Prostate cancer is a malignant (cancerous) tumor that begins in the prostate gland of men. The prostate is a walnut-sized gland located behind the base of the penis, in front of the rectum, and below the bladder. It surrounds the urethra, the tube-like channel that carries urine and semen through the penis. The prostate's main function is to produce seminal fluid, the liquid in semen that protects, supports, and helps transport sperm.
Cancer develops when changes occur in DNA, the genetic material containing instructions for growth and development for all types of cells. When DNA is altered, normal cells may multiple without control or order, and a tumor can form.
Some prostate cancers grow very slowly and may not cause problems for years. Many men with slow-growing prostate cancer live with their disease. In this situation, the cause of death is usually not from prostate cancer, but other causes. However, if cancer does metastasize (spread) quickly to other parts of the body, treatment can help eliminate the cancer and control pain, fatigue, and other symptoms and prolong life. Prostate cancer is somewhat unusual from other types of cancer, in that advanced, metastatic prostate cancer can often be successfully treated, with the person surviving in excellent health for many years.
More than 95% of prostate cancers are adenocarcinomas, cancer that develops in glandular tissue. A rare type of prostate cancer known as neuroendocrine cancer or small cell anaplastic cancer tends to spread earlier, but usually does not produce prostate-specific antigen (PSA), a tumor marker discussed below. For more information, read the Cancer.Net Guide to Neuroendocrine Tumor.
Statistics
Prostate cancer is the most common cancer among men. In 2008, an estimated 186,320 men in the United States will be diagnosed with prostate cancer. It is estimated that 28,660 deaths from this disease will occur this year.
Prostate cancer is the second leading cause of cancer death in men. Although the number of deaths from prostate cancer is declining among all men, the death rate remains more than twice as high in black men than in white men.
More than 90% of all prostate cancer cases are discovered when the disease is apparently limited to the prostate and surrounding organs. In these cases, nearly 100% of patients are expected to live at least five years after diagnosis. The five-year relative survival rate (the percentage of patients who survive after the cancer is detected, excluding those who die from other diseases) of patients with prostate cancer is 98%. The 10-year and 15-year relative survival rates are 91% and 76%, respectively.
Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he will live with prostate cancer. Because the survival statistics are measured in five-year (or sometimes one-year) intervals, they may not represent advances made in the treatment or diagnosis of this cancer.
Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2008.
A risk factor is anything that increases a person's chance of developing a disease, including cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices.
Since the exact cause of prostate cancer is still unknown, it is also unknown how to prevent prostate cancer. The following factors can raise a person's risk of developing prostate cancer:
Age. The risk of prostate cancer increases with age, rising rapidly after age 50. More than 80% of prostate cancers are diagnosed in men who are 65 or older.
Race/ethnicity. Black men are at higher risk for prostate cancer than white men. They are more likely to develop prostate cancer at an earlier age and to have aggressive, fast-growing tumors. The precise reasons for these differences are not known, and probably involve both biologic and socioeconomic factors. Prostate cancer occurs most often in North America and northern Europe and is less common in Asia, Africa, and Latin America. Of importance, it appears that its frequency is increasing in Asian populations living in urbanized environments, such as Hong Kong, Singapore, and North American/European cities.
Family history. A man who has a father or brother with prostate cancer has a higher risk of developing the disease than a man who does not. Researchers have discovered specific genes that may possibly be associated with prostate cancer, although these have not yet been shown to cause prostate cancer or to be specific to this disease. Learn more about The Genetics of Prostate Cancer.
Diet. No study has shown conclusively that diet can directly influence the development of prostate cancer, but many studies have indicated there may be a link. There is not enough information yet to make clear recommendations about the role diet plays in prostate cancer, but the following may be helpful:
A diet high in fat, especially animal fat, may increase prostate cancer risk. In fact, many doctors believe that a low-fat diet may help to reduce the risk of prostate cancer.
A diet high in vegetables, fruits, and legumes (beans and peas) may decrease risk of prostate cancer. It is unclear which nutrients are directly responsible. Lycopene, found in tomatoes and other vegetables, may slow or prevent cancer growth. A low-fat diet that is high in vegetables and fruits can lower blood pressure and the risk of heart disease, with no evidence that such a diet causes harm.
Selenium, an element that people get in very small amounts from food and water, may play a role in lowering the risk of prostate and other cancers. Selenium is currently being tested in clinical trials and has not yet been proven to affect prostate cancer risk.
It has been suggested that vitamin E may help to reduce the risk of prostate cancer; this is currently being tested in clinical trials and has not yet been proven to alter risk. In some studies of vitamin E in other settings, it has been suggested that there may be inherent cardiovascular risks (for example, an increased chance of having heart-related or blood vessel problems) with the use of high doses of vitamin E, and final judgment on the use of this supplement will require the completion of ongoing clinical trials.
Hormones. High levels of testosterone (a male sex hormone) may speed up or cause the development of prostate cancer. Prostate cancer does not develop in men who, for other reasons, were castrated (the removal of the testicles) before puberty and whose bodies no longer make testosterone. Stopping the body's production of testosterone, called androgen deprivation therapy, or castration, often treats advanced prostate cancer.
Often, prostate cancer is discovered through a PSA test or digital rectal examination (DRE) in otherwise healthy men who have not had any symptoms. (Both tests are described in Diagnosis.) When prostate cancer does cause symptoms, the following symptoms may occur. Sometimes, men with prostate cancer do not show any of these symptoms. Or, these symptoms may be caused a medical condition that is not cancer. If you are concerned about a symptom on this list, please talk with your doctor.
Frequent urination
Pain or burning during urination
Weak or interrupted urine flow
Blood in the urine
The urge to urinate frequently at night
None of these symptoms is specific to prostate cancer. The same symptoms occur in men who have a noncancerous condition known as benign prostatic hyperplasia (BPH), or enlarged prostate. Urinary symptoms also can indicate an infection or other conditions.
If cancer has spread beyond the prostate gland, a man may experience:
Pain in the back, hips, thighs, shoulders, or other bones
Doctors use many tests to diagnose cancer and determine if it has metastasized. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis; this occurs very infrequently with prostate cancer. For example, this occurs when a patient has another medical problem that makes it difficult to carry out a biopsy, or when a person has a very high PSA level and a bone scan that indicates cancer. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
Age and medical condition
The type of cancer
Severity of symptoms
Previous test results
The earlier prostate cancer is detected, the more likely it can be cured. Two tests are now commonly used to detect prostate cancer in men: the PSA test and the DRE.
A note about the prostate cancer screening controversy
There is some controversy about using the PSA test as a screening test for large numbers of men with no symptoms of prostate cancer. The PSA test is useful for detecting early prostate cancer, but it has not yet proven to lower death rates from prostate cancer. It also detects conditions that are not cancer and misses some prostate cancers.
Unlike other types of cancer, prostate cancer grows slowly in many men-so slowly that in some men it would not threaten the life even if not treated. Because of this, detecting prostate cancer may mean that some men have surgery and other treatments that may not ever be needed. For this reason, many men and their doctors may consider active surveillance (also called watchful waiting) of their cancer rather than immediate treatment. This option may be best suited for a man with a very small, slow-growing cancer and men who are older or have other life-threatening or life-limiting medical illnesses. Because prostate cancer treatments have significant side effects, treating it unnecessarily may seriously affect a man's quality of life. However, it is important to note that it is not easy to predict which tumors will behave aggressively and which will grow slowly. This has led some doctors to believe that it is safer to use screening tests to detect aggressive cases early even if it means that some patients will receive unnecessary treatment for slow-growing cases of prostate cancer. This is particularly the case as many of the initial screening tests, such as DRE or measurement of PSA, are not dangerous. A major study on the use of prostate screening is under way in Europe, and the results may cast important light on this complex debate.
Until there is more complete research to evaluate this issue, ASCO does not yet have an official statement about prostate cancer screening or recommendations for men regarding when they should begin testing for prostate cancer. Every patient should discuss his individual situation with his doctor and work together to make a decision.
Diagnosing prostate cancer
In addition to a physical examination, the following tests may be used to diagnose prostate cancer:
PSA test. PSA is a tumor marker (a type of protein released by prostate tissue) found in higher levels in a man's blood when there is abnormal activity in the prostate, including prostate cancer, BPH, or prostatitis (inflammation of the prostate). A PSA test detects higher than normal levels of PSA that can indicate the presence of prostate cancer. As noted above, the PSA test is very sensitive, meaning that most people with prostate cancer will have an elevated level, but the test is not specific in that elevated PSA levels can be from noncancer causes. Doctors can look at features of the PSA value, such as absolute level, change over time, and level in relation to prostate size, to determine if a biopsy is needed. In addition, a version of the PSA test allows the doctor to measure a specific component, called the "free" PSA, which can sometimes help find out if a tumor is benign (noncancerous) or malignant.
DRE. A doctor inserts a gloved, lubricated finger into a man's rectum and feels the surface of the prostate for any irregularities. This test is not very precise; therefore, most men with early prostate cancer have a normal DRE test.
If the PSA or DRE test results are abnormal, the following tests can confirm a diagnosis of cancer:
Transrectal ultrasound (TRUS). A doctor inserts a probe into the rectum that takes a picture of the prostate using sound waves that bounce off the prostate.
Biopsy. The only way to be sure of a cancer diagnosis is with a biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. To get a tissue sample, most often a surgeon uses TRUS and a biopsy tool to take very small slivers of prostate tissue. The sample removed with the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). This procedure is usually performed as an outpatient procedure, under local anesthesia, to numb the area.
To determine if cancer has spread beyond the prostate, doctors may perform the following imaging tests:
Bone scan. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient's vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark.
Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors.
Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body.
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.
One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments. After gathering information with the TNM method, the results can be grouped together into a simpler set of stages (called stage grouping). Also, many doctors still use an older method of staging prostate cancer, called the Jewett-Whitmore staging system (stages A, B, C, and D).
Staging for prostate cancer involves reviewing test results to determine if the cancer has spread from the prostate to other parts of the body. The cancer is also given a grade, which is based on its microscopic appearance, according to how much the cancer resembles normal tissue. There are two types of staging for prostate cancer. First, the clinical stage is based on the results of tests done before surgery, such as a biopsy, x-rays, CT scans, and bone scans. (X-rays, bone scans, and CT scans may not be necessary; they are recommended based on the level of serum PSA, the grade and volume of the cancer, and the clinical stage of the cancer.) Then, the pathologic stage is based on information found during surgery, plus the laboratory results (pathology) of the prostate tissue removed during surgery (which often includes the removal of the entire prostate and some lymph nodes).
TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
How large is the primary tumor and where is it located? (Tumor, T)
Has the tumor spread to the lymph nodes? (Node, N)
Has the cancer metastasized to other parts of the body? (Metastasis, M)
Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the stage of the tumor itself. Some stages are also divided into even smaller subgroups that help describe a patient's condition in more detail. This helps the doctor develop the best treatment plan for each patient. Specific tumor stage information, based on the classification system that was implemented in 2002, is listed below.
TX: The primary tumor cannot be evaluated.
T0: There is no evidence of tumor in the prostate.
T1: The tumor cannot be felt during the DRE and is not seen during imaging (any test that produces pictures of the inside of the body, such as a CT scan). It may be found when surgery is done for another reason, usually for BPH, or abnormal growth of benign prostate cells.
T1a: The tumor was found in 5% or less of the prostate tissue resected (when part or all of an organ is removed through surgery).
T1b: The tumor was found in more than 5% of the prostate tissue removed in surgery.
T1c: The tumor was found when a needle biopsy was done, usually because the patient had an elevated PSA level.
T2: The tumor is found only within the prostate, not other areas of the body. It is large enough to be felt during the DRE.
T2a: The tumor has invaded one-half of one lobe (part or side) of the prostate.
T2b: The tumor has spread to more than one-half of one lobe of the prostate, but not to both lobes.
T2c: The tumor has invaded both lobes of the prostate.
T3: The tumor extends through the prostate capsule (into the tissue just outside the prostate on one side).
T3a: The tumor extends through the prostate capsule either unilaterally (on one side) or bilaterally (on both sides of the prostate).
T3b: The tumor has invaded the seminal vesicle(s), the tube(s) that carry semen.
T4: The tumor is fixed, or it is invading nearby structures besides the seminal vesicles, such as the neck of the bladder, the external sphincter (part of the body that helps to control urination), the rectum, levator muscles, and/or the pelvic wall.
Nodes. The "N" in the TNM staging abbreviation stands for node. Lymph nodes are tiny, bean-shaped organs located throughout the body that normally help fight infections and cancer as part of the body's immune system. There are lymph nodes near the prostate in the pelvic area (called regional lymph nodes), and there are distant lymph nodes (lymph nodes in other parts of the body).
NX: The regional lymph nodes (lymph nodes near the prostate) cannot be evaluated.
N0: There is no regional lymph node metastasis.
N1: The prostate cancer has invaded the regional lymph node(s).
Distant metastasis. The "M" in the TNM system describes how much the prostate cancer has spread to other parts of the body (to areas such as the lungs or the bones).
MX: Distant metastasis cannot be evaluated.
M0: The disease has not metastasized.
M1: There is distant metastasis.
M1a: The cancer has invaded nonregional, or distant, lymph node(s), meaning lymph nodes in other places of the body beyond the prostate and pelvic area.
M1b: The cancer has invaded bone(s) in the body.
M1c: The cancer has reached another part of the body.
Grade. A cancer may also be graded, which describes how much cancer cells look like normal cells under a microscope during the biopsy. The grade of a cancer can help the doctor predict how quickly the cancer will spread. A low-grade tumor usually looks more like normal tissue and is associated with a better prognosis; a high-grade tumor looks less normal and more aggressive, and is often associated with a worse prognosis.
The Gleason System is the most common prostate cancer grading system used. This method looks at how the cancer cells are arranged in the prostate and grades them based on a scale of 1 to 5. The doctor looks for a pattern of cell growth, and adds the score to come up with an overall score from 2 to 10. The lower the score, the lower the grade of cancer. A low-grade cancer
(score of 2 to 4) usually grows more slowly and is less likely to spread than a cancer with a higher-grade score.
The TNM system uses the letter "G" to define a grade for prostate cancer.
GX: The grade cannot be evaluated.
G1: The cells are well-differentiated (Gleason 2 to 4).
G2: The cells are moderately differentiated (Gleason 5 to 6).
G3: The cells are poorly differentiated or undifferentiated (Gleason 7 to 10).
Cancer stage grouping. Doctors assign the stage of the cancer by combining the T, N, and M classification and the grade. As mentioned above, some doctors prefer to use the Jewett-Whitmore staging system (stages A, B, C, and D).
Stage I or Stage A: Cancer is found in the prostate only, usually during another medical procedure. It cannot be felt during the DRE. A stage I cancer usually contain well-differentiated cells and is predicted to grow slowly. This can also be called stage A1 prostate cancer when it affects only one lobe of the prostate and stage A2 when both prostate lobes are involved (T1a, N0, M0, G1).
Stage II or Stage B: The doctor can feel the tumor during a DRE. There is no evidence that it has spread beyond the prostate gland, but the cells are usually more abnormal and may tend to grow more quickly. (It has not spread to lymph nodes or distant organs.) Stage II prostate cancer may also be called stage A2, stage B1, or stage B2 prostate cancer (T1, T2, T3; N0; M0; any G).
Stage III or Stage C: The cancer has spread beyond the outer layer of the prostate into nearby tissues. It may also have spread to the seminal vesicles, the glands in men that help produce semen (T3, N0, M0, any G).
Stage IV or Stage D: This describes any tumor of any grade (any G) that has spread to other areas of the body such as the bladder or rectum (T4, N0, M0); bone, liver, lungs (any T, N0, M1); or lymph nodes (any T, N1, M0). Stage IV prostate cancer may also be called stage D1 or D2 prostate cancer.
Recurrent: Recurrent prostate cancer is cancer that has recurred (come back) after it has been treated. It may come back in the prostate area again or in other parts of the body.
Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.
The treatment of prostate cancer depends on the size and location of the tumor, whether the cancer has spread, and the person's overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan.
It is important to discuss the goals and possible side effects of treatment with your doctor before treatment begins. For more information on potential side effects of treatment, please visit the Managing Side Effects section of Cancer.Net. The information in this section is adapted from ASCO's Optimizing Cancer Care: The Importance of Symptom Management, a curriculum that teaches doctors about understanding and treating the side effects of cancer and its treatments.
Active surveillance (watchful waiting), for early-stage cancer
If a prostate cancer is in an early stage, is slow-growing, and if treating the cancer would cause more discomfort than the disease itself, a doctor may recommend watchful waiting, also called active surveillance or watch-and-wait. The cancer is monitored closely, and treatment would begin only when the tumor shows signs of becoming more aggressive or spreading. This approach may be taken in much older patients or in those with other serious or life-threatening illnesses. However, real caution must be taken not to make errors of judgment about the disease. In other words, doctors must collect as much information as possible about the patient's other illnesses and potential life expectancy, so they don't miss the chance to detect an early, aggressive prostate cancer. New information is becoming available all the time, and it is important for men to discuss these issues carefully with a specialist in this field to obtain current information.
Surgery
Surgery is used to try to cure cancer before it has spread outside the prostate. The type of surgery depends on the stage of the disease, the patient's general health, and other factors.
Radical (open) prostatectomy. A radical prostatectomy involves surgical removal of the whole prostate and accompanying seminal vesicles and possibly lymph nodes in the pelvic area. This operation has the risk of interfering with sexual potency. Nerve-sparing surgery, when possible, increases the chances that a man will remain sexually potent after surgery by avoiding surgical damage to the nerves that allow erections and orgasm to occur. Orgasm can occur even if some nerves are cut; these are two separate processes. Urinary incontinence (inability to control urine flow) is also a possible complication of prostatectomy. To help resume normal sexual function, men can receive drugs, such as sildenafil citrate (Viagra) and several similar drugs, penile implants, or injections. Sometimes, additional surgery can fix the complication of urinary incontinence.
Robotic prostatectomy (robotic-assisted laparoscopic prostatectomy). Unlike an open radical prostatectomy, this type of surgery is potentially much less invasive, and therefore, often requires a shorter recovery time. A camera and instruments are inserted through small, keyhole incisions in the patient's abdomen. The surgeon then directs the robotic instruments to remove the prostate gland and surrounding tissue. In general, robotic prostatectomy has less bleeding and less pain, but sexual and urinary side effects can be similar to an open radical prostatectomy. This procedure has not been available for as long a time as open radical prostatectomy, and thus late follow-up information, including permanent cure rates, are not yet certain. Talk with your doctor about whether your treatment center offers this procedure.
Transurethral resection of the prostate (TURP). TURP is most often used to relieve symptoms of urinary obstruction, not to cure cancer. In this procedure, under a full anesthetic, a surgeon inserts a cystoscope (a narrow tube with a cutting device) into the urethra and into the prostate to remove prostate tissue. This is rarely used to treat prostate cancer in current clinical practice.
Cryosurgery. Most commonly used in experimental studies, cryosurgery (also called cryotherapy or cryoablation) involves freezing cancer cells with a metal probe inserted through a small incision in the area between the rectum and the scrotum, the skin sac that contains the testicles. Cryosurgery may be useful for early-stage cancer and for men who cannot have a radical prostatectomy. Some doctors view cryotherapy as experimental and have concerns about complications, which can include the development of fistulae (holes between the prostate and the bowel), although this complication appears to occur much less frequently with the development of newer cryosurgery techniques.
Radiation therapy
Radiation therapy uses high-energy rays to destroy cancer cells. Radiation therapy may be given externally, called external-beam radiation therapy, in which radiation is given from a machine outside the body, or internally, where a radioactive substance or seeds are placed inside the prostate, near the tumor. Radiation therapy can be useful at all stages of localized cancer. It is also used to relieve symptoms, such as pain in patients with advanced or metastatic cancer. Several treatments or "fractions" may be needed.
External-beam radiation therapy. External-beam radiation therapy focuses a beam of radiation on the area affected by cancer. Some cancer centers use conformal radiation therapy (CRT), where computers help precisely map the location and shape of the cancer. CRT reduces radiation exposure to healthy tissues and organs around the tumor by directing the radiation therapy beam from different directions with the intention of focusing the dose on the area of the tumor.
Intensity-modulated radiation therapy (IMRT). IMRT is a form of three-dimensional (3-D) CRT. Conformal radiation therapy uses CT scans to form a 3-D picture of the prostate before treatment. In IMRT, the radiation beams of various strengths are aimed at the tumor from many angles. The doses of radiation treatment are precise enough to avoid damaging healthy tissue around the prostate.
Brachytherapy. Brachytherapy involves insertion of radioactive sources directly into the prostate. These sources (called seeds) give off localized radiation and may be used for hours (high-dose rate) or for weeks (low-dose rate). Low-dose rate seeds are left in the prostate permanently, even after all the radioactive material has been used up.
Radiation therapy may cause the following side effects:
Diarrhea or other disruption of bowel function
Increased urinary urge or frequency
Fatigue
Impotence (inability to get an erection)
Rectal discomfort, burning, or pain
These side effects usually go away after treatment.
Hormone therapy
Since prostate cancer growth is driven by male sex hormones known as androgens, reducing levels of these hormones can help slow the growth of the cancer. Hormone treatment is also called androgen ablation or androgen deprivation therapy. The most common androgen is testosterone. The production of testosterone can be reduced either surgically, with surgical castration, or through the use of drugs that turn off the function of the testicles (see below).
Hormone therapy is used to treat prostate cancer that has continued to grow after surgery and radiation therapy or when it is widespread at the time of diagnosis. More recently, hormone therapy has also been used with radiation therapy in men with a cancer with a higher risk for recurrence (return of the cancer). In some men, hormone therapy will be used first to shrink a prostate cancer tumor before radiation therapy or surgery. In some men with prostate cancer that has spread locally (and identified during a radical prostatectomy), hormone therapy is given after the surgery for two to three years as adjuvant therapy (treatment that is given after the first treatment).
Traditionally, hormone therapy was used until it stopped controlling the cancer. Then the cancer was said to be hormone refractory (meaning that the hormone therapy has stopped working), and other options were considered. Recently, researchers have begun studying intermittent hormone therapy, which is hormone therapy that is given for specified periods and then discontinued temporarily according to a schedule. Giving hormones in this way appears to lower the symptoms of this therapy. In addition, intermittent hormone therapy may possibly maintain hormone responsiveness for a longer period of time than standard (continuous) hormone treatment; this concept is currently being tested in clinical trials.
Types of hormone therapy
Bilateral orchiectomy. Bilateral orchiectomy involves surgical removal of both testicles. Even though this is surgery, it is called a hormone treatment because it removes the main source of testosterone production, the testicles. This surgery is permanent and cannot be reversed.
LHRH agonists. LHRH stands for luteinizing hormone-releasing hormone. LHRH agonists reduce the body's production of testosterone by interfering with hormonal control mechanisms within the brain, which control the functioning of the testicles.
Anti-androgens. While LHRH agonists lower testosterone levels in the blood, anti-androgens block testosterone from binding to so-called "androgen receptors," chemical structures in the cancer cells that allow testosterone and other male hormones to enter the cells.
Female hormones. Estrogen can lower testosterone levels. When this drug is given as a pill, side effects can include heart problems and blood clots. More recently, estrogens have been administered as injections or as skin patches, and this type of treatment may be associated with a lower chance of heart and clotting side effects.
Combined androgen blockade. Sometimes, LHRH agonists are used in combination with peripheral-blocking drugs, such as anti-androgens, to more completely inhibit male hormones. Many doctors feel that this combined approach is the safest way to start hormone treatment, as this protects from a potential flare-up or increase in activity of the prostate cancer cells that sometimes occurs as a result of a temporary surge in testosterone production by the testicles (in response to the LHRH agonists). Major clinical trials have not shown a big difference in long-term survival results from the use of combined androgen blockade as permanent therapy; therefore, some doctors prefer to give combined drug treatment only for the first two to three months. The latter approach has not been validated in clinical trials, and may not be used in some cancer centers.
Hormone therapy may cause significant side effects. Side effects generally go away after hormone treatment is finished, except in men who have had an orchiectomy. Patients may experience:
Impotence (inability to get erections)
Loss of libido (sexual desire)
Hot flashes
Gynecomastia (enlarged breasts)
Osteoporosis (weakening bones)
Patients who have received LHRH agonists for more than two years will frequently have ongoing hormonal effects, even if the drugs are no longer given.
Chemotherapy
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.
Chemotherapy can be taken orally (by mouth) or intravenously, and it may help patients with advanced or hormone-refractory prostate cancer. There is no standard chemotherapy for use against prostate cancer, but a number of clinical trials are exploring chemotherapy for advanced prostate cancer. The most popular, current approach involves the use of a drug called docetaxel (Taxotere) given in conjunction with a steroid called prednisone. This combination has been shown to make men with advanced prostate cancer live longer than another chemotherapy, mitoxantrone (Novantrone), which is most useful for controlling prostate cancer symptoms.
In the United States, the Food and Drug Administration (FDA) has approved the drugs mitoxantrone and docetaxel for use in men with prostate cancer that is resistant to hormone therapy. Also, the drugs paclitaxel (Taxol) and estramustine (Estracyt) have shown some beneficial effects in treating advanced prostate cancer. Estramustine is being used less often in current clinical practice because of its profile of side effects, which includes an increased risk of blood clots. Many new medications for prostate cancer are in development and may be available within clinical trials.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications you've been prescribed, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases.
Advanced prostate cancer
A prostate cancer that develops the ability to grow without the presence of male sex hormones, and causes hormone treatments stop working is called androgen-independent cancer, or hormone-refractory prostate cancer. Although there is no cure for this type of cancer, it is treatable with radiation therapy or chemotherapy.
If all treatments have failed to control prostate cancer, or if cancer comes back after treatment, a patient may experience pain, fatigue, and weight loss. At this point, the goal of treatment switches from curing the cancer to slowing it down and relieving symptoms.
It is important to note that many men outlive their prostate cancer, even those with advanced disease. Often, the prostate cancer grows slowly, and there are now effective treatment options that extend life even further. A few drugs can help treat the symptoms of advanced cancer.
Cytotoxic chemotherapy (see above). Chemotherapy is most commonly used for patients with advanced, hormone-refractory prostate cancer. It can be effective in relieving symptoms, such as pain, weight loss, and fatigue, and may prolong life for some patients.
Strontium and samarium. Given by injection, these are radioactive agents that are absorbed near the area of bone pain. The radiation that is released helps relieve the pain, probably by causing local tumor shrinkage.
Pamidronate (Aredia) and zoledronic acid (Zometa). Given by injection, these drugs reduce the level of calcium in the blood and also cause a reduction of bone complications (such as pain, fracture, need for surgery) due to metastases. A high calcium level is called hypercalcemia and is sometimes present in advanced prostate cancer.
The National Comprehensive Cancer Network (NCCN) has a series of treatment guidelines that have been translated into patient-friendly language. In accordance with Cancer.Net's Linking Policy, please note that this link does not imply ASCO's endorsement of the content, but rather it is an effort to provide additional information that may be helpful to people living with cancer and their families. The NCCN treatment guide for prostate cancer can be found at www.nccn.org.
Doctors and scientists are always looking for better ways to treat patients with prostate cancer. A clinical trial is a way to test a new treatment in order to prove that it is safe, effective, and possibly better than a standard treatment. Patients who participate in clinical trials are among the first to receive new treatments, such as new chemotherapy, before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.
Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and new therapies is the only way to make progress in treating prostate cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future men with prostate cancer.
To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient's options, so the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.
Cancer and cancer treatment can cause a variety of side effects; some are easily controlled and others require specialized care. Below are some of the side effects that are more common to prostate cancer and its treatments. For more detailed information on managing these and other side effects of cancer and cancer treatment, visit the Cancer.Net Managing Side Effects section.
Diarrhea. Diarrhea is frequent, loose, or watery bowel movements. It is a common side effect of certain chemotherapeutic drugs or of radiation therapy to the pelvis, such as in women with uterine, cervical, or ovarian cancers. It can also be caused by certain tumors, such as pancreatic cancer.
Fatigue. Fatigue is extreme exhaustion or tiredness and is the most common problem patients with cancer experience. More than half of patients experience fatigue during chemotherapy or radiation therapy, and up to 70% of patients with advanced cancer experience fatigue. Patients who feel fatigue often say that even a small effort, such as walking across a room, can seem like too much. Fatigue can seriously affect family and other daily activities, can make patients avoid or skip cancer treatments, and may even affect the will to live.
Hormone deprivation symptoms in men. Many men who experience a halt in their hormone levels because of prostate cancer treatment (particularly those treatments that stop the production of testosterone, such as removal of the testicles or androgen ablation [hormone treatment]) experience symptoms, such as hot flashes, osteoporosis (loss of bone mass that makes bones break and fracture easily), decreased libido (desire for sex), erectile dysfunction (problems with erections), fatigue, and depression or irritability, that are caused by the body's lack of testosterone. These symptoms may occur in men without prostate cancer also, as part of the aging process. In men without prostate cancer, treatments to raise testosterone levels can help relieve these symptoms. Since testosterone helps prostate cancer grow, this is not an option for men with prostate cancer.
Sexual dysfunction. Sexual dysfunction is common in all people, affecting up to 43% of women and 31% of men. It may be even more common in patients with cancer, as a result of treatments, the tumor, or stress. Many people, with or without cancer, find it intimidating to discuss sexual problems with their doctors. Sexual problems are most commonly caused by body changes from cancer surgery, chemotherapy or radiation therapy, hormone changes, fatigue, pain, nausea and/or vomiting, medications that reduce libido (desire for sex), fear of recurrence, stress, depression, and anxiety. Symptoms of sexual dysfunction generally fall into four categories: desire disorders, arousal disorders, orgasmic disorders, and pain disorders.
After treatment for prostate cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.
Men recovering from prostate cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about Healthy Living After Cancer.
Research for prostate cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this current time. Always discuss all diagnostic and treatment options with your doctor.
PSA test improvements. Researchers are developing a better PSA test, either a more specific and precise test or another test altogether. With improved testing, larger numbers of healthy men could be screened for prostate cancer, so more prostate cancers can be found and treated early.
Therapy for advanced prostate cancer. Research is exploring different chemotherapy options for advanced prostate cancer through a series of clinical trials. In addition, several approaches designed to stimulate the patient's immune response against prostate cancer are being tested in clinical trials.
Surgery. As surgeons find new techniques for nerve-sparing surgery, more men who need radical prostatectomy may retain their urinary continence and sexual potency after surgery.
Nutrition. Research continues to explore the link between nutrition and lifestyle factors in the development of prostate cancer.
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
Prior to diagnosis/prevention and screening
What type of screening schedule do you recommend for me, based on my individual medical profile and family history?
Are there any changes I can make to my diet that can help me lower my risk of prostate cancer?
After a diagnosis of prostate cancer
What type of prostate cancer do I have?
What stage and grade is my prostate cancer, and what does this mean?
What are my treatment options?
What treatment do you recommend and why?
What clinical trials are open to me?
What are the possible side effects of each treatment option?
Will this treatment affect my fertility (ability to produce children)?
Could this treatment affect my sex life?
What type of recovery should I expect following treatment?
What are the long-term effects of treatment?
What follow-up care is necessary following treatment?
American Urological Association Foundation 1000 Corporate Blvd.
Linthicum, MD 21090
Phone: 410-689-3700
Toll Free: 866-746-4282 www.UrologyHealth.org
National Prostate Cancer Coalition 1154 15th St., NW
Washington, DC 20005
Phone: 202-463-9455
Toll Free: 888-245-9455 www.4npcc.org
Prostate Cancer Education Council 7009 S. Potomac St., Ste. 125
Centennial, CO 80121
Phone: 303-316-4685
Toll Free: 866-477-6788 www.pcaw.com
Prostate Cancer Foundation 1250 Fourth St.
Santa Monica, CA 90401
Phone: 310-570-4700
Toll Free: 800-757-CURE (2873) www.prostatecancerfoundation.org
The Prostate Net, Inc. P.O. Box 2192
Secaucus, NJ 07096-2192
Toll Free: 888-4-PROSNET (888-477-6763) www.prostate-online.com
Us TOO International, Inc. Prostate Cancer Education and Support
5003 Fairview Ave.
Downers Grove, IL 60515
Phone: 630-795-1002
Toll Free: 800-80-USTOO (800-808-7866) www.ustoo.org
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