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Wake Forest Baptist Approach Prostate Cancer Center of Excellence The Prostate Cancer Center for Excellence was established in 1999 as a center for innovative research and treatment of this common but complex cancer. Through integration, collaboration and translation within the Comprehensive Cancer Center Programs, the Prostate Cancer Center of Excellence fosters important multidisciplinary research. The Prostate Cancer Center of Excellence has three broad areas of emphasis:  chemoprevention, molecular epidemiology and novel therapies. Because the optimal treatment for many prostate cancers is still uncertain, our greatest impact on reducing mortality and morbidity from prostate cancer can be achieved by research focused on chemoprevention, on identifying men at high risk for the disease or its recurrence, and on the development of new therapies for men with existing prostate cancer. In chemoprevention, studies are being conducted on soy protein with isoflavones and vitamin D as preventive agents. Risk factor research is examining aberrations at the cellular and molecular level that contribute to increased risk for the disease. Among the new therapies being explored are the use of dendritic (immune) cells and vitamin D to fight off prostate cancer. In clinical treatment, we have brought together experts in genitourinary medical oncology, radiation oncology, urologic oncology, pathology and radiology in a unique and comprehensive multidisciplinary clinic. Through this weekly clinic, our Genitourinary Oncology Group provides assessment of all new patients to determine the most effective treatment program including initial treatment, long-term follow-up and quality of life issues. Our multidisciplinary clinic sees patients with prostate, bladder, testicular, adrenal and other related cancers. Urologic Oncology The Urologic Oncology Program brings together clinicians from multiple departments in the Medical Center to facilitate the provision of multidisciplinary cancer care to patients with genitourinary malignancies.  Special expertise is directed toward the diagnosis, staging, treatment and follow-up of patients with tumors of the prostate, bladder, kidney/ureter, testis and other genitourinary sites. The Program supports numerous in-house and cooperative oncology group trials.  Through these mechanisms, patients have access to clinical trials for most genitourinary malignancies that incorporate multiple modalities of treatment to effect the best possible treatment outcome. 3D Conformal and Intensity Modulated Radiation Therapy Among the newer treatment options for cancer of the prostate, brain, lung, and head and neck are two methods of focusing radiation on the tumor and surrounding at-risk tissues while optimally sparing nearby normal tissues, 3-dimensional (3D) conformal radiation therapy, and intensity modulated radiation therapy (IMRT).  This approach uses anatomic computed tomogrphic and/or magnetic resonance images of the patient, computer-generated radiation dose calculations, and a computer-controlled linear accelerator to conform or “paint” the radiation dose very precisely to match the shape of the tumor to be treated, avoiding critical structures that may be only millimeters away. When the linear accelerator radiation beam intensity is varied, or modulated, over space and time during the patient’s treatment, hence the term “Intensity Modulated” radiation therapy. In combination with advanced imaging techniques like magnetic resonance spectroscopy and positron emission tomography that image both tumor anatomy and biology, IMRT holds great promise for improving local tumor control and survival, even in the most resistant and aggressive human cancers.  Brachytherapy Brachytherapy, which literally means “short therapy”, involves the implantation of radioactive sources in or near a tumor, a procedure which typically involves the collaboration of a surgical oncologist and radiation oncologist.  A full range of brachytherapy treatment options are available for treating cancers of the prostate, breast cervix, uterus, vagina, head and neck, soft tissues, brain, and eye.  In fact, with the availability of both high dose rate (HDR) and low dose rate (LDR) brachytherapy technology and expertise, virtually any area of the body can be implanted if appropriate.  Brachytherapy is often used as a “boost” in conjunction with external beam radiation, particularly for locally advanced cancers. Wake Forest Baptist recently installed the only Digital Integrated Brachytherapy Unit in the U.S. The IBU concept integrates all aspects of brachytherapy treatment – in which the radiation source is placed in direct contact with the tumor via an implant. Patient preparation, applicator insertion, imaging, treatment planning and delivery are all provided in a single, shielded room -- offering real-time savings while implant quality is improved. It allows radiation to be placed directly into the tumor in a single procedure and ensures patients receive an optimal dose of radiation with pinpoint accuracy and reduces overall treatment time.       Prostate cancer Male reproductive anatomy Male urinary tract BPH Prostate cancer   PSA blood test Prostatectomy - series TURP - series Definition: Prostate cancer is cancer that starts in the prostate gland. The prostate is a small, walnut-sized structure that makes up part of a man's reproductive system. It wraps around the urethra, the tube that carries urine out of the body. Alternative Names: Cancer - prostate Causes, incidence, and risk factors: The cause of prostate cancer is unknown. Some studies have shown a relationship between high dietary fat intake and increased testosterone levels. There is no known association with an enlarged prostate or benign prostatic hyperplasia (BPH). Prostate cancer is the third most common cause of death from cancer in men of all ages and is the most common cause of death from cancer in men over age 75. Prostate cancer is rarely found in men younger than 40. People who are at higher risk include: African-American men Men who are older than 60 Farmers Tire plant workers Painters Men who have been exposed to cadmium The lowest number of cases occurs in Japanese men and those who do not eat meat (vegetarians). Symptoms: Thanks to PSA testing, most prostate cancers are now found before they cause symptoms. Although most of the symptoms listed below can occur with prostate cancer, they are more likely to be associated with noncancerous conditions. Urinary hesitancy (delayed or slowed start of urinary stream) Urinary dribbling, especially immediately after urinating Urinary retention Pain with urination Pain with ejaculation Lower back pain Pain with bowel movement Other symptoms that may occur with this disease: Excessive urination at night Urinary leakage (incontinence) Bone pain or tenderness Blood in the urine (hematuria) Abdominal pain Low red blood cell count (anemia) Unintentional weight loss Lethargy Signs and tests: A rectal exam will often show an enlarged prostate with a hard, irregular surface. A number of tests may be done to diagnose prostate cancer: PSA test (may be high, although noncancerous enlargement of the prostate can also increase PSA levels) Free PSA (may help tell the difference between BPH and prostate cancer) AMACR (a newer test that is more sensitive than the PSA test for determining prostate cancer) Urinalysis (may show blood in the urine) Urine or prostatic fluid testing (may reveal unusual cells) Prostate biopsy is the only test that can confirm the diagnosis. The following tests may be done to determine whether the cancer has spread: CT scan Bone scan Chest x-ray Health care providers use a system called staging to describe how far the cancer has grown. Tumor size, and how far the cancer has spread outside of the prostate determine the stage. Identifying the correct stage may help the doctor recommend the best treatment. There are several different ways to stage tumors, including: The TNM staging system (most common) The A-B-C-D staging system, also known as the Whitmore-Jewett system The grade of a tumor describes how aggressive a cancer might be. The more tumor cells differ from normal tissue, the faster these cells are likely to grow. The grading system for prostate cancer is called the Gleason grade or score. Higher scores are usually faster growing cancers. Treatment: The appropriate treatment for prostate cancer is not clear. Treatment options vary based on the stage of the tumor. In the early stages, talk to your doctor about several options including surgery, radiation therapy, or, in older patients, monitoring the cancer without active treatment. Prostate cancer that has spread may be treated with drugs to reduce testosterone levels, surgery to remove the testes, or chemotherapy. Surgery, radiation therapy, and hormonal therapy can interfere with sexual desire or performance on either a temporary or permanent basis. Discuss your concerns with your health care provider. SURGERY Surgery is usually only recommended after a thorough evaluation and discussion of all treatment options. A man considering surgery should be aware of the benefits and risks of the procedure. Surgery to remove the prostate gland is often recommended for treating stages A and B prostate cancers. This is a lengthy procedure and complications are possible. There are many different surgery options. See: Radical prostatectomy and Robotic surgery. Orchiectomy alters hormone production and may be recommended for cancer that has spread to other areas of the body. There may be some bruising and swelling right after surgery, but this will gradually go away. The loss of testosterone production may lead to problems with sexual function, osteoporosis (thinning of the bones), and loss of muscle mass. RADIATION THERAPY Radiation therapy is used primarily to treat stage A, B, or C prostate cancers. Whether radiation is as good as prostate removal is unclear. The decision about which treatment to choose can be difficult. In patients whose health makes surgery too risky, radiation therapy is often the preferred alternative. Radiation therapy to the prostate gland is either external or internal: External beam radiation therapy is done in a radiation oncology center by specially trained radiation oncologists, usually on an outpatient basis. Before treatment, a therapist will mark the part of the body that is to be treated with a special pen. The radiation is delivered to the prostate gland using a device that looks like a normal x-ray machine. The treatment itself is generally painless. Side effects may include impotence, incontinence, appetite loss, fatigue, skin reactions such as redness and irritation, rectal burning or injury, diarrhea, inflamed bladder (cystitis), and blood in urine. External beam radiation therapy is usually done 5 days a week for 6 - 8 weeks. Prostate brachytherapy or internal radiation involves placing radioactive seeds inside you, directly into the prostate. A surgeon inserts small needles through the skin behind your scrotum to inject the seeds. The seeds are so small that you don't feel them. They can be temporary or permanent. Because internal radiation therapy is directed to the prostate, it reduces damage to the tissues around the prostate. Prostate brachytherapy may be given for early, slow-growing prostate cancers. It also may be given with external beam radiation therapy for some patients with more advanced cancer. Side effects may include pain, swelling or bruising in your penis or scrotum, red-brown urine or semen, impotence, incontinence, and diarrhea. Radiation is sometimes used for pain relief when cancer has spread to the bone. MEDICATIONS Medicines can be used to adjust the levels of testosterone. This is called hormonal manipulation. Because prostate tumors require testosterone to grow, reducing the testosterone level often works very well at preventing further growth and spread of the cancer. Hormone manipulation is mainly used to relieve symptoms in men whose cancer has spread. It may also be done by surgically removing the testes. The drugs Lupron and Zoladex are also being used to treat advanced prostate cancer. These medicines block the production of testosterone. The procedure is often called chemical castration, because it has the same result as surgical removal of the testes. However, unlike surgery, it is reversible. The drugs must be given by injection, usually every 3 - 6 months. Possible side effects include nausea and vomiting, hot flashes, anemia, lethargy, osteoporosis, reduced sexual desire, and impotence. Other medications used for hormonal therapy include androgen-blocking drugs (such as flutamide), which prevent testosterone from attaching to prostate cells. Possible side effects include erectile dysfunction, loss of sexual desire, liver problems, diarrhea, and enlarged breasts. Chemotherapy is often used to treat prostate cancers that are resistant to hormonal treatments. An oncology specialist will usually recommend a single drug or a combination of drugs. Chemotherapy medications that may be used to treat prostate cancer include: Adriamycin Docetaxel Estramustine Mitoxantrone Paclitaxel Prednisone After the first round of chemotherapy, most men receive further doses on an outpatient basis at a clinic or physician's office. Side effects depend on the drug, how often you take it, and for how long. Some of the side effects for the most commonly used prostate cancer chemotherapy drugs include: Blood clots Bruising Dry skin Fatigue Fluid retention Hair loss Lowering of your white cells, red cells, or platelets Mouth sores Nausea Tingling or numbness in hands and feet Upset stomach Weight gain MONITORING You will be closely watched to make sure the cancer does not spread. This involves routine doctor check-ups. Monitoring may include: Serial PSA blood test (usually every 3 months to 1 year) Bone scan or CT scan to check whether the cancer has spread Complete blood count (CBC) to monitor for signs and symptoms of anemia Monitoring for other signs and symptoms, such as fatigue, weight loss, increased pain, decreased bowel and bladder function, and weakness Support Groups: You can ease the stress of illness by joining a support group whose members share common experiences and problems. See: Support group - prostate cancer Expectations (prognosis): The outcome varies greatly. This is mainly because the disease is found in older men, who may have a variety of other diseases or conditions such as heart or respiratory disease, or disabilities. The outcome is also affected by the stage and grade of the disease when you are diagnosed. Complications: Impotence is a potential complication after prostate removal or radiation therapy. Recent improvements in surgical procedures have made this complication less common. Urinary incontinence is another possible complication. Medications can have side effects, including hot flashes and loss of sexual desire. Calling your health care provider: Call for an appointment with your health care provider if you are a man over age 40 who has: Never been screened for prostate cancer (by rectal exam and PSA level) Not had regular, annual exams A family history of prostate cancer Discuss the advantages and disadvantages to PSA screening with your health care provider. Prevention: There is no known way to prevent prostate cancer. Following a vegetarian, low-fat diet or one that is similar to the traditional Japanese diet may lower your risk. Early identification (as opposed to prevention) is now possible by screening men over age 40 each year with a digital rectal examination (DRE) and PSA blood test. There is a debate, however, as to whether PSA testing should be done in all men. There are several potential downsides to PSA testing. The first is that a high PSA level does not always mean that a patient has prostate cancer. The second is that health care providers are detecting and treating some very early-stage prostate cancers that may never have caused the patient any harm. The decision about whether to use a PSA testing to screen for prostate cancer should be based on a discussion between the patient and his health care provider. References: Andriole GL, Crawford ED, Grubb RI 3rd, Buys SS, Chia D, Church TR, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009;360:1310-1319. Babaian RJ, Donnelly B, Bahn D, Baust JG, Dineen M, Ellis D, et al. Best practice statement on cryosurgery for the treatment of localized prostate cancer. J Urol. 2008;180:1993-2004. NCCN Clinical Practice Guidelines in Oncology: Prostate cancer. V.2.2009. Accessed June 2009. Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009;360:1320-1328. Walsh PC, DeWeese TL, et al. Clinical practice: localized prostate cancer. N Engl J Med. 2007;357(26):2696-2705. Wilt TJ, MacDonald R, et al. Systematic review: comparative effectiveness and harms of treatments for clinically localized prostate cancer. Ann Intern Med. 2008;148(6):435-448.

Review Date:8/10/2009 Reviewed By:Reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc. Also reviewed by Scott Miller, MD, Urologist, private practice, Atlanta, Georgia.