Treatment Options For Recurrent Bladder Cancer
Treatment options for patients with recurrent bladder cancer include the following:
Palliative radiation therapy should be considered for patients with symptomatic tumors.
Recurrent or progressive disease in distant sites or after definitive local therapy has an extremely poor prognosis, and clinical trials should be considered whenever possible.
Tissue Ablation And Focal Therapy
Tissue ablation treatments destroy the prostate cancer through freezing or heating. These treatments can be applied to all or just part of the prostate . Whereas whole gland ablation has largely fallen out of favor, focal ablation has gained popularity. The two most commonly used energy sources are as follows:
Cryosurgery kills cancer cells in the prostate by freezing them through special needles that are inserted into the gland. The needles are placed under ultrasound guidance. This method is effective in curing cancer but can’t treat lymph nodes and commonly causes erectile dysfunction if the entire prostate is treated. Urinary incontinence is a rare but possible side effect.
High-intensity focused ultrasound uses the high temperatures created by focused sound wave energy to kill cancer cells. While HIFU results over the years have been mixed, modern systems such the one used at UCSF allow real-time monitoring of tissue temperatures during treatment, improving outcomes.
Less commonly used ablation methods include interstitial laser ablation, electroporation , vascular targeted photodynamic therapy, gold nanoparticle therapy, and others under development. Focal radiation is used occasionally as well. Currently, there is little data comparing these technologies.
How Does The Doctor Know I Have Prostate Cancer
Prostate cancer tends to grow slowly over many years. Most men with early prostate cancer dont have changes that they notice. Signs of prostate cancer most often show up later, as the cancer grows.
Some signs of prostate cancer are trouble peeing, blood in the pee , trouble getting an erection, and pain in the back, hips, ribs, or other bones.
If signs are pointing to prostate cancer, tests will be done. Most men will not need all of them, but here are some of the tests you may need:
PSA blood test: PSA is a protein thats made by the prostate gland and can be found in the blood. Prostate cancer can make PSA levels go up. Blood tests will be done to see what your PSA level is and how it changes over time.
Transrectal ultrasound : For this test, a small wand is put into your rectum. It gives off sound waves and picks up the echoes as they bounce off the prostate gland. The echoes are made into a picture on a computer screen.
MRI: This test uses radio waves and strong magnets to make detailed pictures of the body. MRI scans can be used to look at the prostate and can show if the cancer has spread outside the prostate to nearby organs.
Prostate biopsy: For a prostate biopsy, the doctor uses a long, hollow needle to take out small pieces of the prostate where the cancer might be. This is often done while using TRUS or MRI to look at the prostate. The prostate pieces are then checked for cancer cells. Ask the doctor what kind of biopsy you need and how its done.
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Prognosis And Life Expectancy
In general, papillary urothelial cancers have a better prognosis than other types of bladder cancer. Your specific outlook depends on the stage and grade of your cancer. High-grade cancers can spread. Low-grade papillary cancers are less likely to spread. Papillary cancers can also return after theyve been treated.
Differential Diagnosis Of Adenocarcinoma In Needle Biopsy Tissue
Numerous entities, both benign and malignant, should be considered in the differential diagnosis of prostatic adenocarcinoma. Indepth discussion of these entities is beyond the scope of this review.
Recent reviews have highlighted the benign lesions or pseudoneoplasms that may mimic prostatic adenocarcinoma., Atypical adenomatous hyperplasia and atrophy are the benign conditions that are most likely to be misdiagnosed as prostatic carcinoma.,, Crowded benign glands may also be mistaken for prostatic adenocarcinoma. The pathologist should always consider the possibility of a benign mimicker of prostatic carcinoma, particularly atrophy, but also all other entities , before making a diagnosis of adenocarcinoma of the prostate.
A descriptive diagnosis which may be rendered if the histological or immunohistochemical findings are thought to be worrisome but not fully diagnostic of carcinoma, is atypia,, also known as atypical suspicious for carcinoma or atypical small acinar proliferation. Such a diagnosis is given in about 45% of all prostate needle biopsy specimens.,
The main nonprostatic, secondary malignancy to think about before diagnosing prostatic carcinoma in needle biopsy of the prostate is urothelial carcinoma involving the prostate.,
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Figure 1 Location Of The Prostate Gland
The prostate gland, about the size of a walnut, produces fluid that forms part of the semen that is ejaculated during sexual activity. The prostate is located adjacent to the rectum and just below the bladder, and wraps around the upper part of the urethra, which carries urine from the bladder out of the body.
This location creates challenges in both diagnosis and treatment. During a digital rectal exam, for example, a doctor is able to feel only the back portion of the prostate. If cancer has developed in the apex, base, or deep inside the prostate, it may not be palpable.
Surgeons and radiation oncologists also face challenges in eradicating a tumor without causing lasting damage to surrounding organs and structures. When removing a tumor from the breast or colon, a surgeon is able to remove enough surrounding tissue to ensure clean margins, meaning that all the cancer has been removed. But when treating prostate cancer, a comparable amount of tissue cannot be removed surgically or targeted. It takes a skilled surgeon and radiation oncologist to eradicate diseased tissue without harming portions of the rectum, bladder, and penis, thereby minimizing the likelihood of complications.
Its also important to understand the limits of current medical knowledge about prostate cancer.
Is Active Surveillance Right For You
There are some risks associated with active surveillance. They include a low risk of infection with every biopsy and a very low risk of cancer progressing in any one interval of surveillance. Sometimes men choose active surveillance for a period of time and then decide to undergo treatment.
Thousands of UCSF patients have chosen active surveillance to initially manage their prostate cancer. This is one of the largest groups of patients on active surveillance in the world. About one-third of these men receive treatment by five years and 50% by 10 years. The window of opportunity to cure prostate cancer is usually measurable in years or even decades. In fact, treatment results for these men appear to be similar to what would have been expected had they chosen treatment right after their original diagnosis. Based on our experience and those reported from other centers, the risk of significant cancer progression in the short to intermediate term, while not zero, appears to be very low.
Some men with risk factors such as family history, genetic mutations and being African American may still be candidates for active surveillance but need a more careful or intense surveillance regimen to make sure any early signs of progression are identified.
The most common reason for seeking treatment is a biopsy that shows the cancer is growing or becoming more aggressive in appearance . Changes in PSA or cancer stage based on imaging results may also lead to treatment.
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How The Prostate Changes As You Age
Because the prostate gland tends to grow larger with age, it may squeeze the urethra and cause problems in passing urine. Sometimes men in their 30s and 40s may begin to have these urinary symptoms and need medical attention. For others, symptoms aren’t noticed until much later in life. An infection or a tumor can also make the prostate larger. Be sure to tell your doctor if you have any of the urinary symptoms listed below.
Tell your doctor if you have these urinary symptoms:
- Are passing urine more during the day
- Have an urgent need to pass urine
- Have less urine flow
- Feel burning when you pass urine
- Need to get up many times during the night to pass urine
Growing older raises your risk of prostate problems. The three most common prostate problems are inflammation , enlarged prostate , and prostate cancer.
One change does not lead to another. For example, having prostatitis or an enlarged prostate does not increase your risk of prostate cancer. It is also possible for you to have more than one condition at the same time.
Drugs To Treat Cancer Spread To Bone
If prostate cancer spreads to other parts of the body, it almost always goes to the bones first. These areas of cancer spread can cause pain and weak bones that might break. Medicines that can help strengthen the bones and lower the chance of fracture are bisphosphonates and denosumab. Sometimes, radiation, radiopharmaceuticals, or pain medicines are given for pain control.
Side effects of bone medicines
A serious side effect of bisphosphonates and denosumab is damage to the jaw, also called osteonecrosis of the jaw . Most people will need to get approval from their dentist before starting one of these drugs.
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How Tumor Grade Affects Your Treatment Options
Your doctor uses tumor grade and other factors about your cancer to form a treatment plan and in some cases, to estimate your prognosis. Prognosis is an estimate of how the disease will likely go for you. Other factors that go into deciding on a treatment plan include cancer stage, genetic features of the tumor, your age, and your general health. Since a high-grade cancer may grow and spread more quickly, it may require more aggressive treatment right away.
Prostate Cancer: A Guide For Aging Men
Prostate cancer is one of the most frequently diagnosed cancers in the world, despite it only being diagnosed in males . In fact, more than 70 percent of men over the age of 80 have some quantity of cancer cells in their prostate.
Its so common that it sometimes doesnt go diagnosed until autopsies are performed, though that doesnt mean the cancer is the cause of death. On the contrary, the overall prognosis for men diagnosed with prostate cancer is as positive as you can get when talking about the dreaded c word. The five-year survival rates for the disease are close to 100 percent, especially when talking about prostate cancer that is caught early on in the processbefore it spreads.
The five-year survival rates for the disease are close to 100 percent, especially when talking about prostate cancer that is caught early on in the processbefore it spreads.
Nevertheless, prostate cancer is serious business, and the best way to handle a diagnosis is to be informed. Lets take a look at the frequency at which its diagnosed, how youre tested for it, how it can affect your daily life, and what we can do to try and prevent the disease.
Average Age of Prostate Cancer Diagnosis
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Standard Treatment Options For Stage I Bladder Cancer
Patients with stage I bladder tumors are unlikely to die from bladder cancer, but the tendency for new tumor formation is high. In a series of patients with Ta or T1 tumors who were followed for a minimum of 20 years or until death, the risk of bladder recurrence after initial resection was 80%. Of greater concern than recurrence is the risk of progression to muscle-invasive, locally-advanced, or metastatic bladder cancer. While progression is rare for low-grade tumors, it is common among high-grade cancers.
One series of 125 patients with TaG3 cancers followed for 15 to 20 years reported that 39% progressed to more advanced stage disease, while 26% died of urothelial cancer. In comparison, among 23 patients with TaG1 tumors, none died and 5% progressed. Risk factors for recurrence and progression include the following:
- High-grade disease.
TUR with fulguration followed by an immediate postoperative instillation of intravesical chemotherapy
TUR and fulguration are the most common and conservative forms of management. Careful surveillance of subsequent bladder tumor progression is important. Because most bladder cancers recur after TUR, one immediate intravesical instillation of chemotherapy after TUR is widely used. Numerous randomized, controlled trials have evaluated this practice, and a meta-analysis of seven trials reported that a single intravesical treatment with chemotherapy reduced the odds of recurrence by 39% .
TUR with fulguration
Detecting Prostate Cancer With Psa Screenings
Now that we have PSA screening, it means that it is practically impossible for undiagnosed prostate cancer to cause discomfort, urinary problems, difficulty with erections, or any other symptom related to prostate cancer. This is not to say that men cant have prostate symptoms from noncancerous causes, such as prostatitis, benign glandular swelling, urinary tract infections, or sexually transmitted diseases. But PSA testing can ensure that any symptoms that may be present are coming from something unrelated to prostate cancer.
Cancer is such a frightening word that I feel compelled to draw attention to the widely false reporting that prostate cancer causes symptoms. So if prostate cancer is practically guaranteed to have no symptoms, assuming the PSA has been tested and is in the normal range, why do websites provide a long list of symptoms caused by prostate cancer? How can so much misinformation exist?
Basically, these websites hark back to a bygone era, describing a situation that existed before PSA testing was available. The symptoms they list, like bone pain, changes in urination, fatigue, pelvic pain, only occur in men with advanced disease. These websites are not acknowledging that men with normal PSA levels are unable to harbor advanced disease.
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Understand Your Prostate Cancer Risk Group
After intial tests are complete, your Doctors will help you determine your Prostate Cancer Risk Group. Test results for PSA, Gleason Score and Stage define the progression of cancer and risk group: Low Risk, Intermediate Risk or High Risk. Your risk group is key as you develop your treatment plan.
How Serious Is My Cancer
If you have prostate cancer, the doctor will want to find out how far it has spread. This is called the stage of the cancer. You may have heard other people say that their cancer was stage 1 or stage 2. Your doctor will want to find out the stage of your cancer to help decide what types of treatment might be best for you.
The stage is based on the growth or spread of the cancer through the prostate, and if it has spread to other parts of your body. It also includes your blood PSA level and the grade of the cancer. The prostate cancer cells are given a grade, based on how they look under a microscope. Those that look very different from normal cells are given a higher grade and are likely to grow faster. The grade of your cancer might be given as a Gleason score or a Grade Group . Ask your doctor to explain the grade of your cancer. The grade also can helpdecide which treatments might be best for you.
Your cancer can be stage 1, 2, 3, or 4. The lower the number, the less the cancer has spread. A higher number, like stage 4, means a more serious cancer that has spread outside the prostate.
If your cancer hasn’t spread to other parts of the body, it might also be given a risk group. The risk group is based on the extent of the cancer in the prostate, your PSA level, and the results of the prostate biopsy. The risk group can help tell if other tests should be done, and what the best treatment options might be.
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Psa Elevation From Large Prostate Glands
Big prostate glands produce more PSA than small prostate glands. The best way to measure the size of the prostate is by using a scan. Finding an oversized gland can be good news, providing a benign and reassuring explanation for why the PSA is high.
Until recently, the only way to sort through all these possibilities of PSA elevation was to puncture the prostate 12 times with a needle biopsy to remove tissue cores for evaluation under the microscope. Due to an inordinate fear of missing cancer, many doctors recommended random biopsy anytime the PSA was slightly elevated. One million men are biopsied in the United States every year. This aggressive behavior was perhaps justified when biopsy was the only way to find cancer.
We now know, however, that scans using multi-parametric magnetic resonance imaging are more accurate than a needle biopsy. The beauty of using a scan is that only men who have a suspicious abnormality detected by MRI need to undergo a biopsy. And importantly, the biopsy can be targeted. Only one or two cores are required. No more fishing through the rest of the gland with random needle sticks! Men with clear scans can avoid a biopsy altogether. Changing the policy from random biopsy to MP-MRI would solve the problem of over-diagnosis in men with high PSA.
External Beam Radiation Therapy
With EBRT, radiation usually in the form of X-ray photons is focused from a source outside the body onto the prostate and, if needed, surrounding lymph node areas. In preparation for the therapy, internal markers are implanted in the prostate, using a procedure similar to prostate biopsy they’re used to help align and target the prostate with the radiation beam. A planning CT scan is then performed to locate the prostate gland in relation to the surrounding structures and organs. The resulting images are used to make a treatment plan that targets the prostate gland while protecting healthy surrounding tissues .
Most radiation today is given as a type of EBRT known as intensity-modulated radiation therapy , in which the shape and intensity of several fine radiation beams can be varied during treatment to minimize damage to surrounding tissues. At UCSF, patients also benefit from image-guided radiation therapy , where the prostate is imaged immediately before the start of each treatment session to verify and adjust the position of the gland for added accuracy. Stereotactic body radiation therapy, or SBRT , is a special type of IMRT/IGRT in which high doses of radiation are given over a small number of treatments .
The schedule for EBRT treatments varies. Treatment may be delivered in one of the following ways:
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