A Biopsy Is Done To Diagnose Prostate Cancer And Find Out The Grade Of The Cancer
A transrectal biopsy is used to diagnose prostate cancer. A transrectal biopsy is the removal of tissue from the prostate by inserting a thin needle through the rectum and into the prostate. This procedure may be done using transrectal ultrasound or transrectal MRI to help guide where samples of tissue are taken from. A pathologist views the tissue under a microscope to look for cancer cells.
Sometimes a biopsy is done using a sample of tissue that was removed during a transurethral resection of the prostate to treat benign prostatic hyperplasia.
If cancer is found, the pathologist will give the cancer a grade. The grade of the cancer describes how abnormal the cancer cells look under a microscope and how quickly the cancer is likely to grow and spread. The grade of the cancer is called the Gleason score.
To give the cancer a grade, the pathologist checks the prostate tissue samples to see how much the tumor tissue is like the normal prostate tissue and to find the two main cell patterns. The primary pattern describes the most common tissue pattern, and the secondary pattern describes the next most common pattern. Each pattern is given a grade from 3 to 5, with grade 3 looking the most like normal prostate tissue and grade 5 looking the most abnormal. The two grades are then added to get a Gleason score.
Signs You Need A Diagnostic Evaluation For Prostate Cancer
Because there are usually no symptoms of the disease until it reaches advanced stages, the Urology Specialist Group physicians recommend routinemens health screenings and prostate exams if you have risk factors for prostate cancer. You should schedule this type of screening even if you dont have symptoms.
As prostate cancer progresses, you may experience difficulties urinating or notice your output of urine is decreasing. Other potential symptoms of prostate cancer include:
- Pelvic pain
While these symptoms dont necessarily mean you have cancer, you should not delay a diagnostic evaluation. Without prompt treatment, cancerous cells in the prostate can spread to other areas of your body, including into yourbladder or bloodstream.
How Does Hormone Therapy Work Against Prostate Cancer
Early in their development, prostate cancers need androgens to grow. Hormone therapies, which are treatments that decrease androgen levels or block androgen action, can inhibit the growth of such prostate cancers, which are therefore called castration sensitive, androgen dependent, or androgen sensitive.
Most prostate cancers eventually stop responding to hormone therapy and become castration resistant. That is, they continue to grow even when androgen levels in the body are extremely low or undetectable. In the past, these tumors were also called hormone resistant, androgen independent, or hormone refractory however, these terms are rarely used now because the tumors are not truly independent of androgens for their growth. In fact, some newer hormone therapies have become available that can be used to treat tumors that have become castration resistant.
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Watchful Waiting Or Active Surveillance
Your doctor might suggest waiting to see if your tumor will grow or spread before you treat it. Most prostate cancer grows slowly. Some doctors think itâs better not to treat it unless it changes or causes symptoms. In watchful waiting, your doctor will closely track how the disease makes you feel. With active surveillance, youâll also get regular tests to check on the cancer.
What Are The Prostate Cancer Treatment Side Effects Of A Prostatectomy
The primary prostate cancer treatment side effects after a radical prostatectomy are incontinence and erectile dysfunction. These side effects are a product of the location of the prostate and the type of surgery performed. The prostate gland lies deep within the pelvis behind the pubic bone and in front of the rectum. The urinary bladder lies just above the prostate, the urinary sphincter control muscle is located just below it, and the erectile nerves lie just outside the prostate on either side. A patients age and overall health also influence the potential risks of radical prostatectomy just as it does with any major operation. Such risks include cardiac or pulmonary events, infections, blood clots, or injuries to structures around the prostate.
Following surgery, all men will have some urinary leakage. A good amount of bladder control is often regained within 12 weeks and continues to improve over 12 months. Multiple studies have shown that there is often a several month interval before a patient recovers normal erections, even with bilateral nerve-sparing surgery. Advantages to the Robot Assisted Laparoscopic Prostatectomy technique are a reduced risk of intra-operative bleeding and a shortened hospital stay.
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Delaying Time To Metastasize With New Treatments
Prostate cancer can grow and spread to other parts of the body, including the lymph nodes or bones. Castration-sensitive prostate cancer still responds to medical or surgical treatments that lower testosterone, whereas castration-resistant prostate cancer no longer responds to these treatments. Triple therapy for metastatic Castrate-Sensitive Prostate Cancer is a promising new development affording patients prolonged survival. Non-metastatic Castrate-Resistant Prostate Cancer is a type of prostate cancer that hasnt spread to other parts of the body but is no longer responding to testosterone-lowering therapies. nmCRPC has traditionally been difficult to treat, but early treatment and new treatment options, including next-generation testosterone-lowering therapies, are extending patients lives. This has been a huge advance, says Dr. Flax.
Dr. Hotte notes that new hormonal therapies are making a big difference for nmCRPC patients quality of life and delaying the time their cancer takes to overtly metastasize.
What Are Some Treatments For Prostate Cancer
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Most of the common medical treatments have already been discussed by the previous respondents, so I will focus on complementary and alternative treatments.
Alternative treatments for prostate cancer can be broken down into five domains:
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Cancer Cells Under A Microscope
If you have had a biopsy,the biopsied tissue is sent to a laboratory where a doctor called a pathologist will look at the cells in the tissue under a microscope. When healthy cells become cancerous, their appearance begins to change. The more changed the cells look, the more dangerous the cancer is likely to be.
The results from a prostate biopsy are usually given in the form of the Gleason score. On the simplest level, this scoring system assigns a number to describe how abnormal the cells appear under a microscope. Grade 1 and 2 are thought of as normal prostate cells. Grades 3 5 are thought of as cancer cells, with grade 5 being the most abnormal.
The doctor will take more than one sample when you have a biopsy. This is because there may be more than one grade of cancer in the tumour. The pathologist works out an overall Gleason score by adding together the two most common Gleason grades.
For example, if the most common grade of the samples is grade 3 and the second most common is grade 4 then the overall Gleason score is 7. Some doctors write the two scores separately, for example 3 + 4, instead of 7.
The grade can only ever give a doctor an idea of how a cancer might behave. It cannot definitely predict what will happen. Most cancers will behave as expected, but not all.
How Prostate Cancer Is Treated
Doru Paul, MD, is triple board-certified in medical oncology, hematology, and internal medicine. He is an associate professor of clinical medicine at Weill Cornell Medical College and attending physician in the Department of Hematology and Oncology at the New York Presbyterian Weill Cornell Medical Center.
The treatment options for prostate cancer can vary based on many factors, including the aggressiveness of the tumor, the stage of the disease, personal preferences, and more. Curative options may include surgery or radiation therapy. With less aggressive tumors, watchful waiting with treatment begun only if the cancer progresses may be an option. There are also a number of different therapies that can be used to control the growth of these cancers, including hormone therapies, chemotherapy, and newer treatments such as immunotherapy. In addition, many alternative treatments are being evaluated in clinical trials.
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Treatment By Stage Of Prostate Cancer
Different treatments may be recommended for each stage of prostate cancer. Your doctor will recommend a specific treatment plan for you based on the cancers stage and other factors. Detailed descriptions of each type of treatment are provided earlier on this same page. Clinical trials may also be a treatment option for each stage.
Early-stage prostate cancer
Early-stage prostate cancer usually grows very slowly and may take years to cause any symptoms or other health problems, if it ever does at all. As a result, active surveillance or watchful waiting may be recommended. Radiation therapy or surgery may also be suggested, as well as treatment in clinical trials. For those with a higher Gleason score, the cancer may be faster growing, so radical prostatectomy and radiation therapy are often recommended. Your doctor will consider your age and general health before recommending a treatment plan.
ASCO, the American Urological Association, American Society of Radiation Oncology, and the Society of Urologic Oncology recommend that patients with high-risk early-stage prostate cancer that has not spread to other areas of the body should receive radical prostatectomy or radiation therapy with hormonal therapy as standard treatment options.
Locally advanced prostate cancer
Watchful waiting may be considered for older adults who are not expected to live for a long time and whose cancer is not causing symptoms or for those who have another, more serious illness.
How Can Additional Indications For Psma And Grpr Imaging Fill An Unmet Need In Prostate Cancer Treatmeant
Beyond biopsy guidance, as I indicated earlier, guiding what area of the prostate to treat with high-intensity focused ultrasound or high-dose-rate brachytherapy are of great interest to our group. And not only to guide what needs to be treated but also six months later after treatment to see if we can avoid biopsying these patients again to evaluate the response to treatment.
And then if we expand beyond that, the spectrum of prostate cancer patient covers many years. So we can look at earlier stages of biochemical recurrence like an oligometastatic disease. We can think of combination with radioligand therapy. So Lutetium-177 or alpha emitters labeled PSMA combined with immunotherapy, for example. Or we can think of combining disease-targeted therapies with external radiation therapy. At my institution we installed the first biology-guided radiation therapy from a company called RefleXion. So instead of using the anatomical signal to guide the X-ray beam for external radiation you use the PET signal to do that, which has many advantages.
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Active Surveillance And Watchful Waiting
If prostate cancer is in an early stage, is growing slowly, and treating the cancer would cause more problems than the disease itself, a doctor may recommend active surveillance or watchful waiting.
Active surveillance. Prostate cancer treatments may seriously affect a person’s quality of life. These treatments can cause side effects, such as erectile dysfunction, which is when someone is unable to get and maintain an erection, and incontinence, which is when a person cannot control their urine flow or bowel function. In addition, many prostate cancers grow slowly and cause no symptoms or problems. For this reason, many people may consider delaying cancer treatment rather than starting treatment right away. This is called active surveillance. During active surveillance, the cancer is closely monitored for signs that it is worsening. If the cancer is found to be worsening, treatment will begin.
ASCO encourages the following testing schedule for active surveillance:
A PSA test every 3 to 6 months
A DRE at least once every year
Another prostate biopsy within 6 to 12 months, then a biopsy at least every 2 to 5 years
Treatment should begin if the results of the tests done during active surveillance show signs of the cancer becoming more aggressive or spreading, if the cancer causes pain, or if the cancer blocks the urinary tract.
How Is Hormone Therapy Used To Treat Hormone
Hormone therapy may be used in several ways to treat hormone-sensitive prostate cancer, including:
Early-stage prostate cancer with an intermediate or high risk of recurrence. Men with early-stage prostate cancer that has an intermediate or high risk of recurrence often receive hormone therapy before, during, and/or after radiation therapy, or after prostatectomy . Factors that are used to determine the risk of prostate cancer recurrence include the grade of the tumor , the extent to which the tumor has spread into surrounding tissue, and whether tumor cells are found in nearby lymph nodes during surgery.
The use of hormone therapy before prostatectomy has not been shown to be of benefit and is not a standard treatment. More intensive androgen blockade prior to prostatectomy is being studied in clinical trials.
Relapsed/recurrent prostate cancer. Hormone therapy used alone is the standard treatment for men who have a prostate cancer recurrence as documented by CT, MRI, or bone scan after treatment with radiation therapy or prostatectomy.
Hormone therapy is sometimes recommended for men who have a “biochemical” recurrencea rise in prostate-specific antigen level following primary local treatment with surgery or radiationespecially if the PSA level doubles in fewer than 3 months.
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Remission And The Chance Of Recurrence
A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having no evidence of disease or NED.
A remission can be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. Although there are treatments to help prevent a recurrence, such as hormonal therapy and radiation therapy, it is important to talk with your doctor about the possibility of the cancer returning. There are tools your doctor can use, called nomograms, to estimate someone’s risk of recurrence. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.
In general, following surgery or radiation therapy, the PSA level in the blood usually drops. If the PSA level starts to rise again, it may be a sign that the cancer has come back. If the cancer returns after the original treatment, it is called recurrent cancer.
When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence, including where the recurrence is located. The cancer may come back in the prostate , in the tissues or lymph nodes near the prostate , or in another part of the body, such as the bones, lungs, or liver . Sometimes the doctor cannot find a tumor even though the PSA level has increased. This is known as a PSA-only or biochemical recurrence.
Proton Beam Radiati On Therapy
Proton beam radiation therapy capitalizes on a unique physical property of high energy protons generated from a cyclotron. The accelerated charged particles travel through tissue until reaching a depth determined by their energy. Once they reach that depth, the remainder of the radiation dose is deposited in a sharp Bragg peak with no dose going beyond that point. When multiple proton beams are used, a very sharp and tight radiation dose distribution is created. This modality is especially attractive when tumors are in close proximity to sensitive organs. PCa is one of the more common indications in which proton therapy is utilized.
At Washington University in St. Louis we are collaborating with investigators from Massachusetts General Hospital and the Harvard Medical School conducting a randomized clinical trial of IG-IMRT versus proton beam radiation in men with low and intermediate risk PCa. The PARTIQoL trial is seeking to measure and compare relative the impact of the two modalities on patient quality of life after treatment. provides a comparison of these two treatment modalities.
Axial CT slice showing conformality of intensity modulated radiation therapy. Radio-opaque markers are apparent in the anterior aspect of the prostate gland. Axial CT slice showing conformality of proton beam radiation therapy in the same patient as panel a. More sparing of the anterior-lateral rectal wall and less dose to peripheral tissues is apparent.
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What Is Intermittent Adt
Researchers have investigated whether a technique called intermittent androgen deprivation can delay the development of hormone resistance. With intermittent androgen deprivation, hormone therapy is given in cycles with breaks between drug administrations, rather than continuously. An additional potential benefit of this approach is that the temporary break from the side effects of hormone therapy may improve a mans quality of life.
Randomized clinical trials have shown similar overall survival with continuous ADT or intermittent ADT among men with metastatic or recurrent prostate cancer, with a reduction in some side effects for intermittent ADT .
What Are The Side Effects Of Brachytherapy
- Frequent urination or urinary retention or burning with urination
- Erectile dysfunction
- Urethral stricture or narrowing of the urethra
- Diarrhea or blood in the stool
- Secondary cancers
For the short time that the seeds are giving off larger amounts of radiation, you should avoid close proximity to children or pregnant women. Make sure to talk with your radiation oncologist or oncology nurse for instruction about radiation safety and exposure for family members or pets.
If you are traveling through an airport following brachytherapy treatment, there is a chance that radiation detectors will be set off. Talk to your radiation oncologist and ask for a note to indicate youve just had radiation treatment.
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