About Prostate Cancer

Prostate cancer affects approximately 175,000 men a year in the United States with about 30,000 men dying each year from advanced prostate cancer.

Unlike other disease processes, there are many different treatment options offered by various disciplines in medicine and surgery. A urologist is generally the first doctor a patient with prostate cancer encounters. Every person’s prostate cancer is unique. We will help you determine the best treatment option by balancing the aggressiveness of the cancer with your personal health goals.

• I have been diagnosed with prostate cancer. How do I know that the cancer has not spread to other sites?

  If a biopsy of the prostate shows that the disease is aggressive (“high grade”), if the PSA is very high, or if the urologist feels a large mass in the prostate, we may order radiology tests to determine if the disease has spread beyond the prostate. These tests may include a nuclear test called a bone scan to look for spread to the bones, a CT or CAT scan to look for spread within the abdomen, or an MRI.

• How is prostate cancer treated?

  First, we determine if the cancer is localized to the prostate or has spread beyond the prostate. The treatments are very different for these two categories of disease.

• How is localized prostate cancer treated?

  There are many treatment options for prostate cancer that has not spread beyond the prostate. In this case, we are trying to cure the disease by eradicating the cancer before it can spread. These treatment options include:

  • Robotic Prostatectomy: This minimally invasive procedure is the most common surgical option for prostate cancer. It is performed through several one-centimeter or smaller incisions. A one-day hospital stay is typical. Compared to open surgery, there is less blood loss, less pain, faster recovery, and return to normal activity in ten to fourteen days. A Foley catheter is removed in five to seven days. Potency and continence are at least equal to open surgery.

   

  • Open Prostatectomy: This is an operation performed though an incision between the belly button and pelvic bone. Before the development of robotic surgery, this was the most common technique for removing the prostate, and some surgeons continue to prefer an open approach to prostate removal. A two-to-three-day hospital stay is typical. A Foley catheter is removed in seven to fourteen days. You may return to normal activity in five to six weeks.

   

  • Radiation: This involved the delivery of radioactivity to the prostate. There are many ways this can be administered, including brachytherapy (“seeds”), external beam therapy, proton beam therapy, stereotactic radiotherapy, and more. Your radiation oncologist will determine the form, dose, and number of treatments. The most common types involve treatment for four to eight weeks.

   

  • Active Surveillance: Many more men will be diagnosed with cancer of the prostate than will succumb to the disease or develop symptoms from the disease. In addition, some men who undergo treatment for their prostate cancer will develop side effects. For these reasons, it is now quite common to observe the cancer for a period of time, potentially indefinitely. The goal with active surveillance is to avoid treatment and side effects if the disease is slow growing and to institute active treatment if it becomes more significant. Because finger exams and PSA levels are not 100% reliable for determining when prostate cancer is becoming more aggressive, active surveillance requires the use of periodic repeat biopsies of the prostate.

   

  • Watchful Waiting: While watchful waiting and active surveillance sound similar, they are not. With active surveillance, the intent is to cure the cancer if it shows itself to be a cancer that requires cure. With watchful waiting, the patient and the urologist tend to think that the disease will never become a problem in that patient’s lifetime, and if it does, it may be wiser to avoid attempts at cure and the resulting side effects. This would typically be used in order patients or those with other significant medical problems.

   

  • Cryoablation: This procedure involves freezing and thawing of the prostate gland, destroying cancerous cells. Under an anesthetic, the doctor inserts approximately six to ten cryoprobes through the perineum (the area just behind the scrotum) into the prostate. Thermal sensors track the temperature around the prostate to avoid damaging adjacent structures. Liquid argon gas is circulated, and the prostate gland is frozen. Once the target temperature is reached, helium gas replaces the argon gas to thaw the tissue. The freeze/thaw cycle is then repeated.

   

  • High Intensity Focused Ultrasound: This procedure involves delivering focused energy, in the form of ultrasound waves, to the prostate through the rectum. It is a one-time treatment, and patients typically are discharged the same day.

   

  • Partial gland ablation: This is an experimental treatment option to destroy the portion of the prostate that contains cancer while sparing the remainder of the prostate gland. The destruction may be performed with cryoablation, HIFU or lasers.
• How is prostate cancer treated when it has spread beyond the prostate?

  In most cases, prostate cancer that has metastasized (spread) to other sites, while not curable, is treatable. These treatments are designed to control the disease for a period of time and lower the risk for the development of symptoms from the disease. The most common kind of treatment for prostate cancer that has metastasized is “hormone therapy.” This type of therapy is delivered by injection, usually every six months, and it lowers the testosterone level. Because prostate cancer growth is fueled by testosterone, lowering the testosterone level slows the growth of prostate cancer. The most common medication for hormone therapy is leuprolide acetate, also known as Eligard and Lupron.

• How is advanced prostate cancer treated?

  What does advanced prostate cancer mean? While there may be some differences in opinion about what defines advanced prostate cancer, this term is typically used for cancer that has spread and is no longer being optimally controlled by hormone therapy. Over the past 10 years, we have seen many new treatment options for men with this stage of prostate cancer, and these treatments have extended life by years and improved quality of life. They include:

  • A newer generation of hormone agents: These medications target the testosterone receptor and can effectively treat prostate cancer that is no longer adequately controlled by leuprolide acetate. These are oral medications and are usually well tolerated. They include abiraterone (Zytiga), enzalutamide (Xtandi), apalutamide (Erleada), and darolutamide (Nubeqa).

   

  • Immunotherapy: Patients with disease that has spread to other sites may be candidates for sipuleucel-T (Provenge). This is a vaccine-based therapy in which blood is extracted, a vaccine is developed from the patient’s blood (by exposing the patient’s white blood cells to a protein that trains them to fight cancer cells), and the vaccine is delivered back to the patient. Typically, three treatments are performed. This has been shown to extend life for men with advanced prostate cancer, and it is usually very well tolerated.

   

  • Radiation: Radiation can be delivered to metastatic sites. This might involve radiating painful metastases to preserve function. For instance, if the cancer spreads to the vertebrae that surround the spinal cord and begins to compress the spinal cord, it can cause paralysis. Radiation of the metastasis can prevent or forestall the development of paralysis. A newer form of radiation, radium-223 (Xofigo), is delivered intravenously. It is absorbed by bone metastases and delivers radiation directly to the metastasis. It has been shown to extend life and delay the development of bone fractures.

   

  • Chemotherapy: Docetaxel (Taxotere) and cabazitaxel (Jevtana) are chemotherapeutic agents that can extend life in men with advanced prostate cancer.

   

  • Targeted agents in specific populations: Recently, with increasing knowledge about the genetics of prostate cancer, new targeted treatments have been found to be effective in men with certain types of mutations in their prostate cancer cells. For example, 80% of men with BRCA-mutation associated prostate cancer will show significant response to olaparib (Lynparza), a new targeted anti-cancer agent. Determining which medications are likely to be effective for a person’s cancer before treatment is likely to become more common in prostate cancer over the next decade.

   

  • Bone Preservation: Men who take medications to suppress their testosterone levels are at increased risk for the development of weak bones or osteoporosis, which increases the risk for bone fractures. For this reason, it is important to try to prevent the development of osteoporosis and treat it if it does develop. There are new medications available that preserve bone density and can delay the onset of pain or fractures from bone metastases.
• How is advanced prostate cancer managed at Minnesota Urology?

  Because there are so many new treatments available for men with advanced prostate cancer, we believe that optimal care is provided by a specialist. At Minnesota Urology we have urologists who specialize in the care of men with advanced prostate cancer. They will help guide you through the treatments available and adjust your treatment as needed based on personal desires or side effects.