Prostate Cancer

Factors that contribute to an increased risk for developing prostate cancer include:

• Age: Men over 65 account for two-thirds of all prostate cancer diagnoses
• Race: African-American men have a higher incidence than white American men
• Obesity and Diet: Western diets high in fat, sugar, salt and cholesterol
• Environmental Exposures
• Family History
  • Sporadic – cancer occurs by chance in one man at a typical age
  • Familial – cancer present in more than one person with no definitive pattern of inheritance at an older age
  • Hereditary – cancer cluster of three or more in a nuclear family; three consecutive generations of cancer; cluster of two relatives age 55 or younger

The prostate gland produces a substance called PSA, prostate specific antigen. A simple blood test checks PSA levels. Even among those with PSA levels less than one, the chance of prostate cancer is 10 percent. In 2012, the U.S. Preventive Services Task Force recommended against PSA screening. As a result, PSA screening rates have decreased in the US, as first shown by work done by BWH Urology researchers. Dr. Adam S. Kibel, chief of urology at Brigham and Women’s Hospital, however, believes that PSA screenings save lives. Since PSA testing began in the 1980s, prostate cancer deaths have been reduced by 10,000 men per year. Before PSA screening, prostate cancer claimed over 40,000 lives annually; now, prostate cancer claims fewer than 30,000.

Dr. Kibel said the task force based its recommendation on U.S. and European prostate cancer trial results. In his opinion, the U.S. trial did not adhere to proper test controls, screening men who were not recommended for screening. In the European trial, screening procedures were followed correctly. The larger European trial showed a clear benefit for PSA screening with a 20 percent decrease in the risk of prostate cancer deaths.

Brigham and Women’s Hospital PSA Recommendations:

• Accept screening if your risk is high
• Waive screening for patients of advanced age
• Consider treatment options carefully

BWH physicians continue to research new markers that could identify men at risk for prostate cancer.

Since most men do not present with symptoms, prostate cancer may not be discovered in its early stages. Signs and symptoms of advanced prostate cancer may include:

• Trouble urinating
• Decreased force in the stream of urine
• Blood in the urine
• Blood in the semen
• General pain in the lower back, hips or thighs
• Discomfort in the pelvic area
• Bone pain
• Erectile dysfunction

After 50, men should discuss pros and cons of testing with their doctor. If they are African American or have a father or brother who had prostate cancer before 65, they should have this meeting with their doctor at age 45. Screenings include:

• Digital rectal examination (DRE)
• Prostate-specific antigen testing (PSA)

How often men are tested will depend on their PSA level.

If prostate cancer is caught early, the prognosis is excellent. Men with symptoms of advanced disease, elevated PSA levels, or enlarged prostates may also have these diagnostic tests:

• Transrectal ultrasound involves a small probe inserted in the rectum and uses sound waves to make an image of your prostate gland.
• Prostate needle biopsy collects and analyzes tissue samples from the prostate to determine whether cancer is present.
  • More recently, fusion biopsies, where MRI images are overlaid onto ultrasound in real time, have been used for added accuracy.
• Computerized tomography scan (CT-scan) uses a combination of x-rays and computer technology to produce horizontal, or axial, images of the body.
• Magnetic resonance imaging (MRI)uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.
• Radionuclide bone scan involves an injection of radioactive material that helps to locate diseased bone cells throughout the entire body, suggesting possible metastatic cancer.

After a biopsy confirms prostate cancer, the cancer grade and stage will be determined based on the aggressiveness of the cancer and whether it is confined to the prostate or has metastasized (spread to structures beyond the prostate).

• Gleason Score, a pathologist grades the cancer from least to most aggressive with a score from 2-10
• TNM Classification of Malignant Tumors evaluates the size of the cancerous tumor, extent of involved lymph nodes, and any metastasis to classify cancer progression
• Prostate cancer stages:
  • Stage I. Cancer is confined to a small area of the prostate. When viewed under a microscope, the cancer cells aren't considered aggressive.
  • Stage II. Cancer is small but considered aggressive when viewed under a microscope. Or cancer may be larger and involve both sides of the prostate gland.
  • Stage III. Cancer has spread beyond the prostate to the seminal vesicles or nearby tissues.
  • Stage IV. Cancer has invaded nearby organs or spread to lymph nodes, bones or lungs.

Our multidisciplinary team will manage your care in a personal and individualized way. Treatment options depend on your age, overall health, disease aggressiveness, potential adverse effects and your personal preferences. BWH urologic surgeons often recommend a combination of innovative treatments to ensure the best possible outcome for prostate cancer patients. Treatment may include:

• Active Surveillance with periodic PSA tests and prostate needle biopsies over several years. Recommended for non-aggressive prostate cancer and men diagnosed in advanced years.
• Surgery - Open radical prostatectomy is open surgery to remove the entire prostate through an incision in the abdomen or area behind the scrotum.
  • Robotic prostatectomy uses a combination of high-definition 3D magnification, robotic technology, and miniature instruments to enhance a urologic surgeon’s skills when removing a cancerous prostate gland.
  • Robotic prostatectomy benefits
    Adam S. Kibel, MD, Chief of Urology, and members of the urology team use the FDA-approved da Vinci® Surgical System to perform hundreds of robotic prostatectomies each year. Robotic surgery's miniaturization, increased range of motion, enhanced vision and mechanical precision offer significant benefits for our prostatectomy patients, including:
    
    • Decreased length of stay
    • Less blood loss
    • Less post-surgical pain/less medication
    • Quicker recovery and return to normal activities
    • Less scarring
    • Greater probability of maintaining urinary continence
    • Less risk of erectile dysfunction
• High-intensity Focused Ultrasound (HIFU)
  

  Men with localized prostate cancer have many options to treat this disease. The standard surgical treatment for men with intermediate and high-risk prostate cancer is radical prostatectomy to remove the entire prostate gland. On the other end of the spectrum, men with low-risk prostate cancer may opt for active surveillance to avoid possible side effects of treatment, including urinary incontinence (being unable to control urine) and erectile dysfunction (problems getting or keeping erections). Focal therapy such as HIFU is a middle path for some men with low risk, and low-volume, intermediate risk prostate cancer who want a less intensive treatment than surgery but who aren’t suitable for (or are unwilling to pursue) active surveillance. It can also be used in selected cases for men who have recurrent cancer after radiation.

  HIFU is non-invasive image guided procedure performed under general anesthesia. The procedure uses high-intensity ultrasound waves to heat and destroy prostate tissue under image guidance. For men with small prostate cancers, HIFU can be used to treat only the area of the prostate with cancer. Because it leaves a portion of the prostate gland untreated, HIFU is generally associated with fewer side effects than traditional surgery, radiation or chemotherapy. Because it only treats a small area of the prostate, men who choose HIFU will need to be followed with PSA checks and MRIs and a portion of them will need repeat treatments.

  If your urologic surgeon has recommended HIFU as a treatment option, please first check with your health insurance provider to confirm this procedure will be covered under your insurance plan.

• Radiation therapy uses high-energy X-rays to kill cancer cells and keep them from growing
  • External beam radiation also known as Intense Modulated Radiation Therapy (IMRT) uses computer guidance to send precise radiation doses to specific areas
  • Internal radiation, also called implant therapy, implants radioactive seeds that emit small amounts of radiation over a period of weeks or months.
    • High-dose rate (HDR) brachytherapy is an advanced type of internal radiation therapy (implant therapy) being used at BWH.
• Hormone therapy halts or slows cancer growth for advanced prostate cancer.
  • A hormone pill or injection lowers the level of testosterone that fuels prostate cancer. This includes luteinizing hormone-releasing hormone (LHRH) analogs and anti-androgens.
  • Orchiectomy, the surgical removal of both testicles, stops hormone production.
• Chemotherapy is rarely used as a treatment for prostate cancer.
  • Chemotherapy can be administered intravenously or orally and usually involves a combination of drugs. Treatments are often administered in cycles.

Watch video case study of a robotic-assisted radical prostatectomy.

• Erectile dysfunction (ED) or impotence, the inability to achieve or sustain an erection, affects men following prostate cancer treatments.
  • For those who develop ED after surgery, almost all see improvement six months after surgery and ongoing for several years.
  • Some men require drugs to achieve erectile function.
  • Some may experience diminished sex drives.
  • Surgery, non-surgical techniques, and medications can help.
• Incontinence or the inability to control urination affects almost all men after treatment for prostate cancer.
  • Most men recover their ability to control urination during the first six months after surgery. Function continues to improve for several years.
  • Surgery, behavioral modifications, and life-style changes can help.

As you go through treatment for prostate cancer, it is critical that you communicate with your physician so that you have the most accurate information available. We recommend that you bring a loved one or friend with you during initial appointments to help you absorb all the information you will receive. Here are 12 questions to pose to your urologist:

1. How aggressive is my cancer? What is my PSA level and my Gleason score?
2. Do I need to be treated? If not, why?
3. Has the cancer spread? What are my chances of survival?
4. What treatment options are appropriate for me, and which ones would you recommend and why?
5. What are the pros and cons of open versus robotic surgery?
6. What are the pros and cons on radiation therapy versus surgery?
7. I have heard that prostate cancer surgery and treatment will affect my ability to achieve an erection and that it may also affect my urinary control. What are the treatments and how quickly will I recover? What can I do to make the recovery progress more rapidly?
8. How often will you check my PSA levels after surgery? What should the level be and when do I need to be concerned?
9. How will I know if the cancer has returned? Will I experience symptoms?
10. What will my options be if the cancer comes back?
11. Would I benefit from participating in a clinical trial?
12. Are there any limitations to my daily activities because of the cancer and/or treatment?

You will receive a thorough diagnostic evaluation and receive clinically-proven treatment by a board-certified urologist who specializes in prostate cancer. Your experience post-treatment will vary depending upon the stage of your cancer. Early detection and the involvement of an experienced urologic surgeon are important to the successful outcome for prostate cancer treatment. After treatment, routine life-long surveillance is necessary.

Read patient stories to learn about the experiences of prostate cancer patients.

• Prostate Cancer Foundation
• CancerCare
• ZERO Prostate Cancer

Brigham and Women’s Hospital (BWH) practices a multidisciplinary approach to patient care, collaborating with colleagues in other medical specialties. Dana-Farber Brigham Cancer Center gives you access to the world’s best cancer experts. The Division of Urology’s surgical oncologists work hand-in-hand with medical oncologists and radiation oncologists to create an individualized care plan. Specialists also include radiologists, pathologists, nurse specialists, social workers, palliative care specialists and dietitians.

To learn more about our cancer partnership, visit the Dana-Farber Brigham Cancer Center.

BWH’s Division of Urology is dedicated to expanding the boundaries of medicine through research.

Biomarker Studies

Adam S. Kibel, MD, Chief of Urology and an internationally-regarded expert in prostate cancer treatment, is leading biomarker studies. The ability to accurately identify cancer risk is critical, since no two tumors and no two cancer patients are alike. Biomarkers are indicators of a disease state, such as a rising prostate-specific antigen (PSA). PSA screenings can help identify prostate cancer. Biomarkers also help clinicians more precisely define a patient’s risk and potential benefit. Dr. Kibel and his colleagues are developing and validating additional biomarkers that can more effectively detect prostate cancer as well as other urological cancers. During Dr. Kibel’s time at Washington University in St. Louis, where he was the Director of Urology Oncology, he investigated several tumor markers and genetics. His studies examining microvesicles (fragments of plasma membrane) and PCA3 (a prostate cancer biomarker) provide new ways to identify patients at risk, saving many from biopsies and unnecessary treatment. Dr. Kibel plans to use his research results to advance the study of prostate cancer at BWH while also growing a prostate cancer patient database to conduct new investigations into diagnosis and treatment.