Transcript Understanding Prostate Cancer
Understanding Prostate Cancer
A Guide to Treatment and Support
1
Table of Contents
Introduction A Brief Overview of Prostate Cancer Assessing the Prostate: PSA, Grading, and Staging Treatment Options If Prostate Cancer Progresses After Local Treatment 2
Introduction
You are not alone Prostate cancer is the second most common type of cancer diagnosed in American men 1,2 The projected risk of a 50-year-old man being diagnosed with prostate cancer during his lifetime is almost 10% 1 In 2003, an estimated 220,900 new cases of prostate cancer will be diagnosed in the US 2 3
Introduction,
cont.
The good news is that over the past 20 years, overall survival rates for all stages of prostate cancer combined have gone up from 67% to 97% 2 The purpose of this presentation is to provide the information needed to make informed decisions about treatment options 4
A Brief Overview of Prostate Cancer
Who gets Prostate Cancer?
More than 70% of all prostate cancers are diagnosed in men over the age of 65 2 Genetics are an important factor 2,3 Men with one or more first-degree relatives (ie, father, brother) who have had prostate cancer have a 2- to 11-times greater chance of being diagnosed with prostate cancer 3 5
A Brief Overview of Prostate Cancer,
cont.
Who gets Prostate Cancer?
The death rate for prostate cancer is more than twice as high in African-American men than in Caucasian men 2 Earlier screening for prostate cancer (beginning at age 45) is recommended for men at high risk, such as African-American men 2 6
A Brief Overview of Prostate Cancer,
cont.
What causes prostate cancer?
Prostate cancer results from damaged DNA (the genetic blueprint for the body’s cells) 3 This damage can either be inherited or acquired during one’s lifetime 3 7
A Brief Overview of Prostate Cancer,
cont.
What causes prostate cancer?
Researchers don’t know exactly what causes this damage, but have identified some risk factors 3 : Age Race Environment Diet Genetics and family history 8
A Brief Overview of Prostate Cancer,
cont.
Symptoms of Prostate Cancer Early prostate cancer usually does not cause any symptoms 1 As the tumor grows, the following symptoms may appear, but may be alleviated by reducing the body’s production of testosterone 2,4,5 Frequent urination (especially at night) 2 Weak urinary stream 2,4 Inability to urinate 2,4 Interruption of urinary stream (stopping and starting) 2,4 Pain or burning on urination 2 Blood in the urine 2 Pain in the lower back, pelvis, or upper thighs 2,4 9
A Brief Overview of Prostate Cancer,
cont.
What is the prostate?
A chestnut-sized gland that produces fluid for semen 5 Located just below the bladder, in front of the rectum, and wraps around the urethra, the tube that carries urine from the bladder to the tip of the penis 5 10
A Brief Overview of Prostate Cancer,
cont.
What is cancer?
The uncontrolled growth and potential spread of abnormal cells 6 Cells that grow abnormally and become a mass are called a tumor 6 Benign (noncancerous) tumors may interfere with bodily functions, like urinating, but are seldom life threatening 1,6 Malignant tumors invade and destroy surrounding tissue 6 Prostate cancer is a malignant tumor that begins growing in the prostate gland 4 11
A Brief Overview of Prostate Cancer,
cont.
What is metastasis?
When cells break away from a cancerous tumor and spread through the blood and lymphatic system to other parts of the body 4,6 As a result of metastasis, many men with prostate cancer experience aches and pains in the pelvis, hips, ribs, back and other bones 2,4 Cancer can grow and spread slowly or rapidly 6 12
A Brief Overview of Prostate Cancer,
cont.
What role does testosterone play?
Testosterone, a male sex hormone, is an important factor in the normal growth and function of the prostate gland 4 Testosterone can stimulate hormone-dependent prostate cancer 3 As long as the body produces testosterone, prostate cancer is likely to continue to grow and possibly spread 4 For advanced prostate cancer, physicians may prescribe a class of drugs called luteinizing hormone releasing hormone agonists (LH-RHa) that stop the production of testicular testosterone 4,5 13
Assessing the Prostate: PSA, Grading, and Staging
Before determining therapy, physicians normally assess the state of the prostate and the stage of the cancer Doctors may perform the following tests A digital rectal exam (DRE) A PSA blood test A biopsy Men aged 50 or older, and those in high risk groups over the age of 45, should have a PSA blood test and DRE once every year 2 14
Assessing the Prostate: PSA, Grading, and Staging,
cont.
What is the DRE (digital rectal examination)?
A test in which the physician inserts a gloved finger into the patient’s rectum to examine the prostate by touch 7 If the doctor determines that the prostate feels abnormal, he or she may recommend more tests 7 15
Assessing the Prostate: PSA, Grading, and Staging,
cont.
What is PSA (prostate-specific antigen)?
A substance produced by prostate cells 1 The PSA test measures the amount of PSA in the blood 1,8 Very little PSA escapes from a healthy prostate 1,8 Some prostate conditions can cause a large amount of PSA to leak into the blood 8 16
Assessing the Prostate: PSA, Grading, and Staging,
cont.
PSA Levels PSA levels of up to 4.0 ng/mL are considered the upper limit of normal 8 However, high PSA does not always indicate prostate cancer and normal PSA levels do not always mean that cancer is not present 8 Up to 25% of men with prostate cancer have PSA levels below 4.0 ng/mL 8 Some other conditions, such as benign prostatic hyperplasia (BPH), can also lead to high PSA levels in the blood 8 17
Assessing the Prostate: PSA, Grading, and Staging,
cont.
What is a biopsy?
A test that may be necessary if the results of the PSA or DRE tests suggest prostate cancer 4,8 A needle is used to remove a small amount of tissue from the prostate 4,8 Typically, multiple samples are taken 4,8 Only a biopsy can definitely confirm prostate cancer 4,8 It is still possible to have cancer even if the biopsy is negative 8 18
Assessing the Prostate: PSA, Grading, and Staging,
cont.
What is the Gleason grade?
If prostate cancer is found at biopsy, the tumor is graded in a medical lab The grade indicates the difference in appearance between normal cells and cancer cells when seen through a microscope 9 19
Assessing the Prostate: PSA, Grading, and Staging,
cont.
Gleason grades range from 1 to 5 and are based on the degree of differentiation among the cells 9 A Gleason grade of 1 indicates a cluster of cancer cells that resemble the small, regular, evenly spaced prostate tissue 9 A Gleason grade of 5 indicates tissue completely composed of sheets, strings, cords and nests of tumor cells 9 If a prostate tumor has areas with different grades, the two grades are added together to yield a Gleason score between 2 and 10 9 20
Assessing the Prostate: PSA, Grading, and Staging,
cont.
What is staging?
The assessment of the size and location of the cancer (how far the cancer has already spread) 8 Staging is an important factor in determining the most appropriate treatment 8 Two different staging systems are currently in use 8 The A-D system classifies the disease into 4 clinical categories rated A through D 8 The TNM (tumor-nodes-metastases) system is based on tumor size and the locations to which it has spread 8 21
Assessing the Prostate: PSA, Grading, and Staging,
cont.
A-D Staging Stage A is early cancer – the tumor is located within the prostate gland and can’t be detected by a DRE 8 22
Assessing the Prostate: PSA, Grading, and Staging,
cont.
A-D Staging In Stage B, the tumor is confined to the prostate but large enough to be felt during a DRE 8 23
Assessing the Prostate: PSA, Grading, and Staging,
cont.
A-D Staging By Stage C, the tumor has spread outside the prostate to some surrounding areas and can be felt during a DRE 8 24
Assessing the Prostate: PSA, Grading, and Staging,
cont.
A-D Staging In Stage D, the cancer has spread to the nearby and distant organs, such as bones and lymph nodes 8 25
Assessing the Prostate: PSA, Grading, and Staging,
cont.
TNM Staging is based on tumor size (T) and on whether the cancer has spread to lymph nodes (N) or metastasized to distant sites (M) 8 Tumor size is graded from 1 to 4 8 T1 tumors are confined to the prostate gland and can’t be detected by DRE 8 T2 tumors are confined to the prostate but are big enough to be detected by DRE or ultrasound 8 T3 and T4 tumors have spread beyond the prostate into surrounding tissues 8 26
Assessing the Prostate: PSA, Grading, and Staging,
cont.
TNM Staging is based on tumor size (T) and on whether the cancer has spread to lymph nodes (N) or metastasized to distant sites (M) 8 Lymph node involvement is graded from 0 to 3, with 0 indicating that the cancer has not spread into lymph nodes 8 Metastasis is rated 0 or 1, with 0 indicating absence of metastasis 8 27
Treatment Options
Treatment options for prostate cancer depend on several factors, including age, the stage of the disease, and the advice of a physician 28
Treatment Options: Surgical Techniques
Radical prostatectomy Involves removal of the entire prostate gland 1 Performed to remove early-stage prostate cancer before it can spread to other parts of the body 1 Takes about two hours and requires general or epidural anesthesia 10,16 Complications include incontinence and impotence 1 Some physicians may use hormonal therapy to shrink the tumor before surgery so that it can be removed more effectively 10 29
Treatment Options: Surgical Techniques,
cont.
Radical prostatectomy Often, biopsies are taken of the pelvic lymph nodes to determine if the cancer has spread 10 If the lymph node biopsy is positive and the cancer has spread outside the prostate, it can’t be cured with surgery. Other treatment options are available that may stop the spread of the disease 2 30
Treatment Options: Surgical Techniques,
cont.
Cryosurgery Treats localized prostate cancer by freezing and destroying prostate cancer cells 13 A probe filled with liquid nitrogen is guided through a skin incision into the cancer tissue using transrectal ultrasound (TRUS), which allows the physician to monitor the freezing process 13 31
Treatment Options: Surgical Techniques,
cont.
Cryosurgery Some complications can result from the procedure, including 13 : Impotence Incontinence Penile numbness Urinary bladder obstruction 32
Treatment Options: Surgical Techniques,
cont.
TURP (transurethral resection of the prostate) Remove tissue from the prostate by inserting an instrument into the urethra while the patient is under general or local anesthesia 11 Sometimes necessary to relieve the symptoms of BPH or prostate cancer and to make urination easier 11 33
Treatment Options: Alternatives to Surgery
For some men with prostate cancer, surgery may not be the appropriate choice, and some of the following options may be considered: Radiation therapy Hormonal therapy Chemotherapy Watchful waiting 34
Treatment Options: Radiation Therapy
Exposes cancer cells to high doses of radiation with the goal of killing the tumor 14 External beam radiation treats the prostate and other selected tissues with a carefully targeted beam of radiation administered from a machine outside the body 14 35
Treatment Options: Radiation Therapy,
cont.
With brachytherapy, tiny radioactive seeds are implanted in the prostate through a surgical procedure 14 Allows the radioactive seeds to be implanted into the tumor very precisely 1 Allows a higher dose of radiation to be used with potentially less damage to surrounding tissue 1 36
Treatment Options: Radiation Therapy,
cont.
One study showed urinary incontinence was more frequent following radical prostatectomy than following external beam radiation therapy 15 Other potential side effects include: skin reaction in the treated area, frequent and painful urination, diarrhea, impotence, rectal irritation or bleeding 1,14,16 Physicians may choose to combine other treatment options, such as hormonal therapy, with radiation therapy 37
Treatment Options: Hormonal Therapy
Physicians sometimes use hormone therapy before radical prostatectomy or radiation to shrink the tumor 14 Also used to slow the spread of cancerous cells and alleviate the symptoms associated with advanced prostate cancer 14 38
Treatment Options: Chemotherapy
Targets and destroys rapidly dividing cancer cells 17 Unfortunately, chemotherapy also destroys normal cells that divide rapidly, such as blood cells forming in the bone marrow, hair follicles, and cells in the intestines and mouth 17 The destruction of normal cells causes side effects such as fatigue, hair loss, nausea and vomiting, diarrhea, mouth sores, and a low white blood cell count 17 Supportive medication may be given to help offset the side effects caused by chemotherapy drugs 17 39
Treatment Options: Watchful Waiting
Careful observation of the patient’s condition, without immediate treatment for prostate cancer 1,10 May be appropriate for men who have less aggressive tumors, which typically grow slowly 1,10 40
If Prostate Cancer Progresses After Local Treatment
Prior to beginning treatment for localized cancer, such as radical prostatectomy or radiation therapy, it may be possible for a physician to make his or her assessment of the anticipated success of specific treatments Disease progression means prostate cancer was not eliminated and that there is a risk of it metastasizing 1 If the prostate cancer has progressed, there are other treatment options available 41
If Prostate Cancer Progresses After Local Treatment,
cont.
How doctors determine whether the treatment was successful The doctor may consider the Gleason score, PSA level, and stage rating PSA level is an indicator of disease progression because, according to the American Society for Therapeutic Radiology and Oncology Consensus Panel, PSA “warns of recurrent disease long before other clinical signs…” 18 42
If Prostate Cancer Progresses After Local Treatment,
cont.
Physicians may evaluate the success or failure of
radical prostatectomy
based on 19,20 : Gleason score The amount of, and time to, initial PSA increase, and/or The length of time it takes for the PSA number to double 43
If Prostate Cancer Progresses After Local Treatment,
cont.
Physicians may evaluate the success or failure of
radiation therapy
based on: The lowest PSA number after treatment 14,21 PSA value that fails to decline following radiation therapy 22 , and The number of consecutive rises in PSA level following radiation therapy 14,18 44
If Prostate Cancer Progresses After Local Treatment,
cont.
Remember that even if prostate cancer progresses, there may be other treatment options Discuss treatment alternatives with a doctor 45
Hormonal Therapy
Used to decrease the production of testosterone or block its effects, which, in turn, slows cancer cell growth 1,3 A first-line treatment for patients with advanced prostate cancer 1 Used when radiation therapy or radical prostatectomy has failed 10,14 Types of hormonal therapy 12 : Drugs that reduce testosterone to castrate levels (ie, LH-RH agonists) Antiandrogens Surgical removal of the testicles, which produce testosterone 46
Hormonal Therapy,
cont.
LH-RH agonists Shut down the production of testosterone by the testicles, possibly slowing prostate cancer spread 12 The most common side effect is hot flashes, and they may also cause impotence 12 Symptoms may worsen during the first few weeks of treatment 4 Periodic monitoring of PSA and testosterone levels in the blood is recommended 12 47
Hormonal Therapy,
cont.
Antiandrogen therapy Blocks the effect of testosterone 12 An antiandrogen may be administered in combination with an LH-RH agonist to counteract the small amount of testosterone produced by the adrenal glands Side effects include breast tenderness/enlargement, fatigue, liver function abnormalities, and diarrhea 1 48
Hormonal Therapy,
cont.
Orchiectomy A surgical procedure that removes the testicles, resulting in immediate and permanent reduction in testosterone 12 Considered hormonal therapy because, like certain prescription drugs, it reduces testosterone levels 12 Common side effects include impotence, decreased libido, breast tenderness/enlargement, and hot flashes 10 LH-RHa therapy has been shown to be comparable to orchiectomy in decreasing the body’s supply of testosterone 12 49
Risk of Complications May Decrease With Immediate Hormonal Intervention for Advanced Prostate Cancer
Study results from 934 patients with advanced prostate cancer have shown that the risk of serious complications decreased with early hormonal therapy 23 23 50
Salvage Radiation
Used postoperatively in an effort to destroy remaining tumor cells 24 Can lower the local recurrence rates of prostate cancer to 0%-10% when used as an additional form of treatment after the initial surgery 24 May also be used to treat specific sites of bone pain 1 51
There are many treatment options available to men diagnosed with prostate cancer
Information about prostate cancer and the options available can be very helpful in making an informed decision about the course of therapy Discuss all of these options with a physician 52
References
1.
2.
3.
4.
5.
Scher HI. Hyperplastic and malignant disease of the prostate. In: Braunwald E, Fauci AS, Kasper DL, et al, eds.
Harrison’s Principles of Internal Medicine
. 15th ed. New York, NY: McGraw-Hill; 2001:608-616.
American Cancer Society.
Cancer Facts & Figures 2003.
Atlanta, Ga: American Cancer Society; 2003. Reiter RE, deKernion JB. Epidemiology, etiology, and prevention of prostate cancer. In: Retik AB, Vaughan ED Jr, Wein AJ, eds.
Campbell’s Urology.
8th ed. Philadelphia, Pa: Saunders; 2002:3003-3024. Goldspiel BR, Kolesar JM, Kuhn JG. Prostate cancer. In: DiPiro JT, Talbert RL, Yee GC, et al, eds.
Pharmacotherapy: A Pathophysiologic Approach
. 3rd ed. Stamford, Conn: Appleton & Lange; 1997:2539-2557. Marieb E. The reproductive system.
Human Anatomy & Physiology
. 4th ed. Menlo Park, Calif: Benjamin/Cummings Science Publishing; 1998:1030-1077. 53
References,
cont.
6.
7.
Balmer C, Valley AW. Basic principles of cancer treatment and cancer chemotherapy. In: DiPiro JT, Talbert RL, Yee GC, et al, eds.
Pharmacotherapy: A Pathophysiologic Approach
. 3rd ed. Stamford, Conn: Appleton & Lange; 1997:2403-2465. Gerber GS, Brendler CB. Evaluation of the urologic patient: history, physical examination, and urinalysis. In: Retik AB, Vaughan ED Jr, Wein AJ, eds.
Campbell’s Urology
. 8th ed. Philadelphia, Pa: Saunders; 2002: 83-110.
8.
9.
Carter HB, Partin AW. Diagnosis and staging of prostate cancer. In: Retik AB, Vaughan ED Jr, Wein AJ, eds.
Campbell’s Urology
. 8th ed. Philadelphia, Pa: Saunders; 2002:3055-3079. Epstein JI. Pathology of prostatic neoplasia. In: Retik AB, Vaughan ED Jr, Wein AJ, eds.
Campbell’s Urology.
8th ed. Philadelphia, Pa: Saunders; 2002:3025-3037. 10.
Leewansangtong S, Crawford ED. Prostate. In: Haskell CM, ed
. Cancer Treatment.
5th ed. Philadelphia, Pa: WB Saunders Company; 2001:806-828. 54
References,
cont.
11.
12.
13.
14.
15.
Fitzpatrick JM, Mebust WK. Minimally invasive and endoscopic management of benign prostatic hyperplasia. In: Retik AB, Vaughan ED Jr, Wein AJ, eds.
Campbell’s Urology
. 8th ed. Philadelphia, Pa: Saunders, 2002:1379-1422.
Schröder FH. Hormonal therapy of prostate cancer. In: Retik AB, Vaughan ED Jr, Wein AJ, eds.
Campbell’s Urology
. 8th ed. Philadelphia, Pa: Saunders; 2002:3182-3208. Shinohara K, Carroll PR. Cryotherapy for prostate cancer. In: Retik AB, Vaughan ED Jr, Wein AJ, eds.
Campbell’s Urology
. 8th ed. Philadelphia, Pa: Saunders; 2002:3171-3181. D’Amico AV, Crook J, Beard CJ, et al. Radiation therapy for prostate cancer. In: Retik AB, Vaughan ED Jr, Wein AJ, eds.
Campbell’s Urology.
8th ed. Philadelphia, Pa: Saunders; 2002:3147-3170. McCammon KA, Kolm P, Main B, et al. Comparative quality of-life analysis after radical prostatectomy or external beam radiation for localized prostate cancer.
Urology
. 1999;54:509 516. 55
References,
cont.
16.
17.
18.
19.
20.
Bulbul MA, Catton PA, Klotz LH. Treatment of localized disease. In: Klotz LH, ed.
Managing Prostate Cancer: Current Approaches and Techniques in the Early Detection, Staging and Treatment of Prostate Cancer.
Montreal, Quebec: Grosvenor House Press Inc; 1992:42-55. Balmer CM, Valley AW. Cancer treatment and chemotherapy. In: DiPiro JT, Talbert RL, Yee GC, et al.
Pharmacotherapy: A Pathophysiologic Approach
. 5th ed. New York, NY: McGraw Hill; 2002:2175-2222.
American Society for Therapeutic Radiology and Oncology Consensus Panel. Consensus statement: guidelines for PSA following radiation therapy.
Int J Radiat Oncol Biol Phys.
1997;37:1035-1041. Pound CR, Partin AW, Eisenberger MA, et al. Natural history of progression after PSA elevation following radical prostatectomy.
JAMA
. 1999; 281:1591-1597.
Eastham JA, Scardino PT. Radical prostatectomy. In: Retik AB, Vaughan ED Jr, Wein AJ, eds.
Campbell’s Urology
. 8th ed. Philadelphia, Pa: Saunders; 2002:3080-3106.
56
References,
cont.
21.
22.
23.
24.
Critz FA, Levinson AK, Williams WH, et al. Prostate-specific antigen nadir: the optimum level after irradiation for prostate cancer.
J Clin Oncol
. 1996;14:2893-2900.
Chauvet B, Felix-Faure C, Lupsascka N, et al. Prostate specific antigen decline: a major prognostic factor for prostate cancer treated with radiation therapy.
J Clin Oncol
. 1994;12;1402-1407.
The Medical Research Council Prostate Cancer Working Party Investigators Group. Immediate versus deferred treatment for advanced prostatic cancer: initial results of the Medical Research Council trial.
Br J Urol
. 1997;79:235-246. Sarosdy MF. Prostate adenocarcinoma: the management of pelvic confined disease. In: Krane RJ, Siroky MB, Fitzpatrick JM, eds.
Clinical Urology
. Philadelphia, Pa: JB Lippincott Co; 1994:980-995.
57