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The 10 Most Common Questions that Men ask After Prostate Cancer Diagnosis

Bobby N. Koneru, MD
Wendt Regional Cancer Center

Prostate cancer is the second most common cancer in men worldwide.  The behavior of prostate cancer can vary from a low grade tumor that may never be clinically significant to an aggressive cancer that may result in metastases, morbidity, and death. 

The Wendt Center in Dubuque has treated hundreds of patients with prostate cancer over the years.  I did my radiation oncology residency and served as faculty at Northwestern University, which treated the largest number of prostate cancer patients in the city of Chicago. 

In my many years of experience treating prostate cancer, I have found that patients often have many of the same common questions. As you may know, the diagnosis of prostate cancer can be quite daunting   Prostate cancer can be curable if caught early, thus, men are often left pondering the potentially lasting complications of treatment.  To complicate matters, there are several viable treatment options that can have significantly different complications and side effects.  I have tremendous respect for these patients as they have tough decisions to make after diagnosis.  My hope from this article is to provide clarity for some commonly asked questions. 

What is the prostate and what is it's function?

The prostate is a gland found in men that secretes an alkaline fluid at the time of ejaculation.  The alkaline fluid helps neutralize the acidic environment of the female vaginal tract, prolonging the lifespan of sperm and providing better motility.  A normal male prostate is usually about the size of a "walnut" and can range from 7 to 16 grams in weight.

The prostate surrounds the urethra, which is the tubular transport system for urination.  The prostate is also directly below the bladder and adjacent to the rectum.  This is why the prostate can be palpated on a rectal examination. 

The prostate can be divided into several zones: Peripheral, Central, Transitional, and Fibro-muscular.  The peripheral zone accounts for 70-80% of the prostate, surrounds the distal urethra, and accounts for the majority of prostate cancer origination.  The central zone surrounds the ejaculatory ducts and only comprises a small percentage of prostate cancers.  The transitional zone surrounds the proximal urethra and accounts for the remaining 10-20% of prostate cancers.  It is also the area that grows throughout the male lifespan, leading to the condition known as benign prostatic hypertrophy (BPH).  BPH most commonly can present as urinary frequency, nocturia, and hesitancy. 

What is the current recommendation on prostate screening?

This is a complicated answer.  Prostate cancer screening is most commonly done through a digital rectal examination and a blood test looking at the Prostate Specific Antigen (PSA). 

PSA is a glycoprotein produced by the prostate gland. PSA levels may be elevated in men with prostate cancer as well as a number of benign conditions such as benign prostatic hyperplasia (BPH) and prostatitis. The traditional cutoff for an abnormal PSA level in the major screening studies has been 4.0 ng/mL. 

Although screening for prostate cancer with PSA has been shown to reduce mortality, the absolute value has been small in certain studies. There remain important concerns that the benefits of screening are outweighed by the potential harms to quality of life, including the substantial risks for overdiagnosis and treatment complications. 

It is important to discuss with your doctor, the pros and cons of doing a PSA test.  Typically, a discussion regarding prostate screening should begin at the age of 50.

I had my biopsy and it was positive for cancer.  The cancer was also given a Gleason's score.  What does that mean?

The Gleason Grading system is used for prostate cancer staging which predicts prognosis and helps guide therapy. A pathologist looks at the appearance of the prostate cancer and gives it a score which involves two numbers ranging from 0-5.  The first number is the grade of the most common tumor pattern.  The second number is the minority or less then 50% of tumor pattern. When you add these two numbers, you get a Gleason's score.  For example, your score may be a Gleason's 3+4=7.  

Cancers with a higher Gleason score are more aggressive and have a worse prognosis.  From this score, a risk stratification can be determined which may potentially determine what kind of treatment you have.  A Gleason's score of 6 or below would be considered low risk.  A Gleason's score of 7 would be classified as intermediate risk.  Finally, Gleason's scores of 8-10 would be considered high risk.  There are several other factors that are examined, including but no limited to PSA score, whether or not there is palpable disease on rectal examination, any evidence of invasion into the seminal vesicles on MRI, and overall burden of disease on the biopsy specimen.

As the Gleason's score approaches 7 or higher, the risk of prostate cancer spreading outside of the prostate is high.  Thus, the patient may have to have a CT scan of the abdomen and pelvis, as well as a bone scan to make sure there is no evidence of metastatic disease.

What are my treatment options depending on my risk group?

As mentioned earlier, there are several factors that need to be examined carefully.  The anatomic extent of disease, PSA, and Gleason score are used for risk stratification. For men with clinically localized, very low-risk prostate cancer and a life expectancy of less than 10 years, it may be reasonable to do active surveillance without any treatment.  However, this approach is associated with a need for close follow-up and can create significant anxiety, causing many patients to subsequently choose definitive intervention even in the absence of progressive disease. Radiation therapy and radical prostatectomy are acceptable alternatives for patients preferring immediate definitive therapy. 

Cryotherapy may also be an option, but this is considered investigational and is not used in most centers for the treatment of intermediate or high risk prostate cancer as there is not high quality long term data on results and toxicity.  

For men with low-risk prostate cancer and a life expectancy of greater than 10 years, definitive therapy (radical prostatectomy, brachytherapy, or external beam radiation therapy (RT)), or active surveillance may all be appropriate options. The choice of a specific approach requires a consideration of the benefits and risks associated with each approach, taking into account the patient's individual preferences and overall health.

I was diagnosed with low risk disease.  If I decide to get treatment, how do I decide which treatment is best for me?  Is one better then the other?

This is a complicated answer and can lead to anxiety for many patients. Deciding between surgery and radiation therapy can be a difficult choice.  The efficacy and cure rates from both radiation and surgery are similar.  The difference lies in the side effects.  First let's talk about the treatment options in more detail. 

The goal of RT for men with localized prostate cancer is to deliver a therapeutic dose of radiation to the tumor while minimizing radiation to normal tissues. Both external beam RT and brachytherapy are widely used as a single modality for clinically localized low-risk prostate cancer. When used as the primary treatment modality, results with RT are similar to those with radical prostatectomy. 

External beam RT uses a machine called a linear accelerator to deliver radiation to treat the prostate gland and a margin of adjacent normal tissue. Complications have significantly decreased and are low with modern advancements in radiation planning and delivery with techniques such as IMRT (Intensity Modulated Radiation Therapy) and IGRT (Image Guided Radiation Therapy).  External beam RT is generally used alone for low-risk clinically localized prostate cancer.  Brachytherapy directly implants a radioactive source within the prostate to treat the cancer.  Brachytherapy maximizes irradiation of the tumor while minimizing radiation to normal structures. Brachytherapy requires only a one or a limited number of treatments, rather than the daily therapy required by external beam RT.  Unlike external beam radiation, brachytherapy is an invasive procedure that is performed in the operating room under anesthesia.

Radical prostatectomy is another option to treat localized prostate cancer, with high rates of local tumor control and acceptable toxicity.

Irritative and obstructive urinary symptoms are more common after brachytherapy. Incontinence is more frequent after radical prostatectomy, but may improve gradually after surgery. Bowel symptoms (urgency, frequency) are more common after external beam RT than with radical prostatectomy. Erectile dysfunction is common after both surgery and radiation.  At 24 months, sexual symptom scores are similar among men treated with RP, RT, and brachytherapy.

I have a PSA of 8 and Gleason's score of 7.  My doctor told me I have intermediate risk disease.  What would be my best option for treatment?

Radiation is usually combined with androgen deprivation therapy (ADT) in this setting. RT may be given by either external beam or external beam in combination with brachytherapy.

Surgery including pelvic lymph node dissection is also an option. One downside to surgery in this setting is that a patient may need radiation afterwards.  For example, patients with adverse pathology (extracapsular extension, seminal vesicle involvement, positive margins) or a persistent elevation of the PSA after surgery, may be required to receive postoperative RT.

Why do I need to be on ADT?  How long?  What are the side effects?

ADT has been proven to prolong survival in patients with intermediate to high risk prostate cancer when given with RT.  The duration is dependent on stage, but can range from 6 months to 2 years.  A radiation oncologist will assess the duration based on stage as well as the overall health of the patient. 

What are the most common side effects of ADT?

The most common side effects include loss of libido, hot flashes, gynecomastia, and breast tenderness.  These effects are temporary and usually reverse after stopping therapy.

I have a PSA of 12 and a Gleason's score of 9.  My doctor also felt nodules on both lobes of my prostate.  He told me I have high risk disease.  What are my treatment options?

The treatment option would be the same as the previous case.  However, the risk of spread outside the prostate is significantly higher now. 

With all of these options, how do I make the best choice?  Especially since the efficacy between radiation and surgery is similar?

There are pros and cons with each treatment.  As mentioned before, external beam radiation therapy involves a time investment of several weeks.  The most common side effects tend to be bowel related.  With surgery, the time commitment is less, however it is an invasive procedure.  Also, the most common side effects tend to be bladder related.  Both treatments can lead to impotence. 

Both treatments have had technological advances.  For example, radiation therapy uses intensity modulated radiation therapy (IMRT) to deliver a highly conformal and precise treatment.  This has substantially reduced complications over the years.  Surgery with robotic prostatectomy is now available in certain centers.  This has reduced the recovery time dramatically.  So there are definitely advantages and disadvantages to both treatments.

My strong advice is to seek consultation from both a radiation oncologist and surgeon if you have been diagnosed with prostate cancer.  Even if your physician says it's not necessary, make sure that you get both opinions directly from the experts.  For example, a urologist is not an expert in the field of radiation oncology.  Similarly, a radiation oncologist is not an expert in surgery.  In certain states, such as California, it is required by law that a patient diagnosed with prostate cancer sees both a urologist as well as a radiation oncologist.  This is the only way to ensure that one has all of the proper education and can make an informed decision.