Prostate Cancer

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PROSTATE CANCER

Prostate cancer in its early stages will cause no symptoms and can only be identified by regular Digital Rectal Exam (DRE) and Prostatic Specific Antigen (PSA) determinations.

The following information is intended to aid you in understanding prostate cancer and the options of treatment. This brochure is not intended to be a complete synopsis of the disease. Additional more in depth information can be obtained from your Urologist and other references supplied to you. Management of prostate cancer must be tailored to your specific situation and disease stage and according to your individuals preferences. As we feel we are finding your cancer early, your chances of successful treatment and cure are excellent. In order to determine the best management of your cancer the following factors are important:

1. Cancer Grade
2. Cancer Stage
3. Your Age
4. Your General Health
5. Your attitude toward management of the cancer
6. You expectations from treatment

Cancer Grade is a description of the aggressiveness of the prostate cancer. The grade is determined by the pathologists as a microscopic assessment of the cancer.

• Well Differentiated or Gleason Grade 2-4 prostate cancer generally is a slower growing tumor and tends be less aggressive.
• Moderately Differentiated or Gleason Grade 5-6 prostate cancer has an intermediate growth rate.
• Poorly Differentiated or Gleason Grade 7-10 prostate cancer tends to be more aggressive and faster growing.

Knowledge of the the cancer grade will allow us to better understand the risk of the cancer progressing to incurable disease.

Cancer Stage is a description of the degree of spread of the cancer at the time of its recognition. Prostate cancer can grow and spread in the pelvic structures and invade the bladder or rectum. As disease progresses it can infiltrate the lymph nodes that drain the prostate and eventually spread through the blood stream and settle in the bones. By performing various tests and other studies the Urologist can define the stage of the cancer.

Stage I- is cancer found incidentally either because of an elevated PSA or due to cancer cells found in the tissue from a prior prostate operation.

Stage II- is cancer palpable in the prostate and felt to be clinically confined to the gland.

Stage III- is cancer perforating through the prostate capsule and felt not to be confined to the gland.

Stage IV- is cancer that has spread outside the prostate to lymph nodes in the pelvis or to the bone.

1. Digital Rectal Exam (DRE)-The prostate examination performed by an experienced Urologist provides us with a good deal of information on the size and local extent of the cancer.

2. TRansurethral UltraSound (TRUS)- The ultrasound you had performed to biopsy the prostate also will provide us with useful information on the extent and size of the cancer.

3. Prostatic Specific Antigen (PSA)- The blood test you had drawn to help in the early detection of the cancer is also used in conjunction with the cancer grade to determine the stage (Degree of spread) . (See PSA Handout for additional information)

4. Bone Scan- A radiological study used to determine if the cancer has spread to any bones in the body. Prostate cancer has a predisposition to spread to bones of the axial skeleton as it progresses. The scan will be ordered only if you have a higher risk of the cancer having spread to the bones.

5. Computerized Axial Tomography Scan (CAT Scan)- A highly refined radiologic study used to assess the prostate anatomy and to assess the stasis of the lymph glands that filter lymphatic fluids from the prostate.

6. Cystoscopy- A direct look through the urethra into the bladder to evaluate the prostate anatomy and to check the bladder for other diseases.

Other blood tests or X-rays will be ordered as necessitated by your individual situation .

Through accurate clinical staging and grading of the cancer your urologist can reasonably predict your chances of cure with the various modalities available today.

Currently approved treatments of prostate cancer include:

1. Surgery

2. Radiation

3. Hormones

4. Observation

SURGERY: The surgical removal of the entire prostate gland, seminal vesicles, and the sampling of the lymph nodes provides the best long term control of localized prostate cancer. Surgery will be offered if your health, age, and cancer stage and grade are such that your urologist feels the cancer can all be removed surgically.

Early complications of surgery include:

•Hemorrhage: Major bleeding requiring a transfusion occurs in 10% of patients. Autologous blood (Your own obtained prior to surgery) can be obtained if you desire not to run the small risk of disease transmission in the occasion a transfusion is necessary.

•Other major surgical complications include:

Death .2 %, Blood Clots 2 %, and Infection 2 %.

Impotence: Despite the so called Nerve Sparing Radical Prostatectomy (In which the small nerves adjacent to prostate which control erections are carefully preserved), impotence is common after surgery. Factors influencing the risk of impotence are the stage of the cancer and your age. In most situations preservation of potency in men over the age of 65 is unlikely. Also it is not advisable in men with bulkier cancers to undergo a nerve sparing prostatectomy as this can result in inadequate cancer control. The younger men with focal centralized prostate cancer are the best candidates for this type of operation.

There are medical options available including pills (viagra), vaccuum devices, injections, intraurethral instillations and surgical options that can allow you to regain your erections and fulfill you and your partners sexual desires.

Incontinence: The risk of losing some urine control after surgery is 10%. Minimal incontinence (less than 1 pad per day) occurs in 5% of the patients. Generally the pad is worn for security purposes and may often be dry. Partial incontinence (wetness with strenuous activity such as lifting, running, etc.) occurs 5% of the time. Total incontinence requiring several pads, or additional surgery may occur in 1-2 % of patients.

What to Expect after Surgery?

• Pain after surgery will be well managed with epidural or Patient Controlled Anesthesia (PCA) for 1-2 days and should allow you to be quite comfortable post operatively.
• Hospitalization is for 3-4 days.
• You will be discharged with a catheter for a total of 10 days. This will removed in the office at your first follow up visit.
• A complete Discharge Instruction Sheet will be sent home with you when you leave the hospital explaining home care and Precautions.

RADIATION: Is available through the Radiation Center located at the St. Joseph Medical Center in Brainerd. External 3D conformal Radiation is an effective treatment for localized and low to mid grade prostate cancers. Patients with more advanced or higher grade cancers, may also be advised to undo external radiation in combination with hormones and perhaps brachytherapy. The radiation dose is given daily for short internals over 71/2 weeks. Early side effects occur frequently and include proctitis with diarrhea or bleeding in up to 35 % of patients, urinary symptoms with burning, or hematuria, and generalized symptoms including nausea, fatigue, and occasional skin burns. Impotence occurs in 40-50% of patients treated and Incontinence in 2-3%.

BRACHYTHERAPY is a minimally invasive technique of delivering high dose radiation directly into the prostate by implanting Radioactive Seeds. These seeds continually emit internal radiation for several weeks, during which time you can be fully active. The actual inplant is performed as an outpatient and causes minimal morbidity. Complications primarily involve the urinary tract with symptoms of frequency, burning, urgency and obstruction of urination for 2-4 weeks after implantation.

 HORMONES: The Hormone Inhibitors ("Leupolide" or "Zoladex") will slow up the growth of the prostate cancer. Their action is to inhibit the secretion of testosterone from the testicles thus reducing is effect on the growth of the prostate cancer cells. These are standard treatments for patients with more advanced prostate cancer, but are now also commonly given to individuals during and after radiation treatment; there appears to be better cancer free survival in patients treated in such a manner.

OBSERVATION: The recommendation for some individuals may to monitor the cancer growth through regular physical exams and PSA determinations. Since some prostate cancers are relatively slow growing or small in size, this may be the best choice for older men or those in otherwise poor medical health. Utilizing this approach we are assuming that most older men with small localized cancers will die of other causes unrelated to the prostate tumor. It is imperative in patients undergoing this approach that they have regular prostate exams and PSA tests to monitor the stasis of the cancer.

The choice you make for treatment of your prostate cancer is based on your understanding of the disease process, the local extent of the cancer, and your anticipations from the treatment. Although your doctors can advise you of the treatment options, risks of treatment, and expected outcomes you must decide what is best for your individual situation. Of course the earlier and more localized the cancer when detected the better results from the treatment.

There is a Prostate Cancer support group meeting monthly on Thursdays at the St. Joseph Medical Center. You can call Carol Bombadier at 828-7421 to obtain additional information on the meetings.