Prostate Cancer

The prostate gland is located just below the bladder and in front of the rectum. It surrounds the tube (urethra) carrying urine from the bladder out through the penis. A normal prostate is the size of a walnut.

Prostate cancer is the most common non-skin cancer among men in the United States, and it is the second leading cause of cancer deaths among men in this country. The American Cancer Society (ACS) estimates that during 2008 about 186,320 new cases of prostate cancer will be diagnosed in the United States and approximately 28,660 men will die from this disease.

Approximately 70% of prostate tumors are detected in the early stage of the disease while the cancer is still localized within the gland. According to the ACS, when compared to men the same age and race that do not have cancer (called relative survival), the 5-year relative survival rate for these men is nearly 100%.

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Evaluation

Cause and risk factors

The exact cause of prostate cancer is not known but there are certain risk factors which are related to a higher incidence of the disease.

Age: This is one of the strongest risk factors with 2 out of 3 cases of prostate cancer occurring in men over 65 years of age.

Race: The incidence of prostate cancer is higher in African American men than in Caucasians, and African Americans are more likely to have advanced disease at diagnosis. Consequently, more African American men are likely to die from the disease.

Family History: The risk of having prostate cancer increases more than two-fold if a brother or father has been diagnosed with the disease. This suggests the presence of a genetic factor as a cause for the disease, but this has not yet been confirmed.

Diet: Some studies suggest that men with a high-fat diet or excess consumption of red meat might have a slightly higher chance of getting prostate cancer.

Early detection, diagnosis and staging

Early prostate cancer is usually asymptomatic (without symptoms). Prostate cancer screening consists of digital rectal exam of the prostate (DRE) and a blood test that measures serum levels of prostate specific antigen (PSA). The American Cancer Society currently recommends annual prostate screening for all men at age 50. Men at high risk, including African-Americans and men with a first-degree male relative (father or brother) diagnosed with prostate cancer, should begin testing at the age of 45 and consider baseline PSA at the age of 40.

Based upon criteria established in the 1980’s, the normal PSA level is below 4 ng/ml. The risk of prostate cancer is 1 in 4 in men with a PSA level between 4 and 10 ng/ml and 50% for men with a PSA above 10 ng/ml. However, the PSA value is neither perfectly specific nor perfectly sensitive: elevation of PSA may be due to other causes, and normal PSA occurs in men who have prostate cancer. Based upon research assessing frequency of prostate cancer in men with varied PSA values, 17% of prostate cancers are found in men with PSA less than 1.1 ng/ml.

Besides prostate cancer, PSA elevation can be due to other prostate conditions including prostatitis (inflammation), benign (non-cancer) enlargement of the prostate, and advancing age. It is important to inform your physician if you are taking Finasteride (Proscar) or Dutasteride (Avodart), medications used to treat benign prostate enlargement; these medications can decrease the level of serum PSA by as much as 50% but do not prevent prostate cancer.

Currently, prostate biopsy is recommended in men with elevated PSA, men with rapidly rising PSA, and men with an abnormal or suspicious DRE. Prostate biopsy is usually performed in the office using local anesthesia with prophylactic antibiotics to reduce risk of infection. The urologist will use a transrectal ultrasound probe to measure the prostate and guide needle biopsy of six prostate locations. These tissue biopsy specimens are submitted to pathology for microscopic examination. If prostate cancer is confirmed, additional testing will assess the possibility of prostate cancer spread (called cancer staging) prior to definitive discussion regarding treatment options.

Imaging studies that are used to assess prostate cancer stage include bone scan and CT scan. The bone scan entails injection of a radionucleotide followed shortly by scanning the entire skeleton to detect any areas with increased bone metabolism that might indicate prostate cancer. The CT scan is a radiology imaging study which examines the abdomen and pelvis for any areas of lymph node enlargement which might signify spread of prostate cancer. Currently, MRI, another radiology imaging technology, is used to assess the micro-metabolic anatomy in and around the prostate to determine local extent of disease.

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Treatment

As a result of improved screening (PSA and DRE), a significant number of men with prostate cancer are diagnosed at an early stage of the disease. Fortunately, most men can be cured with either surgery or radiation when their cancer is confined within the prostate gland capsule.

There are four standard options for treating prostate cancer. These options include active surveillance, surgery, radiation therapy and hormone therapy. In addition, there are new treatments recently introduced (cryotherapy, high-intensity focused ultrasound or HIFU, chemotherapy, etc.) for which long-term results are pending 5 and 10 year performance evaluation to clarify the risks and benefits compared to the traditional therapies. The treatment plan is individualized for each patient depending on their preferences and clinical situation. (link to Prostate Cancer Program )

Active Surveillance

Prostate cancer progresses slowly and, in many cases, may remain dormant over years without causing clinical symptoms. Certain conditions must be met in order to safely proceed with active surveillance: PSA less than 10.1 ng/ml, minimal prostate cancer volume, and Gleason pathology score less than 7. A surveillance plan must include scheduled PSA testing and DRE. The patient and urologist must establish guidelines to repeat prostate biopsy and staging with intent to treat. Watchful waiting (monitoring prostate cancer with intent to treat only for palliation) is recommended in men with prostate cancer who have other medical problems which pose a greater threat to life (heart disease, other metastatic cancer, stroke, etc.).

Surgery

Surgery for prostate cancer involves removal of the entire prostate gland, the seminal vesicles and often the surrounding lymph nodes (Radical Prostatectomy). Traditionally "open" radical retropubic prostatectomy is performed through a large incision in the lower abdomen. Alternatively, perineal prostatectomy has been performed through a small incision just behind the scrotum. While the perineal approach was less invasive, it suffers due to the inability to assess the lymph nodes when indicated and due to the lack of reliable nerve sparing to maintain erectile function.

Technological advances have dramatically changed the way that prostatectomies are performed today. The advent of laparoscopy for urologic surgeries, combined with the versatility and dexterity provided by the daVinci Robot, has yielded a minimally invasive procedure which allows nerve sparing and is more precise than either the "open" or the perineal approaches.

The Robot-assisted Laparoscopic Radical Prostatectomy (RALRP) requires several small incisions through which trocars are inserted. Trocars, hollow cylinders through which instruments and cameras can be placed inside the abdomen, attach to the Robot and sophisticated robotic instruments are inserted and removed by the surgical assistant. The instruments are controlled by the surgeon who is sitting at a console seeing 3-dimensional magnified images from the telescope positioned in the patient’s abdomen. The enhanced 3-dimensional, binocular vision and the dexterity of the robotic instruments speed the procedure and the patient’s recovery without compromising the primary goal that must always be to cure the Prostate Cancer.

The advantages of RALRP to the patient include less pain, less blood loss, shorter hospital stays, faster postoperative recovery, earlier urinary catheter removal, and quicker return to normal activity. For men whose prostate biopsy or preoperative PSA suggest an aggressive tumor, lymph node excision can be performed at the time of surgery to better stage disease and determine prognosis. In addition, nerve sparing and earlier return to urine continence are attributed to robotic prostatectomy.

In general, early stage prostate cancer will be cured by radical prostatectomy. In all individuals, post treatment PSA is monitored. If evidence of persistent or recurrent prostate cancer is identified, radiation therapy may be added to surgery in the comprehensive treatment plan. However, in cases of radiation therapy failure, surgery is not an option for salvage (see cryotherapy).

Radiation Therapy

As with surgical treatment of prostate cancer, radiation therapy includes several different approaches. The two that are most typically offered include external beam radiation therapy and brachytherapy. (see also Radiation Oncology)

External beam radiation therapy (EBRT) is the use of ionizing radiation energy focused on the prostate using several points of entry into the body. Patients who select EBRT undergo CT and radiology evaluation to provide computer-generated treatment plans that assure satisfactory delivery of dose to the intended target with minimal dose to adjacent structures. Once the treatment plan is set, treatments are scheduled in 35 sessions over 7 weeks with each session lasting 15-20 minutes. Newer refinements of EBRT include Intensity-Modulated Radiation Therapy (IMRT) and 3-Dimensional Conformal Radiation Therapy (3D-CRT). Proton Therapy uses protons to deliver radiation energy to the tumor with purportedly decrease effect to normal tissues adjacent to the prostate.

Brachytherapy (brachy means "near" in Latin) is a method of radiation therapy whereby radioactive seeds are distributed throughout the prostate under transrectal ultrasound guidance. This procedure is performed under anesthesia in an outpatient setting and is completed in one treatment. Dose and distribution are calculated prior to the procedure using ultrasound or MRI to image the prostate.

Individual treatment plans may include combination of brachytherapy and EBRT with or without short-term hormonal treatment (see below).

Hormone Therapy

If the prostate cancer has spread beyond the prostate gland or metastasized to other organs such as bone, its progression can be slowed by hormone therapy. The male hormone, testosterone, promotes prostate cancer growth and progression. Androgen Deprivation Therapy (ADT) will impede prostate cancer cells that are hormone dependent, but will not affect those cells that do not require testosterone (hormone resistant). Testosterone can be eliminated by removing the testicles or by administration of medications that either prevent testosterone secretion or block testosterone binding to prostate cancer cell receptors. Hormone therapy is used in conjunction with radiation therapy in select cases. Hormone therapy is not considered curative and duration of response is variable.

Cryotherapy

This treatment option is currently in the evaluation phase. It involves freezing the prostate cancer cells by inserting multiple small probes into the prostate through the perineum under ultrasound guidance. The prostate gland is frozen using argon gas and thawed using helium gas. The procedure consists of 2 freeze-thaw cycles and takes approximately 2 hours. Cryotherapy for prostate cancer radiation therapy failures is an established use of this technology; cryotherapy as primary treatment for prostate cancer is investigational since the 5 and 10 year results are not available at this time.

Chemotherapy

Chemotherapy is generally considered for patients with advanced prostate disease. The treatment uses drugs to destroy the cancerous cells and prevent tumors from growing. The drugs used for chemotherapy, and the way that they are administered depends on the type and stage of the individual’s cancer.

High-Intensity Focused Ultrasound (HIFU)

High-intensity focused ultrasound (HIFU) is currently under investigation. HIFU is admininstered via a transrectal ultrasound probe that produces and focuses the energy on the prostate causing increase in tissue temperatures (70-900 C) which, like extreme low temperatures in cryotherapy, result in cell death. HIFU will likely be useful in radiation failure cases, but its use as primary treatment for prostate cancer is uncertain at this time.

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The University of Cincinnati Urology Division is one of the leading urology programs, not just in Cincinnati, but in the U.S. UC Urology provides quality health care using the most advanced technology and state-of-the-art diagnostic treatments. Many of our urologists are recognized in multiple national and local "Best Doctors" and "Top Doctors" listings. We provide minimally invasive surgical treatments which include laparoscopic, robot-assisted laparoscopic and endourologic procedures as well as comprehensive care for all urologic conditions.