
subject of much debate
• There is no reliable way to predict which cancers will
be slow-growing and which will be aggressive
• Prostate cancer tends to be a slow-growing disease, and
some of the small tumors that are found by the PSA
test may not be life-threatening; thus some men may
undergo unnecessary treatment
• Treatments for prostate cancer can lead to
complications, such as impotence and urinary
incontinence, which can affect men’s quality of life
Identification and Screening
for Prostate Cancer
• However, some prostate cancers can grow and spread
quickly and are termed aggressive
• In such cases, PSA screening may help find prostate
cancer early, while it is easier to treat
More about Prostate Cancer Screening
PSA testing increases the detection rate of prostate cancers
compared with DRE. Approximately 2–2.5% of men older
than 50 years of age will be found to have prostate cancer
using PSA testing, compared with a rate of approximately
1.5% using DRE alone. Multiplying the difference in these
percentages by the actual number of patients that are screened
suggests that in order to diagnose the most true cases of
prostate cancer, using both tests is highly advisable.
prostatic hyperplasia and those with prostate cancers. Thus
PSA screening will identify a considerable number of men
with high PSA but without prostate cancer. The most
frequent noncancerous causes of elevated PSA include
prostatitis (inflammation of the prostate) and benign prostatic
hyperplasia (BPH). PSA-detected cancers are more likely to be
localized compared with those detected by DRE alone.
On the other hand, screening for elevated PSA will not detect
all prostate cancers. The Prostate Cancer Prevention Trial
provided data demonstrating a significant risk of prostate
cancer even in men with PSA less than 4.0 ng/mL. In fact,
some men with a normal PSA result may have prostate cancer.
Keep in mind that PSA is not specific for cancer, and there
is considerable overlap of values between men with benign
Identification and Screening for Prostate Cancer
15
Additional information about DRE, PSA, and several other
tests used to assess the possibility of prostate cancer are
provided below.
Digital Rectal Exam (DRE)
A digital rectal exam (DRE) is an exam in which the doctor
or nurse inserts a lubricated, gloved finger into the rectum
and feels the prostate for lumps or abnormal areas through
the rectal wall.
Figure 4: Digital rectal exam (DRE). Photo courtesy of the National Cancer
Institute.
16
Identification and Screening for Prostate Cancer
Identification and Screening
for Prostate Cancer
Prostate-Specific Antigen (PSA) Test
As previously described, the PSA test measures the level of
PSA in the blood. PSA is a substance made by the prostate
that may be found in an increased amount in the blood of men
who have prostate cancer. PSA levels may also be high in men
who have an infection or inflammation of the prostate or BPH
(an enlarged, but noncancerous, prostate).
PSA is a protein produced primarily by cells, either benign or
malignant, of the prostate gland. The serum level is typically
low and correlates with the volume of both benign and
malignant prostate tissue. Measurement of serum PSA is useful
in detecting and staging prostate cancer, monitoring response
to treatment, and detecting recurrence before it becomes
clinically evident.
• When used as a screening test, PSA levels are found to
be elevated in up to 15% of men.
• Up to 30% of men with intermediate degrees of
elevation (4.1–10 ng/mL) will be found to have prostate
cancer.
• Between 50% and 70% of those with elevations >10
ng/mL will have prostate cancer.
Patients with intermediate levels of PSA usually have localized
and therefore potentially curable cancers. Approximately 20%
of patients who undergo radical prostatectomy for localized
prostate cancer have normal levels of PSA, meaning that a
normal PSA level does not rule out prostate cancer. A rising
PSA after therapy is usually consistent with progressive
disease, either locally recurrent or metastatic.
Identification and Screening for Prostate Cancer
17
More about PSA Testing
Sometimes results of standard PSA testing suggest the need
for more specialized PSA testing such as:
• PSA velocity (PSAV): PSAV measures how fast PSA
rises over time. Although PSA typically rises with age,
in men who have prostate cancer, PSA levels can rise
faster than normal
• PSA doubling time is a measure of how long it takes
for a man’s PSA level to double.
• Percent free PSA (fPSA): There are 2 forms of PSA
in the blood—PSA that circulates in an unbound or
free form, and PSA that is bound to blood proteins.
fPSA is the ratio of how much PSA circulates in the
unbound form compared with the total PSA level.
fPSA is lower in men who have prostate cancer
compared with those who do not.
• Complexed PSA (cPSA): This is a newer test that
measures the amount of PSA that is bound to blood
proteins. It is an alternative to the fPSA test
18
Identification and Screening for Prostate Cancer
Identification and Screening
for Prostate Cancer
Diagnostic Tests
Once prostate cancer is suspected based on screening tests,
a number of other tests may be performed to establish
or eliminate the diagnosis. These include transrectal
ultrasound, transrectal biopsy, and transperineal biopsy.
Transrectal Ultrasound
During a transrectal ultrasound procedure, a probe about
the size of a finger is inserted into the rectum to check the
prostate. The probe bounces ultrasound waves off internal
tissues or organs, creating echoes. The echoes form a
sonogram picture of body tissues. Transrectal ultrasound may
also be used during a biopsy procedure.
Figure 5: Transrectal ultrasound. Photo courtesy of the National Cancer
Institute.
Identification and Screening for Prostate Cancer
19
As shown in Figure 5, an ultrasound probe is inserted into
the rectum to check the prostate. The probe bounces sound
waves off body tissues to make echoes that form a sonogram
(computer picture) of the prostate.
Transrectal ultrasound has primarily been used for the staging
of prostate carcinomas, where tumors typically appear as areas
without an echo (dark areas on the ultrasound). In addition,
transrectal ultrasound-guided biopsy of the prostate is a more
accurate way to evaluate suspicious lesions than digitally
guided biopsy. Asymptomatic patients with cancers thought to
be localized to the prostate on DRE and transrectal ultrasound
and associated with modest elevations of PSA (i.e., <10 ng/
mL), may not need any further imaging.
20
Identification and Screening for Prostate Cancer
Biopsy
A biopsy involves the removal of cells or tissues to be viewed
under a microscope by a pathologist. The pathologist checks
the biopsy sample for cancer cells and to determine a Gleason
score, which will be discussed in greater detail below. The
Gleason score describes how likely it is that a tumor will
spread. It ranges from 2-10, and the lower the number, the less
likely the tumor is to spread. As described below, there are two
types of biopsy procedures used to diagnose prostate cancer—
transrectal biopsy and transperineal biopsy.
Identification and Screening
for Prostate Cancer
Transrectal Biopsy
A transrectal biopsy involves the removal of tissue from
the prostate by inserting a thin needle through the rectum
and into the prostate. This procedure is usually done using
transrectal ultrasound to help guide the needle. A pathologist
then views the removed tissue under a microscope to look for
cancer cells.
Transrectal ultrasound-guided biopsy is the standard method
for detection of prostate cancer. Local anesthesia is routinely
used and increases the tolerability of the procedure. The
specimen preserves glandular structure and permits accurate
grading. Prostate biopsy specimens are taken from the
several different areas of the prostate gland in men who
have an abnormal DRE or an elevated serum PSA, or both.
A total of at least ten biopsies is associated with improved
cancer detection and risk assessment of patients with newly
diagnosed disease.
Figure 6. Transrectal biopsy. Photo courtesy of the National Cancer Institute.
As shown in Figure 6, an ultrasound probe is inserted into the
rectum to show where the tumor is. Then a needle is inserted
through the rectum into the prostate to remove tissue from
the prostate.
Identification and Screening for Prostate Cancer
21
Transperineal Biopsy
The Gleason Grading System
In a transperineal biopsy, tissue is removed from the prostate by
inserting a thin needle through the skin between the scrotum
and rectum and into the prostate. As in other biopsies, a
pathologist then views the tissue under a microscope to look
for cancer cells.
A pathologist will examine the biopsy samples. If prostate
cancer cells are found, he or she will classify them according to
the Gleason system.
From Epstein JI. Pathology of prostatic neoplasia. In: Walsh PC, eds.
Campbell’s Urology. Philadelphia: WB Saunders; 2002
22
Identification and Screening for Prostate Cancer
Identification and Screening
for Prostate Cancer
The Gleason score represents a composite classification based
on a combination of structural and biological features.
However, because cancer cells in different areas of the
prostate may have different degrees of malignant potential,
the pathologist must use the sum of scores obtained from
various sections of the tissue biopsied from the prostate gland.
Information about the Gleason grading system is summarized
below. It is important not only for you to know about the
Gleason system but also for you to discuss your Gleason score
with your doctor.
• The Gleason score is obtained by assigning one
Gleason grade to the most dominant pattern and
another to the next most common pattern.
• By convention, the result is expressed as a sum,
with the primary pattern listed first.
• Thus, the Gleason score can range from 2
(resulting from 1 + 1) to 10 (5 + 5).
• There are five patterns, or grades, of prostate cells
ranging from normal, noncancerous cells to malignant
cells without any glandular organization.
• Prostate cancers are usually assigned Gleason grades
ranging from 2 through 5, because Gleason scores of 1
are very rare.
Identification and Screening for Prostate Cancer
23
Stages of
Prostate
Cancer
Stages of
Prostate Cancer
Tests Used to Stage Prostate Cancer...................................24
Radionuclide Bone Scan ............................................24
MRI (Magnetic Resonance Imaging)............................25
Other Tests....................................................................26
Prostate Cancer Stages........................................................27
TNM Staging System..........................................................32
How Prostate Cancer Spreads.............................................35
Tests Used to Stage Prostate Cancer
Radionuclide Bone Scan
After prostate cancer has been diagnosed, tests are done to
find out if cancer cells have spread, a process called staging.
The information gathered from the staging process determines
the stage of the disease. It is important to know the stage in
order to plan treatment. This next section describes tests and
procedures that may be used in the staging process.
A radionuclide bone scan is performed to check if there are
rapidly dividing cells, such as cancer cells, in the bone. During
this procedure a very small amount of radioactive material is
injected into a vein that travels through the bloodstream. The
radioactive material collects in the bones and is then detected
by a scanner.
24
Stages of Prostate Cancer
As illustrated in Figure 7, the patient lies on a table that
slides under the scanner where the radioactive material is
detected and images are made on a computer screen or film.
MRI (Magnetic Resonance Imaging)
Figure 7. Bone scan. Photo courtesy of the National Cancer Institute.
Magnetic resonance imaging (MRI) is a procedure that uses
a magnet, radio waves, and a computer to make a series of
detailed pictures of areas inside the body. This procedure is
also called nuclear magnetic resonance imaging (NMRI).
Stages of Prostate Cancer
25
Stages of Prostate Cancer
Radionuclide bone scan is better than regular x-rays in
detecting cancer that has spread to the bones. Most prostate
cancer metastases are multiple and most commonly localized
to the long bones of the skeleton. Men who undergo
radionuclide bone scans generally have more advanced
local lesions, symptoms of metastases (eg, bone pain), more
aggressive disease, or elevations in PSA >20 ng/mL.
MRI allows for evaluation of the prostate as well as regional
lymph nodes; its ability to detect tissue invasion is similar to
that of transrectal ultrasound.
Other Tests
◗◗ PELVIC LYMPHADENECTOMY: A surgical procedure
to remove the lymph nodes in the pelvis so a pathologist
can view the tissue under a microscope to look for cancer
cells.
◗◗ CT SCAN (CAT SCAN): A series of detailed computerlinked x-rays of areas inside the body are taken from
different angles. A dye may be injected into a vein
or swallowed to create a clearer contrasted image of
the organs or tissues. This procedure is also known as
computed tomography, computerized tomography, or
computerized axial tomography.
◗◗ SEMINAL VESICLE BIOPSY: Fluid from the glands
26
Stages of Prostate Cancer
that make semen, the seminal vesicles, is removed using a
needle so that a pathologist can view it under a microscope
and look for cancer cells.
Stages of Prostate Cancer
Prostate Cancer Stages
As prostate cancer progresses from stage I to stage IV, the cancer cells grow within the prostate, through the outer layer of the
prostate into nearby tissue, and then to lymph nodes or other parts of the body.
Stage
Stage I
Description
Illustration
In stage I, cancer is found in the prostate only.
The cancer tissue is found by needle biopsy
(such as for a high PSA level) or in a small
amount of tissue during surgery for other
reasons (such as benign prostatic hyperplasia).
• The PSA level is lower than 10, and the
Gleason score is 6 or lower; or cancer is found
in one-half or less of one lobe of the prostate.
• The PSA level is lower than 10, and the Gleason
score is 6 or lower; or a mass cannot be felt during a digital rectal exam and is not visible by imaging.
Cancer is found in one-half or less of one lobe of the prostate.
• The PSA level and the Gleason score are not known.
Stages of Prostate Cancer
27
Stage
Stage II
Description
Illustration
In stage II, cancer is more advanced than in stage I, but has
not spread outside the prostate. Stage II is divided into
stage IIA and stage IIB.
Stage IIA
Stage IIA
28
Cancer is found by needle biopsy (such as for a high PSA
level) or in a small amount of tissue during surgery for other
reasons (such as benign prostatic hyperplasia).
• The PSA level is lower than 20, and the Gleason score is
7; or cancer is found by needle biopsy (such as for a high
PSA level) or in a small amount of tissue during surgery
for other reasons (such as benign prostatic hyperplasia).
• The PSA level is at least 10 but lower than 20, and the
Gleason score is 6 or lower; or cancer is found in one-half
or less of one lobe of the prostate.
Stages of Prostate Cancer
Stage IIB
Stage
Description
Illustration
• The PSA level is at least 10 but lower than 20, and the Gleason score is 6 or lower; or cancer is found in
one-half or less of one lobe of the prostate.
• The PSA level is lower than 20, and the Gleason score is 7; or cancer is found in more than one-half of one
lobe of the prostate.
• The PSA level is lower than 20, and the Gleason score is 7 or lower; or cancer is found in more than
one-half of one lobe of the prostate.
• The PSA level and the Gleason score are not known.
Stage IIB
Cancer is found in opposite sides of the prostate.
• The PSA can be of any level, and the Gleason score can range
from 2 to 10; or a mass cannot be felt during a digital rectal
exam and is not visible by imaging, and the tumor has not
spread outside the prostate.
• The PSA level is 20 or higher, and the Gleason score can
range from 2 to 10; or a mass cannot be felt during
a digital rectal exam and is not visible by imaging, and
the tumor has not spread outside the prostate.
• The PSA can be of any level and the Gleason score
is 8 or higher.
Stages of Prostate Cancer
Stages of Prostate Cancer
Stage IIA
(cont’d)
29
Stage
Stage III
30
Description
In stage III, cancer has spread beyond the outer layer of the
prostate and may have spread to the seminal vesicles. The
PSA can be of any level, and the Gleason score can range
from 2 to 10.
Stages of Prostate Cancer
Illustration
Stage
Illustration
In stage IV, the PSA can be of any level, and the Gleason
score can range from 2 to 10. Also, cancer has spread beyond
the seminal vesicles to nearby tissue or organs, such as the
rectum, bladder, or pelvic wall; or may have spread to the
seminal vesicles or to nearby tissue or organs, such as the
rectum, bladder, or pelvic wall. Cancer has spread to nearby
lymph nodes or has spread to distant parts of the body,
which may include lymph nodes or bones. Prostate cancer
often spreads to the bones.
Stages of Prostate Cancer
Stage IV
Description
Stages of Prostate Cancer
31
TNM Staging System
TNM staging system, which stands for Tumor, Node,
Metastasis, is an internationally recognized staging system
developed by The American Joint Committee on Cancer. The
table on the following page describes the TNM staging system
in greater detail.
• T refers to the size of the primary tumor
• N describes the extent of regional lymph node
involvement
• M refers to the presence or absence of metastases
In addition, the equivalent stages in the A, B, C, D, or JewettWhitmore, system are given in parentheses in the table.
32
Stages of Prostate Cancer
Table 2: TNM Staging System
Stage TX, T0, T1
Stage T2
T2 Palpable tumor confined
to prostate
TO No evidence of primary
tumor
T2a (B1) Tumor involves half of
one prostate lobe or less
T1 (A) Tumor not clinically
apparent
T1a (A1) Tumor incidentally
found in ≤5% of prostate
sample
T1b (A2) Tumor incidentally
found in >5% of prostate
sample
T1c (B0) Tumor identified at
needle biopsy performed to
investigate PSA elevation
Stage T4
T3 (C1) Tumor palpable and
extends beyond prostate
capsule
T3a (C1) Tumor extends beyond
prostate capsule, either on one
side (unilaterally) or both sides
(bilaterally)
T4 Tumor is fixed or invades
adjacent anatomy other than
seminal vesicles: bladder
neck, external sphincter,
rectum, elevator muscles,
and/or pelvic wall
T2b (B2) Tumor involves more
than half of one lobe but not
both lobes
T2c (B2) Tumor involves both
prostate lobes
T3b (C2-3) Tumor invades
seminal vesicles
Stages of Prostate Cancer
33
Stages of Prostate Cancer
TX Primary tumor
cannot be assessed
Stage T3
N Staging
M Staging
Stage NX, N0, N1
Stage MX, M0, M1
NX Regional lymph nodes cannot be
assessed
MO No distant metastasis
NO No regional lymph node
metastasis
M1a Metastasis to nonregional lymph nodes
N1 Metastasis in regional lymph node
or nodes
M1c Metastasis to other distant sites
34
Stages of Prostate Cancer
M1 Distant metastasis
M1b Metastasis to bone
Prostate cancer can spread throughout the body:
• Through tissue. Cancer invades the surrounding
normal tissue.
• Through the lymph system. Cancer invades the lymph
system and travels through the lymph vessels to other
places in the body.
cancer spreads to the bones, the cancer cells in the bones are
actually prostate cancer cells, not bone cancer. The disease is
then called metastatic prostate cancer.
When prostate cancer comes back (recurs) after it has been
treated, it is called recurrent prostate cancer. The cancer may
recur in the prostate or in other parts of the body.
• Through the blood. Cancer invades the veins and
capillaries and travels through the blood to other
places in the body.
Metastasis is the process of cancer cells breaking away from
the primary (original) tumor and traveling through the
lymph system or blood to other places in the body forming
a secondary tumor. The secondary (metastatic) tumor is the
same type of cancer as the primary tumor, even though it may
be found in another part of the body. For example, if prostate
Stages of Prostate Cancer
35
Stages of Prostate Cancer
How Prostate Cancer Spreads
Questions to Ask Your Doctor
• What kind of tests do I need?
• What does my PSA level mean?
• What is the Gleason score of my prostate cancer?
• What is the stage of my prostate cancer?
• Has the prostate cancer spread to other areas of my body?
• Should I get a second opinion?
36
Stages of Prostate Cancer
Treatment
of Prostate
Cancer
Treatment of
Prostate Cancer
Treatment of Prostate Cancer
37
Treatment of
Prostate Cancer
Overview of Treatment Options.......................................................38
Watchful Waiting or Active Surveillance........................................38
Surgery...............................................................................................38
Cryosurgery..................................................................................41
Possible Side Effects of Surgery...................................................41
More about Surgery.....................................................................41
Radiation Therapy............................................................................43
External Beam Radiation Therapy..............................................43
3-Dimensional Conformal Radiational Therapy........................44
Conformal Proton Beam Radiation Therapy..............................44
Intensity Modlated Radiation Therapy.......................................44
Possible Side Effects of Radiation Therapy.................................45
Hormone Therapy.......................................................................46
Chemotherapy...................................................................................48
Possible Side Effects....................................................................48
Biologic Therapy...............................................................................49
Possible Side Effects.....................................................................49
Clinical Trials..............................................................................49
Possible New Treatments..................................................................50
High-Intensity Focused Ultrasound............................................51
Proton Beam Radiation Therapy................................................52
Overview of Treatment Options
Standard options available for patients with prostate
cancer include watchful waiting or active surveillance and
treatments such as surgery, radiation, hormone therapy, and
chemotherapy.
Standard treatments in current use are discussed below.
Watchful Waiting or Active Surveillance
Since it is often difficult to predict which prostate cancers
will worsen or spread, and because cancer treatments usually
have side effects, watchful waiting or active surveillance is
an approach to consider. With this in mind, until a patient
develops symptoms or until symptoms change after diagnosis
of early prostate cancer, the only treatment recommended may
be to closely monitor a patient’s condition. This is referred to
as watchful waiting. If changes in test results occur, a patient’s
condition can be observed through active surveillance to
38
Treatment of Prostate Cancer
find early signs that the condition is getting worse. In active
surveillance, patients are given certain exams and tests,
including biopsies, on a regular schedule.
Surgery
The are four surgical procedures that may be recommended for
patients with prostate cancer who are in good health. They
include:
◗◗ PELVIC LYMPHADENECTOMY: The lymph nodes in
the pelvis are surgically removed. The doctor will usually
not remove the prostate if the lymph nodes contain cancer
and may recommend another treatment.
◗◗ RADICAL PROSTATECTOMY: The prostate,
surrounding tissue, and seminal vesicles are all surgically
removed. There are 2 types of radical prostatectomy:
◗◗ Retropubic prostatectomy: The prostate is surgically
removed through an incision in the abdominal wall.
Removal of nearby lymph nodes may be done at the
same time.
Figure 8: Two types of radical prostatectomy. Retropubic is shown on the left
and perineal on the right. Photo courtesy of the National Cancer Institute.
Treatment of Prostate Cancer
39
Treatment of
Prostate Cancer
◗◗ Perineal prostatectomy: The prostate is surgically
removed through an incision in the area between the
scrotum and anus. Nearby lymph nodes may also be
removed through a separate incision in the abdomen.
◗◗ TRANSURETHRAL RESECTION OF THE
PROSTATE (TURP): Tissue from the prostate is
surgically removed using a thin, lighted tube with a
cutting tool called a resectoscope that is inserted through
the urethra. This procedure is sometimes done to relieve
urinary symptoms caused by a tumor before other cancer
treatment is given. In such a situation, the surgery is
palliative—done to relieve symptoms—rather than
curative. TURP may also be performed in men who cannot
have a radical prostatectomy because of age or illness.
Figure 9: Transurethral resection of the prostate (TURP). Tissue is removed
from the prostate using a resectoscope (a thin, lighted tube with a cutting tool
at the end) inserted through the urethra. Prostate tissue that is blocking the
urethra is cut away and removed through the resectoscope. [Courtesy of the
NCI, permission requested]
40
Treatment of Prostate Cancer
Cryosurgery, or cryotherapy, uses an instrument to freeze and
destroy prostate cancer cells.
Inguinal hernia, a bulging of fat or part of the small intestine
through weak muscles in the groin, may occur within the first
2 years after retropubic radical prostatectomy.
Possible Side Effects of Surgery
More about Surgery
Cryosurgery
Side effects of surgery can include:
• Leakage of urine from the bladder;
• Leakage of stool from the rectum.
To help avoid impotence, doctors can use a technique known
as nerve-sparing surgery. This type of surgery may save the
nerves that control erection. However, men with large tumors
or tumors that are very close to the nerves may not be able to
have this surgery.
Treatment of
Prostate Cancer
• Impotence;
• Radical prostatectomy can last from about 1.5 to 4
hours. The perineal surgery is generally shorter than
retropubic surgery.
–– After these procedures, a catheter is usually
inserted into the urethra to permit urination
during the healing process and should be needed
for a few weeks or less.
–– After the catheter is removed, a patient should be
able to urinate on his own.
• After the prostate is removed, it is sent for evaluation
of the margins, or edges, of the prostate.
Treatment of Prostate Cancer
41
Questions to ask your doctor
and/or surgeon
• If the margins of the prostate do not have cancer cells
(negative margins), it is assumed that the cancer was
entirely within the prostate and has not spread.
• Laparoscopic radical prostatectomy uses 4 or 5 small
incisions in the abdomen. The surgeon inserts a long
tube-like camera into one of the incisions to see the
prostate area and places long instruments into the other
incisions to remove the prostate and the nearby tissues.
• Is prostate surgery an option for me?
• What type of prostate surgery
do you recommend?
• What are the benefits of
prostate surgery?
• What kind of side effects are
possible, and how can they
be managed?
• How many of these surgeries
have you done?
• What options do I have
besides surgery?
42
Treatment of Prostate Cancer
Radiation Therapy
Radiation therapy is a cancer treatment that uses high-energy
x-rays or other types of radiation to kill cancer cells or keep
them from growing. Radiation therapy can be used in an
attempt to cure prostate cancer or can be palliative — used to
ease symptoms. The two types of radiation therapy are:
External Beam Radiation Therapy
• In external beam radiation therapy, a machine delivers
the radiation in short sessions, usually one session for 5
days each week for 7 to 9 weeks.
• Internal radiation therapy, known as brachytherapy:
uses a radioactive substance sealed in needles, pellets,
called “seeds”, wires, or catheters that are placed
directly into or near the cancer.
• As in an x-ray, the machine focuses on a specific part
of the body.
–– High-dose brachytherapy: Radioactive seeds are
inserted into the prostate for 5 to 15 minutes and
then removed. A few treatments may be given
over the course of several days.
Advances in external beam radiation therapy have led to
three methods of treatment that are described here. These
developments may help reduce side effects and increase
treatment success.
Treatment of
Prostate Cancer
• External radiation therapy: uses a machine outside the
body to send radiation toward the cancer.
–– Severe urinary incontinence is uncommon, but
approximately one-third of men may experience
frequent urination.
• The treatment itself is painless and takes only a few
minutes.
Treatment of Prostate Cancer
43
3-Dimensional Conformal Radiation Therapy
• Computers are used to identify the location of the
prostate and the cancer inside the prostate gland and
irradiate just that area.
• The technique involves the creation of a patientdedicated protection device that is similar to a body
cast, but is molded out of plastic and helps to keep the
body immobile.
• This permits the radioactive beam to accurately deliver
a high dose of radiation to the prostate while limiting
the surrounding areas’ radiation exposure.
Conformal Proton Beam Radiation Therapy
• Conformal proton beam radiation therapy (CPBRT)
relies on a technique similar to that of 3-dimensional
conformal radiation therapy, except that it uses protons
to produce the radiation beam.
• Unlike x-rays, which release energy both before and
after they hit a cancer, protons may produce less damage
to tissues through which they pass and may help to
spare healthy tissue.
Intensity Modulated Radiation Therapy
• Intensity modulated radiation therapy (IMRT) relies
on computed tomography (CT) to create a 3D picture
of the prostate, with radiation delivered only to the
prostate gland.
• In IMRT, a computer-driven machine moves around the
44
Treatment of Prostate Cancer
patient, targeting radiation to the prostate from several
different angles.
• The intensity of the radiation can be adjusted to
reduce the dose that reaches healthy tissue while
enabling a higher dose to reach the cancer.
• Thus, IMRT can permit an increased radiation dose to
be delivered to the prostate gland.
Possible Side Effects of Radiation Therapy
• Skin redness, tenderness, or sensitivity
• Extreme fatigue
• Inflammation inside the mouth after radiation therapy
to the head and neck area.
Make sure to tell your doctor if you experience any
side effects.
Treatment of Prostate Cancer
45
Treatment of
Prostate Cancer
Side effects of radiation therapy may depend on the area that
is having the radiation treatment. The side effects usually
lessen in time. However, sometimes they may continue for
several months after treatment is finished. Your doctor may
be able to provide recommendations for coping with some
of the side effects. Some side effects of radiation therapy
include:
Questions to ask your doctor
• Is radiation therapy an option for me?
• How effective is radiation therapy versus
prostate surgery in early stage prostate
cancer?
• How effective is radiation therapy for
advanced prostate cancer?
• What type of radiation therapy do you
recommend?
• What are the benefits of this type of
radiation therapy?
• What are the possible side effects?
• What are my options besides surgery or
radiation?
46
Treatment of Prostate Cancer
Hormone Therapy
Hormones are substances made by glands in the body and
circulated in the bloodstream. During hormone therapy,
hormones are removed or blocked to prevent cancer cells from
growing. In prostate cancer, drugs, surgery, or other hormones
are used to reduce the amount of male hormones or block
them from working in order to prevent the growth of prostate
cancer.
The side effects of hormonal therapy vary from medication
to medication and can include hot flashes, impaired sexual
function, loss of desire for sex, and weakened bones. Other side
effects may include diarrhea, nausea, and pruritus (itching).
Be sure to mention any side effects you may experience to
your doctor, who may be able to help you to manage them.
Advantages and disadvantages of hormone therapy should be
discussed with your doctor.
Questions to ask your doctor
• Is hormone therapy an option for me?
• What are my hormone therapy options?
• Which hormone therapy do you recommend? Do you recommend drugs or surgery?
• What are the benefits of this treatment?
Treatment of
Prostate Cancer
• What are the side effects, and how can they be managed?
• If I choose hormone drug therapy, how long do I have to take these medications?
• What happens if the hormone therapy stops working?
Treatment of Prostate Cancer
47
Chemotherapy
Possible Side Effects
Chemotherapy is a cancer treatment that uses drugs to stop
the growth of cancer cells, either by killing the cells or by
stopping them from dividing. Some chemotherapy drugs are
taken by mouth as pills, while others are given into a vein
(intravenously) in a doctor’s office or clinic. Chemotherapy
that is placed directly into the cerebrospinal fluid, an organ, or
a body cavity such as the abdomen and mainly affects cancer
cells in those areas is called regional chemotherapy. The way
the chemotherapy is given depends on the type and stage of
the cancer being treated.
Every patient may experience side effects of chemotherapy
differently, and severity can vary from person to person. In
addition, side effects depend on which treatment is used. The
most common side effects of chemotherapy can include:
• Anemia (low red blood cell count)
• Extreme fatigue
• Hair loss
• Increased risk of bruising, bleeding, and infection
• Nausea and vomiting
• Leukopenia (low white blood cell count)
48
Treatment of Prostate Cancer
Biologic Therapy
Biologic therapy, biotherapy, or immunotherapy is a
treatment that uses the patient’s immune system to fight
cancer. Substances made by the body or made in a laboratory
are used to boost, direct, or restore the body’s natural defenses
against cancer.
Biological therapies may also cause side effects. What side
effects occur and how severe these side effects may be depend
on individual patients’ characteristics and their treatment
plans. The following are some side effects that can be
associated with biological therapy drugs.
• When a biological therapy drug is given intravenously,
the injection site can become red and sore. Serious
phlebitis (vein inflammation) occasionally results.
• Fatigue is a common side effect of biological therapy.
• Allergic reactions may also occur including cough,
wheezing, and skin rash.
Clinical Trials
Your doctor can help you decide whether a clinical trial is
an option for you. Clinical trials, also known as research
studies, are used to test a new treatment to determine if it is
safe, effective, and possibly better than standard treatments.
Talk to your doctor to determine if a clinical trial might be an
option for you.
Each clinical trial has a specific policy on what type of
patients should be included and excluded. Factors such as
age, gender, type of disease, prior treatments, or medical
Treatment of Prostate Cancer
49
Treatment of
Prostate Cancer
Possible Side Effects
• Flu-like symptoms may develop, including fever, chills,
gastrointestinal upset, and body aches.
history may determine if the patient is appropriate for a given
clinical trial.
In addition, every trial has specific rules and guidelines for
when patients need to have tests and procedures, as well as
when they will receive medications and at what doses. In
addition, patients will be seen regularly by the research team to
monitor and determine if the treatment is working and if the
patient is experiencing any side effects.
Testing of treatments occurs in phases. Most clinical trials are
categorized as phase I, II, III, or IV. Phase I trials are often the
first studies to test a new drug in people.
• Phase I trials typically evaluate how a new drug should
be given and how much of the drug may be given
safely. Only a small group (20 to 80) of people may be
enrolled.
• Phase II trials further test the safety of the drug and
50
Treatment of Prostate Cancer
begin to measure how well the drug works. A larger
group (100 to 300) of patients is likely to be enrolled.
• Phase III trials typically compare the safety and efficacy
of the new treatment with the current standard
treatment. Phase III trials often enroll a large number of
patients (1000 to 3000) at different sites.
• Phase IV trials are conducted after a new treatment has
been approved and is available to be prescribed.
These trials typically evaluate the safety and efficacy of a drug
over a longer period of time in a larger number of patients.
Possible New Treatments
This summary section describes treatments that are being
studied in clinical trials. It may not mention every new
treatment being studied.
High-Intensity Focused Ultrasound
High-intensity focused ultrasound uses ultrasound waves to
destroy cancer cells. An endorectal probe is used to make the
sound waves for the treatment of prostate cancer.
Proton Beam Radiation Therapy
• www.cancer.gov/clinical_trials—a service of the
National Cancer Institute
• www.clinicaltrials.gov—a service of the US National
Institutes of Health
• www.cancertrialshelp.org—a service of the Coalition
of Cancer Cooperative Groups
Treatment of
Prostate Cancer
Proton beam radiation therapy is a type of high-energy,
external radiation therapy that targets tumors with streams of
protons. This type of radiation therapy is being studied in the
treatment of prostate cancer.
These Web sites provide more information about clinical
research trials
• www.emergingmed.com—a site that helps identify
appropriate clinical trials for patients
Advantages and disadvantages of any
of these treatment methods should be
discussed with your doctor.
Treatment of Prostate Cancer
51
Questions to ask your doctor
• Is a clinical trial an option for me?
• What types of clinical trials are available?
• What do researchers know about the medicines being studied?
• What are the benefits? What are the side effects?
• How long will the clinical trial last?
• Do I have to see another doctor?
• Are extra tests needed?
• Are extra visits to the doctor required?
• Will my health insurance cover the costs of the clinical trial?
52
Treatment of Prostate Cancer
Treatment
Options by
Stage
Although there are different ways that each stage of prostate
cancer may be treated, the following information describes
some of the most common approaches to treatment.
Treatment Options
by Stage
Stage I Prostate Cancer.........................53
Stage II Prostate Cancer........................54
Stage III Prostate Cancer.......................54
Stage IV Prostate Cancer......................55
Recurrent Prostate Cancer....................55
Stage I Prostate Cancer
Treatment of stage I prostate cancer may include the following:
• Watchful waiting or active surveillance
• Radical prostatectomy, usually with pelvic
lymphadenectomy, with or without radiation therapy
after surgery. It may be possible to remove the prostate
without damaging nerves that are necessary for an
erection
• External-beam radiation therapy
• Clinical trials
Treatment Options by Stage
53
Treatment Options by Stage
• Implant radiation therapy
Stage II Prostate Cancer
Stage III Prostate Cancer
Treatment of stage II prostate cancer may include the
following:
Treatment of stage III prostate cancer may include the
following:
• Watchful waiting or active surveillance
• Radical prostatectomy, with or without pelvic
lymphadenectomy. Radiation therapy may be given
after surgery. It may be possible to remove the prostate
without damaging nerves that are necessary for an
erection
• External-beam radiation therapy with or without
hormone therapy
• Implant radiation therapy
• Clinical trials
• External-beam radiation therapy with or without
hormone therapy
• Hormone therapy
• Radical prostatectomy, with or without pelvic
lymphadenectomy. Radiation therapy may be given
after surgery
• Watchful waiting or active surveillance
• Radiation therapy, hormone therapy, or transurethral
resection of the prostate as palliative therapy to relieve
symptoms caused by the cancer
• Clinical trials
54
Treatment of Prostate Cancer
Stage IV Prostate Cancer
Recurrent Prostate Cancer
Treatment of stage IV prostate cancer may include the
following:
Treatment of recurrent prostate cancer may include the
following:
• Hormone therapy
• Radiation therapy
• External-beam radiation therapy with or without
hormone therapy
• Prostatectomy for patients initially treated with
radiation therapy
• Radiation therapy or transurethral resection of the
prostate as palliative therapy to relieve symptoms caused
by the cancer
• Hormone therapy
• Watchful waiting or active surveillance
• Chemotherapy
• Clinical trials
• Pain medicine, external radiation therapy, internal
radiation therapy with radioisotopes such as
strontium-89, or other treatments as palliative therapy
to lessen bone pain
• Clinical trials
Treatment Options by Stage
55
Treatment Options by Stage
Advantages and disadvantages of
various types of treatment should be
discussed with your doctor.
• Biologic therapy with sipuleucel-T for patients already
treated with hormone therapy
Prognosis
Prognosis
Factors Affecting Prognosis.................................................56
Survival by Stage.................................................................56
Treatment Follow-up and Monitoring................................57
Localized or Locally Advanced Prostate Cancer................57
Advanced Prostate Cancer..................................................58
Factors Affecting Prognosis
Certain factors affect prognosis (chance of recovery) and
treatment options, including the following:
• The stage of the cancer (whether it affects part of the
prostate, involves the whole prostate, or has spread to
other places in the body).
• The patient’s age and health.
• Whether the cancer has just been diagnosed or has
recurred (come back).
• The Gleason score and the level of PSA.
56
Prognosis
Survival by Stage
The survival statistics shown in Table 3 are based on what
is called “relative survival.” This is a measure of survival of
cancer patients in comparison to the general population. The
overall 5-year relative survival for 2002–2008 from multiple
geographic areas was 99.2%. Five-year relative survival by
race was: 99.6% for white men; 96.2% for black men.
Prognosis
Table 3: 5-year Relative Survival by Stage
Treatment Follow-up and Monitoring
Percentage of
Patients per
Stage (%)
5-year Relative
Survival
(%)
Localized (confined
to primary site)
81
100.0
Regional (spread
to regional lymph
nodes)
12
100.0
• Patients must be monitored at regular intervals
according to a long-term follow-up plan.
Distant (cancer has
metastasized)
4
27.8
• During and after treatment, PSA tests can help to
determine a patient’s status and whether further
testing may be required.
Unknown
(unstaged)
3
71.1
Stage at Diagnosis
Localized or Locally Advanced Prostate Cancer
After initial treatment for prostate cancer has been
completed, risk of recurrence is the principal concern.
• It is not possible to determine which patients are likely
to have a recurrence.
Prognosis
57
Guidelines recommend that post-treatment PSA levels
be checked every 6 to 12 months for the first 5 years after
treatment and then yearly thereafter.
Advanced Prostate Cancer
Follow-up for advanced prostate cancer is similar to that of
earlier stages.
• An increase or change in the PSA level does not
necessarily signal a recurrence
• Follow-up visits for patients on hormone therapy will
involve injections and/or prescription refills
• Additional tests to determine whether prostate cancer
has recurred include:
• Patients will be monitored for side effects from hormone
therapy
–– Biopsy
–– Bone scan
–– CT or MRI
• Annual DRE is also recommended because prostate
cancer can recur without a change in PSA level
58
Prognosis
Prognosis
Questions Frequently Asked by Patients
• What is the risk of my prostate cancer returning or getting worse?
• What type of follow-up and monitoring do you recommend?
• What is a typical PSA level for a person who has received the treatment
I have received?
• What happens if my PSA level starts to rise?
• Do I need to change treatments if my PSA does not decrease?
• What other tests will I need?
Prognosis
59
Living with
Prostate
Cancer
Living with
Prostate Cancer
Keep a Positive Outlook.......................................................................60
How Should I Feel?...............................................................................60
Take Action...........................................................................................61
What’s the Best Way to Cope with My Diagnosis?..............................62
How Will Prostate Cancer Affect My Relationships?..........................62
How Much Should I Tell My Partner?..................................................62
Keep a Positive Outlook
How Should I Feel?
Prostate cancer may raise feelings that you may find hard
to deal with. Take advantage of all the help you can find,
especially from your family and friends, as well as your health
care team. Tell them what you are thinking and what you
need. There are many ways that men deal with having
prostate cancer, and every man is entitled to his own feelings.
Learning that you or a loved one has prostate cancer may
give rise to concerns and emotions that you may find difficult
to confront. It’s natural to be worried about treatment, side
effects, the future, and how prostate cancer may affect you
and your loved ones. Each person has his or her own way
of dealing with concerns and emotions; there is no right or
wrong way to handle them. Many sources of support and
comfort are available to you, including your family, friends,
and health care team.
If you need to find a support group or other resources to help
you, call the American Cancer Society at 1-800-ACS-2345.
60
Living with Prostate Cancer
After receiving a diagnosis of prostate cancer, many men feel
a range of emotions such as fear and anger. Many men also
have questions and want to know what they can do to take an
active role in their care. There are several ways that you can
become more active in making decisions about your care. For
example, you can:
• Learn about the disease. Educational materials are
available on the Internet as well as from your doctor.
Living with
Prostate Cancer
Take Action
• Find out about the treatment options currently
available and talk to your doctor about which ones may
be appropriate for you.
• Talk to your doctor and health care providers. You
should feel comfortable asking them questions and, if
you want to, getting a second opinion. If you change
doctors after your initial treatment, make sure your new
doctor has a complete set of records from your previous
doctor and hospital.
• Join a support group. You can find valuable information
and resources by talking to others who are going
through the same thing.
Living with Prostate Cancer
61
What’s the Best Way to Cope with
My Diagnosis?
How Will Prostate Cancer Affect
My Relationships?
Being informed and in charge may help you feel more in
control and relieve some fears. Become a partner with your
health care team—your urologist, radiation oncologist,
medical oncologist, nurse, technician, and counselor. Ask
questions about your condition. Find out about the risks,
benefits, and side effects of your treatment options, and how
the treatment you choose will affect your life. It’s a good idea
to write down all of your questions and answers so you can
refer to the information later. Once you have decided on a
treatment option, follow the advice from your health care
team and let them know about any new symptoms or other
concerns you may have.
Talk about your illness with your family and close friends.
Some people may shy away at first because they want to
help you but don’t know how. If you are honest about what
you need, this may help you maintain relationships that will
support you.
62
Living with Prostate Cancer
How Much Should I Tell My Partner?
The more your partner understands and shares in your care,
the more your partner can give you support. Your partner can
help you cope with and manage your illness if you include her
or him; for example, your partner can go with you to doctor
visits and help you go over treatment options. You may want
to talk to a professional counselor if you have concerns about
intimacy with your partner.
Additional
Information
About Prostate
Cancer
Additional Information
About Prostate Cancer
From the National Cancer Institute.........................63
Support Groups and Resources.................................64
From the National Cancer Institute
For more information from the National Cancer Institute
about prostate cancer, see the following:
http://www.cancer.gov/cancertopics/types/prostate
What You Need to Know About™ Prostate Cancer
http://www.cancer.gov/cancertopics/wyntk/prostate
Prostate Cancer Prevention
http://www.cancer.gov/cancertopics/pdq/prevention/prostate/Patient
Prostate Cancer Screening
http://www.cancer.gov/cancertopics/pdq/screening/prostate/Patient
Drugs Approved for Prostate Cancer
http://www.cancer.gov/cancertopics/druginfo/prostatecancer
Prostate-Specific Antigen (PSA) Test
http://www.cancer.gov/cancertopics/factsheet/Detection/PSA
Treatment Choices for Men with Early-Stage
Prostate Cancer
http://www.cancer.gov/cancertopics/treatment/prostate/
understanding-prostate-cancer-treatment/
Cryosurgery in Cancer Treatment: Questions
and Answers
http://www.cancer.gov/cancertopics/factsheet/Therapy/cryosurgery
Additional Information About Prostate Cancer
Additional Information
About Prostate Cancer
Prostate Cancer Home Page
63
Support Groups and Resources
American Cancer Society (ACS)
The following list of resources is provided as a convenience
to you. AstraZeneca takes no responsibility for the content
of, or services provided by, these resources and makes no
representation as to the accuracy or completeness of any
information provided by these resources. AstraZeneca shall
have no liability for any damages or injuries of any kind arising
from the information provided by the resources listed. The
descriptions of the organizations are all directly from their
respective Web sites.
250 Williams Street NW, Suite 600
Atlanta, GA 30303
1-800-ACS-2345 (1-800-227-2345)
www.cancer.org
64
Additional Information About Prostate Cancer
The American Cancer Society is the largest volunteer
organization in the United States and is committed to saving
lives from cancer by helping people stay well, helping people
get well, by finding cures and fighting back. There are 900
local offices nationwide to deliver lifesaving programs and
services at the community level.
CancerCare
1000 Corporate Boulevard
Linthicum, MD 21090
410-689-3990
1-800-828-7866
275 Seventh Avenue
Floor 22
New York, NY 10001
212-712-8400
1-800-813-HOPE (1-800-813-4673)
www.cancercare.org
www.urologyhealth.org
The AUA Foundation is the nation’s leading urologic health
charity that promotes research, education, and advocacy.
AUA Foundation’s mission is to improve prevention,
detection, and treatment of urologic diseases.
CancerCare is a national nonprofit organization that
provides free professional support services to anyone affected
by cancer: people with cancer, caregivers, children, loved
ones, and the bereaved. CancerCare programs — including
counseling, education, financial assistance, and practical
help—are provided by trained oncology social workers and
are completely free of charge. Founded in 1944, CancerCare
provided individual help to more than 100,000 people in
2009.
Additional Information About Prostate Cancer
65
Additional Information
About Prostate Cancer
American Urological Association Foundation (AUAF)
Men’s Health Network (MHN)
Prostate Cancer Foundation (PCF)
Men’s Health Network
PO Box 75972
Washington, DC 20013
202-543-MHN-1 (202-543-6461)
www.menshealthnetwork.org
1250 Fourth Street
Santa Monica, CA 90401
310-570-4700
1-800-757-CURE (1-800-757-2873)
www.prostatecancerfoundation.org
The Men’s Health Network provides information about
disease prevention, screening programs, and disease education
materials for a number of diseases affecting men’s health. The
Men’s Health Network, which currently has a board of advisors
including more than 800 physicians and key thought leaders,
was founded in 1992 by a group of health professionals and
others interested in improving the health and well-being of
men, boys, and families.
The Prostate Cancer Foundation (PCF) is the world’s largest
philanthropic source of support for prostate cancer research
to fund better treatments and a cure for prostate cancer.
PCF pursues its mission by soliciting and selecting promising
research programs and rapid deployment of resources. Founded
in 1993, the PCF has raised more than $370 million and has
provided funding for more than 1,500 research projects at
nearly 200 institutions worldwide.
66
Additional Information About Prostate Cancer
Prostate Conditions Education Council (PCEC)
The Prostate Net
7009 South Potomac Street, Suite 125
Centennial, CO 80112
303-316-4685
1-866-477-6788
www.prostateconditions.org
PO Box 2192
Secaucus, NJ 07096-2192
Phone: 1-888-477-6763
www.theprostatenet.org
Additional Information About Prostate Cancer
Additional Information
About Prostate Cancer
The Prostate Conditions Education Council provides
information on prostate health. The Council, founded in
1989, is made up of a consortium of leading physicians,
health educators, scientists, and prostate cancer advocates.
The aim of the Council is to provide information, conduct
nationwide screenings for men, and perform research that
will aid in the detection and treatment of prostate and men’s
health conditions.
The Prostate Net develops and maintains an interactive
network of educational tools and services for consumers.
These services are offered to educate, inform, and motivate
consumers to make informed choices about prostate cancer
and other prostate diseases.
67
Us TOO International Prostate Cancer
ZERO – The Project to End Prostate Cancer
Education & Support Network
5003 Fairview Avenue
Downers Grove, IL 60515
630-795-1002
1-800-80-UsTOO (1-800-808-7866)
www.ustoo.org
10 G Street NE, Suite 601
Washington, DC 20002
202-463-9455
1-888-245-9455
www.zerocancer.org
68
Additional Information About Prostate Cancer
ZERO – The Project to End Prostate Cancer is committed to
reducing prostate cancer, alleviating the pain from the disease,
and ultimately to end it. To accomplish these goals, ZERO
provides comprehensive treatment information to patients,
education to those at risk, and conducts free prostate cancer
testing throughout the country. They work to increase research
funds from the federal government and fund research in the
pursuit of a better test for this disease.
Glossary
The following is a list of some medical terms that
you may not know.
A
ACTIVE SURVEILLANCE: also called watchful waiting
or expectant management; it is the decision not to treat the
prostate cancer immediately with surgery, radiation, hormone
therapy, or any other treatment options. Instead, the doctor
monitors the patient’s prostate cancer by checking the PSA
level and looking for signs and symptoms of cancer growth/
progression. A decision to start therapy can be made later if
the cancer gets worse.
ADRENAL GLANDS: two small triangle-shaped glands
located on the top of each kidney that make various
hormones, including androgens.
ANDROGEN: any hormone that causes male physical
characteristics (for example, facial hair or a deep voice).
The main androgen is testosterone.
ANESTHESIA: a drug administered for medical or surgical
purposes that causes partial or total loss of sensation with or
without loss of consciousness.
ANTIANDROGEN: drugs that fight prostate cancer
by blocking the effects of testosterone; can be used in
combination with orchiectomy.
ANUS: the opening at the lower end of the rectum.
B
BENIGN: noncancerous tumor that doesn’t spread and is
usually not life-threatening.
BENIGN PROSTATIC HYPERPLASIA (BPH):
noncancerous enlargement of the prostate caused by an
overgrowth of the cells in the prostate.
Glossary
Glossary
69
BIOPSY: a small piece of tissue that is removed from the body
and examined under a microscope for the presence of cancer.
BLINDED: a study design in which patients (and sometimes
their physicians) do not know which therapy or medication is
being given.
BRACHYTHERAPY: a procedure in which tiny seeds made
up of radioactive material are placed directly into the prostate
[see INTERSTITIAL RADIATION THERAPY].
C
CANCER: a term for diseases in which abnormal cells grow
and divide without control and possibly spread to other parts
of the body.
CASTRATION: treatment that stops or lowers testosterone
production by testicles. Castration is done surgically
(orchiectomy) or medically (using an LHRH analog and
antagonist).
70
Glossary
CASTRATION-RESISTANT PROSTATE CANCER: a
term used to describe prostate cancer in which the cancer gets
worse despite a very low level of testosterone (as a result of
hormone therapy or orchiectomy).
CATHETER: a tube that is temporarily put through the
urethra into the bladder to take out urine or to empty the
bladder.
CELLS: the basic units of the body that give it structure and
make it function.
CHEMOTHERAPY: drugs that move throughout the body
in the bloodstream and may kill any rapidly growing cells,
including cancer cells and some healthy cells.
CLINICAL TRIALS: research studies in patients with cancer
or other diseases, usually for a new or investigational drug or
treatment. These studies help answer questions about a new
therapy, or they can look at new ways of using an existing
therapy.
COMBINED ANDROGEN BLOCKADE (CAB):
hormone therapy to treat prostate cancer that combines an
antiandrogen drug with an LHRH analog or an orchiectomy.
Also called maximum androgen blockade or total androgen
blockade.
ERECTION: enlargement of the penis due to increased
blood flow.
EXTERNAL BEAM RADIATION THERAPY: therapy
from machines outside the body that aim radiation beams at
the prostate to destroy cancer cells.
CRYOSURGERY: see CRYOTHERAPY.
CRYOTHERAPY: also called cryosurgery; repeated freezing
and thawing of the tumor cells causing cell death.
D
DIGITAL RECTAL EXAMINATION (DRE): an
examination done by a doctor using a gloved lubricated
finger, which is inserted into the rectum to check for lumps,
enlargements, or areas of hardness in the prostate that might
suggest the patient has prostate disease or an abnormality.
E
HORMONE THERAPY: in prostate cancer, treatment
that affects how much male hormone the body makes or that
blocks the action of male hormones that can feed or fuel
prostate cancer.
I
IMPOTENCE: not being able to have an erection.
IMMUNE CELL: a type of blood cell that fights infections.
IMMUNOTHERAPY: therapy that uses the body’s immune
system to help fight diseases.
Glossary
71
Glossary
EJACULATION: act or process of sudden or spontaneous
discharging of sperm and seminal fluid from the penis.
H
INTERSTITIAL RADIATION THERAPY: treatment
with high-energy radiation from tiny radioactive seeds inserted
into the prostate [see BRACHYTHERAPY].
LUTEINIZING HORMONE-RELEASING HORMONE
(LHRH) analogs: drugs that treat prostate cancer by stopping
the testicles from making testosterone.
INVESTIGATIONAL THERAPY: treatment or drug being
tested in clinical research trials for a particular disease or
condition.
LYMPH: a usually clear fluid from tissues in the body that is
returned to the blood by the lymphatic system. Lymph plays
an important role in the immune system and helps carry waste
away from cells.
L
LYMPH NODES: small, bean-shaped structures scattered
along the vessels of the lymphatic system. The lymph nodes
filter out or remove waste, bacteria, and cancer cells that may
travel through the lymphatic system.
LAPAROSCOPIC RADICAL PROSTATECTOMY: a type
of surgery to remove the prostate and nearby tissues that uses
four or five small incisions in the abdomen and a camera to see
the prostate.
LAPAROSCOPIC SURGERY: surgery that inserts a small
camera (laparoscope) into the body through a small surgical
incision, enabling the physician to view internal organs.
LHRH ANTAGONISTS: drugs that treat prostate cancer
by interfering with the physiological action of luteinizing
hormone-releasing hormone.
72
Glossary
LYMPHADENECTOMY: surgical removal of lymph nodes.
LYMPHATIC SYSTEM: a network of vessels, nodes, ducts,
and organs that help regulate the body’s fluid environment and
protect the body by making lymph. Vessels or tubes that carry
lymph are part of this system. Other parts include lymph nodes
and several organs throughout the body that make and store
cells that fight infections.
M
O
MALIGNANCY: a cancerous tumor that can grow and
spread and may be life-threatening.
ORCHIECTOMY: the surgical removal of the testicles
(testes), the main source of male hormones. It is also called
SURGICAL CASTRATION.
MEDICAL CASTRATION: the use of drugs to reduce
the level of testosterone to levels similar to those seen after
orchiectomy.
MEDICAL ONCOLOGIST: a doctor trained in internal
medicine who has specialized training in how to diagnose and
treat patients with cancer.
METASTATIC: referring to the spread of cancer from the
original tumor to other parts of the body.
N
NERVE-SPARING RADICAL RETROPUBIC
PROSTATECTOMY: surgical removal of the prostate
through an incision in the lower abdomen, in which the
nerves on either side of the prostate are saved, if possible.
P
PATHOLOGIST: a doctor who specializes in the diagnosis
of disease by studying cells and tissues with a microscope.
PERINEUM: the area between the scrotum and the anus.
PLACEBO: a treatment or substance that is not active
but looks similar to, and is given in a similar manner to,
an active drug.
Glossary
Glossary
PLACEBO-CONTROLLED CLINICAL TRIAL:
a study in which a group of patients (control group) is
given a placebo instead of the new therapy or drug being
investigated. To determine if the new therapy or drug works,
this control group is then compared with the group of
patients that was given the new therapy or drug.
73
PROSTATE-SPECIFIC ANTIGEN (PSA): a substance in
the blood made by both normal and cancerous prostate cells.
The PSA level often increases in patients with prostate cancer
and other prostate diseases.
PROSTATITIS: inflammation of the prostate.
PSA DOUBLING TIME (PSA-DT): the time it takes
for a PSA value to double.
R
RADIATION THERAPY: treatment for cancer that uses
radiation to kill cancer cells and shrink tumors.
RADICAL PERINEAL PROSTATECTOMY: surgery to
remove the prostate through an incision in the perineum.
RADICAL PROSTATECTOMY: an operation to remove
the entire prostate gland, seminal vesicles, and some of the
surrounding tissue.
74
Glossary
RADICAL RETROPUBIC PROSTATECTOMY: surgery
to remove the prostate through an incision in the lower
abdomen.
RANDOMIZED: study design in which patients are assigned
randomly (by chance) to individual groups that assess different
therapies, without knowing at the time of the study which
therapy is best. This random assignment allows fair comparison
of the different treatments.
RECTUM: the last 5 or 6 inches of the large intestine leading
to the anus.
S
SCROTUM: the external sac, or pouch, of skin containing
the testicles.
SEMEN: the fluid that is ejaculated during sexual climax; it
contains the sperm and fluids from other glands, including the
prostate.
SEMINAL VESICLES: pouches above the prostate that
store semen.
SPERM: mature male sex cell.
SPINAL CORD COMPRESSION: growth of cancer cells
in or near the spine, pressing on the spinal cord and nerves.
This can cause symptoms such as back pain, numbness,
dizziness, problems urinating, and constipation or other bowel
problems.
STAGE: the size and extent to which the cancer may have
grown and spread.
T
TESTICLES (TESTES): male reproductive glands that
make the sperm and testosterone.
TESTOSTERONE: a male sex hormone made mostly by the
testicles, responsible for the sexual characteristics of men.
TRANSRECTAL ULTRASONOGRAPHY (TRUS): a
procedure in which a special probe is inserted in the rectum
and sound waves are used to produce an image of the prostate
and the surrounding organs so that the prostate gland can be
evaluated.
TRANSURETHRAL RESECTION OF THE
PROSTATE (TURP): surgery to remove extra tissue from
the prostate with a special instrument that is inserted through
the urethra.
TUMOR: an abnormal mass of cells, resulting from cells
that divide and grow in an uncontrolled and disorderly way.
Tumors may be cancerous (malignant) or noncancerous
(benign).
U
URETERS: the tubes that carry urine from each kidney (one
ureter per kidney) to the urinary bladder.
Glossary
TISSUE: a group of cells specially made/organized to do a
particular function in the body.
Glossary
75
URETHRA: the tube that carries urine from the urinary
bladder and semen from the sex glands to the outside of the
body.
URINARY BLADDER: the hollow organ that stores urine.
URINARY INCONTINENCE: not being able to control
the flow of urine from the bladder.
UROLOGIST: a doctor who specializes in diseases of the
urinary and sex organs in males and the urinary organs in
females.
76
Glossary
1709608-Understanding Breast Cancer Guide Book.
AstraZeneca. 8/12.
References
References
American Cancer Society. Radiation therapy. Available
at: http://www.cancer.org/Cancer/ProstateCancer/
DetailedGuide/prostate-cancer-treating-radiation-therapy.
Accessed June 2, 2011.
American Cancer Society. Early Detection Diagnosis and
Staging. Available at: http://www.cancer.org/Cancer/
ProstateCancer/DetailedGuide/prostate-cancer-detection.
Accessed June 1, 2011.
American Cancer Society. Surgery for prostate cancer.
Available at: http://www.cancer.org/Cancer/ProstateCancer/
DetailedGuide/prostate-cancer-treating-surgery. Accessed
June 2, 2011.
American Cancer Society. Hormone (Androgen
Deprivation) therapy. Available at: http://www.cancer.org/
Cancer/ProstateCancer/DetailedGuide/prostate-cancertreating-hormone-therapy. Accessed June 1, 2011.
American Joint Committee on Cancer. Cancer Staging
Manual. 7th ed. Springer Publisher, New York 10013.
American Cancer Society. How is Prostate Cancer Staged?
Available at: http://www.cancer.org/cancer/prostatecancer/
detailedguide/prostate-cancer-staging. Accessed September
13,2012.
Cancer.net. American Society Clinical Oncology. Prostate
Cancer – Risk Factors and Preventions. Accessed on Sept 6,
2012.
MD Anderson Manual of Medical Oncology, Chapter 34,
Prostate Cancer. McGraw-Hill Publishers, New York, 2012.
References
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Meng MV. Prostate Cancer, Chapter 39 in Current Medical
Dx & Tx, McGraw-Hill Publishers, New York, 2012.
Morton DA, Foreman KB, Albertine KH. Male reproductive
system, Chapter 13 in The Big Picture: Gross Anatomy,
McGraw-Hill Publishers, New York, 2011.
National Cancer Institute at the National Institutes of
Health. General Information About Prostate Cancer.
Available at: http://www.cancer.gov/cancertopics/pdq/
treatment/prostate/Patient. Accessed June 5, 2011.
National Cancer Institute at the National Institutes of
Health. Prostate cancer treatment overview. Available at:
http://www.cancer.gov/cancertopics/pdq/treatment/prostate/
Patient/page4. Accessed June 3, 2011.
National Cancer Institute at the National Institutes of
Health. Prostate-Specific Antigen (PSA) Test. Available at:
http://www.cancer.gov/cancertopics/factsheet/detection/PSA.
Accessed September 3, 2012.
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National Cancer Institute at the National Institutes
of Health. SEER Stat Fact Sheets: Prostate. Available at:
http://seer.cancer.gov/statfacts/html/prost.html. Accessed
September 13, 2012.
NCCN Clinical Practice Guidelines in Oncology™. Prostate
Cancer Early Detection.
Standring S. Prostate, Chapter 75 in Gray’s Anatomy 40th
Edition, Churchill Livingstone Elsevier, Philadelphia 2008.
Provided as an educational service by AstraZeneca. If you
have any questions about your condition, talk to your doctor.
Models used for illustrative purposes only.
2012 Astrazeneca Pharmaceuticals LP. All rights reserved.
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