NCCN Prostate Cancer Treatment Guidance, 2011

Prostate cancer is the most common cancer in men, with lung cancer the second most common. Because of significant improvements in screening and early detection of prostate cancer over the past 30 years, the outlook for many men diagnosed with this disease has improved.

If you have been diagnosed with prostate cancer, you probably have many questions. How it is likely to be treated? What happens when treatment is completed? This overview, which is based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™) for prostate cancer, will help you understand the treatments available for prostate cancer. Talk to your doctor about these options so that together you can decide on a treatment plan that is right for you.

BackgroundThe prostate gland lies just below the bladder and produces a fluid that forms part of the semen. Men older than 65 years, those with a family history of prostate cancer (especially if a brother or father has been diagnosed with prostate cancer), and those of African descent are at higher risk for prostate cancer.

Screening for Prostate CancerMany men are choosing to be screened for prostate cancer using prostate-specific antigen (PSA) testing and digital rectal examination (DRE). The decision about whether to be screened is personal, but it should be based on an understanding of the potential risks and benefits of screening. Risks include discomfort, the possible side effects if a biopsy is done, and the physical and mental implications of finding out you have a cancer that may not pose a threat to your life. Benefits include finding prostate cancer at its earliest and most treatable stages.

Experts estimate that deaths from prostate cancer have decreased 40% since PSA testing became widespread in 1992. At the same time, there is a lot of disagreement about the value of early diagnosis with PSA testing. This is because many of the cancers found with screening will probably never pose a threat to a man’s life. Therefore, some men may undergo treatment that has no benefits to their life expectancy---in other words, these men will live as long as they would if they did not have prostate cancer, and the side effects of treatment could decrease their quality of life.

Prostate cancer often can be present for a long time before any symptoms appear. However, some aggressive and life-threatening cancers will be found through screening and therefore will be treated before they can spread. The greatest benefits of screening are for men at high risk for prostate cancer either because of family history or African-American descent. Benefits of screening are also most significant in men younger than 70 years.

Diagnosis of Prostate CancerProstate cancer rarely causes any symptoms until it is advanced and usually incurable. However, prostate cancer may be suspected for several reasons, including:

A lump in the prostate gland or an asymmetric prostate
Inability to pass urine
Difficulty starting or stopping the urine flow
Need to urinate often, especially at night
Weak flow of urine
Urine flow that starts and stops
Pain or burning during urination
Difficulty having an erection
Blood in the urine or semen
Frequent pain in the lower back, hips, or upper thighs
Suspicious findings from a DRE or PSA test do not necessarily mean that a man has cancer, and the symptoms above are not always caused by cancer (they can also be caused by a noncancerous condition called benign prostatic hyperplasia, or BPH.

To determine whether symptoms or an abnormal DRE or PSA results are caused by benign enlargement or prostate cancer, the doctor will perform a biopsy, often called a transrectal biopsy, under ultrasound guidance. In this procedure, the prostate is viewed using a probe the size of a finger inserted in the rectum. Tissue is removed with small needles from many areas of the prostate and examined under a microscope to look for cancer cells. This is the only way to specifically diagnose prostate cancer; an elevated PSA or abnormal DRE does not necessarily mean you have prostate cancer.

More Testing
If the biopsy indicates that you have prostate cancer, tests may be done to find out how aggressive the cancer may be. You may be scheduled for tests that will help your doctor determine whether your tumor is confined to the area where it began (that is, it is localized) or whether it has spread (that is, it has metastasized). Your doctor also will take a detailed medical history and may request other tests to determine your health and whether certain treatments are appropriate for you.

More tests may be ordered depending on how large the tumor is, your PSA level, and the Gleason score of your tumor. The Gleason score or grade is scaled to the aggressiveness of the prostate cancer. The Gleason grade is determined by a pathologist using a microscope to examine your cancer; it reflects the ability of the cancer to form glands. Generally, the lower the score, the more likely the tumor is growing slowly and the less likely it is to spread.

Additional tests may include:

A radionuclide bone scan to see whether cancer cells have spread to the bone
Magnetic resonance imaging (MRI) and/or computed tomography (CAT or CT scan) to show detailed images of the insides of the body
A pelvic lymphadenectomy, which is a surgical procedure to remove lymph nodes in the pelvis to see whether cancer has spread to these nodes
Each of these procedures provides information about grade and characteristics of the cancer that is important for determining the stage of your disease. Knowing the stage of your disease, in turn, is vital to determining which treatment program promises the best results.

Staging of Prostate Cancer A formal system called staging is used to identify how localized or widespread your cancer is. Prostate cancer stages range from stage I (most localized; cancer cells are only in the prostate) to stage IV (cancer cells have spread to distant lymph nodes and/or organs in your body, including the bones).

Staging is an important part of developing the best treatment plan for you.
For a more detailed discussion of staging, see the Cancer Staging Guide.

An elevated Gleason score and an elevated PSA level indicate that the cancer is likely to spread and that there is an increased chance that it might recur (come back) after treatment. This risk (or chance) of recurrence is another important factor in making treatment decisions.

Risk of Prostate Cancer Recurrence The risk that cancer may recur after treatment is a significant consideration in the treatment decisions patients make with their doctors. Many factors influence the risk that prostate cancer might recur. Among the most important are the size and location of the tumor; the PSA level in your blood; how fast the cancer cells are growing; and how far, if at all, the cancer has spread from the place where the tumor began. Many prostate cancers, especially in older men, are relatively slow-growing and may not have an impact on their lifespan or general health. Others, however, are quite aggressive and can spread to the bones and vital organs.

In recommending a treatment for you, your doctor will estimate how long you likely would live if you didn’t have prostate cancer based on your age and general medical condition (this is much the same process an insurance company uses in determining life insurance rates). Then, based on factors specific to your tumor, he or she will estimate how long it would take for your prostate cancer to become life-threatening to you. These two time periods are compared to help decide whether the prostate cancer is likely to reduce your lifespan and whether treatment is recommend.

Your doctor will review the results of your PSA test (and PSA tests that you had in the past, if any) to help determine how quickly your cancer is growing. The PSA level at the time your cancer is discovered is an important indicator. Generally, higher values indicate more aggressive cancer.

Additional important information may be obtained from the length of time it takes for your PSA value to double. For this “doubling” test to be valid, you must have had three separate PSA tests over a period of at least 18 months. In general, the faster the doubling time, the more aggressive the cancer. Some men with early-stage prostate cancer will have had enough tests over time for the doctor to compute this doubling time, but many will not have had enough PSA tests.

In addition to assigning a stage as described above, your doctor will also assign a Gleason score for your disease. This score, which ranges from 2 to 10, is a measure of the aggressiveness of your tumor. The pathologist assigns a number from 1 (least aggressive) to 5 (most aggressive) to the most frequently occurring appearance of cancer cells in the tissue sample used in the biopsy and the next most frequently occurring appearance of cancer cells in that tissue sample—this second sample is also assigned a score ranging from 1 to 5. The two scores are added together to get the Gleason score. The higher the score, the greater the chance that the cancer will (or already has) spread.

Based on your PSA level, cancer stage, and Gleason score, your doctor will estimate how likely the cancer is to grow and spread. Because all treatments for cancer can cause side effects, doctors aim to give patients treatments that will cause the fewest side effects while effectively curing the cancer. In some cases, the risk of the cancer getting worse may be relatively small compared with the side effects of treatment. However, when the risk is high that the cancer will grow quickly or recur after treatment, doctors may prescribe aggressive treatment to reduce that risk.

Treatment of Prostate CancerThe effectiveness of treatment depends on how localized the cancer is and whether or how far it has spread in your body. Depending on the stage of your disease and the other indicators discussed above, the characteristics of your tumor, and your age and general health, your doctor will recommend one or more of the following: active surveillance (also called observation, expectant management, or watchful waiting), surgery, radiation therapy, hormone therapy, chemotherapy, or targeted therapy. These options are discussed in the treatment summaries for localized prostate cancer and advanced prostate cancer.

Because some forms of prostate cancer treatment can cause infertility, if you want to father children you may want to discuss sperm banking before treatment begins. Your doctor can help you with this consideration.

Life After Prostate Cancer Treatment After completion of your treatment, you will begin a period called follow-up. During this period, you will visit your doctor at regular intervals. The doctor will perform a physical exam, ask you about how you are feeling, and order tests to make sure that you remain healthy and that any long-term effects of your prostate cancer or its treatment can be addressed. See Taking Care of Follow-Up Care.



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