General Information about Prostate Cancer

Prostate cancer is the most common cancer among American men, and it is the second leading cause of death from cancer in men. It occurs when cells in the prostate gland mutate and multiply very rapidly. Prostate cancer often stays confined to the area for several years, but it may metastasize or spread to other areas of the body such as the bone.

Prostate Measurement

  • Measurement of the prostate gland by a transrectal ultrasound exam may be helpful to determine the extent of the disease. On the other hand, this exam may not give any valuable information to the physician if the patient has a known metastatic disease. Therefore, it is not always performed.
  • If a transrectal ultrasound exam is done, it is performed by the physician. The prostate gland is measured for size and shape. This information is recorded. The radiation oncologist and medical radiation physicist will use this information to plan your radiation treatment.
  • If the prostate gland measured is found to be large or if you have a more aggressive prostate cancer, the urologist or radiation oncologist may give a medication to block testosterone production. This will stop the tumor growth and decrease the size of the prostate gland. The medication may be given for either a short term or long term basis.
  • A smaller gland will lead to a safer (fewer complications) treatment course and we now feel, that a course of anti-testosterone therapy actually enhances the overall cure rate. Unfortunately, there are some side effects to this medication. This can include hot flashes, lack of sexual drive, fatigue, and muscle weakness. They are temporary, and resolve after the medication wears off.

Gleason Score

A Gleason Score is given in reference to the grade or aggressiveness of the prostate cancer, ranging from 2 to 10. The Gleason Score is the sum of two numbers- the grade of the primary tumor grade and the grade of the secondary tumor grade. These grades depend on the cancer cell's deviation from normal healthy prostate cells, with 1 being the mildest change and 5 being the most severe. A score may look something like a Gleason's grade of (4+3) = 7. This means the primary tumor pattern was a 4, but there were also secondary type 3 cancer cells found in the specimen reviewed.

Treatment of Benign Disease

  • Benign Prostatic Hypertrophy: Surgical Transurethral Resection of the Prostate (TURP), Laser Therapy, and Medical Management
  • Infections: Antibiotics
  • Erectile Dysfunction: Mechanical implants, and oral medication

Signs and Symptoms of Prostate Cancer

Patients with prostate cancer normally do not have any symptoms. However some patients may have pain, difficult or frequent urination, a weakened urinary stream and sexual dysfunction. Diagnosis often begins with a PSA (Prostate Specific Antigen) blood test and digital rectal exam (DRE). Elevated levels of PSA signifies an abnormality in the function of the prostate, which could be the result of an infection, benign hypertrophy (growth of the gland or tissue), or cancer. Depending on the result of the PSA test, a biopsy may be performed to establish the diagnosis.

Helpful Terms Regarding Prostate Cancer and the Central Nervous System

  • BPH - Benign Prostatic Hypertrophy (Hyperplasia) - Noncancerous growth that is common in the prostates of men over the age of 40. These growths compress the urethra, causing difficulty with urination.
  • Brachytherapy - Surgical implantation of radioactive sources into a tumor.
  • Cryosurgery - Treatment that freezes the prostate with liquid nitrogen.
  • DRE - Digital Rectal Exam (finger exam)
  • EBRT (External Beam Radiation Therapy) - A form of external radiation delivered by a linear accelerator machine. The most commonly used form of photon (X-ray) treatment for prostate cancer.
  • Hormonal Therapy - Medication prescribed by your urologist for the purpose of blocking testosterone production. Hormonal therapy may be used in conjunction with primary radiation or for palliation.
  • HDR (High Dose Rate Brachytherapy) - A form of internal radiation. This involves the surgical implant of temporary plastic needles into the prostate. Treatment is then performed by computers under remote control. This treatment serves as a radiation boost to the prostate.
  • LDR (Low Dose Rate Brachytherapy) - Another form of internal radiation. This involves the surgical implantation of permanent seeds into the prostate.
  • Orchiectomy - Surgical removal of the testes to block production of testosterone.
  • Palliation - Course of treatment for patients whose cancer is considered incurable. Goal of palliation is to control pain and improve quality of life.
  • Proton Beam - A radiation technique which uses positively charge protons to treat prostate cancer.
  • Salvage Treatment - Treatment for failed initial course of treatment.
  • Seed, Pellet - Used to describe the radioactive pellet(s) used in brachytherapy. HDR uses 1 high dose seed, whereas LDR uses multiple low dose seeds.

Treatment of Prostate Cancer

Treatment options include active surveillance, surgery, radiation therapies, chemotherapy, cryosurgery, hormonal therapy, or combinations of these treatments. The best treatment option depends on stage of the disease, Gleason Score of the prostate cancer, PSA levels, stage of disease, age, medical condition, and perspective on therapy risks.

Radiation Treatment

1) Full Course External Beam Radiation

External beam radiation delivers radiation via a source outside or external the body, in this case through a linear accelerator. This complex machine uses electricity to produce high-energy x-rays, targeted and delivered to the tumor site. These x-rays deposit the prescribed dose of radiation deep within the body while sparing surrounding structures.

Radiation is invisible, tasteless, odorless, and painless. External beam radiation is a completely non-invasive technique. It works by damaging cancer cells and slowing their ability to grow and divide. Healthy cells can repair the effects of radiation fairly quickly while cancer cells have a difficult time repairing. By delivering radiation over a pre-determined amount of time (approximately 8 weeks), we allow the healthy tissues to repair while repeatedly damaging the cancer cells.

Image-guided Intensity Modulated Radiation Therapy (IMRT) / Dynamic Arc MLC-IMRT Radiation

In conformal radiation, a computer simulation produces a highly accurate image of the tumor and surrounding area in order to aim radiation beams directly at the tumor. The precise focus spares nearby healthy tissue from the beams.

Intensity-Modulated Radiation Therapy (IMRT), a type of conformal radiation, aims very small beams of radiation at a tumor from different angles while varying the intensity of the radiation. Careful control of the shape and position of the beam bends the radiation dose around healthy tissue to hit cancerous cells. Our high-tech PET/CT scanner provides an extremely accurate 3-dimensional map of the tumorous area, allowing this method to be effective and precise. This form of treatment requires sophisticated planning by the doctor, physicist, and dosimetrist. It also requires thorough QA (quality assurance) to make sure the treatment delivered is absolutely safe for the patient.

Full course external beam irradiation treatment allows the radiation oncologist to deliver a dose beyond the prostate gland to the seminal vesicles and/or surrounding lymph nodes in the pelvis.

2) Combination Temporary Implants & External Beam Radiation

"Smart Bomb" Implant Surgery / HDR Temporary Brachytherapy

HDR temporary brachytherapy involves surgically implanting very tiny plastic catheters into the prostate gland and then giving a series of radiation treatments through these catheters. A computer-controlled machine pushes a highly radioactive seed into these catheters, one by one, carefully controlling the dose of radiation by monitoring how long each seed remains inside at a certain position. This enables delivery of a higher dose to the tumor while ensuring the surrounding tissue like the rectum receives lower doses. The catheters are then easily pulled out, leaving no radioactive materials inside the prostate gland.

Patients who receive implant surgery spend the day at the Cancer Center of Irvine. HDR brachytherapy is usually combined with a shorted course of IMRT (external radiation). HDR brachytherapy along with IMRT allows a higher dose to be delivered to the prostate as compared with IMRT alone. This is because the radiation dose is delivered internally and concentrated to the prostate. Numerous studies have shown improved prostate cancer survival with the combination of HDR brachytherapy and IMRT.

Surgery

Nerve-sparing Prostatectomy

This is the most common operation for prostate cancer. The cancerous prostate is removed, without removing the nerve bundles responsible for erections which lie on either side of the prostate gland. This procedure may not be suitable for patients who have cancer involvement of the nerve. This procedure can be either done through laparoscopy or with robotic assistance.

Cryosurgery (Endocare Freezing)

While the patient is under anesthesia, a needle is carefully inserted into his prostate gland through the perineum. Guided by ultrasound to ensure accurate placement and monitor the process, the needle produces sub-zero temperatures to freeze the prostate and tumor. This procedure has high rates of complication and is normally used if the patient's cancer recurs after radiation.

Hormonal Therapy

Since prostate cells are stimulated by testosterone, a drop in this hormone can slow down the proliferation of cancerous cells and shrink the prostate. Hormonal therapy is often with other treatment methods.

Frequently Asked Questions

Q: What do I need to bring when I come to the Cancer Center for treatment?

A: If you are interested in coming to the Cancer Center of Irvine for treatment, you first need to call (949) 417-1100 to make an appointment. The receptionist will let you know what you need to do. Here is a list of things to bring with you when you come in for the first time.

  • Any medical records
  • Recent doctor notes
  • Any recent labs
  • Recent pathology
  • Scans (MRI, CT, PET, Bone Scan, Ultrasound)
  • Films
  • Insurance card(s)
  • Forms (upon calling the Cancer Center, the needed forms will be sent to you along with a map to the Center)

Q: What can I expect during a consultation with my doctor?

A: During your consultation with the doctor, s/he will:

  • Collect your history
  • Review results of tests and pathology reports you brought with you
  • Perform a physical exam (DRE)
  • Review with you your prostate anatomy and cancer
  • Review and discuss your treatment options

All of your test and laboratory results are important in order for your doctor to make the best decision in outlining your treatment options for you. If you were not able to obtain all your information prior to the consultation, it is important to make sure that the results of your tests are forwarded to the doctor.

Radiation Treatment FAQ

Q: What are the side effects of radiation to the prostate?

A: Patients may experience urination symptoms such as burning, frequency, urinating more at night, and weak stream. They may also note loose stools and diarrhea. These are reversible side effects which usually subside in 2-3 months. Long term patients may have decrease in sexual function from the radiation. Patients may also note fatigue which normally subsides 1 month after treatment.

Q: When do these side effects start?

A: They normally happen a few hours after the HDR brachytherapy implant and subside in a few days. For external beam radiation, these side effects normally happen 2-3 weeks into treatment and progressively get worse until the end of treatment. At the end of treatment most patients' side effects are only mild to moderate. Very few patients get severe side effects with our sophisticated radiation planning and treatment methods

Q: Will I feel anything during the radiation treatments?

A: No. The radiation treatments are similar to getting an X-ray. You will not feel anything, but you will hear the machine buzzing when the radiation is being administered.

Q: Can I drink alcohol or caffeinated beverages?

A: Drinking alcoholic or caffeinated beverages is not recommended during radiation treatment, as they can increase frequency and urgency of urination. However, we do recommend drinking plenty of fluids, such as water or Gatorade, throughout treatments to prevent dehydration.

Q: What diet should I be on during radiation treatments?

A: A normal healthy diet is recommended. No special diet is necessary. However if you do have loose stools or diarrhea we recommend eating plain oatmeal, white rice, ripe bananas, applesauce, white toast, canned fruit without the skins, such as peaches and pears, white pasta noodles, cream of rice cereal, and plain unsweetened graham crackers. If you are having diarrhea make sure you are properly hydrated with fluids.

Q: What if I need to miss a day of treatment?

A: Missing a day of treatment is permissible, however, all absences should be cleared with the doctor or radiation therapist first. It is required that radiation treatments be a consecutive series.

Q: Where does the radiation come from?

A: Radiation is generated by the linear accelerator machine. The administered radiation is high-energy X-rays.

Q: What happens after completion of the radiation treatments?

A: Once all the radiation treatments are completed, you will return for a 2-week follow-up appointment to assess your side effects. During a second follow-up, at 3 months, Dr. Tokita will draw a PSA level.

Q: What is a rectal spacer?

A: At the Cancer Center of Irvine, we are proud to offer rectal spacer technology. This allows us to safely deposit a hydrogel compound which pushes the rectum away from the high dose radiation field. This allows less side effects and complications to the rectum. This technique is now being utilized and researched by numerous radiation institutions. Speak to your radiation oncologist at the Cancer Center of Irvine for more information.