Mayo Clinic Study Shows Advanced Prostate Cancer Previously Considered Inoperable May Be Operable, Curable

ScienceDaily (Apr. 12, 2005) — ROCHESTER, Minn. -- New findings from Mayo Clinic indicate that cT3 prostate cancer, a disease in which the cancer has spread locally from inside the prostate to immediately outside it, is operable and has 15-year cancer survival rates of almost 80 percent.

"These patients have a better chance if they undergo surgery and are living longer than if they undergo radiation therapy," says Horst Zincke, M.D., Ph.D., Mayo Clinic urologist and senior study investigator.

Treatment of this type of prostate cancer has been controversial, as it is a stage 3 cancer in which the malignancy has spread. Due to its advanced stage, some physicians have considered it inoperable via radical prostatectomy, according to Dr. Zincke. He explains that many patients come to him for a second opinion after being told their cT3 prostate cancers could not be surgically removed.

"It's considered inoperable by some urologists and referred to radiation oncology," says Dr. Zincke. "They think surgery can't be done because the cancer is outside the prostate. Currently, only 15 percent are referred for surgery."

The problem with radiation therapy as the first line of treatment for cT3 prostate cancer, according to the Mayo Clinic researchers, is the cancer survival rate, which is 79 percent at only five years. In contrast, with radical prostatectomy, 79 percent of the patients lived at least 15 years. Says Dr. Zincke, "So, obviously surgery does a better job for these patients."

Dr. Zincke also explains that when malignant prostate tumors are high grade -- more aggressive -- they are not especially responsive to radiation therapy alone.
He believes the current trend away from surgery is a disservice to patients. "Patients are being denied surgical treatment when indeed they could have had surgery," Dr. Zincke says.

The cancer survival rates for cT3 prostate cancer with radical prostatectomy not only approach those of cT2 prostate cancer (cancer confined to the prostate), which is 90 percent at 15 years, but they are even more impressive due to the ages of the patients, says Dr. Zincke. "It's significant because the average patient is only 62 years old," he says. "So, a 15-year survival is a long time."

In addition to a favorable survival rate for the cT3 prostate cancer patients studied, the Mayo Clinic researchers also found urinary incontinence rates and complications were akin to those for cT2 prostate cancer.

Some of the patients studied with cT3 prostate cancer had additional, or adjuvant, therapy after surgery, such as hormone therapy or radiotherapy. Dr. Zincke indicates that adjuvant therapy is necessary for patients whose prostate cancer affects the lymph nodes. Surgery alone may be sufficient treatment for those without lymph node involvement. Approximately 50 percent of the cases of cT3 prostate cancer do not involve the lymph nodes.

The study also found that 25 percent of the patients were overstaged -- told that they had a cT3 prostate cancer, a more advanced form, rather than what they really had a cT2 prostate cancer in which the malignancy is confined inside the prostate.

Dr. Zincke points to following patients over 15 years post-treatment as a strength of the study.

"The highest incidence of prostate cancer death is not reached until 11 years after treatment, so 15-year data is significant," he says. "In contrast, five-year data is less meaningful."

Dr. Zincke recommends that patients with cT3 prostate cancer seek a surgeon who performs at least one prostate surgery per week and has completed at least 300 prostate surgeries. He explains that currently only 3 to 4 percent of urologists are doing more than one prostate cancer surgery per week. As they seek an appropriate surgeon, he encourages patients that "if someone tells you your cT3 prostate cancer is inoperable, don't give up."

With more common use of prostate-specific antigen (PSA) testing in the United States, more prostate cancers are now caught earlier, before the cancer spreads. Thus, the frequency of cT3 prostate cancers seen at Mayo Clinic has declined to 3 percent of all prostate cancers. Canada and Europe have much higher rates of cT3 prostate cancer, as PSA testing is not conducted as frequently and more cancers are discovered later than in the United States, allowing the cancers more opportunity to spread outside the prostate.

This study was conducted as a single-institution, retrospective study of 5,652 men who had radical prostatectomy at Mayo Clinic for confirmed prostate cancer.

The title of the paper is "Radical Prostatectomy for Clinically Advanced (cT3) Prostate Cancer Since the Advent of Prostate-Specific Antigen Testing: 15-Year Outcome." The first author is a former Mayo Clinic urology fellow, John F. Ward, M.D., Division of Urology, Naval Medical Center, Portsmouth, Va. Other Mayo Clinic authors include Jeffrey Slezak, Eric Bergstralh, and Michael Blute, M.D.

The Impossible Calculus of PSA Testing

New York Times editor Dana Jennings writes every Tuesday about coping with an advanced form of prostate cancer.

By Dana Jennings


Prostate cancer and its treatment breed anger and confusion among the men who have it and those who love them. And in the wake of studies released last week that question the value of screening for prostate cancer, I find myself even angrier and more confused.

I’m angry because the two studies confirm my gut feeling – based on comments to this blog and on the stories of many men I know – that millions of men, especially those in their late 60s and beyond, have received unnecessary prostate cancer treatments that have, at the very least, damaged their bodies and lives, if not outright ruined them.

I’m confused because I’m the statistical exception. I’m the one man in 49 whose life may have been saved because I had the PSA blood test. Most prostate cancers are slow and lazy. But my doctors and I learned after I had my prostate surgically removed last July that my cancer was shockingly aggressive. There’s a good chance that it would’ve killed me if I hadn’t been screened. And, to be blunt, it might yet.

Basically, the two large studies – one American, one European – found that screening tests for PSA, or prostate specific antigen, do a great job of discovering prostate cancer. But that knowledge doesn’t translate into many lives saved, the studies state, and for many men it can lead to needless treatment that diminishes quality of life.

My biggest problem with the studies – and, of course, this is the nature of such studies – is that they reduce me and all my brothers-in-disease to abstractions, to cancer-bearing ciphers. Among those dry words, we are not living, breathing and terrified men, but merely our prostate cancers, whether slow or bold.

The most chilling sentence I’ve read in the past week is this one from The New York Times: “In each study, the two groups were followed for more than a decade while researchers counted deaths from prostate cancers, asking whether screening made a difference.”

The researchers counted “deaths,” not men who had died. As Charlie Brown once said to Lucy as she detailed his baseball team’s shortcomings: “Tell your statistics to shut up.”

My own experience with prostate cancer started pretty typically. My PSA was elevated more than a year ago. That fact led to a biopsy last spring, and on April 7 I learned that I had prostate cancer.

It was determined that my cancer was a probable Stage 1, and that my Gleason score was a 6 or 7 on a scale of 10, with 10 being the worst possible number. It appeared that I had an “ordinary” case of prostate cancer. My doctors recommended surgery. In my case, because of previous operations, I had a radical open prostatectomy.

Now, cancer is a powerful card for any doctor to play. Cancer is a serpent in our bodies that we cannot abide. When most of us learn that we have cancer, we want it out right now. We want it annihilated. And for me, surgery was the right decision, because it was only through the post-op pathology report that we learned that my cancer was an aggressive Stage 3 – a T3B – and that my Gleason was an ominous 9. I was actually that somewhat rare man who could die from prostate cancer, not just with prostate cancer. There are still about 30,000 men who die each year from the disease.

Even so, I will still tell you that I was damaged by the surgery, with impotence and incontinence being the major issues; those were also complicated by my follow-up treatments of radiation and hormone therapy.

And given the findings in these two studies, if my case had been typical, if the cancer had been the slow-growth kind and confined to the prostate, I would feel like an absolute fool for having gone through the physical indignities caused by surgery.

Doctors can tell you and tell you that impotence and incontinence are probable side effects. But until you actually experience them as man trying to regain his life, you have no idea what those multisyllabic curses truly mean.

In our competitive medical marketplace, there is no shortage of surgeons out there who aggressively promote themselves and who do a volume business in prostates. But these two studies indicate that maybe that volume should be reduced.

So, I sit here in limbo. And I wonder whether I’ll be that rare man who ducks death from a cancer that would’ve killed him – because I got screened. But all I can confess to you, in all honesty, is this: I’m still angry and confused.

Locally advanced prostate cancer: hormone therapy and radiation therapy can double survival.

When prostate cancer extends beyond the prostate but is still contained within the prostate region, it is called ‘locally advanced’. Cancer at this stage is at high risk of progression, but is still potentially curable. This report from a US radiotherapy conference suggests that using two therapies can be better than one alone.

From Medscape Medical News, News Author: Zosia Chustecka

September 23, 2008 — Adding radiation to androgen deprivation therapy in older men with locally advanced prostate cancer reduces the risk of dying from the disease by half. These results, from a randomized clinical trial, suggest that men should be offered this additional option, says lead researcher Anders Widmark, MD, professor in radiation oncology at Umea University in Umea, Sweden.

Dr. Widmark presented the results at a plenary session during the American Society for Therapeutic Radiology and Oncology (ASTRO) 50th Annual Meeting in Boston, Massachusetts.

"This trial will change clinical practice," predicted Anthony Zietman from Massachusetts General Hospital in Boston, who was moderating a press briefing at which the results were highlighted. Dr. Zietman is also president-elect of the ASTRO, taking on the role of president effective September 23, 2008.

"At present, there is a bit of a fatalistic attitude towards locally advanced prostate cancer, as it generally considered to have already quietly spread elsewhere," Dr. Zietman commented. "Often the only treatment often offered to older men with this stage of disease is hormonal therapy," he continued. "This attitude is maybe more common in Europe, but it's also prevalent in the United States."

"The thinking is that the cat is already out of the bag," Dr. Zietman commented, but "the results from this trial prove that this is not the case."

"This randomised trial is the first to show that men with locally advanced prostate cancer will survive substantially longer when radiation is added to their treatment plan," Dr. Widmark told journalists. .

American Society for Therapeutic Radiology and Oncology 50th Annual Meeting: Plenary session. Presented on September 22, 2008.


See: Medscape article

Fatigue in People with Cancer

What is fatigue?

Fatigue is feeling tired -- physically, mentally, and emotionally. It means having less energy to do the things you normally do or want to do. It can be caused by cancer, cancer treatment, and other factors. Fatigue can last a long time and can affect your day to day activities.

The fatigue that comes with cancer is different from the fatigue of everyday life. Everyday, normal fatigue is most often a short-term problem that gets better with rest. Cancer-related fatigue is worse and it causes more distress. Rest does not make it go away. And even a small amount of activity may make you feel exhausted. For some people, this kind of fatigue can cause even more distress than pain, nausea, vomiting, or depression. Cancer-related fatigue can:

* Differ from one day to the next in how bad it is and how much it bothers you
* Be overwhelming and make it hard for you to feel well
* Make it hard for you to be with your friends and family
* Make it hard for you to do your normal activities, including going to work
* Make it harder for you to follow your cancer treatment plan
* Last different lengths of time, which makes it hard to guess how long yours will go on

Cancer patients say fatigue is the most distressing side effect of cancer and its treatment -- it can have a major affect on a person's quality of life.


Fatigue is very common in people with cancer

Cancer-related fatigue is the most common side effect of cancer and cancer treatment. Research suggests that anywhere between 70% to 100% of cancer patients getting treatment have fatigue. And about 30% to 50% of cancer survivors have reported fatigue that lasts for months or even years after they finish treatment.

Even though fatigue is a very distressing symptom, doctors and nurses seldom focus on it, and patients and caregivers rarely report it. It may be hard to talk about, but fatigue is normal and common for people with cancer. There are things that can be done to help if your health care team knows you are having this problem.


Talk about your fatigue

Treating fatigue is an important part of care for you and your family. But before anything can be done to help you, your health care team must know about your level of fatigue, or how bad your fatigue is.

People with fatigue describe it in many ways. They may say they feel tired, weak, exhausted, weary, worn-out, or slow; have no energy; and cannot concentrate. They also talk about having heavy arms and legs; little drive to do anything; being unable to sleep or sleeping too much; or feeling moody, sad, irritable, or frustrated. Patients rarely describe their symptom as "fatigue" unless their health care team suggests it.

Only you know if you have fatigue and how bad it is. No laboratory tests or x-rays can diagnose or show your level of fatigue. The best measure of fatigue comes from your own report of your fatigue level to your health care team. But fatigue can be hard to describe.

You can describe your level of fatigue as none, mild, moderate, or severe. Or you can use a scale of 0 to 10, where a 0 means no fatigue at all, and a 10 means the worst fatigue you can imagine. Talk to your doctor or nurse about how to describe your fatigue so they can understand how it is affecting your everyday life.


How bad is your fatigue?

If you have moderate (4 to 6) to severe (7 to 10) fatigue, your doctor may ask you to give as much information as you can about your fatigue. You may be asked questions like:


When did the fatigue first start?

* When did you first notice that this fatigue is different than usual for you?
* How long has it lasted?
* Has it changed over time? How so?
* Does anything make it better? Worse?
* Do you have any other problems or concerns?
* How has the fatigue affected the things you do every day or the activities that give meaning and enjoyment to your life?

In planning how to treat your fatigue, your doctor may take into account your cancer, the type and length of treatment, how likely the treatment is to cause fatigue, and your response to treatment.


What causes fatigue in people with cancer?

Cancer itself can cause fatigue directly by spreading to the bone marrow, causing anemia (low red blood cell count), or indirectly, by forming toxic substances in the body that change the way normal cells work.

Fatigue is also very common with many cancer treatments, such as chemotherapy, radiation therapy, bone marrow transplant, and immunotherapy. Cancer treatments often kill fast-growing healthy cells, especially the blood-making cells in the bone marrow. This causes fatigue because red blood cells carry oxygen to fuel all the cells in the body.

Too few red blood cells (anemia) means too little energy to meet the body's needs. Treatments can kill normal cells and cancer cells, which leads to a build-up of cell waste. The body needs extra energy to clean up this waste and repair damaged tissue.


Here are some questions about fatigue and your cancer treatment that you may want to ask:

* Will the cancer treatment that I am getting cause fatigue?
* How bad will my fatigue likely get?
* Are there ways to control my fatigue or make it better?
* If my fatigue gets bad, how will you decide how to treat it?
* What can be done if the treatment does not make my fatigue better?
* What are the likely side effects of the treatments for fatigue?
* What other health care professionals can help manage my fatigue?
* Is my fatigue caused by anemia? If so, how will it be treated?

Other things that can affect fatigue

Fatigue is different for every cancer patient. Many treatment-related and disease-related factors have been linked to fatigue, but doctors still don't know exactly what causes cancer-related fatigue.

There are some other factors that often worsen fatigue, and you should be checked for them. Managing these factors can greatly help reduce the fatigue.

* Anemia
* Pain
* Emotional distress (including depression and anxiety)
* Sleep problems
* Medicines you are taking that could worsen your symptoms
* Other medical problems (such as infection; low thyroid function; and heart, lung, liver, kidney, or nervous system disease)
* Nutrition problems
* Low level of physical activity

Anemia

A low red blood cell count is called anemia (uh-nee-me-uh). Your red blood cell count will be measured with a blood test called a CBC. (CBC stands for complete blood count.) Doctors often define anemia as a blood hemoglobin (Hb) level of less than 12 g/dL (grams per deciliter). But many people do not feel much different until the hemoglobin level falls below 11 g/dL. Symptoms of anemia get worse as the hemoglobin gets lower. These symptoms can include:

* Rapid heart beat
* Shortness of breath
* Trouble breathing on exertion (such as when walking or climbing stairs)
* Dizziness
* Pale skin
* Fatigue

There are many different causes of anemia. Your health care team will try to find out the cause of your anemia so they can give you treatment that makes it better.


Pain

Cancer pain can make you less active, decrease your appetite, cause sleep problems, and cause depression -- all of which can lead to fatigue. Cancer pain should not be accepted as part of cancer treatment. There is always something that can be done to make pain better.

For more information about treating cancer pain, talk to your doctor or nurse. You can also learn more in our document, Pain Control: A Guide for People With Cancer and Their Families.


Emotional distress

People diagnosed with cancer go through many unpleasant emotions. There are many different types of feelings, from anger to depression, but their overall effect is distress. Distress can include a feeling of sadness about the loss of good health or fear of what will happen in the future. These are normal feelings. But sometimes the distress becomes so great that it causes physical problems like fatigue. Depression and anxiety are common types of distress that can cause the physical symptom of fatigue.


Sleep problems

If you wake up often during the night, have trouble falling asleep, or wake up early in the morning and cannot go back to sleep, you are most likely not getting the rest you need. This change in your sleep can lead to fatigue. Tell your doctor or nurse about your sleeping problems. They will try to find out why you are having trouble sleeping so they can help plan the best treatment for this problem.


Medicines

Many medicines can cause symptoms of fatigue and problems with thinking. This includes over-the-counter drugs, vitamins, herbs, and other supplements, as well as prescription medicines. The drugs most likely to cause fatigue are pain medicines; sleep medicines; anti-depressants; and anti-nausea and anti-seizure medicines. Some heart medicines can also cause fatigue. The degree of sleepiness varies from patient to patient. Taking many drugs with many side effects may make fatigue worse, too. It is important to tell your health care team about all vitamins, herbs, supplements, and medicines you are taking. Keeping a journal may help you keep track of your medicines and symptoms.


Other medical problems

Many people have other medical problems or illnesses that are not related to cancer, but may add to fatigue. These illnesses should be identified and treated. Examples of other medical problems that may be part of fatigue are:

* Heart problems, such as congestive heart failure
* Lung problems, such as emphysema or shortness of breath
* Kidney problems, such as kidney failure
* Brain problems, such as seizures or dementia
* Infections, such as pneumonia or viral illnesses
* Low thyroid function

Low thyroid gland function is very common in people in the United States. Anyone with fatigue should be tested for this. Blood tests are done to find out how much thyroid hormone is present in the blood. If the level of thyroid hormone is low, treatment can be given to replace the thyroid hormone so that the body gets what it needs.


Poor nutrition

The body needs protein, carbohydrates, fats, vitamins, minerals, and water to do its work. In people with cancer, changes in nutrition can affect fatigue. These changes include how well the body can process nutrients; the need for more energy than usual; and poor intake of food, fluids, and certain minerals. The changes can be caused by:

* Changes in metabolism (the body's ability to break down and use food)
* The need to repair damaged cells
* Uncontrolled tumor growth competing for nutrients
* Poor appetite
* Nausea and vomiting
* Diarrhea

You may have blood tests to measure things like sodium, potassium, calcium, and magnesium -- these are important minerals that your body needs. You may ask to be referred to a registered dietitian who can help you learn how to best meet your nutrition during this time.

You can find more information on nutrition in our document, Nutrition for the Person With Cancer During Treatment: A Guide for Patients and Families.


Inactivity

Cancer treatment along with less physical activity can make you less able to do the things you used to do. And you may find that it takes much more effort and more energy to do the things you need to do. This can worsen fatigue. Physical exercise can help you build up your energy level. If you have more energy, it can help you do your usual activities and have less fatigue. Talk to your doctor before you start any exercises. A careful work-up by a physical therapist can help plan the right exercise program for you.

You can find more information in Nutrition and Physical Activity During and After Cancer Treatment: Answers to Common Questions.


Treating fatigue

Many health professionals may be part of fatigue treatment. Treatment may involve doctors, nurses, social workers, physical therapists, nutritionists, and a number of others. Education and counseling are part of the treatment and help you learn how to save energy, reduce stress, and use distraction to think about things other than the fatigue.

Fatigue is often caused by more than one problem. Treating a certain problem, like anemia, may make you feel better, but other things may still need to be done. For this reason your health care team may have you try many different things to ease your fatigue. These may or may not include medicines.

If the cause of fatigue is known, treatment will focus on the cause. For example, if anemia is adding to your fatigue, the anemia can be treated. In another patient, treatment may include correcting fluid and mineral imbalances. A program of regular exercise, managing your stress, and finding ways to deal with anxiety and depression seem to work the best in dealing with fatigue. Still, treating sleep problems and correcting nutrition problems can help decrease fatigue, too.


Tips for managing fatigue

* Save your energy

Saving or conserving energy is one way to make sure you have enough energy to do what needs to be done on a daily basis. You may need to accept the fact that you can't do everything you want to do at your current level of energy. Each day, decide which things are the most important to do and focus on those tasks. Do things slowly, so that you will not use too much energy as you go. Let others help you. This can help them feel useful and get your tasks done, too.

* Distraction

Sometimes feeling tired can become so discouraging and frustrating that it's easy to let it become the focus of your thoughts. Try to distract yourself with other things, like listening to music, having relaxing visits with friends or family, or reading a book. These things can give you an escape from your fatigue without using up too much energy.

* Attention-restoring activities

Certain activities can help you relax, focus better, and direct your attention under stress. These activities include things like walking on a beach, sitting in a peaceful setting, gardening, doing volunteer activities not related to your illness, or bird watching.

* Reduce stress

Having cancer is stressful and cancer treatment can cause even more stress. Talk with a social worker or nurse on your health care team about your level of stress. This can help you know if it is "normal" stress or more worrisome anxiety or depression. Feeling tired may be related to feeling depressed and anxious. Support groups, mental health counseling, stress management training, and relaxation exercises are some ways you can improve the feelings related to fatigue and help you overcome the tiredness you feel.

* Exercise

Research has shown that there are some ways to improve your energy and activity level that do not involve medicine. An aerobic exercise program -- started only with your doctor's OK -- can lead to better heart and lung function, as well as more positive feelings about your life and well-being. You may need to see a physical therapist to learn the best exercise routine for you to follow at this time. You must be careful about any form of exercise if you have any of these:

* Bone metastasis (cancer that has spread to your bones)
* A low white blood cell count
* A low platelet count
* A fever
* Anemia

These factors can lead to more physical problems if they are not taken into account when planning an exercise program.

Not only can the right amount and type of exercise help fatigue, it can also help you sleep better. Another benefit of exercise is that it may make your mood better, too.


Nutritional counseling

Many cancer patients have changes in the way they eat, swallow, and taste during treatment. Talking with a registered dietician may help you learn ways to manage problems like loss of appetite, diarrhea, nausea, or vomiting. A nutritionist also can make sure you are getting enough fluids and nutrients so that your blood chemistry is balanced.


Sleep improvement

Sleep problems are common during cancer treatment. You may have trouble falling asleep or sleep too much. Sleep experts tell us that having a regular time to go to bed and get up helps us keep a healthy sleep routine. Avoiding caffeine in fluids (like coffee or soda), or even in foods (like chocolate) can help, too. Do not exercise too late in the evening; this may cause sleep problems. Naps may be needed, but try to keep them short (less than 45 minutes long) and early in the day so they don't interfere with nighttime sleep.


Medicines

There is no magic pill that can make you less tired and give you more energy. But there are some medicines that may help you with your fatigue. In some cases, fatigue may be bad enough that your doctor or nurse may recommend a stimulant medicine for a short period of time. Examples of this type of medicine are methylphenidate hydrochloride (Ritalin®) or modafanil (Provigil®). Anti-depressant drugs and steroids have also been used to ease fatigue. If you are having problems sleeping, your doctor or nurse may suggest a medicine to help you sleep.

More research is needed and is being done in this area, but there are drugs available that may give you relief if your fatigue gets bad.


Coping with fatigue

Learning about fatigue patterns, how bad it might be, and how long it may last are key parts of dealing with fatigue. Many times, a family member who learns with you can help you talk to your health care team about your fatigue.

Here is a recap of things you can do to manage and reduce your fatigue:

* List your activities in order of how important they are to you, so you can do the more important ones when you have the most energy.

* Ask for help and have other people do tasks for you when possible.

* Put things that you often use within easy reach.

* Set up and follow a structured daily routine, keeping as normal a level of activity as possible.

* Balance rest and activity. Too much time in bed can make you weak. Try to avoid it. Schedule activities so that you have time for plenty of rest that does not interfere with nighttime sleep. Shorter rest periods are reported to be better than one long one.

* Learn ways to deal with your stress. Try to reduce it using things like deep breathing, imagery, meditation, prayer, talking with others, reading, listening to music, painting, or any other things you like to do.

* Keep a record of how you feel each day. Take it with you when you see your doctor.

* Talk to your doctor about how to manage any pain, nausea, or depression you may have.

* Talk to your doctor about physical exercise before you start an exercise program.

* Get fresh air, if possible.

* Unless you are given other instructions, eat a balanced diet that includes protein (meat, milk, eggs, and beans) and drink about 8 to 10 glasses of water a day.

The best thing you can do for fatigue is talk to your doctor or nurse about it. Let them know how bad it is so you can get the help you need to deal with it.


Watch for signs of fatigue

Here is a list of some signs of fatigue that you and your family can watch for. Talk to your doctor if you have any symptoms of fatigue.

* You feel tired and it does not get better, it keeps coming back, or it becomes severe.

* You are more tired than usual during or after an activity.

* You are feeling tired and it is not related to an activity.

* Your tiredness does not get better with rest or sleep.

* You sleep more.

* You become confused or cannot concentrate or focus your thoughts.

* You have no energy.

* You are unable to get out of bed for more than 24 hours.

* Your tiredness disrupts your work, social life, or daily routine.

* You have no desire to do the things you normally do.

* You feel negative, sad, or irritable.

Fatigue can lead to distress. It can interfere with your daily activities and keep you from doing the things you need and want to do. Fatigue can make you unable to take care of yourself, affect your will to do things, and sometimes make you feel like you cannot continue your cancer treatment. Work with your health care team to find and treat the causes of your fatigue.

Remember: There is no one way to diagnose or treat fatigue. The best treatment for you is most likely to be found through open discussions with your doctor and your nurse.

Hormone (Androgen Deprivation) Therapy

Hormone therapy is also called androgen deprivation therapy (ADT) or androgen suppression therapy. The goal is to reduce levels of the male hormones, called androgens, in the body. The main androgens are testosterone and dihydrotestosterone (DHT). Androgens, produced mainly in the testicles, stimulate prostate cancer cells to grow. Lowering androgen levels often makes prostate cancers shrink or grow more slowly. However, hormone therapy does not cure prostate cancer.


Hormone therapy may be used in several situations:

* If you are not able to have surgery or radiation or can't be cured by these treatments because the cancer has already spread beyond the prostate gland
* If your cancer remains or comes back after treatment with surgery or radiation therapy
* As an addition to radiation therapy as initial treatment if you are at high risk for cancer recurrence
* Before surgery or radiation to try and shrink the cancer to make other treatments more effective

Types of Hormone Therapy

There are several types of hormone therapy used to treat prostate cancer.

Orchiectomy (surgical castration): Even though this is a type of surgery, its main effect is as a form of hormone therapy. In this operation, the surgeon removes the testicles, where more than 90% of the androgens, mostly testosterone, are made. With this source removed, most prostate cancers stop growing or shrink for a time.

This is done as a simple outpatient procedure. It is probably the least expensive and simplest way to reduce androgen levels in the body. But unlike some of the other methods of lowering androgen levels, it is permanent, and many men have trouble accepting the removal of their testicles. Some men having the procedure are concerned about how it will look. If wanted, artificial silicone sacs filled with saline (salt water) can be inserted into the scrotum. These look and feel like testicles.

Possible side effects of orchiectomy are generally related to changing levels of hormones in the body. About 90% of men who have had this operation have reduced or absent libido (sexual desire) and impotence. Some men also experience:

* Hot flashes (these may go away with time)
* Breast tenderness and growth of breast tissue
* Osteoporosis (bone thinning) which can lead to broken bones
* Anemia (low red blood cell counts)
* Decreased mental acuity (sharpness)
* Loss of muscle mass
* Weight gain
* Fatigue
* Decrease in HDL ("good") cholesterol
* Depression

Many of these side effects can be prevented or treated. For example, sometimes the hot flashes will be helped by treatment with antidepressants. Brief radiation treatment to the breasts before surgery can help prevent their enlargement.

Men getting this treatment should be watched and treated for osteoporosis to help prevent broken bones. There are several different drugs available. Exercise is a good way to reduce fatigue, weight gain, and the chance of loss of bone and muscle mass. If anemia occurs, it is often very mild and usually doesn't cause symptoms. Depression can be treated by antidepressants and/or counseling.

Luteinizing hormone-releasing hormone (LHRH) analogs: Even though LHRH analogs (also called LHRH agonists) cost more and require more frequent doctor visits, most men choose this method over orchiectomy. These drugs lower testosterone levels just as well as orchiectomy by lowering the levels of androgens (mainly testosterone) made by your testicles.

LHRH analogs are injected or placed as small implants under the skin. They are given either monthly or every 3, 4, 6, or 12 months. The LHRH analogs available in the United States include leuprolide (Lupron, Viadur, Eligard), goserelin (Zoladex), and triptorelin (Trelstar).

Possible side effects of LHRH analogs such as hot flashes, osteoporosis, and others are similar to those of orchiectomy (see above), and are largely due to low testosterone levels.

When LHRH analogs are first given, testosterone production increases briefly before falling to very low levels. This effect is called flare and results from the complex way in which LHRH analogs work. Men whose cancer has spread to the bones may experience bone pain. If the cancer has spread to the spine, even a short-term increase in growth could compress the spinal cord and cause pain or paralysis. Flare can be avoided by giving drugs called anti-androgens for a few weeks when starting treatment with LHRH analogs. (For more on anti-androgens, see below.)

Luteinizing hormone-releasing hormone (LHRH) antagonists: A newer drug, abarelix (Plenaxis), is an LHRH antagonist. It is thought to work like LHRH agonists, but it appears to reduce testosterone levels more quickly and does not cause tumor flare like the LHRH agonists do.

A small percentage of men (fewer than 5%) have serious allergic reactions to the drug. Because of this, it is only approved for use in men who have serious symptoms from advanced prostate cancer and who cannot or refuse to take other forms of hormone therapy.

The possible side effects are similar to those with orchiectomy (see above) or LHRH agonists.

Abarelix is given only in qualified doctors' offices. It is injected into the buttocks every 2 weeks for the first month, then every 4 weeks. You will be asked to remain in the office for 30 minutes after the injection to make sure you are not having an allergic reaction.

Anti-androgens: Anti-androgens block the body's ability to use any androgens. Even after orchiectomy or during treatment with LHRH analogs, a small amount of androgens is still made by the adrenal glands.

Drugs of this type, such as flutamide (Eulexin), bicalutamide (Casodex), and nilutamide (Nilandron), are taken daily as pills.

Anti-androgens are not often used by themselves (see below). An anti-androgen may be added if treatment with orchiectomy or an LHRH analog is no longer working by itself.

Anti-androgen treatment may be combined with orchiectomy or LHRH analogs as first-line hormone therapy. This is called combined androgen blockade (CAB). There is still some debate as to whether CAB is more effective in this setting than using orchiectomy or an LHRH analog alone. If there is a benefit, it appears to be small.

Some doctors are testing the use of anti-androgens instead of orchiectomy or LHRH analogs. Several recent studies have compared the effectiveness of anti-androgens alone with that of LHRH agonists. Most found no difference in survival rates, but a few found anti-androgens to be slightly less effective.

If hormone therapy including an anti-androgen stops working, some men seem to benefit for a short time from simply stopping the anti-androgen. Doctors call this the "anti-androgen withdrawal" effect, although they are not sure why it happens.

Side effects of anti-androgens in patients already being treated by orchiectomy or with LHRH agonists are usually not serious. Diarrhea is the major side effect, although nausea, liver problems, and tiredness can also occur.

The major difference from LHRH agonists and orchiectomy is that anti-androgens may have fewer sexual side effects. When these drugs are used alone libido and potency can often be maintained.

Other androgen-suppressing drugs: Estrogens were once the main alternative to orchiectomy for men with advanced prostate cancer. Because of their possible side effects (including blood clots and breast enlargement), estrogens have been largely replaced by LHRH analogs and anti-androgens. Still, estrogens may be tried if androgen deprivation is no longer working.

Ketoconazole (Nizoral), first used for treating fungal infections, blocks production of androgens and is sometimes used.


Current Controversies in Hormone Therapy

There are many issues around hormone therapy that not all doctors agree on, such as the best time to start and stop it and the best way to give it. Studies looking at these issues are now under way. A few of the issues are discussed here.

Early vs. delayed treatment: Some doctors think that hormone therapy works better if it is started as soon as possible if the cancer has reached an advanced stage (for example, when it has spread to lymph nodes), if it is large (T3) or has a high Gleason score, or if the PSA starts rising after initial therapy, even though the patient feels well. Some studies have shown that hormone treatment may slow down the disease and perhaps even lengthen patient survival. But not all doctors agree with this approach. Some are waiting for more evidence of benefit. They feel that because of the likely side effects and the chance that the cancer could become resistant to therapy sooner, treatment should not be started until symptoms from the disease appear. Studies addressing these questions are now under way.

Intermittent vs. continuous hormone therapy: Nearly all prostate cancers treated with hormone therapy become resistant to this treatment over a period of months or years. Some doctors believe that constant androgen suppression may not be needed, so they advise intermittent (on-again, off-again) treatment.

In one form of intermittent therapy, androgen suppression is stopped once the blood PSA level drops to a very low level. If the PSA level begins to rise, the drugs are started again. Another form of intermittent therapy involves using androgen suppression for fixed periods of time -- for example, 6 months on followed by 6 months off.

Clinical trials of intermittent hormonal therapy are still in progress. It is too early to say whether this new approach is better or worse than continuous hormonal therapy. However, one advantage of intermittent treatment is that for a while some men are able to avoid the side effects of hormonal therapy such as impotence, hot flashes, and loss of sex drive.

Combined androgen blockade (CAB): Some doctors treat patients with both androgen deprivation (orchiectomy or an LHRH agonist) and an anti-androgen. But most doctors are not convinced there's enough evidence that this combined therapy is better than one drug alone.

Triple androgen blockade (TAB): Some doctors have suggested taking combined therapy one step further, by adding a drug called a 5-alpha reductase inhibitor -- either finasteride (Proscar, Propecia) or dutasteride (Avodart) -- to the combined androgen blockade. There is very little evidence to support the use of this "triple androgen blockade" at this time.

Last Revised: 08/25/2008

Radiation Therapy - Week One

DAY TWO

Two down ... 38 (treatments) to go!!!

Today my wife attended the treatment room with me to see first hand just how meticulous the technicians are in ensuring that the measurements precisely match that of the computerised treatment plan.

I must say, I am very impressed with the skill, precision and patience these dedicated personnel demonstrate. I also applaud the attention given to the patient to ensure that every step of the procedure is explained along the way.

Here's a picture showing today's team hard at work.

After carefully ensuring that the right 'positioning' is attained; the team adjourn to the computer station to take a series of X-rays to ensure that the 'gold seeds' (fiducial markers) show that the prostate is in the same relative position as indicated on the 'model'.

With any necessary minor adjustments completed; the Radiation Treatment begins.

Once again, NO discomfort to report. The only 'difficulty' I have is the timing associated with ... empty bowel ... but FULL bladder.

Radiation Therapy - Week One

DAY ONE

Well as noted in the most recent post (over at Cancer Story) my Radiation Therapy commenced a couple of days late. Well ... today was the day! And so off I went, ready for my first experience of Radiation Therapy; flanked by my wife, my daughter AND her two children both under two years of age!

We actually caused quite a stir amongst the nursing staff as both of our grandchildren are (I must admit) quite adorable!

Then it was off to the 'loo' to empty my bladder and then to refill it again with at least '500 mls' of water.

Having taken care of the bowel and rectum situation earlier in the day (with a trusty suppository) I was quite confident that there would be no unnecessary interruptions this time!

Next it was time to undress and put on my specially selected gown - see photo below.

Banjo wanted to give grandad a hug before he headed off! Not sure if the hug was for me, or whether he wanted to see all the brightly coloured, smiley faces.




Then it was to the treatment room for the procedure, with my own doctor (my daughter Lauren) present to oversee the whole event; both in the treatment room and later at the monitoring station. See below:

Now, I'm sure that someone is asking: "Was it uncomfortable?" Well ... yes ... but not in the way you might think! The ONLY discomfort I felt ... was looking at the photos afterwards!

I have never been overweight in my life; but look what 'Hormone Therapy (LHRH implants) does for you! I have gained (for me) a whopping 9 kgs!

More to follow...

More Scans

In a couple of days, I'm scheduled to undergo an MRI, followed by another CT Scan at one of Sydney's premier hospitals. These procedures will assist the Radiation Oncologist to map out the best plan of action for the upcoming 8 weeks of Radiation Treatment to commence on Tuesday 25 March. Since this is my first MRI, I thought I would do some research on the procedure and have included it below.

What is MRI?

MRI is a way of creating pictures of your body that does not use X-rays or radiation. The MRI machine makes pictures by organising and collecting the magnetic fields that naturally occur within the body. MRI pictures show the soft tissues of the body (muscles, nerves, brain, discs, ligaments etc). In many situations MRI offers unique information to help your doctor better plan your treatment and care.

During the scan you will be lying inside a large tubular machine. The Radiographers want you to be comfortable and will ask you to be very still during the scan because even slight movement can spoil the images and reduce their usefulness to you and your doctor.

The inside of the scanner is well lit, and has a fan to blow fresh air gently over you. Music is provided from an FM radio, or from tapes and CDs.

Most MR scans take between 25 and 60 minutes. The Radiographers will talk to you through an intercom system.

Preparation for MRI

In most cases there is no special preparation for an MRI scan. You can eat and drink normally on the day of the scan although it is best to avoid large amounts of coffee or other things that make you restless.

It is very important not to bring any metal into the scan room without letting the Radiographer know. Before the scan you will be asked to remove your watch, keys, coins, credit cards, bus tickets and phone cards. These can all be damaged by the strong magnet of the MRI scanner, or might cause distortions in the MRI pictures.

When you arrive at MRI, you will be asked a series of questions to find out if you have any metal or implants in your body.

Depending on what part of your body is being scanned, you may have to wear a cotton gown.

For some MRI scans we need to measure your heart beat by placing small dots and wires on your back or chest.


Pelvis MRI - Abdomen MRI Special Preparation

If you are having a scan of the abdomen or pelvis, do not eat or drink anything for 5 hours before the appointment. This is important to ensure high quality pictures.


Please Bring Old X-rays

You may have had other X-ray tests, Ultrasound, Thermography, or Nuclear medicine. These films can all be interpreted by the MRI Radiologist and greatly improve the relevance of the MRI report.

It is very important to bring old X-rays etc with you to the MRI scans so they can be reviewed. You may need to supply them before a full MRI report can be made.

Private films will be returned to your referring doctor with the new MRI images.


Getting Comfortable & Keeping Still

MRI images are very sensitive to movement. By keeping very still during the scan you can improve the quality of the images we obtain. We have found that the best way to keep still is to be relaxed, lying comfortably as if you were dropping off to sleep. The MRI Radiographer is very interested in making you comfortable in the scanner so that you feel settled, secure and relaxed, let them know what they can do for you and together you will ensure the best possible pictures.


Problems with MRI

It may not be possible, or safe, to have an MRI scan if you have any of these items:

• Cardiac pacemaker


• Surgical clips in your head (particularly aneurysm clips)


• Some artificial heart valves


• Electronic inner ear implants (bionic ears)


• Metal fragments in your eyes


• Electronic stimulators


• Implanted pumps

Let the MRI Unit know well before your appointment if you have any of these. Experienced MRI staff will have to discuss the exact implant or metal with you to decide if it is safe to perform the scan.

Deciding which implants cannot be scanned takes special knowledge and experience. Please do not try to guess, and don’t just rely on your doctor to determine if we can scan you.

Before the scan you will be asked a series of questions to check that it is safe for you to enter the scan room.

People with dental fillings and bridges, hip and knee replacements, and tubal ligation clips can all be scanned safely. The Radiographers will want to know about these things to minimise the effect they have on your images.


Claustrophobia

If you have experienced claustrophobia, or have trouble in enclosed spaces talk about it with the MRI staff before your appointment date.

For mild claustrophobia we find that the staff can help you to relax enough to get rid of the anxiety in a few minutes.

If your claustrophobia is severe you may need an anti-anxiety prescribed by your referring doctor or G.P. Staff at the MRI unit can be contacted about this and can offer your doctors some advise. You shouldn't drive after taking such drugs, so arrange a safe way to get home.

Because there are no side effects of MRI you can bring a friend into the scan room for support if that will help your anxiety. Children in particular should feel free to bring an adult in with them. Everyone coming into the scan room will be asked the questions about metal and implants.


Contrast Injections (Dye)

Most MRI tests do not need you to have an injection, but in some situations a contrast agent can greatly improve the accuracy of the scan. The contrast is injected into a vein, and the dose is quite small.

MRI contrast is not the same as X-ray contrast. Very few people notice when it is injected.


Pregnancy

If you are pregnant or could be pregnant at the time of your scan appointment, please call us early so we can discuss the situation with you and consult your doctor.

MRI causes a slight heating of your body, so most MRI sites avoid scanning during the first 3 months of pregnancy unless the diagnosis cannot wait and the only alternate test uses X-rays. Beyond that period, MRI is still avoided if the diagnosis can wait till your child is born as a matter of extreme caution. In many sites around the world MRI is used to examine pregnant women and their babies to avoid the need for X-ray tests.

MRI contrast is not used during pregnancy.


Results

MRI scans are usually not reported while you are at the MRI Unit. The images are filmed by the Radiographer who scans you, and then later interpreted by a specialist Radiologist. Their report is sent with the MRI films and any private films you brought along, to the doctor who referred you to us. This delivery usually takes several days. If you have an appointment very soon after your appointment, let us know and we will try to arrange faster reporting and delivery. The referring doctor can also ring MRI for results.

Locally Advanced Disease (Stage T3–T4)

Locally advanced disease refers to prostate cancer that is no longer confined to the prostate and has started to invade nearby organs such as the seminal vesicles, but where there is no evidence of spread to distant sites such as the bone (T3–T4). This may also include those patients with biochemical failure following curative treatment, patients with N+ disease and those who are surgical margin positive after radical prostatectomy.

The aim of treatment for locally advanced disease is to reduce the risk of metastatic spread and tissue invasion and thereby prolong survival (Table 3.3). There are several possible treatment alternatives for patients with this early stage of prostate cancer. Some patients may be cured.


Radiotherapy + Hormonal Therapy

Neoadjuvant hormonal treatment prior to radiation therapy

Neoadjuvant hormonal therapy, used in combination with radiotherapy, is generally administered to reduce prostatic size/symptoms. The term neoadjuvant is used to describe a treatment is given before the primary treatment. Examples of neoadjuvant therapy may include hormone therapy commenced prior to radiation therapy.

EBRT (External beam radiotherapy) is often sufficient to suppress PSA levels to within normal ranges and delay disease progression. However, EBRT following neo-adjuvant hormonal therapy has been shown to produce better local control of disease and effect greater reductions in the risk of clinical or PSA relapse than EBRT alone.

The RTOG 86-10 trial investigated the use of MAB (goserelin – ZOLADEX plus flutamide) given for 4 months, starting 2 months before and continuing for 2 months during radiation therapy in T2–T4 disease. Disease free survival at 8 years was significantly improved (33%) in patients receiving neoadjuvant therapy compared to 21% in patients receiving radiation therapy alone.

Overall survival was improved in patients with a Gleason score of 2-6, although survival in all patients was not improved. In addition such neoadjuvant therapy reduces the number of patients requiring salvage therapy (Pilepich MV et al. Int J Radiat Oncol Biol Phys 2001; 50: 1243–52).

Figure 3.10. RTOG – 86-10 - Disease-free survival, all patients

CAB – Combined Androgen Blockade

Since my therapy has entered a new phase, incorporating 'Combined Androgen Blockade' (CAB) and Radiation Therapy, I thought a review of Hormone Therapy (HT) was necessary. In what follows you will see how HT and Anti-Androgen Therapy combine to become CAB. In a further post, we will look at the combination of CAB and IMRT with 'gold seed markers'.

The male sex hormone testosterone feeds the growth of prostate cells and prostate cancer. Male hormones are called androgens. Prostate cancer hormone therapy works by ablating or depriving testosterone in the body. With no hormone to fuel their growth, the cells stop growing. Hormone therapy does not provide a cure; the prostate cancer does not “starve” to death, but for a time the spread of the disease can be slowed or even halted.

Hormone therapy is most versatile of the postate cancer treatments. the ablation and deprivation of testosterone can be used as adjuvant therapy, neoadjuvant therapy, or monotherapy for either primary or salavage treatment. Adjuvant and neoadjuvant hormone therapy is more common for primary treatment. Androgen ablation and deprivation monotherapy is more common during salvage treatment.

During primary therapy, hormone therapy is given to shrink the volume of the prostate gland and tumor. Eventually, the prostate cells become resistant to the androgen deprivation therapy and begin to grow again. When prostate cells become resistant, the next steps are either to stop hormone therapy to see if the reintroduction of testosterone can slow the growth, or chemotherapy.

The testicles produce 90 percent to 95 percent of the body’s testosterone. The adrenal glands produce the remaining 5 percent to 10 percent. The two types of hormone therapies used to combat prostate cancer are castration or anti – androgens. There are two types of castration: surgical castration, also called orchiectomy or orchidectomy, and chemical castration, caused by LHRH agonists and LHRH antagonists.

LHRH agonists and antagonists are usually taken through injections or analogs which continuously release the therapy over a period of time. Castration affects production of testosterone in the testicles, while LHRH antagonists and agonists interrupt the communication in the brain when the brain is ordering the production of more testosterone.

Anti – androgens affect the hormones that are produced in the adrenal glands. They are designed to block receptors in the prostate cells and prevent androgens from feeding cancer cell growth. Anti-androgens are taken orally as a pill or tablet. The female sex hormone, estrogen is also sometimes used for hormone therapy.

When several hormone therapies are used together, it is called Combined Androgen Blockade or CAB, but may also be called total androgen blockade, combined hormonal therapy, or complete hormonal blockade. Combined androgen blockade usually consists of castration and anti – androgens. All men who undergo hormone therapy will experience side effects, however, men who undergo CAB tend to experience more side effects due to the elimination of 100 percent of the body’s testosterone.

Gold Markers Improve Radiation Treatment For Prostate Cancer Patients At Community CancerCare

Marking a prostate cancer tumor with “gold markers” has improved the efficacy of the latest radiation therapy for prostate cancer patients at the Community CancerCare Radiation Therapy centers located in the John DeQuattro Community Cancer Center in Manchester and the Phoenix Community Cancer Center in Enfield.

“By placing three gold markers into the prostate,” says Tim Boyd, a Community CancerCare and Hartford Hospital radiation oncologist, “we can see precisely where the prostate tumor is each day immediately before the patient is treated, which allows us to be as accurate as possible in developing the radiation treatment.”

Accuracy is always important in radiation treatment. Physicians must protect healthy tissue and organs from radiation that kills all cells, not just cancerous ones. An especially high degree of accuracy in radiation therapy has become even more important as radiation technology has improved. IMRT, intensity modulated radiation therapy, for example, is among the most advanced and accurate now used at the Community CancerCare centers.

With standard radiation therapy, according to Community CancerCare’s radiation oncologist Kenneth Leopold, MD, radiation fields of equal intensity converge from all directions on the tumor. With IMRT, the intensity of each field changes to follow more precisely the shape of the tumor. If the contents of a patient’s bladder or rectum moves the tumor between treatments, or if the patient, and so the tumor, moves even slightly during treatment, the dose to the tumor may be compromised and surrounding healthy tissue in the prostate, bladder and rectum may be damaged.

With the addition of gold seed markers to the therapy, computer software can use the radiation beam itself for alignment and hit the tumor, which is a non-uniform, three-dimensional target, precisely each time.

Three gold markers, each about the size of a grain of rice, are placed into the tumor in the prostate during a 10-minute procedure in the urologist’s office.

Radiation treatment’s side effects have been reduced because of IMRT’s high degree of accuracy, Dr. Leopold says, and in some cases IMRT has allowed increases in radiation dose without increasing side effects. The goal of any cancer treatment is to kill the cancer with the least healthy tissue damage and fewest side effects. Using gold markers may allow physicians to strike this balance even better.

“Prostate cancer patients who undergo gold marker implantation may experience fewer treatment side effects, including bladder and bowel problems,” Dr. Boyd says, “Because the gold markers allow us to be more precise and adjust for any change in position of the prostate internally in the pelvis, we’re treating less normal tissue, like the rectum and the bladder, which may result in reduced side effects.”

The American Cancer Society estimates that 2,900 Connecticut men will be diagnosed with prostate cancer in 2007, and 390 of them will die from the disease, but the good news, according to the National Cancer Institute, is that progress in cancer treatment (like the use of gold seed markers), along with progress in prevention and early detection, continues to reduce American’s risk of dying from cancer.

Transrectal Prostate Fiducial Marker Gold Seed Insertion with Ultrasound

For those who are interested in the preparation that leads to the insertion of the gold seeds, I have included the following.


How it Works

Transrectal prostate fiducial marker gold seed insertion with ultrasound guidance is a method of inserting small gold seeds into the prostate gland using a needle inserted via the rectum/back passage. Three seeds are inserted using a 17G needle and the use of an ultrasound to guide the surgeon to the correct region.

The Radiologist performing the procedure specialises in Prostate procedures, assisted by nursing staff and ultrasound technologists.


Time

The procedure will take about 30 minutes to perform but we will want to observe you following the procedure for 1 hour or so if you are an outpatient, so that you may be at the hospital for a least 2 hours - longer after sedation.


How To Prepare

Before the procedure you should have stopped any tablets or injections that may alter your blood clotting - Heparin and Clexane the day before and Warfarin for 3 days. Clopidogrel, Aspirin and most other anti-inflammatory drugs etc will need to be stopped for 10 days or more. If this has not happened or you have any questions about stopping routine medication, please see your referring doctor or ring us.

Your specialist should arrange oral antibiotics (trimethoprim [Triprim or Alprim] 300 mg at night) for the days before and following the procedure. If you have any symptoms or signs of a urinary tract infection (burning sensation when passing urine etc) please ring us.

If you wish to have strong pain relief or sedation (intramuscular or intravenous), you will need to contact us before the day of your biopsy, stay for 1 or 2 hours longer after the biopsy and have someone take you home if you are an outpatient.


What to Expect

On arrival, you will be given a laxative to empty the rectum. You should also empty your bladder at this time. You will also be given an intravenous antibiotic injection (Gentamicin 240 mg). It is necessary for you to sign a consent form to confirm that you know about the risks and benefits associated with the procedure.

After you are taken to the Ultrasound room your Prostate gland will be clinically examined (as has already been performed by your doctor). The ultrasound probe will then be inserted into your rectum and pictures taken of your prostate gland. Immediately following this, the 3 gold seeds will be inserted. This will be uncomfortable, but is not usually unduly painful. It is very important to stay still. Please do not hesitate to ask us to stop at any point if you do not want us to continue.

Following the ultrasound guided seed placement, plain x-rays of your pelvis will also be obtained.


Side Effects

One of the advantages of performing the procedure under ultrasound guidance is to decrease the risk of damage to adjacent organs; however side effects and complications may still occur from this procedure.

For a day or so following the procedure you may notice MINOR pelvic discomfort or pain. MINOR blood staining of your urine/bowel motions may last for up to a week or so.

For a month or so following the procedure, you may notice blood staining in your ejaculate.


Possible Complications

If any of the following main complications develop:

• Severe infection (symptoms include feeling generally unwell, raised temperature, shivers etc most commonly manifested in the first 24-72 hours.)


• Urinary Retention (inability to pass urine for 8 hours or more.


• Profuse bleeding from the rectum or penis.

Contact your referring specialist IMMEDIATELY and proceed to the Emergency Department.

Infection develops in approximately 1 in 100 procedures and urinary retention/profuse bleeding occur in less than 1 in 1000. Spread of infection to the spine and death from infection is rare.


Afterwards

Following the procedure, for your comfort it is recommended that you should rest for the next 24 hours although you may undertake light activity. You may have minor discomfort over the 24 hours for which you may take paracetamol, but NOT aspirin. Depending on what sort of work you do, you may need to arrange a day’s sick leave.

New Plan of Attack

After a lengthy discussion with my Oncologist, concerning the possible treatment options, the following regime was decided upon as representing the best possible outcomes:

1. We will continue the Hormone Therapy, with the LHRH implants (Zoladex 10.8mg) every three months. This appears to be working pretty well but there remains some concern as to whether it is as effective as expected? I am scheduled to have another PSA test tomorrow; only this time, we will also test the Testosterone levels.
   


2. Because the PSA level has not declined at a faster rate, it has been decided to introduce an anti-agonist (Anandron ie Nilutamide) as well. This will continue for some time concurrent with the LHRH Implant.


3. I have been scheduled for an outpatient procedure, in which the Radiologist will insert several 'gold seeds' into the prostate. More on this procedure in my next post.


4. Following this, there will be a recovery period of 24 hours and then a 'planning week' in which the Radiotherapy treatment is discussed and mapped out.


5. I will most likely continue on the Hormone Treatment for at least 2 to 3 years. This then gives rise to the possibility of 'bone thinning' and so I have commenced a daily regime of Calcium and Vitamin D supplements.
   


6. The Radiotherapy will consist of a precisely targetted (thanks to the gold seeds), high dosage of radiation being applied to the prostate. A lower dosage of radiation will also be applied to certain bones and organs within the pelvic region.

The Radiologist also pointed out: "we only get one shot at this and so we will plan to maximise our chances of a successful outcome". While the prognosis remains, 5 years; it is anticipated that I will enjoy many more years, given the (expected good) results.

Prostate 'Gold Seeds' Improve Radiation Treatment

Today I attended my first appointment with the newest member of my healthcare team - 'Dr T' - my Radiation Oncologist. The appointment lasted for over 90 minutes - I finally got to ask, and have answered, ALL of my questions!!

Firstly, I want to talk about the 'new' technique that I will be undergoing in terms of my radiotherapy - sometimes referred to as 'gold seed technology'.

Gold seed technology is a fairly recent innovation in Australia and is only available in a (very) limited number of places. Fortunately for me, my radiologist is one of the few 'experts' who not only possess such technology, but have become very conversant with it's usage.

Now, some history...


November 2005

A new treatment method for prostate cancer patients undergoing radiation therapy that more accurately and effectively targets the cancer while minimizing side effects is now available in Australia.

Fiducial markers, or "gold seeds," are non-radioactive markers that are placed in the prostate. Because it is natural for the prostate to move around in the pelvic cavity, depending on how much liquid a patient has consumed and other factors, it can be challenging to locate the prostate precisely during radiation therapy.

Unlike brachytherapy, which uses radioactive seeds to treat the cancer, gold seeds simply allow the prostate's location to be tracked on a daily basis using X-ray imaging to ensure treatment accuracy. Only a handful of health care organizations offer this treatment in Australia.

Previously, physicians had to leave a margin of error when locating the cancerous tissue because it was difficult to target the exact location of the prostate before the gold seed technology emerged. During this process, healthy tissue may have been exposed to radiation.

Gold seed technology allows the physician to know exactly where the prostate is at any given time. Therefore, a higher dose of radiation can be delivered to a more precise area, while minimizing exposure to nearby healthy tissues.


Gold Seeds Help Pinpoint Prostate Cancer

WCVB-TV 04.07.2006

BOSTON -- Prostate cancer is the most common cancer among American men. One in six men will be diagnosed with the disease in his lifetime.

NewsCenter 5's Heather Unruh reported Friday that treating it can be tricky -- even a slight movement of the prostate can alter the effectiveness of radiation and potentially damage healthy tissue.

Now, doctors at Mount Auburn Hospital are using new technology to pinpoint prostate cancer with the help of some very tiny but very precious metals.

A tiny gold seed is helping doctors treat Joe Crowley's prostate cancer.

"I feel good about the treatment," Crowley said.

The gold seeds are actual gold, but they are not radioactive. Instead, they serve as markers for radiologists attempting to locate and treat the often hard-to-target prostate.

"In the past, our solution was very simple. You simply enlarge the area you're treating to make sure the target is going to be fully covered by the radiation -- but in the process, we were exposing more normal tissue to the radiation and increasing the risk of injury," Mount Auburn Hospital's Dr. Anthony Abner said.

With Gold Seed technology, [a number of] seeds are placed around the prostate. Using X-ray imaging, doctors can then monitor the location of the seeds. If the seeds have moved, the prostate has moved, and they can alter the radiation accordingly.

"The benefit is that we can dramatically reduce the amount of normal tissue that's hit by the radiation. By doing so, we can actually use higher doses of radiation with better cure rates," Abner said.

The treatment is less painful and more accurate than other options, such as balloon dilation and ultrasound. But it does require almost daily monitoring, which means many trips to the radiologist -- a price Crowley said he is willing to pay.

"It's a little lengthy, but I think I have 34 treatments, but hopefully they'll go by fast and I'll pick up where I left off," Crowley said.

While it's too soon to know exactly how much Gold Seed technology is improving prostate cancer outcomes, doctors said that patients report feeling better during treatment, having fewer side effects and fewer long-term complications.


The implications for me are ...

• I can benefit from the higher doses of radiation , without the risk of 'other organ damage'!


• I can also receive a variation of the 'whole-pelvic' treatment described in an earlier post - safely.

We'll look at this in more details in my next post.

Prostate cancer survival improved with whole-pelvic radiation plus hormone therapy

Abstract

Patients with localized prostate cancer who have a 15% estimated risk of lymph node involvement and an elevated prostate-specific antigen level are good candidates for whole-pelvic radiotherapy plus neoadjuvant and concurrent hormonal therapy.


Complete Article - 16 Jun 2003

These are the findings of a phase III study involving 1323 such patients reported by Dr. Mack Roach III of the University of California in San Francisco and colleagues in the May 15th issue of the Journal of Clinical Oncology.

"This trial tested the hypothesis that combined androgen suppression and whole-pelvic radiotherapy followed by a boost to the prostate improves progression-free survival by 10% compared with combined androgen suppression and prostate only prostate-only radiotherapy," they explain. "This trial also tested the hypothesis that neoadjuvant and concurrent hormonal therapy improves progression-free survival compared with adjuvant hormonal therapy adjuvant hormonal therapy by 10%," they further explain.

According to the team, whole-pelvic radiotherapy was associated with a 4-year progression-free survival of 54% compared with 47% for prostate-only radiotherapy (p = 0.022). Patients treated with neoadjuvant and concurrent hormonal therapy had a 4-year progression-free survival of 52% versus 49% for adjuvant hormonal therapy (p = 0.56).

Compared with the other treatment, the combination of whole-pelvic radiotherapy plus neoadjuvant and concurrent hormonal therapy was associated with the longest progression-free survival (60%).

"This study proves that there is a favorable biologic interaction between whole-pelvic radiotherapy and neoadjuvant and concurrent hormonal therapy, but no advantage to short-term neoadjuvant and concurrent hormonal therapy compared with short-term adjuvant hormonal therapy when only the prostate is irradiated," the investigators conclude.

The benefits of whole-pelvic radiotherapy plus neoadjuvant and concurrent hormonal therapy in the lymph nodes "should not be completely surprising," they add. "Occult lymph node involvement despite negative imaging is a well-recognized problem in patients with prostate cancer, and prophylactic nodal radiotherapy has been shown to prolong survival in women with breast cancer," they add.

(Source: J Clin Oncol 2003;21:1904-1911: Reuters Health: June 13, 2003: Oncolink)

Hormone Therapy and Radiotherapy Combined

As mentioned in my last post, further good news, was received concerning my ongoing treatment and came in the form of a 'green light' to commence radiotherapy ASAP. Originally, it was planned that I would have two consecutive implants (duration of 6 months) and then, providing the PSA level was at an appropriate level, we would the consider radiotherapy.

The upshot of the visit was, that we now move into a new phase of treatment - 'Radiotherapy' (RT) as an adjunct to the Hormone Therapy (HT). The latter will most likely continue for approximately 18 to 24 months. However, there is a possiblity that I could be on HT for the remainder of my life; dependent upon the success of the radiation treatment.

[It has also been decided at this stage, to rule out surgery; because of the likely complications; both during and after the operation].

Radiation Therapy will entail daily radiation treatment, 5 days a week for approximately 6 weeks; (with Saturday and Sunday ... 'off for good behaviour').

Unfortunately this will also involve short stays in hospital for each subsequent treatment; thus further complicating my desire to lead as normal a life as possible e.g. juggling work committments, cancer therapies and home and social life etc.


Hormone Therapy

It has long been known that once prostate cancer develops, the male hormone testosterone, produced by the testicles, is closely involved in stimulating the cancer’s growth and spread. Earlier treatments for the disease often involved removing the testicles surgically to reduce testosterone production by the body. Now products are available that can be taken in the form of tablets or injections to suppress testosterone even more effectively. The process is known as hormone therapy.

Hormone therapy is often used to shrink the prostate and the tumour before commencing radiotherapy. It is now quite common for a course of hormone therapy to be administered after primary treatment by radiation or surgery, particularly if there is evidence that the tumour may have spread beyond the capsule (tissue immediately surrounding the prostate). There is emerging evidence that better outcomes are being achieved from these combined techniques.

If the prostate cancer has already spread to other organs or to bone at the time of diagnosis, hormone therapy becomes the primary method of treatment. Monthly or three monthly injections, possibly also accompanied by tablets, are used to try to reduce the PSA reading as close as possible to zero. Most advanced cancers respond well to hormone therapy for several years. Some doctors apply the therapy intermittently - six or twelve months on treatment then some months off - known as "pulsing". This gives the patient some respite from side effects and may extend the period of effective treatment, although this has not been proved.

The advantages of hormone therapy are that it is simple to administer. The disadvantages are the side effects, which can be distressing. They include hot flushes, loss of libido and erections, sweating, mood swings, disturbed sleep, loss of energy and personal motivation, body hair loss, bone loss, weight gain and breast development or tenderness. Unfortunately, most advanced cancers eventually become resistant to hormone therapy, after which the disease resumes its progress.


Radiation

Radiotherapy involves the use of various types of X-rays to treat cancer.

External beam radiotherapy (EBRT) has been the traditional method of delivering the radiation. Short pulses of tightly focused beams of X-rays are delivered from outside the body into the prostate for a few minutes each day. Treatment continues five days a week for seven weeks. Conformal Radiotherapy, allows the X-rays to be directed very accurately to the prostate in three dimensions. EBRT has a track-record of success in "curing" cancers confined to the prostate that is very close to that of surgery.

From a patient’s perspective, the advantages of EBRT are that it is less intrusive and stressful than surgery, with no risk of infection. It particularly suits older men or those with fitness or other health problems that make the risk of surgery greater. The disadvantages are that time for treatment is much longer and may involve travel and accommodation problems, particularly for country patients. Radiation can damage other organs, particularly the bowel and bladder.

Irritation of the bowel is a common side effect that can trouble patients for six months or longer after treatment. Rates of occurrence of incontinence and impotence are similar to surgery, but tend to occur later. With radiotherapy up to 50% of men develop erection problems and many develop mild to moderate inflammation of the bowel, although only approximately 3% of men develop severe, ongoing bowel problems. It is also important to mention that it is not uncommon after radiotherapy to develop a change in bowel habit, with looser and more frequent bowel movements, increased flatus and possible bleeding.

Once again, the skill, experience and result record of the radiotherapist and standard of the treating equipment are paramount to the outcome. Intending patients should enquire carefully into these matters before making a selection.

After treatment you will have further PSA tests to monitor developments. Your PSA should gradually reduce over about 12 months to between 1 and 2. If it fails to reduce to these levels, your doctor may recommend further treatment, probably by hormone therapy. However, regardless of the post-treatment movement of the PSA reading, it is quite common for doctors to recommend hormone therapy immediately after radiation as part of the total treatment.

Latest LHRH Implant

I attended the Urologist's Surgery in Monavale to receive an injection of a luteinising hormone-releasing hormone (LHRH)- specifically a 'Goserelin acetate implant' (the generic name) or Zoladex (the product name).

For a video demonstration of the proper technique for administering Zoladex please click here.


LHRH Agonists

The 'original' 3.6mg formulation of Zoladex has been available since 1989 as a monthly implant. The new formation, 10.8 mg goserelin acetate implant given every three months, offers greater convenience to subjects choosing treatment with a luteinizing-hormone-releasing hormone (LHRH) analogue.

The 'original' 3.6mg formulation of Zoladex was shown to be as effective as orchiectomy (surgical castration) in controlling the spread of prostate cancer, thus offering men a choice between medical treatment and surgery.

This 12-13 week formulation of Zoladex is, a white to cream coloured, cylindrical implant with a 1.5 mm diameter that contains 10.8 mg of goserelin. Given by subcutaneous injection, into the anterior abdominal wall, the biodegradable implant slowly dissolves, delivering therapeutic levels of the drug continuously over a period of 12 weeks. This means an injection will be required every 12 to 13 weeks.

NB: I asked to be able to inject myself on this occasion, not sure why now; but it seemed like a good idea at the time! Well according to witnesses (the doctor and my wife) I was a real 'pro' (professional).

The instructions were simple: "Grab a good fistful of excess skin ... (to the left of the 'belly button') ... and in one swift downward motion plunge the syringe into the abdomen right up to the hilt! Then depress the plunger and this will release the implant."

Well I must admit, in some strange way, I actually enjoyed the experience!

Perhaps it was because I was 'in control'; for the first time since the cancer was discovered. Perhaps it was the release of adrenalin, associated with the whole procedure; I'm not sure.

However, afterwards I do recall the doctor stating: "Very well done ... but ... I'm still charging you for the procedure, even though you administered the implant yourself"!

The success of this treatment (in my case Goserelin 10.8mg every 3 months) will continue to be be monitored by regular blood tests which look specifically at the Prostate Specific Antigen (PSA) readings.


Good News

Further good news, came in the form of a 'green light' to commence radiotherapy ASAP. Originally, it was planned that I would have two consecutive implants (duration of 6 months) and then, providing the PSA level was at an appropriate level, we would the consider radiotherapy.

The Urologist was so pleased with the PSA result and so keen to start the radiotherapy treatment, that he rang one of our largest public hospitals in the country, and spoke to the doctor who would oversee the procedure and monitor my treatment from now on; and asked him (as a personal favour) to 'fast track' the procedure!

The upshot ... I had an appointment made available to me the very next morning to discuss the options available to me, moving forward!!

The Treatment of Locally Advanced Disease: An Overview

Introduction

The selection and implementation of appropriate treatments for locally advanced prostate cancer are probably the most difficult challenges which face the physician and his or her patients. If making good decisions is difficult in the treatment of localized prostate cancer and advanced prostate cancer, then making good decisions in the treatment of locally advanced disease can only be described as nerve-racking!

Patients need to understand up front that there are absolutely no "right answers" in the treatment of locally advanced disease. The wise patient, while taking an optimistic approach, may wish to consider the following simple realities:

Once prostate cancer has clearly escaped the confines of the prostate, the chances that it is truly curable become very small given currently available forms of treatment. (It is everyone's goal to change this in the near future.)

Despite the fact that locally advanced disease is not usually curable, current forms of therapy can offer long-term remissions (of 10 or even 20 years) to a very high proportion of patients if they receive suitable and early intervention.

Many patients who are initially advised by their physicians that they have locally advanced disease are found to have micrometastases (and therefore advanced disease) at a later date. In other words, what may initially appear to be locally advanced disease can commonly be seen, in retrospect, to have been advanced disease. This is no one's fault. We simply do not have the diagnostic tools available today to be able to specifically identify patients with micrometastatic advanced disease.

The Prostate Cancer InfoLink recognizes that this information is not, by any manner of thinking, the information which a newly diagnosed patient with locally advanced prostate cancer wants to hear. However, over time such patients will, we hope, discover that the best treatment decisions tend to be made by patients who can work with their physicians because both parties are fully aware of the facts surrounding their situation.

We hope that in time we may be forgiven by those patients who initially react by seeing us as the bringers of news they would have preferred not to hear, and that at least some patients will be able to make better treatment decisions because of their early recognition and acceptance of this situation.


Defining locally advanced disease

There are several types of locally advanced prostate cancer, and we will take the time to itemize them here for clarity. This set of definitions will require the reader to have a good appreciation of the "staging" systems used to discuss prostate cancer. If you have not already read the section on clinical staging of prostate cancer, you are strongly advised to now!


Unilateral and bilateral extracapsular extension

Prostate cancer can grow through the capsule (the wall of the prostate) and into the surrounding tissues. If this has happened from just one lobe of the prostrate, this is called unilateral extracapsular extension, which is classified as clinical stage T3/a/Nx/M0. By contrast, if this has happened from both lobes of the prostate, it is known as bilateral extracapsular extension and is classified as clinical stage T3b/Mx/M0. (Note: The use of Nx means that no determination has been made as to whether the disease has spread to the pelvic lymph nodes.)


Seminal vesicle-positive disease

The seminal vesicles are attached to the prostate (see Where is your prostate and what does it do?). It is common for prostate cancer to spread from the prostate into the seminal vesicles. Spread of prostate cancer from the confines of the prostate into the seminal vesicles is a second form of locally advanced prostate cancer. Regardless of whether the disease has spread into just one of the two seminal vesicles or into both seminal vesicles, it is classified as stage T3c/Nx/M0 disease.


Tumor fixed to or invading adjacent structures

If the tumor has escaped from the prostate capsule and it has become attached to or has infiltrated other nearby parts of the pelvic area other than the seminal vesicles, then it is classified slightly differently.

If the tumor escapes the prostate and invades the bladder neck, or the external sphincter, or the rectum, then it is classified as clinical stage T4a/Nx/M0. Similarly, if the tumor escapes the prostate and invades the levator ani muscles or the pelvic wall itself, then it is classified as clinical stage T4b/Nx/M0.


Lymph-node positive disease

The final category of locally advanced prostate cancer is when the patient is found to have prostate cancer cells in his pelvic lymph nodes. In this case his disease is generally classified as either T3/N+/M0 disease or T4/N+/M0 disease, depending on whether he has T3 or T4 disease. In addition, the degree of lymph node invasion allows for subclassification as follows:


N1 = metastasis in a single lymph node (2 cm or less in greatest dimension)

N2 = either metastasis in a single lymph node (2-5 cm in greatest dimension) or multiple lymph node metastases (none more than 5 cm in greatest dimension)

N3 = metastasis in any lymph node greater than 5 cm in greatest dimension.


Two examples

Pete M. is initially diagnosed with locally advanced prostate cancer on the basis of his DRE, his PSA test, his biopsy results (which included a biopsy of his seminal vesicles) and a bone scan. The PSA was 43 ng/ml; the DRE was negative; the biopsy was positive in four of six cores and in one seminal vesicle; the bone scan was negative. The preliminary clinical stage was given as T3c/Nx/M0. However, before they decided on treatment, Pete and his physician decided to carry out a laparoscopic lymphadenectomy. Pete's physician was just sufficiently concerned about his PSA level in combination with the positive seminal vesicle that he suspected a high risk of positive lymph nodes. He was correct, Pete had small foci of metastasis (both smaller than 1 cm) in two pelvic lymph nodes. He was restaged as T3/N2/M0.

Jerry B. is also initially diagnosed with locally advanced prostate cancer. He has a positive DRE with apparent extracapsular penetration through both lobes of the prostate. His PSA value is 14.7 ng/ml. His seminal vesicles are negative on biopsy and his bone scan is negative. He is tentatively staged as T3-4/Nx/M0. His urologist is uncertain as to the extent of local extracapsular disease and whether Jerry may have positive lymph nodes. However, because the urologist considers radical prostatectomy to be inappropriate for Jerry, no attempt is made to evaluate his lymph node status by the use of a laparoscopic lymphadenectomy.


The treatment options: an introduction

The Prostate Cancer InfoLink will gradually expand to offer detailed commentary on the differing options for the treatment of the various types of locally advanced prostate cancer. At this point in time, patients are advised simply that there are a wide range of options and that the selection of the appropriate option for an individual patient is perhaps as much an art as it is a science.

The general rule of thumb should be that the more advanced the disease, the less likely it is that purely surgical or purely radiotherapeutic interventions will succeed in controlling the disease. Indeed, there are now few surgeons who would consider that surgical intervention without some form of neoadjuvant or adjuvant therapy is appropriate for the management of most forms of locally advanced disease. Equally, the radio-oncology community now seems to accept that radiotherapy is much more likely to succeed in offering long-term progression-free survival if it is combined with hormonal manipulation of some form.


Basically, the list of possible categories of treatment is as follows:

Radical prostatectomy alone, which is probably only even potentially appropriate today in patients who are suspected of seminal vesicle involvement but in whom one or more attempts to biopsy the seminal vesicles were negative

Radiation therapy alone, carried out using external beam radiation or brachytherapy or a combination of the two (and it should be noted that external beam radiotherapy alone is now stated by at least some highly regarded experts on the radiotherapy of prostate cancer to be "inadequate")

Radical prostatectomy followed by adjuvant (post-surgical) hormone therapy

Radiation therapy followed by adjuvant (post-surgical) hormone therapy

Radical prostatectomy followed by adjuvant (post-surgical) external beam radiation therapy

Neoadjuvant hormone therapy followed by radical prostatectomy, with or without adjuvant (post-surgical) hormone therapy

Neoadjuvant hormone therapy followed by radiation therapy, with or without adjuvant (post-surgical) hormone therapy

Neoadjuvant hormone therapy followed by cryotherapy, with or without adjuvant (post-surgical) hormone therapy.

It can be seen from this extensive list just how complex the treatment options for management of locally advanced disease can be. When one starts to consider all of the various categories of adjuvant and neoadjuvant hormonal manipulation that are now either available or in clinical trials, the number of options becomes difficult to assess on a purely scientific basis.


Lymph node positive or lymph node negative?

The question whether the cancer has reached the lymph nodes is one of two questions which are absolutely fundamental to the choice of therapy. Basically, if the cancer has escaped into the pelvic lymph nodes, surgical treatment alone is no longer considered to be effective, although surgical treatment in combination with other forms of therapy may be beneficial.

Patients should be aware, however, that it is common (and very reasonable) for urologists to attempt surgery in the hope that cancer is confined to the prostate, but to discover at the beginning of surgery -- using a rapid pathologic technique known as a "frozen section" -- that in fact the cancer has reached the lymph nodes. In such cases it is not unusual to terminate the surgical procedure without removing the prostate and to inform the patient that other forms of treatment will have to be attempted.

All patients who are scheduled for surgery for prostate cancer will normally be advised of this possibility prior to surgery -- even patients definitively believed to have localized disease. There is always at least some risk that the cancer will have progressed to the lymph nodes, despite every indication to the contrary. This situation is altered by the use of neoadjuvant and adjuvant hormonal therapy or by the prior agreement between physician and patient that the prostate will be removed unless, in the opinion of the surgeon, the degree of lymph node metastasis is so high as to make removal of the prostate pointless.

If a patient has positive lymph nodes, the value of radiotherapy as a primary form of treatment is also open to considerable question. As indicated previously, there are now eminent radio-oncologists who consider that radiotherapy alone is inappropriate for the treatment of any form of T3 or T4 prostate cancer. This is surely even more likely to be the case in patients with node-positive disease.


How did the disease escape the prostate?

Just as this issue of lymph node positivity has significant implications for the management of individual patients, so does the question of whether a patient has T3 or T4 disease. In other words, if a patient is seminal vesicle positive, but otherwise the disease is localized to the prostate capsule, different treatment options may be appropriate than if the patient has clear signs that the cancer has escaped through the wall of the prostate and infiltrated the surrounding pelvic tissues.


Is node-positive disease really locally advanced?

It should be noted that the classification of node-positive disease as "locally advanced" is open to question. Many experts would consider that node-positive disease should be classified as "advanced" or "systemic." In the older Jewett-Whitmore staging system for prostate cancer, node-positive disease was classified as stage D1 disease.

The Prostate Cancer InfoLink takes the position that there is a distinction between definitively node-positive disease, in which the cancer has reached the lymph nodes but has not metastasized beyond these nodes (i.e., true T3-4/N+/M0 disease), and true micrometastatic disease, in which the cancer has really has micrometastasized beyond the lymph nodes but is not clearly identifiable as stage M+. The problem, of course, is that in most cases we are currently unable to distinguish between these two situations.

The Prostate Cancer InfoLink would simply note that just because we cannot yet distinguish between these two clinical situations does not alter the fact that the former situation can be clearly seen as locally advanced (because the disease is still confined to the pelvis, and is therefore theoretically amenable to localized therapy), whereas the latter situation is clearly systemic. We would suggest that it time management decisions will be able to take account of this distinction, and that therefore we should take it into account in our thinking.


Concluding remarks

The information offered here should be seen only as a series of introductory remarks on the options available to physician and patient for the management of locally advanced disease.

Please Note: This article is somewhat dated [1996] new advances may have occured since.

Source: The Prostate Cancer Info Link