Getting a Second Opinion

Decisions about prostate cancer treatment are complex. It may be helpful to have the opinion of more than one doctor. Before starting treatment, men may want to have a second doctor review their diagnosis and treatment options. A short delay will not reduce the chance that treatment will be successful. Some health insurance companies require a second opinion; many others will cover a second opinion if the patient requests it. There are a number of ways to find a doctor who can give a second opinion:

• The doctor may be able to recommend a specialist. Doctors who specialize in treating prostate cancer are urologist, radiation oncologist, and medical oncologist.
• People can get the names of doctors from their local medical society, a nearby hospital, or a medical school.
• The Directory of Medical Specialists lists doctors by state and specialty and gives information about their background. This resource is in most public libraries.

Preparing for Treatment

The doctor develops a treatment plan to fit each patient's needs. Treatment for prostate cancer depends on the stage of the disease and the grade of the tumor (how fast the cells are likely to grow or spread to other organs). Other important factors in planning treatment are the man's age and general health and his feelings about the treatments and their possible side effects.

Many people with cancer want to learn all they can about their disease, their treatment choices, and possible side effects of treatment, so they can take an active part in decisions about their medical care. There are a number of available treatments for men with prostate cancer (surgery, radiation therapy, and hormone therapy"). Not all men require treatment. The patient and his doctor may want to consider both the benefits and possible side effects of each option, especially the effects on sexual activity and urination, and other concerns about quality of life.

When a person is diagnosed with cancer, shock and stress are natural reactions. These feelings may make it difficult for patients to think of everything they want to ask the doctor. Often it helps to make a list of questions. Also, to help remember what the doctor says, patients may take notes or ask the doctor whether they may use a tape recorder. Some patients also may want to have a family member or friend with them when they talk to the doctor--to take part in the discussion, to take notes, or just to listen.

Questions may arise throughout the treatment process. From time to time, patients may wish to ask members of their health care team to explain things further.

These are some questions a patient may want to ask the doctor before treatment begins:

• What is the stage of the disease?
• What is the grade of the disease?
• Do I need to be treated? What are the treatment choices? What do you recommend for me?
• What are the expected benefits of each kind of treatment?
• What are the risks and possible side effects of each treatment?
• Is treatment likely to affect my sex life?
• Am I likely to have urinary problems?
• Are new treatments being studied in clinical trials? Would a trial be appropriate for me?

Methods of Treatment

Many men whose prostate cancer is slow growing and found at an early stage may not need treatment. Also, treatment may not be advised for older men or men with other serious medical problems. For these men, the possible side effects and the risks of treatment may outweigh the possible benefits of treatment; instead, the doctor may suggest "watchful waiting"--following the patient closely and treating the patient later for symptoms that may arise.

Researchers are studying men with early stage prostate cancer to determine when and in whom treatment may be necessary and effective.
Treatment for prostate cancer may involve surgery, radiation therapy, or hormone therapy. Sometimes, patients receive a combination of these treatments. In addition, doctors are studying other methods of treatment to find out whether they are effective against this disease.

Surgery is a common treatment for the early stages of prostate cancer. Surgery to remove the entire prostate is called radical prostatectomy. It is done in one of two ways. In retropubic prostatectomy, the prostate and nearby lymph nodes are removed through an incision in the abdomen. In perineal prostatectomy, the prostate is removed through an incision between the scrotum and the anus. Nearby lymph nodes are sometimes removed through a separate incision in the abdomen. If the pathologist finds cancer cells in the lymph nodes, it may mean that the disease has spread to other parts of the body.

These are some questions a patient may want to ask the doctor before having surgery:

• What kind of operation will it be?
• How will I feel after the operation?
• If I have pain, how will you help?
• Will I have any lasting side effects?

Radiation therapy is another way to treat prostate cancer. In radiation therapy (also called radiotherapy), high-energy rays are used to damage cancer cells and stop them from growing and dividing. Like surgery, radiation therapy is local therapy; it can affect cancer cells only in the treated area. In early stage prostate cancer, radiation can be used instead of surgery, or it may be used after surgery to destroy any cancer cells that may remain in the area. In advanced stages, it may be given to relieve pain or other problems.

Radiation may be directed at the body by a machine (external radiation), or it may come from a small container of radioactive material placed directly into or near the tumor (internal radiation). Some patients receive both kinds of radiation therapy.

For external radiation therapy for prostate cancer, the patient is treated in an outpatient department of a hospital or clinic. Treatment generally is given 5 days a week for about 6 weeks. This schedule helps protect healthy tissues by spreading out the total dose of radiation. The rays are aimed at the pelvis area. At the end of treatment, an extra "boost" of radiation is often directed at a smaller area, where the tumor developed.

For internal (or implant) radiation therapy, a brief stay in the hospital may be needed when the radioactive material is implanted. The implant may be temporary or permanent. When a temporary implant is removed, there is no radioactivity in the body. The amount of radiation in a permanent implant is not generally dangerous to other people, but patients may be advised to avoid prolonged close contact with others for a period of time.

These are some questions a patient may want to ask the doctor before having radiation therapy:

• What is the goal of this treatment?
• How will the radiation be given?
  
• When will the treatment begin? When will it end?
  
• How will I feel during therapy?
  
• What can I do to take care of myself during therapy?
  
• How will we know if the radiation therapy is working?
• Will I be able to continue my normal activities during treatment?

Hormone therapy prevents the prostate cancer cells from getting the male hormones they need to grow. When a man undergoes hormone therapy, the level of male hormones is decreased. This drop in hormone level can affect all prostate cancer cells, even if they have spread to other parts of the body. For this reason, hormone therapy is called systemic therapy.

There are several forms of hormone therapy. One is surgery to remove the testicles. This operation, called orchiectomy, eliminates the main source of male hormones.

The use of luteinizing hormone-releasing hormone agonist is another type of hormone therapy. LHRH agonists prevent the testicles from producing testosterone.

In another form of hormone therapy, patients take the female hormone estrogens to stop the testicles from producing testosterone.
After orchiectomy or treatment with an LHRH agonist or estrogen, the body no longer gets testosterone from the testicles. However, the adrenal glands still produce small amounts of male hormones. Sometimes, the patient is also given an antiandrogens, a drug that blocks the effect of any remaining male hormones. This combination of treatment is known as a total androgen blockade.

Prostate cancer that has spread to other parts of the body usually can be controlled with hormone therapy for a period of time, often several years. Eventually, however, most prostate cancers are able to grow with very little or no male hormones. When this happens, hormone therapy is no longer effective, and the doctor may suggest other forms of treatment that are under study.

Clinical Trials

Many men with prostate cancer take part in cancertrials (treatment studies). Doctors conduct clinical trials to learn about the effectiveness and side effects of new treatments. In some clinical trials, all patients receive the new treatment. In the trials, doctors compare different therapies by giving the new treatment to one group of patients and the standard therapy to another group; or they may compare one standard treatment to another.

People who take part in these studies have the first chance to benefit from treatments that have shown promise in earlier research. They also make an important contribution to medical science.

Many clinical trials of treatments for prostate cancer are under way. For example, researchers are comparing treatment against careful observation of men with early stage prostate cancer. The results of this work will help doctors to know whether to treat early stage prostate cancer immediately or only later on, if symptoms occur.

Doctors are studying new ways of using radiation therapy and hormone therapy. Some doctors also are exploring the use of cryosurgery, which uses extreme cold to destroy cancer cells, as an alternative to surgery and radiation therapy. In cryosurgery, an instrument called a cryoprobe is placed in direct contact with the tumor to freeze it, sparing nearby healthy tissue.

Researchers also are testing the effectiveness of chemotherapy and biological therapy for patients whose cancer does not respond or stops responding to hormone therapy. In addition, scientists are looking for new ways of combining various types of treatment.

Men with prostate cancer who are interested in taking part in a clinical trial should discuss this option with their doctor.

One way to learn about clinical trials is through http://cancernet.nci.nih.gov/pdqfull.html, a computerized resource developed by the National Cancer Institute. This resource contains information about cancer treatment and about clinical trials in progress all over the country.

Side Effects of Treatment

Although doctors plan treatment very carefully, it is hard to limit the effects of treatment so that only cancer cells are removed or destroyed. Because treatment also damages healthy cells and tissues, it often causes unwanted, and sometimes serious, side effects.

The side effects of cancer treatment depend mainly on the type and extent of the treatment. Also, each patient reacts differently. Doctors and nurses can explain the possible side effects of treatment, and they can often suggest ways to help relieve symptoms that may occur during and after treatment. It is important to let the doctor know if any side effects occur.

Surgery

Although patients are often uncomfortable during the first few days after surgery, their pain can be controlled with medicine. Patients should feel free to discuss pain relief with the doctor or nurse. It is also common for patients to feel tired or weak for a while. The length of time it takes to recover from an operation varies for each patient.

Surgery to remove the prostate may cause permanent impotent and sometimes causes urinary incontinence. These side effects are somewhat less common than in the past. Some surgeons use new methods, especially when removing small tumors. These techniques, called nerve-sparing surgery, may prevent permanent injury to the nerves that control erection and damage to the opening of the bladder. When this surgery is fully successful, impotence and urinary incontinence are only temporary. However, men who have a prostatectomy no longer produce semen, so they have dry orgasm.

Radiation Therapy

Radiation therapy may cause patients to become very tired as treatment continues. Resting is important, but doctors usually advise patients to try to stay as active as they can. Patients may have diarrhea or frequent and uncomfortable urination. In addition, when patients receive external radiation therapy, it is common for the skin in the treated area to become red, dry, and tender. Radiation therapy can also cause hair loss in the pelvic area. The loss may be temporary or permanent, depending on the amount of radiation used.

Radiation therapy causes impotence in some men. This does not occur as often with internal radiation therapy as with external radiation therapy; internal radiation therapy is not as likely to damage the nerves that control erection.

Hormone Therapy

Orchiectomy, LHRH agonists, and estrogen often cause side effects such as loss of sexual desire, impotence, and hot flashes. When first taken, an LHRH agonist tends to increase tumor growth and may make the patient's symptoms worse. This temporary problem is called "tumor flare." Gradually, however, the drug causes a man's testosterone level to fall. Without testosterone, tumor growth slows down and the patient's condition improves. Prostate cancer patients who receive estrogen or an antiandrogen may have nausea, vomiting, or tenderness and swelling of the breasts. (Estrogen is used less now than in the past because it increases a man's risk of heart problems. This form of treatment is not appropriate for men who have a history of heart disease.)

Chemotherapy

The side effects of chemotherapy depend mainly on the specific drugs that are used.

Biological Therapy

Biological therapy may cause flu-like symptoms such as chills, fever, muscle aches, weakness, loss of appetite, nausea, vomiting, or diarrhea. Patients may also bleed or bruise easily, and some get a rash. Some of these problems can be severe, but they go away after the treatment stops

Research To Understand Prostate Cancer

Prostate cancer is an important public health problem. Prostate cancer accounts for one of every three cancers among American men. Researchers are conducting studies to learn more about the causes and early detection of this common disease.

Causes and Prevention

The causes of prostate cancer are not yet understood. Researchers are looking at factors that may increase the risk of this disease. The more they can learn about these risk factors, the better the chance of finding ways to prevent and treat prostate cancer.

Studies in the United States show that prostate cancer is found mainly in men over age 55; the average age of patients at the time of diagnosis is 72. This disease is more common in black men than in white men. In fact, black men in the United States have the highest rate of prostate cancer in the world. Doctors cannot explain why one man gets prostate cancer and another does not, but they do know that no one can "catch" prostate cancer from another person. Prostate cancer is not contagious.

Some studies have shown that a man has a higher risk for prostate cancer if his father or brother has had the disease. However, researchers are uncertain why some families have a higher incidence of prostate cancer.

Scientists are studying the effects of diet. Some evidence suggests that a diet high in fat increases the risk of prostate cancer and a diet high in fruits and vegetables decreases the risk, but these links have not been proven.

Researchers have studied whether having a vasectomy increases a man's risk for prostate cancer. Some studies suggest there may be such a link, but other studies have not supported this claim.

Other studies show that farmers and workers exposed to the metal cadmium during welding, electroplating, or making batteries may have an increased risk of getting this disease. Also, workers in the rubber industry appear to develop prostate cancer more often than members of the general public. However, more research is needed to confirm these results.

Scientists are also doing studies to determine whether BPH or a sexually transmitted virus increases the risk for prostate cancer. At this time, they do not have clear evidence of increased risk in either case.

Men over age 55 are taking part in a study of finasteride (trade name Proscar®), a drug used to treat BPH. This nationwide NCI study, called the Prostate Cancer Prevention Trial, is designed to help doctors learn whether finasteride can prevent prostate cancer.

Detection

Researchers are studying ways to screen men for prostate cancer (check for the disease in men who have no symptoms). At this time, it is not known whether screening actually saves lives. The NCI-supported Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial is designed to show whether certain tests can detect these cancers early enough to reduce the number of deaths they cause. For prostate cancer, this trial is looking at the usefulness of screening with digital rectal exam and checking the PSA level in the blood in men ages 55 to 74. The results of this trial may change the way men are screened for prostate cancer. The Cancer Information Service can provide information about this trial.

Men should talk with their doctor about prostate cancer, the symptoms to watch for, and an appropriate schedule of checkups. The doctor's advice will be based on the risks and benefits of diagnosis and treatment, as well as a man's age, medical history, and other factors.

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