BODY-MIND-SPIRIT
Tuning up the Fight Against Prostate Cancer Prostate cancer is the second leading cause of cancer for men in the United States.
for prostate biopsy. However, prostate biopsy is recommended regardless of the results, since TRUS misses a sub- stantial number of tumors.
Symptoms Most men with early stage prostate
cancer have no symptoms attributable to the cancer. Urinary frequency, urgency, noc-
turia and hesitancy are seen commonly but are usually related to a concomi- tant benign prostate enlargement.
Diagnosis Men with abnormal prostate
by Gabriel Carabulea, M.D.
prostate specific antigen (PSA). However, dig- ital rectal examination (DRE) retains an im- portant role for early detection as 20% of cases have a prostate nodule that prompts the biopsy. Asymmetric areas of induration or frank
A
nodules are suggestive of prostate cancer. A prostate biopsy is indicated in men with a dig- ital rectal examination that is suspicious for cancer, regardless of the serum PSA. In con- trast, symmetric enlargement and firmness of the prostate are more frequent in men with be- nign prostatic hyperplasia (BPH).
PSA screening PSA is a protein made solely by prostate
cells so the antigen is highly specific for the prostate. However, it is not prostate cancer spe- cific and other prostate conditions such as be- nign prostatic hyperplasia (BPH) or prostatitis can affect PSA levels. The lack of specificity for prostate cancer has led to considerable contro- versy about the role of routine PSA testing. Although more cancers are found through
PSA screening, many men undergo a biopsy which may prove to be negative or are sub- jected to treatment and its side effects for a can- cer that may not be life threatening. This has led the 2012 U.S Preventive Services Task Force recommendation to omit PSA screening from routine primary care. Targeting screening to the most optimal population (those with at least 10 years of life expectancy) and personalized screening strategies that are tailored to a man’s individual risk and preferences may be a more appropriate guide to prostate cancer screening. Transrectal ultrasonography (TRUS) is
often used to evaluate abnormalities detected by digital rectal examination and to guide sites
56 SANCLEMENTEJOURNAL
lmost 80% of men currently diag- nosed with prostate cancer undergo a biopsy due to a suspicious serum
exams (nodules, induration, or asym- metry) should be referred to an urolo- gist for a prostate biopsy, with a histologic diagnosis based upon tissue obtained from the biopsy. A prostate biopsy may also be indicated based upon abnormal PSA values. If a biopsy is to be performed based upon the finding of an elevated serum PSA, con-
firmation of the elevated serum PSA is advis- able prior to proceeding to prostate biopsy. If cancer is found in the prostate biopsy,
the amount of cancer and aggressiveness of the tumor will be determined. The Gleason grade depends on how the tumor looks under the mi- croscope. The higher the Gleason grade, the more likely the tumor is to behave aggressively (grow faster). Over the last 20 years, more men are being
diagnosed with prostate cancer at an early stage, when the cancer is highly curable.
Prostate cancer stage Once prostate cancer is diagnosed, the next
step is to determine its stage. Staging is a system used to describe the size, aggressiveness and spread of a cancer. A cancer’s stage helps to guide treatment and can help predict the chance of curing the cancer. In addition, the PSA (prostate-specific antigen) level and the Gleason grade are used to gauge how aggressive the tumor is, and what treatment options are available.
Treatment Localized prostate cancer- stage I and II -
is cancer that has not spread to the lymph nodes or distant organs. There are three stan- dard ways to treat localized prostate cancer: sur- gery, radiation therapy, and active surveillance also called “watch and wait.” The best treat- ment depends upon age and health, prefer- ences, and the stage of the cancer.
Surgery Radical prostatectomy (also called prosta-
tectomy) is a surgery done to remove the prostate gland and then reconnect the urethra. The most common complications of prostate- ctomy are urinary incontinence, and erectile dysfunction (ED).
Radiation Therapy (RT) Two forms of RT are used to treat prostate
cancer: external beam RT and brachytherapy. These are sometimes used together. External beam RT (EBRT) uses a machine that moves around you, directing X-rays at the pelvis. EBRT is typically done daily five days per week, for five to eight weeks. In brachytherapy, a doctor places a radioactive source directly into the prostate gland.
Active Surveillance Some men choose to delay prostate cancer
treatment, opting for a strategy called active surveillance. During active surveillance one or more additional prostate biopsies may be re- quired and monitored carefully for signs of can- cer growth, with an exam and blood tests every three to six months. Using this approach, may avoid or postpone treatment for long periods of time. Active surveillance may be a reasonable option if the cancer is very small and unlikely to grow quickly.
Androgen Deprivation
Therapy (ADT) Male hormones (androgens, the most
common of which is testosterone) fuel the growth of prostate cancer. Treatments that de- crease the body's levels of androgens (called an- drogen deprivation therapy, or ADT) decrease the size and slow the growth of prostate cancer. ADT is not needed for men with small tu-
mors that are unlikely to grow quickly. ADT might be recommended, in addition to EBRT, for men with intermediate and high-risk prostate cancer. Examples of the medicines used in ADT include: GnRH agonists (Lupron, Zoladex), and antiandrogens.
Treatment of rising PSA After treatment for localized prostate can-
cer, experts advise follow-up testing to monitor for signs that the cancer has returned. This fol- low-up testing usually includes a blood test called PSA (prostate-specific antigen). The PSA test is very sensitive, meaning that the PSA may begin to rise well before the return of the cancer can be seen or felt. Many men with a rising PSA will not have any sign that the cancer has come back for many years (even 15 or more). Thus, not all men with a rising PSA need im- mediate treatment.
Which treatment is
right for me? Advanced prostate cancer is usually man-
aged with a combination of treatments, which may include hormone therapy, chemotherapy, immunotherapy, or radiation. For men with early-stage (localized) prostate cancer, the deci- sion between radiation therapy (RT) and sur- gery is largely a matter of preference. Always talk to your doctor to discuss and understand your options.
Secondary Hormone
Therapy Most men with advanced prostate cancer
initially respond well to ADT, but then the prostate cancer comes back. At this point, the cancer is termed “castrate resistant,” meaning that ADT alone is no longer effective. Once this occurs, secondary hormone therapy is usu- ally considered.
Immunotherapy A newer approach to treating advanced
prostate cancer involves harnessing or strength- ening the body’s own immune response to at- tack the cancer. One form of immunotherapy involves the use of cancer vaccines. Another form involving the use of so-called monoclonal antibodies is under investigation.
Chemotherapy Chemotherapy is commonly given to men
with advanced prostate cancer who have stopped responding to all forms of hormone therapy. Recent clinical trials have shown that when chemotherapy is given earlier it may im- prove how long a man will live.
New Directions New genetic tests are being developed to
support treatment decisions in prostate cancer. A genomic classifier is now available that can indicate a low or high risk for metastasis in men with prostate cancer who have rising prostate- specific antigen (PSA) after a prostatectomy. This test can prevent overtreatment and under- treatment of men with prostate cancer. Men with a low genomic classifier score can safely delay radiation therapy, and may not need fur- ther salvage therapy. Immunotherapy and targeted therapies are
opening new possibilities in the treatment of prostate cancer. The researchers have found that nearly all the tumors have at least one ge- netic aberration known to drive cancers. The most common are abnormalities in genes re- sponsible for the androgen receptor. Also, prostate cancer cells express a number
of tumor-associated antigens that can serve as targets for immunotherapy. Sipuleucel-T (Provenge) is an autologous dendritic cell ther- apeutic vaccine designed to enhance the im- mune T cell response. In randomized trials, sipuleucel-T prolonged survival compared to placebo dendritic cells and had a favorable safety profile. The next generation chemotherapy for
prostate cancer has unique properties that could make it more effective earlier in treat- ment if confirmed in clinical trials. A newer member of the taxane family called cabazitaxel, an FDA approved drug, has properties that could make it more effective for some patients - a hypothesis currently being tested in clinical trials.
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