When is surgery the best treatment for prostate cancer?

In general, prostate cancer surgery is best performed in patients with clinical stage T1 or T2 prostate cancer (confined to the prostate gland) and in selected men with clinical stage T3 disease. While there are no absolute cut-offs, men with a PSA level less than 20 ng/mL and a Gleason score of less than eight have a higher likelihood of cure. In certain circumstances, patients with more serious parameters are offered surgery. Prostate cancer surgery is usually restricted to men who are healthy enough to tolerate a major operation and have a 10-year or more life expectancy. Life expectancy is assessed by both patient age and health.
What types of surgeries are available to treat localized prostate cancer? 

• Open Radical Prostatectomy
• Perinal Radical Prostatectomy
• Retropubic Radical Prostatectomy
• Minimally Invasive
  • Robotic Assisted Laparoscopic Radical Prostatectomy
  • Laparoscopic Radical Prostatectomy

What are the advantages and disadvantages of Active Surveillance/ “Watchful Waiting?”

There are two advantages for utilizing this treatment option – low cost and no immediate complications.    
The risk of active surveillance is that the cancer could grow and spread to other parts of the body between follow-ups, making it more difficult to treat. Not all prostate cancers require active treatment, and not all prostate cancers are life threatening. The decision to implement active treatment is one a man should discuss in detail with a urologists to determine whether active treatment is necessary, or whether surveillance may be an option.

What is Active Surveillance?

Prostate cancer is often a slow progressive disease, and many men with prostate cancer will die from causes other than prostate cancer. Your physician may recommend the active surveillance treatment option if you have been diagnosed with a very early stage of prostate cancer.
Active surveillance is a type of close follow-up for men with prostate cancer. This follow-up usually involves regular prostate-specific antigen (PSA) tests, digital rectal examinations (DREs) and possible prostate biopsies. If these periodic tests show that your cancer is progressing, you and your doctor may begin to discuss other forms of treatment.
The goal of active surveillance is to allow men to maintain their quality of life when the prostate cancer is slow growing or inactive, while allowing them to elect active treatment when the disease becomes more aggressive or begins to grow.

Who is a good candidate for Active Surveillance or “Watchful Waiting”?

Active surveillance may be a suitable option for men who are not experiencing symptoms, or when the cancer is not expected to grow at an aggressive rate.  Active surveillance allows men to maintain their quality of life, thus for those whom avoidance of sexual, urinary, and/or bowel complications are a primary consideration, active surveillance may be considered.   Active surveillance can also be considered for men who are older or have other serious health conditions, which can make the cancer more difficult to treat immediately.

What are the current treatment options for localized prostate cancer?

Because not all prostate cancer is the same and not all are life threatening, it is important to understand the treatment options you choose should be very specific to your personal health history.  It is an individual decision that patients should make together with their doctor and their family. No one treatment is perfect for every man.
Several factors come into play when selecting the best treatment for an individual and they include:

• Tumor stage (extent of local spread) and grade (aggressiveness),
• PSA level (higher levels indicating a greater risk of cancer recurrence after treatment), and extent of disease (number of biopsy cores with cancer), as well as
• competing medical co-morbidities (other diseases that can affect life expectancy) and
• Age at diagnosis (as most prostate cancers take many years to become evident and cause morbidity, the same tumor in an older man may pose a lower risk of causing problems in his lifetime); all play a role in the decision regarding the choice of therapeutic intervention

It is important that you speak to your doctor about which treatment is right for you.
Below is a list of the common medical treatments for localized prostate cancer:

• Active Surveillance
• Surgery
• Radiotherapy
• Cryotherapy

Can prostate cancer be prevented?

There is still a lot of controversy regarding the prevention of prostate cancer.  Some physicians believe anti-androgen drugs, such as finasteride and dutasteride, can prevent prostate cancer. However, others are skeptical, and believe anti-androgens only slow the progression of well-differentiated tumors while allowing higher-grade elements to emerge as the dominant elements in the tumor. In randomized trials, men taking these drugs were less likely to be diagnosed with prostate cancer.  However, whether the drug’s use will affect the cancers aggressiveness and translate into a lower death risk is still unknown. Some physicians believe that general health measures might reduce the risk of prostate cancer, such as eating and maintaining a normal body weight, a healthy diet, being physically active and visiting the doctor on a regular basis. However, the best practice to prevent prostate cancer is to live and practice a healthy lifestyle.

Are there tests to determine if my cancer has metastasized?

To determine if your cancer has spread to other parts of your body your doctor may recommend the following:

• A pelvic CT scan
• MRI scan
• Bone scan

Not all men with prostate cancer need to undergo imaging tests as the risk of spread to other organs can be estimated by PSA levels and cancer grade. It is also standard to omit the bone scan in patients for the following reasons:

• Newly diagnosed, untreated prostate cancer,
• Patients who have no symptoms from their cancer,
• Gleason score of less than 7 and have serum PSA concentrations less than 10 ng/ml
• PSA concentrations less than 15 ng/ml (unless the Gleason score is 7 or higher)

A pelvic CT scan or MRI may not be necessary in men with lower grade cancers, cancers still confined to the prostate, and serum PSA values less than 10 ng/ml.

How do I determine which treatment option is best for me?

Prostate cancer represents a spectrum of disease. Some cancers may grow so slow that treatment may not be needed while others grow fast and are life threatening. Determining the need for treatment can be a complex decision. Initially, the need for treatment should be based on the stage and grade of the cancer as well as the age and health of the patient.
(To determine your risk and need for screening please use the risk assessment tool: Rank Your Risk)
Many physicians have sought to devise risk assessment tools that predict the likelihood of disease recurrence and progression. By combining many types of information (i.e., serum PSA level, clinical stage, Gleason score, extent of cancer in biopsy specimens), patients can be advised of the likely aggressiveness of their cancer and the need for and types of treatment available. However, the longer the patient's life expectancy, the more uncertain the prediction becomes, as most prostate cancers progress with time.
When prostate cancer spreads (metastasizes) it is usually progresses, though not always in such a neat step-wise fashion, first by perforating the capsule and extending into the periprostatic tissues, then to the seminal vesicles, then to the lymph nodes and finally to the bones, lungs, and other organs.

How is prostate cancer staged?

Once prostate cancer has been diagnosed by a prostate biopsy, the physician must stage the disease.  Staging the disease determines the extent of the cancer (i.e., the "T" stage) and whether the cancer has spread from the prostate to other tissues such as the seminal vesicles, the lymph nodes and/or the bones. The T stage is determined by using the DRE and other imaging procedures like the ultrasound scan, CT scan, MRI scan, or MR spectroscopy scan.








The T stage is divided into the following categories:
T1: Doctor is unable to feel the tumor
T1a: Cancer is found incidentally during a transurethral resection (TURP) for benign prostatic enlargement. Cancer is present in less than 5% of the tissue removed and is low grade (Gleason < 6)
T1b: Cancer is found after TURP but is present in more than 5% of the tissue removed or is of a  higher grade (Gleason > 6)
T1c: Cancer is found by needle biopsy that was done because of an elevated PSA
T2: Doctor can feel the tumor when a digital rectal exam (DRE) is performed but the tumor still  appears to be confined to the prostate
T2a: Cancer is found in one half or less of only one side (left or right) of the prostate
T2b: Cancer is found in more than half of only one side (left or right) of the prostate
T2c: Cancer is found in both sides of the prostate
T3: Cancer has begun to spread outside the prostate and may involve the seminal vesicles
T3a: Cancer extends outside the prostate but not to the seminal vesicles
T3b: Cancer has spread to the seminal vesicles
T4: Cancer has spread to adjacent organs, such as the urethral sphincter, rectum, bladder, and/or wall of the pelvis
Imaging tests, such as radionuclide bone scan, CT scan, MRI, and MR spectroscopy may help assess whether the cancer is still confined to the prostate or spread elsewhere. To determine if the cancer has spread to the lymph nodes or bones, the physician may order a CT or MRI scan of the pelvis. Sometimes follow-up images are needed to evaluate abnormalities found on the bone scan. These tests are not recommended for men with a Gleason grade lower than 7 and a PSA level lower than 10 ng/ml as they rarely show disease. 

How does the Gleason Score work?

The Gleason grading system is the most widely used system. In this system, because often several different tumor patterns are seen, the most common tumor pattern is assigned a score from 1 to 5 and the second most common pattern is similarly assigned a score, using the same scale. The two scores are added together to give a Gleason sum ranging between 2 and 10. Scores of 2 to 6 designate mildly aggressive prostate cancer, 7 moderately aggressive and scores of 8 to 10 are highly aggressive cancers.