MRI Guided Detection and MRI Guided Laser Treatment of Prostate Cancer
Dr. Lander has been working in close collaboration for many years with Dr. John Feller at Desert Medical Imaging in the development of a world class MRI program for prostate disease. At Desert Medical Imaging, state-of-the-art MRI technology provides Dr. Lander’s patients with advanced tools that allow screening and early detection of prostate cancer. Research shows that TRUS (ultrasound guided) biopsies miss as many as 30 – 35% of prostate cancers, while MRI guided biopsies miss only 3% of prostate cancers that are Gleason score 7 or above.
Using new software and hardware at Desert Medical Imaging, Dr. Lander’s patients with elevated PSA can undergo MRI screening to determine if they require a biopsy. If a biopsy is required, the biopsy can be done inside the MRI machine using conscious sedation for comfort. An MRI compatible needle sleeve is gently introduced a few inches into the rectum and the MRI imaging process is used to precisely guide the biopsy needle into the target area where a few samples are taken. This is very different from the office biopsy procedure where multiple random areas are biopsied requiring as many as 18 to 20 passes of the needle as opposed to just a few biopsies performed under MRI guidance. Using MRI guidance makes the biopsy less traumatic and much more accurate. Recent publications in the urologic literature support the use of MRI for prostate cancer detection and also for the evaluation of metastatic disease. Knowing exactly where, how large, and even how aggressive the cancer is using MRI imaging gives valuable information to the treatment team and helps identify which patients might be candidates for selective therapy rather than whole gland therapy such as the traditional radiation or surgical removal of the prostate.
For patients who are candidates for focal treatment (small cancers which are confined), Desert Medical Imaging works closely with Dr. Lander to provide MRI guided focal laser ablation of the cancer. This novel technology allows us to destroy a controlled area of the prostate gland and real-time MRI temperature mapping is used to protect collateral tissue and avoid complications such as impotence and incontinence. The focal laser ablation procedure is offered as part of a single institution phase 1 clinical trial. This procedure is IRB approved and is patient funded.
Who may benefit from the MRI prostate program?
- Patients with a suspicious serum PSA (sudden change, stepwise increase, or elevation above normal for age).
- Patients with an abnormal serum PSA and a negative trans-rectal ultrasound guided (TRUS) biopsy
- Patients with positive digital rectal examination and a negative result from a TRUS biopsy.
- Patients with proven prostate cancer from a TRUS biopsy to exclude additional cancer or extension of cancer outside the prostate gland.
- Patients who have been treated for prostate cancer with radical prostatectomy, radiation therapy, cryo therapy, or HIFU when there is concern for recurrence of the prostate cancer (Biochemical recurrence).
Prostate Cancer Information and Standard Treatments
- What is the prostate?
The prostate gland is a small, walnut-sized gland in men. It is located below the bladder and surrounds the upper portion of the urethra. The prostate gland lies in front of the rectum, and its posterior surface can be felt during a rectal examination. The function of the prostate is to secrete a fluid that makes up part of the semen. The prostate gland may be a source of many health problems in men, the most common being benign prostatic hyperplasia (BPH), prostatitis and cancer.
- What is prostate cancer?
Prostate cancer is a significant health-care problem in the United States due to its high incidence. It is the most common cancer in men affecting approximately 189,000 American men each year with approximately 32,000 of these men dying each year. Prostate cancer is different from most cancers in that a large percentage of men may have a silent form of this cancer — it does not cause symptoms or progress beyond the prostate gland. Sometimes this cancer can be small, slow growing and present limited risk to the patient. Clinically important prostate cancers can be defined as those that threaten the well-being or life span of a man.
- What are the causes and risks associated with prostate cancer?
What causes prostate cancer is a subject of intensive research. It is likely that prostate cancer occurs due to many reasons. Predominately a disease of elderly men, the diagnosis of prostate cancer is rare before age 40 but increases dramatically thereafter. In the United States, it is estimated that one in 55 men between the ages of 40 and 59 will develop prostate cancer. This incidence climbs almost to one in seven for men between ages 60 and 79. This association is also reflected in mortality as prostate cancer accounts for 10.8 percent of cancer-related deaths in men between the ages of 60 and 79 and 24.6 percent in those over the age of 80.
Worldwide, prostate cancer ranks third in cancer incidence and sixth in cancer mortality among men. There is, however, a notable variability in incidence and mortality among world regions. The incidence is low in Japan and intermediate in regions of Central America and Western Africa. The incidence is higher in North America and Northern Europe. Although some of these differences may be accounted for by differences in screening for prostate cancer and the risk of other diseases among world regions, it is likely that they can be accounted for, in part, by genetic predisposition as well as diet.
There are also ethnic determinants of risk. Blacks are in the highest risk group, with an incidence of 224.3 cases per 100,000 black men. The incidence in Caucasian and Asian men is considerably lower at 150.3 and 82.2 (per 100,000), respectively. In addition, blacks tend to present with more advanced disease and have poorer overall prognosis than Caucasian or Asian men.
Men with a family history of prostate cancer are at an increased risk of developing the disease. The risk correlates with the number of first-degree relatives (father, brother or uncle) affected by prostate cancer and the age at onset. Men with a family history of disease may have a risk of developing prostate cancer two to 11 times greater than men without a family history of prostate cancer.
There is also considerable evidence showing that prostate cancer is more common in men with a high intake of fat in their diets. The worldwide difference in prostate cancer incidence may be associated with dietary intake of soy proteins. In Asian countries such as Japan and the Republic of Korea where prostate cancer incidence and mortality are just a fraction of that in North America, soy consumption in the form of tofu, soymilk and miso is up to 90 times higher than that consumed in the United States. In a study of more than 40 nations, researchers found soy, on a per calorie basis, to be the most protective dietary factor. This protective role may be associated with two of soy’s components, genistein and daidzein that may act as weak estrogens. Estrogens are female hormones that inhibit prostate cancer growth. Some experts have suggested that the worldwide differences in prostate cancer incidence may also be explained by the high intake of green tea by residents of Asia.
The intake of other certain dietary factors may also reduce the risk of developing prostate cancer. Such substances include lycopene, selenium and vitamin E. Cooked tomatoes are rich sources of the carotenoid lycopene. Lycopenes are antioxidants that may protect cells from becoming cancerous. Several studies have shown that the likelihood of developing prostate cancer is reduced by high intake of lycopene. Researchers found that men ingesting two or more servings of tomato sauce per week had a 36 percent reduction in cancer risk compared to those who did not. Selenium intake has also been reported to lower prostate cancer risk. In a clinical trial designed to determine if selenium could lower skin cancer recurrences, men who took selenium had a 63 percent reduction in prostate cancer incidence compared to those who took a sugar pill (placebo). Attention has also focused on vitamin D’s effect on the prostate. Epidemiologic evidence shows an inverse relationship between prostate cancer risk and ultraviolet radiation, the primary source for vitamin D production. This observation has led some to suggest that higher rates of prostate cancer in the elderly may be partly due to decreased sun exposure or a decline in the body’s ability to make vitamin D with aging.
Finally, the correlation of vasectomy and prostate cancer risk remains controversial. Although some studies have suggested that men who have undergone a vasectomy are at an increased risk of developing prostate cancer, many other studies have failed to show such a correlation.
- What are the symptoms of prostate cancer?
In its early stages, prostate cancer often causes no symptoms. When symptoms do occur, they may include any of the following: dull pain in the lower pelvic area; frequent urination; problems with urination such as the inability, pain, burning, weakened urine flow; blood in the urine or semen; painful ejaculation; general pain in the lower back, hips or upper thighs; loss of appetite and/or weight; and persistent bone pain.
- How is prostate cancer diagnosed?
Currently, digital rectal examination (DRE) and PSA tests are used for prostate cancer detection. The age at which time screening for prostate cancer should begin is not known with certainty. However, most experts agree that healthy men over the age of 50 should consider prostate cancer screening with a DRE and PSA test. Screening should occur earlier, at age 45, in those who are at a higher risk of prostate cancer such as black men or those with a family history of prostate cancer.
DRE: Is performed with the man either bending over, lying on his side or with his knees drawn up to his chest on the examining table. The physician inserts a gloved finger into the rectum and examines the prostate gland, noting any abnormalities in size, contour or consistency. DRE is inexpensive, easy to perform and allows the physician to note other abnormalities such as blood in the stool, which might allow for the early detection of rectal or colon cancer. However, DRE is not the most effective way to catch an early cancer so it should be combined with a PSA test.
PSA test: Is usually performed in addition to DRE and increases the likelihood of prostate cancer detection. The test measures the level of PSA, a substance produced only by the prostate, in the bloodstream. Very little PSA escapes from a healthy prostate into the bloodstream, but certain prostatic conditions can cause larger amounts of PSA to leak into the blood. One possible cause of a high PSA level is benign (non-cancerous) enlargement of the prostate, otherwise known as BPH. Prostate cancer is another possible cause of an elevated PSA level. The frequency of PSA testing remains a matter of some debate. The American Urological Association (AUA) encourages men to have annual PSA testing starting at age 50. The AUA also recommends annual PSA testing for men over the age of 40 who are African-American or have a family history of the disease (for example, a father or brother who was diagnosed with prostate cancer). Some experts have suggested that men with an initial normal DRE and PSA level of less than 2.5 ng/ml can have PSA testing performed every two years. Recently, several refinements have been made in the PSA blood test in an attempt to determine more accurately who has prostate cancer and who has false-positive PSA elevations caused by other conditions like BPH. These refinements include PSA density, PSA velocity, PSA age-specific reference ranges and use of total-to-free PSA ratios. Such refinements may allow for improved increased ability to detect cancer.
Currently, it is recommended that both a DRE and PSA test be used for the early detection of prostate cancer. It is important to realize that in most cases an abnormality in either test is not due to cancer but to benign conditions, the most common being BPH. For instance, it has been shown that only 18 to 30 percent of men with serum PSA values between four and 10 ng/ml have prostate cancer. This number rises to approximately 42 to 70 percent for those men whose PSA values exceeding 10 ng/ml.
Biopsy: Prostate biopsy is best performed under transrectal ultrasound guidance using a spring-loaded biopsy device coupled to the transrectal probe, which is placed in the rectum. Patients are positioned on their side for this procedure. The physician will first image the prostate using ultrasound noting the prostate gland’s size and shape and whether or not any other abnormalities exist, the most common of which are shadows which might signify the presence of prostate cancer. However, not all prostate cancers are visible. Using the spring-loaded biopsy device attached to the ultrasound probe, the physician will perform multiple biopsies of the prostate gland. Generally, six to 14 biopsies will be performed. Recently, many investigators have shown that performing more than six biopsies, especially in certain regions of the prostate gland, will improve the ability to detect prostate cancer. Each biopsy will remove a cylinder of prostate tissue approximately 3/4 inch in length and 1/16 inch in width. The entire procedure will take 20 to 30 minutes. The biopsy tissue taken will then be examined by a pathologist (a physician who specializes in examining human tissue to determine whether it is normal or diseased). The pathologist will be able to confirm if cancer is present in the biopsy tissue. If cancer is present, the pathologist will also be able to grade the tumor. The grade indicates the tumor’s “aggression level” — how quickly it is likely to grow and spread. The most popular prostate cancer grading system is the Gleason score system and is designated between two and 10. Scores of two to four designate low aggressiveness, five to six mildly aggressive, seven moderately aggressive and scores of eight to 10 highly aggressive.
Although transrectal ultrasound guided prostate biopsy is usually very well tolerated, approximately 20 to 25 percent of those undergoing the procedure may find it painful. Injecting local anesthetics into the area before biopsy may minimize this discomfort. Blood in the ejaculate (hematospermia) and blood in the urine (hematuria) are common, occurring in approximately 40 to 50 percent of patients. High fever is rare, occurring in only 3 to 4 percent of patients. Antibiotics and enemas are usually given at the time of the procedure to prevent infection.
- Why is prostate cancer staged?
Once prostate cancer has been diagnosed by a prostate biopsy, the physician seeks to stage the disease; that is, to determine the extent of the cancer (i.e., the “T” stage) and whether it has spread to the lymph nodes and/or the bones. The T stage is determined mainly by the DRE and can be divided into the following categories:
T1: Doctor is unable to feel the tumor or see it with imaging (e.g., transrectal ultrasound)
T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed
T1b: Cancer is found after TURP but is present in more than 5% of the tissue removed
T1c: Cancer is found by needle biopsy that was done because of an elevated PSA
T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still appears to be confined to the prostate
T2a: Cancer is found in one half or less of only one side (left or right) of the prostate
T2b: Cancer is found in more than half of only one side (left or right) of the prostate
T2c: Cancer is found in both sides of the prostate
T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles
T3a: Cancer extends outside the prostate but not to the seminal vesicles
T3b: Cancer has spread to the seminal vesicles
T3c: Cancer has spread to tissues next to the prostate (other than the seminal vesicles), such as the sphincter, rectum and/or wall of the pelvis
To determine if the cancer has spread to the lymph nodes or bones, the physician may order a CT scan of the pelvis or a bone scan. This is only done when the physician deems the cancer to be very serious.
Prostate cancer represents a spectrum of disease. Although some cancers may grow so slowly that treatment may not be needed, others can represent a threat to life. Determining the need for treatment can be a complex decision. Initially, the need for treatment should be based on the stage and grade of the cancer as well as the age and health of the patient. Many physicians have sought to devise risk assessment schemes that predict the likelihood of disease recurrence if patients are treated and progression or significant growth of their cancer if they undergo initial surveillance or watchful waiting. By combining many types of information (i.e., serum PSA level and cancer grade, stage and volume), patients can be advised of the aggressiveness of their cancer and the need for and types of treatment available. Certain imaging tests, such as a radionuclide bone scan, CT scan or MRI, may need to be done to better assess whether the cancer is still confined to the prostate or has spread elsewhere in the body. When prostate cancer spreads (metastasizes) it is usually to the lymph nodes or bones. Not all men with prostate cancer need to undergo imaging tests as the risk of spread to other organs can be estimated on the basis of serum PSA levels and cancer grade. It is reasonable to omit the bone scan in patients with newly diagnosed, untreated prostate cancer, who have no symptoms from their cancer and have serum PSA concentrations less than 20 ng/ml and certainly in those with serum PSA concentrations less than15 ng/ml. Similarly, a pelvic CT scan or MRI may not be necessary in men with lower grade cancers, cancers still confined to the prostate and serum PSA values less than 25 ng/ml.
- Can prostate cancer be prevented?
No. However, you can take measures to reduce the risk by maintaining your health in general — healthy diet, being physically active and visiting the doctor on a regular basis. Clinical studies are ongoing which are testing the ability of some agents like vitamin E and selenium to prevent prostate cancer.
- What is the outlook for prostate cancer?
The number of men diagnosed with prostate cancer remains high. However, survival rates are improving. It is estimated that 89 percent of men diagnosed with the disease will survive at least five years, while 63 percent will survive 10 years or longer.
- What is radiation therapy?
Radiation therapy, also sometimes referred to as radiotherapy, is a general term used to describe several types of treatment, including the use of high-powered X-rays, placement of radioactive materials into the body or injection of a radioactive substance into the bloodstream. These various types of radiation treatments are used in a wide range of settings. These circumstances include primary treatment of localized prostate cancer, secondary treatment for cancer recurring within the region of the prostate and for relief of pain and other symptoms related to prostate cancer that has spread to other parts of the body.
- What are the different types of radiation therapy?
External beam radiation therapy (EBRT): This is the most commonly used type of radiation therapy. The emergence of EBRT as a treatment for prostate cancer occurred in the 1950s with the development of high-powered X-ray machines called linear accelerators. Linear accelerators produce very powerful X-rays that penetrate deep into the body. These X-rays destroy tumor cells by damaging their DNA. Just as with a diagnostic X-ray, there is a brief exposure to the radiation, typically lasting several minutes. Once the treatment is over, there is no radiation in the patient’s body. The treatment is completely non-invasive, so there is no discomfort to the patient during the delivery of the radiation. EBRT is typically given once per day, five days per week. Primary treatment for localized prostate cancer usually requires about eight weeks of treatment.
Brachytherapy: Is also referred to as “seed therapy” or a “prostate implant.” Brachytherapy involves the insertion of a radioactive material, commonly referred to as a source, into the body. Attempts to treat prostate cancer by placing radioactive materials into the prostate date back to the early 20th century. However, the lack of a reliable way to ensure that the radioactive materials were placed in their desired locations limited the use of brachytherapy to treat prostate cancer. In the 1980s, a technique was developed using ultrasound to guide the placement of tiny radioactive “seeds” into the prostate. This technique was first made available in the United States in the late 1980s.
There are two approaches to brachytherapy for prostate cancer: low-dose rate (LDR) and high-dose rate (HDR). Prostate brachytherapy is most commonly performed using the LDR technique. With LDR brachytherapy, the seeds are permanently placed into the prostate. The radiation is given off gradually over a period of months. HDR brachytherapy involves the temporary placement of a highly radioactive source into the prostate. The radiation treatment is given off over a period of minutes and typically repeated two or three times over the course of several days. Both LDR and HDR brachytherapy may be combined with EBRT.
An ultrasound study may be performed prior to the day of the procedure to ensure there are no bones interfering with the placement of needles into the prostate. The ultrasound probe is placed into the rectum to obtain pictures of the prostate and surrounding structures. This study is commonly referred to as a transrectal ultrasound (TRUS). The information obtained from the TRUS can also be used to generate a road map for seed implantation. Ultrasound imaging is typically used to define the prostate although newer approaches using CT scan or MRI may be used.
The LDR seed implant procedure is performed under anesthesia. Radioactive seeds (which are smaller than a grain of rice) are loaded in individual needles that are passed into the prostate gland through the skin between the scrotum and anus. As the needles penetrate the prostate they are seen on a monitor and can be accurately guided to their predetermined position. Once the position of the needle in the prostate matches the intended position the needle is withdrawn leaving the seeds behind in the prostate. The radioactivity of the seeds slowly decays during the months after the operation, and there are few long-term risks associated with this treatment.
Alternatively, HDR brachytherapy may be utilized to place a highly radioactive source temporarily into the prostate. Hollow plastic tubes called catheters are pre-positioned in the prostate using a technique similar to LDR brachytherapy. The patient is then awakened and typically two or three treatments are given over the next several days after which the catheters are removed. A remote control device is used to move the radioactive material, which rests for a calculated period of time at various positions within each catheter. A computerized treatment-planning program is used to determine the required time the radioactive material must stay at each position and the sequential positioning of the radioactive material at each location needed to achieve coverage of the prostate with the prescribed radiation dose.
Radionuclide therapy: Radioactive substances may also be used for treatment of prostate cancer that has spread to the bones. These radioactive drugs, known as radiopharmaceuticals or radionuclides, are injected intravenously (IV). These radionuclides are absorbed by the bones. The radiation given off is weak and does not penetrate very far into surrounding tissues and organs. A single injection is given in the doctor’s office after which the patient may return home. Additional injections may be given after a period of a few months once the effects of the prior injection have diminished.
- What are some of the side effects of radiation therapy?
External beam radiation therapy (EBRT): The principal side effects of EBRT are related to the treated area. Common side effects of EBRT for prostate cancer include increased urinary frequency; mild burning with urination; weakened urinary stream; bowel irritability including mild diarrhea, gas, bowel urgency and tenderness; mild irritation of the skin around the rectum; lower blood counts; and fatigue. Diet modification and medication may be used to manage symptoms. Within one or two months following completion of treatment, most men notice that symptoms disappear. If changes in bladder or bowel function persist, they are typically mild. About 20 percent of men, however, do experience more significant long-term bowel irritability. Relatively rare complications include significant rectal bleeding, bladder irritability and urethral stricture. The loss of sexual function is also a relatively common side effect of radiation. However, the risk of erectile dysfunction (ED) following radiation varies widely, depending on use of other treatments such as hormonal therapies and the presence of other medical conditions that may affect sexual function.
Brachytherapy: Like EBRT, urinary irritation effects are very common. Obstructive symptoms including difficulty with urination are somewhat more common, however, as the prostate usually swells due to the insertion of needles into the prostate for the procedure. Approximately 5 to 15 percent of men will experience complete urinary obstruction within several weeks of the procedure requiring use of a catheter. Usually this problem disappears within weeks as the swelling subsides. Since the radioactive seeds are placed directly into the prostate, short-term bowel side effects are also relatively uncommon. However, as the front part of the rectum lies close to the prostate, over time bowel side effects similar to those of EBRT may occur. As with other radiation treatments, erectile dysfunction may occur.
Radionuclide therapy: The principal side effect of radionuclide therapy is a decrease in blood counts following treatment. Serious side effects including infection and bleeding are fortunately rare. However, an increase in pain may occur in the first several days or weeks after radionuclide therapy but can be managed with increased use of pain medications until the therapy begins to have its desired effect.
- Which treatment is appropriate for each stage of prostate cancer?
In order to guide patients in choosing an appropriate treatment, doctors depend in part on an understanding of prognostic factors that suggest how extensive or aggressive the cancer may actually be. Such factors include digital rectal examination (DRE), PSA test, Gleason score and biopsy. Given the impact on prognosis that each of these factors may have, a combination of these factors is often more useful in understanding the potential for treatment success or failure than the use of any one factor alone. Within the realm of clinically localized cancer, a combination of these factors may be used to categorize patients as “low risk,” “intermediate risk” and “high risk” in terms of treatment failure. It is important to note that while prognostic factors are helpful in guiding treatment choices, there is no “cookbook” for selection of treatment, and other factors including age, overall health, urinary and bowel function and each patient’s own concerns about treatment need to be taken into account. Therefore, a thorough discussion with an individual’s urologist and oncologist is an important part of the decision-making process.
Prostate cancer that has not spread outside the immediate area around the prostate is often referred to as clinically localized cancer. An important distinction within the realm of clinically localized cancer is between prostate cancers confined to the prostate, referred to as organ-confined disease, and prostate cancer that has spread directly outside the prostate or into the seminal vesicles. The term “clinical” is applied to the setting where the determination that cancer has not spread to other sites, including lymph nodes or distant tissues and organs, is based on the findings of physical exam and diagnostic imaging tests that may include CT scan, MRI and/or bone scan. Proof of cancer stage is only obtained by invasive procedures such as surgical removal of the prostate or biopsy.
Treatment of low-risk clinically localized prostate cancer: The “low-risk” category generally includes patients with T1 or T2a cancer (normal examination or small abnormality limited to one side of the prostate), PSA less than 10 ng./ml. and/or Gleason grade less than or equal to six. These men are the most likely to have cancer confined to the prostate. Treatment options may include radical prostatectomy, external beam radiation therapy (EBRT), prostate brachytherapy or in certain circumstances observation. Given that almost all men with early detection of prostate cancer are without symptoms, the impact that treatment may have on quality of life is an important consideration.
Treatment of intermediate-risk clinically localized prostate cancer: The “intermediate-risk” category generally includes patients with bulky T2a disease, PSA greater than 10 ng./ml. but less than or equal to 20 ng./ml. and/or Gleason grade seven. In addition, recent studies have suggested that the extent of tumor on biopsy, often referred to as “percent positive biopsies” may help sort out which men in this category have outcomes more similar to the low or high-risk group. Men with just a little cancer found on biopsy might have outcomes more in line with low-risk patients while men with extensive cancer may be at greater risk for treatment failure. Overall, many men in this category may still have cancer confined to the prostate or along the edge of the prostate. The risk of spread outside the prostate is greater, however, than that for men with all low-risk features.
Given the many nuances in the presentation of intermediate-risk disease a number of treatment options may be appropriate. These options may include radical prostatectomy, EBRT, prostate brachytherapy or a combination of EBRT and brachytherapy. Androgen suppression therapy, commonly referred to as hormonal therapy, may also have a role in treatment of intermediate-risk prostate cancer when combined with radiation. While in men with high-risk prostate cancer the role of hormonal therapy with radiation is now established, the role in treatment of intermediate-risk prostate cancer remains to be fully defined. The results of two large clinical studies now completed are awaited in the next several years and hopefully will provide answers. In the meantime, a large study of previously treated patients at the Dana-Farber Cancer Institute did suggest a benefit to the addition of six months of hormonal therapy to EBRT in this patient group and therefore at least warrants consideration when radiation therapy is used.
Treatment of high-risk clinically localized prostate cancer: The “high-risk” category includes men with any of the following features: T2c, T3 or T4 disease (abnormal examination on both sides of the prostate or cancer that has spread outside of the prostate as determined by digital rectal examination), PSA greater than 20 ng./ml. and/or Gleason grade between eight and 10. Men in this category have a substantial risk of spread of cancer outside of the prostate. Nevertheless, some men in this category do have cancer confined to the prostate and therefore local treatment including prostatectomy may be appropriate. In men deemed to be at greater risk for disease spread, the most standardized radiotherapeutic approach to treatment is the combination of EBRT and hormonal therapy. Other treatments, including combination of EBRT and brachytherapy with or without hormonal therapy, may be considered but the long-term results of newer approaches remain to be fully defined. Two national studies started in the 1980s in the United States and a third large study in Europe all showed benefit to the use of hormonal therapy when combined with EBRT in men with various high-risk features. The European study was the first to show an overall survival benefit to the addition of hormonal therapy to radiation. Early results of another study indicate a benefit to longer duration hormonal therapy in men with high-risk prostate cancer. The use of chemotherapy in this group of men remains to be defined and is now the focus of a few national studies. Given the variety of presentations within the high-risk group, the right treatment for any given individual needs to be carefully considered in consultation with a urologist and/or oncologist.
- Should radiation therapy be used as treatment following surgical removal of the prostate (prostatectomy)?
External beam radiation therapy (EBRT) may be used following prostatectomy when there is concern that cancer may remain in the region of the prostate. The use of radiation in this setting to destroy residual cancer has been sporadic for many years but only in the past five to 10 years has this approach started to gain widespread acceptance. The possibility of success with radiation following prostatectomy depends on the likelihood that any remaining cancer is confined to the region of the prostate where radiation is aimed. Therefore, the success rate varies widely depending on the presentation at the time treatment is contemplated. Diagnostic studies may be helpful but unfortunately no test can exclude the possibility of microscopic spread of the cancer. The physician must therefore assess a number of factors including the pretreatment prognostic factors, pathological findings at the time of prostatectomy and the post-surgical PSA history in determining which patients are most likely to have localized cancer versus cancer that has spread (metastasized).
- How successful is radiation therapy in the treatment of metastatic cancer?
Radiation is often an effective treatment for preventing or managing symptoms of prostate cancer that has spread. External beam radiation therapy is typically very helpful in decreasing or relieving pain related to prostate cancer that has spread to the bones. A short course of therapy usually no longer then two weeks is sufficient in most cases. In other cases, radiation may be used to prevent debilitating symptoms related to the uncontrolled spread of cancer near critical organs or tissues.
- How do I know if radiation therapy is the right treatment for me?
Talk to your urologist and/or oncologist. Every tumor is different, and it is important that your doctor evaluate all aspects of your tumor (such as localization, size, position) in order to prescribe the best treatment.
- Will radiation therapy affect my sexual function?
Possibly. The risk of erectile dysfunction following radiation varies widely, and is dependent on the use of other treatments – such as hormonal therapy – and other medical conditions (such as diabetes and heart disease) that may affect sexual function.
- Since the doctors aren’t removing my tumor, how will I know if it’s gone?
Followup testing is very important in order to be sure that the tumor has been killed. You may require regular ultrasound, a PSA test or a digital rectal examination to be sure that the cancer has not recurred. Sometimes, you may require additional treatment if the initial radiation does not work.
- When is surgery the best treatment for prostate cancer?
In general, prostate cancer surgery is best performed in patients with T1 or T2 (confined to the prostate gland) or very small T3 stage disease; PSA levels less than 20 and a Gleason score of less than eight. In certain circumstances, patients with more serious parameters are offered surgery also. Finally, prostate cancer surgery is usually restricted to men who have a 10-year or more life expectancy and are in sufficient health to withstand the risks of major surgery.
- What are some risk factors associated with prostate cancer surgery?
Risk factors for surgery are urinary incontinence and impotence. Incontinence is rare with occurrence in less than 5 percent of all surgical cases. However, when it does occur, there are procedures that can solve the problem. Impotence, if experienced post-surgery, can also be treated by a variety of medications and/or technical devices like penile prostheses.
- What are the different types of prostate cancer surgery?
Retropubic prostatectomy: During this procedure, the surgeon makes an incision through the lower abdomen. The surgeon can remove the prostate, surrounding tissue and pelvic lymph nodes (if necessary).
Perineal prostatectomy: During this procedure, the surgeon removes the prostate through an incision in the skin between the scrotum and the anus. In general, the perineal surgery is a little easier on the patient, but it may be somewhat inefficient if the cancer is serious and the lymph nodes need to be examined before the prostate is removed.
Laparoscopic prostatectomy: This type of surgery eliminates the need for a large surgical incision to remove the prostate. As a result, the patient may experience less pain and scarring, faster recovery and less risk of infection. During this procedure a telescopic instrument called a laparoscope is inserted into the abdomen through a small incision at the belly button. A camera attached to the laparoscope allows surgeons to view inside the abdomen and perform the surgery without having to make a large incision. Usually, four more small incisions are made in the abdomen to accommodate surgical instruments and the surgery is performed. A patient is not eligible for this type of surgery if they have had previous pelvic surgery.
- What can be expected after surgical treatment?
While in the hospital, the patient begins his recovery and pain is managed with medication. Resumption of a regular diet can usually occur by the second day. Usually, the patient is discharged from the hospital with a catheter in place and is taught how to manage it. The catheter is removed usually on a return visit to the surgeon’s clinic, and exercises (called Kegel exercises) are begun by the patient to strengthen the urinary control valve. Urinary control (continence) can be immediate or take up to six months.
Likewise, erectile potency may be immediate or may take up to one year to return following surgery. Usually, if erections are not sufficient for intercourse at one month, additional therapies are used until the erections become sufficient. One does not lose the ability to have an orgasm. However the orgasm is “dry” — very little (if any) ejaculation comes out — so the ability to procreate is generally lost.
After the surgery, the surgeon reviews the final assessment of the removed prostate and (if applicable) the lymph nodes. Based on this “final pathology,” a follow-up plan is developed. If the pathology is especially serious (e.g., spread to the seminal vesicles or lymph nodes) additional therapy may be recommended. This may include radiation therapy and/or hormone treatment. If the pathology is not especially serious, the follow-up plan entails regular visits to a physician and a regular PSA test. The PSA level should be less than 0.1ng/ml. If it is greater, especially if it is greater than 0.5 ng/ml, then cancer is still present and additional therapies are recommended.
- When can I resume normal activity after the surgery?
The time varies, but usually it is between three to six weeks.
- Will I know if I am cured after surgery?
Not completely and it certainly varies depending on the severity of the cancer removed. In general, one must have PSA test values of less than 0.1 ng/ml for ten years before cure is certain.
- I worry about potency but I am most afraid of incontinence. What are the odds?
That depends mostly on the surgeon and his/her experience. Usually, incontinence is temporary and does not last long although it can persist for as much as six to nine months. With more experienced surgeons, the risk of permanent incontinence is 2 to 5 percent after prostate cancer surgery. Male incontinence after prostate surgery can be effectively treated with a “male sling” operation.
- Where can I get more information?
AUA Guidelines Patient Guides: Prostate Cancer Awareness for Men