Prostate Cancer Stages And Treatment

Gleason Score Vs Grade Groups

What are the Treatment Options for Stage 4 Prostate Cancer?

The International Society of Urological Pathology released a revised prostate cancer grading system in 2014. The grade group system seeks to simplify Gleason scores and give a more accurate diagnosis.

One of the major problems with the Gleason score is that some scores can be made up in different ways. For example, a score of 7 can mean:

3 + 4. The 3 pattern is the most common in the biopsy and 4 is the second most common. This pattern is considered favorable intermediate risk.
4 + 3. The 4 pattern is the most common in the biopsy and 3 is the second most common. This pattern is considered unfavorable and may mean local or metastatic spread.

So, although both situations give a Gleason score of 7, they actually have very different prognoses.

Heres an overview of how the two grading systems compare:

Cancer grade
grade group 5	910

Not all hospitals have switched to the grade group system. Many hospitals give both grade group and Gleason scores to avoid confusion until grade groups become more widely used.

The Staging Grading And Prognosis Of Prostate Cancer

Staging

The tests completed by your specialist help work out whether you have prostate cancer and if it has spread to other parts of your body. This process is called staging. It helps you and your health care team decide which management or treatment option is best for you.

The most common staging system for prostate cancer is the TNM system. In this system, letters and numbers are used to describe the size of the tumour , whether the cancer has spread to nearby lymph nodes , and whether the cancer has spread to the bones or other organs, i.e. whether it has metastasised . The TNM scores are combined to work out the overall stage of the cancer, with higher numbers indicating larger size or spread.

localised – stages 12	The cancer is contained inside the prostate.
locally advanced – stage 3	The cancer is larger and has spread outside the prostate to nearby tissues or nearby organs such as the bladder, rectum or pelvic wall.
advanced – stage 4	The cancer has spread to distant parts of the body such as the lymph glands or bone. This is called prostate cancer even if the tumour is in a different part of the body.

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.

Risk of progression

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis with your doctor, but it is not possible for anyone to predict the exact course of the disease.

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.

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Risks Of Over Treatment Of Prostate Cancer

Over diagnosis is the detection of a cancer that would otherwise not have been diagnosed in the lifetime of the host if the detection test had not been performed. Treatment of men who would otherwise not have known about their cancer in the absence of PSA testing and biopsy are over treated. Over treatment exacts a cost to the health care system and potential harm to a patient , with no benefit. Over treatment is most likely to occur when a low grade is detected, especially in an older man. Data from various sources suggest that in the PSA range where many men are undergoing prostate biopsy today , 15-25% will have prostate cancer detected, and 80-90% will be low grade.

The rate of in the U.S. is similar to the rate of over diagnosis since the majority of men undergo curative intervention after receiving a prostate cancer diagnosis. A range of estimates of over diagnosis between 23% and 42% have been reported based on U.S. incidence. Depending upon the age at diagnosis, and the disease characteristics, the likelihood that a screen detected cancer has been over diagnosed can vary from below 5% to more than 75%.

Psa And Gleason Score

Two other important factors that doctors and specialists use to assess cancer cells are the prostate specific antigen and the Gleason score.

PSA levels: PSA is a protein that appears in higher levels in the bloodstream when there is a problem with the prostate. Normally, PSA levels in the blood are very low, and a test cannot detect them. However, in some circumstance, such as prostate cancer, PSA levels start to rise.

Screening for prostate cancer uses a blood test for PSA. If PSA levels are high, the doctor may recommend further tests to see if prostate cancer is present.

There are various other reasons why PSA levels may rise, including sexual stimulation or an infection.

The grade and Gleason score: Different types of cancer cell act differently. Some types, or grades, are more aggressive and can spread more easily. The Gleason score and grade are different measures, but they both reflect how likely it is that a tumor will spread, and how quickly it will do so. Either a biopsy or surgery can determine the types of cancer cells present in the prostate tissues.

Nearly 50% of males have a condition known as prostatic intraepithelial neoplasia by the time they are 50 years old. PIN is when there are changes in the cells that line the prostate gland.

High grade PIN is not cancer, but the cells can become cancerous in the future. For this reason, a doctor may recommend treatment to remove the cells.

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If Your Prostate Cancer Comes Back

If your cancer goes into remission but later returns, follow-up treatments will depend on where the cancer is located and which treatments youâve already tried.

If the cancer is contained in your prostate, surgery or a second attempt at radiation is suggested. If you’ve had a radical prostatectomy, radiation therapy is a good option. If you had radiation, radical prostatectomy might be the best approach. Cryosurgery might also be an option.

If the cancer has spread to other parts of your body, hormone therapy might be the most effective treatment. External or IV radiation therapy or bisphosphonate drugs can relieve your bone pain.

Treatments For Prostate Cancer

If you have prostate cancer, your healthcare team willcreate a treatment plan just for you. It will be based on your health andspecific information about the cancer. When deciding which treatments to offerfor prostate cancer, your healthcare team will consider:

the type and stage of the cancer
the grade or Gleason score
prostate-specific antigen levels
the risk group
possible side effects of treatments
your personal preferences
your overall healthand any existing medical conditions
your age and life expectancy
whether you have symptoms

Prostate cancer treatments can seriously affect your qualityof life and cause side effects such as erectile dysfunction and incontinence . Manyprostate cancers grow slowly and cause no symptoms or problems.

Seven Types Of Standard Treatment Are Used:

Watchful waiting or active surveillance

Watchful waiting and active surveillance are treatments used for older men who do not have signs or symptoms or have other medical conditions and for men whose prostate cancer is found during a screening test.

Watchful waiting is closely monitoring a patients condition without giving any treatment until signs or symptoms appear or change. Treatment is given to relieve symptoms and improve quality of life.

Active surveillance is closely following a patient’s condition without giving any treatment unless there are changes in test results. It is used to find early signs that the condition is getting worse. In active surveillance, patients are given certain exams and tests, including digital rectal exam, PSA test, transrectal ultrasound, and transrectal needle biopsy, to check if the cancer is growing. When the cancer begins to grow, treatment is given to cure the cancer.

Other terms that are used to describe not giving treatment to cure prostate cancer right after diagnosis are observation, watch and wait, and expectant management.

Surgery

Patients in good health whose tumor is in the prostate gland only may be treated with surgery to remove the tumor. The following types of surgery are used:

Stages Types And Grades

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The tests and scans you have to diagnose your cancer will give some information about:

the type of cell the cancer started in and where it began
how abnormal the cells look under the microscope
the size of the cancer and whether it has spread

In the UK, doctors use the Gleason system to grade prostate cancer. They might also talk about your Grade Group. This is a new grading system.

You might also be told about the TNM stage, or you may see this on your pathology report. Another way doctors may describe your cancer is as localised, locally advanced or advanced.

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Metastases: Whether The Cancer Has Spread

The spread of cancer is measured in two ways: by lymph node involvement, and by its appearance in other organs or parts of the body, or metastasis.

Lymph node staging, or N-staging, determines whether the cancer is present in nearby lymph nodes. Lymph nodes are tiny organs that are part of the immune system.NX: The regional lymph nodes cannot be evaluated.N0: The cancer has not spread to lymph nodes in the immediate area.N1: The cancer has spread to lymph nodes in the pelvic region.

The M in the TNM system indicates whether the prostate cancer has spread to other parts of the body, such as the lungs or the bones. This is called distant metastasis.

MX: Metastasis cannot be evaluated.M0: The cancer has not metastasized beyond the immediate prostate region.M1: The cancer has metastasized deeper into the body.

M1a: The cancer has spread to lymph nodes away from the groin area.
M1b: The cancer has spread to the bones.
M1c: The cancer has spread to another part of the body, with or without spread to the bones.

The combination of your full staging results, including your grade and your T, N, and M stages, paints a more complete picture of how the cancer is progressing. This enables your doctors to determine which treatments have the best chance or controlling or eradicating your cancer.

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.

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Prostate Cancer Treatment & Clinical Trials

Clinical trials provide alternative treatment options for cancer patients. Some aim to test new drugs, reduce side effects, improve current treatment methods, and more. For some patients, clinical trials may be their best option. Once clinical trials complete all four phases, the FDA decides whether to approve the treatment, which may eventually become a standard treatment option.

Below is a list of treatments currently being studied in clinical trials:

Cryosurgery: A cryoprobe is used to freeze and destroy abnormal tissue within the prostate.

High-intensityfocused ultrasound therapy: In this procedure, sound waves are directed at the area of cancer. The sound waves produce heat that kills the cancer cells.

: For tumors just below the surface of the skin, a drug can be injected and activated when exposed to light, killing the nearby cancer cells.

Bisphosphonate therapy: This is used to reduce bone disease once the cancer cells have metastasized to the bone. Clodronate or zoledronate are used to slow the growth of cancer cells within the bone.

Alpha emitter radiation therapy: For patients who have had prostate cancer metastasize to the bone. Radium-223 is injected, which then finds and kills cancer cells in areas of the bone

Getting Help With Treatment Decisions

Making such a complex decision is often hard to do by yourself. You might find it helps to talk with your family and friends before making a decision. You might also find it helpful to speak with other men who have faced or are currently facing the same issues. The American Cancer Society and other organizations offer support programs where you can meet and discuss these and other cancer-related issues. For more information about our programs, call us toll-free at 1-800-227-2345 or see Find Support Programs and Services.

Itâs important to know that each manâs experience with prostate cancer is different. Just because someone you know had a good experience with a certain type of treatment doesnât mean the same will be true for you.

You might also want to consider getting more than one medical opinion, perhaps even from different types of doctors. For early-stage cancers, it is natural for surgical specialists, such as urologists, to favor surgery and for radiation oncologists to lean more toward radiation therapy. Doctors specializing in newer types of treatment may be more likely to recommend their therapies. Talking to each of them might give you a better perspective on your options. Your primary care doctor may also be helpful in sorting out which treatment might be right for you.

External Beam Radiation Therapy

The following three sections refer to treatment using x-rays.

Conventional external beam radiation therapy

a teletherapy “source” composed of

two nested stainless steel canisters welded to

two stainless steel lids surrounding

a protective internal shield and

a cylinder of radioactive source material, often but not always . The diameter of the “source” is 30 mm.

Historically conventional external beam radiation therapy was delivered via two-dimensional beams using kilovoltage therapy x-ray units, medical linear accelerators that generate high-energy x-rays, or with machines that were similar to a linear accelerator in appearance, but used a sealed radioactive source like the one shown above. 2DXRT mainly consists of a single beam of radiation delivered to the patient from several directions: often front or back, and both sides.

Conventional refers to the way the treatment is planned or simulated on a specially calibrated diagnostic x-ray machine known as a simulator because it recreates the linear accelerator actions , and to the usually well-established arrangements of the radiation beams to achieve a desired plan. The aim of simulation is to accurately target or localize the volume which is to be treated. This technique is well established and is generally quick and reliable. The worry is that some high-dose treatments may be limited by the radiation toxicity capacity of healthy tissues which lie close to the target tumor volume.

Intensity-modulated radiation therapy

Types Of Prostate Cancer Staging

There are two types of staging for prostate cancer: clinical staging and pathological staging.

Clinical staging is determined by the PSA testing, Gleason score, and results of the Digital Rectal Exam . Once the doctor has all of this information, then you may need additional testing . The results of these tests can provide more information that your doctor and medical team can then use to identify the stage.
Pathological staging is discovered during surgery as well as through laboratory results of biopsies from the tissue removed from the prostate during surgery. This is typically when lymph node involvement is determined.

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There Are Different Types Of Treatment For Patients With Prostate Cancer

Different types of treatment are available for patients withprostate cancer. Some treatments are standard , and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

The Number Staging System

The Five Stages of Prostate Cancer | Prostate Cancer Staging Guide

There are a few different systems used for staging prostate cancer. A simplified number staging system is described below.

Stage 1 The tumour is contained in the prostate. The tumour is too small to be felt when a doctor does a rectal examination or to be seen on a scan.

Stage 2 The tumour is still contained in the prostate, but your doctor can feel it when they do a rectal examination.

Stage 3 The tumour has started to break through the outer capsule of the prostate and may be in the nearby tubes that produce semen .

Stage 4 The tumour has spread outside the prostate. It may have spread to areas such as the bladder or back passage . Or it may have spread further, for example to the bones.

Using the numbered staging system described above:

stage 4 is known as advanced prostate cancer.