Diseases

Cancer Of The Prostate (Prostate Cancer) Information

Bisphosphonates

The bisphosphonates are a group of drugs used to treat several conditions people can get including osteopenia and osteoporosis. They also can lower elevated blood levels of calcium in people with cancer. They work by affecting cells in the bones called osteoclasts, which work to remove bone. These drugs encourage the death of the osteoclasts. In prostate cancer they impact the course of skeletal-related events including reducing pain in the bones, and delaying the progression of bone metastases associated problems including the appearance of fractures (breaks in bones). While the bisphosphonates can affect the growth of prostate cells in the laboratory, they are presently not considered a targeted or direct-acting drug like a chemotherapy or hormonal treatment. They have also not been shown to prevent the appearance of bone metastases in prostate cancer patients. Nonetheless, they are an important part of the treatment of prostate cancer patients with bone metastases.The most potent of the bisphosphonates is called zoledronic acid (Zometa). It is given intravenously. Its side effects are primarily reactions to the drug infusion. The dose of Zometa may need to be adjusted if the patient's blood tests show signs of deterioration in the function of the patient's kidneys. In addition, its use can predispose patients to serious dental conditions including what is called osteonecrosis of the jaw, which can result in breakdown of the bone of the jaw after dental extractions. It is advised that you see your dentist and have needed dental procedures performed prior to the start of a bisphosphonate.

Bone-targeted therapy

Bone health is an essential component of prostate cancer treatment. Both the disease itself, as well as the treatment of the disease with androgen deprivation therapy, can have a significant impact on bone health. Several bone-targeted therapies have been approved.

Castrate-resistant prostate cancer (CRPC) and metastatic castration-resistant prostate cancer (MCRPC)

A patient is noted to have metastatic castrate resistant prostate cancer if the individual has progressive prostate cancer with metastases while on ADT. The individual should have a serum testosterone level obtained to make sure that it is at castrate level ( 50 ng/dL, this would indicate that the source of the progression is inadequate androgen deprivation and alternative ADT should be considered. If the individual is determined to have a castrate level of testosterone on ADT with progression of disease (rising PSA) on ADT, the individual is considered to have metastatic castrate-resistant prostate cancer. If metastases are identified, then the individual has metastatic castration-resistant prostate cancer. Over the past several years, a number of therapies have been approved for the treatment of metastatic castrate-resistant prostate cancer, including a new androgen receptor blocker, chemotherapy, immunotherapy/vaccine therapy, as well as bone-directed therapies. Though each of these therapies have unique ways in which they work and different side effects, all have been demonstrated to prolong survival by approximately three to four months each. The sequencing of the various treatments (which should be used first) is not well defined at present. Sipuleucel-T, a vaccine immunotherapy, is the only agent that is specifically approved for use early on in the time frame before one has significant symptoms (asymptomatic or minimally symptomatic). Studies are ongoing to evaluate the best sequence of treatments.

Chemotherapy

Chemotherapy or "chemo" for prostate cancer involves the use of medications either in pill form or by injection into the veins, which can kill or at least slow the growth of metastatic prostate cancer cells. It does not presently have a role in the treatment of early stage prostate cancer except as part of clinical trials/research studies. The use of chemotherapy in metastatic prostate cancer is presently not a potentially curative treatment, but it can relieve symptoms of prostate cancer, and can prolong life. It is usually used in the setting of CRPC, castration- (medical or surgical) resistant prostate cancer.Chemotherapy drugs work in many different ways. These drugs may damage the DNA of the cancer cells or disrupt the cells ability to divide (mitosis). These effects can cause cells to die. Not all prostate cancer cells may be sensitive to these drugs, but some may be. A tumor (a mass of cancer cells) will shrink if more cells are killed and removed than continue to grow and divide. As many normal tissues in the body also undergo the same patterns of growth and mitosis, these drugs have numerous side effects due to their effects on normal tissues.Active chemotherapy drugs for the treatment of prostate cancer today include:

• Taxotere (Docetaxel) -- first-line chemotherapy option
• Carbazitaxel (Jevtana) -- option in individuals who have failed docetaxel
• Mitoxantrone (Novantrone)

Complementary and alternative care approaches

In addition to standard types of prostate cancer treatments, there are other approaches that patients may choose during their treatment for their disease.Some of these treatments are called complementary treatments and may help with control of symptoms or problems the patient may be experiencing. Examples of these include acupuncture for pain control, yoga and meditation for relaxation, as well as guided imagery, aromatherapy, and other techniques. Tell your doctors about all treatment approaches you are engaged in. These approaches usually will be of no harm to you, and may be very beneficial. Knowing what you are doing may help your doctor to better understand and coordinate your treatments and medications. Herbal therapies have been demonstrated in the lab to affect prostate cancer cells, but in many cases, have not been proven to be clinically effective. PC-SPES is an herbal therapy that has been used in the past for prostate cancer. It was associated with an increased risk of blood clots. Thus, prior to taking this or other herbal therapies, discuss these therapies with your doctor.Be very careful about alternative treatments. The vast majority of medical professionals keep up-to-date on the latest advances, or are willing to research them for patients when asked. No truly effective treatments are being withheld from patients, though alternative care providers often say they are in an attempt to sell patients on their types of treatment. Such alternative therapies can do harm to patients, and can interfere with conventional treatment. Alternative care providers can be reasonably said to be preying on the desperation of cancer patients.If nutritional supplements are suggested in addition to conventional therapy by an alternative care professional, tell all your doctors what you are taking. Some nutritional substances can interfere with the effectiveness of some conventional cancer treatments. Some "natural" substances can be toxic and can result in side effects or problems your regular doctor may not recognize unless they know what you are taking.Prostate cancer patients, like all cancer patients, are frightened. Discuss your anxiety and concerns with your primary care doctor, urologist, and radiation and medical oncologists. They have many ways to help.

Cryotherapy (cryosurgery, cryoablation)

Cryotherapy is a minimally invasive therapy that damages tissue by local freezing.Cryotherapy is most frequently used as a salvage treatment after failure of radiation therapy. As an outpatient, hollow needles are placed into the prostate through the perineum (the space between the scrotal sac and the anus) under image guidance. A gas is passed through the needles to freeze the prostate. Warm liquid is passed through the urethra at the same time to protect it. The needles are removed after the procedure. While potentially effective for local control of cancer in the prostate gland, the side effects can be significant and include pain and the inability to urinate. Potential long-term effects include tissue damage in needle-insertion areas, impotence, and incontinence. Cryotherapy is not currently recommend as a primary treatment for management of prostate cancer.

Focal therapy

Focal therapy involves ablation of the prostate cancer within the prostate with preservation of the surrounding healthy tissue. A number of focal therapies are being investigated, and a comparison of the efficacy of each of these therapies cannot be made given the limited data on many of these therapies. Focal therapies being investigated include cryotherapy, high-intensity focused ultrasound, laser ablation, photodynamic therapy, irreversible electroporation, radiofrequency ablation, and focal brachytherapy. As many of these are considered experimental, only cryotherapy will be briefly reviewed.

Hormonal therapy

Prostate cancer is highly sensitive to and dependent on the level of the male hormone testosterone, which drives the growth of prostate cancer cells in all but the very high-grade or poorly-differentiated forms of prostate cancer. Testosterone belongs to a family of hormones called androgens, and today front-line hormonal therapy for advanced and metastatic prostate cancer is called androgen deprivation therapy (ADT).In the past, this was accomplished by surgical castration called bilateral orchiectomy. In that procedure, the testes were both removed. Today, doctors can block the function of the testes in a controllable and most often reversible fashion with drugs that prevent the production of testosterone (medical castration). These agents can result in shrinkage of the prostate gland, can stop prostate cancer cells from growing for up to several years, and can relieve pain caused by prostate cancer that has spread or metastasized into the bones by shrinking the cancer. The use of ADT does not produce a cure. Over time, the prostate cancer cells will develop an ability to grow despite the lack of hormones (castrate resistance). Another form of hormonal therapy is the use of androgen receptor blockers; these medications prevent testosterone from attaching (binding) to the prostate cancer cell and being absorbed into the cell where it can help the cell survive and grow.Hormonal treatment today is primarily used in the treatment of locally advanced and metastatic prostate cancer. It may be used in conjunction with primary curative therapies (surgical and radiation based) to shrink the cancer/prostate to increase the likelihood of cure of the treatment, neoadjuvant therapy, and with radiation therapy for several years after treatment (adjuvant therapy). However, the primary role of ADT is in the treatment of widespread or metastatic prostate cancer. While it is not a curative treatment in that setting, it can both reduce symptoms and slow down the growth of the prostate cancer to prolong life.Today medicines used to block testosterone production by the testes include:

• LH-RH agonists: Leuprolide (Lupron), goserelin (Zoladex), histrelin (Supprelin LA), and triptorelin (Trelstar) are examples of these mediations. These are either given by injection into the muscle or under the skin at varying intervals of at least one month or longer.
• LH-RH antagonists: Degarelix (Firmagon) is a monthly injection that is given under the skin.

• Flutamide (Eulexin), bicalutamide (Casodex), nilutamide (Nilandron), and an even more effective form called enzalutamide (Xtandi): Currently Xtandi is recommended for use only in those patients who have metastatic castrate-resistant prostate cancer (prostate cancer that is refractory to traditional ADT). Xtandi is different than the other androgen receptor blockers in that it has three mechanisms of action: (1) It prevents androgens (testosterone) from binding to the androgen receptor, (2) it prevents the androgen receptor from moving into the central area (nucleus) of the cell, and (3) it prevents binding of the androgen receptor to DNA and stimulating growth. Most common side effects of Xtandi include fatigue, back pain, decreased appetite, constipation, arthralgia, diarrhea, hot flush, upper respiratory tract infection, swelling of the legs, shortness of breath with exertion, headache, hypertension, dizziness, and weight loss. Less commonly seizures and posterior reversible encephalopathy syndrome characterized by seizure, headache, lethargy, confusion and blindness, may occur.

• Estrogen: This female hormone has been utilized in the treatment of prostate cancer as it also results in medical castration. Its mechanism of action remains under study, and its association with a high risk of heart attack and blood clots when used in high doses has diminished the frequency of its use, particularly in front-line therapy. Other side effects include breast enlargement/pain (gynecomastia). Estrogen and related drugs may still have a role in the treatment of metastatic prostate cancer in select individuals.
• Adrenal androgen synthesis inhibitors: The adrenal glands, a pair of small glands that are located above the kidneys, also produce a small amount of testosterone. Individuals on traditional ADT have testicular production of testosterone suppressed but still may have testosterone production from the adrenal glands. In individuals on ADT who have continued growth of the prostate cancer (rising PSA), the use of adrenal androgen synthesis inhibitors may be useful. This group includes a drug called ketoconazole, which was primarily developed to treat fungal infections, but has shown to be effective in the treatment of prostate cancer. More recently, an agent called abiraterone acetate (Zytiga) has been developed. It has a similar effect on androgen synthesis, but it is more powerful than an older agent called ketoconazole (Nizoral) and has fewer side effects. The use of Zytiga in combination with prednisone is considered in individuals failing traditional ADT and individuals who have castrate-resistant prostate cancer (failed first-line ADT). More common side effects of Zytiga include fatigue, back or joint discomfort, peripheral edema, diarrhea, nausea, constipation, and low potassium levels. Blood pressure, liver tests, potassium, and phosphate levels should be monitored regularly when initially using Zytiga.
• Steroids: These agents including prednisone may have beneficial hormonal effects in prostate cancer, including slowing the production of androgen by the adrenal glands. They often make the patient feel better, but have many side effects including inducing or worsening diabetes, fluid retention, cataract formation, weight gain, and osteoporosis.
• Agents that block the conversion of testosterone to its active metabolite: Finasteride (Proscar) and dutasteride (Avodart) are not approved by the Food and Drug Administration (FDA) for the treatment of prostate cancer, however, they have been used (off-label) in treating prostate cancer by preventing the conversion of testosterone to its active metabolite called DHT (dihydrotestosterone). These drugs are frequently utilized for the symptoms of prostate enlargement in men without prostate cancer and appear to reduce the risk of development of prostate cancer. Their side effects are limited. They are used in combination with other agents to optimize androgen blockade. As these medications are not currently approved for use in men with prostate cancer, consult with your physician and insurance provider to ensure that their use is medically appropriate and will be covered.

Immunotherapy/vaccine therapy

The immune system works by trying to very specifically target infections or to attack and kill cells which are either cancerous or are not our own. The immune system attempts to eliminate these invading problems using antibodies and cells called T-lymphocytes; in cases of cancer the immune system still struggles to control the problem for many reasons. The cancer seems often to either depress or overwhelm the immune system. Immune therapies (immunotherapy) attempt to boost the capability of our immune system.Provenge (Sipuleucel-T) is a form of immunotherapy, a vaccine therapy, used to treat prostate cancer that has metastasized. It is appropriate in patients whose cancer is no longer responding to hormonal therapy but who are asymptomatic or minimally symptomatic. These patients may be showing a rise in PSA level after previous hormonal treatment has kept the PSA down for a long time.Provenge therapy involves taking some of your own blood cells and growing them outside the body in the presence of a substance that is specific for prostate cancer. The cells are then given back to you by infusing them into the bloodstream. These cells can attack prostate cancer cells, and can help program other blood cells to do the same. Such treatment causes few side effects, including mild to moderate chills, fever, and headache, and can prolong survival by several months.

Monoclonal antibody therapy

Denosumab (Xgeva) is a monoclonal antibody agent that inhibits the work of osteoclasts in a manner different from bisphosphonates. The medication inhibits a protein that tells the osteoclasts to remove bone. This drug is useful as a treatment for all of the conditions for which bisphosphonates are used. Given as an injection under the skin at intervals, it has a better side effect profile than the bisphosphonates. It does not require dose adjustments if kidney function deteriorates. It can still cause osteonecrosis of the jaw to occur. It is considered an important new drug in the treatment of bone metastases in prostate cancer patients. In some studies it appears to be more effective than Zometa in delaying the initial onset of skeletal-related events in patients with bone metastases.

Observation and active surveillance

These two options are not the same. Both observation and active surveillance therapies share in common the decision up front to hold on treatment of the cancer and to follow the cancer periodically to determine if there is progression. Observation involves monitoring the course of the prostate cancer with the goal of treating the cancer with palliative care for the development of symptoms or changes in physical examination or PSA that suggest that symptoms will develop soon. Observation treatment is not trying to cure the cancer, rather to treat symptoms of cancer progression. Thus, observation treatment is preferred for men with low-risk prostate cancer and with a life expectancy of less than 10 years.Active surveillance involves actively monitoring the course of the prostate cancer with the intent to intervene, with the intention to cure if the cancer appears to be progressing. Active surveillance is preferred for men with very low risk prostate cancer and a life expectancy of

Prostate cancer biopsy results

The result of the pathologist's analysis of the biopsy cores under the microscope is the only way to diagnose prostate cancer. The prostate biopsy technique samples many areas of the prostate but rarely the biopsy can miss small areas of prostate cancer in the prostate. Thus, if the initial biopsy results are negative but the urologist is still suspicious based on the results of the examination, the ultrasound images seen during the procedure, or the PSA, additional biopsies or tests may be recommended.The pathologist's report on the biopsy sample showing prostate cancer will contain much detailed information. The size of the biopsy core and the percentage of involvement of each core will be reported. Most importantly the prostate cancer present will be assigned a numerical score, which is usually expressed as a sum of two numbers (for example, 3 + 4) and is referred to as the Gleason Score. This characterizes the appearance of the cancer cells and helps predict its likely level of aggressiveness in the body. It is often also referred to as the grade of the prostate cancer.A new prostate cancer grading system was developed in 2014 to help assess risk and assign a Gleason grade group. This grade group is particularly useful in Gleason score 7, where the predominant cell type could be a 4 or a 3, which may impact prostate cancer risk.

• Gleason grade group 1: Gleason score
• Gleason grade group 2: Gleason score 3+4= 7
• Gleason grade group 3: Gleason score 4+3 = 7
• Gleason grade group 4: Gleason 4+4 =8, 3+5 = 8 and 5+3 = 8
• Gleason grade group 5: Gleason score 9 and 10

Prostate cancer facts

• The prostate is a gland that is a part of the male reproductive system that wraps around the male urethra at its exit from the bladder.
• Common problems are benign (noncancerous) enlargement of the prostate called BPH (benign prostatic hyperplasia), acute and chronic infections of the prostate (acute and chronic bacterial prostatitis), and chronic inflammation of the prostate that is not related to bacteria (chronic prostatitis [non-bacterial]).
• Prostate cancer is common in men over 50 years of age, with the risk of developing prostate cancer increasing with aging. Certain populations are at increased risk for developing prostate cancer, particularly African-Americans and men with a father or brother diagnosed with prostate cancer at a younger age.
• Symptoms of prostate problems (and prostate cancer) include urinary problems such as
  • decreased force of urine stream;
  • difficulty starting (hesitancy);
  • the need to strain to urinate;
  • stopping/starting of the urine stream (intermittency);
  • frequent urination;
  • dribbling;
  • pain or burning during urination,
  • erectile dysfunction;
  • painful ejaculation;
  • blood in urine or semen and/or deep back, hip, pelvic or abdominal pain;
  • other symptoms may include weight loss, bone pain and lower extremity swelling.
• Prostate cancer screening consists of periodic laboratory testing, usually every one to two years, which includes a prostate specific antigen (PSA) test and digital rectal examination. Prostate cancer screening is not for everyone and the pros/cons should be discussed with a primary care provider and/or urologist (specialist who treats problems with the urinary system).
• A concern for prostate cancer is raised when blood testing, PSA, is abnormally increased and/or an abnormal area of the prostate is felt on a rectal examination.
• Prostate cancer is definitively diagnosed by removal of small cores of prostate tissue (prostate biopsies), which are then examined under the microscope by a pathologist.
• Treatments for prostate cancer may include observation, active surveillance, surgery (radical prostatectomy), radiation therapy (external beam or placement of radioactive pellets into the prostate), hormone therapy, chemotherapy, immune/vaccine therapy, and other medical therapies that can affect prostate cancer cell growth.
• Prostate cancer is a leading cause of cancer and cancer death in males; in some men, identifying it early may prevent/delay spread and death from prostate cancer.

Radiation therapy

Radiation therapy as with surgical therapy is a potentially curative treatment that uses radiation to kill cancer cells. Radiation therapy can be performed via external beam therapy (EBRT) or the placement of radioactive seeds into the prostate (prostate brachytherapy).EBRTAn X-ray machine uses a low energy radiation beam to take a picture of a portion of the body. Radiation therapy machines put out high energy beams that can be focused very precisely to deliver treatment to a site. The radiation does not "burn out" the cancer, but damages the cells' DNA, which causes the cancer cells to die. This process can take some time to occur after the radiation treatments have been given.The radiation passes directly through the tissues in EBRT. Radiation treatment used today delivers very little energy to normal tissues. It just passes through. Most of the energy is able to be focused and delivered directly to the area of the prostate gland containing cancer. This process minimizes damage to healthy tissue.EBRT can be administered in a variety of different ways including 3-D CRT, IMRT, and others. EBRT is classically administered in brief daily treatments, 5 days a week over several weeks. While the radiation does not remain in the body with this approach, the effect of the daily fractions is cumulative. Newer forms of EBRT using machines called CyberKnife allow the treatment to be completed in shorter periods of time.A recently popular technique of EBRT is called proton beam radiation, which can theoretically more closely focus on the area being treated. Proton beam radiation therapy is more expensive. Its side effects presently appear similar to those discussed for standard radiation therapy, except for an increased incidence of gastrointestinal side effects with Proton beam radiation. Studies comparing the effectiveness and overall results of conventional radiation therapy versus proton beam therapy have not been completed yet.Radiation therapy to the prostate gland by external beam technique may cause fatigue and bladder and/or rectal irritation. One may experience frequency of urination or stools and blood in the urine or stools. These effects are usually temporary but may recur or persist long after treatments are finished. Radiation damage to adjacent tissues can cause skin irritation and local hair loss. Delayed onset of impotence can occur after radiation therapy due to its effect on normal tissues, including nerves adjacent to the prostate. Radiation therapy may be given alone or in combination with hormonal therapy, which can also shrink up the prostate gland, thereby reducing the size of the radiation area or field that needs to be treated. The NCCN guidelines recommend that patients with high-risk and very-high-risk prostate cancer receive neoadjuvant/concomitant/adjuvant hormone therapy (androgen deprivation therapy [ADT]) for a total of two to three years if the overall health of the patient permits and that patients with intermediate-risk prostate cancer be considered for four to six months of neoadjuvant/concomitant/adjuvant hormone therapy (ADT). Pelvic lymph node radiation may be considered for high-risk and very high-risk prostate cancer patients. Patients with low-risk prostate cancers should not receive ADT or lymph node radiation.EBRT is appropriate for men who are candidates for radical prostatectomy but do not wish to undergo the surgery or who are not ideal surgical candidates.EBRT may also be used to treat recurrent prostate cancer localized to the prostate bed (where the prostate was before it was removed surgically). It is also used to treat bone metastases (spread of the prostate cancer to the bone) to reduce pain or if the cancer is pressing on important structures, including the spinal cord.Brachytherapy refers to the use of radiation sources -- sometimes referred to as seeds -- placed into the prostate gland. Brachytherapy may be done with what is called low-dose rate (LDR) or high-dose rated (HDR) technique. In LDR brachytherapy, types of radioactive seeds, which only briefly put out a form of radiation that does not travel very far through tissues, are permanently implanted in the prostate gland. High-dose rate (HDR) brachytherapy involves the temporary placement of different types of seeds or sources that give off higher amounts of more penetrating radiation. These seeds administer higher doses of radiation for longer periods of time and cannot be left in the body. Such sources are placed in the prostate gland through surgically implanted tubes. These HDR sources are removed along with the tubes in a couple of days. In LDR brachytherapy, the seeds are placed in the operating room using image guidance to ensure the seeds go into the right places -- 40-100 seeds may be placed. With LDR, you can go home shortly after you wake up after the procedure. In HDR, you must stay at the hospital for a few days. If the prostate gland is large, hormonal treatment (ADT) may be used to shrink the gland before the brachytherapy is done. Brachytherapy may also be combined with external beam radiation therapy to further increase the dose of radiation therapy given to the prostate gland.Brachytherapy can cause some blood in the urine or semen. It can cause a feeling similar to constipation due to the swelling of the prostate gland. One can also experience transient troubles urinating, called urinary retention, related to swelling of the prostate gland, that may require short-term catheter placement. It can also make you feel that you want to move your bowels more often. There may be some long-term problems with irritation of the rectum, difficulty urinating due to scar tissue formation, and even delayed-onset impotence.The NCCN guidelines version 2.2017 indicate that brachytherapy can be used as a single therapy (monotherapy) in patients with low-risk cancers and select individuals with low-volume intermediate risk cancers. Intermediate-risk prostate cancers can be treated by a combination of brachytherapy and EBRT +/- four to six months of neoadjuvant, concomitant/adjuvant ADT.High-risk patients can be treated with a combination of EBRT and brachytherapy +/- two to three years of neoadjuvant/concomitant/adjuvant ADT.Patients with a very large prostate or very small prostate, those with symptoms of bladder outlet obstruction, or who have had a previous transurethral resection of the prostate (TURP) are more difficult to treat and have a greater risk of side effects.Brachytherapy can be used as a salvage therapy for recurrent/persistent prostate cancer after external beam radiation therapy (EBRT). The risk of side effects is increased when used as a salvage therapy.

Radiopharmaceuticals

The use of substances that are radioactive as a treatment for bone metastases has been tried for years. Strontium-89 and samarium-153 have been used in the past. They decrease pain in patients with prostate cancer with bone metastases but they do not prolong life; these medications lower levels of healthy blood cells in patients who receive them.Recently a form of radium called Ra-223 (Xofigo) has been approved for use in prostate cancer patients with metastases to bone but not to other internal organs. Radium is like calcium and it migrates to bone where it acts locally. As an alpha emitter, radiation from radium does not travel far enough in the body to damage other healthy tissues. Unlike the bisphosphonates, the use of this agent reduces pain and can prolong survival. It is administered by an injection into a vein. It can cause nausea, diarrhea, and low blood counts.

Research techniques

High-intensity focused ultrasound (HIFU) is an approach to therapy that is presently approved for use in Europe, and is under study in the U.S. It uses high intensity sound waves focused on the prostate gland to heat and thereby kill cancer cells. It should only be used as part of a research study (a clinical trial). The safety, side effects, and comparative effectiveness to surgery and radiation therapy must be established.Clinical trials are research studies being conducted to evaluate new treatments for prostate cancer. These include approaches such as HIFU, as well as modifications of surgical and radiation techniques, and new drugs and immune therapy approaches. The National Comprehensive Cancer Network, a group assembled from the major comprehensive cancer centers of the U.S., considers that the best care of a cancer patient is afforded by their participation in a clinical trial. Patients with prostate cancer should always ask if there is a clinical trial option for them at any point in their therapy. Clinical trial participation assures you that your treatment has been considered by numerous cancer experts and is at least as good as a standard treatment that you may receive off of a clinical trial. In addition, the results of your treatment will be carefully analyzed in anonymous fashion, and results can be used to help others.

Surgery for prostate cancer

The removal of the entire prostate gland and the urethra that runs through the prostate and the attached seminal vesicles is referred to as a radical prostatectomy. A variety of approaches are available for performing this procedure. The type of approach may vary with your surgeon's preference, your physique, and medical conditions. Traditionally, radical prostatectomy was performed through an incision that extended from below the belly button (umbilicus) down to the pubic bone or through an incision underneath the scrotum (perineal approach). In an effort to decrease the morbidity of the procedure, laparoscopic approaches to performing a radical prostatectomy were developed. The use of the robot to perform the laparoscopic radical prostatectomy is currently the most common method to perform a radical prostatectomy. Compared to open radical prostatectomy, robotic assisted laparoscopic radical prostatectomy is associated with less postoperative discomfort and sooner return to full activity, as well as less intraoperative blood loss with comparable outcomes regarding urinary continence, erectile function. Radical prostatectomy is an appropriate treatment option for those individuals with clinically localized prostate cancer that can be removed completely surgically and who have a life expectancy of 10 or more years and have no medical contraindications to surgery.In some men, a pelvic lymph node dissection may be recommended depending on the Gleason score, PSA, and radiologic findings. This involves removing lymph nodes in the pelvis that are common sites for prostate cancer to spread. This may be performed at the time of the radical prostatectomy or rarely as a separate procedure prior to definitive therapy.Side effects of radical prostatectomy may have a significant impact on quality of life. Thus, it is essential that you discuss with your surgeon prior to the surgery the risk of such side effects occurring, as well as treatments that can occur after surgery to treat such sides effects.Erectile dysfunction is a side effect of radical prostatectomy. The risk of developing erectile dysfunction varies with your age, erectile function status prior to surgery, and the need to remove one, both, or neither of the pelvic nerve bundles during the radical prostatectomy. The pelvic nerve bundles lie on either side of the prostate, just outside the capsule or outer edge of the prostate. The pelvic nerve bundles are involved in the erectile process, the ability to have an erection. Impotence -- or the inability to have and sustain an erection of a quality sufficient for successful intercourse -- can occur after radical prostatectomy due to trauma, damage, or removal of the pelvic nerve bundles. Nerve-sparing radical prostatectomy can be performed in select individuals with lower risk prostate cancer. Even after nerve-sparing radical prostatectomy, one may experience transient erectile troubles related to reversible trauma to the nerves during surgery. Specialists treating erectile dysfunction may recommend penile rehabilitation therapy in hopes of helping the nerves recover their function better and faster after radical prostatectomy.Urinary incontinence is another risk after radical prostatectomy. The radical prostatectomy involves the removal of a portion of the urethra, which passes through the prostate gland. During the procedure, the urethra is sewn back to the bladder. When the prostate gland is removed, there may be some trauma to the sphincter around the urethra, which helps prevent leakage of urine. As with the risk of erectile troubles, the risk of incontinence may vary with your continence status prior to surgery, whether or not you have had prior surgery on the prostate (transurethral prostatectomy [TURP]) and the function of your sphincter muscle prior to surgery.Both erectile dysfunction and urinary incontinence are treatable conditions. The treatment for either may involve medical and/or surgical therapies. You should discuss such risks and the treatment of these with your surgeon prior to surgery.Other risks of radical prostatectomy include infection, bleeding, discomfort, and blood clots (deep venous thrombosis [DVT]) and rarely death. To help prevent a DVT, you may be asked to wear special compression devices on your legs or be administered a blood thinner.Radical prostatectomy is rarely performed as a salvage procedure after other primary therapy, such as radiation therapy, has failed. The risk of complications, such as, erectile dysfunction, incontinence, bleeding, and stricture, are greater with salvage therapy.