Prostate Cancer

Prostate cancer is the most common non-skin cancer and the second leading cause of cancer death among men in the United States. It is one of the most common problems I work with on a daily basis. Approximately 300,000 men will be diagnosed with prostate cancer in the United States this calendar year.

The incidence of prostate cancer increases with age. Older men are much more likely to have prostate cancer, with an average age at diagnosis at 65. African American men and men with a family history of prostate cancer are also at increased risk of getting prostate cancer. 

Although prostate cancer usually grows very slowly some cancers grow quickly. Differentiating between the types, stage and grade of cancer is a critical step in determining what is the most appropriate treatment path for each man. The stage of a cancer is a way of describing how much cancer there is. Is it a small or large amount? Is it still contained within the prostate or has it gone beyond? The grade of a cancer is a way of describing how fast the cancer cells are growing. The grade of a cancer is determined by its Gleason Score or its Grade Group.

Your grade and stage determine the appropriate path for you. Treating prostate cancer for men with faster growing or larger volume cancer is critical to improve men's health or help them live longer. Monitoring or "surveillance" is often employed for small, slow growing cancers. 

Surveillance of prostate cancer is typically done with repeat PSA testing, prostate exams, MRI or other radiology testing, and prostate biopsies. The frequency with which those tests are performed may vary depending on your individual case.

There are a wide variety of options for treating prostate cancer. The goal is to get rid of the cancer. For cancer contained within the prostate options include complete removal (radical prostatectomy), radiation with various forms of delivery, and focal therapy options to kill a small, very localized cancer also with a number of options on the market. For cancers that have spread beyond the prostate cure is usually not possible but control and slowing the growth of the cancer is very successful using hormone therapy (androgen deprivation or ADT), chemotherapy, immunotherapy, and radiation therapy.

Navigating a diagnosis of prostate cancer and determining the next best steps can be difficult. Knowledge is power. I hope this webpage helps you get the information you need.

Good luck on your Journey,

Dr Brandt 

DIAGNOSIS, STAGING, AND GRADING OF PROSTATE CANCER

A new diagnosis of prostate cancer can feel overwhelming. This page is dedicated to get you started in the process of learning about prostate cancer and beginning to apply that knowledge to your individual diagnosis and clinical situation.

Pllease do not hesitate to ask questions and provide feedback on the resources you find here.

Good luck on your journey.

Dr Brandt

Stage and Grade

Pictured here is a copy of the original drawing of the Gleason Scoring System as originally drawn by Donald Gleason. Gleason was a pathologist working at the University of Minnesota and the VA Medical Center in Minneapolis when he correlated patterns of cancer growth with patient outcomes. Gleason had formal training as an artist, and this picture that he sketched as a way to teach other pathologist his grading system has been reproduced many, many times and impacted millions. Years ago I recorded a podcast episode telling the story of the Gleason System you can listen to. The link is below.

All men at their initial diagnosis will need to determine if their prostate cancer is “localized” to the prostate or has “advanced” beyond the prostate. While all cancers lie on a spectrum of cancer volume, doctors break the cancer volume into four “stages” of cancer. Here are the clinical stages of prostate cancer. When a prostate has been removed and examined under a microscope then a pathologist determines its pathologic stage.

A stage 1 cancer is detected usually because of an elevated PSA value. The prostate otherwise feels normal to the physician on examination. A cancer is also considered stage 1 if detected because a man has surgery for enlarged prostate.

A stage 2 cancer is detected by an area of irregularity on the prostate.

A stage 3 cancer is detected when the area of irregularity is beyond the prostate capsule.

A stage 4 cancer is when there are findings the cancer has advanced to lymph nodes, nearby tissue, bones, and other distant organs.

Additionally, the speed of cancer growth determines appropriate treament. Aggressive cancers should be treated whereas slow growing and small volume cancer can be monitored over time. The speed of a cancer growth is determined initially by a cancer’s “grade.” The traditional way of quantifying the grade of a cancer is the Gleason scoring system. The Gleason system assigns a number to the two most common growth patterns within a cancer and those numbers are added together to create a Gleason score. The Gleason score is often represented as a simple math equation, eg. 3+4=7. Gleason score totals range from 6 (slow) to 10 (most aggressive). In 2014, the World Health Organization adopted the Grade Grouping system for assigning prostate cancer grade. The Grade Grouping System assigns a single number, 1 (slow) though 5 (most aggressive), to a cancer. Both grading systems are used today but the Grade Grouping System parallels the Gleason system but improves the grading accuracy for moderate risk Gleason 7/Grade Group 2 and 3 cancers.

For Patients With Localized Disease

Localized prostate cancer is still contained within the prostate gland and has not invaded nearby tissues nor has it spread to distant sites in the body like bones or lymph nodes.

Localized prostate cancer is often determined through a combination of prostate-specific antigen (PSA) blood tests, digital rectal exams (DRE), MRI testing of the prostate, prostate biopsy, and possibly other studies such as a PET scan, bone scan or CT scan.

Treatment options for localized prostate cancer vary depending on factors such as the aggressiveness of the cancer, the patient's overall health, and the patient’s personal preferences.

Common treatment approaches may include active surveillance (watchful waiting), surgery (prostatectomy), radiation therapy, focal ablative therapy, androgen deprivation, or a combination of these treatments.

This video is a short presentation (2 min) video with a brief overview of things to learn when first diagnosed with prostate cancer. The slides are downloadable in the link provided as well as a “worksheet” to prepare for a visit to discuss a new diagnosis of prostate cancer. This is intended for men with localized disease.

Treatment for prostate cancer depends on various factors such as the stage and grade of cancer, overall health, and personal preferences of the individual. Here are the questions men must ask themselves as they choose a treatment option.

  1. What is the STAGE of my prostate cancer? Is it localized to the prostate or advanced beyond? Is my cancer locally advanced or widely metastatic? If my cancer is localized to the prostate is it high volume or low volume?

    The STAGE is determined by the PSA, prostate exam, MRI and prostate ultrasound results as well as possibly and PET scan, bone scan or CT scans.

  2. What is the GRADE of my prostate cancer? Is it growing quickly or slowly?

    The grade of the prostate cancer is determined when the pathologist reviews the biopsies under the microscope. The grade of prostate cancer is given either as a Gleason Score or as a Grade Group. Further testing such as Decipher testing can help predict the future growth of the cancer, ie. is it likely to turn to a faster growing variant in the future?

  3. What other health concerns do I have that will determine my choice of treatment? What is my expected longevity?

    Men with longer life expectancy and better health should be biased towards treatment of the prostate cancer at initial diagnosis. Men with shorter life expectancy and multiple health concerns are better candidates for surveillance protocols or watchful waiting of their prostate cancer.

  4. What are my goals for my care? What is important to me?

    Some men will be biased towards more aggressive treatments by their personal choice or tolerance of surveillance. Some men will be more comfortable with surgery; other men will choose radiation. There is no one right answer in each case. Because there are alternative, a man’s personal preferences becomes a major factor in choosing a treatment option

  • Active surveillance is monitoring the cancer over time. Active surveillance is employed for men with slower growing cancer, less cancer volume, and men with shorter life expectancy. 

  • A robotic radical prostatectomy is removal of the entire prostate. This is the most common treatment for localized prostate cancer that is expected to grow in the future.

  • Radiation damages the cancer cells through a concentrated treatment of radiation to the prostate and the cancer cells.  This is a good treatment option for men with localized prostate cancer or for men with local recurrence of prostate cancer after prostatectomy.

  • Focal therapy is used in limited circumstances, the cancer would need to be confined to a portion of the prostate that can specifically be identified on imaging such as MRI. There are several options that can deliver ablativ treatment to a portion of the prostate.

  • Hormone therapy is the standard for slowing down prostate cancer cells.  Prostate cancer is sensitive to the male hormone testosterone. By reducing testosterone the cancer cells will slow their growth and may even top growing entirely and recede. Hormonal treatment are typically used for men with advanced prostate cancer but is also used in conjunction with radiation therpy.

  • Advanced Prostate cancer is cancer that has spread beyond the prostate to other area of the body . Unfortunately there is no cure for this type of cancer and we must focus on slowing its growth. The good news is that there are a number of treatment options that exist. 

In the picture above I outlined the algorithm of treatment choices available for men with prostate cancer. An algorithm takes a man down to treatment choices based on the parameters of his individual cancer.

Active Surveillance

Active surveillance of prostate cancer is the process of monitoring the cancer over time. Many prostate cancers do not need treatment because they are slow growing, and the rate of growth and spread will not impact a man’s quality or quantity of life. For elderly men or men with shorter life expectancy a surveillance process is often the best choice to avoid the complications that can occur with treatment. Some younger and healthier men may also choose surveillance as an option for their cancer if the disease is small and slow growing; the goal of monitoring in men with longer life expectancy is to “catch” the cancer and treat when the disease is showing signs of growth or increased rate of growth.

daVinci Robotic Radical Prostatectomy

Radical Prostatectomy is the most common choice for treatment for men with prostate cancers that are large enough in size and growing fast enough to require treatment. Radical Prostatectomy refers to the removal of the entire prostate and the attached seminal vesicles and, in most cases, a sampling of lymph nodes within the pelvis to check for cancer spread. Although radical prostatectomy is a great choice for many, men choosing prostatectomy should be aware of the potential for urinary incontinence and erection problems that can occur after prostatectomy.

Radiation Therapy

Radiation therapy is a general term used for the various types of methods to deliver radiation to the prostate to treat a man’s cancer. Radiation treatment are a good choice for many men as an alternative to surgical removal of the prostate. A radiation oncologist delivers the radiation treatment. Radiation therapy avoids some of the surgical risks of prostate removal, but complications can occur due to the radiation exposure to organs surrounding the prostate. The bladder and rectum are most at risk of radiation side effects. Changes to sexual function also are possible after radiation.

Focal and Alternative Therapies

As alternative to radiation and surgery, other options exist. While treatments other than radiation and surgery have not proven superior, many are options for whole gland treatment as well as the emerging role for “focal” therapy. Most men requiring treatment will need the entire prostate treated because of the amount of cancer present. Some men with cancer in just one portion of the prostate, however, may be candidates for treating just that portion of the prostate where the cancer exists.

For Patients With Advanced Disease

Advanced Prostate Cancer has spread beyond the prostate and may have invaded nearby tissues or metastasized to distant parts of the body. When prostate cancer progresses to an advanced stage, it poses greater challenges for treatment and management. For most men that means that treatments such as radiation or surgery are no longer an option. Good treatments exist in the form of androgen deprivation, chemotherapy, and immunotherapy.

Advanced prostate cancer often requires a multidisciplinary approach to treatment, involving medical oncologists, radiation oncologists, urologists, and other specialists. Treatment options may include hormone therapy, chemotherapy, targeted therapy, immunotherapy, radiation therapy, or a combination of these modalities.

While advanced prostate cancer is not curable in most cases, treatment aims to slow the progression of the disease, manage symptoms, and improve quality of life. Additionally, clinical trials and emerging therapies offer hope for new treatment options and improved outcomes for individuals living with advanced prostate cancer.