Prostate Cancer:
This handout is designed to answer some of your questions and to help a man make an educated decision about prostate cancer treatment. Please read this and write down any questions so we can discuss them during your doctor appointment.
Anatomy and Function:
The prostate gland is located in the pelvis, below the bladder, above the urethral sphincter and the penis, and in front of the rectum in men. It is made up of glandular tissue and muscle fibers that surround a portion of the urethra, which discharges urine from the bladder. The primary role of the prostate is to produce and secrete fluid to carry sperm.
Incidence and Prevalence:
According to the American Cancer Society (ACS), prostate cancer is the second most common type of cancer in men in the United States, behind only skin cancer. The ACS estimates that about 230,000 new cases will be diagnosed yearly and about 30,000 men will die of the disease each year. Prostate cancer is the second leading cause of cancer death in men, exceeded only by lung cancer. Prostate cancer can be cured when diagnosed early. Prostate cancer occurs in 1 out of 6 men. Reports of diagnosed cases have risen rapidly in recent years and mortality rates are declining, which may be due to increased screening.
Screening:
Adenocarcinoma of the prostate is the clinical term for a cancerous tumor of the prostate gland. The majority of patients are diagnosed with prostate cancer because of an abnormal prostatic specific antigen level (PSA) or abnormal prostate exam. Prior to the discovery of PSA, men with prostate cancer were diagnosed with advanced disease. This is not the case today. The majority of men diagnosed with prostate cancer have localized disease, i.e., cancer is confined to the gland. Therefore, men have multiple options to cure their prostate cancer. This is why prostate cancer screening is crucial and every male should this annually.
Diagnosis and Pathology Results:
A prostate biopsy is the only way to confirm a diagnosis of prostate cancer. The pathologist will look at the samples and determine if cancer cells are present. A Gleason score is assigned to describe the severity of cancer. Values 2 – 5 are non-aggressive, 6 and 7 are moderately aggressive and 8 – 10 are very aggressive. The number of positive samples coupled with the volume of cancer within each sample play an important role in the diagnosis.
Staging:
It is critical to determine if a man has localized cancer (confined to the prostate) once a diagnosis is made. Statistically, a low PSA (< 10 ng/ml) and a moderate Gleason score have a low chance of metastatic disease. A CT Scan and/or Bone Scan may be ordered to look for the spread of cancer to the lymph nodes, bones or other organs. The digital examination of the prostate is also valuable since palpable disease has a higher chance of spreading outside the gland. The following are important factors determining the aggressiveness of a man’s prostate cancer:
—PSA level
—Digital exam
—Age
—Co-morbid factors (example: diabetes and heart disease)
—Gleason score
—Number of positive biopsy cores
Treatment Options:
There are many treatment options for men with cancer confined to the prostate gland. These include surgery, brachytherapy, external beam radiation, hormonal medications, cryosurgery and watchful waiting.
The decision process for the “best” treatment option is complex. A man’s age, overall health, sexual function, Gleason score, number of positive biopsies and PSA score play a role.
Since there is no "one size fits all" treatment, each man must learn as much as he can about various treatment options and, collaboratively with his physician, make his own decision about what is best for him.
Surgery:
There are 4 surgical approaches for the removal of the prostate (prostatectomy): 1) The Radical Retropubic Prostatectomy, 2) Radical Perineal Prostatectomy, 3) Laparoscopic Prostatectomy and 4) Robotic-Assisted (da Vinci) Prostatectomy. A prostatectomy entails the removal of the entire prostate gland and seminal vesicles. The first stage of the prostatectomy is to remove the lymph nodes that drain the pelvic organs. Important: The nodes may not be removed in patients with PSA less than 10 and Gleason scores less than 7 because of low risk cancer has spread to the lymph nodes. The prostate is removed after dissecting the lymph nodes. There are 2 critical points in this step: 1) preserving the urethral stump for urinary continence and 2) sparing the nerves that control erections. It is important to know that this is a cancer operation and sometimes the nerves will be removed for cancer control. The bladder is sewn to the urethral stump once the prostate and seminal vesicles are removed.
The Radical Retropubic Prostatectomy:
Is performed through a low midline incision extending from the pubic bone to just below the belly button. The operation takes approximately 2 hours and can be performed under general or spinal anesthesia. A “cell saver” is used during the operation to help return any lost blood to the patient. If a patient wishes they may donate their own blood a few weeks prior to the operation. A patient is typically in the hospital 48 hours after the operation. A surgical drain, called a JP, exits the skin to help the surgical site heal and a catheter drains the bladder. The catheter is removed approximately 10 – 14 days after the operation.
The Radical Perineal Prostatectomy:
Is performed through a small incision between the scrotum and rectum (the perineum). The lymph nodes cannot be removed during this operation. Therefore, the procedure is not recommended for men with high PSA and aggressive Gleason scores. A surgical drain is not placed after the operation and catheter is left in place approximately 10 – 14 days. Typically, patients are in the hospital about 24 hours.
The Robot-assisted (da Vinci) Laparoscopic Prostatectomy:
Is a recent advancement of the laparoscopic prostatectomy. Five or six small incisions are made and laparoscopic ports are inserted into the abdomen. The largest port is used to place a camera to visualize the surgery. The other ports, which are only 5 to 12 millimeters in diameter, house the robotic arms to perform the surgery. After port placement, the surgeon sits at a console to control and active the robotic instruments. If necessary, the lymph nodes will be removed after the prostate is removed. The operation takes approximately 2 to 4 hours. The majority of patients are discharged the following day from the hospital. Blood loss is minimal and less then 1% of patients will need a transfusion. The catheter is removed approximately 7 - 8 days after the operation.
General Concerns after surgery Hospital Stay:
You will be given a breathing device called an incentive spirometer to use after surgery. This helps you take deep breaths to open the small lung spaces after anesthesia. Air-pumps (SCD’s) will be on your legs to promote blood flow and prevent blood clots. The following day you will get out of bed to walk. It is crucial to walk after surgery; don’t be a couch potato. Surgical drains and catheters: If a surgical drain (JP) is in place it is typically removed within 24 – 48 hours. Relax it is not terrible to remove these tubes. Catheters will be connected to a leg bag while you at home. These are very easy to manage. When the bag starts to get full, simply drain it into the toilet. The urine may be bloody on occasion. It is okay to shower, just blot it dry.
Stitches and Skin Staples:
The Radical Retropubic Prostatectomy is surgically closed with skin staples. These are removed in the office 7 days after your surgery. The Robot-assisted (da Vinci) Laparoscopic Prostatectomy is closed with stitches that absorb underneath the skin and skin glue. The skin glue typically falls off within 2 weeks. It is okay to shower within 48 hours of your surgery.
Urinary Incontinence:
It can take a few weeks to a few months for urinary control to return after the catheter is removed. Please be patient. Urinary leakage will improve slowly day by day. Urinary pads are used to help control leakage. The number of pads used will guide how well a patient is recuperating. Kegel exercises, movements to strengthen the pelvic floor, can be used to improve continence.
Erectile Dysfunction (Impotency):
As your energy returns, you should be able to have erections either spontaneously or with the aide of medications such as Viagra, Levitra or Cialis.
Return to Normal Activity:
As you strength returns you can perform more and more of your normal activities. Be smart, use common sense and don’t do anything silly like change the light bulbs in the house a few days after surgery. Please walk, go up and down stairs and bathe as necessary.
Brachytherapy
Brachytherapy is the insertion of radioactive seeds into the prostate gland. The radiation will locally destroy the cancer cells over a few weeks. A radiation oncologist and urologist work together to strategically implant the seeds. These seeds are only a few millimeters long (less than 1/4 inch). The procedure is performed under sedation or general anesthesia and takes approximately one hour. Men will experience a slow urinary stream and some burning when urinating, blood in the urine and localized discomfort. These symptoms may last a few weeks. Occasionally, a catheter is placed for 24 hours. A medication to help with the slow urinary stream will be provided. The risk of urinary incontinence is low and the risk of impotency is generally low. The radiation oncologist will be able to answer more questions about Brachytherapy.
External Beam Radiation
External Beam Radiation (XRT) delivers high-dose radiation to the prostate gland to destroy the cancer cells. A radiation oncologist is consulted to map the prostate and create a radiation plan. A body cast is made and XRT is delivered daily for approximately 5 weeks. Hormonal therapy, which is discussed below, is commonly used as a part of the XRT protocol. XRT has some minor side effects such as tiredness, skin reactions in the treated areas, frequent and painful urination, upset stomach, blood in the urine, diarrhea, and rectal irritation or bleeding. Erectile dysfunction (impotency) can occur as time passes. The radiation oncologist will be able to answer more questions about External Beam Radiation.
Hormonal Therapy
Prostate cancer lives on the hormone testosterone. Prostate cancer cells will shrink and fail to grow without testosterone. A class of medications called LHRH agonists will stop the production of testosterone. This medication is provided in injection form given every 1 to 4 months, or as an implant given once per year. It is important to know that hormonal therapy will not cure prostate cancer, but it can significantly delay the progression of the cancer cells. Side effects include hot flashes, breast enlargement and osteoporosis. It is important to exercise and take Vitamin D while on hormonal therapy. Surgical castration, the removal of the testis, is an alternative to hormonal therapy.
Cryosurgery
Cryosurgery entails the freezing of the prostate gland. Freezing probes are inserted into the prostate through the perineum (the area under the scrotum.) A dual freeze-thaw cycle is performed to destroy the prostate cancer. Although this procedure is performed as primary therapy for localized disease, it can also be used to treat recurrent cancer after radiation therapy. The long-term studies on cryosurgery are not yet available.
Watchful waiting
In select individuals, watching and waiting is the best option. This may not sound like treatment but it is a common option. The PSA and digital exam are performed on a scheduled basis. A biopsy may have to be repeated as well. Watchful waiting may be used if a patient is not expected to tolerate other therapy due to other adverse health conditions, advanced age or an incidental minute focus of cancer is discovered.
Why is follow-up important?
Close follow-up is crucial once prostate cancer is diagnosed and treatment is decided. PSA is measured by a blood test every 3 months for the first 2 years, every 6 months for the next 3 years then yearly thereafter. Thirty percent (30%) of men will have a rise in their PSA after therapy. This is called biochemical failure and suggests that the prostate cancer is starting to grow again. This rise can occur months or years later and men are usually asymptomatic.
A common question asked is “What happens if the cancer comes back?” This is a difficult question to answer. Additional therapy may be needed in certain men with aggressive cancer. For example, radiation can be performed after a radical prostatectomy and hormonal therapy can be given after surgery or radiation.
What should you do now?
After a patient is diagnosed with prostate cancer, we will sit down and talk about the diagnosis. Please have your family and/or friends attend this consultation. I will give my recommendations and opinions on the situation. We will spend as much time as you need to review the diagnosis and your options. Please write down your questions and concerns. I feel that it is important you know as much about prostate cancer as possible. Please do some research, speak to friends, search reputable websites and attend support groups. In addition, consider getting a second opinion from a urologist, radiation oncologist or medical oncologist. I want you to be comfortable with the decision process.
