Prostate Cancer

• Understanding the disease
• Treatment options
• Side effects of treatment

Stephen Shamp, MD MSEE

David Bloom, MD PhD

Matthew Culbert, MD

Understanding Prostate Cancer

Anatomy, Stage, PSA level, Gleason Score (pathology), Treatment Options and Side Effects

Tumor (T, N, M) Stage

Gleason Scoring System�

From the biopsy, the pathologist grades the appearance of the cells. From least serious (slow growing or Grade 1) to the fastest growing and most dangerous or grade 5). The first number is the most common pattern seen and the second number the next most common. So a 4+3 is more serious than 3+4 even though they both are Gleason 7.

So the slowest is a score of 2 and the fastest is a 10.

www.nccn.org

Estimate life expectancy

Treating prostate cancer

Surgery?

Radiation?

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Or Active Surveillance?

Laparoscopic Prostate Surgery

The surgeon tries to dissect the prostate away from the rectum, bladder, the neurovascular bundle (nerves) and penile urethra

the nerves that can results in impotence if cut are on the side of the gland

Randomized Trial between Surgery or Radiation for Low and Favorable Intermediate Risk…Surgery and Radiation same cure rate

ProtecT Trial, NEJM

ProtecT Trial - 8 years median time to treatment on active surveillance

Treatment Outcomes High Risk

Kishan JAMA 2018;319:895

FLAME Trial JCO 2021

10 Year Cure Rates for Patients with High Risk Prostate Cancer (PSA >20 or Gleason 8-10 or T3)

�Treatment Number Cure Rate�

Radical Prostatectomy 1,238 92%�Radiation plus Hormones 344 92%�Radiation alone 265 88%

Mayo Clinic Study (Boorjian Cancer 117;2883, 2011)

ProtecT Side Effect Comparison

• More incontinence with surgery.
• Better urinary quality of life with radiation.
• More urinary irritation for first 6 months after radiation, but similar after

ProtecT Side Effect Comparison

• Surgery has more effect on sexual quality of life.
• More erectile dysfunction, worse sexual function and lower erection firmness

Side Effects of Surgery or Radiation

Quality of Life Outcomes after Primary Treatment for Clinically Localized Prostate Cancer: A Systematic Review. ��Eur Urol. 2017 Dec;72(6):869-885

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Our review of the current evidence suggests that for a period of up to 6 yr after treatment, men with localized prostate cancer who were managed with active surveillance reported high levels of quality of life (QoL).

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Men treated with surgery reported mainly urinary and sexual problems,

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while those treated with external beam radiotherapy reported mainly bowel problems.

CT simulation (planning session)

• We will build a cradle to hold you in the same position with each treatment.
• Temporary or permanent marks will be made
• CT images are obtained and then imported into the treatment planning computer
• You bladder should to be full and your rectum empty

Example Prostate Radiation Plan

Logistics of External Beam Radiation:

• Usually 28-45 daily treatments
• Treatment days are Monday-Friday 5 days per week, 5.5 to 9 weeks in total
• Daily treatment takes 15 minutes or less. You will be given a schedule
• You do not feel anything during treatment, you will not be radioactive, you are allowed to drive yourself to and from treatment if you are currently allowed to drive

Logistics of MRI-Guided Micro-Boost External Beam Radiation:

• Usually 28-35 daily treatments
• Treatment days are Monday-Friday 5 days per week, 5.5 to 7 weeks in total
• Daily treatment takes 15 minutes or less. You will be given a schedule
• You do not feel anything during treatment, you will not be radioactive, you are allowed to drive yourself to and from treatment if you are currently allowed to drive

Logistics of Stereotactic Body Radiation Therapy (SBRT):

• Option for Certain Patients with Low and Intermediate Risk with good urinary function
• Usually 5 treatments
• Treatment days are Monday-Friday 3 days per week, 2 weeks in total
• Daily treatment takes 15 minutes or less. You will be given a schedule
• You do not feel anything during treatment, you will not be radioactive, you are allowed to drive yourself to and from treatment if you are currently allowed to drive

• Lasers and daily CBCT imaging is used to precisely deliver the daily radiation treatment.
• Full bladder and empty rectum
• Expect to be on the treatment table less than 15 minutes.
• You will not feel any immediate effects.

Significant movement of the prostate gland based on daily gas in rectum

Initial computer target for prostate (red circle) would have badly missed the target if no adjustments were made based on the amount of rectal gas

Side Effects of Prostate Radiation

The structures that will get hit by radiation and have inflammation or irritation: bladder, urethra and rectum

Radiation

zone

Short Term Side Effects: Irritation of bladder, urethra and rectum

Radiation

zone

1. Urinary frequency or urgency (getting up at night very few hours, take NSAID’s, or may benefit from medication)
2. Slight burning or stinging with urination (drink cranberry juice)
3. Diarrhea or more frequent, softer bowel movements, rectal soreness (take Imodium)
4. Mild skin irritation is now rarely seen
5. Fatigue is common

SpaceOAR or Barigel

• Placed by your urologist as an outpatient procedure.
• Typically about 5 days before your planning CT simulation.
• This is a hydrogel that helps separate the prostate from rectum to reduce radiation dose to the rectum.
• After completing radiation, it will slowly be absorbed by the body.

Radiation

zone

Chronic radiation cystitis or proctitis: about 6% of the men will have occasional episodes of blood in the urine or with bowel movements, this usually responds to medication (e.g. cortisone suppositories) The risk of serious damage to the bladder and rectum is now less than 1%�Impotence: about 10-30% of men have problems after radiation. Change in consistency of ejaculate and infertility is also common.

Very low risk of rare but serious complications including but not limited to secondary malignancy, ulcer, fistula

Long Term Side Effects: Irritation of bladder, urethra and rectum

Follow-up: Your PSA will be monitored post treatment. Note that the PSA levels slowly decline after completing radiation

Typical PSA Levels after Radiation

‘bounce’

‘bounce’

Typical PSA Levels after Radiation

The higher the Gleason Score, the lower the cure rates after radiation

Gleason Score