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How Is Early Prostate Cancer Treated

What Is The Purpose Of The Gleason Score

Treatment options for early (localised) prostate cancer

Named after its creator, Dr. Donald Gleason, The Gleason score is a measurement that is given to indicate the aggressiveness of prostate cancer.

Aggressiveness is a medical term used to describe the likelihood of cancer spreading outside the prostate.

The Gleason scoring system was developed at a VA hospital in the 1960s and was quickly adopted all over the world as an effective predictor of the pace of prostate cancer growth.

When he created this measurement, Dr. Gleason assigned a number between 1 and 5 to the different patterns of prostate cancer cell growth. Prostate cancer cells display different patterns of growth, which reveal their aggressiveness.

When your pathologist checks your biopsy samples, they examine your prostate cells under the microscope and will look at the different patterns.

They will then choose the two most commonly appearing patterns and give you a score. The first number indicates the most common pattern in all the samples. The second is the second most common pattern. When these two scores are added together, the total is called the Gleason score.

Figure 2 Why Understaging May Occur

When the prostate is removed, a pathologist examines slices of the gland for evidence of cancer. A. Under a microscope, the pathologist can distinguish tiny tumors, consisting of clumps of visibly abnormal cells. B. With current imaging technology, it is not yet possible for a pathologist to identify micrometastases individual cancer cells shed from the primary tumor that have gone on to seed adjacent tissue. In this image, for example, cancer cells have already penetrated the capsule and migrated to adjacent tissue, even beyond the margin of tissue removed during surgery.

Individual prostate cancer cells can spread to more remote areas of the body in three ways . Whats more, they can do so without being detected with our current technology, essentially escaping under the radar. So its always possible even if you are diagnosed with early-stage prostate cancer that the cancer has already spread and will manifest in the coming years. How likely is it that an early-stage prostate cancer will become active without treatment? A small study provides some clues .

Are Prostate Problems Always A Sign Of Prostate Cancer

Not all growths in the prostate are cancerous, and not all prostate problems indicate cancer. Other conditions that cause similar prostate cancer symptoms include:

  • Benign prostatic hyperplasia : At some point, almost every man will develop benign prostatic hyperplasia . This condition enlarges the prostate gland but doesnt increase cancer risk. The swollen gland squeezes the urethra and blocks the flow of semen and urine. Medications, and sometimes surgery, can help.
  • Prostatitis: Men younger than 50 are more prone to prostatitis, inflammation and swelling of the prostate gland. Bacterial infections are often the cause. Treatments include antibiotics or other medications.

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What Are The Treatments For Prostate Cancer

If you need treatment, your doctor will decide the type. Decisions about how to treat this cancer are complex, and you may want a second opinion before making a treatment decision. Treatment may include watchful waiting, a single therapy, or some combination of radiation, surgery, hormone therapy, and less commonly chemotherapy. The choice depends on many things. Prostate cancer that hasnât spread usually can be cured with surgery or radiation.

Watchful waiting

Since prostate cancer can grow slowly and may not be fatal in many men, some patients — after discussing the options with their doctors — opt for “watchful waiting.” This means not treating it. Instead, the doctor regularly checks the prostate cancer for signs that it is becoming more aggressive. Watchful waiting is typically recommended for men who are older or have other life-threatening conditions. In these cases, a less aggressive cancer may be growing so slowly that it’s not likely to be fatal.

Surgery

Laparoscopic robotic prostatectomy is a surgery using a laparoscope aided by robotic arms. This operation is now the most popular form of radical prostatectomy in the United States.

After surgery, most men have temporary incontinence, but they usually regain complete urinary control over time. If it is severe or lasts a long time, incontinence can be managed with special disposable underwear, exercises, condom catheters, biofeedback, penile clamps, implants around the urethra, or a urethral sling.

Radiation

How Prostate Cancer Is Treated

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In cancer care, different types of doctorsincluding medical oncologists, surgeons, and radiation oncologistsoften work together to create an overall treatment plan that may combine different types of treatments to treat the cancer. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as palliative care experts, physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, dietitians, physical therapists, and others.

The common types of treatments used for prostate cancer are described below. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care.

Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patients preferences and overall health.

Cancer treatment can affect older adults in different ways. More information on the specific effects of surgery, chemotherapy, and radiation therapy on older patients can be found another section of this website.

Because most prostate cancers are found in the early stages when they are growing slowly, you usually do not have to rush to make treatment decisions. During this time, it is important to talk with your doctor about the risks and benefits of all your treatment options and when treatment should begin. This discussion should also address the current state of the cancer:

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Cryotherapy For Prostate Cancercryotherapy

Cryotherapy is a less common treatment for prostate cancer which uses a needle-thin probe and low temperature gases to destroy prostate cancer tumours by freezing them. It may be used if your prostate cancer has come back following radiation therapy treatment, or as an alternative to surgery or radiation therapy for men with low-risk, early-stage prostate cancer.

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In active monitoring, men with localized prostate cancer do not get surgery or radiation right after theyre diagnosed. Instead, they have regular biopsies, blood tests, and MRIs to see if their cancer is progressing. If it is, they can receive treatment.

Although some oncologists advise men with early, low-grade prostate cancer to choose active surveillance and professional groups such as the American Society of Clinical Oncology recommend it many patients recoil at what sounds like lets just wait for your cancer to become really advanced. A decade ago fewer than 10 percent of men diagnosed with prostate cancer chose monitoring, UCLA researchers found. But that is changing. Now at least half of men do.

That made sense to Garth Callaghan, author of the best-selling Napkin Notes, a book of missives he tucked into his daughters lunch box. Diagnosed with early prostate cancer in 2012, he said, none of the choices seemed particularly attractive to a 43-year-old man who dreaded the possibility of side effects of surgery or radiation, including incontinence and impotence. I was completely torn. My previous experience was, just get it out of my body. But after his doctor explained that prostate cancer is grossly overtreated in the United States, I did a complete 180 and chose active monitoring.

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Physical Emotional And Social Effects Of Cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.

Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.

When Is Brachytherapy Alone The Right Choice

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For some patients with disease that is confined to the prostate and not too aggressive , brachytherapy alone is a good option. It is also convenient for the patient as it is done in an outpatient setting and most people can get back to work within a few days.

But brachytherapy is not right for everyone. For some patients with less-aggressive disease, a watch-and-wait approach would be preferred. At MSK, our philosophy is that when the disease is caught very early, it is very appropriate to do active surveillance and hold off on treatment.

This philosophy applies to patients with a low PSA level, or nonaggressive disease as reflected by a Gleason score of 6 with evidence of cancer in only a few of the biopsy samples and no evidence from the MRI of a significant amount of disease. There are also very select patients with Gleason 7 disease who may be candidates for active surveillance.

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Further Tests After Diagnosis

Whether you have any further tests will depend on the risk of the cancer growing quickly. Doctors work out your risk by looking at the PSA level, the stage, and the grade of the cancer.

To help diagnose or stage prostate cancer, you may have staging tests:

Knowing the stage, grade and risk group of the cancer helps you and your doctor to decide on the best treatment for you.

Can Prostate Cancer Be Prevented

Thereâs no evidence that you can prevent prostate cancer. But a few simple things may help lower your odds.

Healthy food

A diet that helps you stay at a healthy weight may cut your chances of having prostate cancer. These steps can help:

  • Choose whole-grain breads, pasta, and cereals over refined grain products.
  • Cut back on red meats, especially processed meats such as hot dogs, bologna, and certain lunch meats.
  • Eat at least 2 1/2 cups of fruits and vegetables each day.

Antioxidants in foods, especially in fruits and vegetables, help prevent damage to the DNA in your cells. Such damage has been linked to cancer. Lycopene, in particular, is an antioxidant that has been thought to lower the risk of prostate cancer. It can be found in foods such as:

  • Tomatoes, both raw and cooked
  • Pink and red grapefruit
  • Weak or interrupted pee stream
  • Peeing often, especially at night
  • Trouble emptying your bladder completely
  • Pain or burning when you pee
  • Blood in your pee or semen
  • Continuing pain in your back, hips, or pelvis
  • Pain with ejaculation

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Active Surveillance For Prostate Canceractive Surveillance

Active surveillance focuses on avoiding or delaying progression to active cancer treatment by monitoring the growth and spread of low-risk prostate cancer which isnt causing symptoms. It typically involves additional tests to monitor the prostate cancer compared to watchful waiting, including PSA tests, digital rectal exams, MRI scans and biopsies. If the results show that your prostate cancer has begun growing and spreading, your doctor may recommend that you begin active treatment.

Treatment For Prostate Cancer

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Prostate cancer treatment depends on a range of factors such as the mans age, physical condition, the stage of his prostate cancer and his personal preference. Prostate cancer can be treated in a variety of ways, so carefully discuss treatment options with your doctor and seek referral to other specialists to discuss each of your treatment options

If you prostate cancer is contained within the prostate treatment may include:

  • Watchful waiting is a way of monitoring prostate cancer symptoms and side effects and treating them as they arise. Treatment is for the purpose of symptom relief and slowing the cancer growth, not to cure the cancer. You may be offered Watchful Waiting if you are older or in poor health and the cancer is not likely to progress and cause a problem in your lifetime. It may also be offered to you if you have other health problems as well as prostate cancer. Watchful Waiting involves fewer tests than Active Surveillance. You may have regular PSA tests. If the level rises or you experience troublesome symptoms, you may also need imaging scans.
  • If your cancer is not contained within the prostate at diagnosis, or if you cancer spreads outside the prostate, your treatments may include:

  • Targeted therapies – PARP inhibitors prevent cancer cells from repairing their DNA so that cancer stops growing. PARP inhibitors may work in those diagnosed with a BRCA 1 or BRCA2 gene mutation.
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    Radiopharmaceuticals That Target Psma

    Prostate-specific membrane antigen is a protein that is often found in large amounts on prostate cancer cells.

    Lutetium Lu 177 vipivotide tetraxetan is a radiopharmaceutical that attaches to PSMA, bringing radiation directly to the prostate cancer cells.

    This drug can be used to treat prostate cancer that has spread and that has already been treated with hormone therapy and chemotherapy. The cancer cells must also have the PSMA protein. Your doctor will order a PSMA PET scan before you get this drug to make sure the cancer cells have PSMA.

    This drug is given as an injection or infusion into a vein , typically once every 6 weeks for up to 6 doses.

    Possible side effects

    Some of the more common side effects of this drug include:

    • Feeling tired
    • Constipation

    This drug can lower blood cell counts:

    • A low red blood cell count can cause tiredness, weakness, pale skin, or shortness of breath.
    • A low blood platelet count can lead to bleeding or bruising more easily than normal, or bleeding that is hard to stop.
    • A low white blood cell count can lead to an increased risk of infections, which might show as a fever, chills, sore throat, or mouth sores.

    This drug might damage the kidneys. Your doctor or nurse will likely advise you to drink plenty of fluids and to urinate often before and after getting this drug, to help protect the kidneys. Tell your doctor or nurse if you start to pass less urine than is normal for you.

    Symptoms Of Early Prostate Cancer

    Early prostate cancer may not cause any symptoms. Symptoms only happen when the cancer is large enough to press on the tube that carries the urine from the bladder . Some prostate cancers grow very slowly. Symptoms may not develop for many years.

    The prostate can also become enlarged due to a non-cancerous condition called benign prostatic hyperplasia .

    The symptoms of benign prostate conditions and prostate cancer are similar. They can include:

    • needing to pee more often than usual, especially at night
    • difficulty peeing for example, a weak flow or having to strain to start peeing
    • feeling like you have not completely emptied your bladder
    • an urgent need to pee
    • blood in urine or semen
    • rarely, pain when peeing or ejaculating.

    If you have any of these symptoms, it is important to have them checked by your doctor. Your GP can do some tests to find out if you need a referral to a specialist doctor.

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    Hormone Therapy For Prostate Cancerhormone Therapy

    As hormones can be a source of fuel for prostate cancer, hormone therapies can be used to block or lower your bodys natural hormones to stop your prostate cancer from growing or returning. Hormone therapy treatment for prostate cancer is also known as Androgen Deprivation Therapy and is used to reduce the amount of testosterone in the body. It may be delivered before, during or after other treatments such as radiation therapy or chemotherapy and is commonly given as a tablet or injection.

    Surgically Removing The Prostate Gland

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    A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing prostate cancer that has not spread beyond the prostate or has not spread very far.

    Like any operation, this surgery carries some risks, such as urinary incontinence and erectile dysfunction.

    In extremely rare cases, problems arising after surgery can be fatal.

    It’s possible that prostate cancer can come back again after treatment. Your doctor should be able to explain the risk of your cancer coming back after treatment, based on things like your PSA level and the stage of your cancer.

    Studies have shown that radiotherapy after prostate removal surgery may increase the chances of a cure, although research is still being carried out into when it should be used after surgery.

    After a radical prostatectomy, you’ll no longer ejaculate during sex. This means you will not be able to have a child through sexual intercourse.

    You may want to ask your doctors about storing a sperm sample before the operation so it can be used later for in vitro fertilisation .

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    How Is Prostate Cancer Diagnosed

    There are several tests your doctor may perform to check your prostate:

    • Digital rectal examination : Your doctor inserts a gloved, lubricated finger into your rectum to feel the prostates size and check for anything unusual.
    • Prostate Specific Antigen test: A simple blood test to measure a protein produced by your prostate. A high PSA might be a sign of prostate cancer, or another condition.
    • MRI scan: A detailed scan of your prostate to help identify signs of cancer.

    While these tests are helpful, a prostate biopsy is the only way to confirm a diagnosis of prostate cancer. A urologist, who your doctor will refer you to, removes some cells from your prostate using a thin, hollow needle. The cells are then examined under a microscope to check for cancer.

    Confirmed prostate cancer is graded on a scale of 1 to 5 , based on how likely the cancer is to grow and spread to the rest of the body. Grade groups 4 to 5 are considered high risk.

    An older system of grading, known as the Gleason score, grades the cancer from 1 to 10. A Gleason score of 8 to 10 is considered high risk.

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