How To Make The Right Treatment Decision
Current expert guidelines for treatment of localized prostate carcinoma recommend potentially curative therapy for patients whose life expectancy is at least 10 years., Patients with limited life expectancy are more likely to die from health conditions other than prostate cancer. Men with a life expectancy of more than 10 years are more likely to die from progressive prostate cancer. This 10-year rule enjoys broad acceptance among urologists and radiation oncologists.,
Conservative management proved to be an acceptable treatment option for men with low-grade Gleason scores, clinically localized disease, and life expectancies of less than 10 years. Increasing age was described as a risk factor for receiving inadequate treatment for prostate cancer. Thus, older men have been shown to receive potentially curative therapy less often than younger men., Radical prostatectomy is preferred treatment in men younger than 70 years, whereas radiation therapy is applied predominantly in patients older than 70 years. Conservative therapy such as watchful waiting or androgen deprivation by luteinizing hormone-releasing hormone analogs is preferentially applied in men older than 80 years. Watchful waiting or hormonal therapy is used to treat 82% of men older than 80 years.
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What Will Happen In The Last Few Days
It can help to know what is normal in the last few days of life so that you know what to expect. You might not be aware of these changes when they happen because you may be drowsy or unconscious.
If you’re supporting someone who is dying, read about what you can do to help and how you can get support.
Pain
Many people worry about being in pain when they are dying. Some people do get pain if their prostate cancer presses on their nerves or makes their bones weak. But not everyone dying from prostate cancer has pain. And if you are in pain, there are things that can help to reduce and manage pain.
You should tell your doctor or nurse if youre in pain or if your pain gets worse. They can talk with you about how best to manage your pain and can help keep it under control.
You may find sitting or lying in some positions more comfortable than others, so ask if you need help getting into a different position.
Your doctor can give you medicines to help manage pain. The type of medicines they give you will depend on what is causing the pain and which medicines are suitable.
Your doctor will monitor how the pain medicines are working and may change the type of medicine or the dose. If youre still in pain or get pain in between taking medicines, its important to tell your doctor or nurse.
Sleeping and feeling drowsy
Not recognising people
Feeling restless or agitated
Changes in skin temperature or colour
Changes in breathing
Loss of appetite
Changes in urinating or bowel movements
What Does It Mean When There Are Different Core Samples With Different Gleason Scores
Cores may be samples from different areas of the same tumor or different tumors in the prostate. Because the grade may vary within the same tumor or between different tumors, different samples taken from your prostate may have different Gleason Scores. Typically, the highest Gleason Score will be the one used by your doctor for predicting your prognosis and deciding treatment.
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The Grade Group And Psa Level Are Used To Stage Prostate Cancer
The stage of the cancer is based on the results of the staging and diagnostic tests, including the prostate-specific antigen test and the Grade Group. The tissue samples removed during the biopsy are used to find out the Gleason score. The Gleason score ranges from 2 to 10 and describes how different the cancer cells look from normal cells under a microscope and how likely it is that the tumor will spread. The lower the number, the more cancer cells look like normal cells and are likely to grow and spread slowly.
The Grade Group depends on the Gleason score. See the General Information section for more information about the Gleason score.
- Grade Group 1 is a Gleason score of 6 or less.
- Grade Group 2 or 3 is a Gleason score of 7.
- Grade Group 4 is a Gleason score 8.
- Grade Group 5 is a Gleason score of 9 or 10.
The PSA test measures the level of PSA in the blood. PSA is a substance made by the prostate that may be found in an increased amount in the blood of men who have prostate cancer.
Stage 2 Prostate Cancer
In stage 2, the tumor is still confined to your prostate and hasnt spread to lymph nodes or other parts of your body. A doctor may or may not be able to feel the tumor during a prostate exam, and it may appear on ultrasound imaging. The survival rate is still near 100 percent.
The PSA score for stage 2 is less than 20 ng/mL.
Stage 2 cancer is further divided into three phases depending on the grade group and Gleason scores:
- Grade group: 1
- Gleason score: 6 or less
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Stage : Prostate Cancer Is Limited To A Small Part Of The Prostate
- Often, the cancer is found as a result of needle examination of tissue for another reason, such as benign prostatic hypertrophy , also known as an enlarged prostate, or because of an elevated result on a prostate specific antigen test, which uses PSA levels as an indicator of potential cancerous growth.
- Cancer cells are only found in a small part of the prostate. The cells look like normal cells and the prostate feels normal with a digital rectal exam .
- PSA is less than 10.
- Gleason score, which assigns a grade to what the cancer cells looks like under a microscope, is less than 6, the Prostate Cancer Foundation notes.
Grade And Risk Category
The biopsy results will show the grade of the cancer. This is a score that describes how quickly the cancer may grow or spread.
For many years, the Gleason scoring system has been used to grade the tissue taken during a biopsy. If you have prostate cancer, youll have a Gleason score between 6 and 10. A new system has been introduced to replace the Gleason system. Known as the International Society of Urological Pathologists Grade Group system, this grades prostate cancer from 1 to 5 .
Risk of progression
Based on the stage, grade and your PSA level before the biopsy, localised prostate cancer will be classified as having a low, intermediate or high risk of growing and spreading. This is known as the risk of progression. The risk category helps guide management and treatment.
Grading prostate cancer
| High risk. The cancer is likely to grow aggressive. |
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Treatments To Control And Prevent Symptoms Caused By The Spread Of Prostate Cancer To The Bones
Palliative External beam radiotherapy
Radiopharmaceuticals: Strontium-89 , samarium-153
Radium-223 dichloride is now licensed and called Xofigo. This is not widely available in the UK but BPC is one of a relatively small number of specialist centres using this treatment.
Zolidronic acid a bisphosphonate given by a 15 minute intravenous infusion every 34 weeks. It reduces the risk of bone complications, including pain and fractures.
Xgeva : this is a newly licensed drug available at BPC.
Pain medications
Surgery may be undertaken to treat bone fractures or to relief the pressure on the spinal cord by bone metastases.
Managing Bone Pain And Weakness
Symptoms like nausea, hot flashes, and pain can usually be relieved with medication. Some people find that complimentary treatments like acupuncture or massage help manage side effects.
Your doctor may also recommend orthopedic surgery to stabilize your bones, relieve pain, and help prevent bone fractures.
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Initial Treatment Of Prostate Cancer By Stage
The stage of your cancer is one of the most important factors in choosing the best way to treat it. Prostate cancer is staged based on the extent of the cancer and the PSA level and Gleason score when it is first diagnosed.
For prostate cancers that haven’t spread , doctors also use risk groups to help determine treatment options. Risk groups range from very low risk to very high risk, with lower risk group cancers having a smaller chance of growing and spreading compared to those in higher risk groups.
Other factors, such as your age, overall health, life expectancy, and personal preferences are also taken into account when looking at treatment options. In fact, many doctors determine a mans possible treatment options based not just on the stage, but on the risk of cancer coming back after the initial treatment and on the mans life expectancy.
You might want to ask your doctor what factors he or she is considering when discussing your treatment options. Some doctors might recommend options that are different from those listed here.
Stomach Cancer Untreated Life Expectancy
Nutrition in cancer care health professional. Nutrition plays major roles in many aspects of cancer development and treatment. Malnutrition is a common problem in cancer patients.
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Radiation Therapy For Prostate Cancer
Depending on the stage of your cancer, it is likely your doctor will incorporate radiation therapy into your treatment plan. Radiation uses extremely accurate, high-energy rays to weaken or kill cancer cells. It is non-invasive and often has few symptoms
For lower stages of prostate cancer, radiation therapy may be your first treatment. It is also often used alongside hormone therapy for prostate cancers that have grown to nearby tissues. Even in higher stages of prostate cancer, radiation therapy can be utilized as an additional treatment if surgery does not remove all of the cancer or if the cancer returns.
Talking To Andrew’s Doctor
For fifteen months, Andrew responded really well to treatment and was feeling reasonably good. But then he developed a very bad spinal cord compression. He was unable to walk and at that point it was clear that things were very serious. He spent nearly a month in hospital and his consultant told us that the cancer was back with a vengeance and that they wanted to fast track him home.
Andrew didnt want to know how long he might have. I know that he knew what the score was but that he just didnt want to speak about it.
Andrew didnt want to know how long he might have.
I asked Andrews doctor how long he might live for. She told me that she could give me some indication of how long Andrew might live for if I wanted to know. I wasnt sure that I wanted to know if Andrew didnt it might have created a barrier between us.
I wanted to know what I should expect. But I wasnt sure that I wanted to know how long Andrew would live for if he didn’t know.
But I wanted to know what I should expect. I needed to plan what was going to happen when he came home, the arrangements that would need to be made and whether I needed to speak to other members of our family and friends. At this point I think I felt quite out of control, so speaking to the consultant was my way of regaining some of that control and it helped me to plan for his homecoming.
Its difficult to accept that cancer takes its own route at its own pace.
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Getting More Information About What To Expect
- National Institute for Health and Care Excellence. Palliative care for adults: strong opioids for pain relief. Clinical guideline 140. 2012.
- National Institute for Health and Care Excellence. Prostate cancer: Diagnosis and treatment. NICE clinical guideline 175. 2014.
- Salvati M, Frati A, Russo N, Brogna C, Piccirilli M, DAndrea G, et al. Brain metastasis from prostate cancer. Report of 13 cases and critical analysis of the literature. J Exp Clin Cancer Res CR. 2005 Jun 24:2037.
- Thompson JC, Wood J, Feuer D. Prostate cancer: palliative care and pain relief. Br Med Bull. 2007 83:34154.
- Vinjamoori AH, Jagannathan JP, Shinagare AB, Taplin M-E, Oh WK, Van den Abbeele AD, et al. Atypical Metastases From Prostate Cancer: 10-Year Experience at a Single Institution. Am J Roentgenol. 2012 Aug 199:36772.
- Kate Bullen, Head of School for Applied Social Science, University of Brighton, Brighton
- Jackie Dawson, Community Palliative Care Clinical Nurse Specialist, Guys and St Thomas NHS Foundation Trust
- Hazel Parsons, Palliative Care Nurse Specialists, Dorothy House Hospice, Winsley, Bradford on Avon
- Elizabeth Rees, Lead Nurse for end of life care, Leeds Teaching Hospitals
- Our Specialist Nurses
Treatments May Have Side Effects
The treatment options for early-stage prostate cancer fall into three broad categories: surgery, radiation therapy, and active surveillance. Your doctor will make a treatment recommendation based on your numbers as well as a mathematical tool known as a nomogram, which can help you and your doctor better assess how extensive your cancer is likely to be and whether it is likely to become active in the future.
Yet clinical studies have not provided any evidence that one treatment is better than another or that any treatment at all actually prolongs life: The average 5-, 10-, and 15-year survival rates are virtually the same for all treatment options in early-stage prostate cancer, including active surveillance. Its also important to understand that no mathematical model is foolproof, and some men diagnosed with early-stage, locally confined disease will later find out that their cancer was more extensive than originally believed.
If you are diagnosed with early-stage prostate cancer, you have a number of treatments to choose from. A brief comparison is listed in Table 2.
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Where Does Prostate Cancer Usually Spread First
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.
The Tnm System For Prostate Cancer Stages
As they do for most cancers, doctors use the TNM system to describe prostate cancer stages. The system uses three different aspects of tumor growth and spread:
- Tumor. Whatâs the size of the main area of prostate cancer?
- Nodes. Has it spread to any lymph nodes? If so, how far and how many?
- Metastasis. How far has the prostate cancer spread?
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Types Of Cancers That Are More Likely To Go Undetected
Some cancers are more easily detected than others. For example, certain types of skin cancer can be diagnosed initially just by visual inspection though a biopsy is necessary to confirm the diagnosis.
But other cancers can form and grow undetected for 10 years or more, as one study found, making diagnosis and treatment that much more difficult.
This table provides an overview of common cancers that often display little or no symptoms early on, and how theyre typically detected and diagnosed:
| Type of cancer |
|---|
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Histopathologic Grade For Prostate Cancer
An additional factor influencing prognosis is histopathologic grading. Tissue obtained from a needle biopsy or a prostatectomy is graded using the Gleason Grading System. Gleason grades range from 1 to 5. Each specimen is assigned two grades based on the most common and second most common pattern. These numerical values are added to calculate the Gleason Score.
|
Gleason score cannot be assessed |
|
|
Gleason 6 |
|
|
Gleason 8-10 |
Poorly differentiated or undifferentiated |
The 8th edition of the AJCC Cancer Staging Manual took effect on January 1, 2018. A major change is that tumor grading now involves the Gleason Score, as well as the grade group.
| 4 + 4 | |
| 5 | 4 + 5, 5 + 4, 5 + 5 |
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Good Prostate Cancer Care
Your MDT will be able to recommend what they feel are the best treatment options, but ultimately the decision is yours.
You should be able to talk with a named specialist nurse about treatment options and possible side effects to help you make a decision.
You should also be told about any clinical trials you may be eligible for.
If you have side effects from treatment, you should be referred to specialist services to help stop or ease these side effects.