Which Prostate Cancers Really Need Treatment
July 9, 2013 by Bert Vorstman
> some 75% of all prostate cancers diagnosed are classed as favorable-risk Gleason 6 > GENERALLY, MOST of these favorable-risk Gleason 6 stage T1c prostate cancers need NO treatment whether through focal therapy or whole gland treatment> GENERALLY, MOST favorable-risk Gleason 6 cancers do NOT PROGRESS while being monitored on ACTIVE SURVEILLANCE> 25% or less of prostate cancers detected are the high-risk significant prostate cancers and it is these cancers which demand treatment> NOT ALL PROSTATE CANCERS ARE EQUAL> more people die from drug resistant infections every year than from breast cancer and prostate cancer combined> the importance of prostate cancer is greatly overemphasized> the preoccupation with PSA prostate cancer screening and detection, particularly for the insignificant Gleason 6 prostate cancer, is disingenuous
THEREFORE, on both MOLECULAR and CLINICAL fronts, it is ABUNDANTLY CLEAR thatthe Gleason 6 prostate cancer is essentially,> INSIGNIFICANT> a MISNOMER and should NOT be called a cancer> grossly MISMANAGED and MISTREATED as if a significant high-risk cancer
Which prostate cancers really need treatment?> only some 25% of prostate cancers diagnosed are classified as high-risk> significant or high-risk prostate cancers needing treatment are: * men with Gleason 4+3, 4+4 and above * men with significant volume of 4s in a Gleason 3+4
Improvements In Life Expectancy
A decade ago, a man with metastatic prostate cancer would typically have a life expectancy of two to three years. Today, life expectancy for men with the same advanced disease is likely to be five to six years. In the UK the survival rate for men with stage 4 prostate cancer is approximately 50%, meaning that 50 out of every 100 men will survive their cancer for 5 years or more after they are diagnosed with stage 4 prostate cancer*. There is now a much broader range of chemotherapy drugs available for men with advanced disease with greater efficacy . We also have better treatments to control the symptoms of advanced prostate cancer, such as pain from metastases. In this section, we consider in more detail the different treatments that are available and evidence for their effectiveness.
Side Effects Of Prostate Surgery
The major possible side effects of radical prostatectomy are urinary incontinence and erectile dysfunction . These side effects can also occur with other forms of prostate cancer treatment.
Urinary incontinence: You may not be able to control your urine or you may have leakage or dribbling. Being incontinent can affect you not only physically but emotionally and socially as well. These are the major types of incontinence:
- Men with stress incontinence might leak urine when they cough, laugh, sneeze, or exercise. Stress incontinence is the most common type after prostate surgery. Its usually caused by problems with the valve that keeps urine in the bladder . Prostate cancer treatments can damage this valve or the nerves that keep the valve working.
- Men with overflow incontinence have trouble emptying their bladder. They take a long time to urinate and have a dribbling stream with little force. Overflow incontinence is usually caused by blockage or narrowing of the bladder outlet by scar tissue.
- Men with urge incontinencehave a sudden need to urinate. This happens when the bladder becomes too sensitive to stretching as it fills with urine.
- Rarely after surgery, men lose all ability to control their urine. This is called continuous incontinence.
After surgery for prostate cancer, normal bladder control usually returns within several weeks or months. This recovery usually occurs slowly over time.
There are several options for treating erectile dysfunction:
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Considering Complementary And Alternative Methods
You may hear about alternative or complementary methods that your doctor hasnt mentioned to treat your cancer or relieve symptoms. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.
Complementary methods refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctors medical treatment. Although some of these methods might be helpful in relieving symptoms or helping you feel better, many have not been proven to work. Some might even be harmful.
Be sure to talk to your cancer care team about any method you are thinking about using. They can help you learn what is known about the method, which can help you make an informed decision.
Remission And The Chance Of Recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having no evidence of disease or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormonal therapy and radiation therapy, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate someone’s risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer returns after the original treatment, it is called recurrent cancer.
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate , in the tissues or lymph nodes near the prostate , or in another part of the body, such as the bones, lungs, or liver . Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA recurrence or biochemical recurrence.
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Provenge For Advanced Prostate Cancer
Provenge isnât your everyday vaccine. Itâs an immune therapy created by harvesting immune cells from a patient, genetically engineering them to fight prostate cancer, and then infusing them back into the patient.
Itâs approved only for treatment of patients with few or no prostate cancer symptoms whose cancer has spread outside the prostate gland and is no longer responding to hormone therapy.
Once a cancer grows beyond a certain point, the immune system has a hard time fighting it. One reason is that cancer cells look a lot to the immune system like normal cells. Another reason is that tumors may give off signals that manipulate the immune system into leaving them alone.
Provenge bypasses these problems. The treatment first removes a quantity of dendritic cells from a patientâs blood. Dendritic cells show pieces of tumor to immune cells, priming them to attack cells that carry those pieces.
The patientâs doctor ships the cells to Provengeâs manufacturer, Dendreon, which then exposes them to Provenge. Provenge is a molecule made inside genetically engineered insect cells.
Once these cells have been exposed to Provenge, theyâre shipped back to the doctor who infuses them back into the patient. This is done three times in one month. The first infusion primes the immune system. The second and third doses spur an anticancer immune response.
Gleason Score For Grading Prostate Cancer
Prostate cancer is also given a grade called a Gleason score. This score is based on how much the cancer looks like healthy tissue when viewed under a microscope. Less aggressive tumors generally look more like healthy tissue. Tumors that are more aggressive are likely to grow and spread to other parts of the body. They look less like healthy tissue.
The Gleason scoring system is the most common prostate cancer grading system used. The pathologist looks at how the cancer cells are arranged in the prostate and assigns a score on a scale of 3 to 5 from 2 different locations. Cancer cells that look similar to healthy cells receive a low score. Cancer cells that look less like healthy cells or look more aggressive receive a higher score. To assign the numbers, the pathologist determines the main pattern of cell growth, which is the area where the cancer is most obvious, and then looks for another area of growth. The doctor then gives each area a score from 3 to 5. The scores are added together to come up with an overall score between 6 and 10.
Gleason scores of 5 or lower are not used. The lowest Gleason score is 6, which is a low-grade cancer. A Gleason score of 7 is a medium-grade cancer, and a score of 8, 9, or 10 is a high-grade cancer. A lower-grade cancer grows more slowly and is less likely to spread than a high-grade cancer.
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How Do Health Care Professionals Determine Bladder Cancer Staging
Bladder cancer is staged using the tumor node metastases system developed by the International Union Against Cancer in 1997 and updated and used by the American Joint Committee on Cancer . In addition, the American Urologic Association has a similar staging system that varies slightly from that used by the AJCC. The combination of both staging systems appears below. This staging gives your physician a complete picture of the extent of the persons bladder cancer.
The T stage refers to the depth of penetration of the tumor from the innermost lining to the deeper layers of the bladder. The T stages are as follows:
- Ta Noninvasive papillary carcinoma
The presence and extent of involvement of the lymph nodes in the pelvic region of the body near the urinary bladder determines the N stage. The N stages are as follows:
The metastases or the M stage signifies the presence or absence of the spread of bladder cancer to other organs of the body.
- Mx Distant metastasis cannot be evaluated
- M0 No distant metastasis
A health care professional then assigns a stage:
Combination Radiation And Endocrine Therapy
Sometimes, patients receive hormone therapy in combination with external beam radiation therapy for the treatment of prostate cancer. This treatment uses a high-energy X-ray machine to direct radiation to the prostate tumor. For patients with intermediate or high risk prostate cancer, studies show this combination is more effective at slowing the disease than endocrine therapy or radiation therapy alone.
Radiation can also come in the form of a monthly intravenous drug called Xofigo. Xofigo is approved for use in men who have advanced prostate cancer that has spread only to the bones. Candidates should have also received therapy designed to lower testosterone. The drug works by binding to minerals within bones to deliver radiation directly to bone tumors. A study of 809 men showed that those taking Xofigo lived an average of 3 months longer than those taking a placebo.
Two other similar drugs are strontium-89 and samarium-153 .
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Another type of prostate issue is chronic prostatitis, or chronic pelvic pain syndrome. This condition causes pain in the lower back and groin area, and may cause urinary retention. Symptoms include leaking and discomfort. In severe cases, a catheter may be required to relieve the symptoms. If the problem is unresponsive to other treatments, your doctor may suggest a surgical procedure. If these do not work, your symptoms could progress and become chronic.
An acute bacterial infection can cause a burning sensation. Inflammation of the prostate can affect the bladder and result in discomfort and other symptoms. This is the most common urinary tract problem in men under 50, and the third most common in men over 65. The symptoms of acute bacterial prostatitis are similar to those of CPPS. Patients may experience a fever or chills as a result of the infection.
The Role Of Adjuvant Chemotherapy
The role of adjuvant chemotherapy after radiation therapy in PCa was recently evaluated in a large Phase III trial, the RTOG 0521 that randomized a total of 563 high-risk PCa patients to either ADT and radiotherapy or ADT and radiotherapy followed by sequential docetaxel and prednisone.86 Androgen suppression was given for 24 months external-beam radiation therapy was given for 8 weeks and docetaxel was given at 75 mg m2 on day 1 for 6 cycles, starting 4 weeks after the completion of radiotherapy along with prednisone 10 mg. The enrolled patients had Gleason scores between 8 and 10, PSA 20 ng ml1 , or T2 stage. At a median follow-up of 5.5 years, 4-year OS was 89% in ADT/radiation arm and 93% with the addition of docetaxel, for an absolute benefit of 4% resulting in a 30% reduction in risk of death favoring adjuvant docetaxel. In addition, there was an absolute 10% reduction in the rate of disease-free survival at 6 years and the risk of biochemical failure was reduced by 20% in the docetaxel-containing arm. As expected, there was more Grade 3 or 4 hematologic toxicity in the chemotherapy arm. This was one of the promising trials that evaluated adjuvant chemotherapy after radiation which was included in a provisionary statement in the National Comprehensive Cancer Network Guidelines for PCa treatment in men with high-risk disease as a consideration for selected patients who are fit to receive chemotherapy.87
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Prostate Cancer Surgery Should Be Individualized To Each Patient
Not every prostate cancer can be treated with a single-port approach or retzius-sparing surgery, but there are other choices. We have a large and expanding repertoire of treatment options that allow us to personalize treatment to each patients needs, says Dr. Sprenkle.
The potential options include several different surgical approaches and robots, as well as the alternative of radiation therapy, which uses high-energy rays or particles to kill cancer cells, delivered in precisely targeted external beam treatments or an implanted radioactive seed. For small tumors, another approach is focal therapy, a term for noninvasive techniques for eliminating the tumors while leaving the prostate gland itself intact.
“Patients come to my office concerned about the potential side effects of surgerythey are afraid they will become incontinent or have erectile dysfunction, says Isaac Kim, MD, PhD, MBA, professor and chair of the Department of Urology at Yale School of Medicine.
The best candidates for single-port surgery are men whose cancer is classified as favorable intermediate risk, Dr. Sprenkle says. He wouldnt recommend it for men with unfavorable intermediate or high-risk cancer, because the approach doesnt provide easy access for pelvic lymph node dissection to assess whether the cancer has spread.
Some simply favor other approaches, Dr. Sprenkle says.
Survival Rates In Prostate Cancer: The Facts
For you as a patient, the disease-specific survival rate is the decisive aspect: what are the chances of surviving prostate cancer? 98 % of our patients who underwent radical prostatectomy, and in whom the tumor was confined to the prostate gland , were still alive 10 years after their operation. Even in patients with an advanced stage tumor , the survival rates are between 72 and 95 %.
Disease-speciic survival rates of our patients after 10 years in percent
The table on the page Results shows the disease-specific survival rate of our patients following surgery, according to the stage of the tumor.
- If the tumor was confined to the protstate or had only spread to the periphery of the prostate, the 10-year survival rate was more than 98%.
- If cancer cells had already spread to the seminal vesicle or to the area surrounding the prostate, the rate was between 87% and 77% respectively.
- If the lymph nodes were affected , 81% of our patients survived.
- If the preoperative PSA value was > 20 ng/mL , the disease-specific survival rate was 93%.
- If the preoperative Gleason Score was 8 or higher, 70% of the patients survived.
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Getting Chemotherapy Through An Iv
If you are getting chemotherapy medicines that are given through an I.V. , you will go to a clinic on the day you are scheduled to have your chemotherapy. If your blood test shows that you can get your chemotherapy, a chemotherapy nurse will start you on an I.V. A thin needle is carefully placed into one of the veins in your arm or in the back of your hand. The needle will be taken out of your arm when your chemotherapy treatment is finished. This needle will be connected to two bags of liquid by a small tube. One bag contains your chemotherapy medicine. The second bag contains a fluid that will be used: 1) to wash all the chemotherapy medicine out of the tubing and into your body and 2) to make sure that you have fluid going into your vein until the nurse removes the needle. This extra fluid will help you feel better during your treatment. The chemotherapy nurse will give the medicine to you slowly through the I.V. Everything will probably go well during your treatment. If you have a problem during your treatment, there will be a nurse nearby who will check on you while you get your chemotherapy. Do not be afraid to tell the nurse if you do not feel good or if your arm starts to hurt at the place where the needle goes into your vein.
Ultimate Outcomes Are Similar Regardless Of The Surgical Approach
In general, while each approach has its advantages, all have been shown to have similar outcomes, adds Dr. Sprenkle. There are no significant differences in outcomes for patients between the open surgery and robotic ones. There is less blood loss on average with robotic surgery, and in the hands of a good surgeon, continence and sexual preservation is the same, he says, adding that while it varies from patient to patient, average recovery time is six weeks. And cancer control is the same. Put another way: Its better to focus on finding the right surgeon rather than the approach or type of surgery.
As far as what that means for patients deciding on which surgery they should get, Dr. Sprenkle says that its important to take time to think about all of your options.
And ask a lot of questions, he says.
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