Prostate Cancer

Your risk of developing prostate cancer may be higher because of:

• Age: The disease is rare before age 40. It is most common in men over age 65.
• Race: African-Americans are twice as likely to develop prostate cancer as Caucasians
• Family History: Prostate cancer runs in families. Men with a blood relative who has the disease have double the risk of having prostate cancer themselves.
• Weight and Diet: Men who are overweight may be more likely to develop prostate cancer. Studies also suggest that eating a lot of read meat and high fat foods increases your risk for prostate cancer.

Prostate cancer screening consists of two parts.

1. PSA Blood Test: A small amount of blood is drawn from your arm and sent to a laboratory to detect the level of Prostate Specific Antigen that is present. Generally, the higher the PSA level, the more likely it is that you have prostate cancer, but other noncancerous conditions can increase your PSA.
2. Rectal Exam: A doctor inserts a gloved and lubricated finger into the rectum to feel the prostate gland. The doctor is checking for any abnormalities that may indicate prostate cancer. The rectal exam is very quick, only 5 or 7 seconds.

Do I Need Both Tests?
It is possible to have an abnormal rectal exam and a normal PSA score or a normal rectal exam and abnormal rectal exam and have prostate cancer. Taking both the PSA and rectal exam together offers the best chances for detecting prostate cancer early.

What Is A Normal Result?
There is no standard score or result from a prostate screening that indicates prostate cancer. What is considered normal for each man varies based on his age and other factors. Your urologist will use his or her expertise to interpret your results. If your results indicate an increased likelihood for prostate cancer, your urologist will recommend more conclusive testing.

When Should I Be Screened and How
Urology San Antonio recommends the following screening guidelines:

Age	Screening Recommendation
Under 40	Not recommended
40 – 49	Recommended at least once in 40s to determine baseline; frequency determined by your doctor based on your results and risk factors
50-69	Recommended yearly unless your doctor suggests a different frequency
70+	Recommended for men with 10+ years of life expectancy; frequency determined by your doctor Not recommended for men with less than 10 years of life expectancy

Screening Limitations
Although prostate cancer screening is simple and can be lifesaving, it’s not a perfect test. Prostate cancer screening may lead to the discovery of a type of prostate cancer that will not spread nor cause problems. Finding and investigating suspicious screening results can cause anxiety, discomfort and may ultimately lead to unnecessary treatment. Despite these limitations, Urology San Antonio feels strongly that men should have the right to decide whether to be tested.

Prostate Biopsy
If your doctor thinks you might have prostate cancer, he or she will do a biopsy. During a biopsy, your doctor removes tissue samples that seem abnormal. A pathologist then reviews the cells in the tissue looking for changes that indicate cancer.

A prostate biopsy can be done in the urologist’s office with the aid of numbing medications, or it can be done in an outpatient surgery center.

New! Fusion Biopsy – This new type of biopsy uses the most advanced technology to precisely target suspicious areas, making the detection and diagnosis of prostate cancer more accurate than ever. Read More

Using your prostate biopsy tissue, your doctor can determine your cancer’s grade and stage. He or she may also order additional tests to better understand the type of prostate cancer your have and how likely it is to spread.

This information can guide you and your doctor in determining treatment options or whether a wait-and-see approach is appropriate.

Prostate Cancer Grade
Your cancer’s grade (referred to as a Gleason Score) tells your doctor about the cancerous tissue and how likely it is to grow and spread. Gleason Scores range from 2 to 10. Usually tumors with higher grades grow faster and are more likely to spread.

• Gleason 2 – 4: Low likelihood of cancer growing and spreading
• Gleason 5 -7: Intermediate likelihood of cancer growing and spreading
• Gleason 8 -10: High likelihood of cancer growing and spreading

Prostate Cancer Grade
After you know how aggressive your cancer is, your urologist needs to find out how much it has spread and where. To do this, your doctor will do a series of scans and also take into account the results of your PSA test and your cancer’s grade. In general, there are four stages of prostate cancer:

• Stage 1 or T1: The cancer is only in your prostate
• Stage 2 or T2: The cancer is still in your prostate but is more advanced
• Stage 3 or T3: The cancer has spread outside your prostate to nearby tissues like the seminal vesicles but hasn’t spread to your lymph nodes
• Stage 4 or T4: The cancer has spread to other parts of your body. It may be in your lymph nodes, bones and other organs like your bladder

Supplemental Tests
In the last few years, new laboratory tests have been developed to help your urologist assess the likelihood of your cancer being or becoming aggressive.  These tests include PHI, OPKO, ConfirmMDX, Prolaris, Oncotype Dx, and Decipher.   Ask your urologist for more information about these tests.

Radiation therapy is a common and highly effective treatment options for early-stage prostate cancer. It uses high-energy x-rays to kill cancerous cells in the prostate. There are two types of radiation therapy.

• External Beam Radiation Therapy: A computer-controlled radiation delivery machine called a linear accelerator to deliver precise radiation doses to the tumor while the patient reclines on a treatment table. External beam radiation is sometimes used after surgery to kill any cancer cells that may remain. This approach is called combination therapy.
• SBRT (Stereotactic Body Radiation Therapy) is a precise method of external beam radiation therapy. A powerful beam of radiation targets the prostate, and requires about 5 sessions lasting only a couple of minutes. Urology San Antonio offers SBRT at the San Antonio Cancer Center.
• IMRT (Intensity Modulated Radiation Therapy) is another type of external beam radiation therapy, which uses a lower intensity beam than SBRT. For prostate cancer, IMRT treatment plans usually include 45 daily treatments, with each treatment lasting only a few moments. Urology San Antonio offers IMRT at the San Antonio Cancer Center.
• NEW: Complete Guide to Radiation Therapy for Prostate Cancer
• Brachytherapy: Delivers radiation through radioactive pellets that are inserting into the prostate by a radiation oncologist during an out-patient operation.
• Xofigo (radium 223) – When infused into the body, radium 223 settles in the bones and radiates the cancer cells concentrated there, killing the cancer from inside the bone with limited damage to surrounding tissue. Xofigo is given monthly for six months through an IV infusion by a radiation oncologist.

Surgery to remove your cancerous prostate and the surrounding lymph nodes is called a radical prostatectomy. It is one of the most commonly used treatment options for prostate cancer that is confined to the organ, and it is highly effective.

At Urology San Antonio, our surgeons use minimally-invasive robotic technology that requires 5 dime-sized incisions rather than a traditional 6-8 inch incision. Patients usually recover within 2-3 weeks.

New Resource: Comprehensive guide to Prostatectomy

Robotic Technology
With robotic surgery, your surgeon sits at a console a few feet away from the operating room table, and he or she manipulates tiny instruments at the end of probes that have been inserted into your abdomen. The surgeon’s console screen provides 3-D, high definition view of the operating field at 10x magnification, which helps him or her see clearly in the small pelvic space. Additionally, the robot technology scales down the surgeon’s hand movements and filters out any unsteadiness, allowing for finer control inside the pelvic cavity and potentially better results for sparing the nerves involved in erections.

Nerve-Sparing Procedure
The nerves that control erectile function run along the edge of the prostate. Oftentimes your surgeon must cut through the nerves to remove the cancer. Whenever possible, your surgeon cuts around the nerves or carefully peels them away the prostate to minimize the effect on your erections.

Robotic Surgeons

Hormone therapy works by cutting off the supply of male hormones such as testosterone that encourage prostate cancer to grow. It targets cancer that has spread beyond the prostate gland and is thus beyond the reach of local treatments such as surgery or radiation therapy.

Although hormonal therapy cannot cure, it will usually shrink or halt prostate cancer, often for years. If prostate cancer stops responding to primary hormone therapy, secondary hormone therapy may be appropriate.

Different forms of hormone therapy work in different ways to stop testosterone. Some work by lowering the levels of testosterone; others block receptor cells for those hormones.

Hormonal control can be achieved with oral or injectable medications (medical castration) or through a surgery to remove the testicles known as an orchiectomy (surgical castration).

Surgery to remove the testicles (orchiectomy or surgical castration) is usually an outpatient procedure. The testicles are removed through a small incision in the scrotum; the scrotum itself is left intact. Some men opt for reconstructive surgery in which the surgeon replaces the testicles with prostheses shaped like testicles.

Cryotherapy is minimally invasive procedure that kills prostate cancer by freezing the cancerous cells.

With cryotherapy, the urologist inserts a number slender probes through the skin between scrotum and anus into the prostate gland. Each probe contains argon gas that’s cold enough to freeze the prostate and kill the cancer. A warming catheter protects the urethra (urine tube) from the very cold temperatures. Temperature sensors carefully monitor the process and precisely determine when target temperatures have been reached.

The cure rates for cryotherapy for early-stage prostate cancer are similar to surgery and radiation. However, the risk of erectile dysfunction is near 100% so the cryotherapy is rarely used as an initial treatment. It is more commonly used when radiation therapy fails to lower a man’s PSA to near zero.

Physicians that provide immunotherapy

Like primary hormone therapy for prostate cancer, secondary hormone therapy works by keeping prostate cancer cells from getting testosterone. Urologists turn to secondary hormone therapies when the prostate cancer cells are no longer responding to initial hormone therapies. Men taking secondary hormone therapy can continue with their normal activities with few side effects.

Two secondary hormone therapies are approved for prostate cancer, and other hormone therapies are being test in clinical trials.

• Zytiga (abirarterone): A daily oral pill. It works by interfering with an enzyme involved in testosterone production and shuts down testosterone creation in the testes, adrenal glands and tumor cells
• Xtandi (enzalutamide): A daily oral pill. It works by binds up testosterone receptors on the cancer cells’ surfaces so they cannot react to the hormone

Doctors that provide Secondary Hormone Therapy

The biggest risk to men with recurrent or advanced prostate cancer is bone problems caused by the cancer spreading to the pelvis or spine. A bone tumor, sometimes called bone metastasis or bony mets, can cause severe pain and weaken the bone, increasing a man’s risk for fractures.

Bone therapies can help minimize the problems caused by bone tumors. Treatments include:

Xgeva (denosumab)
Prevents calcium from being leached from the bone. It decreases fracture risk by 30 to 40 percent and relieves bone pain caused by tumors. It is given through a monthly injection (shot) at the urologist’s office.

Physicians that provide Xgeva

Xofigo (radium 223)
When infused into the body, radium 223 settles in the bones and radiates the cancer cells concentrated there, killing the cancer from inside the bone with limited damage to surrounding tissue. Xofigo is given monthly for six months through an IV infusion by a radiation oncologist.

Physicians that provide Xifigo

Intensity Modulated Radiation Therapy (IMRT)
Kills bone tumors with external beam radiation therapy to slow their growth and limit their harmful effects.

Physicians that provide IMRT

Chemotherapy drugs given through an IV kill cancer cells and can reduce cancer pain, but the drugs also affect healthy cells because your entire body is exposed to the medication, not just your prostate. The side effects of chemotherapy often make it difficult to continue with your daily routine so many prostate cancer patients opt not to undergo chemotherapy. The two chemotherapy drugs used for prostate cancer are Taxotere (docetaxel) and Jevtana (cabazitasel).

Urology San Antonio Research is seeking volunteers to participate in clinical trials evaluating the safety and effectiveness of promising new therapies.  To learn more about research opportunities, please contact our Research department at (210) 617-4116 or speak to your urologist about participation.