Medical Test and Terms
Tumor Stages
Types of Treatment

Watchful waiting, surgery, and radiation therapy are the standard treatment choices for early-stage prostate cancer (see Types of Treatment). Each has benefits (how treatment can help) and risks (problems treatment may cause). There is seldom just one "right" treatment choice.

"The bottom line is to have enough information to know what treatment to choose." - Ken

Treatment choices depend on several factors:

• Prostate cancer characteristics. This includes the size of your prostate, prostate-specific antigen (PSA) score, Gleason score, and stage of cancer. (Go to Medical Tests and Terms to learn more.)

• Health problems, other than prostate cancer. This means whether you have heart problems, diabetes, or other illnesses or have had a previous surgery for an enlarged prostate. Having such health problems may affect which treatment you choose.

• Age. If you are older, you may view treatment choices differently than younger men because the benefits and risks of treatment vary with age.

• Type of care available to you. The skills of specialists and types of treatment can vary. You will need to ask what you may feel are tough questions to make sure that you get the best care and outcomes. See Talking with Your Medical Team ¹ and Asking Questions ² for questions to ask.

• Balancing what you value most.Your unique experiences in life shape your feelings and perceptions about how to deal with your prostate cancer. Keep in mind what is important to you personally to help guide your decision.

  Many men may ask their doctor, "What would you do, if you were me?" Try to remember, the doctor isn't you and his or her personal values may be different from yours.

  How do you view the potential risks and benefits of the treatment options offered to you? Are you a person who could cope with knowing cancer is in your body? Would you rather have the cancer treated and know that there could be side effects? Do you know of other men's experiences with prostate cancer that may influence your decision?

• Spouse or partner. Even though the treatment decision is yours, involve your spouse, partner, or caregiver to help you sort out what is most important to you and your family. Your treatment choice will affect your spouse or partner.

Medical Test and Terms

By now you may have had several tests to find out the extent of your cancer. Your doctor will take into account your physical exam, PSA level, Gleason score, and stage when discussing your treatment options. What do these mean?

• Prostate-Specific Antigen (PSA) test. PSA is a protein made by normal cells and prostate cancer cells. PSA is found in the blood and is measured with a blood test. Doctors sometimes watch the rate of change in your PSA levels over time. A score of 4 nanograms (ng) or higher is often the trigger for further tests.

• Gleason score of your biopsy. When you had a biopsy, tissue samples (called "cores") were taken from several areas in your prostate. The pathologist checked for cancer in the samples using a microscope. He or she can also estimate how much cancer there is by looking at how many tissue samples are positive. A Gleason score (or sum) on a scale of 2 to 10 is assigned to the cancer. This score tells how different the prostate cancer tissue looks from the normal prostate tissue and helps estimate how likely it is that the tumor cells will spread (how aggressive the cancer is).

  A low-risk score is 2 to 4. A low score means that the cancer tissue still looks similar to normal prostate tissue, and the tumor cells are less likely to spread. A score of 5 to 7 means moderate risk, while a score of 8 to 10 means higher risk. As the score gets higher, it means that the prostate cancer tissue becomes more and more different from normal tissue and that the tumor cells are more likely to spread.Most men with early-stage prostate cancer have a Gleason score of 5, 6, or 7.

• Stage. The stage of cancer is an important factor in choosing a treatment. The stage tells how much the cancer may have grown within the prostate and whether it has spread to other tissues or organs. Doctors use a standard rating system to describe the stage, called the TNM System. T means the size of the main tumor, N means whether nearby lymph nodes are involved, and M means whether the cancer has spread beyond the region around the prostate.

  First, the doctor will assess the stage of your prostate cancer based on clinical findings (such as a physical exam, digital rectal exam, or DRE, and biopsy). If you have surgery to remove your prostate, seminal vesicles or nearby lymph nodes, then your cancer can be assessed from a pathologic stage. This means that by looking at what is removed, doctors are better able to predict your outcome and survival.

  Your doctor may also suggest other tests such as a bone scan, MRI, CT scan, removing lymph nodes in the pelvis, or a seminal vesicle biopsy.

  Prostate cancer tumor stages range from stage T1 to T4. They may also be further classified a, b, or c. This article addresses early stages, which are Stage T1 and T2, where the cancer is confined to the prostate.

Types of Treatment

Surgery

Surgery is often a treatment choice for men who have earlystage prostate cancer and are in good health. Surgery to remove the prostate is called prostatectomy (PRAHS-ta- TEK-toe-mee). There are two approaches that are typically used by surgeons:

• Retropubic prostatectomy. Your surgeon can remove the prostate through an incision just above the pubic bone in your lower abdomen. He or she can also check nearby lymph nodes for cancer (see drawing below). This approach gives the surgeon a better chance to spare the nerves (called nerve-sparing surgery) located next to your prostate that control your bladder and erections.

  You may want to talk with your surgeon about techniques that may spare the nerves that control your bladder and erections.

• Perineal prostatectomy. This type of surgery, which is not used as often, reaches the prostate through an incision between your scrotum and anus.With this method, your surgeon is not able to check the lymph nodes for cancer. It is also more difficult to spare the nerves that control erections. This approach is used when the cancer is confined to the prostate.

Radiation Therapy

This type of treatment uses high doses of radiation energy to treat cancer. Radiation therapy is an option when cancer is in your prostate but has not spread to other organs. It is also used when you cannot have surgery because of your age, health, or personal choice. There are two types of radiation therapy:

• External beam radiation. A machine aims radiation at your cancer cells. It rotates around your body, sending radiation from many directions. After the doctor maps out the exact part of your body that needs radiation, treatment usually happens once a day, 5 days a week, for 6 to 8 weeks. Each treatment session usually lasts about 15 minutes. The latest types of radiation are called 3-D Conformal Radiation Therapy and Intensity-Modulated Radiation Therapy (IMRT). These types of radiation are more precise in destroying cancer while leaving nearby healthy cells unharmed. They are designed to lower the exposure of the rectum and bladder to radiation to help lessen side effects.
• Brachytherapy (BRA-kee-THAYR-uh-pee). This is a type of internal radiation therapy. It is also called seed implants. Radiation is delivered inside your body by implanting tiny seeds in your prostate. Usually 40 to 130 seeds are inserted into the prostate, depending on the size of your prostate. Each seed has a small amount of radioactive material that emits radiation within an inch of its surroundings. Low-dose seeds are left in the prostate permanently, although their radiation lasts for only 3 to 6 months. This procedure is usually done on an outpatient basis, without a hospital stay.

Both types of radiation can be used together (placing radioactive seeds internally and using external beam radiation to kill any cancer that may be close to the prostate) or with hormone therapy.

Watchful Waiting

Comparing Your Treatment Options

The chart in the next section ³ lists common questions and answers for the three options outlined in this booklet. As mentioned earlier, most men will need more information than this booklet gives to reach their decisions. You may use this chart as a guide for talking with your doctor or researching your options.

Glossary Terms

A procedure that uses a computer to create a 3-dimensional picture of the tumor. This allows doctors to give the highest possible dose of radiation to the tumor, while sparing the normal tissue as much as possible. Also called 3-dimensional radiation therapy.

A series of detailed pictures of areas inside the body taken from different angles. The pictures are created by a computer linked to an x-ray machine. Also called CAT scan, computed tomography scan, computerized axial tomography scan, and computerized tomography.

An examination in which a doctor inserts a lubricated, gloved finger into the rectum to feel for abnormalities. Also called DRE.

An examination in which a doctor inserts a lubricated, gloved finger into the rectum to feel for abnormalities. Also called digital rectal examination.

A system of grading prostate cancer tissue based on how it looks under a microscope. Gleason scores range from 2 to 10 and indicate how likely it is that a tumor will spread. A low Gleason score means the cancer tissue is similar to normal prostate tissue and the tumor is less likely to spread; a high Gleason score means the cancer tissue is very different from normal and the tumor is more likely to spread.

Treatment that adds, blocks, or removes hormones. For certain conditions (such as diabetes or menopause), hormones are given to adjust low hormone levels. To slow or stop the growth of certain cancers (such as prostate and breast cancer), synthetic hormones or other drugs may be given to block the body’s natural hormones. Sometimes surgery is needed to remove the gland that makes a certain hormone. Also called endocrine therapy, hormonal therapy, and hormone treatment.

In medicine, refers to the inability to have an erection of the penis adequate for sexual intercourse. Also called erectile dysfunction.

Inability to control the flow of urine from the bladder (urinary incontinence) or the escape of stool from the rectum (fecal incontinence).

A type of 3-dimensional radiation therapy that uses computer-generated images to show the size and shape of the tumor. Thin beams of radiation of different intensities are aimed at the tumor from many angles. This type of radiation therapy reduces the damage to healthy tissue near the tumor. Also called IMRT.

A procedure in which radio waves and a powerful magnet linked to a computer is used to create detailed pictures of areas inside the body. These pictures can show the difference between normal and diseased tissue. MRI makes better images of organs and soft tissue than other scanning techniques, such as computed tomography (CT) or x-ray. MRI is especially useful for imaging the brain, the spine, the soft tissue of joints, and the inside of bones. Also called magnetic resonance imaging, NMRI, and nuclear magnetic resonance imaging.

A type of surgery that attempts to save the nerves near the tissues being removed.

A protein made by the prostate gland and found in the blood. Prostate-specific antigen blood levels may be higher than normal in men who have prostate cancer, benign prostatic hyperplasia (BPH), or infection or inflammation of the prostate gland. Also called PSA.

An operation to remove part or all of the prostate. Radical (or total) prostatectomy is the removal of the entire prostate and some of the tissue around it.

The use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body. Also called irradiation and radiotherapy.

A gland that helps produce semen.

The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.

A hormone made mainly in the testes (part of the male reproductive system). It is needed to develop and maintain male sex characteristics, such as facial hair, deep voice, and muscle growth. Testosterone may also be made in the laboratory and is used to treat certain medical conditions.

Closely monitoring a patient's condition but withholding treatment until symptoms appear or change. Also called active surveillance, expectant management, and observation.