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Prostate Cancer Evaluation and Treatment Options

Howard B. Abromowitz, MD, FACS

Prostate Cancer Evaluation and Treatment Options

The prostate is a sex organ similar to the size and shape of a walnut and is located between the bladder and the urethra.
Prostate Cancer is a malignant disease that develops from cells from prostate tissue and is generally known as adenocarcinoma of the prostate.

Prostate cancer is the most common non-skin cancer diagnosed in men. It is also the number two cause of cancer death in men in the US. Lung cancer is the number one cause of cancer deaths.  Roughly 230,000 new cases of prostate cancer are diagnosed each year in the US; approximately one-in-six men will be diagnosed during his lifetime.

The key to treating cancer has always been early diagnosis. The difficulty with prostate cancer is that when a man becomes symptomatic (fatigue, weight loss, voiding symptoms, bone pain) it is generally advanced and not curable. Therefore, primary care physicians must be involved in the process of early diagnosis. Screening considerations include risks factors such as: age, family history, ethnic background, and symptoms.

Typically, a patient is referred to a urologist because the patient has one or all of these indicators; an elevated PSA (Prostate Specific Antigen), an abnormal prostate exam during routine physical or related symptoms.

The urologist‘s evaluation will most likely will include a prostate ultrasound and biopsy. This procedure is usually preformed in the office under local anesthesia and is normally well tolerated. Potential side effects include; blood in the urine or rectum which generally clears quickly, bloody ejaculation with sexual activity that can last up to one month and fever and chills, which can be related to an infection. Infection is uncommon but can be very serious and requires IV antibiotics. Prostate tissue is then sent to our in-house pathology lab for analysis. Using the latest biomarkers and tests our expert pathologists provide fast, accurate results.

If the biopsy demonstrates adenocarcinoma of the prostate, then evaluation will continue. Many factors are considered prior to proceeding. Patients’ age, overall health status and Gleason score (the aggressiveness of the cancer) are of primary concern when proceeding with further evaluation.

Next steps in the evaluation process may consist of CT scan, bone scan and PET scan. Not everyone will need every test, sometimes very little imaging evaluation is necessary.

At this point the cancer stage is determined and treatment options are discussed.

Prostate Cancer treatment options depend on a few important factors:
o How localized is the cancer?
o How far has it spread?
o How is the patient’s overall health?
o What are the benefits and the potential side effects of the treatment

Treatment options:

  • Active Surveillance: For some men with early disease or very slow growing disease.  No intervention or delayed intervention is an option.  This generally requires regular follow up with blood test, rectal exams and possibly biopsies.  Active surveillance is also an option for those who have other serious health conditions or advanced age.

 

  •  Radiation Therapy: This uses radioactive high-powered energy to kill cancer cells in a very controlled and focused manner. Radiation therapy can be delivered by either using external beam radiation therapy or brachytherapy (placing radioactive seeds internally inside the prostate). Side effects of radiation therapy can include fatigue, painful urination, and frequent urination; rectal symptoms such as loose stools and rectal bleeding, as well as, erectile dysfunction. It is generally well tolerated and symptoms can usually be managed with medications.

 

  •  Surgery: Radical Prostatectomy includes removing the entire prostate, surrounding tissues and seminal vesicles. Lymph nodes are also often removed.  The surgery can be done though an open incision,laprascopically or done with the aid of the daVinci robot. The majority of surgical cases today use the robotic method.  Side effects of surgery include the risks of urinary incontinence as well as erectile dysfunction. The other general risk of anesthesia and surgery are also included.

 

  • Cryosurgery: Involves freezing tissue to kill cancer cells. This technique uses ultrasound guidance to place probes into the prostate directly and with use of very cold gas thru the probes the prostate tissue is frozen to the point of cell destruction. This is an excellent treatment but does carry some increased side effects. These include voiding issues secondary to scar formation in the urethra, high potential for erectile dysfunction and potential rectal injury.  It can be used as primary treatment as well as salvage treatment for men who have failed radiation therapy.

 

  • Hormone Therapy: This is used to decrease the male production of testosterone. Prostate cancer cells require testosterone to help them grow. By blocking this source of fuel the cancer cells will die or grow slower. They can also make cancer cells more sensitive to radiation therapy.   Hormonal Therapy can be administered many ways; with LH-RH agonists that prevent the testicles from producing testosterone, medications that block testosterone from reaching cancer cells; as well as, surgery to remove the testicles (orchiectomy).   Hormone Therapy is used in men with early disease as adjuvant therapy or in men with advanced disease to reduce the cancer burden and slow the cancer progress. Hormones alone will not cure prostate cancer but it can significantly reduce the cancer progression.   Side effects of hormonal therapy include; erectile dysfunction, hot flashes, decreased sexual desire, weight loss and loss of bone mass.

 

  • Chemotherapy: uses drugs to kill cancer cells directly and is administered either intravenous or orally.   Chemotherapy is used in men with advanced disease and often is used in combination with other treatments.

 

  • Immunotherapy (sipuleucel-T/Provenge): in this treatment the patient’s own cells are harvested and then genetically engineered in a lab to fight prostate cancer and then injected back to the patient through an IV.   This treatment is used for advanced disease.

 

As you can see the process is very involved and each case is very unique and must be evaluated as its own individual case. At Dayton Physicians we have experts who have treated thousands of patients with our team approach. We want to help you make appropriate and well-informed decisions.

We’re here for you; we have the capability to meet all of your needs while helping you get through this very difficult and confusing time.

Multiparametric MRI/Transrectal Ultrasound Fusion

Mark-Monsour-MD

 

Multiparametric MRI/Transrectal Ultrasound Fusion

Multiparametric MRI/Transrectal Ultrasound Fusion is a new modality that now is available at Miami Valley Hospital and Dayton Physicians Urology.  Many patients with an elevated PSA undergo prostate biopsy using standard transrectal ultrasound guidance. When the biopsy result is negative, and the PSA continues to rise, it is not uncommon for patients to undergo 3 and 4 sets of prostate biopsies. This can prove frustrating for both physician and patient. Now we have a technique available that can minimize the number of biopsies needed to diagnose cancer.

Although MRI of prostate has been available for years, 3TMRI is now available, which provides better resolution. Using this MRI, a multiparametric MRI can be performed to better identify lesions that may represent prostate cancer.  Then a fusion biopsy is performed. Fusing MRI images with real time transrectal ultrasound so that both targeted and systematic biopsies can be performed.  This results in a higher degree of accuracy in detecting cancer. This technique had been found to diagnose more clinically relevant prostate cancer.

Currently, it is felt that this technique is best suited for the patient who has a rising PSA despite a prior negative prostate biopsy.

Multiparametric MRI with or without biopsy has also been used in patients who have prostate cancer and have chosen active surveillance or to help confirm patients are possibly eligible for active surveillance. MRI can be useful for surgical planning, to assess whether a nerve sparing prostatectomy can be performed.  This technique can also be used to better stage prostate cancer, to detect whether prostate cancer has spread beyond the prostate or or whether seminal vesicles or pelvic lymph nodes are involved.

At Dayton Physicians Network we use cutting edge technology, right here, close to home.  Talk to your doctor to determine if this test is an option for you.

Xofigo-Therapy for Prostate Cancer Bone Pain

Gregory Rasp, MD

Bone pain due to metastatic prostate cancer hurts; we’re here for you with a new treatment to ease your pain.

An exciting new drug has been released for patients with metastatic prostate cancer to bone. Xofigo is a radioactive drug that homes in on just the areas in the bone where cancer is active. Once there, it gets taken into the bone and gives off a radioactive alpha particle to shrink the cancer. An alpha particle is a helium nucleus that consists of two protons and two electrons. Since it is relatively heavy, it does not travel very far in the body. That means it gives the cancer almost all of its “punch” with very little collateral damage.

Approved by the FDA in mid-2013 this drug has fewer side effects than most Chemotherapy regimens. It also appears to have fewer side effects than other similar radiopharmaceuticals. That’s great news for our patients. Even better, Xofigo has been shown in randomized trials to improve survival for prostate cancer patients suffering from bone metastases and delay the onset of progression of cancer. Our experience with administering the drug has been very positive, many of the patients receiving this treatment have enjoyed less pain and better quality of life.

Xofigo is not for everyone. A patient should have painful bone metastases from prostate cancer without spread to liver or lungs. They also should have failed front line hormone therapy before trying Xofigo.

Ask your doctor if Xofigo might be right for you.
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Advanced/Recurrent Prostate Cancer

John J. Haluschak, MD

We treat advanced/recurrent prostate cancer right here, close to home.

Historically, advanced/recurrent prostate cancer was treated with anti-androgen based therapy to achieve very low levels of testosterone (androgen). When that therapy stopped working, the cancer was called – castrate resistant prostate cancer. A decade ago, for those patients with castrate resistant prostate cancer and who were in pretty good health, the next step would be to try an older chemotherapy agent – Mitoxantrone.

Thankfully, we have come a long way in helping prostate cancer patients. Since those days we have number of treatments that address androgen (testosterone) dependent and androgen independent prostate cancers.

In the near future prostate cancer specific genetic information will likely dictate treatments but also which prostate cancers are not serious and which are life threatening or will cause serious problems. That is the whole concept behind active surveillance and appropriate watchful waiting. It’s even more important to know if the progressive cancer is dependent on the androgen pathway or not. It’s also important for us to understand the benefits of current, as well as; future immune based treatments.

 

For now I would like to address approved and soon to be approved treatments for progressive life-threatening prostate cancers needing treatment when castrate type treatments (ADT with or without Casodex) stop working.

Treatments approved for this situation includes Xtandi, Zytiga, Xofigo, Taxotere, Jevatana, Provenge and the likely soon to be approved, ARN509, Octorenel, Galetrone. One major questions, is best to try first and should some of these drugs be given together.

In simple terms, when dealing with advanced castrate resistant prostate cancers we have to decide if we want to treat the cancer using approaches that work for androgen dependent prostate cancers or assume this won’t work (we currently call these cancers, androgen independent). In the US it is common to at least try the drugs that work on androgen dependency. This would be Xtandi or Zytiga and likely soon to be approved, Octorenel, ARN509 and Galetrone. Each of these products has their pros and cons. It’s not necessarily Zytiga is better than Xtandi, but which is better for you. We are also studying giving them together.

The other approved treatments are for androgen independent prostate cancers. The first approved immune therapy was for prostate cancer, called Provenge. One collects a patients T-cells (collection usually at the blood collection center taking about 3 hours) that are then modified to recognize the prostate cancer better and the product is then given as an infusion (3-4 days later) to the patient. This is done every two weeks over 3 treatments with the course of treatment lasting just over a month. It’s important to look at the FDA approved information – on the product website, if want wants to learn more about Provenge.  By itself this is not that useful a treatment. But if responding to other treatments, especially Zytiga or Xtandi – a 3rd all patients can attribute their survival at 3 or 4 years just to getting Provenge.

Another treatment that helps survival is Xofigo. This is a monthly injection of a radioactive agent that works for prostate cancer patients when the prostate cancer mainly involves just the bones and is causing significant bone related pain. Fortunately prostate cancer, like breast cancer likes to metastasis just to bones. The pain improvement can be early and dramatic.

Both Provenge and Xofigo can be used with or sequentially with Zytiga, Xtandi, and likely as stated above, works best if those agents work.

 

The remaining approved treatments for prostate cancer are cytoxic or chemotherapy agents. Often people understandably worry about the side effects of chemotherapy, but the majority of time the side effects are much less concerning than the symptoms that often occur from the cancer. The most successful chemotherapy to date is Taxotere and its’ cousin, Jevtana.

Jevtana has the advantage of be very well tolerated with few side effects, including very little nausea, fatigue, or hair loss. The real risk for most patients- will it work. Grade I side side effects are frequently seen,sometimes from the drug, but they are more often not related to the actual product. We still must watch closely for any side effects.

 

Currently, we are interested in allowing our immune system to fight the cancer and recognizing that the cancer cell may produce proteins that resist our immune system. That’s the idea behind Provenge. We are currently exploring a number of treatments that can help with this problem. If we can negate this resistance of the cancer cell resisting our own wonderful immune system, then we should restore our ability to fight the cancer.

The good news is we should only have more options in the future, to deal with advanced/recurrent prostate cancer.

I encourage patients to review the FDA approved product information that provides accurate information on each of the specific products. Fortunately there are numerous helpful web sites to learn more about advanced or recurrent prostate cancer. Here are a few recommended sites that have reliable information; National Comprehensive Cancer Network, American Cancer Society and Cancer.Net

At Dayton Physicians Network we offer one of the country’s best comprehensive prostate cancer programs including clinical trials not available in Cincinnati, Columbus or Cleveland.  We bring the best prostate cancer care to the Midwest and we are privileged to treat these patients, who are the real heroes in this enormous battle against life threatening prostate cancer.

We’re here for you For more information, please call 937.771.2326

 

Men’s Health Month

Men’s Health Month
Article: Mens-Health-Month-060115

June is National Men’s Health Month. Dayton Physicians Network joins healthcare professionals across the US in encouraging men to take time this month to focus on their own health and well-being.

We recommend that all men take the time to schedule an appointment with their primary health care provider to have an open and frank discussion about their health status. This is the first step towards becoming the healthiest you possible.

At Dayton Physicians we know that many diseases, and in fact, many cancers are preventable. So, when you have that conversation with your healthcare provider be prepared to also discuss your personal family history and recommended cancer screenings for your age and health status. We recommend that all men discuss cancer screening for testicular, prostate and colon cancers in particular.

Get Checked! Do it for yourself, your family, and for a healthier future…cancer screenings save lives!