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From: J on 5 Jul 2008 09:18
Primer on Prostate Cancer for the Newly Diagnosed Patient
http://www.bcm.edu/urology/?PMID=5977

You have been diagnosed with prostate cancer, what should be your next
step? Here are some facts about the disease which you should know.

1. First of all, you are not alone. Prostate cancer is the most common
cancer diagnosed in men in the United States. In fact, the American Cancer
Society estimated that over 232,000 men were diagnosed with this disease
in 2005.

2. Do not panic. About 90 percent of men diagnosed today have cancers
still clinically localized to the prostate and, as such, have an excellent
chance of being cured.

3. This is a slow-growing tumor. It is estimated that prostate cancers
have been developing for 8 to 15 years before being diagnosed. You should
have time to study the issue, talk to your doctors, and select a treatment
plan suitable for your particular condition. The interval between
diagnosis and treatment of this disease is measured in weeks and months in
most large centers in the United States. Do not feel pressured to decide
right away.

4. Most prostate cancers diagnosed in the "PSA era" are totally
asymptomatic. Any bladder symptoms or general symptoms you may be
experiencing are very likely not related to your prostate cancer. In fact,
left untreated, prostate cancer may not cause symptoms or spread for 5 to
15 years. However, make no mistake about it, prostate cancer is a cancer
and it can and will behave like one given enough time.

5. The next step in acquiring information about your prostate cancer is
determining its stage and grade. The stage defines the extent of your
cancer, namely, how far has it spread within the prostate, has it grown
through the wall (capsule) of the prostate, or has it spread to other
organs (lymph nodes, bones, etc).

Again, keep in mind that less than 10 percent of patients diagnosed in the
modern era have evidence of prostate cancer spread to the lymph nodes or
beyond. Most prostate cancers diagnosed in the united States fall into the
T1 - T2 stages (disease still confined to the prostate).

The grade of the cancer is a measure of its aggressiveness. It is
determined by the pathologist based on the biopsy. The scale most commonly
used in the United States is the "Gleason scale". The Gleason score
actually consists of two digits and their sum (for instance, Gleason
3+3=6). The individual numbers reflect the two most common patterns within
the cancer. Each pattern is scored on a scale of 1 to 5 (1 is the least
and 5 is the most aggressive). Thus, the total Gleason score consists of
the numbers 2 to 10 (i.e. a minimum of 1+1=2 and a maximum of 5+5=10).
Your doctor uses both the total Gleason score and the individual Gleason
scores when making treatment decisions and recommendations.

A total Gleason score of 2 (extremely rare) indicates that the cancer is
not aggressive at all and, in fact, should be left alone. A total Gleason
score of 10, on the other hand, indicates the most aggressive cancer. Most
patients are diagnosed with intermediate total Gleason scores of 5, 6 or
7.

Additional tests may be ordered by your doctor to determine the extent of
spread of your cancer (if any). Most commonly, these tests consist of:

* A bone scan
* A CT scan of the abdomen

In many newly diagnosed patients, however, these tests are not needed and
are not ordered. Your doctor should discuss this issue with you.


Prostate Cancer Treatment Options

There are several treatment options for patients with prostate cancer:

* surgery to remove the whole prostate (radical prostatectomy)
* palliative surgery to treat obstruction and facilitate bladder
emptying (transurethral prostatectomy)
* radiation therapy to the prostate
* cryotherapy (freezing of the prostate)
* hormone therapy
* chemotherapy

Only two of these options are considered standard curative treatments:
radical prostatectomy and radiation therapy.

Remember that cure is only possible when the cancer is still localized to
the prostate. If it has spread or "metastasized" to the lymph nodes or to
bones or to other organs, cure is no longer possible in most cases.

As mentioned earlier, most patients diagnosed in the modern era have
localized cancers. Consequently, they are confronted with a choice between
surgery (a radical prostatectomy), and radiation therapy.

Radical Prostatectomy

A radical prostatectomy is considered the "gold standard" of prostate
cancer treatment. The operation has been around for more than 50 years. In
the last 20 years it has been improved dramatically. If performed
correctly, it offers the best chance for a cure while preserving a
patient's bladder control and sexual function. Modern perioperative
management has reduced hospital stay to 2-3 days and serious complications
are rare. Most patients resume full activity in 3-5 weeks.

Be aware, however, that temporary loss of bladder control (lasting several
weeks), is common and recovery of sexual function may take 9-18 months.

If the cancer is pathologically confined to the prostate, this operation
affords a cure rate (defined as undetectable serum PSA for more than 5
years after surgery) of better than 90 percent.

The operation involves removal of the entire prostate with the two
attached seminal vesicles. In addition, in many cases, the surgeon also
removes the regional pelvic lymph nodes for staging purposes. Once these
tissues are examined by the pathologist under the microscope, it is
possible to determine more accurately the exact nature of the cancer and
whether or not it was truly confined to the prostate. Additional treatment
decisions can then be based on this information.

Many factors influence the outcome of prostate cancer surgery: the nature
of the disease, the size and configuration of the prostate, the anatomy of
the pelvis, the age and weight of the patient, coexisting diseases and
medical treatments, previous prostate or pelvic surgery, etc. In recent
years, however, studies have documented that an important determinant of
the outcome is the experience of the surgeon. Surgeons who do large
numbers of this operation, year after year, tend to have better results
and fewer complications.

See a video discussion of radical prostatectomy.


Radiation Therapy

Radiation therapy is also capable of curing localized prostate cancer. It
can be delivered by placing the patient in a sophisticated machine which
focuses a radiation beam directly on the prostate (called "external beam"
radiotherapy), or by the implantation of radioactive pellets into the
prostate (called "brachytherapy"). Some physicians prefer to combine these
two techniques. The choice between these techniques depends on a number of
clinical factors as well as on the availability of radiotherapy
instrumentation and the training of the radiation oncologist.

External beam radiotherapy is delivered over a period of 6 weeks, in daily
sessions, 5 days a week. Brachytherapy is a minimally invasive procedure,
usually performed under general or regional anesthesia.

Most patients tolerate radiation therapy well with few side effects.
Impotence, is a common side effect, however, occurring in 15 - 40 percent
of the patients within four years of treatment. Serious side effects
(rectal or bladder bleeding, severe voiding symptoms, tissue sloughing,
etc.) develop in 3 - 4 percent of patients. These side effects may require
major surgery for correction. Finally, there is evidence to suggest that
radiotherapy for prostate cancer may increase the risk for subsequent
development of rectal or bladder cancer, many years later. This is rare,
however, and happens in less than 1 percent of these patients.

In long term, 15-year follow up retrospective studies, surgery had a 15-20
percent better cure rate than radiation. To date, there is no prospective
randomized study comparing the two modalities head to head. In the
urological community, the current consensus is that surgery is a better
treatment option in patients younger than 70. Between the ages of 70 and
75, surgery and radiation are accepted with equal enthusiasm. Patients
older than 75 years are rarely offered surgery. There are many exceptions
to this general rule and your doctor should advise you which option is
best for you.

It is important to keep in mind that for large, extensive prostate
cancers, surgery may need to be combined with radiation in order to
achieve local control. Radiation therapy has been given to many patients
after radical prostatectomy without any additional side effects. On the
other hand, if a patient had radiation therapy to start with, and the
cancer returned, surgical removal of the prostate is no longer possible.
Radiotherapy induces scar tissue in and around the prostate and makes
subsequent surgery extremely difficult.


Finally

This is an overview designed to help you understand prostate cancer and
assist you with your choice of therapy. The specific details of your
disease and the optimal treatment for you will be addressed by your
physician and tailored to your particular circumstances.



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