(1)Howard University College of Pharmacy, Nursing and Allied Health knowledge, attitudes and perceptions of prostate cancer and early detection methods. of advanced prostate cancer and thoughts on the role of old and new therapies . . There was no Level 1 evidence to support any pharmaceutical therapy at. When you're diagnosed with prostate cancer at an early stage, usually It's important to pick one that's right for your condition and one that will.
thought on Cancer” 1 “Prostate
Most advised against immediate therapy and specifically against radiation. But is PSA recurrence after radical prostatectomy due to local failure or distant failure, or both? My bone and computed tomography CT scans were normal, as is usually the case, and were not helpful in making this determination. I made the decision to receive 6 months of androgen deprivation along with prostate bed radiation. The bone mineral density preserving effects of zoledronic acid had just been reported and I opted to receive zoledronic acid during androgen deprivation.
Observational studies from Stanford demonstrated the benefit of using androgen deprivation and whole pelvic radiation versus prostate bed radiation alone. I received radiation in a traditional four-field box technique up to a dose of 64 Gy. Urinary and rectal symptoms of irritation I experienced resolved with time. Androgen deprivation was quite tolerable, but the dramatic suppression of libido and function brought me to the powerful recognition, beyond any text description, of the power of the steroid molecules to imprint and drive behavior.
I was delighted to discontinue androgen deprivation after 6 months of therapy at which time my PSA had fallen to less than 0. This level was maintained over the next 3 years. Serum testosterone recovered and I truly felt that the clock had been reset and that my quality of life had been restored to the pre-hypogonadal state.
Equipoise had been re-established and life was good. That is not to say that life had been previously bad. I only use this well-understood colloquialism to express my renewed state of well-being. However, 36 months after initiation of androgen deprivation and 33 months after completion of salvage radiation, the PSA began another series of rises.
It is worth reflecting on the emotional impact of the first rise after radical prostatectomy and this second and subsequent rises. There was significant anxiety and disappointment that actually exceeded the negative visceral response at diagnosis. I was entering the universe of the ticking PSA clock. The second PSA failure confirmed that I was in the story for the long haul. Anti-androgens were withdrawn without response. There is ample data that a PSA nadir is a prognostic factor with regard to subsequent outcome [ 18 ] and further data suggests that PSA lower than 0.
I had entered the castration resistant disease state. Ample evidence now exists that the androgen receptor AR continues to drive prostate cellular proliferation and prevents pharmaceuticals from blocking AR activity which provides effective treatment and survival prolongation. In with a testosterone level within the castrate range, and with a PSA on the rise after trial of bicalutamide withdrawal, I was searching for other options. There was no Level 1 evidence to support any pharmaceutical therapy at that time and unfortunately that remains true to this day.
I was advised with regard to transdermal estradiol patch which I began and have continued to the present. A few observations about estrogen therapy are pertinent. Recall that the Veterans Association Urologic Research Group studies demonstrated that oral diethylstilbesterol DES was associated with a cancer survival superior to orchiectomy.
The cardiovascular morbidity associated with oral estrogen, however, overwhelmed the cancer specific benefits resulting in an inferior overall survival outcome. David Byar, the lead statistician for the veteran studies concluded that DES, in addition to lowering testosterone, exerted a direct cytotoxic effect on the prostate cancer cell.
Estrogen is barely mentioned in the guidelines of the major oncology societies. It is essentially overlooked and very much underappreciated. Traditional ADT deprives the male of both testosterone and estrogen thereby compounding adverse events. Hopefully the Patch trial will substantiate the benefits of estrogen therapy and bring it back into the mainstream of prostate cancer therapy.
Abiraterone acetate is characterized as an androgen synthesis blocker as it interferes with the C hydroxylase, C20, 21 lyase enzymes on the pathways converting precursor steroid molecules to androgens. Enzalutamide is characterized as an androgen receptor blocker as it displaces androgens from binding to the AR by preferentially occupying the receptor niche. With different mechanisms of action to interfere with androgen receptor activity, there was the potential for inducing as complete an androgen blockade environment — as with all trials LHRH agonist therapy continued — as was currently possible.
Furthermore there appeared to be no indication for overlapping toxicity other than that associated with further depletion of testosterone activity. The trial protocol required pre-entry bone biopsy which was accomplished under CT guidance without difficulty.
The vertebral biopsy analysis seemed ideal for this drug combination. The specimen stained strongly positive for the androgen receptor. There was no evidence of neuroendocrine de-differentiation, no androgen receptor splice variant AR-V7 detectable and steroid receptor co-activator SRC , a proliferation driver, was negative.
All factors lined up for an excellent response. There was no good explanation. It was time for a new start. Our department at Eastern Virginia Medical School had been involved with the earliest sipuleucel-T trials. The IMPACT trial had randomized men with asymptomatic or mildly symptomatic metastatic castration resistant prostate cancer to a cellular based immunotherapy treatment arm versus a control arm and demonstrated a statistically significant survival benefit for the patient receiving immunotherapy.
FDA approval was a breakthrough decision which brought the first immunotherapy for any cancer to the clinic. Since then there has been an explosion of interest in immunotherapy with a number of dramatic successes in its use in the treatment for other malignancies.
Immunotherapy can be characterized with attributes that are admirably suited for addressing the same characteristics associated with tumor cell survival as flexible, durable, targeted, and adaptable, there was no hesitation on my part to move forward with Sipuleucel-T Provenge immunotherapy. There was also developing evidence that radiotherapy might potentiate immunotherapy.
Some of the beneficial effects of radiotherapy might be attributed to the abscopal effect. Cellular death caused by radiation, specifically high dose radiation producing double-strand breaks and mitotic death, releases a host of antigens which provide a broad repertoire of targets for immunotherapeutic activity. My PSA gradually fell. Obviously I am very much appreciative of this good fortune and it has influenced my thinking and management of patients with good performance status and oligometastatic disease.
The future is bright with a wealth of developing treatment possibilities on the horizon. Radium xofigo [ 32 ] will be an option for control of osseous metastases with a survival benefit.
Immunotherapies with checkpoint inhibitors are promising. However, if high dose testosterone does enter into the clinic, it perhaps will be the only treatment for an advanced cancer that both controls disease while simultaneously allowing the patient to feel stronger and better! Against the background, I will make some personal observations pertinent to the care and disposition of men diagnosed with prostate cancer. The emotional impact of a cancer diagnosis is quite profound regardless of how well educated or well informed the patient.
I will describe my mindset with a cardiovascular event which I experienced 2 years before the diagnosis of prostate cancer — a mindset that I have discussed and confirmed as similar to the experience of others in the same situation. Certainly the coronary occlusion, which fortunately was promptly treated with two stents with good results was sobering. Nevertheless, there was optimism.
Plans for better diet, more exercise, and healthier lifestyle would allow me to partner with my heart with anticipation of a productive future. The emotional impact of the cancer diagnosis was quite different - a visceral reaction, almost a sense of betrayal and fear - a desire to rid myself of the alien invader by whatever means was my primary thought and plan of action.
This, despite the fact that I knew very well that the greatest risk for future morbidity and mortality rested with cardiac disease - I have had six additional stents placed as a reminder of this - and that any prostate cancer morbidity and mortality were certainly many years into the future. With the encouraging recent advances in knowledge about treatments for advanced prostate cancer, morbidity and mortality will decline even farther. I will paraphrase here an observation made by Wendy Harpham, a physician and medical writer, who was faced with one of many recurrences of a hematologic malignancy.
She observed that cancer did not make her life uncertain but exposed her to the uncertainties of life. When she put aside her fears, apprehensions, and concerns about tomorrow and appreciated what she now had, in a way never before possible.
Intertwined with the disappointment of PSA recurrences, is the hope that rests with new effective and approved therapies and the promise of new therapies that are in the process of clinical trial testing and that might be even more effective. The promise of investigative therapies certainly provides hope. However, the time, testing, and travel that clinical trials often demand are daunting and often frustrating.
Patients are prepared to participate in and take risks that trials may present in hopes of deriving benefit. They are essential partners in the team moving cancer therapy forward. The time has arrived to fulfill the promise that trials must be more patient-friendly. I have entered many patients into clinical trials, and have personally participated in 2 trials one after PSA failure following salvage radiation plus androgen deprivation therapy, and one upon developing castration-resistant metastatic disease and can attest to the difficult regulatory gauntlet they present.
I believe the global effect of androgen deprivation is underappreciated and that the debilitating effects of impaired sexual health are often inadequately addressed.
The long-term strain placed on relationships can be as significant as the strain of the initial prostate cancer diagnosis. It deals with problems and possible solutions. Even with my real life experience with androgen deprivation therapy ADT accumulated over decades, I know I cannot, within the limits of one or even several office visits, begin to prepare and educate patients for their new reality.
I could not even do that for myself! If only a complete user-friendly manual existed. The world of cancer has developed its own vocabulary. When used in certain contexts they deliver a specific message. Three of these words are survivor, cure, and war. Soldiers, persevering through battle, just as cancer patients enduring chemotherapy or a surgical procedure, consider themselves as a survivor. Injuries to the intestines are more common with laparoscopic and robotic surgeries than with the open approach.
If lymph nodes are removed, a collection of lymph fluid called a lymphocele can form and may need to be drained. In extremely rare cases, people die because of complications of this operation. Your risk depends, in part, on your overall health, your age, and the skill of your surgical team. The major possible side effects of radical prostatectomy are urinary incontinence being unable to control urine and erectile dysfunction impotence; problems getting or keeping erections.
These side effects can also occur with other forms of prostate cancer treatment. You may not be able to control your urine or have leakage or dribbling. There are different levels of incontinence. Being incontinent can affect you not only physically but emotionally and socially as well.
There are 3 major types of incontinence:. Rarely after surgery, men lose all ability to control their urine. This is called continuous incontinence. After surgery for prostate cancer, normal bladder control usually returns within several weeks or months. This recovery usually occurs slowly over time. In general, older men tend to have more incontinence problems than younger men.
Large cancer centers, where prostate surgery is done often and surgeons have a lot of experience, generally report fewer problems with incontinence. Incontinence can be treated. Erections are controlled by 2 tiny bundles of nerves that run on either side of the prostate. If you can have erections before surgery, the surgeon will try not to injure these nerves during the prostatectomy.
This is known as a nerve-sparing approach. But if the cancer is growing into or very close to the nerves, the surgeon will need to remove them. If the nerves on only one side are removed, you might still have erections, but the chance is lower than if neither were removed.
If neither nerve bundle is removed you might have normal erections at some point after surgery. Your ability to have an erection after surgery depends on your age, your ability to get an erection before the operation, and whether the nerves were cut. All men can expect some decrease in the ability to have an erection, but the younger you are, the more likely it is that you will keep this ability. Surgeons who do many radical prostatectomies tend to report lower impotence rates than doctors who do the surgery less often.
If your ability to have erections does return after surgery, it often occurs slowly. In fact, it can take from a few months up to 2 years.
During the first few months, you will probably not be able to have a spontaneous erection, so you may need to use medicines or other treatments. Most doctors feel that regaining potency is helped along by trying to get an erection as soon as possible once the body has had a chance to heal usually several weeks after the operation. Some doctors call this penile rehabilitation. Medicines see below may be helpful at this time. Be sure to talk to your doctor about your situation.
For more on coping with erection problems and other sexuality issues, see Sexuality for the Man With Cancer. In some men, orgasm becomes less intense or goes away completely. Less often, men report pain with orgasm. Radical prostatectomy cuts the vas deferens, which are the pathways between the testicles where sperm are made and the urethra through which sperm leave the body. This means that a man can no longer father a child the natural way. Often, this is not an issue, as men with prostate cancer tend to be older.
To learn more, see Fertility and Men With Cancer. This is a rare but possible complication of removing many of the lymph nodes around the prostate. Lymph nodes normally provide a way for fluid to return to the heart from all areas of the body. When nodes are removed, fluid can collect in the legs or genital region over time, causing swelling and pain.
Lymphedema can usually be treated with physical therapy, although it may not go away completely. You can learn more on our lymphedema page. Change in penis length: A possible effect of surgery is a small decrease in penis length.
This is probably due to a shortening of the urethra when a portion of it is removed along with the prostate. This operation is more often used to treat men with non-cancerous enlargement of the prostate called benign prostatic hyperplasia BPH. But it is also sometimes used in men with advanced prostate cancer to help relieve symptoms, such as urination problems. It is not used to try to cure the cancer. During this operation, the surgeon removes the inner part of the prostate gland that surrounds the urethra the tube through which urine exits the bladder.
The skin is not cut with this surgery. An instrument called a resectoscope is passed through the tip of the penis into the urethra to the level of the prostate. Once it is in place, either electricity is passed through a wire to heat it or a laser is used to cut or vaporize the tissue.
Spinal anesthesia which numbs the lower half of your body or general anesthesia where you are asleep is used. The operation usually takes about an hour.
After surgery, a catheter thin, flexible tube is inserted through the penis and into the bladder. It remains in place for about a day to help urine drain while the prostate heals. You can usually leave the hospital after 1 to 2 days and return to normal activities in 1 to 2 weeks. You will probably have some blood in your urine after surgery.
Other possible side effects from TURP include infection and any risks that come with the type of anesthesia used. The American Cancer Society medical and editorial content team. Our team is made up of doctors and master's-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.
February 16, Last Revised: For reprint requests, please see our Content Usage Policy. Prostate Cancer Treating Prostate Cancer. Surgery for Prostate Cancer. Open approaches to radical prostatectomy In the more traditional approach to doing a prostatectomy, the surgeon operates through a single long skin incision cut to remove the prostate and nearby tissues.
There are 2 main ways to do this operation. Radical retropubic prostatectomy For this operation, the surgeon makes an incision cut in your lower abdomen, from the belly button down to the pubic bone.
Radical perineal prostatectomy In this operation, the surgeon makes the cut incision in the skin between the anus and scrotum the perineum , as shown in the picture above. Laparoscopic approaches to radical prostatectomy Laparoscopic approaches use several smaller incisions and special long surgical tools to remove the prostate. Laparoscopic radical prostatectomy For a laparoscopic radical prostatectomy LRP , the surgeon inserts special long instruments through several small incisions to remove the prostate.
16 Famous Men Who Have Had Prostate Cancer
Prostate cancer is the second most common cancer diagnosed in men in Australia and the third most common cause of cancer death. One in 7. There is no single cause of prostate cancer. Fats stimulate hormone production , and the one lifestyle-related cause that most researchers agree Naturally high testosterone levels are also thought to trigger prostate cancer. In most cases, prostate cancer symptoms are not apparent in the early stages The symptoms of prostate cancer may be different for each man and any one of.