Prostate Cancer
Prostate Cancer Specialists - Make an appointment
- Wayne C. Waltzer, MD, FACS
- John Fitzgerald, MD, MSCI
- Massimiliano Spaliviero, MD
- Howard L. Adler, MD, FACS
- Matthew Petersen, PA-C
- Arielle Maggio-Ferguson, MS, PA-C
- Deborah Feliciano, NP-C
Introduction
Over the course of a man’s lifetime, some prostate cells may become cancerous. Due to advances with PSA screening, most cancers detected are very small, localized, and confined within the prostate. In other cases, the cancer is present may be more locally advanced. As cancers progress cells can undergo a process called metastasis - some cancer cells can spread outside the prostate to nearby regional lymph nodes or organs in the pelvic area. They eventually can spread to more distant parts of the body through the blood and lymph systems–most often to the bones. Determining whether the cancer is confined to the prostate or whether it has spread either locally or to more distant sites is often accomplished by radiographic imaging tests and a key step in selecting treatment.
PSA Screening
Most prostate cancers in the United States are identified through prostate-specific antigen (PSA) screening or digital rectal examination. Prostate-specific antigen is a protein in the blood produced by prostate cells. It is widely used as a screening test for prostate cancer. PSA is not specific for prostate cancer and can be elevated in benign conditions (infection, urinary retention). Your PSA level can be measured with a simple blood test. The higher the PSA level, the more likely that prostate cancer is present. In a digital rectal exam, a physician checks the prostate through the rectum to feel for any irregular areas on the prostate. While most prostate cancers are indicated by PSA results, some cancers produce little PSA but can be detected by exam. In addition, the percentage of free PSA to total PSA and other tests can be performed to gauge your risk of finding prostate cancer.
An elevated PSA may suggest an increased risk of prostate cancer. However, elevations of PSA can also occur in benign conditions. The decision to proceed to biopsy is sometimes complex. Some of the factors involved include the PSA level, nature of the prostate on exam, positive family history, age, race and other medical comorbidities. Biopsy should be performed only after discussing the risks and benefits with a urologist. The urologists at Stony Brook Medicine can often use nomograms to give you a sense of what the likelihood of finding cancer on biopsy might be.
Getting a Diagnosis of Prostate Cancer
If you are diagnosed with prostate cancer, deciding on which therapy to select can be a confusing process. Each treatment has its own mix of benefits, risks and impacts on quality of life. There is no treatment that has zero risk for complications or side effects. The good news is that several treatments are very successful for many prostate cancer patients, either in providing a cure or keeping the cancer under control for many years. These treatments can also minimize complications and side effects maintaining quality of life. However, your physician cannot always tell you specifically which treatment to choose, because for most men, the choice is significantly influenced by personal preferences.
In addition to the tumor risk factors described above, treatment choice is a balance between such factors as:
• Your age, life expectancy, general health and specific medical conditions
• Your feelings about cure vs. managing cancer without curative intent
• Your needs, concerns, values and social relationships
• Your feelings about specific side effects
Treatment options
Active Surveillance
As previously discussed, many prostate cancers do not pose an immediate risk to health. Treatment may therefore represent overtreatment of disease and may not require curative intervention. Active surveillance is a way to monitor low risk prostate cancer (cancer that is not an immediate risk to your health or well-being) with a plan of timely intervention should the tumor progress.
Radical Prostatectomy
A radical prostatectomy is surgery to remove the entire prostate gland and seminal vesicles after a diagnosis of prostate cancer is made. Sometimes, this also entails removal of the regional lymph nodes, depending on a number of factors. Side effects include urinary incontinence and loss of erections. Traditional surgery was performed via an open incision. Modern approaches include the use of a robotic surgical system – operated by the surgeon – to achieve a minimally invasive approach. This approach has resulted in less blood loss, shorter hospital stays and quicker recovery time. It may improve time to urinary continence and minimize trauma to the nerves controlling erections improving functional outcomes maintaining quality of life.
Radiation Therapy (External)
Radiation therapy is done with the intent of curing the disease by killing cancer cells. Radiation can be given as external beam radiation therapy (EBRT) and/or as brachytherapy (temporary or permanent radiation seed implants). This treatment is sometimes coupled with hormone therapy because most prostate cancers are driven by testosterone. Hormone therapy attempts to establish very low levels of testosterone in an effort to control the cancer progression. Side effects can include urinary urgency, incontinence, loss of erections, rectal urgency and occasionally bladder bleeding.
Brachytherapy (Seed Implants)
With brachytherapy, radiation is given from inside the body, with radioactive seeds placed permanently in the prostate or with narrow, seed-filled tubes that are placed temporarily for one or two days. Brachytherapy has similar side effects to radiation therapy
Proton Therapy
Proton therapy may have theoretical advantages over traditional radiotherapy. However, to date, no high level data has supported improved outcomes for cancer control or improved side effects. Additionally, it is known to be the most costly method of prostate cancer therapy.
HIFU (High Intensity Focused Ultrasound)
This treatment option has yet to be approved by the FDA for primary treatment of prostate cancer unless performed on a clinical trial. As such, it remains an experimental method of treatment.
Cryosurgery
This procedure, used to treat localized prostate cancer, kills the cancer cells in the prostate by freezing them. This procedure is mainly used in a salvage setting when radiation therapy fails.
Hormonal and Chemo-Therapy
Hormonal and chemotherapies are not curative treatment options for localized disease and are often used as in addition to the above therapies to improve cancer control.
Treatment of Locally Advanced Disease
Modern approaches to locally advanced prostate cancer – cancer that has not yet spread but is high risk to spread – include combining surgery first with post-operative radiotherapy. Sometimes, this will include hormonal therapy as well. These multidisciplinary approaches have been shown to result in improved outcomes.
What If Initial Treatment Is Not Sufficient or Your Cancer Recurs?
Despite advances in the diagnosis and management of prostate cancer, sometimes cancer can recur. The risk of recurrence increases with more advanced disease states at diagnosis. There are usually a number of treatment options that men in such situations can consider to successfully treat or control the cancer.
The Urologists that manage prostate cancer at Stony Brook Medicine are part of a multidisciplinary team that often collaborate to tailor therapy based on individual patient factors to achieve the following goals:
1) Cure cancer
2) Maintain quality of life (urinary continence and erectile function)
3) Provide minimally invasive treatment options
Men's Health Update: The Latest on PSA Screenings and Prostate Cancer
