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Prostate Cancer Radiation Treatment

Prostate Cancer Treatment: Radiation Oncology UCLA

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1. Facts About Prostate Cancer
2. Risk Factors Prostate Cancer
3. Screening for Prostate Cancer
4. Diagnosing Prostate Cancer
5. Treating Prostate Cancer
6. Stereotactic Body Radiotherapy (SBRT)

7. External Beam Radiation Therapy
8. Prostate Brachytherapy
9. Hormone Therapy
10. Helpful Websites About Prostate Cancer
11. About Oncologists
12. Prostate Cancer Publications

1. Facts About Prostate Cancer

Prostate cancer is the most common cancer in American men.

  • According to the American Cancer Society, about 235,000 men will be diagnosed with prostate cancer in 2006.
  • More than 27,000 men are expected to die of the disease in 2013.
  • One in six men will get prostate cancer in his lifetime. However, only one in 34 men will die of the disease.

2. Risk Factors For Prostate Cancer

  • Age: The chance of getting prostate cancer goes up as men age. About two-thirds of prostate cancers are found in men over age 65.
  • Race: Prostate cancer is more common among African-American men and Jamaican men of African heritage than in white men.
  • Family history: Men with a father or brother with prostate cancer are more likely to get it themselves.

3. Screening for Prostate Cancer

According to the American Cancer Society, men age 50 or older should be offered a digital rectal exam (DRE) and a blood test to check the level of prostate specific antigen (PSA). African-American men and men with a family history of prostate cancer should be examined beginning at 45.

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4. Diagnosing Prostate Cancer

Figure 1: Pelvic Anatomy
Figure 1: Pelvic Anatomy

Prostate cancer usually presents without specific symptoms. Parts of the posterior prostate gland can be felt by a digital rectal examination (DRE) and the presence of a tumor nodule, if present, may be detected. However, the most common event that leads men to an early diagnosis of prostate cancer is through a blood test, the PSA. PSA (prostate specific antigen) is a protein that is produced by the normal prostate gland, but is also by prostate cancer tumors. It is generally elevated and progressively rising among men with prostate cancer, above what is considered a normal PSA level (less than about 4 ng/mL). The PSA level and the rate at which it increases can be used to assess the aggressiveness of the cancer and its likelihood of having possibly spread.

Figure 1: Anatomy - Pelvic anatomy cross section illustrating the relative position of the prostate (in yellow), the seminal vessicles, the bladder, the urethra and the rectum.

The diagnosis of prostate cancer can only be confirmed through a trans-rectal ultrasound-guided biopsy of the prostate gland and the identification of cancer cells under miroscopic examination. Once identified, prostate cancer is given a tumor grade (called Gleason grade).

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Figure 2: Grading of Prostate Biopsies
Figure 2: Grading of Prostate Biopsies

Figure 2: Grading of prostate biopsies on the Gleason scale.

This is simply a number that describes how aggressive this cancer is. It is reported as two separate numbers (eg. 3+4), with the first number representing the primary grade (that which is present in greater proportion) and the second number representing the secondary grade (that which is present in a lesser proportion). These two grade can be summer up to produce a Gleason ‘score’, eg. 3+4=7. There are basically 3 types of cancers: low grade (Gleason 3+3=6), intermediate grade (3+4=7 or 4+3=7), and high grade cancers (Gleason grade 4+4=8 up through 5+5=10).

The clinical stage for prostate cancer, referred to as T-stage, simply describes whether or not a nodule can be felt on a digital rectal examination (DRE). Sometimes, the DRE can detect whether this nodule appears to have invaded outside of the prostate capsule. If a nodule cannot be felt, the stage is given the name T1 (T1a, T1b or T1c). If a nodule can be felt, then it is called stage T2 (T2a, T2b or T2c). If there is suspicion of extension outside of the capsule, then it is called T3 (T3a or T3b).

Once cancer is found on biopsies, one can put all the pieces together in order to place this diagnosis into one of three risk groups: low-risk, intermediate-risk, or high-risk. This step is useful in order to get a sense as to how aggressive this cancer is and to navigate through the appropriate treatment options.

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Download Prostate Cancer Brochure PDF
Download Prostate Cancer PDF

Risk Groups
It is first useful to separate the diagnosis of prostate cancer into 3 risk groups, as the prognosis, workup and therapeutic recommendations differ among these three groups. By risk is meant the likelihood of disease beyond the prostate, either by direct extension through the capsule, or into the seminal vesicles, or spread to lymph nodes, or a more distant spread to bones. There are three main risk groups described below, based on PSA, tumor grade, and clinical stage (T-stage).

  • Low-risk : clinical stage T1; and PSA 10 or lower; and Gleason grade 3+3 or lower
  • Intermediate-risk : clinical stage T2; or PSA 10 to 20; or Gleason grade 3+4 or 4+3
  • High-risk : clinical stage T3; or PSA above 20; or Gleason grade 4+4 or higher

Other relative risk criteria include: a) the amount of cancer on biopsies (ie. the number of positive cores and the proportion of cancer within positive cores), with more cores involved meaning that the tumor is larger; b) the rate of rise in PSA in the months or years leading up to the diagnosis, with a faster rise in PSA being associated with a more rapidly growing tumor; and c) the presence of peri-neural involvement (PNI), meaning tumor cells near nerves that can sometimes be seen in the biopsies. The presence of PNI may be associated with a more aggressive cancer.

Work Up (additional tests)
Your doctors at UCLA will determine if your prostate cancer needs additional tests. Not all patients need these tests, but those patients with more aggressive cancer features often do. These additional tests would consist of one or more of the following radiology scans: Bone Scan, CT scan, or MRI. These scans can help further determine if the cancer has spread to other areas, such as bones, lymph nodes, seminal vesicles, or beyond the prostate capsule.

5. Treating Prostate Cancer

If you find out you have cancer, you should discuss your treatment options with a radiation oncologist, a cancer doctor who specializes in treating disease with radiation therapy, and a urologist, a surgeon who specializes in the urinary tract. Options for dealing with prostate cancer include:

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Sometimes a combination of treatments is best for your cancer, such as surgery followed by external beam radiation. Some men can safely postpone treatment and watch it closely until treatment is needed. This is called watchful waiting.

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7. External Beam Radiation Therapy

External beam radiation therapy (also called radiotherapy) involves a series of daily treatments to accurately deliver radiation to the prostate. Successful treatment requires tight coordination between the physicians, medical physicists, and therapists.  UCLA medical physicists/dosimetry provide Quality Assurance testing on each treatment plan of the highest quality.  This team maintains the performance of the treatment machines and checks each IMRT plan PRIOR to the actual treatment starting on any patient.  All of this is done "behind the scenes" by this well known and talented group of professionals helping to make the treatment process as safe and smooth as possible.

There are several ways to deliver external beam radiation.

  • Before treatment, a targeting CT scan allows the radiation oncologist to target the treatment on the prostate. Usually several radiation beams are combined to shape, or "conform", the radiation to the prostate cancer.  Tailoring each of the radiation beams to accurately focus on the tumor allows doctors to target the prostate cancer while keeping radiation away from nearby organs such as the bladder or rectum.
  • UCLA treats most prostate patients with intensity modulated radiation therapy or IMRT. IMRT allows doctors to change the intensity of the radiation within each of the radiation beams. The planning team can increase the radiation to the prostate while reducing radiation to nearby normal tissues using this technique.
  • In a few clinics in the country, proton beam therapy is used to treat prostate cancer. Proton therapy is a form of external beam radiation that uses protons rather than X-rays to treat cancer cells. Proton therapy is precise like IMRT only it uses a different kind of radiation.

Each of these treatments is acceptable. With all external beam therapy, painless radiation treatments are delivered in a series of daily sessions, each under 30 minutes in duration, Monday through Friday, for six to 10 weeks. The duration of your treatment will depend on your condition and the type of radiation used. Possible side effects include fatigue, increased frequency or discomfort of urination, and loose bowel movements. These usually go away a few weeks after completing treatments. Impotence is also a possible side effect of any treatment for prostate cancer. However, many patients who receive radiation therapy for prostate cancer are able to maintain sexual function.

 

6. Stereotactic Body Radiotherapy (SBRT) for Prostate Cancer

The UCLA Prostate SBRT program is led by Dr. Chris King and Dr. Michael Steinberg, recognized leaders in the field. SBRT is a technique that uses 5 fractions (treatments) of highly focused radiation on a special treatment machine that allows for maximal accuracy.  UCLA physicians were some of the first in the world to have pioneered the use of stereotactic radiosurgery techniques for prostate cancer.  Dr. King has published seminal papers and lectures extensively. His publications on SBRT can be found below.

 More about SBRT for Prostate Cancer >>

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8. Prostate Brachytherapy

Dr. Jeff Demanes and Dr. Mitchell Kamrava lead the brachytherapy division at UCLA. Dr. Demanes is an internationally renown brachytherapist, has pioneered many techniques and protocols, and has published extensively.  The brachytherapy division at UCLA is a specialized team and capable of performing complicated implants not available elsewhere. The team currently offers a CT-image guided approach to placement of catheters to maximize safety and precision.

Prostate brachytherapy involves treating the cancer by inserting radioactive sources directly into the gland.

  • Permanent seed implants (also called PSI or prostate seed implants) are performed by inserting small metal seeds of radioactive iodine or palladium directly into the gland under anesthesia. The seeds are temporarily radioactive and deliver the radiation to the prostate over several weeks. After losing their radioactivity, the seeds remain in the prostate and are harmless.
  • High-dose-rate prostate implants deliver radiation to the prostate with a few treatments using a single small radioactive iridium source on the end of a computer controlled flexible wire. The radiation is delivered through narrow tubes called catheters inserted into the prostate by your radiation oncologist. You will be under anesthesia and will not feel pain. The tubes remain in place for only one or two days. Once the treatment is complete, the tubes and the radioactive source are taken out. After this type of radiation, you will not need to take special precautions around others.

Depending on your cancer, prostate brachytherapy may be combined with external beam radiation therapy. The side effects from these treatments are similar to those seen with external beam radiation therapy, such as urinary frequency, discomfort on urination or bowel irritation. Medication helps control these symptoms that typically go away within a few months after treatment.
Brachytherapy For Prostate Cancer >>

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9. Hormone Therapy

Depending on your cancer, you may benefit from adding hormone therapy to radiation.

  • Works by starving the tumor of the male hormones it needs to grow. This may make your radiation therapy treatments work better.
  • May be used together with radiation therapy or before radiation to shrink the tumor.

The length of time you will receive hormone therapy depends on your cancer. Ask your doctor for more information. Side effects can include hot fl ashes, mild breast tenderness, diarrhea, nausea and tiredness.

10. Helpful Websites About Prostate Cancer

11. About Oncologists

Radiation oncologists are the doctors who oversee the care of each person undergoing radiation treatment. Other members of the treatment team include radiation therapists, radiation oncology nurses, medical physicists, dosimetrists, social workers and nutritionists.

12. Prostate Cancer Publications

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