Prostate Cancer

Prostate cancer is the most common non-skin cancer and the second leading cause of cancer death among men in the United States. Approximately 300,000 men will be diagnosed with prostate cancer in the United States this calendar year.
 
The incidence of prostate cancer increases with age. Older men are much more likely to have prostate cancer, with an average age at diagnosis at 65. African American men and men with a family history of prostate cancer are also at increased risk of getting prostate cancer. 

Prostate cancer usually grows slowly but some can grow quickly. Finding a cancer before it has spread and differentiating between the fast and slow is a critical step in determining what is the most appropriate treatment.

The stage of a cancer is a way of describing where cancer is. Is it still contained within the prostate or has it gone beyond? The grade of a cancer is a way of describing how fast the cancer cells are growing. The grade of a cancer is the Gleason Score or Grade Group.. 

Your grade and stage determine the appropriate path for you. Aggressively treating prostate cancer for men with faster growing or larger volume cancer is critical to improve a man's health and help him live longer. Monitoring, or "surveillance", is often employed for small, slow growing cancers. 

There are a wide variety of options for treating prostate cancer. For cancer contained within the prostate, options include complete removal (radical prostatectomy), radiation (external or brachytherapy), and focal therapy options to kill a small, very localized cancer also with a number of alternative options always being studied.

For cancers that have spread beyond the prostate cure is usually not possible. What is achievable is control and slowing the growth of the cancer using hormone therapy (androgen deprivation or ADT), chemotherapy, immunotherapy, and radiation therapy.

You are not alone. Others have gone before you, and will walk beside you on along the path from diagnosis to treatment.

Best of luck on your journey,

Dr Brandt

Stage and Grade

Stage

All men at their initial diagnosis will need to determine if their prostate cancer is “localized” to the prostate or has “advanced” beyond the prostate. While all cancers lie on a spectrum of cancer volume, doctors break the cancer volume into four “stages” of cancer. Here are the clinical stages of prostate cancer. When a prostate has been removed and examined under a microscope then a pathologist determines its pathologic stage.

  • A stage 1 cancer is detected usually because of an elevated PSA value. The prostate otherwise feels normal to the physician on examination. A cancer is also considered stage 1 if detected because a man has surgery for enlarged prostate.
  • A stage 2 cancer is detected by an area of irregularity on the prostate.
  • A stage 3 cancer is detected when the area of irregularity is beyond the prostate capsule.
  • A stage 4 cancer is when there are findings the cancer has advanced to lymph nodes, nearby tissue, bones, and other distant organs.
 

Grade

The speed of cancer growth determines appropriate treament and is estimated by its grade.  Aggressive cancers should be treated whereas slow growing and small volume cancer can be monitored over time. The speed of a cancer growth is determined initially by a cancer’s grade.The traditional way of quantifying the grade of a cancer is the Gleason scoring system. The Gleason system assigns a number to the two most common growth patterns within a cancer and those numbers are added together to create a Gleason score. The Gleason score is often represented as a simple math equation, eg. 3+4=7. Gleason score totals range from 6 (slow) to 10 (most aggressive). In 2014, the World Health Organization adopted the Grade Grouping system for assigning prostate cancer grade. The Grade Grouping System assigns a single number, 1 (slow) though 5 (most aggressive), to a cancer. Both grading systems are used today but the Grade Grouping System parallels the Gleason system but improves the grading accuracy for moderate risk Gleason 7/Grade Group 2 and 3 cancers.

 

Treatment Options

Localized prostate cancer is still contained within the prostate gland and has not invaded nearby tissues nor has it spread to distant sites in the body like bones or lymph nodes. Distant or metastatic disease is when the prostate has extended beyond the prostate

Treatment options for localized prostate cancer vary depending on factors such as the aggressiveness of the cancer, the patient's overall health, and the patient’s personal preferences.

Common treatment approaches may include active surveillance (watchful waiting), surgery (prostatectomy), radiation therapy, focal ablative therapy, androgen deprivation, or a combination of these treatments.

Treatment for advanced disease requires hormonal therapy, chemotherapy, and radiation most commonly.

Treatment for prostate cancer depends on various factors such as the stage and grade of cancer, overall health, and personal preferences of the individual.

Radiation damages the cancer cells through a concentrated treatment of radiation to the prostate and the cancer cells.  This is a good treatment option for men with localized prostate cancer or for men with local recurrence of prostate cancer after prostatectomy.

Focal therapy is used in limited circumstances, the cancer would need to be confined to a portion of the prostate that can specifically be identified on imaging such as MRI. There are several options that can deliver ablativ treatment to a portion of the prostate.

Hormone therapy is the standard for slowing down prostate cancer cells.  Prostate cancer is sensitive to the male hormone testosterone. By reducing testosterone the cancer cells will slow their growth and may even top growing entirely and recede. Hormonal treatment are typically used for men with advanced prostate cancer but is also used in conjunction with radiation therpy.

Advanced Prostate cancer is cancer that has spread beyond the prostate to other area of the body . Unfortunately there is no cure for this type of cancer and we must focus on slowing its growth. The good news is that there are a number of treatment options that exist. 

Choosing a treatment option can feel daunting. The first step is determining what options are available for your particular cancer? What is the stage and grade? Is it curable? Does it need treatment now or can it be monitored?

Next comes larger questions. What other health concerns do I have that will determine my choice of treatment? What is my expected longevity?What are my goals for my care? What is important to me?

Men with longer life expectancy and better health should be biased towards earlier treatment of the prostate cancer after initial diagnosis. Men with shorter life expectancy and multiple health concerns are better candidates for surveillance protocols or watchful waiting of their prostate cancer.

Some men will be biased towards more aggressive treatments by their personal choice or intolerance to a surveillance protocol. Some men will be more comfortable with surgery; other men will choose radiation. There is often no one right answer in each case. Because there are often alternatives, a man’s personal preferences becomes a major factor in choosing a treatment option.

 

daVinci Robotic Radical Prostatectomy

Radical Prostatectomy is the most common choice for treatment for men with prostate cancers that are large enough in size and growing fast enough to require treatment. Radical Prostatectomy refers to the removal of the entire prostate and the attached seminal vesicles and, in most cases, a sampling of lymph nodes within the pelvis to check for cancer spread. Although radical prostatectomy is a great choice for many, men choosing prostatectomy should be aware of the potential for urinary incontinence and erection problems that can occur after prostatectomy.

I began using the daVinci robotic techniques around the year 2008. This video I recorded in 2020 originally to introduce a video series for the VidScrip video platform. The daVinci robot has changed the way I practice and what I can offer to patients.

I am proud to be a certified robotic surgeon of excellence at United and St John’s Hospitals.

The “SIMS” Postoperative Class Video

What’s a SIMS? SIMS stands for Surgical Impotence Management Strategy. The class was originally designed as a way to educate men about the changes in erections that occur after a robotic radical prostatectomy. We began over 20 years ago at Minnesota Urology (then Metro Urology) educating men in a lecture format on a monthly basis.This page contains a video I made about the SIMS class that became a very important tool during COVID-19 and men continue to find it helpful.

Active Surveillance

Active surveillance of prostate cancer is the process of monitoring the cancer over time. Many prostate cancers do not need treatment because they are slow growing, and the rate of growth and spread will not impact a man’s quality or quantity of life. For elderly men or men with shorter life expectancy a surveillance process is often the best choice to avoid the complications that can occur with treatment. Some younger and healthier men may also choose surveillance as an option for their cancer if the disease is small and slow growing; the goal of monitoring in men with longer life expectancy is to “catch” the cancer and treat when the disease is showing signs of growth or increased rate of growth

Radiation Therapy

Radiation therapy is a general term used for the various types of methods to deliver radiation to the prostate to treat a man’s cancer. Radiation treatment are a good choice for many men as an alternative to surgical removal of the prostate. A radiation oncologist delivers the radiation treatment. Radiation therapy avoids some of the surgical risks of prostate removal, but complications can occur due to the radiation exposure to organs surrounding the prostate. The bladder and rectum are most at risk of radiation side effects. Changes to sexual function also are possible after radiation.

Focal and Alternative Therapies

 
As alternative to radiation and surgery, other options exist. While treatments other than radiation and surgery have not proven superior, many are options for whole gland treatment as well as the emerging role for “focal” therapy. Most men requiring treatment will need the entire prostate treated because of the amount of cancer present. Some men with cancer in just one portion of the prostate, however, may be candidates for treating just that portion of the prostate where the cancer exists.Advanced Prostate Cancer has spread beyond the prostate and may have invaded nearby tissues or metastasized to distant parts of the body. When prostate cancer progresses to an advanced stage, it poses greater challenges for treatment and management. For most men that means that treatments such as radiation or surgery are no longer an option. Good treatments exist in the form of androgen deprivation, chemotherapy, and immunotherapy.

Advanced Prostate Cancer

 
Advanced prostate cancer often requires a multidisciplinary approach to treatment, involving medical oncologists, radiation oncologists, urologists, and other specialists. Treatment options may include hormone therapy, chemotherapy, targeted therapy, immunotherapy, radiation therapy, or a combination of these modalities. While advanced prostate cancer is not curable in most cases, treatment aims to slow the progression of the disease, manage symptoms, and improve quality of life. Additionally, clinical trials and emerging therapies offer hope for new treatment options and improved outcomes for individuals living with advanced prostate cancer.
 

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