Prostate Cancer

Prostate cancer is the most common cancer among American men.  This year, there are estimated to be nearly 250,000 new cases in the United States.  The risk of prostate cancer increases with age and is higher in men who have male relatives with prostate cancer and who are of African-American ethnicity.  Due to improved screening and early detection, many men with prostate cancer are being diagnosed early, when the cancer is still contained, or localized. 

The decision as to when and how to treat prostate cancer is difficult and it is important that a patient receives sufficient education on the options available to him.  Meeting with experts, like the faculty surgeons in the UMass Department of Urology, can help guide you through the decision-making process.

Please note that the following overview of prostate cancer is designed to be educational and does not substitute for the personalized conversation between a patient and his physician

Basic Facts about the Prostate

The prostate gland is a small firm organ, about the size of a chestnut, located below the bladder and in front of the rectum.  The urethra, the channel that carries urine from the bladder and through the penis, runs through the prostate.  The primary function of the prostate gland is to produce fluid which helps transport and nourish sperm as it passes through the prostate and out the urethra.

Natural History of Prostate Disease

In the mid-1980s, with the advent of PSA [Prostate-specific antigen] screening, prostate cancer began to be diagnosed in younger men when the cancer was still localized.  Thus began the current “modern era” of prostate cancer, when tumors are diagnosed while still contained within the prostate and, therefore, curable.   

Because of the ability to diagnose prostate cancer earlier and more reliably, more men are amenable to attempts at curative therapies.  Consequently, we have developed improved surgical and radiation-based treatment approaches with which we are able to treat local lesions with greater curative success and fewer side effects.  There has also been the development of the active surveillance approach in which treatment is deferred.  Although advances in the diagnosis and treatment of localized prostate cancer have become well-established, the optimal approach to the management of men with prostate cancer can differ from man to man due to the variable biologic course of each patient’s tumor.

Prostate Cancer Screening

A key to curing prostate cancer is to diagnose it when it is localized.  This has become a very controversial topic.  Still, many patient advocate groups as well as the following organizations support prostate cancer screening, as does the Department of Urology at UMass: the American Urologic Association, the American Cancer Society, and the Massachusetts Department of Health.  Key to prostate cancer screening is making sure that patients are educated and the benefits and risks of prostate cancer screening and is involved in shared decision-making with his physicians.  Please see our section of prostate cancer screening on this website for more details.  

Decision-Making Once Cancer is Detected

The decision as to which treatment method is best for an individual patient involves many factors including the stage and aggressiveness (grade) of the cancer, the patient’s health, and the preconceived conceptions of the patient and his family.  There are so many nuances and intricacies in the management of prostate cancer that the counsel of a urologic surgeon who specializes in prostate cancer is highly recommended to help maneuver through the decision-making process.  There is no need to rush into making a treatment decision: there is time to become educated and informed before settling on a management plan.

Determining the Clinical Significance of a Prostate Tumor

The approach to treating a man diagnosed with prostate cancer depends on several factors.  Two of these factors (determined by the cancer itself) are the stage and the grade.

(1) Stage: has the tumor spread beyond the confines of the prostate? It must be determined whether the cancer is localized (contained within the prostate), locally-advanced (spread beyond the prostate, but not invading or minimally involving surrounding organs or vital structures), or disseminated (metastatic lesions in bone, lymph nodes, or other viscera).  This process is called staging.

• Stage T1 disease is always found incidentally, usually because of an elevated PSA blood test.
• Stage T2 disease signifies that the physician can feel the tumor while doing a digital rectal exam [DRE]; the tumor feels contained to the prostate.
• Stage T3 and T4 disease denotes extension of prostate cancer tissue through the so-called "prostatic capsule" and out of the prostate into the immediately surrounding tissue. 
• N+ means that microscopic (or macroscopic) amounts of prostate cancer can be identified in the pelvic lymph nodes. 
• M+ means that metastases are clearly evident outside the pelvic area. Prostate cancer has a predilection for bone, which is where prostate cancer metastases most often occur.
• For accurate staging, some men diagnosed with prostate cancer may require a nuclear medicine bone scan and/or a CT or MRI scan to evaluate for the presence of spread.  There are nuances as to when such studies should be obtained and consultation with a surgeon who specializes in the treatment of prostate cancer is recommended.

(2) Grade: does the tumor have an aggressive behavior?  The outcome of a patient with prostate cancer ultimately depends upon the tumor’s capacity for un-hindered growth, local invasion, and the establishment of distant metastasis.  The process of assigning behavioral characteristics based on histologic findings (appearance of the tumor under the microscope) is called grading. 

• For prostate cancer, we use the Gleason grading system.
• Based on appearance under the microscope, a patient’s prostate cancer is assigned a value between 1 and 5, with higher numbers representing more aggressive tumors.
• Gleason Score: a single prostate can harbor multiple grades of disease.  The Gleason score (or Gleason sum) is generated by combining the values of the first and second most predominant grades (for example in a tumor with mostly Gleason grade 3 and less Gleason grade 4 disease will have a Gleason score will be 3+4 = 7. 
• Gleason grades or scores are used to counsel patients with regard to management strategies.

Risk Stratification: Before treatment option are discussed, it is important to use the PSA, DRE, and Gleason score (from the biopsy) to assign a risk classification.  In the simplest explanation, there are three risk classes for a man with localized disease: favorable prognosis (low risk), intermediate prognosis (risk), and unfavorable prognosis (high risk) disease.  Prognosis and treatment options vary depending upon which of these a patient is assigned.

Management Options

Once prostate cancer is detected, several different treatment options exist.  Treatment needs to be tailored to each individual patient.  Some patients may be candidates for many types of treatments; others may have limited options, usually due to the aggressiveness of their cancer and their overall health. 

• Localized disease: Radical prostatectomy (open and robotic or laparoscopic) and radiotherapy (external beam or brachytherapy [seeds]) and active surveillance are usually considered the standard treatments for patients with localized prostate cancer.
• Locally-advanced disease: For patients with locally-advanced lesions (stage T3) or high grade disease (Gleason grades 4 and 5), radical prostatectomy and external beam radiotherapy are the mainstay treatments, but might be combined with drug therapy as the risk of metastasis and recurrence are increased. 
• Advanced disease: Once prostate cancer has metastasized or become disseminated (M+ and/or N+), it is no longer considered curable and treatment is geared towards palliation.  Since prostate tumors are initially very sensitive to male hormones (androgens, primarily testosterone), treatment for metastatic disease usually initially involves androgen ablation or androgen deprivation therapy.  This can consist of surgical castration (removing the testes) or chemical castration (giving a combination of injections and pills which block testosterone production and activity).  Both approaches have similar efficacies and produce the same end-effect: depleting the body of male hormones.  Unfortunately, the effect of hormonal ablation therapy is of limited duration.  These tumor cells become resistant to the effects of castration and they proliferate and disseminate rapidly.  Eventually other treatment approaches, such as chemotherapy, immunotherapy, or targeted therapies, are needed. 

Nerve-sparing Radical Prostatectomy

• Radical prostatectomy involves removal of the prostate, the adjoining seminal vesicles, and, often, the surrounding lymph nodes.
• Surgical removal of the prostate gland is the most common form of therapy for localized prostate cancer. For many patients, the ten-year post-prostatectomy disease specific survival rate averages 85 to 90%. 
• Radical prostatectomy is usually performed in robotic-assisted laparoscopic (minimally-invasive) manner.
• Every attempt is made to spare the nerves that enable sexual function. 
• Aside from the normal risks associated with anesthesia and any major surgical procedure, complications of radical prostatectomy can include urinary leakage (incontinence) and erectile dysfunction (impotence).  Reported complications vary significantly due to differences in the experience of the treating surgeon and due to variations in the size and location of each tumor and the underlying health and function of each patient.
• For men with locally-advanced, high risk, or aggressive cancers, additional treatments may be given in addition to surgery.   In addition, there may be an advantage of open surgery in these patients.
• UMass urologic surgeons specialize in robotic and open prostate surgery.

Radiation

Radiation therapy is a viable and equally effective alternative treatment to surgery for men with prostate cancer.  There are two methods of delivering radiation to the prostate: external beam, intensity-modulated radiotherapy [IMRT] and brachytherapy (seed implants).

IMRT

• IMRT treatments involve beaming radiation from the outside.  It is given Monday through Friday over a seven to eight week period for a total of 42 treatments.
• The prostate and lymph nodes are targeted.
• The treatments tend to be painless and are generally tolerated well; most people continue to work and maintain their normal activity schedule.
• Significant advancements in computer technology have led to the development of CT based simulation and improved targeting with less damage to surrounding tissues. 
• Patients treated with external beam radiation can experience temporary fatigue.  Irritability of urinary and bowel function and sexual dysfunction is common.

Brachytherapy

• Brachytherapy (also known as seed implantation) is another form of radiation therapy in which radioactive pellets are placed directly into the prostate gland as permanent seed implants.
• This is done as a 1-2 hour outpatient operation under anesthesia in which radioactive seeds are placed through the perineum under ultrasound guidance into the prostate.
• Only the prostate is targeted.
• Return to normal activities is expected within a few days.  Temporary urinary retention can occur and catheterization may be necessary.
• Patients treated with brachytherapy can experience temporary fatigue.  Irritability of urinary function is common.  Effects on bowel and sexual function tend to be less than with IMRT.

Active Surveillance

In active surveillance, the patient and his physician decide to defer on treatment.  This is offered to patients with early stage disease.  This approach requires periodic examinations and tests and a formal protocol is followed. 

• The ideal candidate for active surveillance has low volume cancer with no more than Gleason grade 3 disease and a PSA well under 10ng/ml.  These criteria are under consideration for being expanded and the use of new molecular tests might help patients with Gleason grade 4 disease feel more comfortable with active surveillance.
• The patient on active surveillance will return every 6 months for a DRE and PSA blood test and every 12-24 months for a repeat biopsy until the risk of progression is best estimated.
•  If worrisome changes are noted on any of these studies (increases in: PSA, volume of disease, grade of disease, induration or nodularity of the prostate) then intervention (such as surgery or radiation) may be initiated.
• Active surveillance doesn’t always eliminate the need for definitive treatment (such as surgery or radiation) but may delay the timing of its application.

Salvage Prostatectomy

In a certain percentage of patients, prostate cancer can return after attempted cure with radiation.  If a man experiences a recurrence of prostate cancer limited to the prostate, then he may be candidate for a salvage prostatectomy. 

• This can be performed as a surgical radical prostatectomy (in which the prostate, the adjoining seminal vesicles, and the surrounding lymph nodes are removed) or through cryotherapy (freezing; in which just the prostate is targeted). We do not offer salvage cryotherapy at UMass.
• Because of scarring from the radiation, salvage prostatectomy is more difficult than traditional (initial or de novo) prostate surgery.  Consequently, side effects from treatment are more common.  These include bladder and sexual dysfunction.
• Every attempt is made to spare the nerves that enable sexual function, although this is quite difficult during a salvage prostatectomy.
• UMass urologic surgeons specialize in salvage prostatectomy surgery.

Prostate cancer can also recur after initial surgery.  For this, salvage radiation can be used with good effectiveness if the disease recurrence is still limited and localized.

Prostatic Intraepithelial Neoplasia (PIN)

Prostatic intraepithelial neoplasia (PIN) is believed to be a precursor of prostate cancer, given the strong association between high grade PIN and prostatic adenocarcinoma.  The presence of high grade PIN is often indicative of the presence of prostate cancer. Although a diagnosis of high-grade PIN is insufficient by itself for performing surgery or radiotherapy, men with high grade PIN on a biopsy specimen must be followed very closely with serial PSA tests and often repeat biopsy.