Prostate Cancer

From your first visit for prostate cancer screening, diagnosis and treatment, you are the focus of an incredible team of experts at UofL Health – Brown Cancer Center. The team at Brown Cancer Center personalizes every aspect of your care for your unique situation. Our Multidisciplinary Genitourinary Cancer Clinic provides cutting-edge therapy and is backed by our expertise and compassionate care.

This specialized group communicates and collaborates closely to be sure you receive the most advanced prostate cancer care with the least impact on your body. Your team includes medical, surgical and radiation oncologists, as well as a specially trained support staff. They work with the latest technology and techniques. Your cancer treatment will be under the care of a multi-disciplinary team that integrates various expert opinions to formulate the best, most personalized treatment plan.

At Brown Cancer Center we have clinical trials available, ensuring you have access to cutting-edge treatment options.

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Facts

Understanding a disease is the first step toward finding the right care. Get the facts about prostate cancer, including the different types and who is at risk.

Prostate cancer is the type of cancer found most often among men in the United States, and more than 192,000 cases are diagnosed each year. It’s second only to lung cancer as a cause of cancer deaths among men in this country.

Chances are that you know someone who has prostate cancer or has been treated for it. One out of every seven American men will be diagnosed with the disease in their lifetime.

The survival rate is increasing, and awareness, screening and improved therapies are some of the reasons. If found early, prostate cancer has a good chance for successful treatment. In fact, prostate cancer sometimes does not pose a significant threat to a man’s life and can be observed carefully instead of treated immediately.

The prostate is a walnut-size gland in the male reproductive system. Just below the bladder and in front of the rectum, it surrounds part of the urethra, a tube that empties urine from the bladder. The prostate helps produce semen and nourish sperm.

The prostate begins to develop while a baby is in his mother’s womb. Fueled by androgens (male hormones), it continues to grow until adulthood.

Sometimes, the part of the prostate around the urethra may keep growing, causing benign prostatic hyperplasia (BPH). While this condition may interfere with passing urine and needs to be treated, it is not prostate cancer.

Prostate cancer types

Almost all prostate cancers begin in the gland cells of the prostate and are known as adenocarcinomas.

Pre-cancerous changes of the prostate: By age 50, about half of all men have small changes in the size and shape of the cells in the prostate. This is called prostatic intraepithelial neoplasia (PIN).

Some research has indicated these cellular changes may eventually develop into prostate cancer; however, this is controversial and preventive treatment is not recommended.

If PIN is present, the best strategy is to be certain a thorough biopsy procedure shows no invasive cancer. If PIN is the only finding, then careful follow-up screening with a prostate-specific antigen (PSA) blood test and digital rectal examination (DRE) is recommended.

Risk factors

Anything that increases your chance of getting prostate cancer is a risk factor. These include:

• Age: This is the most important risk factor. Most men who develop prostate cancer are older than 50. About two of every three prostate cancers are diagnosed in men older than 65.
• Family history: Risk is higher when other members of your family (especially father, brother, son) have or had prostate cancer, especially if they were young when they developed it.
• Race: African-American men have nearly double the risk of prostate cancer as white men. It is found less often in Asian American, Hispanic and American Indian men.
• Diet: A high-fat diet, particularly a diet high in animal fats, may increase risk. Diets high in fruits and vegetables may decrease risk.
• Nationality: Prostate cancer is more prevalent in North America and northwestern Europe than other parts of the world.
• Some research suggests that inflammation of the prostate (prostatitis) may play a role in prostate cancer. Sexually transmitted diseases (STDs) are being investigated as possible risk factors as well.

Prevention

Certain actions may help lower your risk of prostate cancer:

• Eat at least five servings of fruits and vegetables daily and eat less red meat. Decrease fat intake.
• Tell your doctor about the supplements you take. Some of these may decrease the PSA level. A recent large study found that selenium and vitamin E, once thought to decrease risk of prostate cancer, have no effect.
• Exercise regularly
• Maintain your ideal weight

Other ways to avoid prostate cancer are being investigated. These include:

• Lycopenes: These substances found in tomatoes, pink grapefruit and watermelon may help prevent damage to cells.
• Proscar® (finasteride) or Avodart® (dutesteride): If you are at high risk for prostate cancer, talk to your urologist or other provider who is familiar with studies about these drugs.
• Research shows that many cancers can be prevented.

Symptoms

Most cancers have the same symptoms as other, less serious conditions. Still, it’s important to know the signs.

Prostate cancer often shows no symptoms in the early stages. If symptoms do appear, they vary from man to man. Signs you may have prostate cancer may include:

• Painful or burning urination
• Inability to urinate or difficulty in starting to urinate
• Difficulty trying to hold back urination
• Weak or interrupted urine flow
• Frequent or urgent need to urinate
• Trouble emptying the bladder completely
• Blood in the urine or semen
• Continual pain in the lower back, pelvis, hips or thighs
• Difficulty having an erection

Having any of these symptoms does not mean you have prostate cancer. Some of the same symptoms can occur with BPH (benign prostatic hypertrophy) or other health problems. If you notice one or more of these symptoms for more than two weeks, see your doctor.

Diagnosis

Blood tests, imaging exams and even surgical procedures are used to check for cancer. Learn what methods doctors use to diagnose prostate cancer.

The experts at Brown Cancer Center specialize in diagnosing prostate cancer. They have the expertise and technology to evaluate the growth pattern and extent of each particular cancer, which will affect treatment.

If you have prostate cancer, it’s important to get an accurate diagnosis as soon as possible. This helps increase the odds for successful treatment and recovery.

If you have symptoms that may signal prostate cancer, your doctor will ask you questions about your health, your lifestyle and your family medical history.

One or more of the following tests may be used to find out if you have cancer and if it has spread. These tests also may be used to find out if treatment is working.

Digital rectal exam (DRE)

The simplest screening test for prostate cancer is the digital rectal exam (DRE). The health care provider gently inserts a gloved forefinger into the rectum to feel the prostate gland for enlargement or other abnormalities, such as a lump.

The DRE is not a definitive cancer test, but regular exams help detect changes in the prostate over time that might signal cancer or pre-cancerous conditions.

Although this test usually is not as reliable as the PSA blood test, a DRE may be able to find cancer if a man has a normal PSA level. A DRE also may be used to tell if prostate cancer has spread or returned after treatment.

Prostate-specific antigen (PSA) test

Prostate-specific antigen (PSA) is a protein produced by the cells of the prostate gland. It is found mostly in semen, but a small amount is in the blood as well.

A blood test measures the amount of PSA circulating in the blood, expressed in nanograms per milliliter (ng/mL). This level is used to assess prostate cancer risk. A higher PSA level usually means a higher chance of having prostate cancer.

However, the test has limitations. PSA is produced by both prostate tissue and prostate cancer. Sometimes prostate cancer does not produce much PSA and higher levels can be caused by factors other than cancer, including:

• Enlarged prostate, also called benign prostatic hyperplasia (BPH), which is found often in older men
• Age: PSA levels normally go up slowly as men age
• Infection or inflammation of the prostate, which also is called prostatitis
• PSA may rise briefly after ejaculation, then return to normal levels

On the other hand, certain conditions may make PSA levels low, even when a man has prostate cancer. These include:

• Some drugs used to treat BPH or other conditions
• Certain herbal medicines or supplements
• Obesity

Despite its limitations, PSA testing has helped detect prostate cancer in countless men. In 1984, before PSA testing was available, the chance of finding early prostate cancer was about 50 percent. In 1993, after PSA testing became widely used, that figure jumped to more than 90 percent.

Men with very low PSA levels may need to be tested every two years. However, if PSA is higher, the doctor may recommend more frequent testing.

Because prostate cancer develops slowly, physicians usually do not recommend the PSA test for men who are older than 75 or have other significant health issues.

Additional PSA testing

Besides screening, PSA testing can be used in other ways in men who have been diagnosed with prostate cancer. For instance, it may:

• Help doctors plan your treatment or further testing
• Determine if cancer has metastasized (spread beyond the prostate)
• Find out if treatment is working or cancer has returned
• Aid in active surveillance (also called watchful waiting) by showing if cancer is growing

Biopsy

If your doctor suspects prostate cancer, a biopsy may be performed. This is the only way to tell for sure if you have prostate cancer.

Biopsies for prostate cancer are done in a doctor’s office or another facility as an outpatient procedure. A local anesthetic like dentists use, often lidocaine, is injected into the area close to the prostate to make the procedure more comfortable.

A small transrectal ultrasound (TRUS) probe with an imaging device is inserted into the rectum so the doctor can view the prostate on a video screen. Using this image as a guide, the physician injects a thin needle through the wall of the rectum into the prostate. Several tiny samples of tissue are removed.

Sometimes a biopsy will not find prostate cancer, even if it is there. If your doctor is concerned that you may have prostate cancer based on a follow-up PSA test, a second biopsy may be performed.

Some people have an elevated risk of developing prostate cancer. Review the prostate cancer screening guidelines to see if you need to be tested.

In rare cases, prostate cancer can be passed down from one generation to the next. Genetic counseling may be right for you. Visit our genetic testing page to learn more.

Treatment

Common cancer treatments include chemotherapy, radiation treatment, and surgery. Doctors select a treatment plan based on your diagnosis and disease stage.

At Brown Cancer Center, you receive customized care that is planned by some of the nation’s leading experts. Your personal team of specialists communicates and collaborates at every step to be sure you receive the most advanced therapies with the least impact on your body.

Your options for prostate cancer treatment may include:

• Open prostatectomy (often with nerve-sparing techniques)
• Minimally invasive laparoscopic robotic surgery
• Intensity modulated radiation therapy (IMRT)
• Proton therapy
• Brachytherapy
• Cryotherapy
• Molecular-targeted therapy
• Vaccine therapy and gene therapy
• Hormone therapy
• Active surveillance

Brown Cancer Center has a multidisciplinary prostate cancer clinic to help you decide which prostate cancer treatment is best for you.

If you and your physician decide surgery is your best alternative, you should look for a surgeon with as much experience as possible in performing the procedure. Studies have shown this increases the odds for a successful surgery with fewer side effects.

Our surgeons are experienced in prostate cancer procedures and have the latest technology and equipment as well as an effective team approach.

If you are diagnosed with prostate cancer, your doctor will discuss the best options to treat it. This depends on several factors, including:

• Your age and general health
• Stage and grade of cancer
• Whether the cancer has spread
• Side effects of treatment

Your treatment for prostate cancer will be customized to your particular needs. One or more of the following therapies may be recommended to treat the cancer or help relieve symptoms.

Surgery

The most frequent surgical procedures to treat prostate cancer is radical prostatectomy, which is removal of:

• The entire prostate gland
• Both seminal vesicles, which play a part in making semen
• A short segment of the urine tube that passes through the prostate

The urinary system is reconstructed by suturing (sewing) the bladder opening to the urethra. In some patients, one or more lymph node groups in the pelvic area may be removed to find out if the prostate cancer has spread. This is called lymphadenectomy or lymph node dissection. In more advanced prostate cancer, one or both of the neurovascular bundles, which play a part in erectile function, may be partially or completely removed.

The two main surgical techniques for removal of the prostate are:

Open: A large incision is made in the lower abdomen, and the prostate is removed.

Robot-assisted (laparoscopic) minimally invasive: Multiple small incisions are made in the abdomen, and then an endoscope connected to robotic arms is inserted. A miniature video camera and surgical tools are attached to the end of the endoscope. The surgeon, seated at a console, can view the surgery site on a video screen and control the robotic arms. Brown Cancer Center surgeons are experts at nerve-sparing techniques and sural nerve grafts that may help men keep urinary and sexual function.

The robotic technique is commonly used in the United States. Studies show robotic-assisted surgery may result in:

• Less blood loss
• Shorter hospital stays
• Less urinary tract scarring
• Fewer complications

However, the techniques are fairly equal in retaining urinary and sexual function and controlling cancer. The experience of the surgeon probably will affect your result more than which set of tools is used.

Recovery of function after prostate cancer surgery

Urinary control: Most men have stress urinary incontinence (leakage of a small amount of urine when laughing, sneezing, coughing, etc.) after a radical prostatectomy.

• Within a few days to three months, most men have 90 percent or more of the urinary function they had before surgery.
• At one year, approximately 95% of men have pre-surgery levels of urinary control or are very close.
• Approximately 10% have rare urinary accidents and wear protective pads.
• Fewer than 5% have permanent significant leakage problems.

Sexual function: Since the prostate and seminal vesicles produce the majority of semen, sexual climax after a prostatectomy does not produce fluid. However, the climax response is preserved.

The success of preserving sexual function depends on:

• Age, sexual function before surgery and medical history
• Number of nerve bundles spared
• Experience and expertise of the surgeon

Radiation therapy

Radiation often is used to treat prostate cancer that is contained within the prostate or the surrounding area. For early-stage disease, patients often have a choice between surgery and radiation with similar outcomes. For larger or more aggressive tumors, radiation therapy may be used in combination with hormone therapy. Radiation also may be used to treat prostate cancer tumors that are not completely removed or that come back after surgery.

The newest radiation therapy techniques and remarkable skills allow our doctors to target tumors more precisely than ever before, delivering the maximum amount of radiation with the least damage to healthy cells.

Brown Cancer Center provides the most advanced radiation treatments for prostate cancer, including:

• Intensity-modulated radiotherapy (IMRT): External radiation which is tailored to the specific shape of the tumor, avoiding surrounding normal organs
• Cyberknife radiosurgery, which is not really surgery: The CyberKnife’s robotic arm will position itself around your body, delivering radiation with pinpoint precision.
• Brachytherapy: Tiny radioactive seeds are placed in the prostate very close to the tumor and left permanently

Because the prostate can move within the body from day to day, techniques are used to ensure the radiation is being given to the exact location of the organ each day. These include:

• Ultrasound imaging through the abdomen
• Implanting gold markers that show up on X-rays
• CT or CAT (computed axial tomography) scan
• Proton therapy

Proton therapy delivers high radiation doses directly into the tumor, sparing nearby healthy tissue and vital organs. For many patients, this results in better cancer control with fewer side effects.

Hormone therapy

The majority of prostate cancers are hormone-sensitive, which means male hormones (androgens) such as testosterone fuel growth of the cancer. About one-third of prostate cancer patients require hormone therapy (also called androgen deprivation), which blocks testosterone production or blocks testosterone from interacting with the tumor cells. This reduces the tumor size or makes it grow more slowly. While hormone therapy may help control prostate cancer, it does not cure it.

Hormone therapy is most often used for late-stage, high-grade tumors (Gleason score of 8 or higher) or in patients with cancer that has spread outside the prostate. However, doctors have different opinions about the length and timing of hormone therapy.

Hormone therapy may be used to treat prostate cancer if:

• Surgery or radiation is not possible
• Cancer has metastasized (spread) or recurred (come back after treatment)
• Cancer is at high risk of returning after radiation
• Shrinking the cancer before surgery or radiation increases the chance for successful treatment

Intermittent hormone therapy is a variation of hormone therapy in which drugs are used for a period of time, then stopped and started again. For some men, this approach to prostate cancer causes fewer side effects. The effectiveness of this approach is still being studied, but it appears particularly useful in some situations.

The types of hormone therapies for prostate cancer are:

Anti-androgens: These drugs, which include Eulexin® (flutamide or flutamin) and Casodex® (bicalutamide), block testosterone from interacting with the cancer cell. They are taken by mouth every day.

Anti-androgens are used most often in combination with LHRH agonists (see below). Occasionally, anti-androgens are used as an alternative to LHRH agonists if the side effects are excessive for the patient.

LHRH agonists: These drugs work by over-stimulating the pituitary gland to release luteinizing hormone-releasing hormone (LHRH). After an initial surge, this signals the testicles to suppress testosterone production. Treatments are injections, which last from one to six months, or implants of small pellets just under the skin.

LHRH agonists may cause a spike or flare in the testosterone level before treatment takes effect. To offset this effect, anti-androgens may be given for a few weeks before the initial LHRH injection. The effects of LHRH are usually not permanent, such that testosterone production may resume once the medication is stopped.

Orchiectomy: Surgical removal of the testicles. This removes the organ, which produces testosterone, and is another way to keep testosterone from the prostate cancer. Orchiectomy is an efficient, cost-effective and convenient method of reducing testosterone, and it is an option if you will be treated with testosterone suppression indefinitely. After this surgery, most men cannot have erections.

Side effects of hormone therapies for prostate cancer may include:

• Impotence, inability to get or maintain an erection
• Loss of libido (sex drive)
• Hot flashes
• Growth of breast tissue and tenderness of breasts
• Loss of muscle mass, weakness
• Decreased bone mass (osteoporosis)
• Shrunken testicles
• Depression
• Loss of self-esteem, aggressiveness/alertness and higher cognitive functions such as prioritizing or rationalization
• Anemia (low red blood cell count)
• Weight gain
• Fatigue
• Higher cholesterol levels
• Increased risk of heart attacks, diabetes and high blood pressure (hypertension)

If you are treated with hormone therapy and have side effects, be sure to mention them to your doctors. Many of these side effects can be treated successfully.

Gene therapy

We have the expertise to examine each prostate cancer tumor carefully to determine gene-expression profiles. Ongoing research will help us determine the most effective and least invasive treatment targeted to specific cancers. This personalized medicine approach sets us above and beyond most cancer centers and allows us to attack the specific causes of each cancer for the best outcome.

Cryotherapy

The tumor is frozen with a long, thin probe inserted into the tumor. Intensive follow-up with X-rays or other imaging procedures is required to ensure that the tumor has been destroyed.

Targeted therapies

Targeted therapies are specially designed to treat each cancer’s specific genetic/molecular profile to help your body fight the disease.

Vaccine therapy

These agents help the body fight the cancer on a molecular basis.

Chemotherapy

Most physicians reserve the use of chemotherapy for prostate cancer that has spread to other organs and is no longer responding to hormone therapy.

• Taxotere® (docetaxel) is the one of the standard chemotherapy agents for adenocarcinoma of the prostate.
• Cisplatin-based chemotherapy is used to treat the small-cell variant of prostate cancer.

Active surveillance

Because prostate cancer usually grows slowly, some men with prostate cancer, especially those who are older or have other health problems, may never be treated for it. Instead, their doctors may recommend active surveillance, an approach also known as "watchful waiting."

This approach involves closely monitoring the prostate cancer without active treatment such as surgery or radiation therapy. Biopsies and PSA tests are repeated at set intervals, and treatment may be recommended if the tumor shows an increase in the volume or the grade (Gleason score).

Long-term studies of active surveillance for men with low-volume, low-grade prostate cancer tumors show that approximately 70 percent can maintain this approach for up to 10 years without requiring treatment.

Side effects of treatment

After treatment for prostate cancer, you may have side effects. These depend the therapy you received and may involve:

• The urinary tract (the bladder and the urethra)
• The bowels, particularly the rectum
• Impotence and sexual function

Talk to your doctor about any side effects you have. Treatments are available to help with most of them.

Sexuality after prostate cancer

Impotence, or not being able to maintain an erection to have sex, may be a problem after prostate cancer treatment. This may be temporary or permanent. If you are able to get an erection, you may be able to achieve orgasm. However, no semen will be ejaculated during orgasm. Some people call this dry orgasm.

Talk to your health care provider about erection problems. Treatments include pills (such as Viagra®, Levitra® or Cialis®), vacuum erection devices and medications given by injections (shots).

Fertility after prostate cancer

Surgery to treat prostate cancer usually requires cutting the tubes between the testicles and urethra that transport the sperm and semen. Furthermore, surgery removes the prostate and seminal vesicles that produce the semen. Radiation significantly decreases the amount of semen that is produced, and semen is necessary to carry the sperm. This makes it impossible to father children without highly sophisticated sperm retrieval and in-vitro fertilization procedures.

If you want to have children in the future, it may be a good idea to bank sperm before cancer treatment. Speak to your doctor if you want more information or have questions.