Prostate Cancer

Hormone Therapy

- LHRH agonists - block production of androgens Lupron Zoladex Trelstar Vantas - Anti-androgens - block androgen receptors Eulexin Casodex Nilandron

Radiation Therapy

- External beam radiation therapy (ERBT) - Brachytherapy

Hormone therapy may be used in several situations

- If the patient is unable to have surgery or radiation or can't be cured by these treatments because the cancer has already spread beyond the prostate gland. - If the cancer remains or comes back after treatment with surgery or radiation therapy. - As an addition to radiation therapy as initial treatment if the patient is at high risk for cancer recurrence. - Before surgery or radiation to try and shrink the cancer to make other treatments more effective.

Stages

Stage I - Not felt during DRE, possibly by elevated PSA Stage II - Felt during DRE, no spread Stage III - Tumor extends but not in other organs or lymph Stage IV - Spread to other organs or lymph nodes

Risk Factors

Age Race/ethnicity Nationality Family history Genes Diet Obesity Exercise Inflammation of the prostate Infection

Hormone Therapy

Androgens or male hormones produced mainly in the testicles stimulate prostate cancer cells to grow. One of the ways to treat prostate cancer is to remove androgens from the body, thus making the cancer shrink and then grow more slowly. Hormone therapy is also called androgen deprivation therapy (ADT) or androgen suppression therapy. The main androgens are testosterone and dihydrotestosterone (DHT). It does not cure prostate cancer.

Anti-androgens - block androgen receptors

Drugs that block androgen receptors (called anti-androgens). Anti-androgens block the body's ability to use any androgens. Even after orchiectomy or during treatment with LHRH analogs, a small amount of androgens is still made by the adrenal glands. Drugs of this type such as Eulexin, Casodex, Nilandron are taken daily as pills. *Anti-androges are not often used by themselves. An anti-androgen may be added if treatment with orchiectomy or an LHRH analog is no longer working by itself.*

LHRH agonists - block production of androgens

Drugs that block the production of androgens called LHRH agonists (These are injected or placed as small implants under the skin. Depending on the drug used, they are given anywhere from every month, every 3-4 months, up to once a year. The LHRH analogs available in the US include Lupron, Zoladex, Trelstar and Vantas). ***When LHRH analogs are first given testosterone production increases briefly before falling to very low levels. This effect is called *flare* and results from the complex way in which LHRH analogs work. Men whose cancer has spread to the bones may experience bone pain. If the cancer has spread to the spine, even a short-term increase in growth could compress the spinal cord and cause pain or paralysis. *Flare can be avoided by giving drugs called anti-androgens for a few weeks when starting treatment with LHRH analogs.*

Signs and Symptoms

Early - usually detected with PSA tests or DRE before they cause symptoms More advanced symptoms: Trouble starting urination Frequency Feeling of not releasing all of urine Blood in urine or semen Pain on urination or ejaculation Impotence Bone pain Fatigue

Obesity

Most studies have not found that being obese (very overweight) is linked with a higher risk of getting prostate cancer overall.

Watchful Waiting

Older men with small, low-grade tumors Life expectancy less than 10 years

Diagnostic Workup

PSA (Prostate-antigen) blood test DRE (Digital rectal exam) Transrectal ultrasound (TRUS) Core needle biopsy Other tests Bone scan CT scan MRI

Complications

Pain Bone pain Urinary incontinence Painful urination/hematuria Erectile dysfunction Spinal cord compression (SCC)

Nationality

Prostate cancer is most common in North America, northwestern Europe, Australia, and on Caribbean islands. It is less common in Asia, Africa, Central America, and South America. The reasons for this are not clear. More intensive screening in some developed countries probably accounts for at least part of this difference, but other factors such as lifestyle differences (diet, etc.) are likely to be important as well.

Age

Prostate cancer is very rare in men younger than 40, but the chance of having prostate cancer rises rapidly after age 50. Almost 2 out of 3 prostate cancers are found in men over the age of 65.

Race/ethnicity

Prostate cancer occurs more often in African-American men than in men of other races. African-American men are also more likely to be diagnosed at an advanced stage, and are more than twice as likely to die of prostate cancer as white men. Prostate cancer occurs less often in Asian-American and Hispanic/Latino men than in non-Hispanic whites. The reasons for these racial and ethnic differences are not clear.

Family history

Prostate cancer seems to run in some families, which suggests that in some cases there may be an inherited or genetic factor. Having a father or brother with prostate cancer more than doubles a man's risk of developing this disease. (The risk is higher for men who have a brother with the disease than for those with an affected father.) The risk is much higher for men with several affected relatives, particularly if their relatives were young at the time the cancer was found.

PSA (Prostate-antigen) blood test

Prostate-specific antigen is a substance made boy cells in the prostate gland 9it is made by normal cells and cancer cells). Although PSA is mostly found in semen, a small amount is also found in the blood. Most healthy men have levels under 4 nanograms per ml of blood. The chance of having prostate cancer goes up as the PSA level goes up. When prostate cancer develops the PSA level usually goes above 4. Men with a PSA level in the borderline range between 4 and 10 have about a 1 in 4 chance of having prostate cancer. If the PSA is more than 10 the chance of having prostate cancer is over 50%. The PSA level can also be increased by things other than prostate cancer such as BPH, age, prostatitis, and ejaculation. Ejaculation can cause the PSA to go up for a short time. Some doctors suggest that men abstain from ejaculation for 2 days prior to testing. Some things can cause PSA levels to go down (even when cancer I present). These include certain emdicines used to treat BPH or urinary symptoms (Proscar, Avodart) and some herbal mixtures that are sold as dietary supplements for "prostate health". Obese men tend to have lower PSA levels. The PSA test is used mainly to detect prostate cancer early but it is useful in other situations: In men diagnosed with prostate cancer, the PSA test can be used together with clinical exam results and tumor grade (from the biopsy) to help decide if further tests (such as CT scans or bone scans) are needed. It can help tell whether the cancer is still confined to the prostate gland. If the PSA level is very high the cancer has likely spread beyond the prostate. This may affect treatment options, since some forms of therapy (such as surgery and radiation) are not likely to be helpful if the cancer has spread to the lymph nodes, bones, or other organs. After surgery or radiation treatment, the PSA level can be watched to help determine if the treatment was successful. PSA levels normally fall to very low levels if the treatment removed or destroyed all of the prostate cells. A rising PSA level (especially after surgery) likely means that prostate cancer cells are present and the cancer has come back. If a "watchful waiting" appraoch to tretment is chosen, PSA level can be used to help decide whether the cancer is growing and if active treatment should be considered. During hormonal therapy or chemotherapy the PSA level can help indicate how well the treatment is working or when it may be time to try a different form of treatment. If prostate cancer has recurred after treatment, or if it has metastasized, it may be more important to look at the way the PSA level is changing rather than the actual number. The PSA number does not predict whether or not a person will have symptoms or how long he will live. Many people have very high PSA values and feel just fine. Other people have low values and have symptoms.

Genes

Scientists have found several inherited gene changes that seem to raise prostate cancer risk, but they probably account for only a small number of cases overall. Genetic testing for most of these gene changes is not yet available. Some inherited gene changes raise the risk for more than one type of cancer. For example, inherited mutations of the BRCA1 or BRCA2 genes are the reason that breast and ovarian cancers are much more common in some families. Mutations in these genes may also increase prostate cancer risk in some men, but they account for a very small percentage of prostate cancer cases.

Brachytherapy

Small radioactive pellets or seed each about the size of a grain of rice. Used only in men with early stage prostate cancer that is relatively slow growing.

Inflammation of the prostate

Some studies have suggested that prostatitis (inflammation of the prostate gland) may be linked to an increased risk of prostate cancer, but other studies have not found such a link. Inflammation is often seen in samples of prostate tissue that also contain cancer. The link between the two is not yet clear, but this is an active area of research.

External beam radiation therapy (ERBT)

Standard EBRT is used much less than in the past . Newer techniques allow doctors to give higher doses of radiation to the prostate gland while reducing the radiation exposure to nearby healthy tissues. You may see 3D-CRT or IMRT (Intensity modulated radiation therapy). It uses a computer-driven machine that actually moves around the patient as it delivers radiation. In addition to shaping the beams and aiming them at the prostate from several angles, the intensity or strength of the beams can be adjusted to minimize the dose reaching the most sensitive normal tissues. This allows doctors to deliver an even higher dose to the cancer areas.

Surgery

Surgery - Radical retropubic prostatectomy: lower abdominal incision - Radical perineal prostatectomy: episiotomy - Laparoscopic radical prostatectomy: 2. minimally invasive (laparoscopic) access in the lower abdomen * The goal of radical prostatectomy is to remove the entire prostate with its capsule, the adjacent seminal vesicles and the local lymph nodes. -Robotic-assisted laparoscopic radical prostatectomy - Transurethral resection of the prostate (TURP) - Cryosurgery

Diet

The exact role of diet in prostate cancer is not clear, but several factors have been studied. Men who eat a lot of red meat or high-fat dairy products appear to have a slightly higher chance of getting prostate cancer. These men also tend to eat fewer fruits and vegetables. Doctors are not sure which of these factors is responsible for raising the risk. Some studies have suggested that men who consume a lot of calcium (through food or supplements) may have a higher risk of developing prostate cancer. Dairy foods (which are often high in calcium) might also increase risk. Most studies have not found such a link with the levels of calcium found in the average diet, and it's important to note that calcium is known to have other important health benefits.

Cryosurgery

To treat localized prostate cancer by freezing it. Also called cryotherapy or cryablation. This may not be a good option for men with large prostate glands. Several hollow probes or needles are placed through the skin between the anus and scrotum (the perineum). The doctor guides them into the prostate using TRUS. Very cold gases are passed through the needles, creating ice alls that destroy the prostate gland. Before cryosurgery a suprapubic catheter is placed through a skin incision on the abdomen. And into the bladder. The catheter is removed a couple of weeks later, once the sellig goes down. After the procedure there will be some bruising and soreness in the perineum where the rpboes were inserted.

Robotic-assisted laparoscopic radical prostatectomy

the surgeon sits at a console several feet away from the operating table and manipulates robotic arms, which are fitted with tiny cameras and surgical instruments, to locate and remove the diseased prostate gland. The console contains two full-color computer screens that provide a magnified, three-dimensional view of the prostate and surrounding tissues. The surgeon guides the robotic arms by manipulating manual controls while watching the screens. Proponents of this approach claim that robotic-assisted laparoscopic prostatectomy offers greater magnification and surgical precision than the alternatives, but thus far the evidence indicates that success rates and chances of complications are about the same as for traditional laparoscopic prostatectomy and radical prostatectomy (so-called "open" surgery).