Initial Treatment Of Prostate Cancer By Stage And Risk Group
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 if more tests should be done and to help guide treatment options. Risk groups range from very-low-risk to very-high-risk, with cancers in the lower risk groups 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 important 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. Taking part in a clinical trial of newer treatments is also an option for many men with prostate cancer.
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Does It Matter Where Treatment Is Performed
A large body of evidence shows that in the case of surgery for prostate cancer, surgical experience matters greatly. Medical centers and surgeons performing a high number of prostatectomies per year demonstrate better outcomes in terms of both cancer control and quality of life than those performing relatively low numbers. We don’t have similar data regarding radiation outcomes, but performing brachytherapy well certainly requires expertise and experience, particularly in prostate ultrasound. Planning and administering EBRT effectively has many subtleties, which likely translate to better outcomes with more experienced doctors. No matter what the practice volume of specific surgeons or radiation oncologists, they should be able to discuss their own demonstrated outcomes both in terms of cancer control and quality of life.
Hormonal Therapy And Its Complications
Several different hormonal approaches are used in the management of various stages of prostate cancer.
These approaches include the following:
- Abiraterone acetate .
- Aminoglutethimide.
Abiraterone acetate
Abiraterone acetate has been shown to improve OS when added to ADT in men with advanced prostate cancer who have castration-sensitive disease. Abiraterone acetate is generally well-tolerated however, it is associated with an increase in the mineralocorticoid effects of grade 3 or 4 hypertension and hypokalemia compared with ADT alone. It may also be associated with a small increase in respiratory disorders.
Bilateral orchiectomy
Benefits of bilateral orchiectomy include the following:
- Ease of the procedure.
- Immediacy in lowering testosterone levels.
- Low cost relative to the other forms of ADT.
Disadvantages of bilateral orchiectomy include the following:
- Psychological effects.
Bilateral orchiectomy has also been associated with an elevated risk of coronary heart disease and myocardial infarction.
Estrogen therapy
Estrogens at a dose of 3 mg qd ofdiethylstilbestrol will achieve castrate levels of testosterone. Likeorchiectomy, estrogens may cause loss of libido and impotence. Estrogens also cause gynecomastia, and prophylactic low-dose radiation therapy to the breasts is given to prevent this complication.
Luteinizing hormone-releasing hormone agonist therapy
Evidence :
Antiandrogen therapy
ADT
Evidence :
Antiadrenal therapy
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Tnm Staging For Prostate Cancer
The TNM system is a way of staging prostate cancer. It stands for Tumour, Node, Metastasis. Staging means describing the size of the cancer and how far it has grown.
Doctors in the UK now use a tool called the Cambridge Prognostic Group to divide prostate cancer into 5 groups. The CPG uses information about:
- the T stage from the TNM staging
- Grade Groups or Gleason score
- Prostate specific antigen level
Treatment Option Overview For Prostate Cancer
In This Section
Local treatment modalities are associated with prolonged disease-free survival for many patients with localized prostate cancer but are rarely curative in patients with locally extensive tumors. Because of clinical understaging using current diagnostic techniques, even when the cancer appears clinically localized to the prostate gland, some patients develop disseminated tumors after local therapy with surgery or radiation.
Treatment options for each stage of prostate cancer are presented in Table 6.
| Stage | Standard Treatment Options |
|---|---|
| EBRT = external-beam radiation therapy LH-RH = luteinizing hormone-releasing hormone PARP = poly polymerase TURP = transurethral resection of the prostate. | |
| Stage I Prostate Cancer | |
| PARP inhibitors for men with prostate cancer and BRCA1, BRCA2, and/or ATM mutations |
Side effects of each of the treatment approaches are covered in the relevant sections below. Patient-reported adverse effects differ substantially across the options for management of clinically localized disease, with few direct comparisons, and include watchful waiting/active surveillance/active monitoring, radical prostatectomy, and radiation therapy. The differences in adverse effects can play an important role in patient choice among treatment options. Detailed comparisons of these effects have been reported in population-based cohort studies, albeit with relatively short follow-up times of 2 to 3 years.
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Psa Measurable By Standard Blood Test
Producing seminal fluid, the prostate also generates a molecule known as Prostate-Specific Antigen, or PSA. It is a prostate specific substance that circulates in the prostate and blood . PSA is a tumor marker used at all stages of prostate cancer treatment: screening, diagnosis, post-treatment follow-up, diagnosis after recurrence.
PSA tests are often recommended from about age 50. Dosageis done with a standard blood test for which it is not necessary to be fasting.8 days must separate PSA dosage from a rectal examination and 2 months in caseof a recent rectal examination. However, PSA is not specific to prostate cancerbecause it also increases with other prostate pathologies: Benign ProstaticHyperplasia, inflammation and infection of the prostate. One of the first stepsof prostate cancer diagnosis, PSA test must be completed by other diagnostics:5 to 10% of cancers that can be felt during a rectal examination have a normalPSA at the start.
- Thresholdvalue used for prostate cancer screening is 4 ng/mL: from 4 to 10 ng/mL, 70% ofdiagnosed cancers are localized.
- APSA higher than 30 ng/mL reflects an advanced localized prostate cancer with a highprobability of locoregional lymph node metastases.
- APSA higher than 100 ng/mL reflects anadvanced localized prostate cancer, with a high bone metastases probability.
Diagnostic Tests Are Limited
We always knew that prostate cancer is common and that, until recently, it often went undiagnosed: Autopsies of men who died of other causes have shown that about one-third of men over age 50 have some cancerous cells in their prostate, while 90% of men over age 90 have such cells.
As PSA screening has grown more widespread, we are finding more tumors that otherwise would have escaped detection. Yet current diagnostic technology does not always enable urologists to determine which tumors will lie dormant and which will become active, spreading elsewhere in the body.
Studies estimate that anywhere from 16%56% of men diagnosed with prostate cancer, generally because of an abnormal PSA test, have tumors that might never have caused problems had they not been found. And the landmark Prostate Cancer Prevention Trial unexpectedly yielded data that early-stage prostate tumors are incredibly common, even at PSA levels considered normal.
The PCPT was a randomized controlled study the type considered to be the gold standard in research . The study, which involved almost 19,000 healthy men, was designed to evaluate whether the drug finasteride could prevent prostate cancer from developing. Finasteride is a hormonal medication originally approved to treat benign prostatic hyperplasia , but which has also been investigated as a potential treatment for prostate cancer.
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Stage I Prostate Cancer Treatment
In This Section
Vascular-targeted photodynamic therapy using a photosensitizing agent has been tested in men with low-risk prostate cancer. In the CLIN1001 PCM301 randomized trial, 413 men with low-risk cancer were randomly assigned in an open-label trial to receive either the photosensitizing agent, padeliporfin , or active surveillance. Median time to local disease progression was 28.3 months for patients receiving padeliporfin and 14.1 months for patients who were assigned to active surveillance . However, the appropriate population for photodynamic therapy may be quite narrow, as it may overtreat men with very low-risk disease and undertreat men with higher-risk disease.
Table 1 Why A Low Psa Does Not Mean You Are Cancer
The Prostate Cancer Prevention Trial included a provision that men randomized to receive placebo undergo a prostate biopsy at the end of the study, even if they had normal PSA levels and digital rectal exams. To their surprise, investigators found that many of these men had prostate cancer in some cases, high-grade prostate cancer.
PSA level 13 *Note: A PSA level over 4.0 ng/ml traditionally triggers a biopsy. Adapted with permission from I.M. Thompson, et al. Prevalence of Prostate Cancer Among Men with a Prostate-Specific Antigen Level 4.0 ng per Milliliter. New England Journal of Medicine, May 27, 2004, Table 2.
This study inadvertently provided evidence not only that prostate cancer occurs more often than once believed, but also that PSA levels may not be a reliable indicator of which cancers are most aggressive. Both findings add weight to the growing consensus that many prostate tumors currently being detected may not need to have been diagnosed or treated in the first place.
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What Tests Check For Prostate Cancer
Common tests to check for prostate cancer include:
- Digital rectal exam: Your doctor inserts a finger into your rectum and touches your prostate gland. The doctor feels the shape of the prostate gland and checks for any hard spots.
- PSA blood test: This blood test tells how much PSA is in your blood. Many men with prostate cancer have PSA levels that are higher than normal or that have gotten higher over time.
- A high PSA level does not always mean a man has prostate cancer. As men get older, their prostate gland may grow larger over time. This growth, and other health conditions, can cause a high PSA level in men who do not have prostate cancer.
If the test results are not normal, your doctor may recommend more tests, such as a biopsy. During a biopsy, the doctor uses a needle to take out a tiny piece or pieces of the prostate gland. An ultrasound probe may be used to guide the needle. Another doctor called a pathologist looks at the tissue under a microscope to check for cancer cells.
Note
Living With Prostate Cancer
Receiving a prostate cancer diagnosis can be stressful. Even though most people who receive a diagnosis of prostate cancer live for many years after receiving the diagnosis, treatment can be exhausting and cause side effects that impact your quality of life.
Many resources are available to help you get through these difficult times:
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British Columbia Specific Information
You are considered a low-risk patient if you have a PSA value that is equal or less than 10 nanograms per millilitre , a Gleason score that is equal or less than 6, and your cancer stage is T1c/T2a. PSA is your prostate specific antigen measured by a blood test, the Gleason score indicates how aggressive the cancer is by looking at tissue biopsy results, and the cancer stage describes how much the cancer has spread.
Active surveillance has been developed to allow for careful management of men with low-risk prostate cancer. For more information, visit BC Cancer Agency Prostate.
Top of the pageDecision Point
You may want to have a say in this decision, or you may simply want to follow your doctors recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.
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What Are Prostate Cancer Survival Rates By Stage
Staging evaluation is essential for the planning of treatment for prostate cancer.
- A basic staging evaluation includes the patient examination, blood tests, and the prostate biopsy including ultrasound images of the prostate.
- Further testing and calculations may be performed to best estimate a patient’s prognosis and help the doctor and patient decide upon treatment options.
Prognosis refers to the likelihood that cancer can be cured by treatment, and what the patient’s life expectancy is likely to be as a consequence of having had a prostate cancer diagnosis.
If cancer is cured, your life expectancy is what it would have been had you never been diagnosed with prostate cancer. If cancer cannot be cured due to it recurring in distant locations as metastases, or recurs either locally or in an area no longer able to be treated in a curative manner, then estimates can be made of what is likely to be your survival-based again on group statistics for people who have been in the same situation.
Nomograms are charts or computer-based tools that use complex math from the analysis of many patients’ treatment results.
The prognosis for prostate cancer varies widely and depends on many factors, including the age and health of the patient, the stage of the tumor when it was diagnosed, the aggressiveness of the tumor, and cancer’s responsiveness to treatment, among other factors.
The 5 and 10-year survival rate of prostate cancer chart
| Stage and 5-Year Survival |
|---|
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Figure 1 Location Of The Prostate Gland
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.
As you evaluate treatment options, Id suggest that you think not only about your situation today, but also about where you expect to be in five or 10 years because chances are, youll still be alive. And you need to be sure that you would make the same treatment decision five or 10 years from now as you will right now.
Will you be able to deal with impotence if it occurs? What about incontinence ? How will the possible side effects of treatment affect your relationship with your wife or significant other and your very sense of self? Its vital to really think about these issues: In my experience, truly informed patients are much better able to deal with adverse consequences than patients who are uninformed or rush into making a decision.
Its also important to understand the limits of current medical knowledge about prostate cancer.
Gleason Prostate Cancer Score
1960s as a way to measure how aggressive your prostate cancer may be.
A pathologist determines your Gleason score by looking at a biopsy of your prostate tissue under a microscope. They grade the cells in the biopsy on a scale of 1 to 5. Grade 1 cells are healthy prostate, whereas grade 5 cells are highly mutated and dont resemble healthy cells at all.
The pathologist will calculate your Gleason score by adding together the number of the most prevalent type of cell in the sample and the second most prevalent type of cell.
For example, if the most common cell grade in your sample is 4 and the second most common is 4, you would have a score of 8.
A Gleason score of 6 is considered low-grade cancer, 7 is intermediate, and 8 to 10 is high-grade cancer.
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Options For Dealing With Recurrence
With a persistently increasing PSA, the suspicion for recurrence increases. The most important factor in assessing your long-term outcome is determining the location of the prostate cancer cells producing the PSA. Advanced imaging techniques, such as MRI and PSMA PET/CT, are often helpful in learning where the cancer is located, and in the case of post-radiation recurrence, repeat biopsy may be required.
If a man underwent surgery as an initial treatment, revisiting the post-operative pathology report may help to identify what contributed to the recurrence. If there was still cancer present , the cancer was aggressive , or genomic profiling of the tumor showed high-risk features, several options are available:
- EBRT to the prostate bed with or without the pelvis.
- EBRT accompanied by hormone therapy. The duration of hormone therapy will depend on the PSA level just prior to radiation and to a lesser extent on the Gleason score and staging of the cancer.
- Systemic treatment using hormone therapy, other treatments for those at risk for metastatic disease, or a combination.
- Active surveillance if the remaining cancer appears insignificant. You and your doctor can decide whether to intervene more aggressively and, if so, when.
If you’re seeking additional or different approaches, you may be eligible to participate in an appropriate clinical trial . You can research this with the help of your doctor.
Prostate Cancer Risk Assessment
Prostate cancer represents a wide spectrum of disease. Some prostate cancers progress and need treatment, while others grow slowly, if at all, and can be managed conservatively with a system of careful monitoring called active surveillance. It is important to learn the characteristics of your cancer before making treatment decisions. There are many ways to determine prostate cancer risk, most of which incorporate information from several parameters, including the PSA, Gleason score and tumor extent .
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